In terms of clinical features, dementia usually starts with complaints of deteriorating shortterm memory. The patients are not aware of their problems and it is usually their loved ones who notice subtle signs, which include:

• Asking questions repeatedly, misplacing valuables such as house keys, identity card or bank book, forgetting their PIN, leaving food burning on the stove, frequent accidents when driving or getting lost on the road.
  
• Forgetting skills such as how to use a handphone, remote control or kitchen equipment, or having difficulties learning new skills.
  
• Unable to recognise people and places, getting their family members mixed up, and forgetting friends and relatives whom they have not seen for a while.
  
• Problems with navigating familiar places, getting lost in their own house, forgetting their way home, asking their family repeatedly that they want to go home when they fail to recognise their house.
  
• Trouble with language, difficulties in understanding spoken or written words even in their mother tongue, or difficulties expressing themselves, which often comes across as answering questions irrelevantly, becoming quieter or appearing disinterested.
  
• Changes in behaviour or temper, such as becoming more moody and depressed or not motivated to take part in activities.

As dementia progresses, a person’s brain shrinks and eventually even long-term memory is lost. Patients become unsteady on their feet and fall frequently at home or outside, eventually becoming bedridden and dependent on their caregivers for their basic needs.

They will also develop problems with their bladder and bowel control. Initially, they frequently have problems delaying micturition (elimination of urine from the urinary bladder through the urethra), but as dementia progresses, they become unaware of their need to go to the toilet and eventually become incontinent.

Not all dementia sufferers share the initial symptoms of progressive short-term memory loss. Certain types of dementia, such as the rarer frontotemporal lobe dementia, can cause changes in personality, behaviour or speech disorders, or changes in food preference. The patient’s family usually complains of tempers flaring at home or unpredictable behaviours that can be embarrassing in public.

Dementia affects each person differently because each of us uses our brain differently. It can affect an individual by making activities of daily living (ADL) difficult, as well as through behavioural and cognitive symptoms.

Dementia affects the whole brain progressively, hence patients show deterioration in all physical functions. Eventually, the sufferer becomes bedridden and ADL-dependent, needing assistance with using the toilet, bathing, grooming and feeding. Towards the end of life, they are uncommunicative, wear diapers and have difficulty eating and drinking.

The behavioural symptoms of dementia may cause significant caregiver burden and stress. These symptoms are present in 90 per cent of patients with Alzheimer’s disease at some point during the course of their condition.

The onset of behavioural symptoms is difficult to predict and often catches caregivers off guard. Caregivers can become emotionally overwhelmed as they try to cope with the various behaviours. Examples of behavioural symptoms include depression, anxiety, mood swings, aimless pacing, poor sleep, loss of motivation, screaming, shouting, unprovoked aggression, agitation, stripping, or passing urine and faeces at inappropriate times and places.

There are no standardised treatment recommendations for behavioural symptoms, and drug treatments are often compounded with undesirable side effects. Managing these symptoms requires an understanding of the patient’s background, life story, personality before the onset of dementia, hobbies, occupation and coping styles in order to form creative strategies in managing their outbursts as well as to understand why they behave the way they do. It is time-consuming and labour-intensive, but is also rewarding for the caregivers when it works.

The cognitive decline that manifests as the brain’s function declines is easier to predict compared to the behavioural symptoms and are often not a source of stress for caregivers. Caregivers are able to cope with increasing dependency on ADL, such as when their loved ones are unable to dress or feed themselves any longer.

Find out what happens when a dementia patient is hospitalised.

Ref: O17