Understanding Dementia and the Different Stages

Ajouté : 2026-05-20

[00:00:03]this is dr. bill Gibson he's an assistant professor of geriatrics at the University of Alberta and a consulting physician at geriatrician at the University Hospital he trained at the University of Sheffield not only UK because graduate training in the South Yorkshire UK and at the U of A his primary clinical and research interests are urinary and fecal incontinence dementia and delirium he also provides role or research in Vanderbilt as far away as Lloydminster so I would like to thank once again dr. Gibson for joining us this evening and please feel free to take it away I will flip over to now okay a lot of people joining us this evening yeah supposed to be able to see me I'm sorry about that I should have your so I think the slide should be up now and so thank you very much for the opportunity to come and talk at you all it's very strange to be sitting in my office at home talking to my computer and lots of people and listening out there across Alberta yes charlie feel free to shout questions at any time and I will interrupt and answer them no problem at all much better to have some questions coming on as we go through because otherwise you know we the moment may past if there something you want to ask just then just do come out then come on out and ask or wait so so Who am I my name's bill keeps not a geriatrician and geriatricians are physicians and we are specialists in all the people so much like electricians look after children or and geriatricians are experts and specialists in the pair of all the people and you may ask you know what's so special about all the people that means that they get their own their own specialists Oh home with audio for some people can anyone else not Amy can actually gave me Oh people can hear yes so all the people tend to have more than one thing wrong with them we we set up a healthcare system and we trained our physicians to be very good at looking after people who've got one thing wrong with you so if you or you know my kind of age or little bit older and you have a heart attack we go into hospital get looked after by a by a cardiologist who's very good at looking after hearts they make the heart stop back it better and you go home and that's great and it works really well the problem is that when we get older we start to have more than one thing wrong with us so if we you know a great Hospital with our heart attack you're also having problems you know you've got reading difficulties you have arthritis you are struggling at home and you take lots of tablets often all the people have different priorities in their life they're not as interested in having very invasive uncomfortable and burns and treatments like major surgery they'd be mad maybe more and more interested in in their quality of life rather than trying to do absolutely everything they can to give themselves a longer life and people as they get older will often develop both physical problems with their physical functions of doing things and be able to do things and also with often with cognitive function and if we have problems with our cognition that is often dementia which like maybe talking to you about today and the other thing that geriatricians do which other physicians perhaps don't concentrate on as much is involving people both involving the family the patient but also involving their family involving other professionals like physiotherapists speech therapists and there's an awful lot of teamwork involved so that's why that's what I do that what I do as a geriatrician so one of the things that we kind of often come across in clinic people that we we n we we ask is what's actually normal as we get older we know that our you know throughout our lifespan what our brains do and how our brains work changes when we born you know we don't know how to speak we don't have to walk we don't know how to focus on things and through our childhood and development and a lesson said our hood we gain intelligence gain skills we our our cognition changes and what happens as we get old that we kind of you know assume that everything works pretty well up until a certain age in fact intelligence how open you define intelligence isn't affected by normal aging so people who remain as clever as they ever were very late into life it is normal however for people with short term memory to start to get a little bit worse as they get always normal to do come and get a bit forgetful and however people's long-term memory is normally completely unaffected by by normal aging so as people get older their memories of events in the distant past that were very significant that's things like no their wedding wedding anniversaries birth of their children and what they did for a living their job these are often unchanged and in normal aging people can recall a lot of details from their early life we're talking a bit about how that's important in dementia because often these long-term memories become much more important people with short-term memory is there is failure as we get older with normal healthy aging our reaction times get slightly longer so we often find it more difficult to drive and make decisions very quickly and the processing speed can deteriorate so it takes longer to think things through your vocabulary carries on increasing throughout your life so we can carry on learning new words and maintaining maintaining our vocabulary maintaining our language ability with normal aging and our ability to learn new things and new skills remains unchanged and it is perfectly possible to learn new skills even in late life with normal aging this is one of my favorite cartoons about how often see the caption reads high above the hushed crowd Rex try to remain focused still he couldn't shake one nagging thought he was an old dog and this was a new trick so if not memory gets worse in normal aging which we send people short Auto memory does start to get get slightly worse we get older when does it start to become a call and when do you need to think that you need to see someone like me or when do we need to assess your memory and when do we start to think okay this isn't normal I'm two kind of key questions we ask at that point is it's your memory worse than your peers is it getting worse than other people of a similar age is it noticeable to them is it noticeable to you do you feel that you are the one in your peer group or your friendship group who is not doing as well with their memory but the second thing is is it causing problems on a day-to-day basis if you're a little bit forgetful and you put your car keys down and can't remember where they were but then find them fairly soon afterwards then that's no problem that's not a not a major inconvenience but if you start to forget whether or not you've taking your tablets in the morning or forget where you left the car when you drove or forget you know things like going shopping and not paying any other things that you want it that's when it would start to cause a problem and that's when you we wouldn't want to start getting and getting some assessments now start looking into things in a bit more detail so one of the things that we will deal with in normal aging there's a concept called mild cognitive impairment so mild cognitive impairment is a condition where people have short term memory impairment their memory is getting worse over time but it's worse than we would expect that we would define as normal for age but of course normal is a very very broad continuum it's very difficult to say this is normal this is not not we have a a series of of tests that we can do and we will consider things in contact as someone gone from having a very good memory to having in slightly below average memory or someone always be forgetful and got a little bit worse sometimes that can be less of a change if there's you know a small change can cause more of a problem but the question is is it worse than one would expect is it worse than people's piezas it's starting to cause problems in Malcolm and we also know that they are there any other cognitive cons other difficulty do it with any other what we call the main of cognition I'll talk about that in a moment and finally to say someone has a mild cognitive impairment and to be just quote unquote mark up within that it has it hasn't known no major impact on people's day-to-day function so they need to be able to live their life pretty independently without having any extra help at home or happy to rely on other people to do things to keep themselves functioning and keep themselves independent so if we have someone who has worsening short-term memory who's getting more forgetful it's more than we would expect for being normal for their age it's worse than their peers but it's not affecting any other aspects of what their brain does and what how they think about things and isn't causing any major impact of their day-to-day focus them and stopping them from doing things on a day to day basis this will be someone that we would diagnosis having mild cognitive leap and now my own cognitive impairment is a problem that causes difficulty to the memory but for the majority of people about two in three people who have mild cognitive impairment they will not go on to develop further the cognitive their memory about one in three people so about a third of people who have mild cognitive impairment will go on to develop more significant memory or cognitive problems in the future so will progress on to having a dementia syndrome so what is dementia dementia is a group of conditions it's not one diagnosis it's not one thing dementia is defined this cognitive impairment which affects more than one domain so a domain of cognition is a job that your brain does it's something that and something that you use your brain to do so memory is an obvious example your brain is what you use to remember things and but all the things that are and that we use for our brains form or that domains of cognition things like a language so as I'm talking to you now I'm processing my thoughts I'm thinking about what I want say I'm converting those into into speech and I'm expressing myself verbally so there are so with different parts of my brain and working together in the moment to plan decide what I'm going to say choose the really words that I want to use and get them out there there's planning so planning is something called executive function so executive function is all about how we all want to do and how we sequence and problem-solve those those those activities so as an example cooking is a good example of an executive function so to prepare a meal you have to think what do I want to eat what do I have in the cupboard do I need to go shopping and then when you start to prepare you get your key ingredients together you have to do certain things in order you have to peel your carrots before you cut them off you have to then put them in the pan you know things have to happen in a certain order at the right time lots of other things around the house knots of a sort of daily activities of daily living personal hygiene all these things require planning and convolution sequence of events and that's part of executive function so using using tools and using things again around the house cooking is another good example so there's a domain of cognition called visual spacial dysfunction so that's working out how to put things inside other things how to manipulate objects in the space all of these things are individual domains of cognition and with the dementia syndrome one or more of these are by definition more than one of these will get worse over time it's also progressive so we to make sure things start off normal and then get slowly worse over time to diagnose someone with dementia with or typesafe not present since birth and has to mean going on for more than six months well if I see someone in clinic who's only had problems for three months I wouldn't say this is dementia I would say one it might be the beginning of dementia you can't actually put that label on it until that you until you have been having problems and until you've been having problems for for six months or more and and the final thing to make a diagnosis of dementia if that we have to demonstrate some functional impairment so a lot of people have noticed difficulties with planning things and it will take them longer to do it but if they're still able to do things independently without resorting to AIDS or other problems or other assistance then we would again call this a dementia syndrome so the diagnosis of dementia can be very difficult to make earlier because the changes are often quite subtle they come on over a lot a long time people are very good at managing and coping and covering up the fact that things are getting difficult and we don't do this deliberately or mendacious ly we do it almost subconsciously we the time assume that everything is fine we try and cope and marriage art and and carry on so