Dementia

According to recent studies conducted in Indians, the prevalence of dementia is lower compared to that of developed nations. These studies show that prevalence of dementia varies in different region of the country:

•  In urban regions it varied from 18 per 1000(1.8%) (Vas et al, 2001) to 33.6 per 1000 (3.36%) (Shaji, 2005)
• In rural areas it was found to be 1.36% to 3.5%. The predominant type of dementia is dementia of Alzheimer’s type, and the next being vascular dementia.

The prevalence of Alzheimer’s disease is very low in India, but the predilection to diabetes and coronary artery disease increases the risk of multi-infarct dementia.

Lower Prevalence of Dementia in Asian Indians

The overall prevalence of dementia in developed countries has been reported to be between 5% and 10% after 60 or 65 years and older (Biswas A, Chakraborty D, Dutt A, et al 2005). In contrast, the reported prevalence of dementia in Indian elders is much lower (Shaji S, Bose S, Verghese A., 2005).

Lower life expectancies, under diagnosis, false negatives are thought to be contributing reasons. However, it cannot be denied that the decreased prevalence could also be due to decreased genetic risks and also possible dietary and environmental factors.

Curcumin and Dementia in Indians

Recent research has focused on the possible protective effects of curcumin in dementia. Curcumin (Diferuloylmethane) is the active ingredient found in turmeric, a key ingredient in Indian curry. Curcumin has anti-inflammatory and anti-oxidative properties and is thought to suppress oxidative damage, inflammation, cognitive deficits, and amyloid accumulation in the aging brain, thus serving as a protective factor in dementia (Yang F, Lim GP, Begum, 2004).

Assessment of Dementia

Culturally sensitive interviews of the patient and family member and clinical assessment are the most important diagnostic tools for dementia. A comprehensive history and physical examination with special attention to the onset and rate of progress of cognitive problems, a laboratory evaluation to rule out hypothyroidism (TSH), syphilis (VDRL), B12 deficiency are recommended. Brain imaging studies should be considered in patients if:

1. dementia onset occurs at an age below 65 years;
2. presence of focal neurologic deficits and
3. the clinical picture suggests normal-pressure hydrocephalus (triad of onset has occurred within 1 year, gait disorder and unexplained incontinence).

Disclosure of Diagnosis

Once the healthcare professional has made the diagnosis of dementia, it is of critical importance to disclose the news about the diagnosis in a culturally competent and compassionate manner. As in many other Eastern cultures, the autonomy unit of an Asian Indian family many consist of the patient and one or more key family members. Acculturated elders who have embraced (American) mainstream values may prefer to make their own decisions.

Others may still defer to key family members to make all healthcare decisions for them. In certain cases, families may request that the patient not be told of the diagnosis of dementia. In such cases, the health professional should first check in with the patient and ascertain their wishes.

For example, saying “Mrs. Reddy, I understand that you would prefer that I not discuss your illness with you and that you would prefer to have your husband/ son/daughter make health care decisions for you. Is this true?” … “Ok, I will have further discussions with your husband/son/daughter. But if you ever need any information about your health status or have any questions, please feel free to ask me.”

Management of Dementia

At present, there is no curative therapy for dementia. Thus, the primary treatment goals for patients with dementia are to enhance and preserve quality of life and optimize functional performance by improving cognition, mood, and behavior.

• Both pharmacologic (donepezil, galantamine, rivastigmine and memantine) and nonpharmacologic treatments (light therapy, reminiscence therapy etc) should be considered.

• Choline esterase inhibitors (donepezil, galantamine and rivastigmine) slow down the progress of the disease.
• Memantine, a n-methyl-d-aspartate receptor antagonist, recently approved by the FDA is indicated in moderate to severe dementia.
• In addition, modifiable risk factors like hypertension and dyslipidemia should be carefully treated.
• Co-morbid conditions like coronary vascular disease and diabetes should be carefully managed
• Establishing a therapeutic alliance with both the patient and the family fosters an ongoing trusting relationship and facilitates management.
• Proactive education of the patient (in the early stages of dementia) and caregiver are helpful.

Caregiver stress

According to CDC data on caregiver stress:

• 48% of those caring for adult care for someone with Alzheimer’s
• 1 in 3 report their health as gotten worse due to care responsibilities
• 25% of Alzheimer’s caregivers are caring for both an adult and a child
• 60% rate their emotional stress as very high or high. As many as 40% report symptoms of Depression
• Alzheimer caregivers report negative effect on employment, income, and financial security.

Health professionals caring for dementia patients should:

• monitor the patient’s caregivers for signs of caregiver stress
• make appropriate referrals to caregiver support groups as these have been shown to effectively alleviate stress.
• consider offering support services like respite care and other community resources like dementia adult day care as these interventions reduce caregiver stress, offer meaningful social stimulation to the patient and may possibly help post pone patient institutionalization.

Interacting with Reluctant Caregivers

While some Asian Indian caregivers may be open and vocal about the stresses experienced, others (especially elderly wives) may feel reluctant to voice their stresses as they may feel such expressions to be demonstrative of a lack of loyalty to their loved ones.

• Gentle and explorative questions will likely elicit the true state of affairs.
• Normalizing their experience: “Mrs. Rao, often care-givers of dementia patients become very stressed. Your are working hard taking care of your husband and I admire you for this. However, you may become tired and exhausted for doing this on a long term basis. This may cause health problems for you in the future. There are some simple things we can do to help with care-giver stress. Can you please tell me what a typical day looks like for you?”