Expert: Mary Gordon - 8/2/2006

Question
Hi Mary,

my grandmother is 89 yrs old and has been bedridden from the past 7 years due to a debilitating knee injury. Her memory has shown a gradual decline over the past so many years and also a gradual loss of control over bowel functions. She has also complained of problems such as anxiety, palpatations, etc intermittently. She has a medical history of angina and hypertensiveness and a recent CT scan has revealed multiple minute infarctions.

She also had a history of displaying neurotic symptoms such as recounting old experiences over and over again. or repeating the same phrase over and over again during a bout of anxiety.

But by and large she was mentally quite fit for someone her age (my family feel). she savoured eating good food and frequently asked to be fed preprations of her choice and looked forward to family dinners. Overall she was cheerful and enjoyed in the company of family members recounting her life experiences and even passing humorous comments.

but the past month she contracted a viral infection and her cognitive functions have suffered a drastic setback. there is a marked loss in alertness and understanding and she has started refusing food.  

she had once before suffered from a phase of delerium when she was extremely excitable and incohrent. but that was diagnosed as a sodium deficency and she recovered after being administered a sodium rich diet.

i read a few articles on end stage dementia and was wondering if that is what my grandmother is passing through.

is the onset of this condition sudden with a major medical condition such as infection or gradual?  

please advice!!

Answer
Its sounds like your grandmother's overall mental decline (prior to her current illness) is likely due to what they call multi-infarct dementia. It is caused by culmulative brain damage from a series of tiny strokes - which her doctors have confirmed seeing on CT. This is the second most common type of dementia after Alzheimer's, and sometimes multi-infarct and Alzheimer's occur simultaneously in the same person. The two tend to follow a similar course, other than the multi-infact tending to progress in fits and starts as the strokes happen, and Alzheimer's decline tending to be smoother. The strokes can be happening without symptoms.

She may well have had more strokes contributing to her decline, but her current viral illness is more likely to be the culpret, so she may recover cognitively - at least a bit - with time. With people who are in mid or later stage dementia, any illness at all will affect their cognition. Think of your own health - if you get a bad cold or flu, you feel sleepy, and fuzzy headed - and you are a young, healthy person with an intact brain. Now imagine what it must be like for an elderly person whose brain is damaged, and who is holding on with their fingernails to mental function. Any illness that might make you a bit groggy or dopey, will really impact them much more noticably.

My mother in law had Alzheimer's, but I remember one episode when she was in middle to early late stage AD. She was relatively well at the time, able to talk, enjoy a visit - but one day when we went to visit her to attend a special Mother's Day Tea, she was almost in a stupor - could barely talk, was sleeping all the time - just a shocking state compared to her "norm" at the time - and it was all due to a minor infection.

Usually when a person heads into the final stages of dementia, they will have long since stopped talking intelligibly, and often spend their days sleeping, don't know anyone, start to have trouble with chewing and swallowing, are totally incontinent etc. It is rarely a sudden thing. What ends their lives is usually a combination of starvation and dehydration (they eat and drink less, despite coaxing, and get into a spiral of getting weaker and weaker - but don't seem to FEEL thirsty or hungry) and then opportunistic infection such as pneumonia.

So, I think all you can do is watch and wait and see what happens next.  She may come around a bit as she recovers from the infection, or she may continue to spiral down. You have to keep in mind, that dementia or no, she is like an egg balanced on end. Anyone who is 89 and bedridden, with all her physical ailments, will be extremely frail and susceptible to all kinds of infection - and it will take very little to cause a decline leading to death.  

Your family will have to decide next steps. Do you know her wishes? Would you want her treated for major illness, taken to hospital, tubes installed etc. ?
Would you have her rescusitated if she has a crisis?  If she is declining, would you call in hospice care and let nature take its course? If she stops eating and drinking, are you ready to let her go, as long as she is kept comfortable and out of pain? Only those who love her and know her best can answer those questions.

Hope this helps. I know its very hard to watch, and hard to live with the uncertainty, but people with dementias can be very unpredictable in terms of how they will react to illness. Its not easy to give concise answers.

She's lucky to have loving family members thinking of her and looking out for her best interests.

Mary G.