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Dementia

Dementing Neurological Disease or Syndrome

Dementia is a loss of cognitive abilities severe enough to interfere with normal activities of daily living. It is most common in elderly individuals, with advancing age being the strongest risk factor. The most common cause of dementia is Alzheimer disease (AD), but there are numerous other known causes. Most types of dementia are nonreversible. Symptoms vary depending on the cause and the area of the brain that is affected.


Presentation

Dementia is a progressive condition. It presents initially with mild signs and symptoms that usually go unnoticed. These include restlessness and agitation, depression, anxiety, forgetfulness and confusion. Gradually the patient may progress to a state in which he/she complains of tremors, balance and coordination problems, decline of thinking and planning capacity, delusions, distorted memory, impaired speech and difficulty in swallowing and/or eating.

Weight Loss
  • Feeding and eating difficulties leading to weight loss are common in the advanced stages of dementia.[ncbi.nlm.nih.gov]
  • BACKGROUND: Weight loss, malnutrition and dehydration are common problems for people with dementia.[ncbi.nlm.nih.gov]
  • Eating and swallowing difficulties may place an individual at greater risk for choking and aspiration pneumonia (Bourgeois & Hickey, 2009) and may eventually result in malnutrition, dehydration, and weight loss (Hanson, Ersek, Lin, & Carey, 2013; Jensen[asha.org]
  • Despite her weight loss, then, he declined medical intervention. In February, Mrs. Jewell began refusing food altogether and soon slipped into a coma . Dr. Jewell and his children were with her when she died, at 89. Continue reading the main story[web.archive.org]
  • Despite her weight loss, then, he declined medical intervention. In February, Mrs. Jewell began refusing food altogether and soon slipped into a coma. Dr. Jewell and his children were with her when she died, at 89.[nytimes.com]
Down Syndrome
  • Down syndrome increases the likelihood of young-onset Alzheimer's. Early signs Early signs of dementia can include: Changes in short-term memory. Changes in mood. Trouble finding the right words. Apathy. Confusion. Being repetitive.[medicalnewstoday.com]
  • Most people with Down syndrome develop Alzheimer's. This may be because people with Down syndrome have an extra copy of chromosome 21, which contains the gene that generates harmful amyloid.[nia.nih.gov]
  • This is not useful in the presence of Down's syndrome. CSF examination may occasionally be helpful if Creutzfeldt-Jakob disease or other forms of rapidly progressive dementia are suspected [ 7 ] .[patient.info]
  • Down syndrome Ageing Study Group A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Down syndrome and Alzheimer's disease—pilot study.[doi.org]
Fatigue
  • Difficulty in concentrating, fatigue, and sleep disturbance do not. 17 No studies to date have examined anxiety disorders other than GAD in this population.[web.archive.org]
  • Difficulty swallowing, bowel problems such as constipation and diarrhoea, fatigue, memory loss – all of these can be combatted to varying extents with careful nutrition.[telegraph.co.uk]
  • These are normal parts of aging and can also occur due to other factors, such as fatigue. Still, you shouldn’t ignore the symptoms. If you or someone you know is experiencing a number of dementia symptoms that aren’t improving, talk with a doctor.[healthline.com]
  • Figures and Tables - Analysis 4.4 Comparison 4 Trazodone versus Placebo, Outcome 4 Occurence of Fatigue. Figures and Tables - Analysis 4.5 Comparison 4 Trazodone versus Placebo, Outcome 5 Occurence of Tremor.[doi.org]
