Vanishing: Living With Dementia

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It is currently estimated that some 30% of adults aged 60 and older will at some stage require medication with psychotropic agents. And South Africa’s elderly population is growing rapidly without adequate state mental health care.

South Africa’s most recent population census (Stats SA June 2017) shows an increase from 2.8 million older people in 1996 (7.1% of the total population) reaching 4.6 million (8.1%) in 2017. World-wide it is expected that the number of older people will surpass the number of children by 2045, and that the global population of people older than 60 years will double from 900 million in 2015 to two billion in 2050. By the end of this century, one third of the global population will be elderly.

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Prof Felix Potocnik, member of the South African Society of Psychiatrists (SASOP), says that the demographic trend of South Africa representing one of the most rapidly ageing countries in Africa, demands an awareness of the challenges and needs facing the elderly.

“There is a difference between normal ageing and impaired mental health and it’s important to distinguish between the two. Often depression and dementia are under- diagnosed, overlooked and untreated in older adults owing to a variety of factors which may include and / or overlap with other conditions and behaviours. The presentation of their illness is so varied that it is often difficult to establish meaningful key criteria that would help distinguish ‘classical’ cases.”

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Prof Potocnik expresses concern regarding the lack of care for the elderly with mental health conditions in South Africa.

The WHO Global Health Observatory data estimates that there is one psychiatrist per 100 000 of the South African population, and even less (0.4%) in the State sector; a situation which is deemed grossly inadequate. The USA and the United Kingdom by comparison have 12.4 and 14.6 psychiatrists per 100 000 respectively. Of South Africa’s 650 psychiatrists only three are specialist old-age psychiatrists compared to the international trend of two to seven psychogeriatricians per 100 000 persons older than 65.

“We used to have five dedicated psychogeriatric units at our South African universities, whereas now there is only one situated at Stikland Hospital in Bellville, Western Cape. Stikland Hospital is a public hospital and has the only HPCSA recognised Geriatric Psychiatry unit and training facility in South Africa. The Unit consists of three wards with a total bed capacity of 77 (33 male beds and 44 female beds). Even so it is over- subscribed with a waiting list exceeding several weeks. The reason for this is that the Western Cape has some 600 000 elderly of whom an estimated 40 000 (6.6%) are suffering with dementia.”

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He says the greater reliance are placed on family, friends, social support groups, district clinics and regional hospitals to help with this task of providing services for the elderly. In addition, medication is costly.

“We have medications available to treat Alzheimer’s disease and which at half the dose are also effective in vascular dementia, diffuse Lewy Body disease and dementia in Parkinson’s disease. Treatment with both agents using the generic equivalents is available at below R500 per month, but is not available through the State health sector and is currently not funded by most medical aids. Most medical aids also do not recognise Alzheimer’s disease as a Prescribed Minimum Benefit which makes medication and care very costly.”

But why are the elderly at such risk of mental health problems?

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Prof Potocnik says the challenges one faces with advancing age create strong emotions such as sadness, anxiety, loneliness and lowered self-esteem. Coupled with physical and/or mental disabilities, it renders the individual more vulnerable and unable to engage in many activities in daily life.

“Older adults who are suffering from depression experience symptoms that disrupt their daily lives, resulting in withdrawal from social activities, friends and family and all the things that used to bring them joy. It is important for family members to be vigilant and recognise any changes in behaviour and to seek help from medical and allied services.”

In South Africa, as many as 6%-7% of the elderly population suffer from dementia while more developed countries such as the United Kingdom are working with figures of 1 in 3.

Prof Potocnik says dementia is usually a slow and progressive condition that requires specialised monitoring and treatment from a psychiatrist.

“While some element of forgetfulness accompanies one’s later years, it is important to realise that it is not a disability if you can still make rational decisions and get on with your daily life. Although the key symptoms of dementia include forgetfulness, in the earlier stages it is about multiple cognitive deficits that herald a decline in one’s ability to think abstractly and logically, to use language properly and to make sensible decisions.”

