The following article is adapted from a talk on dementia by Dr Prof Aaron Ang. He is currently the Adjunct Associate Professor at NUS-YLL School of Medicine and LKC-NTU School of Medicine, and a Senior Consultant Psychiatrist in the Department of Psychological Medicine, Tan Tock Seng Hospital. Dr Ang’s clinical interests include the Psychiatry of Old Age, Mental Capacity Assessment, and the Psychiatry-Medicine interface. As a Psychiatrist and a former HOD, he believes in holistic care, as well as the need for collaboration at intra- and interdepartmental levels.
We will be covering why dementia can be seen as a brain failure, the challenges in finding a cure for this disease, why it is important to be able to recognise its early signs and symptoms, and how to get diagnosed and treated for dementia.
Table of Contents
1. Dementia can be Thought of as a Brain Failure
When the vital organs such as the heart, liver or kidneys fail to function optimally, doctors recognise the symptoms and are quick to diagnose them as “heart failure”, “liver failure” or “renal failure”. Similarly, dementia can be thought of as a brain failure. The loss of brain function, however, is often profoundly more debilitating.
Firstly, one’s mind is inextricably linked to the self and one’s identity. As such, failure of brain function can lead to the loss of self and identity changes. People with dementia may act differently, become depressed or withdrawn, and over time, lose the ability to manage their most basic activities of daily life. This has a massive psychological impact on the patient as well as their family and caregiver.
Secondly, there remain challenges in finding an effective dementia treatment, as we will discuss later in this article. Available medications aim to manage dementia symptoms and slow down the progress of the disease. But there is yet a solution to reverse the loss of cognitive functions. Brain failure in the case of dementia is progressive and permanent. Until a cure is found, early detection offers another avenue to fight dementia.
2. Dementia Affects 10% of the 60+ Population in Singapore, More Women than Men
A robust local population study in 2015 done by IMH researchers found that the prevalence of dementia in Singapore is about 10% among those aged 60 years and older. The chances of dementia increase exponentially with age and double every 5 years after the age of 65. As the population ages, the number of people with dementia in Singapore is expected to increase, estimated to be 187,000 by 2050. Though old age is the most common risk factor of dementia, other factors can contribute to triggering the condition, such as genetics, obesity, diabetes, high cholesterol and other medical conditions.
Worldwide, more women are affected by dementia than men, especially after the age of 80. Moreover, they tend to develop more severe symptoms of dementia than men. One of the reasons is that women live longer than men. The role of gender in dementia is a topic of interest to researchers, as it can potentially help to uncover different ways to lower the risk of developing dementia and managing the condition in each gender.
3. Finding a Cure for Dementia
Let us imagine the brain as a factory. The factory is made up of the workers, i.e., the brain cells. Internally, the factory can be at various levels of health. However, externally, the health of the factory can be superficially measured by its ability to maintain a viable level of production.
In a well-run factory, there is sufficient spare capacity such that the factory can maintain production regardless of transient fluctuation in the productivity of individual workers. For instance, if some workers retire or quit their jobs, production is not affected. This is what happens with a normal ageing brain. Despite ageing-related cell loss, adequate reserves are available to maintain production.
However, if the factory is not running well, and starts laying off its workers through retrenchment after retrenchment, its reserve gets overwhelmed. Very soon the production cannot be maintained. In a similar manner, the brain affected by dementia loses its workers so fast that it cannot continue normal efficient functioning. This comparison explains the phenomenon of a shrinking brain and how cognitive functioning is affected.
In this light, finding a cure for dementia involves a two-prong approach:
- Finding Disease Modifying Agent (medications) that can arrest disease progression and/or “reverse” the degenerative process, i.e., stopping the ‘workers’ from quitting en masse and taking back control of production output.
- Early Detection: to detect the disease before significant damage is done. i.e., catching the signs of workers leaving the factory and preventing or delaying it from happening.
4. Why is it Challenging to Find a Cure for Dementia?
Now that we have a clear approach to treating dementia, what stands between us and a cure?