  • […] system 2 65 Peto Odds Ratio (Peto, Fixed, 95% CI) 9.36 [2.23, 39.34] 6.3 Number experiencing at least one gastrointestinal adverse event 3 791 Peto Odds Ratio (Peto, Fixed, 95% CI) 2.84 [1.12, 7.22] 6.4 Number experiencing at least one adverse event of fatigue[doi.org]
Nocturnal Awakening
  • awakenings assessed with: actigraphy follow‐up: 10 weeks The mean number of nocturnal awakenings in the placebo group was 34 The number of nocturnal awakenings was, on average, 6 fewer in the melatonin group (2.65 more to 14.65 fewer) ‐ 33 (1 RCT) LOW[doi.org]
  • awakenings (MD -3.71, 95% CI -8.2 to 0.8; N 30; one study).[ncbi.nlm.nih.gov]
Whipple Disease
  • Castle J, Sakonju A, Dalmau J, Newman-Toker DE: Anti-Ma2-associated encephalitis with normal FDG-PET: a case of pseudo-Whipple’s disease . Nat Clin Pract Neurol 2006, 2: 566–572; quiz 573. PubMed CrossRef Google Scholar 14.[doi.org]
Hypophonia
  • Abstract A 42-year-old woman presented with a 6-month history of diffuse headache of moderate intensity and gradual onset of generalized weakness, imbalance, apathy, memory decline, hypophonia, dysphagia, constipation and urinary incontinence.[ncbi.nlm.nih.gov]
Dysphagia
  • Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia.[ncbi.nlm.nih.gov]
  • Leder , Comments on Selected Recent Dysphagia Literature , Dysphagia , 27 , 4 , (562) , (2012) .[doi.org]
  • Abstract A 42-year-old woman presented with a 6-month history of diffuse headache of moderate intensity and gradual onset of generalized weakness, imbalance, apathy, memory decline, hypophonia, dysphagia, constipation and urinary incontinence.[ncbi.nlm.nih.gov]
  • Wei Yi Tay, Lian Leng Low, Shu Yun Tan and Farhad Fakhrudin Vasanwala , Evidence-Based Measures for Preventing Aspiration Pneumonia in Patients with Dysphagia , Proceedings of Singapore Healthcare , 23 , 2 , (158) , (2014) .[doi.org]
  • […] progressive aphasia experience gradual loss of language function but relatively well-preserved memory; and individuals with Binswanger's disease (a type of vascular dementia) experience stroke-related neurological symptoms, including dysarthria and dysphagia[asha.org]
Constipation
  • Abstract A 42-year-old woman presented with a 6-month history of diffuse headache of moderate intensity and gradual onset of generalized weakness, imbalance, apathy, memory decline, hypophonia, dysphagia, constipation and urinary incontinence.[ncbi.nlm.nih.gov]
  • […] in people with dementia -- 21.Delirium in dementia -- 22.Psychosis in people with dementia -- pt. 6 Physical health problems -- 23.Sensory impairment -- 24.Falls -- 25.Nutrition Note continued: 26.Protecting and caring for skin -- 27.Continence -- 28.Constipation[worldcat.org]
  • Difficulty swallowing, bowel problems such as constipation and diarrhoea, fatigue, memory loss – all of these can be combatted to varying extents with careful nutrition.[telegraph.co.uk]
  • There were no statistical differences found in adverse events affecting other body systems or particular symptoms (e.g. dizziness, constipation). No statistical differences were found in measures of cognitive function (e.g. the MMSE).[doi.org]
  • Urinary or faecal incontinence or constipation. Quality of life and how this was measured. Other behavioural and psychiatric symptoms of dementia and the scales used to measure this.[doi.org]
Delusion
  • […] include physical/verbal aggression, agitation, disinhibition, restlessness, wandering, culturally inappropriate behaviors, sexual disinhibition, and hoarding, and the psychological symptoms of dementia are anxiety, depressive mood, hallucinations and delusions[ncbi.nlm.nih.gov]
  • False beliefs (delusions) are common, especially paranoid delusions involving others stealing from them or conspiring against them.[web.archive.org]
  • BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes.[ncbi.nlm.nih.gov]
  • Dementia is a collective term that refers to a decline in brain activity resulting in loss of memory, deceased capacity to think and make logical decisions, impaired speech and motor functioning and delusions.[symptoma.com]
