‘When we are brought face to face with the unfortunate physical wrecks of humanity, we are compelled by duty not to shrink, but to examine carefully the sources of the wreck, and to patch it up and make it more comfortable and habitable for its spiritual occupant, if possible.’ A quote whose origin is untraceable but which aptly defines ‘Dementia’.
A burgeoning geriatric population compels a closer look at this disabling and debilitating syndrome. For, central to the concept of health is the right and the ability to lead a productive life.
Dementia is defined as a deterioration in intellectual abilities that is of sufficient severity to interfere with social or occupational functioning. It is manifested as a difficulty in memory, attention, thinking and comprehension and affects mood, personality and social behaviour.
The International Classification of Disease (ICD- 10) describes four categories of dementia,
- Dementia in Alzheimer’s Disease
- Vascular dementia
- Dementia in diseases classified elsewhere
- Unspecified dementia.
Alzheimer’s disease is the most common cause of dementia in the elderly. The next most common among the senile dementias is cerebrovascular dementia especially seen in patients with long standing diabetes or hypertension which predisposes them to atherosclerotic changes and consequent thrombosis- embolism and cerebrovascular accidents. Other causes are those due to frontal lobe pathology, brain tumours, hydrocephalus, parkinsonism or associated with depression.
Alzheimer’s disease is a neurodegenerative disorder associated with diffuse loss of brain tissue and characterised by impairment of memory, inability to retain and recall events, names and faces of relatives, where thinking, learning and executing is severely affected as the patient progressively declines in his intellectual abilities and in severe cases may present with delusions, disorientation and behavioural disturbances. There may be associated disruptions in language and motor ability and the patient eventually deteriorates into an existence isolated from reality and dependent on his care givers for his daily activities. Grossly the brain exhibits a widening and deepening of sulci and ventricular dilatation which suggests a shrinkage of neurons. Microscopically, the presence of amyloid plaques and neurofibrillary tangles confirms the diagnosis.
A thorough clinical history, physical examination, biochemical and radiological investigations, examination of the mental status and computerised axial tomography and magnetic resonance imaging can help to establish the diagnosis conclusively. Once that is done, the need is for a definitive, multidisciplinary, therapeutic approach and Homoeopathy can serve to be a viable option.
Principles of management
Dementia is a chronic, progressive degenerative disorder and as in every chronic disease, we need to understand the individual in front of us in terms of the basic disposition, environmental factors and the interaction between the two in the genesis and evolution of the present malady. Not to mention the hereditary influences in the patient’s makeup. If we have a homogenous totality which has developed since the onset of dementia (which is quite obscure as dementia usually begins imperceptibly as a mild cognitive deficit) we have fine guidelines to go ahead with. But what is observed generally is that very few characteristic symptoms are available to us and the patient has lost his sense of memory, judgement and discrimination. So the approach remains largely constitutional (unless otherwise indicated) so a consideration of the premorbid personality becomes necessary in our search for the simillimum.
The case in question is of an 83 year old elderly lady, a retired school teacher who was brought by her son and daughter-in-law. She was wheel chair bound because of arthritis and there were gradual changes in her memory and behaviour since the last 5-6 years. She had become forgetful wherein she forgets what she was about to say in mid-sentence and mixes up the names of people. She could not even recollect the name of her daughter. She tends to perform repetitive acts, will fold and unfold a watch strap, open and close a book. Her speech had become slow and she had become indifferent to everything including television. Recently she had become incontinent too. She was a known case of bilateral knee osteoarthritis and hypertension.
She looked obese and depressed and her appetite and thirst were diminished. She used to love non vegetarian food and eggs but now had no particular cravings. Perspiration was scanty and stools and urine were passed regularly. Her sleep was not refreshing and she sleeps for almost 13 hours daily. During sleep she talks and gives instructions to her children. She is a chilly patient.
Information was obtained from her daughter-in-law. The patient grew up in a rich family. Her father was the chief justice in Kerala. She grew up in opulence, was always full of life and full of fun. Her husband was a teacher and a journalist and a freedom fighter. He as a very quiet sort of a person and the patient always had her way with him. He died in 1988.
The patient was a teacher in a local school. She used to be busy with her work, yet always liked to have the house full of people. She loved to party and show off her new possessions and spend money at such times. She was very particular about her appearance and used to dress up well. Even when she had to go to school daily, she used to put on foundation and lipstick. She was very religious in the ritualistic sense and never ventured out without her daily and prolonged prayers. She had some definite ideas about her religion and at times even wanted the other family members to follow them without questioning. But she was not very helpful to others in need. She always had in mind her interests first and would not hesitate to lie if the situation demanded or to prove her point. She was a Karnataki singer with a rich voice and used to enthral the audience with her singing. She never used to walk, always took a rickshaw even if she had to go for a short distance.
She had six children and one son in particular was a little low in IQ. Somehow she always used to feel guilty for him. In the middle of the night she would cry, ’save me’ since the time her health took a turn for the worse.
She always dictated what others should do and what they should not. Nobody in the house or outside dared speak against her, she always had her way.
General examination – NAD
Systemic examination – CNS – Consciousness and Orientation – Poor, Memory – unable to recall clearly any recent events, Speech – Slow, deliberate and incoherent. Reduced discrimination for touch, temperature and vibration, reduced power in muscles and slow reflexes. Poor coordination though can walk with assistance and can maintain body posture.
R/S, CVS, P/A – NAD
Mental status examination – Patient exhibited difficulty in recall of events. She was conscious but poorly oriented with respect to time, place and person. A sad affect was prominent, which was unnatural to her. She refuses to budge from the wheelchair although can walk around slowly with a stick. She was engaged in repetitive actions and her speech was slow, abrupt and lacked flow.
CT-brain – Not done
Serum electrolytes, serum B12 and thyroid profile was normal.
The totality formed was,
Religious, despair of salvation, fanaticism
Rx Veratrum Album – based on:
The patient was always the sort who would want the company of people and she would love to mingle and show off. What was very prominent was her religious nature, in the god- fearing sense, so that she would go to extremes and also wanted to enforce her views on others (natural for a dominating person). She used to cry out, ‘save me’ and if we try to correlate all these symptoms, we can see a person with a lot of guilt who becomes ritualistic rather than spiritual, she seeks salvation for her actions due to some imagined guilt rather than actively seeking out spiritual lessons. So what is the source of such guilt? Is it the fact that she has a child with a low IQ? Or is it a fact that she tends to lie or that she is primarily selfish? Whatever the reasons, it is most definitely not a spiritual yearning. So now we have a self-centered, religious, foppish, dominating personality who loved to socialise and display her possessions coming down with irreversible brain atrophy exhibiting a peculiar trait of repeating gestures (folding and unfolding watch strap, opening and closing book) and this quality of the patient matched Veratrum closely.
She was prescribed Veratrum Album 200, 1 powder and SL tds for 15 days. The other medicine closely resembling the totality was Lachesis but the extreme loquacity, jealousy and suspicion which are its strong features was absent. Also Veratrum is more of a show-off than Lachesis.
In the next follow-up, her sleep had improved and her incontinence was better but the rest of her complaints were the same. She was continued on SL and thereafter over the next 6 months was given infrequent repetitions of Veratrum Alb 200. The changes in her were gradual but consistent. She had started praying with her rosary and had become conscious of what was going on around her. Her face was cheerful, smiling and what she said made sense to others. She started walking around voluntarily with her stick and her appetite improved. She started watching television and even went back to putting on foundation! Her family members were absolutely amazed at this transformation (and truthfully…so was the physician)!