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Dementia the sun downing in golden years

Published : Saturday, 28 September, 2024 at 12:00 AM  Count : 283
Dr Zubair Khaled Huq
Dementia is a decline in mental function from a previous level which is severe enough to interfere with daily living. A person with dementia has two or more of these specific difficulties, including a decline in memory which is gradual, reasoning is impaired, decline in language skill. Coordination, a person's mood, even behavior get changed. Dementia develops when the parts of your brain involved with learning, memory, decision-making or language are affected.. There are various types of dementia, vascular dementia, Dementia with Lewy bodies, front temporal dementia, and dementia due to Parkinson's disease.

Dementia is considered to be an expensive medical illness and the potential costs are huge as conditions associated with it are typically progressive and irreversible. The care of dementia patients is extremely time consuming and costly. There is a lack of information on economic costs and social burden of dementia in the population. Sometimes a person with dementia may become intensely distressed and agitated in the later afternoon or towards the end of the day. This is sun downing. It is difficult to estimate the accurate cost of dementia in countries where out of pocket health expenditure is high. The time spent on informal care of a demented person is almost ten times higher than formal care. Families take over roles and responsibilities and compensate for the deficiencies of the demented, thereby masking the real burden.

The average life expectancy of citizens has increased. However, living longer did not mean living well as the increased life expectancy did not translate to improved quality of life due to lifestyle-related chronic non communicable diseases and its sequel. Dementia is one such disease of the elderly with high morbidity and considerable socioeconomic impact. It is a neurodegenerative disease of multifactorial causation, heterogeneous presentation, and variable prognosis. It is characterized by a decline in performance and cognitive impairment in multiple domains and affects a person's independence in doing activities of daily living.

It is projected that around one in five persons from low- and middle-income countries are going to be above 60 years of age by 2050. In countries like Bangladesh, elderly are taken care of by families. And there is a rise in elderly persons, but this ratio will increase further by 2100. With the increase in the elderly population, there would be a proportionate rise in elderly suffering from dementia. In absolute terms, there are about 35.6 million people living in the world currently with dementia and 7.7 million new cases of dementia added every year, nearly one case every four with highest projections in South Asian nations. The number of people living with dementia worldwide is projected to double by 2030 and more than treble by 2050.

One of the most fundamental changes in society is the breakdown of the joint family and the growth of the nuclear and extended family systems. Recent changes in the family structure and the relationships between old parents and adult children have amply shown that adult children find it challenging to handle the growing demands of caring for their elderly parents. Dementia is considered to be an expensive medical illness and the potential costs are huge as conditions associated with dementia are typically progressive and irreversible. The care of dementia patients is extremely time and cost intensive. There is actually no information on the economic costs and social burden of dementia in our population. It is difficult to estimate the accurate cost of dementia in countries like us as health-care expenses are majorly borne by individual families and indirect costs such as decreased productivity of the individual, caregiver, and loss of wage days of caregiver are difficult to quantify. The time spent on informal care of a demented person is almost ten times higher than formal care.

Since it is a chronic medical illness, the objective in dementia is to prevent the onset, stop the start in senior citizens and eliminate the disease or control the symptoms in the affected. Prevention can be broad based. Primary prevention emphasizes on delaying, stopping the incidence of dementia by addressing risk factors. Not all risk factors can be changed, as there are non modifiable factors like ageing, gender, genetic risk, and ethnicity. The modifiable factors such as cardiovascular risk factors, diabetes, hypertension, and obesity, lifestyle factors such as smoking, alcoholism, unhealthy diet, and physical inactivity, depression, and head injury prevention modalities should be looked at.


Early identification of symptoms has many advantages such as halting the disease process, controlling the vascular risk factors, and preparing the family to face challenges and prevent the progress to severe dementia. Early intervention also enhances the quality of life and is known to cause less severe behavioral and psychological symptoms of dementia. Disease process of dementia starts many years before the development of clinical symptoms and after onset of brain lesion before the onset of the first clinical symptom. Mild cognitive impairment is an intermediate prodromal stage of memory impairment with normal cognitive function. Identification of individuals during the preclinical or prodromal stage would help in early intervention, thereby altering the course of dementia. Neuroimaging techniques such as MRI, PET, and single-photon emission computed tomography are also used widely for early detection of changes, and monitoring progress and other causes of dementia. The major challenge in secondary prevention is the diagnosis of the preclinical stage as it is difficult to diagnose in the absence of brain abnormalities and clinical symptoms.

The focus is on timely diagnosis and treatment of cognitive, behavioral, and psychological symptoms along with decreasing caregiver burden and improving quality of life. The pharmacological agents such as donepezil, rivastigmine, galantamine, and memantine do not have conclusive evidence in controlling the symptoms of dementia in the long run. For effective implementation of the above preventive strategies, we need to have adequate trained workforce and financial resources. The formal training in identification is rare, more so with trained gerontologists, geriatric mental health experts. Dementia is degenerative in nature. Hence, the chance of treating is very minimal unless immunomodulant therapies and replacing neurons by utilizing the mirror neurons becomes a reality. The focus should be primary prevention of risk factors in all individuals' rights from a young age and universal screening for risk factors and adequate management.

Programs to raise awareness to reduce stigma, and wide screening using a reliable tool should be considered. Controlling vascular risk factors during midlife and early old-age prevents or postpones or delays progression of dementia. Comorbid psychiatric illness like depression, improves functional well-being. Considering the increasing dependency ratio, the caregiver burden is going to be huge. The options such as dementia corner in every health facility, old homes can be thought of wherein demented persons will be taken care by gerontologists, mental health professionals, thereby decreasing family burden. Research should focus on understanding the neuropathological changes of disease and its correlation to clinical features. It helps in finding appropriate screening and diagnostic tools along with strategies or drugs to halt or reverse the progression of disease.  It also contributes to significant cuts on health-care costs, making it a public health priority. We should be grateful enough to our senior citizens, help them in their golden days, return the debt and carry it forward.

The writer is Public Health, Gerontology, Family Medicine Specialist 



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