brain, spinal cord, and nerve disorders
Dementia
Treatment of Dementia
Management of conditions that may be causing dementia or making it worse Safety and supportive measures Medications that may improve mental function Caregiver care End-of-life decisions For most dementias, no treatment can restore mental function. However, treating disorders that are causing or worsening dementia can sometimes stop or reverse the dementia. Such disorders include an underactive thyroid, a subdural hematoma, normal-pressure hydrocephalus, and vitamin B12 deficiency. When such disorders develop in people who already have dementia, treating them sometimes slows mental decline. For people who have dementia and depression, Medications for Treatment of Depression (such as Pain and any other disorders or health problems (such as a urinary tract infection or constipation), whether they are related to the dementia or not, are treated. Such treatment may help maintain function in people with dementia. Creating a safe and supportive environment can be remarkably helpful, and certain medications can help for a while. The person with dementia, family members, other caregivers, and the health care practitioners involved should discuss and decide on the best strategy for that person. Safety is a concern. A visiting nurse or an occupational or a physical therapist can evaluate homes for safety and recommend useful changes. For example, when the light is dim, people with dementia are even more likely to misinterpret what they see, so lighting should be relatively bright. Leaving a night-light on or installing motion sensor lights may also help. Such changes can help prevent accidents (particularly falls) and help people function better. Doctors may evaluate how well people with dementia function in specific situations, such as while preparing food or driving. If skills are impaired, safety measures, such as hiding knives or taking the car keys away, may be needed. People who have mild to intermediate dementia usually function best in familiar surroundings and can usually remain at home. Generally, theenvironmentshould be bright, cheerful, safe, and stable and include some stimulation, such as a radio or television. The environment should be designed to help with orientation. For example, windows enable people to know generally what time of day it is. Structure and routinehelp people with dementia stay oriented and give them a sense of security and stability. Any change in surroundings, routines, or caregivers should be explained to people clearly and simply. Before every procedure or interaction, they should be told what is going to happen, such as a bath or a meal. Taking time to explain can help prevent a fight. Following a daily routine for tasks such as bathing, eating, and sleeping helps people with dementia remember. Following a regular routine at bedtime may help them sleep better. Other activitiesscheduled on a regular basis can help people feel independent and needed by focusing their attention on pleasurable or useful tasks. Such activities can also help relieve depression. Activities related to interests people had before dementia are good choices. Activities should also be enjoyable and provide some stimulation but not too many choices or challenges. Physical activity relieves stress and frustration and thus can help prevent sleep problems and disruptive behavior, such as agitation and wandering. It also helps improve balance (and thus may help prevent falls) and helps keep the heart and lungs healthy. Continued mental activity, including hobbies, interest in current events, and reading, helps keep people alert and interested in life. Activities should be broken down in small parts or simplified as the dementia worsens. Excessive stimulationshould be avoided, but people should not be socially isolated. Frequent visitsby staff members and familiar people encourage people to remain social. Some improvement may occur if Daily routines are simplified. Expectations for people with dementia are realistic. They are enabled to maintain some sense of dignity and self-esteem. Extra helpmay be needed. Family members can get a list of available services from health care practitioners, social or human services, or the Internet (throughEldercare Locator). Services may include housekeeping, respite care, meals brought to the home, and daycare programs and activities designed for people with dementia. Around-the-clock care can be arranged but is expensive. TheAlzheimer’s Associationoffers a Safe Return program. This program alerts a community support network that can help return people to their caregiver or a family member. Planning for the futureis essential because dementia is usually progressive. Long before a person with dementia needs to be moved to a more supportive and structured environment, family members should plan for this move and evaluate the options for long-term care. Such planning usually involves the efforts of a doctor, a social worker, nurses, and a lawyer, but most of the responsibility falls on family members. Decisions about moving a person with dementia to a more supportive environment involve balancing the desire to keep the person safe with the desire to maintain the person’s sense of independence as long as possible. Such decisions depend on many factors, such as the following: Severity of the dementia How disruptive the person’s behavior is Home environment Availability of family members and caregivers Financial resources Presence of other, unrelated disorders and physical problems Somelong-term care facilities,including assisted living facilities and nursing homes, specialize in caring for people with dementia. Staff members are trained to understand how people with dementia think and act and how to respond to them. These facilities have routines that make the residents feel secure and provide appropriate activities that help them feel productive and involved in life. Most facilities have appropriate safety features. For example, signs are posted to help residents find their way, and certain doors have locks or alarms to prevent residents from wandering. If one facility does not have these and other safety features, transferring a person who develops a behavior problem to a facility that has these features is usually a better solution than using medications to control the behavior. People with dementia can benefit from an environment that is the following: Safe:Extra safety measures are usually needed. For example, large signs can be posted as safety reminders (such as “remember to turn the stove off”), or timers can be installed on stoves or electrical equipment. Hiding car keys may help prevent accidents and placing detectors on doors may help prevent wandering. If wandering is a problem, an identification bracelet or necklace is helpful. Familiar:People with dementia