Dementia… a disease of losses

In the Emergency Department, caring for older adults is a challenge. Caring for demented older adults is also difficult but there point of view is probably even more traumatizing that we think.

Imagine this scenario (not uncommon): 92 years old lady from home with caregiver, advanced dementia and she is refusing that we take her blood pressure, and don’t think about blood work! We find it difficult, we have strategies to overcome this, and we probably will do things against her will anyway – for her own good of course!

But let’s take a step back and let’s wear dementia glasses for a minute.

According the the World Health Organisation, dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing.

They call it the 7 “A”s of lost in dementia.

Anosognosia. It means that the person has lost insight about what is going on in her life and disease. She can no longer understand that something is wrong. When you are trying to tell her that she is sick and needs her blood pressure taken, that does not make any sense to her.

Amnesia. She does not remember short term events and eventually will loose her long term memory. You may have to repeat yourself, and she may not remember that she fell.

Aphasia. This is all about communication skills. Some will loose more comprehension, others more expression, or both. It then become more difficult to verbalize if she wants to go to the bathroom and that is the reason why she does not want you to take her blood pressure. On the other end, if you carefully explained what you will do but in a 5-step way, that may be too distressful.

Agnosia. They will loose ability to recognize things through their senses (touch, smell, sight, sound and taste) and then persons. She may not recognize a blood pressure cough, or the fact that she is in a hospital or that what is in front of her is food and she should eat it (although hospital foods can often not look like food but anyway…!).

Apraxia. It is a lack of voluntarily coordination to perform certain task like holding a pen, doing up buttons or even use a walker.

Altered perception. They can experience visual hallucinations, delusions and illusions. For example, a low level of light and a new environment can create some distorsions that are wrongly interpreted. It may be the reason why she fears you because she thinks that you are going to hurt her purposely or your shadow is scary.

Apathy. It is the lack of motivation to initiate activities. This is usually not a significant problem for care but could impaire our ability to evaluate her walking gate, etc.

Imagine if for a moment, you loose all those cognitive function. Imagine that your comfy home becomes suddenly a cold noisy place. Imagine that there are tons of people you don’t know wanting to touch you all the time. Imagine being a demented older adults in the Emergency Department. How would you react? I am persuaded that you would show some behavior disorder that we now call “responsive behavior” which I think is the correct  appellation.

Think about this next time you take care of an older adults with dementia. It will change your care plan and your communication strategies for sure! Next blog, strategies in details!



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