Case Study: Appropriate Care for an 80 Year Old Man from India with Dementia

Introduction

A number of studies have reported relatively low incidence of Dementia in both rural and urban India. As is well known, age is the single most risk factor for developing dementia. The life expectancy in India is lower than in the western countries according to the recent World Bank figures. But as the life expectancy in India rises and so should the incidence of Dementia.

Case Presentation

I have known of an 80 years old business man in India who started with memory loss a couple of years ago and was diagnosed with dementia. I had followed his progress with the disease. In the past year he started wandering, he would insist on keeping his books at his place of business that he had much difficulty with and had to be carefully supervised. His disease progressed to a degree that he lost appetite, aspiration of food started causing recurrent pneumonia requiring hospitalizations. At his last hospitalization, he was given multiple antibiotics, a nasogastric tube was inserted to provide feeding and hydration. Patient at this stage was poorly cognizant of his surroundings, did not recognize his family members and did not respond to verbal commands.

What is an appropriate approach to his care at this stage?
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Definition of Dementia:

Dementia is characterized by progressive loss of memory that is sooner or later accompanied by impairment of the executive function. As a result, the patient is unable to perform well learned activities such as book keeping, driving, using the telephone etc. Ultimately there is loss of ability to do even the routine daily activities e.g. bathing, dressing, feeding self-etc. In later stages, incontinence develops both of bowel and bladder. Behavior issues such as wandering, falls, agitation, hallucinations, delusions, paranoia and changes in circadian cycle complicate management. Patients lose their appetite due to loss of taste and smell accompanied by swallowing difficulties, loss of weight and onset of frailty. At this late stage of the disease, patient usually needs 24-hour personal care. The median survival from the time of diagnosis is usually around 5 years, reported in the literature. The death usually ensues from infection of one kind or another (aspiration pneumonia, urosepsis etc.). The other cause of death is a major bodily injury such as a hip fracture or trauma to the head from falls.

Assessment of Cognition:

There are a number of scales available to assess cognition (Mini-mental State Examination or MMSE; Montreal Cognitive Assessment Scale or MoCA; Mini-Cog or a shorter version of the MMSE; Saint Louis University Mental Status Examination scale or SLUMS and others). Mini-Cog is easy to administer and least time consuming. It has also been shown to have good predictive value. It is beyond the scope of this paper to review in detail all the scales mentioned.

Mini-Cog is done as follows:

  1. 3-Word Registration. Give the patient 3 words (these should be unrelated such as cow, pencil and street). Ask him to repeat after you and then remember the 3 words.
  2. Clock drawing. Draw a circle like the face of a clock and have the patient fill in the numbers. Then to draw small and the long hands to indicate time (e.g. 11.10)
  3. Delayed Recall (now ask the patient to repeat the 3 words he or she was asked to remember).

For each correct response patient is awarded one point.

Severity of Dementia:

Severity of dementia has been defined in a number of ways including by MMSE or SLUM scores. More important however, is to define the severity of dementia by functional impairment e.g. inability to ambulate, feed or dress by himself, by onset of behavior issues such as wandering, agitation etc. and by dementia related complications such as falls, pneumonia, swallowing problems, urosepsis or incontinence. Higher the severity of dementia, higher the caregiver needs and more the need for additional medications (control behaviors, treat infections).

At this stage of the disease, patient often requires institutional care or 24-hour personal care.

Drug Treatment:

Acetyl cholinesterase Inhibitors (ACHE-I) – Donepezil, Rivastigmine and Galantamine and Memantine (a N-Methyl-D aspartate or NMDA receptor antagonist). These drugs have only marginal beneficial effect in reducing care giving issues. Memantine is usually reserved for moderate or severe dementia and given in combination with an ACHE-I. These drugs are only approved for use in Dementia of the Alzheimer type.

Additional medications may be necessary from time to time to treat the complicating illnesses. Patients with concurrent illnesses such as Diabetes, Coronary artery disease, Hypertension etc. will need to be treated appropriately.

It should be noted that there are no approved drugs to prevent or delay the onset of dementia.

Drugs with Cholinergic side effects (such as Diphenhydramine) are best avoided. These drugs cause increasing confusion and delirium in patients with dementia.

Abnormal Behaviors in dementia:

Agitation-verbal and/or physical, wandering or pacing, mood disorders especially anxiety and depression are common at any stage of the disease but even more so in moderate or severe dementia. As much as possible these should be treated by non-pharmacological means and the antipsychotic drugs (Quetiapine, Haloperidol, Resperidone and others) avoided unless patient becomes a risk for injury to himself or others. Pain and depression are common concomitant symptoms and should be addressed appropriately and may lead to control of the abnormal behavior. Infections especially in the urine are common in these patients and should be ruled out if there is new onset of an abnormal behavior.

Caring for a patient with End Stage Dementia:

This is the stage of the disease when dementia should be considered a terminal disease. Only comfort care measures are appropriate. The consideration is given more to the patient’s quality of life and not to prolonging life. Resuscitation by chest compressions, ventilator support, insertion of a feeding tube, urinary catheter (unless needed for another reason) should be avoided.

This can only be achieved by educating the family and referral to hospice or similar organization.

Our patient:

At the last hospitalization, patient required prolonged intravenous therapy, I.V. antibiotics, insertion of a nasogastric tube for feeding and hydration. Despite these supportive measures, patient continued with fever and persistent pneumonia confirmed by chest x-ray and hypotension. He was also intubated and placed on a ventilator. Permanent tracheostomy was considered. The ominous prognosis was obvious. After further consultation with the family, these measures were discontinued, and patient brought home where he died a couple of days later with the family on the bed side. It would have been best for the patient and the loved ones if these interventions were not instituted in the first place.

About The Author

PL AroraDr. P. Lal Arora is a practicing Geriatrician in Lorain County, Ohio (USA). He is the Medical Director of Kendal, Northern Ohio. He is a graduate of Medical College, Amritsar, Punjab University and did his postgraduate training in Internal Medicine, Pulmonary Diseases and Geriatrics in the US. He is Board certified in these specialties and is also a Fellow of the Royal College of Physicians of Canada.

 

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