in the early stages of dementia in very early dementia often no one notices what's going on and sometimes people partners or children or or close friends will notice but people will often be able to manage very well and it only when things start to cause significant countenance that people come to our attention so why does this happen your brain as I said before doesn't offer a lot of really important useful things it plans and does things and neglect your function it remembers things it solves problems it manipulates objects so these are the things that we consciously think about you know if you want to make a phone call you think where's my phone what no matter how dry down or number you have to think those things through but there are other less obvious things that our brain does and does all the time that we don't really think of as requiring much in the way of cognitive import or much in the way of thinking and the dots come to join me and so that's things like walking you know walking down the street or walking up the stairs is actually very difficult thing to do it's why we can't do it when we're first boy it's why we have to learn how to do quite a difficult thing too have to do because that's where sitting or standing and as we're walking we're making lots and lots of very rapid adjustments to our balance we're making sure that our feature in the right place we're planning where we're gonna put our feet and we are constantly thinking and planning and doing and our brains are putting lots of input into this bladder control is another really good example it's what my PhD thesis was all about is that your bladder is under our conscious control we decide when and where we're going to go to the bathroom but that's not an automatic process that is something that needs us to work on and us to think about so our bladder is something else that when dimension and effect awesome becomes a problem our bladder control can debate what can get worse and we'll talk about that a little bit as well no thing that our brains do that we really don't think about what sometimes have to be showing a bit more than we do is how we behave ourselves how we respond to social cues and social niceties how we react to other people how we express our needs and all these things can become problematic and people living with dementia because if those control mechanisms start to become and affected it can be very difficult to express our needs and express our desires and express our wants in a constructive way and it can become challenging for people to to deal with and express those and people's behaviors can be affected as well so Alzheimer's receives this specific type of dementia it and normally affects the short-term memory using the most common thing that those persons the most noticeable thing but can also affect people's language long term memory and visual spatial functions that's manipulating and using objects often behavioral homes are careful to relate to you in our times compared to other types of dementia and we don't really know why Alzheimer's disease happens we know that there are proteins that get laid now in our brain cells that aren't forward correct when we create proteins we have to earn and we have to fold the operator of click together very neatly no timers disease those proteins don't fold correctly and when they're laid down on brain cells it damages the brain cells we don't know why that happens there were lots of theories as lot to research going on but we don't really know exactly why why that happens so the communist question I mean ever ask whenever we do on these events whenever I'm in clinic whenever I tell someone that I'm giving them a diagnosis of dementia out sinus disease they always want to know what's the difference between dementia and outside this do I have outsiders or do I have to mention or does Mike Hartman have out signs of you document the best way of thinking about it is that dementia is what we call a syndrome so a syndrome is a collection of symptoms that has several possible underlying causes what are the causes of dementia is Alzheimer's disease so choose a slightly more attractive visual aid both of these are my pets the cat is Esme Bobbi's truly wearing my wife's glasses I don't know why her philosopher and but all cats and dogs are almost always pets but not all pets are cats and the whole pack of dogs so we can think about dementia in the group of being the the group the syndromes of the pets and then individual type being cats or dogs or whatever anatomy so Alice is disease is the most common form of dementia but there are several other types which we deal with so the second most Communism called vascular dementia that occurs when there's hardening or firming of the blood vessels that supply blood to the brain and that causes a series of tiny strokes so you have a large strokes usually fairly obvious you suddenly lose the ability to speak or you suddenly get weakness down one side of the body whatever it may be well in fact given a vascular dementia each stroke is really very small each one is far too small to see on its own but over time they start to eat away at the brain the drink explained moth-eaten you get a classical appearance on the brain scan where there's lots and lots of bit of little bits of brain missing and that causes a gradual accumulation of difficulties with that often that will affect slightly different parts of the brain to to to outside disease so people with vascular dementia will often develop challenging behaviors more early on their disease often present earlier with bladder control problems and things and often with only the language difficulties earlier rather than well from the memory loss that we see early on in our times disease the want of Lewy body dementia which is different cause advantage to the brain cells we get this thing called Lewy bodies forming and this will usually presents with memory loss and cognitive difficulty but also with symptoms of Parkinson's disease so people often get quite shaky or tremulous and they are very commonly experienced visual hallucinations as well and then there's Parkinson's disease which you know I think most people will notice is a disease that causes slowness and shaking and stiffness and shuffling and that can also be associated with dementia later on in life and particularly late in the disease of Parkinson telling the difference between Lewy body dementia and Parkinson's related dementia can also be quite bunging often if people present for the first time they've come to the attention of a physician it's with their memory problems or hallucinations it's much more likely to be Lewy body dementia whereas if they've been having movement problems and tremors for a long time and then develop a dementia syndrome then and then that will be more likely Parkinson's related dementia and then we we're running down into commerce law print stuff and I always say to people in this kind of event this going that I need to really worry about a new guys don't unless I told you to worry about it so things like picks disease which is then a complete language disorders first posterior cortical atrophy and a very rare disease called cadasil which is one of these genetic and forms of dementia which usually affects some of you on the people so lots of lots of different types of dementia lots of all dimensions that have features in common and then there are different features along the way which make us say okay this is this type or all this is that type and very commonly will tell people that they have mixed now that as their as the name suggests describes someone who has two types of dementia two underlying causes for their dementia syndrome the most common combination is our time disease and vascular dementia and that is mainly because our time is of us for the dementia other tumors common on their own so clearly it's going to be the most common to have in combination as well also because if you do a brain scan on an older person you will see a degree of shrinkage of the brain and heart and enthrone of the arteries it's almost ubiquitous and if we scan everyone in a fiber I can't go to the mall and find people now obviously but if when people were around about I just kind of pulled random old people off the street and scanned them I would find an awful lot of them would have changes on their drinks cap now they may well have absolutely no problems with their memory absolutely no problems with their cognition whatsoever but when someone presents with cognitive changes and brain scan changes Ellie okay that's probably a degree of vascular dementia here but the clinical features are largely Alzheimer's will label that as mixed dementia but a mixed mentor can be any combination so I know Eileen at the outside Society mentioned to me of the week when we were talking that they've had a few people who've been diagnosed with mixed dementia who have actually got park and Lewy body dementia and Alzheimer's and that's that's fine that does happen but it is much rare so most people have mixed dementia will have outsides and vascular and so you know how do we how we diagnose dementia this is what I do for a living and dementia is what we call the clinical diagnosis which i think is great because it means that all I have to do to make a diagnosis of dementia is talk to people I love talking to be books I'm nosy and people are really interesting and fun and you can find out all about them and that's fantastic and lots of my colleagues in other specialties do lots of tests they do scans and biopsies and blood tests and ECG and all sorts of things and that's great and close there though and thanks very much for doing it but yeah I'm a people person and I really like to get the story and 99 times out of 100 we can make a good accurate diagnosis of dementia based on the story alone so all we need to do is spend a good length of time talking to you or talking to your partner or talking to your family and finding out what's being going on finding out about you finding out what the differences and the problems and the challenges are that you've noticed and based on that that can help us the majority of time make a diagnosis work out what's wrong now there are no specific tests that we can do that tell us that someone has dementia or does not have to make and the only exception for that is if I take your brain out and spice up and look at a valley microscope yeah okay we can make a pretty accurate diagnosis there but people tend not to like me doing that so I don't and brain scans don't give us an agonist of dementia they show changes that may cause dementia they make a completely normal I've seen people vary about the affected by Alzheimer's disease very very disabled learning late stage disease have a almost Club normal almost the pristine brain scan I've seen people coming into hospitals other reasons how brain scan that looks horrendous but they are philosophy normal in fact I have a colleague years ago now I'm now working in the UK what am I and what am i doing doctors you know been to medical school fully qualified doctor working very well she's made good and came in with a headaches and a brain scan and she had half of her brain was missing huge system like this kind of big on her brain span and no irony idea was there very abnormal scan completely unaffected cognitive function so a brain scan tells us what your brain looks like in a scanner that's all it does do total blood tests there are some abnormalities on blood tests I'll talk about those in a couple of slides which can make people's cognition worse and they are things that we look for to see if we can treat them and make them better but as things stand there is no blood test and that gives us a diagnosis of dementia there's no blood test which says you have Granger and this is the tactic you have there are some tools that we use to help measure and quantify your cognitive ability of someone's cognitive ability so people who've been through clinic or Oh David has a thing David Matters has a question I'm gonna stop there and take a question type away David okay okay I'm talking about David's time and so cognitive assessment and our tools that we can use and tests that we can use to see how well people's memory and how all people's brains are doing so the two common ones which people may well have heard of some call the Montreal cognitive assessment of MOCA and which is a paper-based test it's Donna she paper in the office and it's got score out of 30 and you just basically go through different questions so there's question where you have to link some circles together drawing the clock drawing this in the shapes naming some animals remembering some words things like that what that does is it tests various aspects of what people's brains do various cognitive domains so it's a way of testing people for language skills short-term memory testing people's executive function planning visual spatial function concentration attention all of these domains of cognition can be tested takes about 10 15 minutes to do it's very reproducible which means you can do it several times and get the same score and can be and can be can be is very accurate and the mini-mental State Examination is a slightly older test very similar to the Montreal cognitive assessment but doesn't test as many domains of cognition is there less good test in my view and we still do it the simple reason that blue cotton makers do it before they'll pay for people's medications which I'm also going to talk about in a moment so David have a question how do that a loved one we suspect has dementia into testing the best thing to do is to talk to your family doctor and often family doctors are rather fantastic and do it very well they are able to do a lot of the kind of screaming and questioning and things and some of the more simple tests if they are concerned or not sure then the further off the specialist assessment will be someone like me or one of my colleagues at one of the hospitals or community centers around the em around the cities so your first port of call is your your family doctor or you can home health link on any one wall and they've got some really good then good contacts and they'll be able to call people in as well if you don't have a family doctor and I would encourage you to get one and we know that the single thing there are three things that are really important to maintain good health in all age you rich have friends and have a regular family doctor and I can't make you rich or and or find your new friends I'm afraid but and I can encourage you to get a family doctor and if you go on Alberta Health Services website they have a list of family physicians who are accepting new patients and do all the cognitive assessment that I was sometimes refer people for it so they called neuro psychology so I mentioned that the Montreal cognitive assessment takes about 15 minutes to do it's very straightforward it's not a challenging thing for for someone to administer our nursing staff will will are able to do that for us it's a relatively simple test but often it's not enough it doesn't give me the information that I need and there is a service over the hospital called neuropsychology and basically a Montreal cognitive assessment takes about 15 minutes and check some domains of cognition newest psychology takes about three hours it's administered by a specialist neuropsychologist who has doctoral level education they're not physicians there are psychologists and psychiatrists but they they tend to have PhDs in the subject and they will go through everything in exacting detail really kind of put people through their paces and talk through in great detail when do I send progeny or psychology it's usually when something isn't quite right if it's if it's not quite a pan that fits with any particular type of dementia or I'm concerned there may be something else it gives me a much more detailed overview in a more detailed picture of what's going on so what else do I think about you know what I'm seeing someone in clinic I want to know you have okay have they got progressive cognitive impairment lastly more than six months affecting more than one domain of cognition causing from impairment doc wasn't since birth I can establish all those by talking through and okay you know this is a looks like a dementia syndrome what else I need to think about because there are lots of other illnesses and other things that can make people's memory and make people's cognition not work so well you know we more i suspect on most of us a feeling the position on a Friday or Saturday night well we've been out with some friends we've had a few drinks and we've done about cognitive dysfunction we are socially confused as we often though now that is a very obvious you know someone a drunk you wouldn't you wouldn't say they've got to mention doesn't it gets better very quickly it's not being going on very long and it gets better very quickly whether there are other more chronic and longer term conditions which can cause cognitive impairment so the obvious one is always had a stroke often a stroke will affect a particular area of cognition if it affects your language Center for example so it takes out of your brain that you use to speak then you lose the ability to speak but that can get better it's also not progressive one big stroke causes a problem but either stays the same or gets better at the time and there are various endocrine courses or endocrine systems your hormone system and so typically having a very low thyroid hormone being profoundly hypothyroid can cause people to have cognitive function thyroid hormone is the-- is the driver is the corpsman makes you go and if you're not producing it everything slows down so your heart rate slows down your bowels slow down your metabolism slows down so you put on lots of weight and you're thinking that slows down as well then people with really bad hyperthyroidism can present as if they are profoundly demented but you replace the thyroid hormone less thing gets better due to depression if you have really severe depression really your brain just shuts down altogether you lose the ability to to think things through and there's a condition called pseudo damage which is just actually a really severe depression which looks like mention when you start you've gone appropriate empty antidepressants and start people getting better and their dementia will often get better so one of the things that I'll be assessing mean thing because people move so I'll be asking has been fairly cheerful recently have you be down in the dogs how you sleeping how's your appetite very common one that I see of medication side effects so the list of medications that can stop your thinking properly is as long as your arm but the classic ones are things like sleeping tablets semantic depressants antipsychotic medications and he histamines so benadryl and things like that it can make people confused and opioids and pain killers so I've had people who've be having bad arthritis have been started on oxycodone or fentanyl and for their their pain and then they start to get confused and drowsy and forgetful and people think they have dementia but you stop the opioids and then he gets better and disordered sleeps obstructive sleep apnea something else that can make people's cognitive function get worse you know we've all had a bad night's sleep and I felt really sluggish in the next step if you have severe obstructive sleep apnea and you're not sleeping at all well ever that can present as a dementia type syndrome and yet you can see how getting and sleeping better and make everything gets better as well and the final one which is really small playing stuff and it's very very rare a brain clueless so very occasionally people can be developing the grating that can present the content there but I will almost always present with other symptoms as well so that's things like headaches weakness visual changes so one of the things I'll be asking about is how do you notice any changes you're breathing have you noticed any change to your your motor strengthening things like that we've got another question thanks for the question we're being hyperthyroid cause any dementia signs of symptoms much less commonly than hypothyroidism so hype having a look under active thyroid is a much more common cause of dementia overactive thyroid but it has been reported in it can happen so one of the things that we will check as part of a sort of routine workup is it's a thyroid working normally and if it's not will correct it and so who is it that that I would see I think actually I want more testing here I'm gonna do some blood tests I'm gonna do some brain scans or anything like that it's basically when something doesn't fit if there is something on the story which isn't quite right if it doesn't fit with how I would expect a disease to progress in an individual someone who's presenting very young for example someone who got a very rapid onset so some of those groans friend perfectly normal to very severely affected in three months and much more likely to be aggressive with a lot of tests then it's someone who's been getting slowly worse over ten years and people have unusual patterns of difficulties so Outsiders present usually was short-term memory and then other things it's when things start going in unusual orders or neutral ways that I start to think is it something else people who have associated symptoms like weakness and headaches and things that's when I start thinking about tumors or lots and bumps and people have got a lot of vascular risk factors because these the guys are likely to be having lots of small strokes they're presenting with changes on their brain scan and vascular type dementia I want to be much more aggressive with lowering that question or getting their blood sugar under control getting their high blood pressure and different for all those kind of things the problem is of course that by doing all those things I can cause more problems you know fine lowering someone blood pressure I'm gonna make them feel dizzy and unwell so I need to make sure I'm doing it to the right reason rather than just to choose a number I always have to be treating a patient and probably having at the moment and if that we've got very long wait times for for brain scan so brain scans I'm requesting now and be booked about 18 months hence and that's a decision that's well above my paygrade unfortunately so without Glasgow Jason over the leg why why that's occurring but is there is there is a big problem at the moment hopefully I'll get we'll get sorted out so Helen has a question about research I'll talk about research and at the end if you've got mine so I'll come back to that if I forget it just remind me so I see something clinic I asked lots of questions I perform an opinion that this is a you know dementia syndrome specifically a type of which specific type of dementia it is I decide when North you some tests one of the next questions people ask is okay so if you a medication that can help the first thing I need to do of course is identify the identify the and any underlying cause I can reverse so can I make that thyroid better can I control their diabetes better whatever it may be but if we make a diagnosis of Alzheimer's disease and we've decided that's the time and dimension that we're dealing with there are a group of medications called cognitive enhancers and the way these work is that our thoughts are actually just seals between brain cells so one brain cell sends a signal for the next brain cell and that's fairly simple but when you've got enough brain cells doing that you can generate some very complex thoughts in exactly the same way of computer does and now that signal is a little chemical called acetylcholine what happens is that the nerve cell releases a little birth of a star choline and the nerve cell next week detective now the cognitive enhancers work by stopping that from breaking down so when we release acetylcholine it's broken down by something common and to cholinesterase which is a type of enzyme which takes a molecule and breaks it apart if that didn't happen we wouldn't be able to stop that signal so you have to be able to turn it on and turn it off the egos work by blocking the turning off mechanism so the chemical is released and detected but then it hangs around for longest with boost the transmission between brain cells there are four main ones that we use so those are two metal or receptors for those : go out Tamina reminyl we distinct me X long it's more useful in Lewy body dementia and the manatee or a dickster works in a slightly different way but it's not covered by Blue Cross unfortunately so in whom do we use these these are useful in people who have what we will call mid stage disease and that's defined by the New Cross and by the scientific literature as having a mini-mental State Examination between ten and twenty five that's out of 30 so you may want thing or wine what's so special about those numbers well the answer is that if your mercy is above 25 your dimension is so mild that there is no benefit to be had by taking medication or rather the benefit that there is is so small that the side effects outweigh outweigh the benefits and likewise if your MMS is below 10 and you have quite severe disease and then they do very little because I'm is insufficient brain activity left to be boosted by by the drugs so they are very useful in the middle stage of the disease and what they do is they slow progression of disease but the absolutely crucial worms are the last two here which is this grow progression of the disease on average and what that means is if I take a big group of people who have a diagnosis and out-science disease and measure their MMSE and find the average I can then split them into two groups who have the same average MMSE I give half off of a drug half on the dummy pill of sugar tablet and then six months later I come back and measure everyone's MMSE again in the group that had the drug there MMSE would have thought but it will have dropped by last been in the group that didn't have the clock so there is an average fall or average deterioration which is smaller in those that take the drug than those that don't but you can't say anything at all about each individual person in those groups I can't say you know Jim here is better than he would have been how you not taking the medication because he was honored or Dave we didn't get the drug would have been better because there is a lot of variation within these so on average it slows the rate of progression of disease and that's pretty much all they so who do I give them to well what they want the down side to make it oh you know to quote Donald Trump what have you got to lose and roll with with continent hands is what you have to lose our control of your bowels unfortunately and got they could also cause headaches they can cause an upset Tom and diarrhea they can make you lose weight they can cause and the gesture making cause dizziness then feelings of faintness and very rarely they cause problems with the heart rhythm slow the heart down and so the risk that has that has a question here and missus says I was under the impression that medication didn't slow these down and they're just massive symptoms of it so it may seem like the progression of slow even the progression is still happening on the news messages does it actually slow the progression of the disease that's a really interesting question and answer actually we don't know we don't know whether or not it's close the changes within the brain what it does is it slows the symptoms now the thing about a syndrome is that the symptoms are all that's important I said before I could do a brain scan someone with no signs or symptoms of dementia whatsoever and find a really damaged looking gray or I could do a brain scan someone who's got really about to mention a family Christine looking great works the same with the drugs the drugs slow the rate of progression of the symptoms and the problems we don't know what they're doing to metal brain itself so those sort of million-dollar questions are the drugs worth it and sometimes if these somewhat unsatisfactory answer my crack is is that if I feel the drugs were appropriate for someone if I think they're likely to help and that the benefits of taking the job is going to be more than the harms that the drugs can be causing we'll give it a go we'll start off alone dose will increase the dose for about six to eight weeks and if things are being tolerated not causing any side effects or carry on with it the problem is we don't know how well they're working because we can't say how whether working we can only say there is an average benefit I would tend not to use them in people who are very elderly people who are frail or have lots of other problems people have severe disease or presenting relatively late in their disease and people who have lots of other medical problems and taking lots and lots of pills I will often see people coming into clinic who have you know a sack full of tablets then rattle when they walk they're spending hundreds of dollars a month on medications you know the last thing they need is another pill being thrown in for the gospel so what I've try and do with those guys is that to get them off some of the coals that they don't need to reduce their tablet burden and reduce that side effect and other medications only sometimes consider for people living with dementia a medication a school back seat empty psychotics so these are drugs like haloperidol or Haldol quetiapine risperidone olanzapine drugs like this these are used in much later stage disease and often in people who are exhibiting what are called behavioral and psychological symptoms of dementia or bps D now this is the term which is kind of going out of fashion we're using it less and less now because if the labels and cuts are quite sort of negative label on what is often quite reasonable reasonable behavior if you see it from the person living with dementia is perspective so they describe behaviors which are challenging or difficult which are really kind of expressions of unmet need you know to use an example if I you know was hungry then I would either go downstairs and make myself get yourself a snack or me a sandwich or whatever or I could express to my wife and say could you get me a snack I'm feeling if you're off you bathroom you will go in this find the bathroom do what you needs a bit if you need to excuse yourself because you're in the middle of a conversation you will say excuse me obviously to bathroom and off your girl if you're living with dementia of dementia is severe you can't process and understand and verbalize and express those so you may be very uncomfortable because you really need to pee but you can't process the sensation think I need to pee and you can't say to anyone I need to pee and if you have severe dementia you may well not be able to find where the bathroom is where identify wet bathroom is so you can't calmly and calmly and reasonably explain that you need help getting the bathroom so you can pee all you can do is get agitated and shout and sometimes get aggressive so these unmet needs will often express themselves with behaviour which other people find challenging and often unfortunately these sort of they're the first and the the first and the first tactic that people use is to reach for the prescription pad and give someone a drug to Carmen nap now if you need pee you don't need a pill to calm you down you need to want to take you to the toilet help you pee and so the the drugs and psychotics can be helpful they have a place they have an awful lot of side effects they are very high-risk medications of course Falls they can cause diabetes they now see they predispose people to infections they make people fall and break their hip and they are associated with a quite significant increased risk of death so they are you know these are serious drugs it's a very difficult decision and I feel that this is a decision that should really be taken by an expert in conjunction with people and of course I would say enough because I am an expert but you know that's kind of the point of the expert and I'm just going to break off there and there's a few and a few questions here so and so Bill wants know how you mention the slow down well that's the difficult thing isn't it so it's tricky to know what would have happened otherwise so all you can do which is what they've done in the files it's compared two groups of people one group of people who've been taking the drug one group you have the dummy drops so everyone starts off here people who tend to get to here even though we feel get to here so we know there's been a slowdown we know people have got worse but it's less than it would have be on average but it's a very very difficult thing to measure and it's always impossible thing to measure in an individual you only do it to group the people and it's a way to test for Lewy body dementia my own imaging yeah there is a scam called the DAT scam which can be used to test first and doing body dementia there's also thing called the PET CT which is there a type of CT scan which awesome which is brain activity and you get different patterns of changes with Lou you maile dementia and Alzheimer's disease but the the key thing with all types of dementia is the story that people tell so how people's patterns of cognitive change have happened how it's affecting their that's how we tell the rebodied dementia classically behavioral difficulties early visual hallucinations early movement disorders early and then memory problems a little bit later on so it's like I just think Pam you will get without sinus disease lisa has asked a very aggressive question what's considered very elderly and although my dad is my usual faith benchmark and but actually it very much depends on the individual I have 65 year olds who are physically very elderly because they have an awful lot problems they're very frail I have 19 year olds who are decidedly sprightly and when we extremely annoying if I referred them in oak so that is a judgment call there's no no cutoff it depends very much on the on the image or individual and so Debbie has a question time lounge of hearing aids how can we tell if a person with Bagley's dementia is with it or not are you having experiencing one person that has different story events with someone else neither people sure which story is great one person thinks the person they can send a conversation at the time other than the other things it might not be reasonable how many different events and conversations creating conflict within a family oh oh that's a tough one Debbie that is a really difficult thing and it's it's something which often causes and causes conflict within these and causes causes problems and I think the the key thing really and that sort of situation is to remember that the someone living with dementia may not be any reliable narrator so you have to be really careful to keep a very open mind about what has happened what may be happening about what they what this issue of the situation may be in and really trying not to get into conflicts with with the person living dementia or with other members of the family and really trying to corroborate and and be be open-minded and try and really kind of get to the bottom of things as best you can but it really does depend on Pauling individual circumstance and exactly what's going on the moment we we do get a lot of problems with one person says one thing one person there's another who's right who's wrong and and it's it's almost impossible thing to to to resolve sometimes and one thing I do end up doing the clinic is it sort of orbiter almost being the judge in arbitrator between between family members who have different different views and different opinions so what are your medications which people often use with dementia are the antidepressants so depression and dementia will often coexist that's partly because of the changes in the brain you know the the brain cells which you use to regulate your mood are being damaged by I or dementia symptoms so low mood is a very common cause of dementia and if you are depressed that will make dementia worse independently so we're often quite read quite keen to treat it the other thing of course is that literally dementia is difficult it is a challenge it makes things more or more challenging to use and more challenging to do difficult to solve problems and and you know it's understandable you have a low memory if you be diagnosed with a horrendous disease you know if you had someone living with cancer would be perfectly reasonable for them to be to be a bit upset about it and be depressed exactly the same for dementia so the the selective you're taking images or SSRIs these are things like citalopram certainly paroxetine fluoxetine esta teletraan can be very useful in people with depression and mild to moderate dementia they are somewhat overused in people with severe dementia because when you have very severe disease the concept of being depressed becomes a little bit more fluid and much more difficult to work out and the evidence is that they really don't work very well in severe disease so this is awesome all the things that I will try and cut my back off because of their side effect but as Elena's fine different class of drug it's a similar face as her eyes which works in a slightly different way this is a really specific place because it's a antidepressant so in cures you moodiness makes you drowsy so you can use it at night to help you sleep but it also makes you really really hungry now that make James who's a GP back in England siting here for his his lone mood and it made him ravenous he told me once that he was a one time Christmas Christmas it even lost when he was taking with a subpoena he was psyched the whole needed a basting the entire turkey on his own and but people live in dementia particular my fast manager will often lose their appetite start losing weight so Matassa beam can be really helpful drunk not because it's good antidepressant although it is but because the side effect is it makes them hungry so we given a job their staffing rather than eat more way it works really nicely you're the one that we often uses trazodone which again isn't that depressant with scientifically being drowsy feeling use that at night to help regulate people's sleep which brings us neatly on to sleep how is sleep affected by dementia there is a condition called day/night reverse on what that means is as the name suggests day becomes night in night becomes day people stem to stay on later and sleeping more it's basically basically and bit like being a teenager then you don't to get up in the morning you want to step 3 o'clock in the morning and the question about his past I assume that's a realistic meaning patch and yeah it can cause very visual very and very dreams we normally recommend tea people take their cognitive enhancers and platon things first thing in the morning because they they stimulate your thought that's how they work that's the point and so they can they can if you're either you take them at night or the patch which works throughout the day and can make you have very very vivid dreams yes and and sometimes sometimes can can can cause problems with sleep a question about Matassa peeing canvas has been caused cognitive impairment no not particularly and isn't one which which we Wardle remain being a being a cause of cognitive impairment and the drugs however which do cause cognitive impairment a sleeping tablet so benzodiazepines and what call those eggs are things like zopiclone very well associated quite a strong link with cognitive impairment and increase risk of dementia so these are drugs which we really try and get people off there is a problem of course that the vendor's benzodiazepines are incredibly addictive they're terribly Moorish and they are quite difficult to get people off if they feed on this a long time so the real economy important message there is don't start and there could be possibly can avoid it we need a sleeping tablet melatonin is a safest option and that's over-the-counter if possible if you're living with someone who is living with dementia and you're having problems with them wanting to stay up late and sleep in late if you can try and go with it just try and shift your routine with them and because it's actually safer and easier to adjust your own bedtime and stay of later we can have a cover lying rather than trying to force someone onto our timetable the problem is of course if you don't need carers to come in from homecare they're on their own timetable and we run into terrible problems with people who need care is to help put them to bed the care is shown up at 7 o'clock in the evening and people don't you want to go to sleep until 3:00 in the morning so then when lying in bed and brought out in our minds nothing to do find difficult to express those feelings and start to get agitated so that's in the morn of these problems where people live in dementia if we compare them run with what they want it makes things a lot yeah so this is the the question that I get two questions that I dread in my job are this one and the other one which is you're looking after my elderly relative in hospital there and well I in Australia do I need to come over and the question of course is is it time to move someone into care then the fact is I cannot answer that question I can't tell you that it's it's time or it's not time and there are some triggers that we will look out for when I'd start to say maybe it's time to start thinking about this people that need frequent assistance because of their dementia both during the day and overnight and especially when that care is unpredictable if you know that someone's going to need help to get up in the morning and go to bed at night we can usually manage that with carers coming in and but if you are needing help random times by day and by night and often leave more than one person - if you need two people to get you on off the toilet for example that may be a trigger that we need to think about moving for a higher level of care the other thing which really worries me is people that feel they can't leave their spouse or their are not alone so if you are not able to go out and get your hair done or going meet your friends for coffee or go to the war without someone supervising your partner that again is one of those triggers that makes me think it may be time that we need to think about looking at a higher level of care the caveat here of course are that everyone's an individual Engles needs are different animals physical and cognitive abilities as a partner are also different so if you're built like me that's perfectly okay you know it's much easier to get your very slender wife in the mount of the bath than if it's the other way around and you've got someone who weighs 40 pounds charlie someone my size in there they're going to need a lot more help but needing care needing help and needing to go into care is absolutely not a failure this is a real kind of common that people run into and there's an article in The Globe and Mail couple weeks ago about people in care and the current pandemic and basically saying you should remove your your system care homes and that's really unhelpful because of course people go into care homes for a really good reason and you can just work this out because if you go into any care home and long-term care facility I'll just count the staff you know in a 24-hour period there will be at least three staff members per per resident working in a time shift if you include the cleaners and the cooks and the management all these staff will have two days off a week so they'll not weather weekend they'll have some days off midweek and they also get four weeks paid holiday a year where they can just go away and do their own thing and got if you're a care barn for someone living with dementia you are doing this on your own you know you're doing it seven days a week it's two weeks a year 24 hours a day you don't get to go home at the end of the day and forget about you don't get to go off to Mexico for two weeks on a nice holiday every so often you are completely sober and so feeling guilty that you're not able to do ten people's work it's completely irrational it's extremely common hey does it everyone thinks I should be I should be able to do more if only I'm tired harder know people who come to my clinic and say well why can't I look after there's not 12 we mentioned right back at the beginning that you're glad you're back now oh and our conscious control our brain is controlling them and and dementia impairs that ability the way our bladder works it's actually really interesting and I can throw that as a whole other lecture having nothing works but you're glad that is basically telling you continually how full it is so all the time your ladder is saying to your brain I'm not fooling a bit for I'm getting fun I'm getting fine I'm getting four and sending these messages over and over again and I agree nalu's and ignores that all the time so we're constantly just telling our bladder to hold on and we're just then we're just using a little bit of our brainpower all the time tell um I will hold up and gradually as everyone gets formed in a fuller and fuller it gets more and more difficult it starts to get uncomfortable and that's when we think okay I'm going to go and pee now when you have dementia the areas of your brain which you use to do the whole thing off are being affected by the dementia which makes it more difficult to hold on so you get this condition of urgency where you get this sudden I've got to be the right now healer and that's when people are until you find it all of a sudden if you mind they've got to go and the only thing of course is that if you have dementia that makes finding the bathroom more difficult particularly if you're in hospital if you're in a care home environment we don't like talking about toilets we don't like forming our bathrooms are we don't often point them out as well as we should we can't talking around the corner we don't have good signage so if you have visual spacial dysfunction you can't find the bathroom very difficult to to navigate your way there so what can we do to help with that there are medications that we can use and Owen the continence clinic at the Glen Road we do use those so there are medical things that physician can help with so it's worth a chat with your family doctor again but also learning to what the signs are so people living with moderate to severe dementia you'll remember back when the children were tiny and then you will need a wig act when the potty training there are sounds like that and you can be caught in your partner and when you see them ask them and remind them say do you want to go and feed take them off to the toilet if that's not working you can also tie something called time dividing which led basically every 90 minutes for two hours you offer an encourage someone to tie in going Pete much like you would do before a long car journey you just do that throughout the day that gives you a bit more predictable bit more predictable toileting in terms of the bowels there's a really clever thing called the gastrocolic reflex which is basically about half an hour after breakfast you need to empty your bowels so if someone's living with dementia as I'm in trouble without control after breakfast about half an hour later go and sit them on toilet and see if they'll move that house and that's the best time to do it because with your bowels what you want is a predictable controllable male version incontinence is common in dementia but is not inevitable and there are often treatments available so this is something that again it's really worth talking to your family about coming off your about and how the end of life this is is something that people often often come and struggle with and and often often becomes an issue and very late stage disease dementia unfortunately for many people can be a terminal illness and on average the survival rate is between 10 to 15 years after diagnosis but this is incredibly variable and their eyes there was no good way of predicting this most people or a lot of people who are living with dementia well actually reach the end of their natural life for another reason unrelated to their dementia they'll have a halfback or a stroke or fall off a tall building and their dementia will never be a threat to their life but for some people unfortunately their dementia is the thing which which ends their life the reason this happens is that in really civilian venture people actually forget the need and that lose the ability to eat and drink safely first and homier are both become very primal desires but they still require your brain to process and interpret so into the parts of your brain that you used to do that are becoming damaged right by dementia often it becomes something that you are not able to do and we can help with that in terms of offering food looking appetizing food supplements I mentioned it has a clean energy ROM as an option these are all things that can help but if they're not working often it's it's the thing which will lead to the end of someone's life is that there will just lose weight they'll become dehydrated because they're just not able to eat and drink so one of the things that we really need to encourage and some people living with dementia and their care partners and their families is to have these conversations about what you would like end of your life to look like because I guarantee you not one of us is making out of here alive so we all need to think what's gonna happen toward the end of mine towards the end of my life I want to pass away at home but I want to be a hospital I want to be in a care home hospital one of the options these are things that we talked about early talked about them openly no one likes talking about that of death of course but if we do talk about it then we can get a much better idea of what someone's wishes will be rather than having to make a decision in a panicked situation in a rush and have someone like me who's not met me before or someone in emergency department or in ambulance making decisions for you and so where are we 10 I think okay and so this has been a real kind of quick and slapdash an overview of of dementia I've covered what dementia is how we diagnose it how we work through the process and what the different types of dementia are we talk about the available treatment options we've talked briefly at some other problems in terms of behaviors in terms of placement and change in living environment we've talked about bladder and bowel continence we've talked about some issues at the the end of life and I'm very happy to take questions I'm not on the clock at all I have no great answer most of the evening and so we can we can carry on sending questions in there was a question earlier on about research and what's going on okay I think the good news is that there are there's a lot of research going on at the moment in terms of about thymes disease particularly her all the dementia syndromes and there's a lot of preclinical work going on so there's a big unit at the University of Alberta who are interested in what's called prions so prions are the things which called mad cow disease so close to my heart so I spent all of the 1980s eating British beef but there are similarities between between misfolding of proteins in prion diseases and in Alzheimer's so there's some therapeutic options working there there's something called the oxy user also deoxycholic acid and besan works on vaccines so the idea that we can do a give a vaccine to try and prevent the changes caused by these proteins that's being tried and mainly in animals at the moment so I think we're a long way off the being being of any