Many people have enjoyed gardening during their life and will retain certain basic skills, physical problems permitting. A small area of garden in which simple flowers or vegetables can be grown may provide a lot of stimulation. As well as the need to plant and sow and then to tend the growing plants, it can be an interesting focus of attention on other occasions. A short stroll into the garden, especially if it is sunny, can be very soothing. It can also be used as a diversional activity to be returned to at times of stress or agitation.

If an outdoor plot is, or becomes, impractical for any reason, consider creating an indoor garden with plants in pots or trays on the windowsill, in a conservatory, or elsewhere. It is best to use unbreakable or inexpensive materials and to grow simple plants. These could be purely decorative, grown only for interest, or productive such as mustard and cress, beansprouts, and even indoor tomatoes if the space allows.

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Many carers feel extremely isolated when the immensity of the task ahead dawns on them. Some have struggled on for years before realizing that many people are in a similar position to themselves. The isolation is not just psychological, but also physical. Some sufferers with dementia require almost constant attendance, twenty-four hours a day. This gives little opportunity for a carer, particularly an elderly spouse who may have physical problems of his or her own, to get out and meet other people, other than the occasional short trip to the shops. Social activities often take second place to what appear to be more essential daily tasks. The situation is often compounded by embarrassment at the behavioural abnormalities that so frequently occur. If the doctor or other professionals are found to be caring, supportive, and understanding of the carer’s predicament, they may themselves help to break the feeling of isolation and at the same time point a carer in the direction of additional forms of help.

Many people find themselves in a situation where it is the very person to whom they would have turned for help that has developed the dementia. This can be a particularly cruel predicament and it is essential that a carer in this situation makes contact with others, either through a support group, or day hospital, or day centre, or via family and friends. In particular, discover what type of day care and sitting-in services are available in your area, which will enable you to break free and meet other people.

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These invaluable members of the health care team are often part of the supporting system for families caring for people with dementia and for the many demented elderly people who are living alone at home despite their illness. They are trained psychiatric nurses and many have also trained in general nursing and can therefore appreciate and understand the physical as well as the psychiatric problems. In some areas they are based in a hospital, attached to a psychiatrist’s team; in others they are attached to health centres. Sometimes they operate from both. The CPN liaises across all the different services – social services, geriatric service, psychiatric service — and may have to work closely with the general practitioner. Many of them have close links with the voluntary bodies in the locality. They do not carry out physical nursing tasks; these are the province of the district nurse. A CPN will usually become involved after the general practitioner has referred a patient for assessment to a psychiatric clinic or asked a psychogeriatrician to make a visit to the person’s home. In some areas, a general practitioner can himself initiate the CPN’s involvement.

The CPN has a wealth of experience and knowledge, will be able to give practical advice about coping with routine problems, may be able to arrange attendance at a day hospital or day centre as appropriate, and can alert others if the need arises.

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Although diagnosis is often most easily made with the help of a brain scan, the outwardly discernible character of the disease provides many clues to its presence.

As discussed, the disease will often have an abrupt onset and there will be gradational deterioration with a fluctuating course; although a person with multiple infarct dementia will suffer from an intellectual decline that is in many ways similar to that associated with Alzheimer’s disease, to begin with the disease will pick out different areas of intellect, resulting in a rather patchy intellectual loss compared with the steady and relentlessly progressive deterioration that is seen in most of the other conditions that cause dementia. Personality is often preserved until quite late in the disease, as is insight, and this can result in severe depression. People with MID are often very unstable emotionally.

There is often evidence of an underlying medical condition that puts the patient at particular risk of having strokes, such as high blood pressure or heart disease. If some of the small strokes have affected the part of the brain controlling the face or the limbs, there will be signs of this when the subject is examined by a doctor. The following account describes a fairly typical case history.

Mrs Brown

Mrs Brown was sixty-eight when her husband took her along to their general practitioner because he was worried about his wife’s forgetfulness. It was clear that she had been becoming more and more forgetful and that this had started suddenly, after she had experienced a ‘dizzy turn’ on Christmas Eve. Although she had never lost consciousness, she had had several more funny turns after most of which she was a little confused for a day or two. The doctor knew that Mrs Brown suffered from diabetes and needed to take tablets, so he checked the level of sugar in her blood. This was normal and she didn’t have any of the other symptoms of high blood sugar. He therefore examined her carefully and discovered that she had a high blood pressure. He treated this with the appropriate medicines.

When he saw her again a month later, Mrs Brown was still very forgetful, had some difficulty with her speech, and needed a little help with dressing. This was only a little better than her condition when he had seen her a month previously.

A further year passed during which Mrs Brown was seen on several occasions by her doctor, who ensured that her blood sugar level and her high blood pressure were properly treated. During this year she only had one further dizzy spell, after which she had again become a little more confused. Although there was some recovery over the ensuing two or three days, she was a little more muddled than before.

In summary, Mrs Brown had some of the characteristic features of multiple infarct dementia and careful attention to the underlying risks — the blood sugar level and the high blood pressure – had probably slowed down the rate of intellectual deterioration.

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Dementia provides two important diagnostic challenges. The first of these is the need to establish whether what appears to be an exaggeration of the normal mental changes of ageing is really dementia. The second involves determining the nature of the underlying illness if the diagnosis of dementia is confirmed.

This chapter will provide an outline of the procedures involved and will also give some information about many of the more important conditions, both treatable and untreatable. As Alzheimer’s disease and multiple infarct dementia are the two most common causes, and much is known about them that will be of interest to those caring for sufferers, each has a chapter of its own and is not discussed in detail here.

It is probably unnecessary for most readers to refer to the sections dealing with each of the different underlying illnesses – it may be less confusing to refer only to that condition which is affecting the person for whom they are caring. Professional carers – those working in old people’s homes, nursing homes, or with patients in their own homes – may find it helpful to read this section in its entirety, or to refer to it from time to time as necessary.

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