Dementia is also known as chronic mental disorder or chronic organic psychosis.
Dementia is a chronic,irreversible physical deterioration of an anatomic part of the brain which is characterized by impairment of memory,occupation,and social functioning.
Dementia is a broad category of brain diseases that cause a long-term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning. Other common symptoms include emotional problems, difficulties with language, and a decrease in motivation. A person's consciousness is usually not affected. A dementia diagnosis requires a change from a person's usual mental functioning and a greater decline than one would expect due to aging. These diseases also have a significant effect on a person's caregivers.
The most common type of dementia is Alzheimer's disease, which makes up 50% to 70% of cases. Other common types include vascular dementia (25%), Lewy body dementia (15%), frontotemporal dementia. Less common causes include normal pressure hydrocephalus, Parkinson's disease dementia, syphilis, and Creutzfeldt–Jakob disease among others. More than one type of dementia may exist in the same person. A small proportion of cases run in families. In the DSM-5, dementia was reclassified as a neurocognitive disorder, with various degrees of severity. Diagnosis is usually based on history of the illness and cognitive testing with medical imaging and blood tests used to rule out other possible causes. The mini mental state examination is one commonly used cognitive test. Efforts to prevent dementia include trying to decrease risk factors such as high blood pressure, smoking, diabetes, and obesity. Screening the general population for the disorder is not recommended.
There is no known cure for dementia. Cholinesterase inhibitors such as donepezil are often used and may be beneficial in mild to moderate disorder. Overall benefit, however, may be minor. There are many measures that can improve the quality of life of people with dementia and their caregivers. Cognitive and behavioral interventions may be appropriate. Educating and providing emotional support to the caregiver is important. Exercise programs may be beneficial with respect to activities of daily living and potentially improve outcomes. Treatment of behavioral problems with antipsychotics is common but not usually recommended due to the little benefit and side effects, including an increased risk of death.
Globally, dementia affected about 46 million people in 2015. About 10% of people develop the disorder at some point in their lives. It becomes more common with age. About 3% of people between the ages of 65–74 have dementia, 19% between 75 and 84, and nearly half of those over 85 years of age. In 2013 dementia resulted in about 1.7 million deaths up from 0.8 million in 1990. As more people are living longer, dementia is becoming more common in the population as a whole. For people of a specific age, however, it may be becoming less frequent, at least in the developed world, due to a decrease in risk factors. It is one of the most common causes of disability amongst the old. It is believed to result in economic costs of US$604 billion a year. People with dementia are often physically or chemically restrained to a greater degree than necessary, raising issues of human rights. Social stigma against those affected is common.
TYPES OF DEMENTIA
Vascular Dementia
Dementia of the Alzheimer's Type
Dementia due to head trauma
Dementia due to Rick's disease
Dementia due to other General Medical Conditions
Dementia due to Parkinson's Disease.
Signs and symptoms
The symptoms of dementia vary across types and stages of the diagnosis. The most common affected areas include memory, visual-spatial, language, attention and problem solving. Most types of dementia are slow and progressive. By the time the person shows signs of the disorder, the process in the brain has been happening for a long time. It is possible for a patient to have two types of dementia at the same time. About 10% of people with dementia have what is known as mixed dementia, which is usually a combination of Alzheimer's disease and another type of dementia such as frontotemporal dementia or vascular dementia.
Neuropsychiatric symptoms that may be present are termed Behavioural and psychological symptoms of dementia (BPSD) and these can include:
- Balance problems
- Tremor
- Speech and language difficulty
- Trouble eating or swallowing
- Memory distortions (believing that a memory has already happened when it has not, thinking an old memory is a new one, combining two memories, or confusing the people in a memory)
- Wandering or restlessness
- Perception and visual problems
- Behavioral and psychological symptoms of dementia almost always occur in all types of dementia and may manifest as:
- Agitation
- Depression
- Anxiety
- Abnormal motor behavior
- Elated mood
- Irritability
- Apathy
- Disinhibition and impulsivity
- Delusions (often believing people are stealing from them) or hallucinations
- Changes in sleep or appetite.
When people with dementia are put in circumstances beyond their abilities, there may be a sudden change to crying or anger (a "catastrophic reaction").
Psychosis (often delusions of persecution) and agitation/aggression also often accompany dementia.
Mild cognitive impairment
In the first stages of dementia, the signs and symptoms of the disorder may be subtle. Often, the early signs of dementia only become apparent when looking back in time. The earliest stage of dementia is called mild cognitive impairment (MCI). 70% of those diagnosed with MCI progress to dementia at some point. In MCI, changes in the person's brain have been happening for a long time, but the symptoms of the disorder are just beginning to show. These problems, however, are not yet severe enough to affect the person's daily function. If they do, it is considered dementia. A person with MCI scores between 27 and 30 on the Mini-Mental State Examination (MMSE), which is a normal score. They may have some memory trouble and trouble finding words, but they solve everyday problems and handle their own life affairs well.
Early stages
In the early stage of dementia, the person begins to show symptoms noticeable to the people around them. In addition, the symptoms begin to interfere with daily activities. The person usually scores between a 20 and 25 on the MMSE. The symptoms are dependent on the type of dementia a person has. The person may begin to have difficulty with more complicated chores and tasks around the house or at work. The person can usually still take care of him or herself but may forget things like taking pills or doing laundry and may need prompting or reminders.
The symptoms of early dementia usually include memory difficulty, but can also include some word-finding problems (anomia) and problems with planning and organizational skills (executive function). One very good way of assessing a person's impairment is by asking if they are still able to handle their finances independently. This is often one of the first things to become problematic. Other signs might be getting lost in new places, repeating things, personality changes, social withdrawal and difficulties at work.
When evaluating a person for dementia, it is important to consider how the person was able to function five or ten years earlier. It is also important to consider a person's level of education when assessing for loss of function. For example, an accountant who can no longer balance a checkbook would be more concerning than a person who had not finished high school or had never taken care of his/her own finances.
In Alzheimer's dementia the most prominent early symptom is memory difficulty. Others include word-finding problems and getting lost. In other types of dementia, like dementia with Lewy bodies and fronto-temporal dementia, personality changes and difficulty with organization and planning may be the first signs.
Middle stages
As dementia progresses, the symptoms first experienced in the early stages of the dementia generally worsen. The rate of decline is different for each person. A person with moderate dementia scores between 6–17 on the MMSE. For example, people with Alzheimer's dementia in the moderate stages lose almost all new information very quickly. People with dementia may be severely impaired in solving problems, and their social judgment is usually also impaired. They cannot usually function outside their own home, and generally should not be left alone. They may be able to do simple chores around the house but not much else, and begin to require assistance for personal care and hygiene other than simple reminders.
Late stages
People with late-stage dementia typically turn increasingly inward and need assistance with most or all of their personal care. Persons with dementia in the late stages usually need 24-hour supervision to ensure personal safety, as well as to ensure that basic needs are being met. If left unsupervised, a person with late-stage dementia may wander or fall, may not recognize common dangers around them such as a hot stove, may not realize that they need to use the bathroom or become unable to control their bladder or bowels (incontinent).
Changes in eating frequently occur. Caregivers of people with late-stage dementia often provide pureed diets, thickened liquids, and assistance in eating, to prolong their lives, to cause them to gain weight, to reduce the risk of choking, and to make feeding the person easier. The person's appetite may decline to the point that the person does not want to eat at all. They may not want to get out of bed, or may need complete assistance doing so. Commonly, the person no longer recognizes familiar people. They may have significant changes in sleeping habits or have trouble sleeping at all.
Causes
Reversible causes
Causes of easily reversible dementia include hypothyroidism, vitamin B12 deficiency, Lyme disease, and neurosyphilis. All people with memory difficulty should be checked for hypothyroidism and B12 deficiency. For Lyme disease and neurosyphilis, testing should be done if there are risk factors for those diseases in the person. Because risk factors are often difficult to determine, testing for neurosyphilis and Lyme disease, as well as other mentioned factors, may be undertaken as a matter of course in cases where dementia is suspected. Hearing loss may also be associated with dementia. There is tentative evidence that hearing aids may have some benefit.
Alzheimer's disease
Alzheimer's disease accounts for 50% to 70% of cases of dementia. The most common symptoms of Alzheimer's disease are short-term memory loss and word-finding difficulties. People with Alzheimer's disease also have trouble with visual-spatial areas (for example, they may begin to get lost often), reasoning, judgment, and insight. Insight refers to whether or not the person realizes they have memory problems.
Common early symptoms of Alzheimer's include repetition, getting lost, difficulties keeping track of bills, problems with cooking especially new or complicated meals, forgetting to take medication, and word-finding problems.
The part of the brain most affected by Alzheimer's is the hippocampus. Other parts of the brain that show shrinking (atrophy) include the temporal and parietal lobes. Although this pattern suggests Alzheimer's, the brain shrinkage in Alzheimer's disease is very variable, and a scan of the brain cannot actually make the diagnosis. The relationship between undergoing anesthesia and AD is unclear.
