Mens Health Blog. Medical Blog

Sometimes when there is something wrong with people with dementia all that they can indicate to us is that they are in discomfort. This may be apparent from an increased level of agitation or a deterioration in their behavioural pattern. It can be extremely difficult to discover whether pain really is at the root of the increased confusion and, if so, what it is caused by. The source of pain can be a full bladder that won’t empty, as happens in some men with an enlarged prostate gland, or perhaps an undetected broken bone; indigestion from ulcers can also be the culprit, and so on. A person with dementia is just as likely to develop all the physical problems that the rest of us can have. All that the doctor can normally do is exclude obvious and easily diagnosed causes of pain, and if a specific diagnosis is not apparent, treat the pain in a general way in the hope either that it will settle down or that other indicators of the underlying problem will eventually become apparent.

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Hallucinations – seeing or hearing people, voices, or things that aren’t really there – often happens as a result of dementia. It can be very frightening, both for the sufferer and the carer. Some people with dementia form quite a close attachment to their ‘invisible friend’ but more often than not the experience is a distressing one. This situation is best handled by reassurance. Explain that you know they can see someone who you can’t and try to be supportive.

Sometimes visual hallucinations result either from a false impression given by an inadequately lit and dimly perceived object or from poor sight. If the illumination in the room appears poor, improve it and see whether this helps.

If hallucinations become a major problem it is important to seek medical advice, as this is one situation where medication may actually be helpful. There is, however, no point in treating them unless they are causing distress or upset or are disrupting the daily routine.

A similar problem, although not really a hallucination, can occur when people with dementia see their own reflection in a mirror. They may fail to realize that it is their own image they are seeing and interpret their reflection as indicating the presence of a stranger. This can sometimes provoke an aggressive or fearful response. If this is a particular problem, a small curtain or cloth can be draped across the mirror, enabling others to use it when necessary, while at the same time removing the cause of the distress.

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There is no doubt that the brain of a sufferer from Alzheimer’s disease contains an unusual quantity of aluminium. It now also seems fairly clear that the aluminium is especially concentrated in those structures that are most affected in Alzheimer’s disease and that it is found in association with the senile plaques and the neurofibrillary tangles. This of course has led to considerable speculation that aluminium could be the cause of, or a contributory factor to, the development of this type of dementia in at least some sufferers, if not most.

This theory is further strengthened by the results of experiments on animals that have shown neurofibrillary-tangle-like structures developing in brain cells exposed to large quantities of aluminium. Further, people with kidney failure who have to undergo renal dialysis run the risk of developing a confusional state if the dialysis procedure allows too much aluminium to enter their body. Although this is now rigorously controlled, in earlier days before the relationship between aluminium and brain damage in kidney patients was established, some people with kidney failure died of a condition known as dialysis encephalopathy. Excess levels of aluminium were implicated in this process.

Although this all makes for a good prima facie case for aluminium as a potential cause of Alzheimer’s disease, one has to remember that aluminium might be accumulating in the brain as a result of the condition rather than as an agent which is causing it. It is possible that damaged tissue may accumulate aluminium in greater quantities than undamaged tissue. Most people working in this field believe that aluminium accumulates passively as a consequence of ageing or damage to brain cells. Moreover, accumulation of aluminium is known to occur in other brain disorders, in which the characteristic changes of Alzheimer’s disease do not occur. The people dying of dialysis encephalopathy did not develop the same changes in the brain as are found in Alzheimer’s disease or if they did, to only a very minor and possibly insignificant extent. In addition, aluminium does not accumulate in all places where plaques and tangles occur and in at least one study it was found not to have accumulated in that part of the brain that is usually most severely affected by the abnormal changes. If aluminium really were important, one would have expected the highest levels in this area – the hippocampus.

A lot of prominence has recently been given to the level of aluminium in drinking water. Aluminium is added to the water supply as part of the purification process and in many parts of the country water has a naturally high level of aluminium dissolved in it. Although a recent study claims that Alzheimer’s disease appeared to be more common in parts of the country with higher than average levels of aluminium in the water, even this evidence is not strong enough to implicate aluminium as the cause of Alzheimer’s disease.

The study is a difficult one to interpret for a number of reasons; although in general it was reported that there were more cases of Alzheimer’s disease in areas where the water was high in aluminium, some areas with the highest levels were not associated with the greatest number of cases. Besides, we take in a lot more aluminium with our food than in our drinking water. The latter is responsible for only a small proportion of the 5-6 mg of aluminium that most adults ingest each day.

If aluminium is one day shown to be an important contributory factor and the scepticism of many of us shown to be inappropriate, it will prove very difficult to minimize our intake of the substance. Aluminium is one of the most common elements in the earth’s crust and is present all around us. Not only does it occur in our water and naturally in our food, it is a common component of some food additives. It is present in cosmetics and talcum powder and in the dust that we breathe.

