Dementia

Definition

Dementia is the name given to a group of disorders of the brain. They progressively damage the ability of the brain to function normally. In order to be diagnosed with dementia, there must be:

  • A disturbance in memory
  • A decline in two or more cognitive domains that cause functional impairment in:
    • Language
    • Visuospatial function
    • Executive function (foresight, planning, anticipation, insight, etc)
    • Praxis (learned motor skills)

Some Areas of the Brain Affected by Dementia

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Causes

Causes of dementia include:

Risk Factors

Risk factors for dementia include:

Symptoms

They often begin mildly and progress over time. Symptoms vary according to the cause of the dementia, but often include:

  • Increasing trouble remembering things, such as:
    • How to get to familiar locations
    • The names of friends, family members
    • Where common objects are usually kept
    • Simple math
    • How to perform usual tasks, such as cooking, dressing, bathing, etc.
    • How to drive
    • Bill paying
  • Trouble concentrating on tasks
  • Trouble completing sentences, due to lost/forgotten words (this may progress to complete inability to speak)
  • Inability to remember the date, time of day, season
  • Getting lost in familiar surroundings
  • Mood swings
  • Withdrawal, loss of interest in usual activities
  • Personality changes
  • Slow, shuffling walk
  • Poor coordination
  • Slowness and then loss of purposeful movement

Diagnosis

Doctors diagnose dementia by:

  • Taking an extensive history from the patient and his or her family
  • Closely observing the patient
  • Performing a physical exam
  • Performing mental status and psychological tests

There are no blood tests or exams that can definitively diagnose Alzheimer's disease. Certain types of brain imaging such as a SPECT or a PET scan can aid in a diagnosis. Tests to rule out other causes of dementia and other medical conditions that may mimic dementia include:

  • Blood tests for syphilis, vitamin B12, folate, thyroid, liver, and kidney function
  • CT or MRI scans of the head—tests that use a computer (CT scan) or magnetic waves (MRI scan) to create detailed images of structures inside the body, in this case the head
  • Lumbar puncture—collecting a sample of cerebrospinal fluid by inserting a needle between two vertebrae (rarely needed)
  • Electroencephalogram (EEG)—a test that records the brain's activity by measuring electrical signals from the brain

Doctors must take care not to miss the diagnosis of depression. It can often present like dementia.

Treatment

Currently there are no treatments to cure many types of dementia. Various drugs are being studied to see if they can decrease the symptoms of dementia or slow its course.

Medications

Medications being used or studied for possible use include:

  • Cholinesterase inhibitors
  • NMDA receptor antagonists
  • Antioxidants (vitamin E and others)
  • Estrogens
  • Anti-inflammatory agents
  • Ginkgo biloba (herbal supplement)

Only two types of medications have been approved to reduce the symptoms of Alzheimer's disease:

  • Cholinesterase inhibitors—approved and recommended for mild-moderate Alzheimer's disease:
    • Donepezil (Aricept)
    • Rivastigmine (Exelon)
    • Galantamine (Reminyl)
  • NMDA receptor antagonist—approved for moderate to severe Alzheimer's disease:
    • Memantine (Namenda)

These medications at best only have a modest effect on the disease.

Lifestyle Management

This type of support is critical for people with dementia. Behavioral and environmental support includes:

  • Keeping the patient safe in their home or other place of residence
  • Providing a calm, quiet, predictable environment
  • Providing appropriate eyewear and hearing aids, easy-to-read clocks, and calendars
  • Music therapy
  • Encouraging light exercise to reduce agitation and relieve depression
  • Discussing healthcare wishes with family members and doctors, and appointing a healthcare proxy and a legal power of attorney

Psychiatric Medications

People with dementia often develop psychiatric symptoms and may need appropriate treatment such as:

  • Antidepressants
  • Anxiolytics—to treat anxiety
  • Antipsychotics—to treat severe confusion, paranoia, and/or hallucinations
  • Mood stabilizers—to treat dangerous or disruptive behaviors

Caregiver Support

Caring for a person with dementia is very difficult. Those providing care will need support. The Alzheimer’s Association is an excellent resource for families and caregivers.

Prevention

There is no known way to prevent Alzheimer's disease. In general:

  • A healthy diet will help maintain good levels of vitamin B12 and cholesterol
  • Exercise can also enhance cardiovascular health, which may delay the onset of vascular dementia
  • Limiting alcohol intake can prevent dementia from alcoholism
  • Avoiding drug abuse and practicing safe sex reduces the risk of AIDS-related dementia
  • There is some evidence that engaging in mentally stimulating activity over a lifetime may also reduce the risk of Alzheimer’s disease

RESOURCES:

Alzheimer's Association
http://www.alz.org/

American Academy of Neurology
http://www.aan.com/

CANADIAN RESOURCES:

Alzheimers Association of Canada
http://www.alzheimer.ca/

Toronto Dementia Network
http://www.dementiatoronto.org/

References:

APA. The American Psychiatric Association's Practice Guideline for the Treatment of Patients With Alzheimer's Disease and Other Dementias of Late Life. Arlington, VA: American Psychiatric Association;1997.

Beers MH, Berkow R, Bogin RM, et al. The Merck Manual of Geriatrics. 3rd ed. Whitehouse Station, NJ: Merck & Co. Inc.;1995-2000.

Cecil RL, Goldman L, Bennett JC. Cecil Textbook of Medicine. 21st ed. Philadelphia, PA: WB Saunders Company;2000.

Dementia: It's not always Alzheimer's. Mayo Foundation for Medical Education and Research website. Available at: http://www.mayoclinic.com/health/dementia/AZ00003. Accessed July 22, 2008.

Detection, diagnosis, and management of dementia. American Academy of Neurology website. Available at: http://www.aan.com/professionals/practice/pdfs/dementia_guideline.pdf. Accessed July 20, 2008.

Kaduszkiewicz H, Zimmermann T, Beck-Bornholdt HP, van den Bussche H. Cholinesterase inhibitors for patients with Alzheimer's disease: systematic review of randomized clinical trials. BMJ. 2005;331(7512):321-327.

Ledger AJ & Baker FA. An investigation of long-term effects of group music therapy on agitation levels of people with Alzheimer’s Disease. Aging & Mental Health. 2007;11(3): 330-338.

Mendez MF, Cummings JL. Dementia: A clinical Approach. 3rd edition. Boston, MA: Butterworth Heinemann;2003.

Obrien JT, et al. Dopamine transporter loss visualized with FP-CIT SPECT in the differential diagnosis of dementia with Lewy Bodies. Arch Neurol. 2004; 61: 919-925.

Tierney L. Current Medical Diagnosis & Treatment. 44th ed. New York, NY: McGraw-Hill;2005.



Last reviewed November 2007 by Ryan Estévez, MD, PhD, MPH

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

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