use of humans the drug companies are obviously carrying on the commerce planet trying to find better and more targeted drugs or stuff going on there the good news is that the rate of new diagnoses is falling the dementia so although the number of people with dementia is getting higher because people are living long with dementia and because our our aging population the number of new cases per head of population per age group is actually falling largely because people are smoking as much as they used to and largely because we are better at treating diabetes and heart disease and strokes and things like that but that is there sort of a good news story so there are few and new cases of dementia than they used to be but there are cause more and more people dementia because in can you case adds to the answer the caseload and there's lots of work going on around best practice for people living with dementia so what's the best way of managing how do we cope with things with my challenging behaviors how do we make sure that our care homes are high quality what's the best practice at their homes there's a there's an awful lot of research going on when for what there is not is a magic cure or fantastic pill anywhere in the near future so all the research that's going on will be great for people in ten years time or 20 years time not much useful now unfortunately I suppose and so you know else have any questions unless it was doing nothing or it was typing furiously I've got no way of telling Oh dr. Gibson here I'm begging it oh okay I'm sorry my apologies yes you do know quite a few functions I could come through in the chat time to answer is as possible and el2 trying to pushing them through yeah the continued need to leave you've given our past yeah however this is being recorded and it will be posted tomorrow on our sod cafe so if you'd like to finish the presentation and hear the answers to some of the questions being asked me to take a look for it there and yes so I'll start with the first question came back around the time when you're discussing sleep I'll just post it in the chat for you to see okay okay so so I was talking about day/night reverse on people going to bed late Kingstown is completely opposite so just a case like please try and make me look silly so and that's the opposite you also get up very early and go to bed early you're supposed to take naps during the day should we let him sleep whenever he wants and okay again not uncommon for people sleep to change the other way so people kind of shift forward and start getting up really early morning and in general my advice for people who are caring for people living with dementia is to as best you can roll with what you've got and not try and change things that you don't have to change you know always kind of ask yourself is this the hill I want to die on it's this the argument I want to have do I need to have this disagreement and I think that yes certainly if he's if you got is getting overly and then his time during the day having a a scheduled nap after lunch a siesta will do him no harm at all may will give the rest of the family a little bit of time off as well half time and recharge the batteries and have a have half an hour - now I have a coffee and relax and yeah I think do you and do you entry whenever he wants it's one nice or gray yeah if you want sleep literally all the time probably not you know if he's having a four-hour nap in the afternoon and then come here to sleep in the evening I try and keep up during the day but if you're able to get to sleep in the sleeping well and once have another sneeze during the day I wouldn't be too concerned about that is not something that I would I would fight because I think having the having the argument and trying to keep what when he wants to sleep it's just going to upset everybody and it's probably not not worth it so question and from Laura what's the next step after asking general position of assessment for dementia who you referred to and where and well it might be me it might be someone else and so there are basically two groups of doctors or three groups of doctors who reveal one dimension who is Neurology who with the brain doctors they're more likely to be referred if you are younger there's geriatrics like geriatricians are internists who are especially trained in older people and in our birds and also have what we call caring only physicians who are family doctors with actual training in carrying on people so there are clinics for carry only and genetics at the University at the Glen Rose and the Alex and they're not the other side University at the Glen Rose that the great lines and at the maids and there is a clinic out in st. Albert there I think you want to show a park there's a clinic in I think there's one in the Duke there is a clinic for Saskatchewan and my colleague dr. why does a clinic out in Mayer thought I'm your clinic having big reveal so and you will be referred through what we call central access so basically you're you're fine doctor fills in a form that basically says I've got someone who I think has dementia please will you see our advise and then that go you on the pile and if you or you hope to have expressed a preference what we do individual physician or an individual note Asia and then then that will will be honored but may will be a slightly longer wait time if you say I'll go wherever in the city not a problem then you'll go on the next available appointment and so it's yes so basically family doctor referral goes into central access and then you'll get allocated to to one of either geriatrician or parallely and our clinics throughout the city and throughout the province I call from further south for the new also clinics in spectryx in Calgary and concerning towns as well of course and so the other question the king is and we respected forgetting how to eat well absolutely forgetting how to eat certain foods at first and not particularly and people who are living with dementia who are not at the point of you know kind of really end-stage when they're not eating at all may well become more picky about certain foods their tastes they change and our tastes often change as we get older anyway because of changing the taste buds lots of medications can cause problems with with with tastes we have normal tastes you could also get an oral thrush we can get a kind of infection on your tongue which tastes horrible and so that's then cocaine use and pomace with the teeth something else or if you've got ill-fitting dentures that can make you stop eating and people will often you know something go off to roots and if you sit down for a really big meal often people find that a little bit intimidating they can sort of sit down and and face a huge great playful they look at it and want to munch and lose their appetite so they and one thing that's really helped from there is to offer small needles but really frequently so you'll have a small breakfast and then loading later we'll have a small second breakfast and then you have some elevenses then light lunch and then a little early afternoon snack and then tea and cake at 3:00 in the afternoon and then a like soccer and then a second supper and then a snack before that and spreading out your food throughout the day little and often offering favorite foods and things that you know people like and trying to get as much you know as much bang for your buck as many calories as you possibly can you know the time third sugar-free cakes and you know low-fat yogurt that's gone you know if you're living dimension and it's a struggle to get enough food into you you want to get the good stuff so it's you know kind of all the nice things even then I use else on that 70 years and you know good biscuits cakes cheese whatever it is that you fancy some people and perfectly recently find a look like to show you before dinner can be very useful it's got a decent the more calories in it and and and there's also appetite stimulants own aperitif can be a good idea obviously if you find that giving someone a little showy makes their memory significantly worse you know something you need to stop doing but often worth a try and if we modern disease and and and bombs with their with their Akutan calls either in take another question Haven teen about is it common for people with Alzheimer's to score food in their cheeks and yeah it can be and pouching people do it because they really sort of um chewing and swallowing isn't it's a really complicated series of muscles as low as 57 muscles involved I think from memory correlate a certain way you have to chew and move around and create a food bolus and then move it back and then swallow it there's a lot of kind of coordinated actions there so and yes it can do and the best way to remind them is just to say you know and to say you have you finished that mouthful don't forget that you and having a lot of sip of water link between them between things that are between between bites can be helpful and the food clinic we have a dietician who is a specialist in in nutrition and and diet and intake will have speech-language pathologists and they're very good at offering and suggestions around how to help with things like repairing and scribbling I see Gail's got the same question as well about taking too much through you nothing against the two and swallow yes so and it's about sickly people as they eat and trying to remind them to take small bites to to copy to move it around to swallow it can be very tiring you know you and it's a real kind of effort in the battle and it's it can be one of those and one of those times which is a kind of source of stress for people food and nutrition and you know through is love in many ways isn't it it's one of the ways that we we express affection for each others by preparing food we mark all of our kind of milestone with cake birthday cakes and all parties and things so often there's a lot of kind of emotionally involved in York of having food and people are enjoying it or people are on to arts art it's not giving them the pleasure that you wanted to give them and so this it can be a difficult thing to deal with it but taking the main food shop even got plenty of time to eat offering small meals and they're not getting again not being overwhelmed and things I hope that answers the food question but and this is one of those things that he's becoming an issue and mention it to your geriatrician or two-time doctor and we can get speech-language therapy to do some exercises and to and to to sort of give symptom tips and clicks so don't know about bowels is random diarrhea parcel of dementia and not particularly the two things that I think of in someone who has random diarrhea is going about to diarrhea and firstly well first thing is there something directing the mouse or things like diabetic you like to do - well syndrome can both cause cause diarrhea so I'll ask questions about that and lots of medications including rivastigmine can upset the bowels and cause diarrhea metformin is build along what we commonly see faster people diabetes they're starting metformin that can cause Gordon to have died over inopportune times real thing that I really look for is what we call overflow diarrhea and what happens there is someone has beginning constipated so their bowel is filling up and when their markets completely full of old hard stool there's nowhere for the new stuff to go so when you're when you eat food it goes into your your Cola into your small intestine nor the nutrients are taken out and it forms a sort of a brown watery slurry which then gets dragged out and convert it into a solid motion by the large bowel now if your large bowel is completely full then that slurry has got nowhere to go sorry brush it around the sides and you get all of a sudden you get diarrhea and I apologize in advance but the classical description is that it looks like a McDonald's chocolate milkshake it's that kind of consistency so if you have new random that I mean which just comes on all of a sudden and it's worth popping on to doctor to have a chat and be examined and check the backend and make sure you don't really have constipation because constipation presents the diarrhea which is really weird and counterintuitive so people people and people take imodium or something to try and stop there they down here which of course makes the constipation worse so it's something that needs you need to probably worth getting getting checked out and having a chat with yes I'm a doctor yeah at your next opportunity so Janet also NZ time to consider taking over control of family members affairs it's a really another really difficult question because it's really individual and it's a kind of thing that we need to think about quite carefully because it will get it wrong that can be disastrous in both ways you know if we if I declare someone unable to manage their own affairs when they really are then someone could sell their house against their wishes but if I say people are