Dementia, Mental Illness, and Alcoholism: Assessment and Care recommendations.
My first job out of college was working with adults who had both mental illness and dementia. Their treatment course was complex but it gave me an opportunity to problem solve in an extremely unique way. After having this experience, I was able to notice a flaw in the care provided in most care-settings.
Providers, in facilities and in the home, are only treating dementia, even if the person has a diagnosis of mental illness. Providers either miss a mental illness completely or mistake a symptom of mental illness as part of dementia. You’ve probably heard “Oh she walks like that all the time” about the resident who is power walking up and down the hallway never stopping to sit for a meal?
Well, then residents are issued 30 day move-out notices because the techniques they’ve been taught aren’t working! While it may not make sense to diagnose a mental illness at this stage, we can look at the symptoms and say “hey, maybe this isn’t just dementia” and start to provide better care.
Mental Illness
Mental illness also plays a role in dementia diagnosis and treatment. If you’re not speaking with someone experienced in dementia, you could miss a mental illness. I was conducting an assessment for a woman who was having cognitive challenges. I asked her all the questions and she did score poorly on the cognitive assessment. For me, it is never enough to do the assessment and leave. I spend at least 30 minutes building a rapport and chit chatting. Thankfully, the rapport was built so this woman revealed some signs that she may be depressed. I was able to consult with her primary care physician who confirmed she was not on antidepressants despite having a history of inpatient care for depression! Once she was on a treatment plan for depression, I reassessed and her cognitive assessment scores improved drastically. This is one example of when dementia can be misdiagnosed.
Alcoholism
Various forms of addiction can be considered a mental illness. Sometimes, with addiction, a mental illness also exists. This is important to note because alcoholism can lead to a specific type of dementia: Wernicke-Korsakoff.
There are many types of alcoholics. They do not always appear to be “drunk” or “disheveled” as one may believe. You might not see them sleeping at the bar on a Wednesday night or drinking alone in the bath tub. For some, alcoholism may look like binge drinking every day but for others they may have extended periods of abstaining from alcohol. Some may be high-earning business people and others may be unable to hold a steady job.
Because of excessive alcohol consumption, the body can’t absorb the vitamin necessary for creating energy for the brain from the food consumed. The long-term effects of alcohol abuse could lead to Wernicke-Korsakoff.
Wernicke Korsakoff
This dementia starts with Wernicke Encephalopathy, damage or malfunction of the brain, which presents with symptoms like: confusion, altered mental status or complete loss of mental activity, jerky or involuntary eye movement, paralysis (specifically of the eyelids), double vision, poor balance, difficulty walking, and loss of muscle coordination.
Korsakoff syndrome is next but can usually improve over time. This part of the disease presents with memory loss, especially short term. We may also see problems with: managing day-today tasks, learning new information, they may also experience confabulation (often mistaken as lying but it is an unconscious brain response rather than a deliberate deception), apathy, loss of empathy, more talkative, repetitive behavior.
Depression
Symptoms of depression need to occur for at least 2 weeks. People who have dementia and depression at the same time tend to express less suicidal ideation and may not have the symptoms for as long as others. They may fluctuate more. Depression is more than just feeling sad.
Attention Deficit Hyperactivity Disorder (ADHD)
Have you ever been distracted by something and forgot to do something that was asked of you? This can be common for someone with ADHD. I wasn’t diagnosed with ADHD until my mid 20s so I went through college and graduate school having developed coping mechanisms for studying. However, you can still tell when I am being impacted by my ADHD. Sometimes, this can look like memory loss as I forget tasks, loss of interest, or difficulty multi-tasking. For an older adult, this can be misdiagnosed as dementia.
Late Onset Schizophrenia
Late onset schizophrenia is diagnosed after the age of 40. It is not very common so when these symptoms occur, it may be dementia more so than late onset schizophrenia. However, a proper diagnosis is important. Sometimes, the symptoms of schizophrenia are brought on by age related changes such as: eyesight loss or hearing loss.
Late onset bipolar disorder
Late onset bipolar disorder typically is diagnosed after the age of 50. The symptoms are similar to bipolar diagnosed at a younger age as well with episodes of mania and depression.
Dual Diagnosis: Mental Illness and Dementia
Many Trovato’s clients may have mental illness and dementia. I say “may” because I am not a psychiatrist and cannot diagnose mental illness. Some of the time, we do notice that the person has a diagnosis and other times we are recognizing signs that are similar to some mental illnesses. When it comes to some that are more difficult to treat, the diagnosis may not be as important. However, recognizing the signs so we can treat both at the same time is. This is similar to how we advise getting to know the person and understanding their personality before we begin a treatment plan for dementia.