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“The brain’s inability to function properly starts affecting every day activities. The person may thus present with an inability to keep their attention and focus long enough to meaningfully reading a book, an article, or follow a TV program. An artist might fail in the standard of their art, a person might incessantly fall asleep at work, or there may be a steady increase in pathological hoarding.”

Prof Potocnik says that aberrations of mood are a very early sign of impending dementia. There is usually an underlying current of irritability, often accompanied by emotional outbursts. The patient may also present with relapsing bouts of depression or anxiety which become increasingly difficult to treat and contain.

“The personality may change. This may range from subtle exacerbations of existing characters traits to uncharacteristic behaviour where for example a clergyman is found shoplifting, or businessmen making injudicious and rash decisions and investments, quite contrary to their previous behaviour.”

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He says memory loss amongst those suffering from dementia includes the inability to learn new information, losing items of value such as keys and wallets, and becoming lost in unfamiliar surroundings. Apart from becoming forgetful, one becomes repetitive and may forget to feed pets or food cooking in the oven. In more advanced stages of memory loss one may forget crucial details and dates as well as not remembering or even recognising family members.”

“Additionally, the combination of failing cognition and motor activities may result in the person being unable to get dressed appropriately or being able to write. Others have difficulty recognising and naming certain objects such as pens, different denominations of money and keys, and what they are used for. In very advanced stages they may not even recognise their own reflection in a mirror. Speech becomes increasingly vague, lacking in substance and detail. With further deterioration incomprehensibly long sentences and jargon dysphasia, is evident.”

“Overall, the duration of dementia may be as short as six months, or exceed two decades. While the patient themselves rapidly lose insight and are unaware of any problems they may be causing, this “second childhood” is extremely stressful for the caregiver. Their incidence of depression and other illnesses, need for medication, or even hospital admissions is double that of their peers. The caregiver looking after a dementing spouse has a six times higher rate of dementing themselves (12 times higher for male caregivers) when compared with peers where both partners enjoy normal mental health.”

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He points out that although it is not always known what causes or triggers dementia, there are some preventative measures for Alzheimer’s disease and vascular dementia that may delay the onset and possibly ameliorate the course of the disease itself. It is worth nothing that they offer little benefit once the condition has occurred or is advanced:

• Hormone replacement therapy (oestrogen with or without progesterone) is only effective if initiated at the time of menopause where a deficiency in female sex hormones has clearly been established. Treatment should not exceed 2-4 years.

• Vitamin E (<400 IU) and C (400 mg) daily, preferably in combination. Note that continuous high-dose vitamin E (+400 IU daily) supplementation may be associated with an increased mortality risk.

• Red wine (one unit for females and two for men where one unit equals 125ml ml daily). The benefits are ascribed to resveratrol and other aliphatic compounds.

• Non-steroidal anti-inflammatory drugs (NSAIDs). Conventional NSAIDs such as ibuprofen and voltaren as well as naproxen used for as little as 2-3 years may protect against AD.

• Coffee. Consuming two cups of coffee (not decaffeinated or instant) a day decreases the risk of neurocognitive disorders/Alzheimer’s disease later in life.

• Cocoa. The equivalent of 40 grams of 80% dark chocolate per day.

• A diet rich in vitamins B, C, D and E (fruit and vegetables) and omega 3 fatty acids (fish) and low in high trans-fat (processed foods) reflects in beneficial blood nutrient biomarker patterns influencing both cognitive function and brain

  volume.

• Intellectual stimulation and higher education improve brain reserve by

  improving synaptic connectivity.

• Reduction in stress. This is also linked to having close friends or confidants, a

  good social network and leisure activities and hobbies.

• The control of vascular risk factors as these are closely linked to the

  pathophysiology of Alzheimer’s disease. These risk factors are linked to transient ischaemic attacks (TIAs) and vascular risk factors (correct management of hypertension, diabetes and dyslipidaemia, prevention of platelet aggregation, adequate exercise, moderate alcohol use and cessation of smoking).