Q: Dementia is a progressive disease, so how is early detection helpful?

Dementia is increasingly common in those over 60 years of age (American Geriatrics Society [AGS], 2014). While 11% of adults 60 years and over have dementia, over 30% of those over 85 years have the disease (Alzheimer's Association, 2016a). Home healthcare clinicians will frequently encounter patients with early dementia; therefore, it is imperative they are able to detect early signs and educate patients and caregivers. The two most common types of dementia are Alzheimer disease (which accounts for 60-80% of dementia cases and is caused by damage and death of brain cells) and vascular dementia (about 10% of dementia cases fall under this category caused by blockages in the blood's brain vessels) (Alzheimer's Association, 2016a). Neither can be cured, but they can be treated in ways to help people live to their fullest potential possible. Early detection of dementia can help patients get maximum benefit from available treatments, including maintaining their independence longer. Early detection may improve access to medical and support services (including clinical trials); provide an opportunity to make legal, financial, and care plans while the patient is still able (i.e., an advance directive); improve quality of life by decreasing co-occurring and secondary conditions (including reducing the risk of falls and injuries); and it may reduce the need to place a patient in a nursing home, thus decreasing healthcare costs (Alzheimer's Association, 2016a).

Increased risk of dementia occurs with certain diseases and health problems such as Parkinson disease, brain infections, heart disease, stroke, hypertension, diabetes, vitamin deficiencies, thyroid problems, and delirium (AGS, 2014). Additionally, some health problems such as vision and hearing loss, paralysis from stroke, loss of bowel and bladder control, difficulty eating and drinking, malnutrition and dehydration, difficulty walking, and falls can cause or increase the risks and complications of dementia (AGS). Interventions home healthcare clinician can utilize in a wellness program for patients with dementia include:

* Lowering the risk of stroke by lowering high blood pressure, cholesterol levels, and preventing blood clots.

* Finding behavioral approaches to manage loss of bladder control, anxiety, and agitation (try to avoid medications).

* Ensuring the patient gets enough calcium and vitamin D to lower the risk of osteoporosis and bone fractures; using vitamin B12 supplements to protect against dementia if a deficiency exists.

* Designing a diet and exercise plan to help prevent malnutrition; bone, weight, and muscle loss; lower risk of falls; and improve balance and sleep.

* Preventing dehydration by encouraging fluids (this will also help prevent constipation).

* Treating conditions (such as diabetes) that can contribute to vascular dementia.

* Monitoring all medications to prevent interactions and watch for side effects (AGS, 2014).

The Alzheimer's Association (2016b) published a list of 10 warning signs and symptoms of dementia:

1. Memory loss that disrupts daily life, especially forgetting recently learned information, important dates or events, asking the same information over and over, or relying on memory aids or family members for things the patient used to handle on their own.

2. Challenges in planning or solving problems, such as developing and following a plan or working with numbers. Patients may have difficulty following a familiar recipe or keeping track of monthly bills.

3. Difficulty completing familiar tasks at home or work. This may include having trouble driving to a familiar location or managing a budget.

4. Confusion with time or place, such as losing track of dates, seasons, or the passage of time. Some patients may forget where they are or how they got there.

5. Trouble understanding visual images and spatial relations, such as having trouble reading, judging distances, and determining color or contrast.

6. New problems with words in speaking or writing, such as having trouble following or joining a conversation; stopping in the middle of a conversation and not knowing how to continue, or repeating themselves.

7. Misplacing things and losing the ability to retrace steps. Some patients may also accuse others of stealing, which may occur more frequently over time.

8. Decreased or poor judgment, where the patient may have difficulty with decision making or experience changes in judgment. Patients may use poor judgment when dealing with money, or may pay less attention to grooming.

9. Withdrawal from work or social activities, where the patient removes themselves from hobbies, social activities, work projects, or sports.

10. Changes in mood and personality. Patients may become confused, suspicious, depressed, fearful, or anxious, and may be easily upset.

If a patient is diagnosed with dementia, some measures the home healthcare clinician can implement and educate caregivers about include:

* Encouraging physical activity and a moderate amount of interesting, stimulating activity.

* Making sure there is adequate lighting.

* Speaking in simple sentences and remind the person of the topic of conversation.

* Providing regular daily activities and follow a predictable schedule.

* Reminiscing about pleasant experiences from the past.

* Reviewing the patient's need for medications they are prescribed, and reviewing side effects of all medications. Anticholinergic drugs may contribute to mental decline (e.g., nifedipine [antihypertensive], ranitidine [antacid], and tolterodine [for loss of bladder control]). Cholinesterase inhibitors may temporarily slow decline in cognition, mood, behavior, and daily activity in those with early dementia, but gastrointestinal effects must be monitored. Common cholinesterase inhibitors include donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon). Atypical antipsychotics are often prescribed for behavioral symptoms of dementia, but these drugs often lack optimal effectiveness and can lead to serious side effects such as stroke and death. Thus, they should be avoided unless nondrug approaches have consistently failed.

* Easing agitation and aggression by creating a soothing environment with little stress; soothing, using medications for sedation only as a last resort, as these medications can increase confusion.

* Improving sleep by making sure the bedroom is quiet, dark, and at a comfortable temperature; treating any pain; limiting naps to 20 to 30 minutes; cutting back on fluids late in the day; not giving the patient caffeinated drinks or alcohol later in the day and discouraging smoking at night.

* Discouraging wandering by addressing issues of agitation, depression, hallucinations, pain, boredom, and the need to frequently use the bathroom. Lock doors as necessary, and have the patient wear an identification bracelet (AGS, 2014).

Home healthcare clinicians play a key role in identifying early signs of dementia and educating caregivers on how to care for those affected. Recognizing the early signs and symptoms of the disease as well as helping create a care plan with the caregiver and healthcare team will provide the patient with optimal opportunities for quality of life with as much independence as possible.

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