Dementia: A Growing and Serious Psychological Issue

¶ … dementia disorder and how healthcare professionals embrace theories, research and practical strategies, in order to help dementia sufferers cope with their difficulties.

Behavioral and Psychological symptoms in primary care

Doctors, nurses, other healthcare professionals and caregivers are challenged when it comes to the care of patients suffering from dementia. That is because dementia is frequently accompanied by a variety of neuropsychiatric symptoms, according to a peer-reviewed article in the journal Mental Health in Family Medicine. Those symptoms include "disturbed behavior, thought, mood and perception" (Buhagiar, et al., 2011).

The point of the article was to find out how much confidence that doctors (general practitioners) have as regards their ability to identify and manage the various behavioral and psychological symptoms of dementia. The authors designed a two-page questionnaire and sent it to 160 general practitioners in north Dublin, Ireland. About 109 general practitioners returned the questionnaires (that is a 68% rate of response), and of those 106 were "usable" (Buhagiar, 227).

There were two sections in the questionnaire; the first was strictly designed to gather demographic data, and the second section asked nine questions of the doctors. Those nine questions were designed to evaluate the amount of "confidence" that the doctors reported regarding their ability to manage the behavioral and psychological symptoms of dementia (BPSD), Buhagiar explains (228).

The purpose of this research is theoretical and is based on two facts: a) clinically "significant symptoms" are very common in about 30% of those who suffer from "mild dementia"; and b) general practitioners are dealing "more frequently" with individuals who are experiencing "cognitive decline for the first time" (Buhagiar, 228). The bottom line is that BPSD is not always managed appropriately, and there are often incorrect prognoses given because general practitioners do not necessarily come into contact with dementia patients. However, Buhagiar explains, it is necessary for general practitioners to have knowledge of patients in the early stages of dementia because "…more than one quarter of people over 75" may be showing early signs of dementia.

Management of the "more dramatic forms" of dementia "can be even more daunting" because of the general lack of "clarity" on the symptoms (by general practitioners), and also the lack of "specific pharmacological and non-pharmacological treatments" (Buhagiar, 228). What the authors are saying, frankly, is that because "primary care" does not prepare physicians to give an "optimal quality of care" to individuals with BPSD (Buhagiar, 228).

The results of this scholarly survey showed that: a) only 7.3% of the 106 doctor respondents had undergone "…postgraduate training in geriatric psychiatry or medicine"; b) most general practitioners associated dementia "with memory loss rather than behavioral disturbance"; and c) a "substantial number of the GP's (67.9%)…encounter major difficulty in accessing secondary care services" when they need help managing BPSD (Buhagiar, 231).

In conclusion the authors emphasize that general practitioners do not show a strong level of confidence when it comes to providing care for individuals with serious dementia. Hence, "GPs need to be supported by educational programmes that bolster their confidence" when it comes to the care of people suffering with dementia.

Dementia and its relationship with food

Within the psychopathological milieu surrounding dementia, there are a number of important issues that caregivers, doctors and other healthcare providers must be familiar with. One of those is diet and nutrition, which are vitally important aspects of care for everyone and in particular for older people. Writing in the peer-reviewed British Journal of Community Nursing, author Stephanie Ragdale explains that as people age they lose brain cells (and hence, they require the best possible nutritional support), but when a person is hit with dementia, the loss of brain cells is "catastrophic" (Ragdale, 2014). Hence, it is very important that caregivers and professional healthcare providers approach the question of nutrition with great care and interest.

On page S21 Ragdale, an Admiral Nurse in the UK, writes that a Mediterranean diet that is "rich in unsaturated fatty acids," and features consistent intake of "cereals, fruits, fish, legumes and vegetables" lowers the health risks associated with "vascular dementia." Also, eggs and oily fish are both strong in Vitamin D, which is known to reduce the risk of dementia to begin with (Ragdale, S21).

The reason this article is pertinent is because everyday life for folks with dementia is difficult to begin with, and when the patient with dementia is undernourished, or not eating properly, that can "increase confusion and irritability" in the individual. As for the caregivers who help those with dementia, they may find the patient's inconsistent "…association with food frustrating and upsetting," and leave the caregiver "…feeling helpless" because the struggle with proper eating can lead the caregiver to believe it is simply a sign of "the inevitable progress of the disease" (Ragdale, S22).

Eating problems are fairly common with people who suffer from dementia. A survey in the United States showed that over an 18-month period some 85.8% of residents in a nursing home "with advanced dementia" had developed a serious eating problem (Ragdale, S23). Some dementia patients have poor nutritional habits and they lose weight because of a loss of appetite. In fact the loss of appetite can result from a loss of the sense of smell and taste among older people; hence, it is important for the caregiver to encourage good eating habits.

Ragdale explains that for those dementia patients whose weight has fallen below normal levels, a theory has been constructed based on a fortified diet for the dementia sufferer. The caregiver can achieve success in helping a very thin dementia sufferer by providing "…high-calorie ingredients" like Vitamin D milk (the fattiest milk available), cheese, butter, oil, yoghurt, cream and mayonnaise along with the patient's regular meal (Ragdale, S24). Also, the caregiver should be serving nutritious drinks such as smoothies, fresh fruit juices, and other milky drinks; moreover, research reflects the fact that there is "strong evidence that oral nutritional supplementation" can and does increase weight, even though the dementia patient may not know that extra calories are supplementing his or her regular diet (Ragdale, S24).

If a dementia patient has "excessive stimulation" in the caregiving environment, that can easily disrupt normal eating habits, Ragdale continues. In fact the meal time should be consistent every day (we have lunch at noon and dinner at 5:30 every day, the patient must be reminded). In addition, providing "clear visual and sensory cues" reduces the potential of disorientation in the dining area; that is, the meals should be attractive, must smell good and taste delicious in order to keep the patient interested in good eating habits (Ragdale, S24).

The author also recommends not robbing people with dementia of their ability to feed themselves; assisting a dementia sufferer with eating can "…lead to a loss of self-esteem and a sense of powerlessness" (Ragdale, S24). Sensitivity to the patient should be the watchword when it comes to helping him or her to eat, and so when families are the caregivers, they must be "…equipped with the knowledge and skills required" (Ragdale, S24).

Musical intervention for patients with dementia

Music therapy is an "attractive form of intervention" for demented patients, and that is not just theoretical -- it is a proven practice, according to a peer-reviewed article in the Journal of Clinical Nursing. In fact music therapy is used in many situations where there are "psychological, psychiatric and physical conditions," and so it is a reasonable assertion that music could be used as an intervention for patients suffering from dementia (Vasionyte, et al., 2013). Especially when pharmacological interventions have not worked as expected, and have led to "undesired side effects," music therapy can be substituted. The authors of this article conducted a meta-analysis on the subject of music as therapy for dementia.

They used the key words "music and dementia," and through databases they accessed nineteen studies with a total of 478 dementia patients. And they determined through this meta-analysis that music interventions "seem to be effective," and moreover, music interventions have the potential of "…increasing the quality of life" for those who struggle with dementia (Vasionyte, 1203).

What exactly is a musical intervention vis-a-vis dementia? Vasionyte explains first that a 1997 study summarized 69 other studies including "clinical empirical studies of music interventions, theoretical and philosophical papers," along with case studies and anecdotal accounts of music therapy (1204). That meta-analysis resulted in the findings that music interventions improved the "social, emotional and cognitive skills"; and music interventions also helped to decrease "behavioral problems among demented people" (Vasionyte, 1204).

The author is quick to differentiate between "mere music listening" and "receptive vs. active music therapy" provided by a trained therapist. Active music therapy involves "active involvement" by the participant; it's not just playing pre-recorded music and having the demented person kick back and listen. Instead, participants in active music therapy may actually play instruments, sing along with music, dance to musical numbers, or engage in "song-drawing" (Vasionyte, 1204).

The therapist selects the music based on the taste of the dementia patient. Active music therapy is used for "arousal of positive emotions and increasing self-confidence," Vasionyte explains (1204). Ideally, the music should be played live by the therapist or by a choral group from a nearby church or school, or by piano players on site playing live music that can stimulate the patient, Vasionyte explains. When the music is played live, the theory is that it "creates a stronger sense of reality" and the patient benefits from actually observing the musician or musicians playing, and by singing along with them, or humming (Vasionyte, 1204).

Who decides what music is most appropriate for the patient? The patient should be consulted of course, but his or her relatives and caregivers can also be expected to be knowledgeable as to what musical style would be most appropriate. The arousing of positive memories can go a long way to making this kind of intervention effective. Another dimension that is attached to music therapy is this: sometimes a group can get more out of music therapy than an individual, hence, the author suggests that group music therapy has been shown to be "more effective for improving social and socio-emotional skills of dementia patients" (Vasionyte, 1205).

Still another dimension alludes to the type of music (not the specific artist or genre) that is most appropriate. Vasionyte explains that if the music therapist wants to get the patient to quiet down, relax, and just enjoy the sounds, then semi-classical music or simply relaxing music is appropriate. But if the music therapist has the goal of arousing vivid memories in the patient, then folk songs from that person's formative years, or rock "oldies," or other kinds of music would likely work best (Vasionyte, 1205).