able to manage their affairs when really they're not then they can be taken advantage of and he'll lose huge amounts of money and the key thing with the Affairs is making sure that well ahead of time you have your power of attorney in your personal directive in place signed sealed and put away for a rainy day the reason for that is if you have those documents sorted now then when we need them they're ready in Waiting getting a power turning personal directive is a very very simple thing to do if you are able to make that decision at the time it's kind of even that any high school boy and how it with it's a you know two or three hundred dollars it's not very expensive it's not particularly difficult if you are unable to make the decision to nominate of how attorney who you don't have them and we need to appoint a guardian or appoint you an attorney then we need to go to courts we have to get a judge after getting lawyers and you're looking at five figures in bills it's a huge amount of money and it also takes several months so we've had people in hospital who had to stay in hospital for you know up a year in some places some some occasions rather because they do not have these paperwork the paperwork the meantime and then there's a disagreement out who the attorney is going to be and it ends up getting horribly messy so if you can get your own cart and you sort it out and the trigger for when we will need to activate that is when is there a decision that we need to make so do we have to make a decision about someone making large financial commitments or moving home or whatever it may be and when there is a trigger and decision to be made we can assess if someone can make that decision they can't we allow the person that they've nominated as their attorney to take that it's not and it is so to directly on for question how you telling it time it's a very very individual decision it's a very complex discussion it's the kind of thing that often I spend a lot of time with coming going over to meet latitude and Israel limit as to how often you can do an MSc or a mocha and technically not I tend to do once or twice a year and kind of six months tops because things don't change till early quickly so it's not worth doing the more often you do get a degree of what's called learning effect they are you know you can actually practice billing the mokra so if you do them too often you can get a falsely high score because people remember the the five words are you know face of our church daily read for example the five words on the no I do like 12 days a week so a bit I develop dementia because I'm gonna be really good at doing omocha when I'm when I'm off and but and there are several different versions of the motor so that is less of an issue but yeah I would always never do one within three months of hanging on a previous one they occasionally do one slightly more or slightly less often than once a year again depends on on the situation so next question here is around CBD oil leading from dementia syndrome and very very popular we get a lot of questions about it in clinic I have seen people who have dementia with associated anxiety and associated with chronic pain who have found CBD all really helpful I've also seen people who've tried see video and it's made their dementia significantly worse like any other drug that can affect your brain it has significant significant side effects and I personally don't recommend CVD of the simple reason that there is no good evidence of how it works how well it works whether it works in whom it works what the dose knees or anything else so if you're using CBD or oil it is a fun randomized you know contract it's a trial good main anything's better but they things make things worse we have no guidance from experience and definitely no guidance many good science as to how well it might work and I don't personally recommend it but that's not the same as saying that I recommend that you don't do it if you see what I mean so I've never said to someone hey you should try CBD oil but I've also not said don't classy if tide misses individual being the new adventure is hard if your brain is not working as well as it should you have to work much harder to do everything that you took for granted before you had dementia so I've been talking for the last hour and a half I've had to think about what I'm saying I've had to come through how to make sure I'm using appropriate language our love our lobbying putting a lot of effort in but it's not particularly tiring for me because it's what I do I'm very used to doing it it to learn still by half and my brain is fully capable of doing that but if you're living with the bench things like having a conversation following the plot of a television program preparing a meal doing the laundry putting your clothes on all of these things which require cognitive in gaad's you have to work harder to do which means you're always working harder so you're always getting more tired and so the people who are literally dementia find everyday life more tiring so can feel tired it also disposed people sleep it causes changing asleep and so you can be more time because of that the other thing which I want to think about early on in the in the kind of process when I think about diagnosis is is there an underlying cause that's causing both tiredness and the dementia type syndrome and that's why I start thinking about hormone imbalances and thyroids and things like that so ty this is the symptom all sorts of diseases it can be a symptom adventure if you have severe tiredness which is out of keeping with your other symptoms there may well be you know anemia or something else on the line that we need to think about and Alain's question is why is it that some family members get dementia or the members don't and really interesting question and there are we don't really understand the causes of the fundamental causes of dementia we know a lot about how it happens in what happens but there are things that we don't understand and we know that there are some genetic causes of dementia so I mentioned cadasil earlier on if you have the gene to cadasil you will get dementia if you don't have the gene you will not get dementia if your parent has the gene you have a 50-50 chance of getting the gene yourself so it's passed down a very sort of could way if you go back to the very beginning I Louis alzheimer himself when he first described outsider disease was actually describing a woman who had something called a priest in line one mutation so she had a genetic abnormality which caused her dementia and again this is the gene which is passed down 50/50 to your children so if you you have it half of your children on average inaudible but the vast majority of people who have dementia and particularly health science it is not genetic or the genetic component is quite small so people who have a first degree relative with dementia so apparently dementia are about 10 percent more likely to get dementia than the general population but still the majority of them will not there are certain lifestyle and environmental factors associated with dementia so recurring head injury heavy alcohol use smoking diabetes high cholesterol high blood pressure these are all risk factors for dementia so these are things which make it more likely to develop dementia but fundamentally some people get the mention some people go is largely down to dumb luck okay so Jamie has especially most of it the more severe stages I mentioned need to eat drink if Sargon there wasn't be partly any stage of death and I absolutely true how do you telling is abnormal or part of than Baal or dying phase I think the context everything there if you have someone who is you know very elderly in trail has been fading away for a few months who losing weight and know is you know kind of in their 90's and just kind of fading but their cognition and their mind and relatively good they don't have severe dementia then i would say that's part of the norm on dying process that they are not interested in eating and drinking at the very end of their life but if you have someone who's been living with dementia for a very long time who's been getting more and more severe disease who's getting very very dependent because of their dementia so they're not able to do they really have basic things like toilet in my dressing like feeding themselves and then they start to lose interest in food and then they stop I mean difficulty to swallow that largely bet that this is when you'd so this is the dementia causing it again it all depends on the details of the story and the richness of a story that people tell equal people given and people's experience as to how we make these diagnoses but certainly someone who is reaching the end of their life because of dementia and they're not eating food because of their dementia we will have an awful lot of warning that that is happening because they would have had fairly severe disease for quite a long time this isn't something that happens in in moderate dementia you don't get someone who's who's a bit forgetful and then suddenly and suddenly loses the ability to eat you think if that happens we need need to look for another course Gail have a question about grief and people with Alzheimer's remembers her husband has died but doesn't have cognition words to express her grief other than say he died any suggestion I would that's a that's a really difficult thing for everyone to hum business because of course her talking about her grief will bring that or giri's because he's lost your dad as well as her master husband and I see no harm in not telling people often the problem people have is that people have forgotten that someone has died so rather than you know people people talking about their wares where's my husband who's been dead for several years the instinct the natural react of course is to say no he's done but that just means they grieve again so sometimes saying things like at least he's just he's just popped out or he's not around at the moment or something that's not quite true can be really useful so on this is aware that someone's died and this is sadness as it died what I would do actually is talk about them when they were alive I tell ya sad isn't it do you remember when or tell me about your wedding or how did you meet that or something like that to sort of acknowledge the person's emotion knowledge their feelings but reassure and redirect them onto a more comfortable subject so people aren't in the grief you can move them on to talking about about a happier memory relating from a tourism and I see that there's going to be a live meeting the couple this time of that brief which I think be really helpful to change too as well oh that's a same question again yeah that Daly's questions have popped back up don't know yeah so the question is is it common to choke on food and drink it's because they've forgotten how to swallow yes that's exactly what's happening the swallowing is a complex and complex coordination of lots of muscles and that's been quite a difficult thing to do it's the first thing we learn how to do after we're bought and yes people with late stage dementia do develop what we call them on the stage swallow which means that through dancing can go down the end the way and the problem is that if it goes into lungs it can cause an infection cause pneumonia now that can happen to anybody at any time you know feeling being choked but in dementia it becomes more common and more likely as the disease progresses there are certain things which are easier to chew and swallow than others so there are modifications to your diets that we can put in place this is on the advice of speech therapy so what's called the mints diet or pure a guy is easy to swallow you also thicken fluids so instead I could a spotty powder that you mix with with a liquid and it turns it into a gel so you can then depending on how severely affected people swallow is you can have some here is a little bit thicker like cream consistency all the way up to a custard or even sort of something is almost like a jelly and you can think of any liquid that you like so if they can't call me of course its water but I've seen juice being thickened I've given someone a thickened cup of coffee and we have one chap who had quite sedate eventually who are we thinking this whisky because you always have got a whisky before bed I saw movies and taking risk and ravemon just couldn't swallow very well anymore so he's thinking that his whisky engaging that and he got greatly the pleasure from that if you've got someone who's losing the ability to swallow state because of dimension he's often a sign that this is very late stage disease that we're moving towards the very latter stages of someone's life and we really need to be concentrating at that time on people's comfort on people's pleasure on giving them as much quality of life as we can if that means typically knock something like a a gin and tonic because that's the