If symptoms are not caused by Psychiatric/Emotional factors, then exactly what is causing them?

Stacks Image 33
Mental Retreat into Emptiness
When a dementia patient is left alone, they retreat into their mind which is an increasingly empty and scary place. When you wake up at night and your thoughts start ruminating–are they happy thoughts about the coming day? (Picture source cancer.gov)

No, more often your thoughts turn to worries, concerns about things you have to do or even regrets over past events all leading to an “anxious” sleepless night. This is how we are wired. Over the millions of years we evolved, when a cave woman woke up to a noise she’d say to her caveman husband “Did you roll the rock in front of the cave door?” or “Did you throw another log on the fire.” These folks survived to pass her worry genes down to the next generation.

In contrast, the cave person who heard something, woke up and said “Oh, look at the lovely stars” got eaten by the saber tooth tiger and never passed those happy-go-lucky genes down to us. We
all inherited the worry gene, not the happy gene, as a survival mechanism. Without stimulation, like lying in bed on a sleepless night, worrisome thoughts intrude and make it harder to sleep. So you get up and read a book for a while or engage in mindfulness meditation or count sheep to force your thoughts towards something more pleasant, so as to fall asleep again. Our internal world is filled with worries, guilt and rumination over what went wrong in the past, present and future. We need external stimuli to distract us from this, and engage with the real world outside out heads. Luckily, the average person has tools at hand to do this, but a patient with NCD has lost those advantages.

When a dementia patient has no external distracting interesting activity to engage in, or is left to sit alone without constant social contact–they retreat into their internal world, which is no longer organized or purpose-driven. This can be a chaotic place, disorganized and prone to scary thoughts and fears just like those that impinge on your mind over a sleepless night. You may see labile mood with sudden tearfulness, or the patient gets up and starts puttering aimlessly about, or picking at lint–in an effort to self-distract–and then you’re seeing agitation.

The human mind seeks stimulation, if there is nothing external to watch, hear or feel then we look internally and start “ruminating” among the chaotic, disorganized feelings and thoughts that occur spontaneously in all of us. Eventually, we start wandering and folding towels over-and-over, or repeatedly cleaning the kitchen. We are driven to seek external stimulation. However, while you can quit the behavior or engage an alternative strategy (e.g., practice a relaxation technique), the NCD patient can’t organize such a plan and carry it out – precisely because their reasoning and intellectual skills have become compromised. They lack the tools to create an internal response, and must always look to the external world which means picking lint off the carpet, folding towels or making the same recipe over and over which is comforting in its repetitiveness. Order in the world reduces the fear from a chaotic inner world.

So if the problems are not Emotional/Psychiatric– What are they?

The symptoms associated with Neurocognitive Disorders are not well described as “psychiatric” although they certainly look the same. Social withdrawal and self-isolation sure looks like it is caused by depression, but it is not. Isn’t picking lint off the floor or aimlessly cleaning the same parts of the house over and over a sign of anxiety? No it isn’t in this case. Crazy statements not based in reality, paranoia are not psychotic? Not in this case. It is important to recognize these problems are not due to a psychiatric etiology, otherwise you’ll be tempted to seek treatment with psychiatric drugs and therapy. In fact, this write sees few patients with cognitive changes who aren’t started on an antidepressant for signs of depression, which of course doesn’t help much if at all.

A sad likelihood is that when a patient with cognitive impairment sits and stares at nothing, their mind is blank – not thinking at all. In a way it is at rest, but this is not good. Eventually, intrusive thoughts will occur and cause the previously described chaos leading to what appears to be anxiety, but is better described as simple agitation. Offering a patient an hour or two of companionship a week is not enough. More about that later, in the section on alternative to drugs.

A good example of the misapplication of psychiatric diagnosis to dementia patients is the frequent statement I hear that the patient “is in denial.” Family, say not matter how often the explain to him he is forgetting, s/he refuses to acknowledge this, or s/he minimizes the impact. Family assume the patient is defending herself by denying problems exist, which then makes it hard for the family to intervene. The patient seems to sabotage their efforts. They don’t recognize or appreciate the superhuman efforts of their family who are trying to help, in fact the patient doesn’t seem to recognize anything about their disease at all! But it is not denial. The term for this is “anosognosia.” Once you realize the patient is not purposely denying or sabotaging your efforts, you can really begin to bring good reasoning to the task of trying to help. This is important enough to address in its own section, so read on.

<– Previous Page ––– Next Page –>