In any case the link, if one exists, between aluminium and Alzheimer’s disease is unlikely to be a simple matter of cause and effect. Two people can live side by side for sixty years, having got married in their late teens or early twenties, consuming a very similar amount of aluminium throughout their life. Only one of them develops Alzheimer’s disease and their neighbours who probably have a not dissimilar lifestyle, are also spared. Why this selectivity? It is possible that some subjects with Alzheimer’s disease inherit a tendency to be particularly sensitive to aluminium or process it within their nervous systems in an abnormal manner. Although this possibility does exist, there is as yet no firm evidence in its favour.

Finally, an alternative and totally speculative hypothesis involves the suggestion that the aluminium that we consume during our adult lives is irrelevant and that if this element plays any part at all in causing Alzheimer’s disease, it is aluminium intake in early life, perhaps even before birth, that is important, causing damage to nerve cells in the brain which does not become apparent until much later in life. There is, however, no evidence at all at the moment to support this possibility and I only mention it for the sake of interest.

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The frontal lobe is the part of the brain that controls certain aspects of our personality, particularly keeping our behaviour in check. Some forms of frontal lobe damage will lead to uninhibited behaviour, for example when a person has drunk too much alcohol. It seems as if alcohol is a stimulant, but in fact it depresses those parts of the frontal lobe that control behaviour, releasing inhibitions.

One of the features of Alzheimer’s disease that is said to differentiate it from the dementia that is characteristic of small strokes, is the change in personality often noticed in the Alzheimer’s sufferer. This can take the form of being unusually irritable or apathetic, or showing a lack of concern about matters that would formerly have been of importance to the sufferer, such as the management of the family finances. In the early stages the subject may realize that forgetfulness is a problem, but it may cause no undue anxiety; in some cases, however, the realization may be accompanied by considerable anxiety. It is usually relatives or friends who are responsible for alerting the doctor to the fact that something is wrong. Sometimes mood is very unstable, with anger or tears suddenly appearing for no obvious reason. This, however, is also a feature of the dementia that is caused by small strokes. As the disease progresses, restless wandering may occur and later becomes particularly troublesome at night. Eventually there is an almost complete disintegration of personality, with a lack of interest in personal hygiene, standards of dress, and occasionally the development of unpleasant behavioural habits -including going to the toilet in inappropriate and embarrassing places.

Many sufferers from Alzheimer’s disease lose things and accuse others of having stolen them. This paranoid behaviour sometimes progresses to the stage where it is imagined that others are plotting or planning against them, especially if there has been any talk of alternative accommodation. Hallucinations may also occur and these may take the form of the sufferer seeing people or objects that are not really there or, less occasionally, being told to do things by voices from uncertain sources.

As mentioned earlier, another feature of Alzheimer’s disease is the development of difficulty with speech. Speech and language functions are controlled by special centres in different parts of the brain, not just the frontal lobe, but will be considered here for convenience.

The most important language disorder is difficulty with names. This can take two forms. The names of common objects may be forgotten so that when a pen is required, it will be referred to as ‘that thing you write with’ and as the disease progresses even this way round the problem may not be possible, with the sufferer just pointing at an object and demanding that he or she be given it. Sometimes, however, a second type of difficulty with language occurs and this is not so much the naming of an object, but difficulty recognizing the name as used by somebody else.

There is a particular area of the left frontal lobe in most people that is responsible for the control of language and this is affected early on in the course of Alzheimer’s disease. Sometimes it isn’t noticed in the very early stages unless careful tests are undertaken. However, once the language disorder has become marked, it usually indicates that the disease is going to progress more rapidly than hitherto. Generally, difficulty in using the name of an object occurs earlier in the disease whereas difficulty in understanding the name of an object when somebody else uses the word occurs later.

One further aspect of frontal lobe function that is often abnormal in the later stages of Alzheimer’s disease is the reappearance of reflexes that are more typically found in young babies. If the palm of an infant is stroked with a finger, the finger will be seized. Because these reflexes occur early in life and disappear as the nervous system matures, they are referred to as primitive reflexes. When there is significant degeneration in the frontal lobes, the grasp reflexes and others reappear. Although they are occasionally present in apparently normal people throughout life, their presence in an Alzheimer’s sufferer usually indicates quite an advanced stage in the disease.

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When a diagnosis of ‘dementia’ is made, it is essential not to accept this on its own but to insist that a proper diagnosis of the underlying cause is made, as early in the course of the illness as possible, in case the underlying cause is treatable. The family, or others who are in a caring role, can then make sure that they are aware of what is available locally by way of support from both the statutory bodies – the health service and social services — and also from the voluntary sector, such as the Alzheimer’s Disease Society. Where the provision of support is inadequate, if a group of carers gets together they may be able to press for better resources more effectively than individuals on their own.

If someone you care about has an illness causing dementia the path ahead will probably be a long and difficult one. The purpose of this book is to try to help lighten your load while at the same time assisting you to improve the quality of life of the person who is afflicted.

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