  • Yokukansan was more efficacious in reducing BPSD subscale scores (delusions: SMD   -0.51, 95% CI   -0.98 to -0.04, hallucinations: SMD   -0.54, 95% CI   -0.96 to -0.12, agitation/aggression: SMD   -0.37, 95% CI   -0.60 to -0.15) than placebo UC.[ncbi.nlm.nih.gov]
Withdrawn
  • In these trials, different types of antipsychotics prescribed at different doses were withdrawn. Both abrupt and gradual withdrawal schedules were used.[ncbi.nlm.nih.gov]
  • Thirty-five patients were withdrawn from the study because of adverse reactions, deterioration or death: 25 (31.3%) during active treatment [23 (52.3%) who received buprenorphine], and ten (12.2%) in the placebo group.[ncbi.nlm.nih.gov]
  • Use of physical restraint in people withdrawn from antipsychotics versus people continuing on antipsychotics compared with baseline. 2.5. Mortality in people withdrawn from antipsychotics versus people continuing on antipsychotics. 2.6.[doi.org]
  • Common symptoms of mild dementia include: memory loss of recent events personality changes, such as becoming more subdued or withdrawn getting lost or misplacing objects difficulty with problem-solving and complex tasks, such as managing finances trouble[healthline.com]
Aggressive Behavior
  • This study classified agitated behaviors into 5 main subtypes: physically agitated behaviors, destructive behaviors, verbally agitated behaviors, handling things behavior, and aggressive behaviors.[ncbi.nlm.nih.gov]
  • Lewy body dementia may also cause aggressive behavior or depression, tremors, and an increased risk of falling. The Roots of Compassion & Kindness Apply to Everything We Do Read Our Story[homewatchcaregivers.com]
  • Behavior; Combative Behavior; Violent Behavior; Wandering off 294.8 - Persistent Mental Disorders Due to Conditions Classified Elsewhere, Other; Amnestic Disorder NOS; Dementia NOS; Epileptic Psychosis NOS; Mixed Paranoid and Affective Organic Psychotic[web.archive.org]
  • According to Cohen-Mansfield (1999) four distinct categories of agitation are: (1) physically non-aggressive behavior; (2) verbally non-aggressive behavior; (3) physically aggressive behavior; and (4) verbally aggressive behavior.[doi.org]
  • Aggressive Behaviors in Alzheimer Disease and Mild Cognitive Impairment: Systematic Review and Meta-Analysis . The American Journal of Geriatric Psychiatry, CrossRef Google Scholar Matsunaga, Shinji Fujishiro, Hiroshige and Takechi, Hajime 2018.[doi.org]
Emotional Lability
  • Behavioral and cognitive changes include mental slowness (bradyphrenia), emotional lability, personality changes, and depression. 15 Depression is common in VaD, occurring in up to 20% of cases, and is disproportionately prominent in those cases with[doi.org]
  • EMOTIONAL LABILITY Patients with delirium may display a wide range of emotions, including anxiety, sadness or tearfulness, and euphoria. They may have more than one of these emotions during the course of delirium.[web.archive.org]
Psychiatric Manifestation
  • The first step to better understand the psychiatric manifestations of dementia is to appropriately recognize and describe the psychopathology and accurately distinguish between similar symptoms (e.g., depression vs. apathy).[doi.org]
Urinary Incontinence
  • Abstract A 42-year-old woman presented with a 6-month history of diffuse headache of moderate intensity and gradual onset of generalized weakness, imbalance, apathy, memory decline, hypophonia, dysphagia, constipation and urinary incontinence.[ncbi.nlm.nih.gov]
  • Specifically, HICPAC recommends not using a catheter to manage urinary incontinence in the PA/LTC setting.[choosingwisely.org]
  • Hashimoto MImamura TTanimukai SKazui HMori E Urinary incontinence: an unrecognised adverse effect with donepezil. Lancet 2000;356 (9229) 568 PubMed Google Scholar 47. Gill SSMamdani MNaglie G et al.[doi.org]
