Confusion: An Exploration Of Dementia

The myth of senility permeates our culture and casts a cloak of alarm over the elderly when they notice mild forgetfulness in themselves. "She's senile hecause of hardening of the arteries in her head," our grnadrnother would say. Gram combined the concept of hardening of the arteries (atherosclerosis) and senility because she recognized that both occur in older individuals. Yet it is unclear that aging is necessarily associated with mental decline, yet as atherosclerosis is not usually responsible for states of confusion. The word senility has always heen used to describe a host of mental disorders which result in confusion in the aged. The Unabridged Oxford English Dictionary offers the following definition for senility: "the mental or physical infirmity due to old age." This is the myth we have created, for there is no mental infirmity due primarily to the fact that an individual has aged. The word senility should only be used as an adjective when describing certain disease processes associated with aging such as senile dementia of the Alzheimer's type.

The Aging Of The Brain

What changes occur as the brain ages? When cognitive functions of elderly people were tested several times over of many years, apparently contradictory data were obtained. Some 'had clear-cut declines in scores, some remained the same and some irnproved. Several attributes were noted to affect the results: degree of education, social support structure and the extent of chronic disease. Thus, like many other changes in aging, cognitive loss is significantly affected by enviromental influences, which are modifiable and controllable. In fact, it is now known that with training reasoning and cognitive performance may Marked changes of cognition found in elderly individuals are virtually due to disease. Alzheimer's dementia, for example, insidiously destroys an elderly person's short-term memory and ultimately daily functioning. This a disease and not a factor in normal aging. Other forms of dementia, various states of confusion and different degrees of stroke are additonal abnormal changes of the brain, yet the obvious effects that they have on a segment of the elderly population negatively bias our perceptior fo thinking in all older individuals. Similar to organ systems, the brain undergoes age-dependent changes. Most advanced elderly people experience some degree of short-term memory loss. The older brain is less plastic and therefore more affected by enviromnmental insults, which partly explains why the elderly are more prone than younger individuals to confusional states. They also have more difficulty learning new tasks, and experience a decrease in speed with which they can process new information. Nevertheless, overall intelligence remains untainted by aging. IQ does not change until the eighth decade or later, and then only slows. Verbal skills actually improve with age and peak in our 50's and 60's. AAMI...

"Benign Forgetfulness" (case history)

Julia 88

Julia's fears began to show itself in her daily calls to her daughter. "I forgot to feed Heather this morning," she said one day with great alarm. "Don't worry, Mother. A cat won't starve to death if it misses one meal," her daughter replied. "You don't understand and aren't listening to me! I forgot to feed my little cat. I am going senile. I am losing my mind and before long, you'll stick me "Nonsense, Mother. The damn cat is too fat anyway. "Yesterday I couldn't remember your cousin Margaret's married name. Today I forgot the cat. What next?" "What are you going to wear to Helen's wedding next week?" her daughter asked in an attempt to change the subject. "The same gray dress and alligator pumps I wore to her last wedding and will probably wear to her next wedding. That is, if I don't go senile first and become a vegetable."

Julia has a mild form of memory loss which is called benign forgetfulness. This term refers to forgetfulness which is common to normal aging. It is characterized by a gradual onset of minor memory loss for unimportant aspects of daily life. Although Julia forgot to feed her cat one meal, and could not recall cousin Margaret's married name, important details such as the wedding plans were not forgotten. Moreover, she is preoccupied with her memory deficit. Patients with early- to mid-stage dementia may go to great extremes to hide their forgetfulness from other family members. They will usually deny or ignore their problem. Julia's agitation suggests that her problem is not serious. She should be reassured that an occasional memory lapse is a normal part of aging and not a disease.

When Is it More? (case history)

Herhert N., 86

Herbert's widowed daughter, Natalie, with whom he lived, knew that her father had a problem the day he came down to breakfast without shoes or socks. Her father had owned a fashionable haberdashery store for over 30 years, and had insisted that he and his clerks dress impeccably as an advertisement for the shop. That morning he wore gray slacks, creased to a knife like edge, a snow white shirt with regimental tie, a navy blue sport jacket with a red handkerchief in the breast pocket but no shoes or socks. She had chuckled at what she initially thought was some sort of joke a his part. At first he had looked puzzled, and then as she pointed to his naked feet, he became concerned, and then agitated. "Why did you take off my shoes and socks?" he had demanded. "I didn't," she had replied. "Why did you do it?" Her laughter faded. "But I didn't." Herbert's color changed as his face reddened. His face pinched in anger as he stood over her. "Where are my things!"

Herbert's response reeks of dementia. His confusion stems from forgetting to perform an activity which is reflexive for most individuals. People with age-dependent memory loss forget minor, unimportant details; they would not forget to dress. People with early dementia will either laugh or become agitated when they are asked a question they cannot answer. Their responses are thin veils which do not conceal the central is: the underlying severe memory loss.

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