"Who was he before he took ill?"

24/Oct/2014

Armin von Gunten / Valérie Chételât

Senile dementia is generally incurable. In order to alleviate suffering, therapy should also take into account life stories, says the geriatric psychiatrist Armin von Gunten. By Ori Schipper

Horizons: Prof. von Gunten, your research into senile dementia focuses on the role played by personality traits such as anxiety. Such connections are absent from most research into Alzheimer’s, which instead is concerned with revealing biological mechanisms.
Prof. Armin von Gunten: That’s right. When we collect data about a patient, take blood samples or record brain activity, we get a snapshot in time: a picture of how the patient is at the time of the examination. That’s all well and good. But we should also be interested in the patient over the course of time. What kind of person was the Alzheimer patient before he or she took ill? The answer to that can help us better adjust our treatment to his or her individual needs. If a dementia patient in the clinic vehemently resists showering, for example, then that might not be the result of an irrational, behavioural disturbance. Perhaps the patient had only been accustomed to bathing two or three times a week, and now finds it unreasonable to be washed every morning and evening.

H: So should doctors turn their attention more to the patient’s pre-history and less to a snapshot of the present?
AG: I’m not talking about an ‘either/or’, but an ‘as well as’. We shouldn’t pay any less attention to the findings made in the clinic, but we should also take the personality of the patient into consideration. If we know the hygiene preferences of a patient, then we can better understand his or her defence reactions – the result of this is that we can try to adjust our nursing and psychosocial procedures instead of using drugs to prevent abnormal behaviour.

H: Do you feel that drugs are prescribed too often?
AG: I’m not saying that drugs are bad – on the contrary, they are often very helpful. But anxiety-reducing, tranquilising drugs, such as the neuroleptics that are often prescribed to patients with dementia, can produce side-effects that have a negative impact on the brain. As a result, neuroleptics might in fact intensify the origins of the symptoms, even if superficially they are alleviating them and are helping to calm an unsettled patient.

H: What else can we do against Alzheimer’s?
AG: As a rule, senile dementia isn’t curable. But we have to ‘catch’ the patient better. If a patient had always been interested in cars, but you now try and get his or her attention with animal films, then you’re probably setting off on the wrong foot. In daily clinical practice, the personality and the habits of a patient are decisive. If a male patient was accustomed to walking about while thinking when he was healthy, then if he gets dementia he’ll belong to those patients who have restless motor functions. This restlessness doesn’t have to be a behavioural disorder in need of correction.

H: You propose an approach that is adjusted to the individual personality. Normally, the catchword ‘personalised health’ is applied to therapies that are adapted to the patient’s genetic make-up.
AG: The mapping of the human genome has not yet brought any progress to geriatric psychiatry. Genetic analysis and magnetic resonance images of brain activity offer important information that can help us to answer questions such as: what is the connection between brain function and abnormal behaviour? If the brain chemistry becomes unbalanced, then we’re simply dealing with a neurotransmitter problem. But the ‘why’ of it remains unanswered – why does a patient behave in one way, and not another? Perhaps it allows her to get around her anxiety or at least reduce it. What we describe as abnormal behaviour is a result of the adjustment mechanisms of a diseased brain. Instead of just altering the brain chemistry, we should try more often to alter the environment to which the brain – even a diseased brain – is trying to adjust.

H: Your results suggest that people with incipient dementia become more anxious.
AG: Yes. It is interesting that the personality of a human being always alters in the same way. Whereas the manifestation of specific characteristics – such as having an ‘agreeable’ personality – stays roughly the same, incipient dementia is coupled with a reduction in openness and an increase in neuroticism – that’s an anxiety that is difficult to overcome.

H: How do you explain this?
AG: Mental decay influences your personality. Both in tests and in everyday life, people generally act more circumspectly and more distrustfully than before. Why that is, however, remains unclear. On the other hand, our brain is also marked by our personal history. It seems that severe or recurring depression increases the risk of Alzheimer’s because it leaves clear traces in the brain and destroys nerve tissue. We have also found out that certain personality traits – such as increased anxiety – are probably risk factors with regard to the later onset of dementia.

H: How can your findings be put to concrete use?
AG: Personality changes can herald the onset of dementia and thus have diagnostic potential. In contrast to brain imaging, for example, they can be determined by simple means and are thus useful for family doctors. But they can also help us to improve the situation in emerging and developing countries. Over half of the world’s total dementia cases are found in those countries today, but only a small minority is diagnosed and treated properly. The World Health Organization believes that the number of people with dementia will quadruple in the next 40 years, from over 30 million to almost 120 million people. The biggest rise is expected in emerging and developing countries, so there will undoubtedly be an increasing interest in simple screening and diagnostic tools.

H: How do people react to the diagnosis?
AG: In very different ways. A few commit suicide, like the celebrity Gunter Sachs. But most don’t have the feeling that they are sick. After all, dementia isn’t something that you can physically feel. It doesn’t hurt. Many people are not at all concerned but regard a failing memory as one of the natural side effects of getting older. Often, they’re quite right. Other people who lack a feeling of being ill nevertheless sense subconsciously that they don’t function like others any more. They then react to stress with anxiety and inappropriate behaviour.

H: What does this mean for their relatives?
AG: Often, patients are themselves protected by the fact that they don’t feel ill. But this can cause additional problems for the family members who look after them, many of whom adopt a lecturing tone with them – but this just makes things worse for the patients. It can make them even more anxious, and their behaviour even more disturbed. The result can be even more detrimental to quality of life than their actual cognitive decline. So we direct our therapy not just at the people with dementia, but also at their families. We try to help them deal with having a family member with dementia.

(From "Horizons" No. 102, September 2014)

Armin von Gunten

Armin von Gunten grew up in eastern Switzerland and studied medicine at the universities of Fribourg and Lausanne. After various research visits including to London and New York, he returned to Lausanne where since 2011 he has headed the university service for geriatric psychiatry and run the research group ‘Neuropsychiatry and premorbid determinants’.

Alzheimer’s disease

Alzheimer’s disease is the most frequent form of old-age dementia, accounting for roughly half of all cases. In Switzerland it affects some 60,000 people and is on the rise. Alzheimer’s can’t be healed, but there are different therapies that enable the patient to remain independent for longer. Statistics show that there is a slightly lower risk of Alzheimer’s among those who have a higher level of schooling, a healthy lifestyle, who get about enough and have neither high blood pressure nor diabetes.

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