Management of irreversible dementia by mikeholy


									PETER V. RABINS, M.D., M.P.H.

Management of
irreversible dementia
ABSTRACT: This article describes a multidisciplinary                 approach      to      with dementia.3 These patients suf
the patient with irreversible dementia. Many such patients con                             fer from chronic, often progres
tinue to enjoy life, and their adjustment can be facilitated by at                         sively deteriorating illnesses, and
tention to their somatic and emotional              problems.    An improved,              their problems are based as much
                                                                                           in the social environment as in the
well-structured environment and an understanding family are
                                                                                           somatic health realm. Although
particularly important. The author discusses the use of the ben                            such fflness@scannot be cured or
zodiazepines for insomnia and neuroleptics for emotional and                               reversed by therapeutic interven
behavioral       problems.                                                                 tion, the skills of interested physi
                                                                                           cians, nurses, social agencies, and
Dementia is the development            of      called senility) is neither an inevi        other health care professionals may
intellectual    impairment   in a state of     table consequence of aging nor              greatly improve the quality of life
dear consciousness. The group of               necessarily irreversible. Kay,2 for         of the patient and his family.4
disorders that produce it represent            example, found normal cognitive                This multidisciplinary manage
a major health problem, especially             function in 90% of persons over age         ment of irreversible dementia de
among the elderly, with the pre-se             65. Further, some forms of demen            scribed below was developed on a
nile form of Alzheimer's disease               tia are treatable, and thus physi           geriatric psychiatry service with in
alone estimated to be the fourth or            cians should fully evaluate all             patient and outpatient compo
fifth most common cause of death               changes in the mental state of el           nents. Although the approaches
in the United States.' Since 12% of            derly persons rather than automat           have not been proven effective in
the US population will be 65 years             ically assume that the condition is         controlled studies,5 the measures
old or older by the year 2000, phy             irreversible.                               are humanistic and seem to help
sicians will be seeing many more                  Thorough evaluation studies do           many patients.
such patients.                                 reveal irreversible conditions in
   However dementia (sometimes                 60% to 90% of geriatric patients            Initial evaluation
                                                                                           All patients presenting with a his
Dr. Rabins is assistant professor ofpsychiatry and director of the T. Rowe and Eleanor     tory of deterioration of memory or
Price Teaching Service at the Johns Hopkins University School of Medicine,                 behavior should be investigated
Baltimore. Reprint requests to Dr. Rabins at the Department of Psychiatry and              thoroughly to rule out treatable
Behavioral     Sciences, the Johns Hopkins   University School of Medicine,   Baltimore,   metabolic, infectious, psychiatric,
MD 21205.                                                                                  focal, or other treatable etiolo

JULY 1981 - VOL 22• O 7
                    N                                                                                                       591

gies.6'7 If irreversible dementia is     that patients with dementia need.                          by
                                                                                strophic reaction― Goldstein,@ is
diagnosed,   a discussion   with the     The management principle that          common among elderly patients
family members concerning prog           seems to help most is the establish    with an organic brain syndrome.
flosis, probable course, and realistic   ment of a constant, predictable,       These reactions may take the form
expectations can help them plan for      and familiar environment.          A   of explosive rage or sudden crying
the future. For example, apraxia         schedule in which activities such as   in response to minor change. One
may interfere with a patient's abil      arising, eating, medication-taking,    such patient, a 73-year-old man
ity to dress and cook. By knowing        and exercise occur at the same time    with a two-year history of Alz
that this condition will not abate,      each day maximizes the patient's       heimer's disease and no previous
the family is better able to decide      familiarity with his personal envi     history of violent behavior, sud
whether the patient's needs can          ronment. This structure can be         denly became enraged when his
best be met at home or in a nursing      strengthened by placing familiar       young grandson tripped while
facility.                                objects such as pictures, magazines,   playing and began to cry. The pa
   Physicians familiar with avail        television, and radio in sight.        tient rushed into the kitchen,
able community resources or agen         Nightlights, calendars, and clocks     grabbed     a knife, and began
                                         are useful. Frequent efforts toward    screaming threats of killing who
                                         orientation to time and place, and     ever had harmed the child. The
Dementia is neither an                   toward keeping the patient abreast     family was taught to respond to
inevitable consequence of                of current events, may help main       such behavior by remaining calm
agingnor necessarily                     tain the patient's familiarity with    and removing the patient from the
irreversible.                            the surrounding environment.           threatening situation. Such epi
                                            The physician or other health       sodes subsequently became much
                                         care worker should inquire about       less frequent.
cies can help families make such         the family's adaptation to the pa         In taking a history, one should
decisions. Many agencies con             tient's needs. He should explicitly    ask specifically about whether such
cerned specifically with the needs       recommend that family members          emotional outbursts have occurred;
of the aged and handicapped have         arrange for periodic respite from      predicting their possible recurrence
valuable information on matters          care providing.                        and suggesting that the family react
such as the availability of visiting        Guilt, unrealistic expectations,
nurses, physical therapy, activity       and assumption of excessive re
centers, and mental health clinics.      sponsibility are common responses      The management principle
Such services allow patients to re       of families. In discussing these and    that seems to help most is
main in their families' homes.           similar issues, the physician should    the establishment of a
   Whether the diagnostic and            focus both on physical realities and   constant, predictable and
prognostic findings should be            on the family's emotional responses
shared with the patient is an issue      to the patient. One common source
                                                                                familiar environmenL
to be decided individually and           of difficulty is that the care of an
often depends on the patient's           elderly person often represents a    in a nonconfrontational, supportive
awareness of his deficits. Individual    reversal of parent/child roles. This manner can often minimize subse
psychotherapy may be indicated to        issue may concern both the family    quent difficulties. Since cata
help the patient adjust to his im        and the patient. There is no single  strophic reactions are often seen in
pairments, make realistic plans for      correct therapeutic mode of inter    response to minor stress or change,
the future, and maximize his re          vention in such a situation; each    they do not in themselves indicate
maining attributes.8                     family will require an approach in   failure of management or predict
                                         accord with its specific strengths   constant problems.
Environmental structure                  and weaknesses.                         Just as minor environmental
I encourage patients and their fam                                            changes can lead to major emo
ilies to establish an environment        Specific problems                    tional reactions, minor somatic im
that allows as much freedom as           A massive emotional over-response    pairments can trigger major de
possible but also offers the structure   to minor stress, called the “¿cata compensations in cognitive func

