Dementia

Causes and Risks:
Disorders that cause dementia are usually disorders that impair the vascular (blood vessel) or neurologic structures of the brain ( organic brain syndrome ). A few causes of dementia are treatable. Treatable causes include normal pressure hydrocephalus , brain tumors, and dementia due to metabolic causes . However, many of the disorders associated with dementia are progressive, irreversible, degenerative conditions.

Dementia may be diagnosed when there is impairment of two or more brain functions, including language, memory, visual-spatial perception, emotional behavior or personality, and cognitive skills (such as calculation, abstraction, or judgment). Dementia usually appears first as forgetfulness . Other symptoms may be apparent only on neurologic examination or cognitive testing. Loss of functioning progresses slowly from decreased problem solving and language skills, to difficulty with ordinary daily activities, to severe memory loss and complete disorientation with withdrawal from social interaction.

Dementia is a medical, social, and economic problem. It becomes increasingly significant as the number of elderly people increases.

Prevention:
Most of the causes are not preventable.

Symptoms:
  • progressive loss of memory
  • inability to concentrate
  • decrease in problem solving skills and judgment capability
  • fluctuating mental status, hyperactive to limited alertness
  • confusion , severe
  • hallucination, delusions
  • altered sensation or perception
  • impaired recognition (agnosia)
    • impaired recognition of familiar objects or persons
    • impaired recognition through stimuli of any or all senses

  • altered sleep patterns
    • insomnia
    • need for increased sleep
    • disturbance or change of sleep-wake cycle

  • motor system impairment
    • impaired skilled motor function ( apraxia )
      • inability to reproduce geometric figures
      • inability to mimic hand positions
      • inability to dress self

    • gait changes
    • inappropriate movements
    • other impairment of motor system

  • disorientation
    • person, place, time
    • visual-spatial disorientation
    • inability to interpret environmental cues

  • specific disorders of problem solving or learning
    • inability to generalize
    • loss of abstract thinking
    • impaired calculating ability
    • inability to learn

  • memory deficit
    • short-term memory
    • long-term memory

  • absent or impaired language ability ( aphasia )
    • inability to comprehend speech
    • inability to read (alexia)
    • inability to write (agraphia)
    • inability to speak , without muscle paralysis
    • inability to form words
    • inability to name objects (anomia)
    • poor enunciation
    • inappropriate speech, use of jargon or wrong words
    • inability to repeat a phrase
    • persistent repetition of phrases
    • other language impairment

  • personality changes
    • irritable
    • poor temper control
    • anxiety
    • depression
    • indecision
    • self centered
    • inflexible
    • no observable mood (flat affect)
    • inappropriate mood or behavior
    • withdrawal from social interaction
    • inability to function or interact in social or personal situations
    • inability to maintain employment
    • decreased ability to care for oneself
    • decreased interest in daily living activities

  • lack of spontaneity

Additional symptoms that may be associated with this disease:



Signs and Tests:
A neurologic examination may reveal abnormalities, including the presence of abnormal reflexes and abnormal levels of normal reflexes. Psychologic studies and tests of sensation, cognitive function, and motor function may be abnormal.

DSM-IIIR criteria for diagnosis of dementia include:

  • reduced attention
  • disorganized thinking as evidenced by speech patterns
  • 2 or more of these symptoms:
    • altered consciousness
    • perception changes
    • disturbance of sleep-wake cycle
    • psychomotor changes
    • disorientation to person, place, time
    • impairment of memory, problem solving, learning, language

  • symptoms develop rapidly, may fluctuate
  • one of these factors:
    • evidence from the history, physical exam, and testing of specific disorders that are judged to cause the disturbance
    • organic (physical disease) factor can be presumed if there is no evidence of non-organic (psychiatric, emotional, and so on) disorder

The extent of damage and cause of dementia may be indicated by tests and procedures that include, but are not limited to:



Treatment:
The goal of treatment is to control the symptoms of dementia. Treatment varies with the specific disorder. Hospitalization may be required for a short time. The underlying causes should be identified and treated, including treatment for reversible organic lesions (such as tumors).

Stopping or changing medications that worsen confusion , or that are not essential to the care of the person, may improve cognitive function. Medications that contribute to confusion include anticholinergics, analgesics , cimetidine, central nervous system depressants, lidocaine, and other medications.

Disorders that contribute to confusion should be treated. These include heart failure , decreased oxygen ( hypoxia ), thyroid disorders , anemia , nutritional disorders, infections, and psychiatric conditions such as depression . Correction of coexisting medical and psychiatric disorders often greatly improves mental functioning.

Medications may be required to control aggressive or agitated behaviors or behaviors that are dangerous to the person or to others. These are usually given in very low doses, with adjustment as required.

Medications that may be considered for use include:

  • anti-psychotics, given at night
  • beta blockers if dementia is related to central nervous system lesions
  • serotonin-affecting drugs (lithium, trazodone, buspirone, clonazepam)
  • dopamine blockers (such as haloperidol)
  • carbamazepine, particularly in senile dementia, Alzheimer's type
  • fluoxetine, imipramine, may help to stabilize mood
  • cerebral vasodilators (variable results reported)
  • stimulant drugs (such as methylphenidate), may improve mood
  • ergotoxine alkaloids, may improve mood and self care without altering cognitive function
  • cholinergic stimulators (such as tacrine phosphatidyl choline) have been effective for some persons with senile dementia, Alzheimer-type

Sensory function should be evaluated and augmented as needed by the use of hearing aids, glasses, or cataract surgery .

Formal psychiatric treatment (psychotherapy, group discussions, etc.) is seldom effective because it may overload limited cognitive resources in the person with dementia.

Long term treatment:
The provision of a safe environment, control of aggressive or agitated behavior, and the ability to meet physiologic needs may require monitoring and assistance in the home or in an institutionalized setting. This may include in-home care, boarding homes, adult day care, or convalescent homes.

Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may be helpful in caring for the person with organic brain syndrome . In some communities, there may be access to support groups . (See elder care - support group )

In any care setting, there should be familiar objects and people. Lights that are left on at night may reduce disorientation. The schedule of activities should be simple. Behavior modification may be helpful for some people in controlling unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety ). Reality orientation , with repeated reinforcement of environmental and other cues, may help reduce disorientation. Family counseling may help in coping with the changes required for home care.

Legal advice may be appropriate early in the course of the disorder, before the person becomes so incapacitated that he or she cannot make decisions. Advance directives, power of attorney , and other legal actions may make it easier to make decisions regarding the care of the person with dementia.

Prognosis:
The outcome varies. Acute disorders that cause delirium may coexist with chronic disorders causing dementia. Chronic brain syndromes are often progressive and usually result in decreased quality of life and decreased life span.

Complications:
Complications vary depending on the specific disorder:

  • loss of ability to function or care for self
  • loss of ability to interact
  • increased incidence of infections anywhere in the body
  • reduced life span
  • abuse by an over-stressed caregiver
  • side effects of medications used to treat the disorder



Call Your Healthcare Provider:
Call for an appointment with your health care provider if
dementia develops or sudden change in mental status occurs.

Call for an appointment with your health care provider if the condition of a person with dementia deteriorates to the point where you are unable to cope with care of the person in the home.