drink that they really enjoy that we find no problem with doing that so and getting the question is that saying that dad doesn't remember family members but ask where his wife that is insist on calling the meeting to see it how do we answer it internally without I think that's a really good idea again like I've got the rapids of grief if you can knowledge someone's in motion that know if someone's need reassure that you're going to meet that need and then redirect them on to something which is more achievable that can be really useful way of helping people come to terms with that because obviously it's often that you can't just get hold of someone or someone can't come and visit or go and see them to take click the moment with also knock down what's going on that's becoming very difficult and so yes so and saying it someone's out and switching the conversation I had people who I have had and you've recorded themselves and recorded someone's wife on a lot tape recorder saying hey how are you looking forward to seeing you so you can hear their voice that can be very helpful or you know using technology like Skype or FaceTime or zoom or whatever it may be if you can't be physically together a way of seeing and interacting can be can be useful got acknowledging someone's emotion reassuring them redirecting the rescue cab as always with these it's about finding a solution that works for you you know the your individual circumstance and your your individual loves life because everyone is very very different so there's no kind of prescriptive do this this will work and but there are lots and lots of different different ways around and how talking through with family and friends and professionals and trying to find the solutions that can be really helpful I hope those related to dementia no commonly apart from Lujan dementia but it can't happen or Never Say Never and there is a condition called delirium which are not retouched are but basically delirium is where and know the illness makes your cognition much worse that's much more common if you have dementia and can be associated to this nation the other thing with dementia is you do get changes to your visual field so you're able to see things less well you have a visual spatial dysfunction so you can't process visual information as well and also you are people often develop what's called illusions so different hallucinations a hallucination is a visual and a visual image with no stimulus an illusion is a misinterpretation of a normal stimulus so I think we've all had that feeling when you've woken up and there's like a bathroom pounding on the door and you think it's a person and then you realize as the bath roving it's fine if you're living with dementia often you may see a shadow or a hanging coat or something else and believe it to be something else but can't then conceptualize and can't think through anything well it's not a person it's a coat hanging on a hook it's all okay so often people will say you know song was in my room last night or someone came in because they will misinterpret what they see and then create a narrative within their own minds so very important to distinguish between that sort of thing and the truth hallucination the other thing she's very common in all the rage is visual loss so independent or developing dementia and people and people will get macular degeneration that's a canoeing of Charles bonnet syndrome where people who've got visual loss will see things and look classically and mostly they are aware that they're not real but if you have a combination of Charles lighting your fundamenta that can appear like hallucinations as well and Elaine has a question about driving how do you get someone with dementia to start driving or get their license revoked after being diagnosed so this is another one of those really emotional and challenging times when when people do run into bombs because you don't want to take someone's driving license away climbing is a real sort of freedom if you live in a city it's okay but if you're an Baker middle of a million or hiking or your exit then it's very very difficult to manage without access to a car dementia in itself is not a reason to stop driving it's not a legally mandated you have to stop when you have a diagnosis of dementia compare let's say epilepsy if you have a seizure you have to stop driving you are not legally allowed to drive after a seizure with a diagnosis of dementia you ask the like to drive unless there are converse with your dialing your dementia is interfering with your drive so if you're if you're if you're the one of your parent it has a diagnosis of making sure then and you're concerned about that know anything then you need to alert your little phone your doctor and or you can alert the driver license knowledge isms himself and they will ask for a medical report there is a sense that the gunner is called drive able and they do two things they do a paper test and then an on-road test so if things are if it's a gray area you know if someone is absolutely fine Noelle's raised any concerns they're not getting any tickets then my next that's an ongoing lost there's no concern they can carry on driving if someone has you know driven into a bus queue and can never find their way and can barely see then clearly they're not able to drive and I can say you need to stop driving and in the gray area there are assessments that we can do it's very difficult for you guys as families to stop people driving and that's okay because it's you know I've got fairly broad shoulders and I can because I've died at this point and I can say to people I'm going to have to take your driving license away now if the ones driving license has been rescinded and they're still Niveen that then becomes a challenge if people will genuinely not be persuaded and cannot believe that they are unable to drive and you have two options you can either take the car keys and drive the car away but that often causes a lot of upset and concern and if you're feeling the sadness I have on occasion found that people can either disconnect the battery or remove a spark plug from the engine which means the car won't go of course the car won't start so they can't drive anywhere then you say I'll get the car men didn't take it away and then for the next few weeks telecast being mended and try and segue there like that into not driving it's one of those things it's often useful and it's course through with the family and discuss through with with one of us see the family doctor or or with someone like me to talk about what sort of level of of intervention we need to do but fundamentally if someone is a danger behind the wheel you need stopping driving for someone gets hurt okay so I think we've got a last couple of questions before we before we tie up so what might what what would my advice be to someone who has dementia and becomes belligerent and lashes out notice they come it's very difficult to ignore and take personally even a logical enactment this is the this is the worst cases - it's really difficult and I think it's it's important to try and avoid getting in that situation if you possibly can so not getting into an argument you don't have to have but if you find yourself getting annoyed and when I'm not and upset my advice is just ladies just to go outside to say I just need to pop out for a few minutes and then go outside and get some fresh air and get over distance and take ten minutes and you know don't go out and run away for miles and miles and miles but just be in a different room so you can still be there if there's a problem but just getting a little bit of space because staying in the situation just both end up whiny each other wrong and you can't reason someone out of position they didn't reason themselves into so often people who were caring on the dual adventure will end up getting into arguments or fights or having conversations and disagreements when really they they should of a if possible just allow it to slide but if you are if people are getting wound up and rotated and especially they start getting physically aggressive it's not what you're doing get out and give it a little bit of time and there's no there's very rarely a problem leaving someone for the ten dudes for for 10 to 15 minutes if you really can't leave someone even that length of time that might be the figure that we need to think about moving someone into into into an alternate facility your thing is to look out for any patterns is when you particular time of day is only particular trigger is it related to needing the bathroom is it related to being congregated really in pain things like that is real underlying cause for someone becoming villager and very complex and consumers question is bones diagnose in mild cognitive impairment but she thinks Sumer thinks that this is maybe it's dementia she's very reluctant see doctors how many tests is it worth fighting with to get a formally diagnosed and I think a question that you have to ask yourself is if I have a formal diagnosis what am I going to do differently am I going to do a house attorney when I wouldn't do otherwise won't know because you've got the power of attorney anyway am I going to get some more helping at home well probably not because having a diagnosis as mentioned I'm not having no matter dementia you your needs are still the same so I would look at what your what your mum's needs are what her problems are where her challenges are where their skills are and say okay it's a guy those going to make a huge difference often people who are not very keen on getting the diagnosis are also not very keen on taking the medication so there is no point to see me me saying yes you have mentioned giving you a prescription but then then it gets built yeah I'm having to do that I'm very happy to see people but it doesn't actually change what it's not going to change what we're doing a diagnosis is not help you in any particular way unless you are someone who likes to have all the answers and I can't answer that for you and it is in and of itself the diagnosis is not that useful what is useful if the whole package is saying what's the situation what can we do to make things better what can we allow what we ignore what do we have to do and so I think if you are seeing things progressing and you're concerned I think it's worth having a I've got a chat with with with your family doctor and often doctors are very happy to receive written communication so if you you know put your concerns down on paper drop it into faucet and then make an appointment of your mom and then if you need a subtext so you know you need to go and have you and your visit call or get your blood pressure checked or whatever it may be or you have a look at that rationale you know doesn't matter you don't either any to get in through the door and then your family doctor you're pretty worn because you've written to them so don't be able to sort of guide through that conversation about whether or not and things need to be needs to be done I wouldn't be too concerned about I'm not having a formal diagnosis because there's not a great deal that we would need to do differently other than thinking about medications because if things do care I'm getting worse and starts cause problem problems the diagnosis will become obvious further down the line so if there's nothing that you need help with at the moment in terms of pills or decision-making or assistance at home a diagnosis is only just going to label you already know rather than changing anything [Music] I think I was lost two questions is that right that was definitely the last question and just for the sake of not letting or your child you had tons of thank you excellent presentation session was great knowledgeable there was tons of those messages so I just wanted to let you know that and saving the society again for taking time of your evening tonight to present to us it's really appreciated we had a record-breaking attendance that we're over capacity for us we did and it is great to see and I do want to let people know that are still online that we are going to be doing weekly webinars and we will up up our capacity for the coming weeks to accommodate everybody who wanted to join as well we would just like to let and you know people who did join tonight who possibly aren't connected to the society that we are still open although we are working remotely our offices are closed please feel free to reach out to us still we're also working our regular hours and are very happy to still support people however we can with that being said I will say once again thank you a whole other flood of thank yous just came in again or you a dr. Gibson so thank you again for your time and with that I will end the meeting and thank you again do do please ask me back oh I feel like we will definitely be asking all right thanks again and good night everyone the presentation will be available at some point tomorrow on the asan cafe and have a good night everyone