Vascular dementia
Vascular dementia is the cause of at least 20% of dementia cases, making it the second most common cause of dementia. It is caused by disease or injury affecting the blood supply to the brain, typically involving a series of minor strokes. The symptoms of this dementia depend on where in the brain the strokes have occurred and whether the vessels are large or small. Multiple injuries can cause progressive dementia over time, while a single injury located in an area critical for cognition (i.e. hippocampus, thalamus) can lead to sudden cognitive decline.
On scans of the brain, a person with vascular dementia may show evidence of multiple strokes of different sizes in various locations. People with vascular dementia tend to have risk factors for disease of the blood vessels, such as tobacco use, high blood pressure, atrial fibrillation, high cholesterol or diabetes, or other signs of vascular disease such as a previous heart attack or angina.
Dementia with Lewy bodies
Dementia with Lewy bodies (DLB) is a dementia that has the primary symptoms of visual hallucinations and "Parkinsonism". Parkinsonism is the symptoms of Parkinson's disease, which includes tremor, rigid muscles, and a face without emotion. The visual hallucinations in DLB are generally very vivid hallucinations of people or animals and they often occur when someone is about to fall asleep or just waking up. Other prominent symptoms include problems with attention, organization, problem solving and planning (executive function), and difficulty with visual-spatial function.
Again, imaging studies cannot necessarily make the diagnosis of DLB, but some signs are particularly common. A person with DLB often shows occipital hypoperfusion on SPECT scan or occipital hypometabolism on a PET scan. Generally, a diagnosis of DLB is straightforward and unless it is complicated, a brain scan is not always necessary.
Frontotemporal dementia
Frontotemporal dementias (FTDs) are characterized by drastic personality changes and language difficulties. In all FTDs, the person has a relatively early social withdrawal and early lack of insight into the disorder. Memory problems are not a main feature of this disorder.
There are six main types of FTD. The first has major symptoms in the area of personality and behavior. This is called behavioral variant FTD (bv-FTD) and is the most common. In bv-FTD, the person shows a change in personal hygiene, becomes rigid in their thinking, and rarely recognize that there is a problem, they are socially withdrawn, and often have a drastic increase in appetite. They may also be socially inappropriate. For example, they may make inappropriate sexual comments, or may begin using pornography openly when they had not before. One of the most common signs is apathy, or not caring about anything. Apathy, however, is a common symptom in many different dementias.
Two types of FTD feature language problems (aphasia) as the main symptom. One type is called semantic variant primary progressive aphasia (SV-PPA). The main feature of this is the loss of the meaning of words. It may begin with difficulty naming things. The person eventually may also lose the meaning of objects as well. For example, a drawing of a bird, dog, and an airplane in someone with FTD may all appear just about the same. In a classic test for this, a patient is shown a picture of a pyramid and below there is a picture of both a palm tree and a pine tree. The person is asked to say which one goes best with the pyramid. In SV-PPA the person would not be able to answer that question. The other type is called non-fluent agrammatic variant primary progressive aphasia (NFA-PPA). This is mainly a problem with producing speech. They have trouble finding the right words, but mostly they have a difficulty coordinating the muscles they need to speak. Eventually, someone with NFA-PPA only uses one-syllable words or may become totally mute.
Progressive supranuclear palsy (PSP) is a form of FTD that is characterized by problems with eye movements. Generally the problems begin with difficulty moving the eyes up or down (vertical gaze palsy). Since difficulty moving the eyes upward can sometimes happen in normal aging, problems with downward eye movements are the key in PSP. Other key symptoms of PSP include falling backwards, balance problems, slow movements, rigid muscles, irritability, apathy, social withdrawal, and depression. The person may also have certain "frontal lobe signs" such as perseveration, a grasp reflex and utilization behavior (the need to use an object once you see it). People with PSP often have progressive difficulty eating and swallowing, and eventually with talking as well. Because of the rigidity and slow movements, PSP is sometimes misdiagnosed as Parkinson's disease. On scans of the brain, the midbrain of people with PSP is generally shrunken (atrophied), but there are no other common brain abnormalities visible on images of the person's brain.
CLINICAL FEATURES
Impairment of intellectual functions.
Lability of mood.
Deterioration in habit.