usually function best in familiar surroundings. Moving to a new home or city, rearranging furniture, or even repainting can be disruptive. Stable:Establishing a regular routine for bathing, eating, sleeping, and other activities can give people with dementia a sense of stability. Regular contact with the same people can also help. Planned to help with orientation:A large daily calendar, a clock with large numbers, a radio, well-lit rooms, and a night-light can help with orientation. Also, family members or caregivers can make frequent comments that remind people with dementia of where they are and what is going on. Some people with dementia worsen when they are moved from their home to a long-term care facility. However, after a short time, most people adjust and function better in the more supportive environment. are used to treat Alzheimer Disease and Donepezil,galantamine, andrivastigmineare cholinesterase inhibitors. They inhibit acetylcholinesterase, an enzyme that breaks acetylcholine down. Thus, these medications help increase the level of acetylcholine, which helps nerve cells communicate. These medications may temporarily improve mental function in people with dementia, but they do not slow the progression of dementia. They are most useful in early dementia, but their effectiveness varies considerably from person to person. About one third of people do not benefit. About one third improve slightly for a few months. The rest improve considerably for a longer time, but the dementia eventually progresses. If one cholinesterase inhibitor is ineffective or has side effects, another should be tried. If none is effective or all have side effects, this type of medication should be stopped. The most common side effects include nausea, vomiting, weight loss, and abdominal pain or cramps. Tacrine, the first cholinesterase inhibitor developed for treating dementia, is rarely used anymore because it can damage the liver. Memantine, an NMDA (N-methyl-d-aspartate) antagonist, may improve mental function in people with moderate to severe dementia.Memantineworks differently from cholinesterase inhibitors and may be used with them. The combination may be more effective than either medication alone. If disruptive behavior develops, medications are sometimes used. However, disruptive behavior is best controlled with strategies that do not include medications and are tailored to the specific person. Medications are used only when other strategies, such as changes in the environment, are ineffective and when using medications is essential to keeping the person with dementia and/or others safe. These medications include the following: Antipsychotic drugs : Antiseizure medications : Sedatives(including benzodiazepines such aslorazepam) are sometimes used for a short time to relieve anxiety related to a particular event, but such treatment is not recommended for the long term. Medications for depression , If medications are used, family members should talk with the doctor periodically about whether the medications are really helping. , a dietary supplement, is marketed as a memory enhancer. However, studies do not show any benefit from taking Ginkgo , and in high doses, it may have side effects. Vitamin B12 supplements are effective only in people who have vitamin B12 deficiency Before using any dietary supplement, people should talk with their doctor. Caring for people with dementia is stressful and demanding, and caregivers may become depressed and exhausted, often neglecting their own mental and physical health. The following measures can help caregivers: Learning about how to effectively meet the needs of people with dementia and what to expect from them:Caregivers can get this information from nurses, social workers, organizations, and published and online materials. Seeking help when it is needed:Caregivers can talk to social workers (including those in the local community hospital) about appropriate sources of help, such as day-care programs, visits by home nurses, part-time or full-time housekeeping assistance, and live-in assistance. Counseling and support groups can also help. Caring for self:Caregivers need to remember to take care of themselves. They should not give up their friends, hobbies, and activities. Caring for people with dementia is stressful and demanding, and caregivers may become depressed and exhausted, often neglecting their own mental and physical health. The following measures can help caregivers: Learning about how to effectively meet the needs of people with dementia and what to expect from them:For example, caregivers need to know that scolding about making mistakes or not remembering may only make behaviors worse. Such knowledge helps prevent unnecessary distress. Caregivers can also learn how to respond to disruptive behavior and thus calm the person more quickly and sometimes prevent disruptive behavior. Information about what to do on a daily basis may be obtained from nurses, social workers, and organizations, as well as from published and online materials. Seeking help when it is needed:Relief from the burdens of around-the-clock care of a person with dementia is often available, depending on the specific behavior and capabilities of the person and on family and community resources. Social agencies, including the social service department of the local community hospital, can help locate appropriate sources of help. Options include day-care programs, visits by home nurses, part-time or full-time housekeeping assistance, and live-in assistance. Transportation and meal services may be available. Full-time care can be very expensive, but many insurance plans cover some of the cost. Caregivers may benefit from counseling and support groups. Caring for self:Caregivers need to remember to take care of themselves. For example, engaging in physical activity can improve mood as well as health. Friends, hobbies, and activities should not be abandoned. Before people with dementia become too incapacitated, decisions should be made about medical care, and financial and legal arrangements should be made. These arrangements are called Advance Directives . People should appoint a person who is legally authorized to make treatment decisions on their behalf (health care proxy) and discuss As dementia worsens, treatment tends to be directed at maintaining the person’s comfort rather than at attempting to prolong life. Often, aggressive treatments, such as artificial feeding, increase discomfort. In contrast, less drastic treatments can relieve discomfort. These treatments include Adequate control of pain Skin care (to prevent Pressure Sores ) Attentive nursing care Nursing care is most helpful when it is provided by one caregiver (or a few) who develops a consistent relationship with the person. A comforting, reassuring voice and soothing music may also help. 