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Dementia

Dementia

Definition

Dementia is not a specific disorder or disease. It is a syndrome (group of symptoms) associated with a progressive loss of memory and other intellectual functions that is serious enough to interfere with performing the tasks of daily life. Dementia can occur to anyone at any age from an injury or from oxygen deprivation, although it is most commonly associated with aging. It is the leading cause of institutionalization of older adults.

Description

The definition of dementia has become more inclusive over the past several decades. Whereas earlier descriptions of dementia emphasized memory loss, the last three editions of the professional's diagnostic handbook, Diagnostic and Statistical Manual of Mental Disorders (also known as the DSM ) define dementia as an overall decline in intellectual function, including difficulties with language, simple calculations, planning and judgment, and motor (muscular movement) skills as well as loss of memory. Although dementia is not caused by aging itself most researchers regard it as resulting from injuries, infections, brain diseases, tumors, or other disorders it is quite common in older people. The prevalence of dementia increases rapidly with age; it doubles every five years after age 60. Dementia affects only 1% of people aged 6064 but 30%50% of those older than 85. About four to five million persons in the United States are affected by dementia as of 2002. Surveys indicate that dementia is the condition most feared by older adults in the United States.

Causes and symptoms

Causes

Dementia can be caused by nearly forty different diseases and conditions, ranging from dietary deficiencies and metabolic disorders to head injuries and inherited diseases. The possible causes of dementia can be categorized as follows:

  • Primary dementia. These dementias are characterized by damage to or wasting away of the brain tissue itself. They include Alzheimer's disease (AD), frontal lobe dementia (FLD), and Pick's disease. FLD is dementia caused by a disorder (usually genetic) that affects the front portion of the brain, and Pick's disease is a rare type of primary dementia that is characterized by a progressive loss of social skills, language, and memory, leading to personality changes and sometimes loss of moral judgment.
  • Multi-infarct dementia (MID). Sometimes called vascular dementia , this type is caused by blood clots in the small blood vessels of the brain. When the clots cut off the blood supply to the brain tissue, the brain cells are damaged and may die. (An infarct is an area of dead tissue caused by obstruction of the circulation.)
  • Lewy body dementia. Lewy bodies are areas of injury found on damaged nerve cells in certain parts of the brain. They are associated with Alzheimer's and Parkinson's disease, but researchers do not yet know whether dementia with Lewy bodies is a distinct type of dementia or a variation of Alzheimer's or Parkinson's disease.
  • Dementia related to alcoholism or exposure to heavy metals (arsenic, antimony, bismuth).
  • Dementia related to infectious diseases. These infections may be caused by viruses (HIV, viral encephalitis); spirochetes (Lyme disease, syphilis); or prions (Creutzfeldt-Jakob disease). Spirochetes are certain kinds of bacteria, and prions are protein particles that lack nucleic acid.
  • Dementia related to abnormalities in the structure of the brain. These may include a buildup of spinal fluid in the brain (hydrocephalus); tumors; or blood collecting beneath the membrane that covers the brain (subdural hematoma).

Dementia may also be associated with depression, low levels of thyroid hormone, or niacin or vitamin B 12deficiency. Dementia related to these conditions is often reversible.

Genetic factors in dementia

Genetic factors play a role in several types of dementia, but the importance of these factors in the development of the dementia varies considerably. Alzheimer's disease (AD) is known, for example, to have an autosomal (non-sex-related) dominant pattern in most early-onset cases as well as in some late-onset cases, and to show different degrees of penetrance (frequency of expression) in late-life cases. Moreover, researchers have not yet discovered how the genes associated with dementia interact with other risk factors to produce or trigger the dementia. One non-genetic risk factor presently being investigated is toxic substances in the environment.

EARLY-ONSET ALZHEIMER'S DISEASE. In early-onset AD, which accounts for 2%7% of cases of AD, the symptoms develop before age 60. It is usually caused by an inherited genetic mutation. Early-onset AD is also associated with Down syndrome, in that persons with trisomy 21 (three forms of human chromosome 21 instead of a pair) often develop early-onset AD.

LATE-ONSET ALZHEIMER'S DISEASE. Recent research indicates that late-onset Alzheimer's disease is a polygenic disorder; that is, its development is influenced by more than one gene. It has been known since 1993 that a specific form of a gene (the APOE gene) on human chromosome 19 is a genetic risk factor for late-onset AD. In 1998 researchers at the University of Pittsburgh reported on another gene that controls the production of bleomycin hydrolase (BH) as a second genetic risk factor that acts independently of the APOE gene. In December 2000, three separate research studies reported that a gene on chromosome 10 that may affect the processing of a protein (called amyloid-beta protein) is also involved in the development of late-onset AD. When this protein is not properly broken down, a starchy substance builds up in the brains of people with AD to form the plaques that are characteristic of the disease.

MULTI-INFARCT DEMENTIA (MID). While the chief risk factors for MID are high blood pressure, advanced age, and male sex, there is an inherited form of MID called CADASIL, which stands for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. CADASIL can cause psychiatric disturbances and severe headaches as well as dementia.

FRONTAL LOBE DEMENTIAS. Researchers think that between 25% and 50% of cases of frontal lobe dementia involve genetic factors. Pick's dementia appears to have a much smaller genetic component than FLD. It is not yet known what other risk factors combine with inherited traits to influence the development of frontal lobe dementias.

