| Definition: |
The term "dementia" refers to a group of symptoms involving progressive impairment of all aspects of brain function.
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| Alternative Names: |
Chronic brain syndrome
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| Causes, incidence, and risk factors: |
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Disorders that cause dementia include conditions that impair the vascular (blood vessels) or neurologic (nerve) structures of the brain. A minority of causes of dementia are treatable. These include normal pressure hydrocephalus, brain tumors, and dementia due to metabolic causes and infections. Unfortunately, most of the disorders associated with dementia are progressive, irreversible, degenerative conditions.
The two major degenerative causes of dementia are Alzheimer's disease, which is a progressive loss of nerve cells without a known cause or cure and vascular dementia, which is loss of brain function due to a series of small strokes. Vascular dementia may or may not play a role in the progression of Alzheimer's disease: the conditions often occur together and neither can be diagnosed definitively except until autopsy. In those with the genetic and environmental susceptibility to develop Alzheimer's disease, the concomitant presence of small infarcts (lacunar strokes) speeds up the onset of Alzheimer's disease to an earlier age than if it were to occur alone (i.e., without small infarcts).
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, abstract thinking, 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.
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| Symptoms: |
- progressive loss of memory
- inability to concentrate
- decrease in problem solving skills and judgment capability
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confusion, severe
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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
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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
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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
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memory deficit
- short-term memory problems (can't remember new things)
- long-term memory problems (can't remember past)
- absent or impaired language ability (aphasia)
- inability to comprehend speech
- inability to read (alexia)
- inability to write (agraphia)
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inability to speak, without muscleparalysis
- 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
- irritability
- poor temper control
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anxiety
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depression
- indecisiveness
- self centeredness
- inflexibility
- 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:
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| Signs and tests: |
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A neurologic examination may reveal abnormalities. Early on, there may be only mild memory or attentional deficits. As time progresses, there may be evidence of other cognitive difficulties. These include language problems, disorientation, changes in personality, visuo-spatial problems, slowness of thinking, apraxia (impaired ability to carry out motor activities despite normal motor function), agnosia (failure to identify objects despite intact sensory function), and difficulty with planning and organizing.
Eventually there may also be symptoms of weakness, incontinence, falling and other abnormal neurological function.
The work up includes identifying any possible reversible causes. These are usually rare. The extent of damage and cause of dementia may be indicated by tests and procedures that include, but are not limited to:
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| 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 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
- serotonin-affecting drugs (trazodone, buspirone)
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dopamine blockers (such as haloperidol, Risperidal, olanzapine, clozapine)
- cholinesterase inhibitors -- donepezil (aricept), rivastigmine (exelon), or the newly approved galantamine (reminyl) in Alzheimer's-type dementia
- fluoxetine, imipramine, Celexa may help to stabilize mood
- stimulant drugs (such as methylphenidate), may increase activity and spontaneity
- Vitamin E
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 helpful 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 dementia. 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.
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| Expectations (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.
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| 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
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| Calling your health care provider: |
Call your health care provider if dementia develops or sudden change in mental status occurs.
Call 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.
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| Prevention: |
Most causes are not preventable. Eating a low fat diet and exercising regularly may reduce the chances of vascular dementia, which is caused by repeated small strokes. Vascular dementia may also play a role in the progression of Alzheimer's disease.
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