  • Other symptoms that support the diagnosis but are of less clear‐cut diagnostic value are repeated falls, syncope, transient disturbances of consciousness, severe autonomic dysfunction (for example orthostatic hypotension), urinary incontinence, systematised[doi.org]
  • In two of the other studies, patients were described as having "advanced dementia" and this was then staged, most commonly using the FAST scale ( Reisberg 1994 ) at a severity level of 6d and above (urinary incontinence) ( Alvarez‐Fernandez 2005 ; Meier[doi.org]
Agitation
  • Currently there are relatively few studies of antidepressants for the treatment of agitation and psychosis in dementia.[ncbi.nlm.nih.gov]
  • Effects of the BACE intervention on agitation of demented residents in long-term care . Gerontologist 2003 ; 43 : 233 . 26 Cohen-Mansfield , J , Jensen , B .[doi.org]
  • This study classified agitated behaviors into 5 main subtypes: physically agitated behaviors, destructive behaviors, verbally agitated behaviors, handling things behavior, and aggressive behaviors.[ncbi.nlm.nih.gov]
  • Apathy, depression, irritability, agitation, and anxiety are the most frequently detected neuropsychiatric symptoms of AD.[ncbi.nlm.nih.gov]
  • agitation using the CMAI.[doi.org]
Confusion
  • Treating conditions that can lead to confusion often greatly improve mental function.[nlm.nih.gov]
  • Further understanding of what exactly causes Alzheimer’s disease will help to clear any confusion and hopefully lead to better treatments plans and, ultimately, a cure.[alzheimers.net]
  • These include restlessness and agitation, depression, anxiety, forgetfulness and confusion.[symptoma.com]
  • Search Our Award Winning Knowledge Base for Answers to your Questions About Alzheimer's and dementia Confusion about Alzheimer's and dementia on the part of family and friends The confusion is felt on the part of patients, family members, the media, and[alzheimersreadingroom.com]
Forgetful
  • They often know about their forgetfulness. Not everyone with MCI develops dementia.[nlm.nih.gov]
  • In… Read More memory function In memory abnormality: Diffuse brain diseases …a characteristic early sign of senility, as well as of hardening of the brain arteries (cerebral arteriosclerosis) at any age, with exaggerated forgetfulness for recent events[britannica.com]
  • Early (Mild) In this stage, people may: Forget words or misplace objects Forget something they just read Ask the same question over and over Have increasing trouble making plans or organizing Not remember names when meeting new people Middle (Moderate[alzfdn.org]
Personality Change
  • From Wikidata Jump to navigation Jump to search long-term brain disorders causing personality changes and impaired memory, reasoning, and normal function senility Dementia rare dementia edit English dementia long-term brain disorders causing personality[wikidata.org]
  • […] long-term brain disorders causing personality changes and impaired memory, reasoning, and normal function[commons.wikimedia.org]
Apathy
  • Apathy, depression, irritability, agitation, and anxiety are the most frequently detected neuropsychiatric symptoms of AD.[ncbi.nlm.nih.gov]
  • Clinical examination revealed several elements of a frontal lobe dysfunction including apathy with motor impersistence, presence of primitive reflexes, generalized hyperreflexia with bilateral Hoffman sign and ankle clonus.[ncbi.nlm.nih.gov]
  • Although lack of motivation occurs both in apathy and depression, apathy denotes a lack of motivation without dysphoria.[doi.org]
  • Most studies used the Neuropsychiatric Inventory as a behavioral outcome measure although three used specific scales for either agitation or apathy.[ncbi.nlm.nih.gov]
  • BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes.[ncbi.nlm.nih.gov]

