Expert: Mary Gordon - 1/7/2009

Question
QUESTION: My dad has vascular dementia and has been accessed as borderline EMI.  He has been in hospital since 4 10 08 and he seems to have got worse, believing he has been locked up by his sister, or that his house was burgled and set on fire which resulted him being in hospital.  Around 10 days ago he started to speak like a child, for example he will say, me want sweet, or me go to toilet, however the last copule of days he is speaking properly again.  What could be the reason for this?

ANSWER: Hi Anne, you must be in the UK - I'm in Canada and in North America you never hear the "Elderly, Mentally Impaired" label used for care requirements.

There are several kinds of vascular dementia. One of the most common is called multi-infarct. It is caused by a series of tiny blockages, which cause damage to the cortex of the brain. This can be from strokes (i.e. tiny blood clots blocking blood flow), or infarcts, which can be small bits of tissue. Each blockage may be so tiny that there are no symptoms you'd expect from a stroke, other that the person gradually accumulates more and more damage to their brain. A person with multi-infarct often has  better insight into their condition in the early stages than people with Alzheimer’s disease. Parts of their personality may remain intact for longer. Having said that, it is progressive, incurable and irreversible.

Another relatively common type of vascular dementia is called Binswanger's disease.
Sometimes this is called subcortical vascular dementia or dementia from small vessel disease. It affects  “white matter” deep within the brain. It is caused by high blood pressure, thickening of the arteries and inadequate blood flow. Symptoms often include slowness and lethargy, difficulty walking, emotional ups and downs, lack of bladder control early in the course of the disease, gradually progressive dementia developing later.

Its also possible to have more than one thing going on at once - for example, a person can have a vascular dementia at the same time as they have Alzheimer's disease, or dementia due to Parkinsons, or a frontal lobe dementia like Lewy-Body. Given what a constellation of health problems that many older people have, it is no surprise that many of their health issues can impact their brain.

You don't mention why your father was hospitalized. I wouldn't describe his current mental condition as borderline EMI. He sounds quite confused and impaired, and unless he makes a remarkable recovery, it does seem like he will need 24/7 supervision and support when he leaves hospital.

What happens to people with cognitive impairments is that any health issue laid on top of their brain damage will make them seem much worse. Think of yourself, with your healthy, intact brain. If you get a virus, you can get foggy headed, and feel so dopey and awful that you can't think straight. Now imagine your father - if he was just holding on with his fingernails mentally  due to his vascular damage, any health issue, from infection to injury will really make him seem to have gone down mentally.   

I can remember visiting my mother in law at the specialized dementia unit she lived in in later Alzheimer's. They were having a special tea for the ladies for Mother's Day. She had been doing quite well, but we were really shocked to visit see her that day - she was terribly confused and disoriented. It turned out she had a minor infection - something that would have hardly affected you or I at all - but it threw her for a loop mentally.

Sometimes, when a person gets really confused during an illness, it is termed a "delirium" - which basically just means short term impairment due to some physical illness.

Your dad may come back and improve somewhat as he recovers from whatever his latest illness has been. It is also quite common for people to fluctuate in their abilities. They will seem much worse mentally when they are tired or stressed in any way - so for example, they may seem more with it in the morning after a good night's sleep and a good breakfast - but by late in the day, when they are tired, hungry or stressed out by all the activity around them, they may seem much more confused. That one is so common, it even has a name - it is called "sundowning". The trauma of any big changes, a physical injury, pain, or even something upsetting can also show itself as a decline in cognitive function.

You may also find that he has good days and bad days, or good weeks and bad weeks and you will never know the reason.

What he has IS progressive though, so he will continue to deteriorate. It may be slow and gradual, or it may be in sudden drops. He may come back a bit after a big drop, or he may not. Its hard to say. Everything has to do with where the brain damage occurs, and how much damage each incident causes - and as I said, many of the blockages are going to be so tiny that you see no evidence other than his decline over time. Small blockages may also clear themselves, and some function return to the area (i.e. you may see a big drop, followed by a rebound, but not quite to where he was before).

Hope this helps a bit.

Mary G.
Toronto

---------- FOLLOW-UP ----------

QUESTION: hello Mary
dad is still in hospital waiting placement in an EMI unit.
I know there are 7 stages of dementia and am wondering what stage dad would be at.  He recognizes us when we visit, however once we leave he has no memory of this.  Most days he does not realize he is in hospital, believing that he is in his own house, and can get agitated that all these people{the visitors of patients} come into his house and sit down without being invited.  Other times he thinks he is back at work.  He asks everynow and again about mum, who died 12 years ago, wondering where she is and when she will visit.  I also notice that unless you actually tell him to do something; like put on your cardigan if you are cold; he will just sit there feeling cold and not put his cardigan on.  He had for a while been talking strangely., for instance I GO TO TOILET, OR ME EAT DINNER, but now his speech is back to normal.  The hospital also have put him on quepatine, sorry about spelling, and this seems to make him very drowsy. Does this information give any clue as to what stage he is at.

Answer
Hi Anne

Below my signature I've pasted the most commonly used set "stage descriptions. Keep in mind that the stages are artificial divisions of a gradual continuum - so this will not tell you when something specific will happen to your dad. Many people will experience symptoms of more than one stage at a time (i.e. they have lost certain abilities, but retained others), so use these as a general guideline only.

