Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-057Acute Management of DementiaBrice PittSt Mary’s Hospital, London, UKAlzheimer’s disease (AD) and senile dementia of the Alzheimertype (SDAT) have an insidious onset and a prolonged course(sometimes running for 20 years); so, on the face of it, the need foracute management should seldom arise.Indeed, perhaps for many sufferers—the ‘‘silent majority’’—itmay not. Some old people become ever more forgetful and adaptgradually and graciously to their limitations, while their familiesand friends perceive them simply as starting to show their agerather than as demented. They give them a little more help everyfew months, which is accepted appreciatively as appropriate. Theold person may receive a lot of care at home, or move to live nearor with one of the family, or agree that it would be wise to go intosheltered housing or a home, until in due course a gentle deathbrings life to a dignified end.However, the course in those referred to professional services—general practitioners, social workers, geriatricians and psychogeriatricians—isoften less tranquil. Usually such patients have beendementing for a year or two and the referral has been precipitatedby a crisis.CRISESSuch a crisis could be when the family doctor is telephoned byanxious and irate relatives who have visited their parent over theweekend and found things worse than when they last visited 2months previously, or the belated awareness that he/she is notcoping very well and that a long weekend, like Christmas orEaster, is imminent and that there could be problems. Relativesare usually very caring and the culture supportive, but in thedeveloped nations families are small and dispersed and both menand women are employed, while the elderly population is large—over the age of 65 in Britain 1 ; so to take care of a dementing elderat a distance requires considerable adaptation.Crises also arise where the demented people react to theirdisorder not with insight, but with robust denial. These areexemplars of the ‘‘Dylan Thomas syndrome’’:Do not go gentle into that good night;Rage, rage against the dying of the light!They age disgracefully, fighting the implications of a failingmemory, mind and body every step of the way, stubbornlyindependent unto death unless society intervenes, either byoverruling their rights or by using some form of mental healthlegislation. These denying demented patients are a huge challengeto the health and social services.Traditionally, the dementias may be dichotomized into thepresenile and senile forms, or Alzheimer’s and non-Alzheimer’s.However, for the purposes of this chapter, the most practicaldivision is into those who live with others and those who live allalone. The prognosis for survival of the latter, even if given gooddomicilary support, is far worse 2 .LIVING ALONEDemented people who live alone may do so because they aresingle, divorced or widowed and without children. Widowing canbe an acute event, and one of the crises in dementia is when a keycarer dies, leaving the dependant not only emotionally bereft butalso suddenly deprived of his/her main prop. An acutegrief reaction is compounded by the abrupt removal of aprincipal support. The work of grieving is complicated byforgetting or denying that the loss has taken place. Plans for thefuture may be undermined by the fitful expectation that the lostone will return.There may be personal as well as social factors in a dementedperson’s living alone. Some people react to the early intimationsof their disorder by withdrawing and leading a very simplified,limited existence. Finding it an effort to sustain conversation withneighbours, friends and even family, they adopt an isolated,frugal life. Those who deny that they have any difficulties areunlikely to accept the help that is willingly offered. ‘‘I don’t wantanyone coming to my house to do my housework and shopping—poking their nose in where it’s not wanted’’. ‘‘Are you saying Ican’t look after myself? I’ve managed very nicely for all theseyears?’’ ‘‘Why would I want to come and live with you (or insheltered housing, or in a home)? I’ve got a perfectly good homeof my own, thank you very much!’’ These denials are often madeby people with a well-preserved, assertive personality, and enoughretention of language to make their wishes plain (althoughwithout the hearing, comprehension, insight or will to listen toreason!).Living alone with so devastating a disorder as dementia isevidently risky. Accidents occur easily in those who lack theforesight or the judgement to prevent them, and demented oldpeople are consequently over-represented in general hospitalwards. Drugs needed to control diabetes, heart failure, epilepsy orarthritis may be taken erratically or not at all, with seriousconsequences. Malnutrition is a hazard for those who cannotremember whether they have eaten or not, to draw their money orwhere they have put it, where and when to shop and for what,and what to do with what they may have bought if they can find it.Cold weather adds to the dangers of falls and hypothermia.Floods and conflagrations are always possible, and failingsPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd