Kelly Asks…. Do you know these facts on Dementia?

Kelly Asks…. 

Do you know these facts on Dementia? 

The term dementia on its own, is not a specific disease. It is an umbrella term used to describe a variety of disease processes, involving damage to the brain that impact a persons overall cognitive function. 

What does this look like for the person? 

The damage occurring to the brain can change a person’s ability to process and interpret information, their ability to plan and carry out everyday activities of daily living, their mood, feelings, judgment and insight. At the end of the day, the person is no longer capable of living independently and requires the support of others. 

Dementia, known as the “Silent Creeper” is progressive, slow and insidious meaning, changes are gradually occurring over time. There are many different types of dementia including Alzheimer’s disease (being the most common) Vascular dementia, mixed (Alzheimer’s and Vascular dementia combined), frontotemporal and Lewy Body to name a few. Although these types of dementia may be more common to us, to date, there are over 120 different types of dementia currently affecting individuals. It is important for us as care providers to understand the specific type of dementia diagnosed as this will indicate the area of the brain being impacted by the disease.

The impact of dementia?

We can all appreciate how devastating the impact of a dementia can be not only for the person experiencing the changes, but for us as care providers. Supporting someone living with a dementia can be both challenging and heart breaking at the same time. As care providers, we struggle to engage with our loved one, friend, neighbour or colleague. We no longer recognize who they have become and why they may be responding to us, or a particular circumstance in a negative way. Is there something we can do differently? Is there an opportunity for a greater understanding of the disease process, an opportunity for a new care approach, based on these changes within a person?

What are the 8A’s of Dementia? 

In this segment, I will introduce the 8A’s, review one “A” at a time and discuss opportunities for enhanced care strategies.

The 8 A’s of dementia represent damage that is occurring within a specific region of the brain, as a result of the disease process. Each “A” represents the nature of the deficit associated with the specific function of the brain. It is important to understand that although there are 8A’s, this does not mean that a person living with dementia will experience all 8 A’s at one time. The person may experience one or two initially and as the disease progresses, experience another “A”. It is also important to be made aware that there is not a specific sequence in how a person will experience them.

The 8 A’s include;

Amnesia

Aphasia

Agnosia

Apraxia

Anosognosia

Altered Perceptions

Apathy

Attention Deficits

1. Amnesia

Amnesia is associated with memory loss and involves the temporal lobes of the brain. In dementia, short term memory is lost first, long term memory secondary and lastly sensory memory. Within our long-term memory, we have both declarative and procedural memory. Declarative memory is our factual storage center, everyday facts about life and the world. For example; todays date, or the name of a place. Procedural memory is our “How to” storage center. Something we have learned to do at a young age and have repeated it thousands of times. For example, tying our shoes, learning to feed ourselves, brushing our teeth, or dressing ourselves. Out of the declarative and procedural storage centers of long-term memory, it is procedural memory that will be retained and declarative memory that will be lost by the person living with dementia. The reason being, the person living with dementia is reverting to younger years and younger life experiences as the disease progresses. As a result, their “here and now” does not match ours and therefore those everyday facts about life and the world are no longer relevant. 

Things you may observe?  

• Repetition of questions/comments; “Where do I go”, “What do I do”?

• Forgetting that they have just eaten.

• Getting lost in what was once a familiar place.

• Difficulty identifying the day/month.

• Forgetting appointments

• Forgetting to complete personal care.

• Forgetting what they saw or just heard.

What can be helpful?

• It’s important to recognize that the person is living “in the moment.”

• Living in the moment with them and providing reassurance is key

• Avoid arguing, or statements such as; “Don’t you remember”?

• If the person is asking to go home, or for a loved one that has passed away, instead of stating; “This is your home”, or “they passed away remember”? try; “Tell me about your home, or tell me about your husband, wife, partner” etc.…