Firstly, it is not a disease with only one cause. There are many possible causes of dementia, such as Alzheimer’s disease, Parkinson’s disease, stroke, vascular diseases (more about these causes in our article here). Thus, development of multiple effective treatments is required. However, our biomedical system is designed to develop and test one drug at a time.
As far as diagnosis is concerned, there are challenges to accurately diagnose dementia. The crucial requirement for the development of therapies is an accurate diagnosis. Only when we identify with confidence and precision who has and who does not have the disease can we begin the development of the effective drug.
5. How to Spot the Early Signs and Symptoms of Dementia?
Let us now discuss the second prong of the above approach to treat dementia – early detection of the disease. The challenge is that the early signs of dementia are often not obvious. The patients themselves, family members and caregivers often fail to recognise these symptoms as they mistakenly assume that these changes are a part of the normal ageing process. Thus, these symptoms may go unnoticed for a long time.
To aid with identifying dementia early, it is crucial to be able to distinguish between normal age-related and dementia-related behaviours. Below are the common signs and symptoms of dementia, with comparison to similar behaviours in a normal ageing individual where possible:
- Progressive and frequent memory loss of recent events: It is normal to forget events and remember them later. However, a person with dementia may forget events frequently and not remember them at all. The memory loss is significant enough to have an impact on the ability to carry out day-to-day activities.
- Language difficulties, e.g., troubles finding the right word and understanding conversations. We can all be tongue-tied occasionally. The difference with a dementia-affected person is that the issue happens with very common words rather than complex words and discussions. Losing the train of thought mid-sentence or mid-conversation could be another related symptom.
- Difficulty planning and thinking logically: Dementia can lead to poor judgement. Pay attention when your loved ones make ‘unusual’ decisions, for instance, wearing thick layers of clothes on a hot day.
- Misplacing things: It is normal to misplace your wallet or phone from time to time. However, a person with dementia places the items in places where they should not be, for example, an handphone in the freezer.
- Difficulty processing visual and spatial information: For instance, a person with dementia may start to have problems judging distance when driving or parking a car, finding it difficult to climb a staircase or recognising objects.
- Disorientation to time and place: As dementia progresses, the affected person may feel confused about what day or time it is or where they are even in familiar places.
- Changes in mood or behaviour: It is normal to become upset or moody sometimes. However, a person with dementia may display rapid mood swings for no obvious reason. They may become confused, suspicious, depressed or withdrawn from their surroundings.
- Other signs and symptoms of dementia include: Increasing confusion, loss of concentration, changes in personality, difficulty performing daily familiar activities (preparing a meal or getting dressed), loss of interest in previously enjoyed activities, tremors, difficulty balancing, hallucinations, delusions
It is important to visit a doctor when you notice these signs and symptoms in yourself or your loved ones for professional evaluation.
6. How is Dementia Diagnosed
Diagnosis of dementia for someone with dementia symptoms involves a series of steps. There is no single test that can confirm or disconfirm the disease.
The first step is to rule out other medical causes
There are many conditions that have symptoms similar to dementia. If you notice the above symptoms in yourself or loved ones, do not immediately assume dementia. Endocrine disorders such as thyroid disease, autoimmune conditions, infections, neurological conditions and others all cause dementia-like symptoms and these conditions can be treated. Psychiatric conditions such as depression can also mimic dementia in symptoms exhibited.
Once the doctors have identified a number of possible causes, an investigation is carried out to check for possible illnesses responsible for the symptoms. Possible tests include:
- Full blood count: To investigate for anaemia, infection, electrolyte imbalance, liver function, thyroid function.
- Renal panel: Kidney function test
- Liver function test: Abnormal liver function or abnormal levels of liver enzymes are associated with dementia.
- ESR / CRP: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are indicative of inflammation in the body. Many forms of dementia are characterised by inflammation in the brain.
- Vitamin B12 / Folate: Symptoms of dementia can mirror the symptoms of a vitamin B12 deficiency. Unlike dementia, vitamin B12 deficiency is reversible.
