Some Non-specialist Doctors in Imphal, diagnosing Elderly People with normal Age-related Forgetfulness as Dementia

Dr. Irengbam Mohendra Singh *

Hello! Happy New year to all the readers of E-Pao.

My name is Mohendra. Irengbam Mohendra. I was born and brought up at Uripok, Imphal. I have been living in the UK for over half a century, but visiting Imphal every year. I am a physician by profession, albeit retired.

During our annual pilgrimage to Imphal in November 2019, I came across a couple of elderly people with very mild forgetfulness and being labelled (diagnosed) as Dementia/Alzheimer's disease, and having been referred to Memory (Dementia) Clinic, somewhere in Imphal.

I as a doctor, find it hard not to complain. It sticks in my craw. Diagnosing an elderly person with normal age-related forgetfulness as dementia is unethical. It is extremely worrying for and depressing to the non-dementia patients, wondering when they are going to become bonkers.

Memory lapses or occasional forgetfulness in the elderly is called 'Senior Moments' in the English vocabulary - Ahal oibagee kaoganba in Manipuri. This is not dementia of any kind. Dementia is defined as a decline in mental function that is severe enough to interfere with daily living.

Jimmy Carter, while he was President of America, left the "codes" needed to launch a missile strike, in the pocket of one of his suits, which was sent to the dry cleaners. President Nixon also of America, arrived in Paris for the funeral of French President Georges Pompidou. At the airport, he forgot what he came for and declared, "This is a great day for France". They were not demented.

Old age only comes to people who are lucky to be living past the average age of death. The average age of death differs from country to country. There is no fixed definition of old age. It is simply comparative. The societal definition of old age changes with time. Old age is a normal continuous process that ends with death.

Being occasionally forgetful is part of old age and there is good news for it. A scientific study conducted by the University of Toronto has claimed that having a strong memory is a severely overrated asset and in fact, being forgetful could actually be a benefit to your intelligence, as it is important that the brain forgets irrelevant details and retain only really essential ones.

Ageing is an unavoidable property of life. The evolutionary theory of ageing says: 'any animals that include humans, will age at a rate commensurate with its likely survival prospects in the wild'. The vital organs of our bodies, especially the heart, give up on us after an age when we would have expected to die through starvation, disease and or being eaten.

The UN report (2007) points out that the world is about to cross a demographic landmark of huge social and economic importance, with the number of old people (65 and over) set to outnumber children under 5 for the first time in 2047. This is known as 'population ageing shift'.

The UN predicts that the Indian population will grow by 50% in the next 50 years and the elderly population is expected to grow another fourfold. This includes Manipur, with the ever-increasing problem of who is going to look after the elderly.

The population of ageing arises from increasing longevity and declining fertility. Declining fertility, which means people are having only 2 or 3 children because of economy, is the largest contributor to population ageing in the world today. This will impact on the rapidly changing modern western-style Manipuri society with its increasing college-educated youth and more participation of women in the workforce.

The urbanisation of Imphal city with a population shift from the villages in the valley and hills, will leave old people fending for themselves. As government and private jobs are scarce in Imphal, many well-qualified youngsters will tend to go outside Manipur and abroad to find work. The emigration of these nuclear families will adversely affect the age-old joint family system in which old people who have no social security benefit, are cared for.

Ageing is affected by many factors such as hereditary, diet, workplace-related stress, and the surrounding environment. There are several physical and mental declines associated with ageing with their inevitable encumbrance on the carers, which in Manipur, are the family members.

Old age consists of physical, biochemical (chemical process in the body) and mental ageing. The process of ageing comprises two simultaneous biological processes, growth and involution, which are opposed. In the early years of life, growth predominates, but by the time of 'old age', involution takes the upper hand. The growth then, is only concerned with replacement of cells and tissues (collections of cells) where changes are continuous.

The process of involution seems to cause old people to grow smaller and lighter from late middle age onwards. Height, on average of about two inches are lost because of softening and wedge-shaped collapse of vertebral bones due to lack of calcium. This causes distortion of the thoracic cage with a fixed stooping posture forward.

