There are over a hundred different recognised types of dementia, the most common of which is Alzheimer’s disease. In fact, up to sixty percent of diagnosed dementia is Possible/Probable Alzheimer’s Disease (PAD). Alzheimer’s is very rare in under forty fives, we see more cases between the ages of sixty and eighty (about one in twenty) and, above the age of eighty, we can expect to see one in five people diagnosed. What we need to recognise from these statistics is that it is not as common as we would be lead to believe – we can see this by noting that nineteen out of twenty people between the ages of sixty and eighty do not get diagnosed with Alzheimer’s disease.
Other interesting statistics surrounding dementia are that it is more prevalent in females than males (although there may be a correlation with the fact that females tend to live longer), people who have suffered with mental illness such as depression or schizophrenia are more likely to develop dementia and people with diabetes WILL ultimately develop dementia should they live long enough. Although the causes for developing the disease are unknown, there are four agreed hypotheses surrounding the condition.
Age – the older you are, the more at risk you become from developing some form of dementia. Those people who develop it at a younger age tend to decline far quicker.
Down’s Syndrome – People with Down’s Syndrome are at a higher risk of developing Alzheimer’s as, by the age of thirty five, they will have developed plaques and tangles in the brain containing Beta Amyloid protein which destroys neurons. This is linked to a gene on chromosome ‘Trisomy 21’, of which people with Down’s have an extra copy.
Heredity – Less than one percent of dementia is a hereditary form and generally, hereditary types of Alzheimer’s tend to be ‘early onset’ (before sixty five). As well as presenting at a younger age, hereditary dementia also affects a larger percentage of relatives within the family.
Apolipoprotein status – when we are born, we receive one of these proteins from each of our parents, depending on which protein we receive – v2, v3 or v4 – we are more or less susceptible to developing dementia.
It is often inaccurate to predict a lifespan for a patient diagnosed and living with dementia as they very infrequently die from the condition, in fact, people can develop dementia up to ten years before it presents. Dementia patients tend to die from other causes.
As already discussed, Alzheimer’s is the most common of the many forms of dementia that exist, the next most common type is Vascular dementia. Vascular dementia presents as a series of small strokes or Transient Ischemic Attacks (TIAs). Vascular dementia is very much a lifestyle disease and can be brought on by too much alcohol, high cholesterol, heart disease, poor diet, hyper-tension and even lack of fun. It presents in a similar way to Alzheimer’s and the way to detect it is to do either a Psychometric test or a Positron emission tomography (PET) scan as well as looking at the patient’s history.
The third most prevalent form of dementia is Lewy Body dementia. This form tends to present relatively younger (around the mid fifties). This dementia is identified by the way it presents and through diagnostics as it presents in a similar way to Parkinson’s disease (shakes, lack of expression, fretting and aggression). It presents in this fashion as both diseases affect the same part of the brain. Diagnostically, you can note ‘tip-toe walking’ due to visual and spacial impairment.
Hallucinations are common in all forms of dementia but are particularly powerful with Lewy Body and more frequent. The way to deal with the (very often) scary hallucinations is by distraction. If distraction does not work, another solution is with anti-psychotic drugs – the problem being the ‘doctrine of double effect’ in that anti-psychotic drugs are far more likely to kill a patient suffering with Lewy Body dementia. The biggest indicator of Lewy Body is a large and notable fluctuation of the patient’s abilities, character, behaviour and personality. This large fluctuation is not present in other forms of dementia.
Pick’s disease, or frontotemporal dementia is the forth most common form of dementia and is frontal lobe damage. It presents much earlier than the other more common forms of dementia - usually when the patient is in their thirties. Because it is frontal lobe damage, it wipes out the inhibitors – patients become hyper-sexual, aggressive and difficult to manage in a normal environment. It is a very quickly degenerating disease as it presents earlier in the lifespan of the patient, affecting language, behaviour and personality.
Other forms of dementia include Huntington’s disease, Normal Pressure Hydrocephalus, Korsakoff’s Psychosis and Creutzfeldt-Jakob Disease (CJD) and Variant CJD.
When dementia develops in a patient, it consists of two different processes – a biological process and a psychological process. When interacting with the patient, their family or the staff, we need to be very clear that we cannot claim any impact upon the biological process of dementia. The gradual decline is going to happen. Where we can claim to have an impact however, is upon the psychological processes associated with dementia. We can focus on helping the patient ‘live with their dementia’ in as positive way as possible. If we can get people to be positive and worry less about their situation, we can help prevent anxiety and help them to spend time remembering rather than worrying about not being able to remember.