- Thyroid Function Test: To screen for any thyroid abnormalities since thyroid dysfunction is associated with cognitive impairment and dementia.
- Syphilis screening (if indicated): Certain infections such as HIV and syphilis are known to cause dementia.
- Chest X-ray
- ECG (Electrocardiogram): Dementia affects not just the brain but the entire body, including the cardiovascular system. ECG findings that support a diagnosis of dementia are the slow alpha activity and an increase in slow frequency activity.
- Neuro-imaging e.g. CT head/ MRI brain: A Computed Tomography (CT) scan of the head or a Magnetic Resonance Imaging (MRI) of the brain looks for a treatable cause of dementia or the presence of atrophy in the brain.
- PET scan where indicated: Advanced Positron Emission Tomography (PET) scan can confirm the presence of amyloid plaques and tau protein in the brain – substances that are believed to play a central role in the development of dementia.
Although patients are often not required to go through all the above steps, as you can see, dementia diagnosis can be a complex, time-consuming and costly process. The good news is, in many cases, the cause is not dementia and the condition is treatable.
7. An Effective Dementia Treatment: Are We There Yet?
There is currently no cure for dementia. Current medications and therapies aim to manage dementia symptoms and slow down its progression. These include anti-dementia medications and other treatments to optimise the function of the brain cells by reducing the overwhelming cognitive capacity and maintaining optimal function of the brain.
In the context of Singapore and Asia, conducting and participation in research is important for us to understand dementia among Asians. Our current knowledge of the disease is mostly derived from studies on non-Asian populations. We are yet to know if there are differences on the biological level that would make treatment of dementia in Asians different, and therefore more effective.
Coming back to the analogy of the brain as a factory above, today’s treatment of dementia can be understood as a ‘workaround’ to help the factory maintain its production. Eventually, even with the presence of highly productive workers, the factory will one day be overwhelmed. But it is our hope that before long, there will be an effective cure to truly restore the factory’s production to its viable level.
8. The Role of Family Physician
You may ask, which doctor should I go to if I see signs of dementia, a psychiatrist, a family doctor or someone else? Our general advice is to visit your family GP first as dementia-like symptoms can be caused by other medical conditions rather than dementia.
Family doctors often know what other conditions or comorbidities the patient has and understand the family and their social background. As for dementia care, they can conduct the initial examination and then refer the patient to a specialist for diagnosis and ongoing management of dementia.
As the first line of defence in patient care, family physicians play a special role through the course of this illness. They can:
- Work with the patient to reduce risk factors: Managing co-existing medical conditions (e.g., hypertension, diabetes, obesity, depression) and/or unhealthy lifestyle habits which can worsen dementia and the patient’s health. The GP doctor can also help the patients seek holistic care to improve the management of dementia and their overall well-being.
- Guide patients and families through the course of this illness and prepare them psychologically for what is coming next, the type of treatments and the care needed as the disease progresses. More about the progression of dementia through stages and what to expect in our dedicated article here.
When dementia advances to the late stages, a patient would typically require:
- A dedicated caregiver to provide support with daily activities such as bathing, eating, dressing, etc.
- Palliative or end-of-life care to relieve symptoms for the patients and the care burden on the caregiver and family.
- Lasting Power of Attorney (LPA) to appoint a trusted person to act on behalf of the patient when he/she is unable to do so due to dementia.
- Advance Care Planning (ACP), to plan ahead the type and level of care the dementia patient desires in the future.
9. Takeaway message
From developing a vaccine for Alzheimer’s disease, to gene therapy that aims to inhibit the production of amyloid protein, scientists all over the world are hard at work to find an effective treatment for dementia. While waiting for the good news on that front, we can play our part by raising awareness of the signs and symptoms of dementia, helping with early detection of the disease. Though not yet a silver bullet, by catching these early signs of dementia, with the help of family doctors, psychiatrists and other specialists, together we can push back the decline of the ‘brain factory’ for this debilitating condition.