Workup

There are no definitive diagnostic tests for dementia. There are however, a number of screening tests available, such as:

  • Mini Mental State Examination (MMSE)
  • Trail-making test
  • Clock-drawing test
  • Montreal Cognitive Assessment (MOCA)

Laboratory tests

Routine blood tests may be performed to rule out reversible causes such as tests for vitamin B12 levels, thyroid function tests, complete blood count, liver enzymes, renal function tests, etc.

Imaging 

  • CT scan
  • PET scan 
  • MRI

Other tests

  • Brain biopsy

Test results

Diagnosis is based on history physical examination and by the help of test results.

Slowing
  • Only limited evidence indicates that any other pharmacologic or nonpharmacologic intervention slows decline in persons with early dementia.[ncbi.nlm.nih.gov]
  • While these drugs cannot cure dementia or repair brain damage, they may improve symptoms or slow down the disease. NIH: National Institute of Neurological Disorders and Stroke[web.archive.org]
  • Electroencephalography demonstrated bifrontal slowing with left-sided emphasis, and captured two focal onset partial seizures with the clinical correlate of the syndrome described above.[ncbi.nlm.nih.gov]
  • While these drugs cannot cure dementia or repair brain damage, they may improve symptoms or slow down the disease. Loss of intellectual abilities in an elderly person, interfering with this person's activities.[icd9data.com]
  • Given that there is currently no definite cure for dementia and the cost of care for this condition soars dramatically, slowing the decline and maintaining independent living are important goals for supporting people with dementia.[ncbi.nlm.nih.gov]

Treatment

Medications

Currently, no medications have been shown to prevent or cure dementia [8]. Anti-psychotic drugs, cholinesterase inhibitors and anti depressants may be given as needed.

Food and nutrition

Careful assessment for potentially treatable causes of swallowing and appetite problems, honest communication about uncertainties over prognosis and the impact of interventions and ascertainment of individuals' values and beliefs make for better care for people with dementia and better decisions about feeding [9].

Prognosis

Comorbidity (the presence of more than one disease process) is the rule rather than the exception for dementia in elderly persons [7]. Prognosis depends upon the stage of disease.

Stage 1

In this stage, the effected person does not act differently. Just a slight memory loss is evident, which is still more than normal memory loss at old age.

Stage 2

Small changes occur in the affected person’s behaviour. He sometimes takes a bit too long in solving some queries or making a quick decision. He faces problems in terms of time management. But he is still able to lead his life without being taken care of.

Stage 3

In this stage, there are behavioural changes, agitation and restlessness and inability to complete household tasks. The affected person finds it difficult to care for himself.

Stage 4

The disease becomes severe. More loss of memory occurs. Rapid personality changes occur during this stage.

Stage 5

The disease gets more violent with increased memory loss, hallucinations, extreme confusion, agitation and personality changes. The affected person is unable to function without help.

Etiology

Alzheimer disease is the most common form of dementia [1]. The etiology of AD remains, in large part, unresolved, however, RORA (Retinoic Acid Receptor-related Orphan Receptor) emerges as a gene with a probable central role in the AD pathology/etiology [2].

The main reversible causes of dementia include vitamin B12 deficiency, hypothyroidism, neurosyphilis and Lyme disease. Other causes of dementia include old age, trauma to the head, cognitive impairment, progressive supranuclear palsy, Krabbe’s disease, Nieman Pick disease type C, Ataxia syndrome and acidemias. The production of abnormal level of protein in the brain is also one of the main causes of dementia.

Epidemiology

Incidence

Dementia is a fairly common disease and according to the World Alzheimer’s Report 2009, it was estimated that there were 35.6 million cases of dementia worldwide in 2010.

Sex

Studies reveal that dementia is slightly more common in females.

Age

The incidence of dementia increases with age, with dementia affecting 5% of the population older than 65 and 20–40% of those older than 85 [3].

Sex distribution
Age distribution

Pathophysiology

Dementia occurs due to degeneration of neurons in the brain, particularly of the cerebral cortex and later, of other parts like cerebellum. The exact pathophysiology behind dementia is still unclear. Discussed below is the pathogenesis of 2 common etiologies of this condition.