592                                                                                              PSYCHOSOMATICS

     tion and level of consciousness.         flurazepam for example—are often        acetylcholine levels.'4-'5 Whether
     Thus, the physician should institute     preferred for sleep disturbances,         these agents improve behavior of
     a diligent search for common caus        especially because this class of          patient's with Alzheimer's disease
     ative conditions such as infection,      drugs does not cause rebound in           must be determined before general
     dehydration,    and drug toxicity        somnia. However, we have also             clinical use of these agents would
     when a patient manifests any sud         seen paradoxical reactions in pa          be indicated.
     den worsening in behavior, intel         tients taking these drugs, and have          Some families find books useful
     lectual functioning,   or level of con   used chloral hydrate as an alterna        in understanding dementia and the
     sciousness.                              tive. Small amounts of beer, wine,        emotional issues that may arise. I
        Since adequate nutrition is also      or sherry seem to work best as so         recommend     When Your Parents
     important in ensuring that patients      ponfic agents for some elderly pa         Grow Old'6 and Living with Chronic
                                              tients.                                   Neurologic Disease.'7
                                                 Severe, frequent catastrophic re         Questions about power of attor
     Guilt, unrealistic                       actions, marked emotional     lability,   ney, wills, or competency are com
     expectations, and assuming               and other management problems             mon. A suggestion early in the
     excessive responsibility are             in the early evening are often con        course of treatment that families
     common responses of                      trolled by low doses of neuroleptic       obtain. competent legal advice may
                                              medications such as haloperidol,          avoid crisis situations at a later
                                                   riaz'     or thiothixene.'2 Be       date.
                                              cause of the high incidence    of tar
     function maximally, a dietary his        dive dyskinesia among the elderly,        Conclusion
     tory is important. Hot lunch pro         we prescribe these drugs only when        There are many rewards in helping
     grams and meals-on-wheels may be         nondrug management has failed             patients with dementia, their fami
     important supports. Multivitamin         and the patient's behavior would          lies, and friends. Many such pa
     therapy may be indicated for pa          otherwise lead to severe discomfort       tients continue to enjoy life; their
     tients on nutritionally inadequate       for him or his family, would neces
     diets.                                   sitate a change in his living situa
                                                                                        Just as minor environmental
                                              tion, or would present a danger to
      Management                              him or to others. Liisuch patients, a     changes can lead to major.
      Such common problems as marked          daily dose of 1 to 2 mg of haloperi       emotional reactions, minor
      emotional lability, catastrophic re     dol or an equivalent dose of an           somatic impairments can
      actions, “¿sundowning―(worsening    other neuroleptic can be given ei          trigger major
      in function after sunset), and sleep    ther three times a day or in one          decompensations in cognitive
      disturbance can often be effectively    daily dose at 5:00 P.M.or 6:00 P.M.
                                                                                        function and level of
      managed by environmental ma             Administering the total daily dose
      nipulation or behavior modifica         early in the evening seems to de           consciousness.
      tion techniques. Occasionally, only     crease “¿sundowning,―  improve
      medication can effect changes in        sleep, and lessen the intensity of        families and friends can share and
      such behavior, but it must be borne     daytime sedation. Because these           impart joy. Applying common
      in mind that elderly persons are        drugs are known to cause confu            sense and paying attention to the
      often very sensitive to psychotropic    sion, I recommend stopping the            details of social and psychological
      drugs.                                  drug rather than increasing tl@e          issues can contribute to the quality
         Insomnia is a frequent complaint     dose if the patient's behavior or         of life of all concerned. However,
      in the elderly. Aging is normally       cognition deteriorates after psy          the untested nature of many of the
      accompanied by an increase in time      chotropic medication is begun.            ideas presented here demonstrates
      required for sleep onset, and this is      The use of cerebral vasodilators       the need for continued research
      a more severe problem in elderly        remains controversial,'3 and in my        into the social, biologic, and psy
      persons with dementia.'° Because       practice they have not proved to be       chological aspects of health care of
      barbiturates may have a paradoxi        effective. Administration of drugs        patients with dementia and their
      cal effect, the benzodiazepines         such as choline may increase brain        families.                 (continued)

