Dementia affects one in ten Singaporeans aged 60 and above, and one in two for those aged 85 and above, according to a study by Singapore’s Institute of Mental Health. Not just a medical condition to be treated, dementia takes a huge financial and emotional toll on those involved. Another study conducted on monetary cost of family caregiving for people with dementia in Singapore by Lai, Thompson and Magadi in 2017 revealed the cost for dementia care to be a staggering amount of S$2.8 billion, and estimated to triple by 2030. Apart from financial burden, 3 in 4 people with dementia report feeling lonely and isolated, while their families struggle to handle the change of personality and a tendency to increased aggression in their loved ones. Dementia awareness, early intervention and support therefore are key in helping sufferers and their families navigate the battle against the disease.
We approached A/P Dr. Aaron Ang - Senior Consultant and Former Head of Department of Psychological Medicine, Tan Tock Seng Hospital for an interview to better understand dementia disease, how to identify dementia symptoms early, dementia treatment and dementia care options in Singapore.
Dementia is the progressive loss of cognitive functions such as remembering and thinking. It occurs when there is damage to or loss of brain cells and their connections in the brain. These changes may lead to psychological and behavioural changes which interfere with a person’s daily activities. Although memory problems are most common, dementia can cause other symptoms depending on the brain area that is affected by the damage.
The types of dementia are related to the different causes of damage or loss of the nerve cells in the brain. The commonest types of dementia include Alzheimer’s disease, vascular dementia and Lewy body dementia.
Alzheimer’s disease, the most common cause of dementia among the above three types, leads to the accumulation of breakdown products of the brain cells. These breakdown products are seen as amyloid plaques and neurofibrillary tangles under a microscope. Plaques are clumps of beta amyloid, and fibrillary tangles of tau protein. Together, they are thought to damage healthy nerve cells. Patients with Alzheimer’s disease progressively lose their memory and thinking skills, and eventually their ability to carry out simple tasks.
In vascular dementia, brain damage happens as a result of loss of blood vessels that supply blood to the brain, often as a result of stroke disease. Some of these strokes are silent and patients do not present with obvious weakness or numbness. Common symptoms of vascular dementia include issues with problem solving, focus, organisation and slowed thinking. Patients may also have low mood and depression.
Lewy body dementia is the type of dementia related to Parkinson’s disease. The accumulated breakdown products in this case produce abnormal balloon-like clumps of protein termed as Lewy bodies found in the brains. Apart from the symptoms of Parkinson’s disease, patients experience visual hallucinations and problems with focus and attention.
Although the risk of dementia increases with aging, especially after 65 years, it is important to understand that dementia is not part of normal aging. Also, dementia can occur in younger people, though less common.
There is no sure way to prevent dementia. What we can do is to manage the risk factors of dementia, by maintaining overall health through a healthy diet and staying physically active. Engaging in social interaction and physical activity in addition to mental activities such as reading, solving puzzles and memory training may delay the onset of dementia and reduce dementia symptoms. Quitting smoking can improve your health, reduce your risk of vascular conditions and dementia. If you have pre-existing health conditions such as diabetes, sleep apnea, depression and anxiety, seek a doctor for treatment.
Dementia itself does not cause death. However, in the late stage of this illness, the person may pass away from common concomitant medical problems like chest or urinary tract infections. It is important to look out for these risks when caring for dementia patients, especially in dementia home care.
It is easy to miss early symptoms of dementia and therefore miss the chance for early intervention. While some of the symptoms are easier to spot, such as delusion, visual hallucinations, anxiety or depression, others such as difficulties with communication, reasoning, problem solving, coordination or handling complex tasks at the mild dementia stage can be mistaken for problems of the aged. The subtle difference to look out for is that a person with dementia often has trouble recalling recent events but no such issue remembering things from a longer past. For example, they don’t remember if they have taken a meal, where they put their keys and wallets, or ask the same question repeatedly. Symptoms worsening over time is another sign of pathological forgetfulness that may relate to dementia. Night wandering and sleeplessness are also quite common.
If you or your family member are experiencing memory issues, see a doctor as soon as possible for early assessment. Dementia symptoms may also be caused by other treatable medical conditions, therefore it is important to determine the underlying cause.
There is no single test for dementia. Dementia needs to be diagnosed by specialists through a combination of testing and examination, including:
In Singapore, you can go to Khoo Tech Puat Hospital, Institute of Mental Health, Changi General Hospital, Tan Tock Seng Hospital, National University Hospital or Singapore General Hospital to test for dementia. You can also get screened at community medical clinics first before going for intensive tests at hospitals. But get screened only if there are cognitive or behavioral dementia symptoms. Dementia screening should not be done for everyone.
Treatment depends on the identified cause. For dementia patients in mild to moderate stages, doctors can use a combination of medications and therapies to manage the symptoms and behavioural problems, slowing down deterioration of the disease and promoting memory and recall of events. In some cases where dementia causes are treatable such as infections, hormonal problems or just nutritional deficiencies, doctors will treat these reversible causes first before tackling the irreversible ones. Unfortunately, progressive types of dementias cannot be cured.
When patients are first diagnosed, they can experience feelings of anger, fear, and anxiety. The first thing families can do is to provide emotional support to help their loved ones overcome this stage. Subsequently, beware that certain lifestyle changes are due to come with dementia. Dementia sufferers need a hard-to-miss daily routine and lots of safety measures at home. As the disease progresses, they would need even more help, supervision as well as empathy.
In terms of long-term treatment, doctors often schedule periodic follow-up visits to monitor medicines and the patient’s level of brain functioning. Unless there is an emergency situation, the rest of the care happens at the patient’s home or place of residence. Dementia caregivers therefore play a very important role in caring for dementia patients. The pressure and stress on them can get overwhelming. It is advisable for caregivers and families to get the necessary training and support from community organizations, professional services and care providers, such as Alzheimer’s Disease Association (ADA tel 63770700).
Since the disease often progresses slowly, dementia diagnosis would give the patient and family an opportunity to plan and prepare for the slow and gradual decline of the person's cognitive function. The doctor would be able to help guide the patient and family with the medical as well as the psychosocial aspects of the illness. This would also include negotiating testamentary issues, mental capacity and appointing a donee or deputy, for example Lasting Power of Attorney.
The best option is to care for the person at home, because persons with dementia do best in a familiar environment. They can attend day activities depending on the level and severity of dementia. However, as the illness progresses, there are options for specialized carers, dementia day care centres, and as a last resort, nursing homes.
By the time the symptoms of dementia manifest, there is already significant damage to the brain. As such, I believe future treatments in dementia would have a 2-pronged approach. Firstly, tests and investigations would be made available to predict who will develop dementia. Secondly, such high-risk persons would be started early on medications to arrest or even reverse the damage to the brain cells.
Until then, technology to monitor the dementia sufferers’ activities, health status, sleep and waking pattern, mood and behaviors may be crucial for appropriate prescription of medication and other therapies. There are also solutions available for 24/7 dementia home monitoring, helping family and caregivers. I believe these solutions are going to get better with medical and technological advances.
The daughter of a dementia sufferer once told me that looking after her father was not only the least she could do for someone who sacrificed so much to bring her up, but also rewarding for her as it was a way to repay him for the many years he had cared for her.
As such, my advice to family members would be that, as challenging it will be, it can be the opportunity to provide your loved one with the care he or she would deserve.