Second Opinion: Preserving human dignity while caring for those with dementia remains the real priority, says Dr Denis Eustace
The impact of dementia on society and our healthcare services is significant and, as people continue to live longer, is likely to become even more pronounced. Current estimates suggest 35,000 people in Ireland have dementia, the majority of these affected by Alzheimer's disease (AD).
Approaches to the management of dementia have changed radically in recent years and continue to evolve.
Most recently, the availability of medications with the potential to delay progression of disease symptoms offers a further bolster to patients and their carers living with this disease. As a physician looking at the changing face of dementia management over the past 20 years, more can be done to achieve the primary objective - preserving the dignity of the dementia patient.
Dementia is, of course, not treated as such; it is managed, and the way we manage dementing illness here in Ireland has undergone a sea of change in the past 15 or so years.
In the late 1980s the picture was very bleak. Residential facilities were inadequate for the needs of the elderly dementing person. Nursing homes were poorly equipped and there were no units specialising in private care. It was only in 1991, here at Highfield, that the first specialised Alzheimer Care Centre was built, modelled on units already existing elsewhere in Europe.
Awareness of dementia back then was low, particularly awareness of the plight of carers. Support groups such as the Alzheimer's Society were in their infancy and approaches to treatment were limited.
Awareness of the needs of dementia patients and their carers has grown over the past decade and a half, and today the picture of dementia care is a changed one.
The majority of people are managed in the community and the principle is to try to keep the person at home for as long as possible. The needs of patients and their carers are assessed by a multi-disciplinary team led by a psychiatrist of old age, and various management options suggested. Four domains of the illness are assessed: cognition, activities of daily living, care-giver burden and behaviour problems.
An appropriate management solution is devised for each individual case, and that may include medication, attendance at a day centre/hospital or respite care. While the situation is far from perfect, it must be remembered that none of this was available 14 years ago.
The advent of drugs with the potential to slow the progressive decline of dementia has given clinicians new options to help improve the quality of life and independence of their patients.
It had been known for some time that people with Alzheimer's disease had low levels of a specific brain chemical. This was thought in some way to be linked to memory impairment. Then scientists developed a drug that could block the natural elimination of this compound, in effect, increasing its concentration. Today we have three medications based on this action and while they are not wonder drugs, they can make a real difference.
Occasionally, a more dramatic improvement is seen but usually the illness is slowed down and there can be a calming effect, giving everyone concerned some respite before the next stage of the disease.
In the past two years, another medication has arrived. This medication, Memantine, is licensed for moderate to severe illness. This is important as prior to this there was nothing that could be used to treat severe stage illness. Current opinion suggests the drug may now be used as an add-on to the other class of medication when a patient is deteriorating towards severe stage.
In general, improvements may be seen in the behavioural domain - patients appear more settled, and nursing staff and carers often report positive observations in terms of communication, behaviour and even activities of daily living. Dementia sufferers are generally under-treated, but it must also be remembered that these are not normalising drugs.
The extent to which the pharmacological effects of these new medications translate into real improvements in the lives of patients and their carers remains a matter of debate for some, but for others the debate has moved on.
The question of whether dementia, and in particular Alzheimer's disease, should be treated with medication or not, is a question that has already been answered. If the implied question is whether there are any real benefits, one would ask why would we deprive a person with a defined illness of any treatment that is shown to be worth trying? We should use whatever we have to try to achieve that for our patients.
The management of people with dementia in this country has progressed in recent years, but we still have more to do. The improvements we made are not enough to deal with emerging problems. We need to develop more memory clinics, centres where people can be diagnosed earlier.
We need to look at our social structures - the type of housing we're building and how this will affect the elderly dementing person, with the loss of neighbourly support.
Of course, people always ask will there be a cure for dementia. While there is lots of very exciting research ongoing, we have many years to go as it's an illness of great difficulties, and is in many ways an enigma. Until that day we have to concentrate our efforts on providing care that preserves human dignity.
Dr Denis Eustace is a consultant psychiatrist specialising in care for older people and medical director of Highfield Hospital, Dublin.