Vascular dementia

Two criteria that have been suggested for the pathologic diagnosis of vascular dementia include:

  • Multiple large and/or strategic infarcts in cerebrum [4]. The neuropathology of the dementia is caused by the breakdown of small cerebral vessels (silent microbleeds), that the microbleeds result from pulse-induced damage to the cerebral vessels, and that pulse becomes increasingly destructive with age, because of the age-related stiffening of the aorta and great arteries, which causes an increase in the intensity of the pressure pulse [5]. 
  • A threshold of 3 or more microscopic infarcts identified in a systematic screening of cerebral cortex and deep cerebral structures [6].

Alzheimer disease

In this disease, there is progressive atrophy of first the neurons of hippocampus and temporal lobe, and then gradually of the frontoparietal lobes and finally the sensory and motor cortex. It is characterized by the presence of amyloid plaques which are eosinophilic deposits of A beta peptides, and intraneuronal neurofibrillary tangles.

Prevention

Some of the most promising strategies for the prevention of dementia include vascular risk factor control, cognitive activity, physical activity, social engagement, diet, and recognition of depression [10].

Summary

Dementia is a collective term that refers to a decline in brain activity resulting in loss of memory, deceased capacity to think and make logical decisions, impaired speech and motor functioning and delusions. It is not a disease itself, instead it is a collection of many disorders which may be alike or, in many cases, differ from each other. Dementia is commonly associated with Alzheimer disease, but it occurs in many more diseases and conditions. It occurs mostly at the age of 65-75 and is known to be the disease of the old.

However, if a person gets old and becomes forgetful, it does not mean he has dementia. This is because some memory loss in old age is quite natural. But along with memory loss, if that person’s actions are different, for example, in the way of his communication towards others or his decisions are somewhat absurd, this may point towards dementia and thorough testing and evaluation by the clinician is in order.

Patient Information

Definition

Dementia is a term used to describe brain disorders in which there is progressive loss of memory, thinking and motor ability.

Cause

The most common causes of dementia include old age, Alzheimer disease and vascular disorders. Some people may be genetically prone to this condition.

Symptoms

Dementia presents initially with restlessness, slight memory loss and depression. It may progress to severe memory loss, confusion, hallucinations, delusions, tremors, impaired speech, motor dysfunction and difficulty in eating. In the end, the affected person is unable to function on his own.

Treatment

Dementia has no cure. It may be symptomatically treated with proper diet and some medication.

References

Article

  1. Thompson SBN. Dementia and memory: a handbook for students and professionals. Aldershot: Ashgate 2006.
  2. Howard R, McShane R, Lindesay J, et al. Donepezil and memantine for moderate-to-severe Alzheimer's disease. N Engl J Med 2012; 366:893.
  3. Raina P, Santaguida P, Ismaila A, et al. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline. Ann Intern Med 2008; 148:379.
  4. Jellinger KA. The pathology of "vascular dementia": a critical update. J Alzheimers Dis. May 2008;14(1):107-23.
  5. Sonnen JA, Larson EB, Crane PK, et al. Pathological correlates of dementia in a longitudinal, population-based sample of aging. Ann Neurol. Oct 2007;62(4):406-13
  6. AD2000 Collaborative Group, Bentham P, Gray R, et al. Aspirin in Alzheimer's disease (AD2000): a randomised open-label trial. Lancet Neurol 2008; 7:41.
  7. Bennett DA, Schneider JA, Arvanitakis Z, et al. Neuropathology of older persons without cognitive impairment from two community-based studies. Neurology. Jun 27 2006;66(12):1837-44.
  8. Quinn JF, Raman R, Thomas RG, et al. Docosahexaenoic acid supplementation and cognitive decline in Alzheimer disease: a randomized trial. JAMA 2010; 304:1903.
  9. Wolfson C, Wolfson DB, Asgharian M, et al. A reevaluation of the duration of survival after the onset of dementia. N Engl J Med 2001; 344:1111.
  10. Verghese J, Crystal HA, Dickson DW, Lipton RB. Validity of clinical criteria for the diagnosis of dementia with Lewy bodies. Neurology. Dec 10 1999;53(9):1974-82.

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Last updated: 2017-08-09 18:13