Convulsions, which are sometimes known as fits, seizures, or epilepsy can be very frightening. They do occur in a small number of people with dementia, but not in the majority. Again, like so many other symptoms, they can be caused by illnesses other than the dementia and so it is important that a doctor establishes that there is no other cause that might be treatable.
Most fits can, in fact, be prevented by medicines, so if convulsions become a major problem, the frequency with which they occur can be considerably reduced and often they can be prevented altogether.
Fits are usually associated with loss of consciousness, jerking movements of the arms and legs and sometimes the whole body and the head and neck, disturbance of breathing pattern, and in some a period of extreme stiffness. This is the picture of a fullblown fit, but very often they are much less dramatic, involving only abnormal movements of a single limb for a short period. The disturbed electrical activity may, however, affect the whole brain and this can result in a period of sleepiness or drowsiness after the fit is over.
Although they can be alarming to onlookers, fits rarely result in any harm to the sufferer. When they do, the damage is usually caused by trauma resulting from the abnormal movements, or a head injury if the fit is accompanied by a fall. Sometimes a person vomits while they are fitting, or shortly afterwards. For this reason it is best to lay those who have had a fit on their side or face downwards, but making sure that they can still breathe and that their breathing passages are not obstructed. The ideal position is that known to first-aid workers as ’semi-prone’.
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Many people with dementia become depressed. This can be the result of a realization, usually early on in the course of the disease, that the brain isn’t working as it should be. Sometimes it happens for other reasons and occasionally an apparent dementia can, in fact, be depression. There is a difference between being depressed and feeling miserable. A person who is depressed will usually be withdrawn and unhappy, will speak, act, and think slowly. This can affect the daily routine and interest in food, and is sometimes associated with early morning awakening with difficulty in getting back to sleep. Some people with depression experience mood swings, and are much happier in the evening than they are when they first get up in the morning.
If depression is present against a background of dementia, it can be difficult to realize that the increased impairment in the sufferer’s intellectual ability is the result of depression rather than of a worsening of the dementing process. If you ever have any fears that the sufferer has depression, it is best to ask the doctor for advice. He should be able to help, even is he has to refer the sufferer to a psychiatrist for a more expert assessment.
The presence of depression will often mean that the sufferer requires even more love and support. If he or she is given medicine for the depression, this may actually cause a worsening of the memory for a while and may have other side-effects. It is important that you ask the doctor to let you know what you should be looking out for, and also important to decide whether the treatment seems worthwhile. In some patients, anti-depressants just make the situation worse. Nevertheless it is often necessary to undertake a few weeks’ trial of treatment, just to see whether there is any improvement.
One very important thing not to forget is that one mustn’t expect someone with depression to ’snap out of it’. A person with normal intellectual function can’t manage this and it is even less possible for someone with dementia. Depression is an illness that has a physical basis to it and is not just an attitude of mind. It has to be regarded in the same light as other medical illnesses that are more clearly due to physical abnormality.
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Virus infections, albeit with a very long period between initial infection and development of symptoms, are known to cause some other dementing illnesses. It is probably not quite right to call them viruses as the infective agents which are responsible for diseases like Creutzfeldt-Jakob disease are very unlike conventional viruses. There is also a rare brain disease which occurs in New Guinea and an infectious disease of sheep called scrapie in which an infectious particle of some sort appears to play a part as seerris to be the case too for the more recently publicized disease of cattle — bovine spongiform encephalopathy (BSE). The interrelationships, if any, between these conditions are complex but the fact that an infectious agent seems to be involved has led to the search for the presence of a virus or similar particle in Alzheimer’s disease. So far, none has been definitely implicated.
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The parietal lobe puts together all the information that our brains obtain in order to allow us to undertake quite complicated activities. For instance one of the characteristic problems experienced relatively early in the course of Alzheimer’s is difficulty with operating machinery or equipment such as a washing machine or television, and later with dressing. Difficulties like this, which are not caused by a specific abnormality in one of the nervous pathways outside the brain, are called apraxias. The presence of apraxias for a variety of activities usually indicates that the disease is going to progress fairly rapidly.
The parietal lobe also integrates the information that is obtained from the senses. Most people will be able to distinguish between a ten pence piece and a fifty pence piece when put in their hand, even if their eyes are closed so that they can’t see what the coin looks like. A person with parietal lobe damage won’t be able to do this and is said to be suffering from an agnosia.
A frequently employed test of parietal lobe function, which is really trying to elicit evidence of the presence of apraxia, is to ask the subject to draw or copy a diagram. This may be a simple clock-face or a more complicated structure such as intersecting geometric shapes.
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Our brain is such an important part of our body, even of our very existence, that it is protected by the bones of the cranial cavity within the skull. Any damage to the head sufficient to break the skull bones has serious consequences for the brain, ranging from loss of consciousness to permanent brain damage, with subsequent impairment of intellect or physical body function.
It is less well known that the brain also has other protective systems. These consist of a series of membranes and a fluid known as the cerebrospinal fluid (CSF). These are arranged in such a way that the brain is enclosed within a tough outer membrane called the dura mater, and within this lies another sack containing the CSF and the brain. Suspending the brain within the bag of fluid protects it not only from the day to day jolts that it would otherwise receive, but also from more serious damage — say a blow on the head that is insufficient to fracture the skull bones. Despite this protection, excessive physical force is still capable of causing damage, although this would be much greater if the fluid wasn’t present. The membranes also stretch tightly between the major subdivisions of the brain, thus limiting the degree to which any part of the brain can be displaced if physical trauma occurs. Our brain is therefore very well-protected from the outside world.
The brain is a pinkish structure, the pink colour coming from the blood that is circulating in the minute blood vessels that nourish the nerve cells. Each brain contains some 10 to 12 billion nerve cells – also called neurones. The brain is so important that it takes up about 20 per cent of the blood that our hearts pump out, and consumes a similar amount of the oxygen that we breathe in through our lungs. Despite requiring such a large amount of blood and oxygen it weighs only a fraction of our total body weight, usually in the region of 2-3 lb (1—1.5 kg). It is often assumed that the larger a person’s brain the more intelligent they are; this is fine for male chauvinists as in general men appear to have larger brains than women! Sadly, however, at least for us men, intelligence or other aspects of mental ability are not related to the size of the brain.
In order to allow us to understand more easily some of the illnesses that cause dementia, this chapter will describe some aspects of the structure of the brain, and how it works. The brain is, however, such an enormously complex organ that it would be confusing, and to a certain extent irrelevant, to explore these subjects at other than a simple level. The description that follows is, therefore, particularly arranged to take into account structures and functions that are important for the understanding of some of the dementing conditions.
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