Of the many studies that this research unearthed (through meta-analysis), of the 19 studies the authors located, most studies / research reflected that there were "large" positive outcomes on cognitive, behavioral, and physiological aspects; and "medium effects on affective measures" (Vasionyte, 1203).

The burden that caregivers must deal with An article in Geriatrics Gerontology International presents recent research into how caregivers in Mexico that are treating dementia patients are negatively impacted by their work. The authors were aware of the "accelerated growth of the elderly population" in Mexico, and the increase of mental illnesses, including dementia; hence they carried out a study with six health-related institutions in Mexico City (Rosas-Carrasco, et al., 2014).

The caregiving experience can become "a heavy burden" especially when the older person has greater dependence on caregivers; the caregiver can become emotionally weary and can struggle to sleep well, can suffer from depression and suffer from Dysexecutive syndrome (which includes problems with planning, abstract thinking, social flexibility and control of one's behavior patterns) (Rosas-Carrasco, 146).

Some of the behavioral disturbances associated with caregiving for dementia patients include: "aggression, agitation, apathy, dysphoria and aberrant motor behavior" (Rosas-Carrasco, 147). Given these known dynamics, the authors of this article patients and caregivers were interviewed at six general hospitals in Mexico between January 2007 and January 2010. Patients 60 years of age and older were included if they suffered from the following dementia types: Alzheimer's disease; vascular, mixed, frontotemporal, Lewy bodies and Parkinson's-associated, Rosas-Carrasco explained, adding that the patients surveyed needed to be able to read and write, and the caregivers also needed to be able to read and write.

The structure of the research included: a) the Dysexecutive Questionnaire (DEX) (a 20-item questionnaire using a Likert scale ranging from 0 to; b) the "Mini-Mental State Examination" (helps determine the degree of cognitive impairment the patients are suffering from); c) the Geriatric Depression Scale (a 15-item scale that assesses depression in older people); d) the Barthel Index (10-item test measuring a patient's ability to carry out "independently… the basic activities of daily living"); e) the Lawton Scale (this evaluates a person's performance in daily living activities); f) Neuropsychiatric Inventory (a 12-item inventory validated for Spanish-speaking people which evaluates caregivers' symptoms); g) Patient comorbidities (assessing caregivers' negative impacts from their work); and h) Sleep Disturbances Inventory (an 8-item questionnaire measuring the quality of caregivers' sleep) (Rosas-Carrasco, 148).

The results from the caregivers side of the research showed that most caregivers were women; the mean age was 57; fifteen percent of the caregivers were in dementia support groups; most caregivers worked 6 days a week and over 8 hours a day; and 52% of the caregivers were full time (Rosas-Carrasco,, 150). Interestingly, the higher the education level of the dementia patient the greater the caregiver burden in Mexico; this might mean that higher education leads dementia patients to argue, refuse to take medication, or otherwise become recalcitrant.

The caregiver burden is greatly increased when one family member assumes the full responsibility of caregiving, Rosas-Carrasco explains (150). Personal needs go out the window, and the caregiver is unable to have another job for income. The Dysexecutive syndrome that was researched showed that caregivers showed: a lack of "initiative"; an inability to "plan and organize"; difficulty in presenting good communication to those who are not demented; disturbed thinking processes; and also, when the dementia patient suffered sleep disorders, this contributed to the burden of the caregiver (Rosas-Carrasco, 150).

Using dog-assisted interventions for dementia patients

An article in the journal Nursing Older People points to the success when it comes to helping and modifying the behavioral and psychological symptoms of dementia patients. This research resulted from a theory that when pharmacological treatments are not successful, using an animal like a trained dog can be a worthy alternative to drugs. The 2014 article asserts that there are about 36 million people in the world who are known to have dementia, and "this number is expected to double every 20 years," according to the World Health Organization (Nordgren, et al., 2014). Because the number of people with dementia is expected to grow so astronomically, positive interventions are necessary, and in this research, the authors show that dogs are the most commonly used animals for interventions.

Earlier in this paper music therapy was posited as a worthy alternative to pharmaceuticals, but in this article it is shown that an interaction between a trained animal in a nursing home and a person with dementia can result in a positive outcome. The authors conducted research using 33 residents with dementia in 8 nursing homes in Sweden. Twenty of the patients were placed in the intervention group and 13 were in the control group. The Cohen-Mansfield Agitation Inventory (CMAI) and the Multi-Dimensional Dementia Assessment Scale (MDDAS) were both used to evaluate the success of the dog-assisted interventions (Nordgren, 31).