Some mental illnesses that may be a challenge include:
- Borderline Personality Disorder
- Narcissistic Personality Disorder
- Paraphilias (exhbitionism or transvestism)
- Borderline Personality Disorder
Borderline Personality Disorder
Borderline personality disorder can be especially challenging because of the mood fluctuations. Typically, someone with Borderline personality Disorder may have other mental illness, such as depression, anxiety, or antisocial behaviors. However, their compulsive behavior and mood swings make it difficult to help them. When working with someone who has dementia and borderline personality disorder (or suspected to have) these may be some helpful guidelines:
- Focus on your message
- Join their reality
- Simplify the message
- Operating from their feelings before facts using validation
- Redirection will help to distract them
- Using a caregiver that did not know this person prior is important
- May require multiple caregivers for “tag-teaming” to reduce burn out
Narcissistic Personality Disorder
Narcissistic Personality Disorder is different than being “self involved.” The term “narcissist” is thrown around casually a lot. The sense of entitlement and anger when special treatment is not received can be quite challenging. Many of these feelings come from a fear of rejection or inferiority. These guidelines may make working with someone with narcissistic personality disorder and dementia easier:
- More praise and adoration may be effective
- Remain calm
- Best to have caregivers that did not know this person well prior to dementia
Paraphilias:
One of the most common paraphilias (or potential paraphilias) we see is exhibitionism or the “flasher,” one who is sexually aroused by exposing themselves to others. This can be the case when someone is masturbating in public but it shouldn’t be assumed that someone with dementia is an exhibitionist if they are masturbating in public. What I recommend is to review the person’s legal history if possible and ethical. That way, you may know if they have a history of indecent exposure. If the behavior is not successfully redirected, then it may be exhibitionism. Keep in mind that redirecting this behavior is not as simple as asking them to stop, taking them to an activity, or distracting them. The urge to masturbate is normal and should be permitted/encouraged in the correct environment. Many older adults still have sexual interest
If you have exhausted all techniques for redirection and suspect it is exhibitionism, then you’ll have to get creative.
- Guide them to their room and leave the TV on
- Use background noise that sounds like people, posters, or life size cut outs to give the perception that others are watching.
- You may have to consult a psychiatrist if non-pharmacological interventions don’t work.
- Sometimes, doctors may prescribe medication to reduce sexual urges
Another I commonly see is transvestism, being sexually aroused by dressing up in clothing belonging to the opposite sex. Men or women may have participated in this their whole life, however, they likely had better problem solving skills and inhibition, so they were able to keep it more private. With dementia, these cognitive abilities (problem solving and inhibition) may decline which is why it can seem like this is a sudden change. If the behavior is not harmful to themselves or others, many would recommend that it is OK for it to continue.
Bipolar Disorder
We discussed bipolar disorder earlier. It is important that an older adult with both dementia and bipolar disorder still receive adequate support. The following tips may be helpful:
- Use a behavior log to attempt to predict manic/depressive behaviors
- Have support ready for person
- Hire extra help to spend more time with the person one-on-one
- Keep your cool
- Utilize validation and redirection
Impact on Care
When there is a diagnosed or suspected mental illness, it can greatly impact the care of someone with dementia. Determining whether it is mental illness or dementia. Keep in mind that dementia is progressive and the mental illness severity may decrease as the disease progresses or the symptoms of dementia may be exacerbated by mental illness. The techniques that worked for mental illness before may not work any longer or they may change as the dementia progresses.
In order to find out if mental illness may be a concern, there are some questions we can ask ahead of time. These questions should usually be directed toward the primary caregiver who has known them the longest:
- How would friends and coworkers describe them when they were younger, before dementia?
- When did you start to notice a change?
- What was your childhood (adult child) or early marriage (spouse) like?
- What challenges did you have in your marriage (spouse)?
- How did he/she handle challenges before dementia?
- What kind of interactions or experiences would “set him/her off?
Even if it isn’t mental illness, these questions can still reveal personality traits that may impact the way we care for someone with dementia. Mental illness can take a toll on family members and it is likely they have been dealing with the challenges for a long time. It is important to exercise empathy with those involved in the lives of someone with dual diagnosis. While it isn’t covered in this article, you can read more about empathizing with family members here.
If you’re not sure which techniques to use or when, Trovato, LLC can provide an assessment and develop a care plan for you, other care partners, and the person with dementia.