The Seniors Health Network each month poses a question to health-care professionals. This month, Dr. Michael Zaitzow, a practising psychiatrist at Peace Arch Hospital, was asked:
My wife has Alzheimer’s and is still at home with me. It’s very exhausting caring for her as her disease progresses. I was prepared for the memory loss but now she demonstrates behaviours that I just don’t understand. She became very angry in the grocery store the other day and it’s so unlike her; she is usually very sweet and kind. Is there medication that would help?
Alzheimer’s dementia – in the research literature – is a unique illness.
It is the only disease that clinical trials identify a target that is outside the individual – the caregiver. If the caregiver is relieved, the medication trial is working – and vice versa. This is because, in dementia, the caregiver is not only caregiving, but on a medical level is compensating for the failing Alzheimer’s brain with their own.
The caregiver often hopes or expects the patient to behave as they did before. And when they don’t, the most common frustration is: we have already talked about this before; don’t you remember?
The caregiver is put in a position to compensate for all of the brain functions that the patient is losing – memory, planning, personality, (potentially bad) behaviour.
The patient cannot remember; you have to remember for them. The patient cannot make meals; now it is your job. The patient cannot explain; that is up to you, too. And you know that as much as it is difficult now, in the near future it is likely to be worse.
When this reaches a significant threshold, we say the patient has BPSD, or behavioral and psychiatric symptoms of dementia.
When the brain is threatened by dementia, the highest brain functions are affected first. These are the most integrative and will usually be detected by the family before professionals. The patient is just not the same, repeating things, forgetting names, is not as interested in activities. Personality changes classically involve loss of interest or signs of impulsive behaviour.
Despite all of our neurobiological research, the most important factors in dealing with dementia are still understanding, providing supportive social engagement and trying to be humane.
Medications have a limited role. Some can help with behavioural containment and are not, strictly speaking, treatments; they do not reverse the illness. If the patient is stressed, depressed, sad, agitated – a natural reaction – they sometimes gently respond to medicines such as antidepressants. However, if they become disinhibited to the point of causing significant social difficulties, then we try other, more powerful medicines.
There is no actual treatment at the present time. The cognitive enhancers (such as donepezil) are supposed to support the beleaguered cholinergic nerves by giving them an extra year or two of stable memory before the illness damages them for good.
Sometimes these medicines have a positive effect – sometimes the patient becomes less stressed, less agitated, even though brain functions may not change. Sometimes the use of these medicines slows down the illness, buys a year or two of stability, delays admission to a facility and/or calms the person down.
The science of medication for dementia is young and basically all off-label. We try to use medicines that we understand and adapt them, hoping for the best. And they often do help, especially if integrated into a broader treatment plan. The emphasis should usually be on that broader treatment plan – from stable housing and a supportive living environment to optimal social engagement.
Remember that change is difficult for everyone, especially if one’s brain resources are limited. But if one’s needs are being met, change is ultimately for the good. And, usually, if the BPSD settles down reasonably, so do the caregivers.
The South Surrey White Rock Seniors Health Network is a coalition of seniors service providers working under the auspices of the Mayor of White Rock’s office – visit sswr.fetchbc.ca. If you have a question for publication, please email email@example.com