2. Aphasia

Aphasia is the loss of language. There are three types of aphasia; expressive aphasia- our ability to communicate to others, receptive aphasia- our ability to process information and lastly global aphasia- a mix between both expressive and receptive aphasia. The lobes of the brain responsible for this function are our temporal lobes. The person living with dementia may have difficulty communicating their thoughts or feelings however, still have the ability to understand what you are communicating to them. Alternatively, the person may struggle to understand the message you are conveying to them, however, can articulate themselves to you and, or others. In the event the person is experiencing global aphasia, they will struggle to readily communicate their message, as well as comprehend and process information given to them. It is important to be made aware that a person in early stages of a dementia will miss one out of every four words spoken to them, in moderate to severe stages, they will miss two to three out of every four words spoken and by end stages of the disease, all four words will be lost. Another important fact is that although it is not known why, what is known is that dementia affects the left side of the brain first and the right side of the brain last. Therefore, the person living with dementia will lose functions of the brain housed on the left side and retain functions of the brain housed on the right side. What does this mean? Functions on the left side include reading, writing, speech, language, comprehension and basic arithmetic skills. Functions on the right side include music, dance, rhythm, poetry and unfortunately sex talk, swear words and racial slurs. This is the reason why a person could become frustrated or appear not to understand what it is you are telling them, but in turn can play a beautiful piece of music or sing every lyric to a specific song if it was part of their life experience. Alternatively, it could also be the reason why a person has an inability to tell you what they need however, will swear at you quite clearly.

Things you may observe? 

• Word-finding difficulties.

• Not participating in conversations.

• Returning to their first language.

• Has difficulty writing/reading

• Words are not within context of the conversation.

• Misunderstanding of your intention as a care provider

• Frustration and upset.

What is helpful?

• Use simple instructions or directions

• Allow the person time to respond

• Use visual cues as much as possible

• Use gestures to mimic the task you are helping them complete

3. Agnosia

Agnosia is the loss of recognition of sensory information- sight, sound, touch, smell and taste. The person living with dementia has lost the ability to identify an object and its purpose, or use. They may no longer recognize themselves when looking in the mirror or recognize those once closest to them. For example, spouses may become strangers, or children may become siblings. The person may also loose recognition of places that were once familiar. Agnosia can occur across all the 5 senses, what is seen, heard, touched, smelt and tasted. For example, the person may not recognize the sound of a car horn and attach the meaning of a warning signal, or the sound of a fire alarm indicating danger of a fire. The person could also struggle in identifying a particular location. The areas of the brain responsible for this function are the temporal lobes.

Things you may observe:

• Inability to attach meaning to what is seen & heard;

• Inability to recognize people including themselves; and ,

• Misidentification of objects and their uses.

Examples: The person may be seated at the breakfast table, however, just holds the spoon or fork in their hand. The person may begin pouring their glass of juice into their cereal bowl, begin brushing their hair with a toothbrush, or begin brushing their teeth with a hairbrush. 

What can be helpful?

• Keep the environmental stimulation to a minimum;

• Provide visual cues surrounding tasks

• Help get them started in the task

• Be aware of their dominant side

• Give the person one item at a time

• Cover, or remove mirrors

4. Apraxia

Apraxia is the loss of ability to initiate purposeful movement. The person living with dementia will have difficulty initiating and sequencing through a series of steps required, in order to complete a task. An example of this could be that you are walking with the person and you ask them a question, “What would you like for lunch”? The person will then stop to answer you. The problem being is that the person will then become “stuck” unable to resume the task of walking. The reason for this is that the person experiencing apraxia is unable to shift from one task (respond to the question)and then shift back to the original task (resume walking). In order to re-initiate a task, the person requires cueing and assistance from the care provider. In the example given, this would include the care provider taking large, exaggerated steps beside the person to cue them in initiating the purposeful movement involved in the task of walking. The areas of the brain responsible for this function are the temporal, frontal and parietal lobes. Additional examples can include, the person maintaining the ability to take themselves to the bathroom, however, misses the step of pulling down their pants before sitting on the toilet. The person goes to get out of bed, however, misses the step of removing the covers before getting up, gets caught up in the covers, slips and then falls. The person sits down to eat a meal, however, is unable to initiate the task of eating. The person has difficulty with instructions such as “up and down”, “sit and stand”. The person retains the ability to dress themselves, however, misses the sequence of the order and which item goes on first. As a result, you may see the person place their underwear over their pants, or bra over their shirt.

Things you may observe:

• Has difficulty understanding basic directions such as “up”, “down” and “please sit here”.

• Has difficulty dressing themselves; and,

• Has difficulty coordinating hand and leg movements

What can be helpful?