The pattern of disease in an ageing population differs fundamentally from that of the younger age group. The most prevalent long-term disorders found amongst the elderly are mental and nervous system diseases, most of which are to be classified as degenerative (wear and tear including the brain). They in turn, are followed by arthritis of joints, heart disease, diseases of blood vessels (thickening of arteries), cancer, and among many smokers with 'chronic obstructive pulmonary disease' – COPD (damaged lungs with severe breathing difficulties).

The nerve cells in the nervous system have the same life span as the individual itself. As they cannot reproduce further nerve cells while there is a steady loss, changes in muscle tone, and coordination in muscular activity occur while retaining the normal intellectual function. In many, old age is associated with dementia often called "senile dementia" due to a gross loss of cells in the brain.

Dementia is a syndrome ie group of symptoms, not just age-related forgetfulness, whilst Alzheimer's is a disease - a degenerative and terminal disease of the brain, which usually begins in people just over 65, before the usual age of senile dementia (70 or over). It is important for doctors to remember that forgetfulness is not always the beginning of dementia that may include Alzheimer's disease.

The most characteristic change in most old people is age-related impairment of memory (not mental disease), which is more marked for the present than the past memory. They may even be partially confused sometimes, about time and place because they have forgotten where they have recently been or at what time of the day. These mental changes, we doctors in the UK, simply label as "Confusional state". The term 'dementia' carries a stigma for the family.

Even the most famous scientist Albert Einstein was not exempt from senior moments. The story goes as his wife Elsa told. "During their second visit to America he first lost his wife, then found her, then he lost tickets and then found both.

Forgetfulness may also be caused by depression due to personal circumstances or side-effects to one or more drugs doctors have prescribed for other conditions. Not eating enough healthy foods or lacking in vitamins and minerals is another cause.

Emotional problems, such as stress, anxiety or depression can make a person forgetful of present events as the mind is occupied with the ever present mental problems. Trying to cope with such life changes, causes many people to be forgetful. Forgetfulness can also be caused by temporary emotional problems, which fade away when the problems disappear. A person who cannot remember what he or she ate last night or the neighbour's name does not have dementia. It is normal part of getting old.

Memory consists of (1) attention (2) retention and (3) recall. As one gets older, recall or remembering past life events takes longer. Often the saying: oh! It is on tip of my tongue. Dementia isn't just about memory loss. It also affect the way you speak, think, feel and behave.

The following is a rough differentiation between normal ageing forgetfulness and Dementia, which I quote:

Normal Aging	Dementia
Wrong decision and judgement once in a while	Poor judgements and wrong decisions a lot of the time
Forgetting which day or month it is today but remembering after a while	Completely confused about the date and time of the year
Sometimes having problem remembering which word to use	Trouble having a normal Conversation
Losing things/articles from time to time and finding them later	Losing things often and being unable to find them

In order to diagnose dementia of a person by a doctor, it is necessary that the person's memory and general behaviour must be such that they affect his/her daily living, not just an occasional forgetfulness. The person should continue to have new problems in his/her day-to-day activities in the house, at work or in the community.

According to Mayo Clinic, a not-for-profit organisation in Arizona, US, where 4,500 physicians and scientists work together, there is a stage between the mental changes that are seen in normal ageing and early dementia.

It is called Mild cognitive impairment (MCI), which may increase your risk of later developing dementia caused by Alzheimer's disease or other neurological conditions, such as Parkinson's disease. But some people with mild cognitive impairment never get worse, and a few eventually get better. It is therefore, a very grave mistake to label someone with mild cognitive impairment as dementia.

How to improve or slow down forgetfulness in a healthy old age:

Eat healthy food and multi-vitamins containing minerals.

Take part in social gatherings like Utsav chaba, spending time with relatives and talking of old times.

Have some hobby that can exercise the brain,
such as playing cards or learn to do something new,
such as trying to remember old songs in their entirety or,
for the brave, to learn to operate a computer or cell phone,
which is difficult and needs to exercise the brain.

We all dread old age, especially with the misty imaginary accounts that surround death. It is more dreadful if we doctors carelessly traumatise old people with senior moments as insane, and send them to a living death.

---

* Dr. Irengbam Mohendra Singh wrote this article for e-pao.net
The writer lives in the UK and can be contacted at irengbammsingh(AT)gmail(DOT)com
This article was webcasted on December 31 2019.

---