     JULY 1981 . VOL 22@NO 7                                                                                             593

  This investigation      was supported               gressive intellectual deterioration. Arch                                    R
                                                                                                      logicalagingin man.J Psychiatr es5:107-
                                                     Neurol 33:658-659, 1976.                          144, 1967.
in part by the National Institute of              4. Branch CHH: Maintenance versus treatment      11. Lehman H: Use of medication to prevent
Mental Health's      Psychiatry-GP                   in medicine and psychiatry. Psychosomatics        custodial care, in Eisdorfer C, FriedelA (eds):
                                                     20:143-144, 1979.                                 Cognitive and Emotional Disturbance in the
Special Training grant 5 to 1 MH                  5. Folstein M, McHugh P: Phenomenological            Elderly. Chicago, Yearbook Medical Publish
14325-02 and the T. Rowe and                                                                psy
                                                     approach to the treatment of ‘¿organic'         ers, 1977, p 132.
                                                     chiatric syndromes, in Wolman B (ed): The     12. Aada A, Kellner A: Thiothixene in the treat
Eleanor Price Foundation. The au                                                         M
                                                     Therapist's Handbook—Treatment ethods           mentof geriatric patients with chronic organic
thor expresses thanks to Marshal                     of Mental Disorder. New York, Van Nostrand,       brain syndrome. J Am Geriatr Soc 24:105-
                                                     1976, pp 279-286.                                 107, 1976.
Foistein, M.D., for reviewing an                  6. McHugh P: Dementia, in Beeson PB, McDer       13. Anonymous: Drugs for improvement @f       cere
early draft.                       0                 mofl W(eds): Textbookof Medicine. Philadel        bral function in the elderly. Medical Letter
                                                     phia, Saunders, 1975, pp 559-560.                 18:38-39, 1976.
                                                  7. Wells CE: Diagnosis of dementia. Psychoso     14. Boyd W, Graham-White J, Blackwood G, et
                                                     matics 20:517-522, 1979.                          al: Clinical effects of choline in Alzheimer
REFERENCES                                        8. SolomonJG: Treating an elderly woman with         senile dementia. Lancet 2:711, 1977.
1. Katzman A: The prevalence and malignancy          organic brain syndrome. Psychosomatics        15. Ferris 5, Sathananthan G, Gershon 5, et al:
   of Alzheimer disease. Arch Neurol 33:217,         21:165-166, 1980.                                 Seniledementia:Treatmentwith deanol. JAm
   1976.                                          9. Goldstein K: The effect of brain damage on             S             1
                                                                                                      Geriatr oc25:241-244, 977.
2. Kay 0, Beamich P. Roth M: Old age mental          the personality. Psychiatry 15:245-260,       16. Often J, Shelley F: When Your Parents Grow
   disorders in Newcastle-upon-Tyne: A study         1952.                                             Old. New York, Funk and Wagnalls, 1976.
   of prevalence. Br J Psychiatry 110:146-158.   10. Feinberg I, Koresko A, Heller F: EEG sleep    17. Cooper IS: Living with Chronic Neurologic
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                             28th Annual Meeting
                       Academyof PsychosomaticMedicine
                                      Dallas,Texas,Novem 1-4, 1981

                  Featuring an informative and exciting program of scientific
             papers and symposiaon the application of psychological, behavioral,
                pharmacological, or medical interventions to the treatment and
            preventionof medical conditions or their sequelae. Major topics include:
            Consultation-liaisonpsychiatry                                 Forensic medicine
            Geriatric medicine                                             Substance abuse and alcoholism
            Biologicalpsychiatry                                                             a
                                                                           Psychoendocrinologynd immunology
            Violence and its psychosomaticsequelae                         Psychosomatic illness in children

                           For complete program and registration materials, contact:
                     Academy of PsychosomaticMedicine 70 West Hubbard Street, Suite 202
                                                       Phone: 312-644-2623
                                   Chicago, IL 60610 •¿

                22@NO 7
JULY 1981 ‘¿VOL                                                                                                                                597

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