• Hand one item at a time

• Laying clothing out in the order of what goes on first

• Provide cueing in order to help the person get started on a task

• Be aware of dominant versus non dominant side

• Provide visual cues

Examples: Pictures of steps needed to complete a task, the use of reminders within the home, or person’s room

5. Anosognosia

Anosognosia is the loss of ability to realize there is anything wrong. “They don’t know what they don’t know, and they forget that they forget”. The person experiencing anosognosia can be difficult to care for as they do not have any insight into the fact that they require assistance and support and are no longer able to do the things they once were able to do. The person may still believe that they have the ability to drive, or walk even though this is clearly not the case as they lost their drivers license years ago, or they are now dependant upon a wheelchair. Anosognosia is quite common within the earlier stages of disease progression, most commonly within Alzheimer’s disease. Confabulation is something that is quite often seen and is described as the person “filling in the gaps” as a result of not having insight into the nature of their deficits. For example, the person may hide something, or forget where they have placed something and draw the conclusion that it has been stolen. The problem with this is that the person firmly believes the item has been stolen, not that it has simply been misplaced. 

Things you may observe:

• Frequent falls related to not using mobility aids;

• Increasingly argumentative; and,

• Refusal to take medications

• Refusing assistance with tasks and, or care
  

  What can be helpful?

• Avoid arguing, and statements such as; “you need to have a bath, or you need to take your medications”

• Encourage the persons independence as much as possible

• Use personalized calendars for scheduled activities

• Reframe your approach to make the person feel as though you need their help instead of them needed yours

6. Altered Perception

Altered Perception is the misinterpretation of sensory information including the loss of depth, colour and visual perception. I can occur across all the 5 senses including; sight, sound, touch, smell and taste. Altered perception can be used in conjunction with an illusion as like an illusion the source of stimulus exists within the environment however, the person is misinterpreting the information and meaning of the stimuli. For example: Coat racks become people. The person will pass by a window and not recognize the reflection within the window to be theirs and become upset over the fact that “someone is watching them”, or “why is the person not answering me when I speak to them”? Other challenges could include, any transitioning between flooring: this could be interpreted as a step, or a ledge and the person may refuse to cross the threshold, or loose their balance in trying to manoeuvre themselves over the obstacle. There could also be challenges in having any type of fleck in a carpet or ceiling which could be interpreted as bugs and cause distress within the person. The person will also struggle in distinguishing between surfaces if everything is the same colour i.e. the basin, seat and toilet itself are all white and you find that the person is urinating everywhere but in the toilet. The bath tub is white and the water is clear and the person is now afraid to have a bath because there isn’t a defined bottom to the tub.

Things you may observe:

• Frequently bumps into objects;

• Frequently falls when attempting to sit down;

• Has difficulty distinguishing between objects that are the same colour; and,

• Sun downing

What can be helpful?

• Avoid dark mats as this may be interpreted as a hole

• Be aware of shiny surfaces, as they may appear as water

• Try colourful patterns on the bottom of a bathtub i.e. a coloured towel or decals

• Use colour contrast amongst objects i.e. bowls, plates, toilet seat etc.

• Ensure all areas of the home are well lit

7. Apathy

Apathy is the loss of drive or initiative. The person presents as not having any “get up and go” and appears to be indifferent about everything. For example, “Good morning, do you want to get up for breakfast”? And the persons response is “No”. Or the person who once enjoyed outings, or social time, now could not be bothered in engaging in these events. It is important to understand that apathy and depression are not the same thing. The difference being, the person who is apathetic, once motivated and supported to engage in whatever the task or event may be, they will thoroughly enjoy themselves. The person who is depressed, no matter what approach is taken, they will not enjoy themselves, gain a sense of purpose or feel content. Depression is a mental illness and does require treatment.

Things you my observe:

• Have difficulty initiating activities;

• Rely on other’s cues to keep them involved in a conversation or task; and, 

• Little or no emotional response
  
  What is helpful?

• Avoid statements such as; “Do you want to get up, or come for dinner”?

• Instead try; “It’s time for dinner”

• Use the personal history/life story of a person to engage them in conversations

• Provide cueing and assistance to help get them started in a task

8. Attention Deficits

 Is defined as difficulty sustaining or shifting attention. There is too much going on for the person to focus on a task. The person experiencing attention deficits is unable to process multiple sources of stimuli within their immediate surroundings and in turn becomes very overwhelmed as it all becomes “white noise” causing distress. As a result, the person may exhibit an inability to sit still, appearing to be continuously on the go.

Things you may observe:

• Continually leaving the breakfast table

• Not easily distracted when focused on an object or task

• Ceases an activity when asked a question and has difficulty engaging in the task again

What is helpful?

• Give simple instructions one step at a time

• Minimize distractions

• Try serving the person first at meal times

• Offer finger foods

• Try substitution by offering another object for the person to try, instead of taking something away from them

Remember not all individuals living with Dementia experience all 8 A’s. A person could be experiencing only one, or only a few at a time.