Treating a patient with dementia is all about ‘giving back’. We need to be realistic in our approach - we are not going to be able to cure their dementia. We should be asking ourselves ‘how we can give something back to our patient in order for them to live with their dementia as comfortably as possible?’
If we are able, through our treatment plan, to help the patient become less anxious through a combination of our interaction, assessment and relaxation, we can expect them to begin to socialise more as withdrawal is one of the early problems with the dementia patient. Generally, immediate memory loss is one of the first indicators to the patient that something is wrong. With memory loss comes disorientation, forgetting names, places, even forgetting where they are which leads to withdrawal. If you fear you will not be able to remember people or information, you will naturally tend to remove yourself from a situation where this may be highlighted. Withdrawal will then lead to depression and anxiety which are all considered to be the early stages of dementia.
Dealing with dementia is about tapping into the patient’s strengths, what do they have left to work with? We need to focus on what is good!
Along with our detailed initial assessment, the information gathering should include talking to the matron & nursing staff (if the patient is in a care home) and the family about the patient’s life story. Writing to the patient’s general practitioner is important to ensure against any possible contraindications but we are not necessarily seeking permission from them in order to use hypnotherapeutic techniques.
We should be looking to gather information to help us to answer some important salient questions such as whether they have any visual or hearing impairments, what type of dementia they have, what stage they are at with their dementia? (from care home assessment forms such as the Global Deterioration Scale Assessment), are there any psychological considerations to take into account?, what is their routine?, any relevant personal or family history to consider, current competency levels, and even how they like to be referred to.
Formulating good background information before our assessment will afford us the best opportunity to step into our patient’s world and strike up rapport with them which will enable us to establish a supportive and nurturing environment to get the best possible results to help the patient live with their dementia.
Once we are with our patient and doing our assessment, we should have enough information to help us use the most appropriate language. With dementia, it is crucial that our communications are altered in that we need to speak slower and in a clearer language and it is especially important to leave more time for the patient to answer our questions – we need to check our expectations and our patience and allow the patient more thinking time. The assessment of a dementia patient, by nature, tends to be a much lengthier process and this extends to all therapeutic interventions including induction, deepener, the therapy itself right through to the termination stage of the hypnotic procedure. All of these areas need to be handled with far more care and consideration for the dementia patient to avoid confusion, distress or Parasympathetic Bounce-back in the case of a quick termination. Dementia patients often have poor levels of concentration and motivation but these are both areas that we can work with during therapy as well as small changes in memory retention.
Key discussion topics with the patient during the assessment would be to ensure they are happy with you taking notes, to establish that they have some level of understanding as to why you are there (avoiding using the term ‘hypnosis’ if possible), whether they have had any previous sessions of relaxation, how they like to relax, that they are happy and comfortable that you are with them, and asking them to tell you their life story. From a conversational, naturalistic assessment such as this we can also assess their level of lucidity, their overall demeanour, whether they are open minded or not and to what extent their memory and concentration levels are.
With dementia, the most important thing for the patient is what is happening in their life right now. We should never make any assumptions other than to assume that the patient understands everything that is going on, even if they appear none responsive. We may not be able to see any noticeable results, but the patient may be comforted by what we are doing and saying, this asks the question about whether ethically, we should stop our interventions if we cannot see any noticeable effects.
The quality of our contact will increase other aspects of the patient’s mind. Should our interventions prove fruitful, we can hope that the quality of life for our patients will improve as they stop withdrawing and begin to socialise more this will have other impacts such as a reduction in agitation, worry and frustration in every-day activities. A positive relationship gives the patient the opportunity to ‘hang on’ to things rather than stressing and worrying about not being able to hang on. This reduces anxiety and frees people up.
There are currently several GPs with special interests in dementia in the UK. These days, medics take more of an interest in alternatives to drugs and they have to go through communication training which amongst other things, increases their openness to alternative treatments to drugs. The NHS has spent £190 million on employing psychotherapists but there are still up to eighteen month waiting lists in some areas.
There are too many dementias to completely eradicate it and the drugs are primarily focussed on Alzheimer’s but we are gradually beginning to open our eyes to alternative forms of treatment in areas such as Post Traumatic Stress Disorder which has been proven to have good results using Eye Movement Desensitisation and Reframing (EMDR) so, despite hypnosis having more of a darker history, it does show that there is movement on the way people think about alternatives to drugs.
