WASHINGTON—Dementia refers to a group of illnesses that involve memory, behavior, learning and communicating problems. Although dementia is rare in people under the age of 60, the risk for dementia increases as a person ages.

As in the general U.S. population, beneficiaries in the Indian Health Service also suffer from dementia. Its prevalence is a concern in the Indian Health Service where risk factors, such as an aging population, diabetes and cardiovascular disease are on the rise, according to Bruce Finke, M.D., a family physician and a geriatric specialist who serves as lead for Elder Care in IHS.

“We do know dementia exists and is a significant health problem for American Indians and Alaska Natives,” Dr. Finke said. “There are a couple of reasons to suggest that it is increasing. One is that the age of the American Indian and Alaska Native population is increasing and we know that dementia of all sorts increases in prevalence with age. So, it is a blessing to have more elders in Indian Country, but we know as our population ages that we expect to see more dementia. The other thing is that there are other conditions that contribute to the rate and severity of dementia, especially high blood pressure and cardiovascular disease and stroke. Those rates are higher in American Indian and Alaska Natives and increasing because of the relationship with diabetes.”

Signs of Dementia

Two major causes of degenerative (non-reversible) dementia are Alzheimer’s disease and vascular dementia, according to the National Institutes of Health.

Memory impairment and the impairment in functioning that it causes are the most common signs of dementia. “We often pay attention to the memory and thinking aspect of it, and we forget to pay attention to the function piece of it,” Dr. Finke said. “So, for me as a clinician I think in those terms. I think it is important to look at, ‘Is my elder having trouble with memory and thinking?’ ‘Are they having trouble with function?’ Obviously, people focus in on short-term memory loss—forgetting names and forgetting appointments—and it is hard sometimes to tease out whether that is just a busy elder with a lot on their mind versus true memory loss.”

An example of loss of function due to memory loss is when an individual forgets directions to a place they commonly drive or gets lost in a store they often frequent. “When folks begin to lose function, for example, people who drive who knew how to get to a place and then suddenly can’t remember how to get there or become disoriented in familiar situations—these are functions that should raise the red flag. A great example is getting lost in the grocery store or an elder who isn’t paying attention to their meals,” Dr. Finke said.

While screening on a population basis is not done for dementia, it is important for providers to follow up when patients have any signs of dementia so that help can be offered early on.

“We need to have a high index of suspicion and to follow up on the early signs so we can be a little proactive with families in the clinical setting to identify issues and look to provide support and resources before a crisis happens,” Dr. Finke explained. “Both within the Indian health system, and I would say in the general population, there is a big problem in that dementia is frequently not identified and sort of emerges around a health crisis.”

Treating Dementia

Dementia is progressive and even with the use of medications its progression is not halted. While standard medications for dementia are available in the IHS, Dr. Finke said that his impression has been that the IHS relies less on medications and more on non-pharmacological management in dementia care. “My impression is that there is less reliance on medications in the elderly. That said, the standard medications are available,” Dr. Finke said.

According to Dr. Finke, when using medications to improve function in Alzheimer’s and dementia patients, it is important to have a good understanding of the patient’s baseline function and any problematic behaviors when the medications are started. If, after the dose adjustment period, the patient does not improve with the medications, they should be stopped.

“I would argue that it is important to at least give a trial and see if it benefits the patient and family,” Dr. Finke said. “The challenge with those medications is to be tuned into whether they are improving function, and if they are, then they should be used.”

For behavioral issues associated with dementia, nonpharmacological approaches should first be considered. “The reality of American medicine on the whole is that we tend to use medications over nonpharmacologic approaches,” Dr. Finke said. “We don’t have access sometimes to nonpharmocologic approaches. For behavioral issues it is definitely preferred to use the nonpharmacologic approaches.”

Nonpharmacological approaches would include techniques and approaches to help the elder with personal hygiene and to bathe, for example.

“So, bathing and personal hygiene tends to be, especially with moderate to severe dementia, a problem that families have,” Dr. Finke said. “There has been some really nice work done on approaches that minimize the stress for the person with dementia and kind of minimize resistant behavior. It is more time consuming and training is necessary so that people know how to do it.”

One of the issues for IHS and the mainstream medical system in the U.S. is that adequate attention has not been given to training family caregivers in these approaches, according to Dr. Finke.

“We require a level of training for professional caregivers of people with dementia, but we don’t provide a similar level of training for family members and family member provide most of the care with dementia,” he said. “So, a big issue both with Indian health and outside of Indian health is developing the resources to provide the training to family members of people with dementia in best practices, techniques and approaches to improve quality of life. Nonpharmacological approaches to dementia—whether it is bathing, around food, around reorientation—these are active approaches, not just monitoring. They are active techniques that can help make life better for those with dementia and we definitely need more attention to being able to deliver that.”

In addition to primary care management, an important piece in providing care to dementia patients is in community-based settings. The Administration on Aging funds community-based programs for elders, both nationally and in Indian Country. In Indian Country the AoAAmerican Indian, Alaska Native, and Native Hawaiian program provides funding for elderly nutrition, information and referral and caregiver support, including respite care. In addition, the states and tribes also provide services.

“That is an important resource for people with dementia and their families. Increasingly, tribes have worked very hard to develop long-term care resources and these run the continuum. The majority of these are home- and community-based resources, respite care, personal care services and home-based services. But it goes the gamut from facility-based care to assisted living,” said Dr. Finke.

Preventing Dementia

One of the benefits of preventing diabetes, hypertension and heart disease is that it may have a positive impact on the rates of dementia in IHS. “From a public health standpoint, the bang for the buck around prevention of dementia is in the prevention of diabetes, hypertension and heart disease. That is where the money is,” he said.

One reason that Dr. Finke said that he is optimistic about the care and prevention of dementia is that IHS is pursuing an initiative called the Chronic Care Initiative that is focusing in on redesigning how care is delivered in IHS. This will, he said, help in the delivery of care of people of all ages, including elders.

“That really focuses in on redesigning the delivery of care, not just for elders, but across the population to provide more comprehensive patient-centered care in the primary care setting and to redesign care so that we are not providing just serial acute visits, but really true comprehensive care over time, both for prevention and management of chronic conditions. I think that is the kind of approach that builds capacity to care for people with problems with dementia. The issue with care for dementia is it has to be done in relationship with the care team and there has to be an eye toward understanding the experience of the elder and their family. That doesn’t happen in a system that is just designed around episodic visits, and it doesn’t happen in a system in which care takes place only within the four walls of the clinic.”