Dementia is probably one of the more feared illnesses of old age.
More than almost any other medical condition, it affects not only the patient’s independence, but also their very presence and sense of self.
It also has a significant impact on those around the patient, who have to deal with a loved one who is still often physically able, but unable to take care of themselves properly due to their memory problems.
According to the United Kingdom National Health Service, dementia is actually a syndrome, i.e. a group of related symptoms, associated with an ongoing decline of the brain and its abilities.
It can be caused by a number of medical conditions, of which the most common is Alzheimer’s disease.
Says Universiti Malaya consultant geriatrician Prof Dr Philip Poi: “Alzheimer’s disease is actually one of the diseases that cause dementia, but it is commonly regarded as the one that is most frequently seen as you get older.”
He adds: “We have an increasing number of people who are getting old, and age, unfortunately, is an irreversible risk factor for developing Alzheimer’s disease – the older you are, the more likely you are to get it.
“From 5% of people over the age of 65 to 20% of all those over the age of 80 have a risk of getting cognitive impairment.”
When the brain is damaged
He explains that a person with cognitive impairment has difficulty performing their usual activities due to the damage to their brain.
Most people with such problems tend to first experience short-term memory loss, like forgetting where they just parked their car or what was just said in an ongoing conversation.
Some will start having difficulty finding the right words, while others exhibit problems with planning.
“For example, a lady who used to cook very well now doesn’t cook so well because she can’t plan the meal very well; the man who used to be able to calculate well is now not able to calculate well,” des-cribes Prof Poi.
Some might also start accusing other people in or around the house – like the maid or a family member – of stealing objects that they have misplaced themselves.
As time goes on, the person’s ability to remember, reason, understand and communicate will progressively decline.
Eventually, they will be unable to care for themselves due to their deteriorating memory and inability to understand what’s going on around them.
Unlike most other medical conditions where the patient might be physically incapacitated, but still mentally sound, those suffering from dementia may become easily upset, angry or aggressive – most likely because they themselves are frustrated at their own lack of memory or understanding, or because they are misinterpreting the situation due to their increasing inability to reason or judge well.
They may also act strangely or inappropriately, e.g. getting up in the middle of the night and acting like it is daytime, or going out in their pyjamas.
Their memory loss may result in them forgetting to perform routine activities like eating or cleaning up, or insisting on doing these activities repetitively because they have forgotten they have already done them.
They might also forget the people around them and treat them as strangers, or wander out of the house and getting lost.
This often becomes very wearing, worrying and frustrating for those around them, especially their primary caregiver.
No cure, just care
Unfortunately, there is no cure for most of the common conditions that cause dementia, although certain medications can help enhance the patient’s ability to concentrate and understand what is going on around them, i.e. helping to mitigate their short-term memory loss, says Prof Poi.
More importantly, he notes that the patient’s family and caregivers can help improve the patient’s quality of life by understanding the nature of the disease, and tailoring their reactions appropriately.
For example, he says that as dementia patients have difficulty remembering and learning new things, there is no point trying to get them to do an unfamiliar task, even though it might be something very simple.
“It’s important for us to try to focus on how we can improve the quality of life through changing our behaviour towards that person.
“That means trying to avoid confrontations, avoid arguments and avoid ‘scoldings’,” he says.
A mix of dementia
While the prognosis for dementia might sound quite grim, Prof Poi says that dementia cases are “not ‘fated’, you can actually alter it and reduce the risk of it being accelerated”.
He was referring to the increasing number of patients who are being discovered to have mixed dementia – usually a combination of Alzheimer’s disease and vascular dementia.
“They thought about 60-80% of cases were due to Alzheimer’s, but they are seeing now more and more patients with a mixed picture, especially in Asia where we have a high percentage of people who smoke, who have uncontrolled blood pressure, (and) who do not look after their diabetes properly, so that the vascular issues are much more prominent in the Asian population.”
Vascular dementia by itself is also the second leading cause of dementia in the world.
This form of dementia is actually caused by white matter disease.
White matter disease starts off when the small blood vessels that supply the brain’s white matter harden as we age, resulting in a decrease in the supply of nutrients and oxygen to these areas of the brain.
The affected areas then become fibrosed, or scarred, resulting in white matter lesions that are more likely to cause electrical miscommunication within the brain.
These white matter lesions are a common finding in the magnetic resonance imaging (MRI) brain scans of older people, and were once thought a natural artefact of increasing age.
However, doctors now suspect that this condition is a cause of vascular dementia and silent strokes.
According to a 2014 ScienceDaily article, which cited materials from the British Psychological Society, white matter disease is a contributing factor in up to 45% of dementia cases and is responsible for about a fifth of all strokes worldwide.
Slowing it down
The effects of vascular dementia can actually be mitigated by lifestyle changes.
Says Prof Poi: “So, actually, one of the advice I give to people who come to me (for dementia) is that they have to control and look after their blood pressure and their diabetes if they have those problems, because those two issues can contribute to and worsen the memory loss, even if it is thought to be Alzheimer’s dementia.
“The vascular issues can cause and worsen the memory issues.”
High blood pressure, diabetes and smoking, which are common in our population, all contribute towards arteriosclerosis – the thickening and hardening of our artery walls.
So, controlling blood pressure, diabetes and smoking all help towards decreasing white matter disease, and thus, vascular dementia and its resulting symptoms.
In addition, research into tocotrienols – one of the two types of vitamin E – has shown promising results in terms of protecting the brain against further development of white matter lesions.
One such clinical trial was conducted at Universiti Sains Malaysia and published in the journal Stroke in 2014.
The trial involved 121 volunteers, all of whom had cardiovascular risk factors and white matter lesions, who were divided into two groups.
One group took 200mg of mixed tocotrienols in pill form twice a day, while the other group was on a placebo.
The first group showed no further significant growth of their white matter lesions after two years of taking tocotrienols, while the placebo group had an average 23.3% increase of their white matter lesions by the end of the same period.
Prof Poi explains that this is probably due to the effect tocotrienol has on glutamate.
The release of glutamate is a contributing factor in cell death.
When cells die normally, the body is able to remove the glutamate using the body’s supply of glutathione.
However, in white matter disease, too many cells are damaged and the amount of glutamate released tends to overwhelm the body’s supply of glutathione, resulting in more damage to the affected area.
Tocotrienols, which are a common dietary supplement and found naturally in palm oil, help to reduce the amount of glutamate in such situations.
We can’t cure Alzheimer’s, says Prof Poi, but we can try to control these other factors that affect vascular dementia in order to prevent the condition from progressing too quickly.