Also keep in mind that he has been ill, so it's hard to tell exactly where he will be when he is more recovered. I did a search on the drug you called quepatine and can't find anything that matches, even with phonetic spelling - if you can find out what it is for, and the name, I can find more for you. Is it for the dementia itself, or for associated problems, such as depression, delusions, anxiety...?

From what you have described, my guess would be he's probably about Stage 6. Scroll down and see if you agree.

A good book to buy is the 36 Hour Day (4th edition) by Mace and Rabin, published by Warner in softback. Its inexpensive, and I found it very helpful. It is full of useful insights and tips.
http://www.amazon.co.uk/36-hour-Day-Alzheimer-Disease-Dementias/dp/0801885094

Also, here is a link to a really excellent article you may find helpful to better understand what is happening to him. Although it is about Alzheimer's, and your father has a vascular dementia, he will have similar issues and experiences.
http://www.alzheimer.guelph.org/downloads/12%20pt%20Understanding%20the%20Dement

With respect to his language, most people with progressive cognitive problems will have increasing difficulties understanding speech. Even if they can talk well, they may not be able to understand what is said to them. Because their memories are so short, and their ability to process speech so slow, they may forget the first part of your sentence by the time you get to the end. Very short, simple, direct instructions or questions may help - especially those he can answer with a yes or no. Are you cold? Cardigan? Let's put it on.

Cognitive impairment may mean that he can't make the connection between the physical sensation of being cold, what it means, and what he should do about it - let alone initiate the action of reaching for the cardigan and putting it on. You may have to help him, the same way you would help a toddler you see shivering. You don't ask them to make a judgement or decision - they may not come up with a solution that is rational (I'm cold so I need my cardigan). You may find that taking a task apart down to its simplest steps, and doing them one at a time with guidance works better than expecting him to initiate action on his own.  

I used to accompany my mother in law to her medical appointments, and by Stage 6 she had great difficulty answering even simple questions. It became very difficult to converse with her other than via very short statements or questions. Medical staff would try to talk to her, and she would really have no idea what they blethering at her about. I think she'd catch the part that included her name, and the rest was gibberish.  When she tried to answer questions, she'd lose her train of thought and tell long "shaggy dog" stories that looped around, and never answered the original query.

Hope this helps

Mary G.

Stages of Alzheimers

In 1982 Dr. Barry Reisberg published what was to become the best and most widely accepted description of the stages of Alzheimer's disease. Even today, years later, when experts refer to a person being in stage 5 or stage 6, they are referring to Dr. Reisberg's scale of seven stages.

Adapted from Reisberg, B., Ferris, S.H., Leon, J.J. & Crook, T. The global deterioration scale for the assessment of primary degenerative dementia. American Journal of Psychiatry, 1982

Level 1

No cognitive decline - (or Normal Adult). No subjective complaints of memory deficit. No memory deficit evident on clinical interviews.

Level 2
Very mild cognitive decline (forgetfulness or normal older adult). Subjective complaints of memory deficit, most frequently in the following area:
(a) forgetting where one has placed familiar objects;
(b) forgetting names on formerly knew well.
No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern regarding symptoms.

Level 3
Mild cognitive decline (early confusional or Early AD). Earliest clear-cut deficits. Manifestations in more than one of the following areas:
(a) patient may have gotten lost when traveling to an unfamiliar location;
(b) co-workers become aware of patient's relatively low performance;
(c) word and name finding deficit becomes evident to intimates;
(d) patient may read a passage of a book and retain relatively little material;
(e) patient may demonstrate decreased facility in remembering names upon introduction to new people;
(f) patient may have lost or misplaced an object of value;
(g) concentration deficit may be evident on clinical testing.
Objective evidence of memory deficit obtained only with an intensive interview. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.Deficits noticed in demanding employment situations.

Level 4
Moderate cognitive decline (Late Confusional or Mild AD). Clear-cut deficit on careful clinical interview. Deficit manifest in following areas:
(a) decreased knowledge of current and recent events;
(b) may exhibit some deficit in memory of one's personal history;
(c) concentration deficit elicited on serial subtractions;
(d) decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas:
(a) orientation to time and person;
(b) recognition of familiar persons and faces;
(c) ability to travel to familiar locations.
Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations occur.

Level 5
Moderately severe cognitive decline (Early Dementia or moderate AD). Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Level 6
Severe cognitive decline (Middle Dementia or Moderately Severe AD). May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to orient in familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include
(a) delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
(b) obsessive symptoms, e.g., person may continually repeat simple cleaning activities;
(c) anxiety symptoms, agitation, and even previously nonexistent violent behavior may occur;
(d) cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

6a - Requires Assistance dressing
6b - Requires Assistance bathing properly
6c - Requires Assistance with mechanics of toileting
6d - Urinary incontinence
6e - Fecal incontinence

Level 7
Very severe cognitive decline (Late Dementia or Severe AD). All verbal abilities are lost. Frequently there is no speech at all - only grunting. Incontinent of urine, requires assistance toileting and feeding. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently present.

7a - Speech ability limited to about a half-dozen intelligible words
7b - Intelligible vocabulary limited to a single word
7c - Ambulatory ability lost
7d - Ability to sit up lost
7e - Ability to smile lost
7f - Ability to hold up head lost