Prevention
A number of factors can decrease the risk of dementia. A group of efforts is believed to be able to prevent a third of cases and include early education, treating high blood pressure, preventing obesity, preventing hearing loss, treating depression, being active, preventing diabetes, not smoking, and preventing social isolation. A 2018 review however concluded that no medications have good evidence of a preventative effect including blood pressure medications.
Among otherwise healthy older people, computerized cognitive training may improve memory. However it is not known if it prevents dementia. Exercise has poor evidence of preventing dementia. In those with normal mental function evidence for medications is poor. The same applies to supplements.
The early introduction of a strict gluten-free diet in people with celiac disease or non-celiac gluten sensitivity before cognitive impairment begins has a potentially protective effect.
Management
Except for the treatable types listed above, there is no cure. Cholinesterase inhibitors are often used early in the disorder course; however, benefit is generally small. Cognitive and behavioral interventions may be appropriate. There is some evidence that educating and providing support for the person with dementia, as well as caregivers and family members, improves outcomes. Exercise programs are beneficial with respect to activities of daily living and potentially improve dementia.
Psychological therapies
Psychological therapies for dementia include some limited evidence for reminiscence therapy (namely, some positive effects in the areas of quality of life, cognition, communication and mood – the first three particularly in care home settings), some benefit for cognitive reframing for caretakers, unclear evidence for validation therapy, and tentative evidence for mental exercises, such as cognitive stimulation programs for people with mild to moderate dementia. Reminiscence therapy can improve quality of life, cognition, communication, and possibly mood in people with dementia in some circumstances, although all of these benefits may be small.
Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Adult daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers. In addition, home care can provide one-on-one support and care in the home allowing for more individualized attention that is needed as the disorder progresses. Psychiatric nurses can make a distinctive contribution to people's mental health.
Since dementia impairs normal communication due to changes in receptive and expressive language, as well as the ability to plan and problem solve, agitated behaviour is often a form of communication for the person with dementia. Actively searching for a potential cause, such as pain, physical illness, or overstimulation can be helpful in reducing agitation. Additionally, using an "ABC analysis of behaviour" can be a useful tool for understanding behavior in people with dementia. It involves looking at the antecedents (A), behavior (B), and consequences (C) associated with an event to help define the problem and prevent further incidents that may arise if the person's needs are misunderstood. The strongest evidence for non-pharmacological therapies for the management of changed behaviours in dementia is for using such approaches. There is low quality evidence that regular (at least five sessions of) music therapy may help residents in institutions. It may reduce depressive symptoms and improve overall behaviour. There may also be a beneficial effect on emotional well-being and quality of life, as well as anxiety reduction.
Eating difficulties
Persons with dementia may have difficulty eating. Whenever it is available as an option, the recommended response to eating problems is having a caretaker do assisted feeding for the person. A secondary option for people who cannot swallow effectively is to consider gastrostomy feeding tube placement as a way to give nutrition. However, in bringing person comfort and keeping functional status while lowering risk of aspiration pneumonia and death, assistance with oral feeding is at least as good as tube feeding. Tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers. Tube feedings may also cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction, and may increase the risk of aspiration.
Benefits of this procedure in those with advanced dementia has not been shown. The risks of using tube feeding include agitation, the person pulling out the tube or otherwise being physically or chemically immobilized to prevent them from doing this, or getting pressure ulcers. There is about a 1% fatality rate directly related to the procedure with a 3% major complication rate.
Diet
In those with celiac disease or non-celiac gluten sensitivity, a strict gluten-free diet may relieve the symptoms when there is a mild cognitive impairment. Once dementia is advanced there is no evidence that a gluten free diet is useful.
Alternative medicine
Aromatherapy and massage have unclear evidence. There have been studies on the efficacy and safety of cannabinoids in relieving behavioral and psychological symptoms of dementia.
Omega-3 fatty acid supplements from plants or fish sources do not appear to benefit or harm people with mild to moderate Alzheimer's disease. It is unclear if taking omega-3 fatty acid supplements can improve other types of dementia.
Palliative care
Given the progressive and terminal nature of dementia, palliative care can be helpful to patients and their caregivers by helping both people with the disorder and their caregivers understand what to expect, deal with loss of physical and mental abilities, plan out a patient's wishes and goals including surrogate decision making, and discuss wishes for or against CPR and life support. Because the decline can be rapid, and because most people prefer to allow the person with dementia to make their own decisions, palliative care involvement before the late stages of dementia is recommended. Further research is required to determine the appropriate palliative care interventions and how well they help people with advanced dementia.
Person-centered care helps maintain the dignity of people with dementia.
We end here.
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