FAMILIAL BRITISH DEMENTIA (FBD). FBD is a rare autosomal dominant disorder that was first reported in the 1940s in a large British family extending over nine generations. FBD resembles Alzheimer's in that the patient develops a progressive dementia related to amyloid deposits in the brain. In 1999, a mutated gene that produces the amyloid responsible for FBD was discovered on human chromosome 13. Studies of this mutation may yield further clues to the development of Alzheimer's disease as well as FBD itself.

CREUTZFELDT-JAKOB DISEASE. Although Creutzfeldt-Jakob disease is caused by a prion, researchers think that 5%15% of cases may have a genetic component.

Symptoms

The fourth edition, text revised version of the DSM was published in 2000, and is known as DSM-IV-TR. DSM-IV-TR identifies certain symptoms as criteria that must be met for a patient to be diagnosed with dementia. One criterion is significant weakening of the patient's memory with regard to learning new information as well as recalling previously learned information. In addition, the patient must be found to have one or more of the following disturbances:

  • Aphasia. Aphasia refers to loss of language function. A person with dementia may use vague words like "it" or "thing" often because he or she can't recall the exact name of an object; the affected person may echo what other people say, or repeat a word or phrase over and over. People in the later stages of dementia may stop speaking at all.
  • Apraxia. Apraxia refers to loss of the ability to perform intentional movements even though the person is not paralyzed, has not lost the sense of touch, and knows what he or she is trying to do. For example, a patient with apraxia may stop brushing their teeth, or have trouble tying their shoelaces.
  • Agnosia. Agnosia refers to loss of the ability to recognize objects even though the person's sight and sense of touch are normal. People with severe agnosia may fail to recognize family members or even their own face reflected in a mirror.
  • Problems with abstract thinking and complex behavior. This criterion refers to the loss of the ability to make plans, carry out the steps of a task in the proper order, make appropriate decisions, evaluate situations, show good judgment, etc. For example, a patient might light a stove burner under a saucepan before putting food or water in the pan, or be unable to record checks and balance their checkbook.

DSM-IV-TR also specifies that these disturbances must be severe enough to cause problems in the person's daily life, and that they must represent a decline from a previously higher level of functioning.

In addition to the changes in cognitive functioning, the symptoms of dementia may also include personality changes and emotional instability. Patients with dementia sometimes become mildly paranoid because their loss of short-term memory leads them to think that mislaid items have been stolen. About 25% of patients with dementia develop a significant degree of paranoia , that is, generalized suspiciousness or specific delusions of persecution. Mood swings, anxiety, and irritability or anger are also frequent occurrences, particularly when patients with dementia are in situations that force them to recognize the extent of their impairment.

The following sections describe the signs and symptoms that are used to differentiate among the various types of dementia during a diagnostic evaluation.

ALZHEIMER'S DISEASE. Dementia related to AD often progresses slowly; it may be accompanied by irritability, wide mood swings, and personality changes in the early stage. Many patients, however, retain their normal degree of sociability in the early stages of Alzheimer's. In second-stage AD, the patient typically gets lost easily, is completely disoriented with regard to time and space, and may become angry, uncooperative, or aggressive. Patients in second-stage AD are at high risk for falls and other accidents. In final-stage AD, the patient is completely bedridden, has lost control over bowel and bladder functions, and may be unable to swallow or eat. The risk of seizures increases as the patient progresses from early to end-stage Alzheimer's. Death usually results from an infection or from malnutrition.

MULTI-INFARCT DEMENTIA. In MID, the symptoms are more likely to occur after age 70. In the early stages, the patient retains his or her personality more fully than a patient with AD. Another distinctive feature of this type of dementia is that it often progresses in a stepwise fashion; that is, the patient shows rapid changes in functioning, then remains at a plateau for a while rather than showing a continuous decline. The symptoms of MID may also have a "patchy" quality; that is, some of the patient's mental functions may be severely affected while others are relatively undamaged. Other symptoms of MID include exaggerated reflexes, an abnormal gait (manner of walking), loss of bladder or bowel control, and inappropriate laughing or crying.

DEMENTIA WITH LEWY BODIES. This type of dementia may combine some features of AD, such as severe memory loss and confusion, with certain symptoms associated with Parkinson's disease, including stiff muscles, a shuffling gait, and trembling or shaking of the hands. Visual hallucinations may be one of the first symptoms of dementia with Lewy bodies.

FRONTAL LOBE DEMENTIAS. The frontal lobe dementias are gradual in onset. Pick's dementia is most likely to develop in persons between 40 and 60, while FLD typically begins before the age of 65. The first symptoms of the frontal lobe dementias often include socially inappropriate behavior (rude remarks, sexual acting-out, disregard of personal hygiene, etc.). Patients are also often obsessed with eating and may put non-food items in their mouths as well as making frequent sucking or smacking noises. In the later stages of frontal lobe dementia or Pick's disease, the patient may develop muscle weakness, twitching, and delusions or hallucinations.

CREUTZFELDT-JAKOB DISEASE. The dementia associated with Creutzfeldt-Jakob disease occurs most often in persons between 40 and 60. It is typically preceded by a period of several weeks in which the patient complains of unusual fatigue , anxiety, loss of appetite, or difficulty concentrating. This type of dementia also usually progresses much more rapidly than other dementias, frequently over a span of a few months.

Demographics

The demographic distribution of dementia varies somewhat according to its cause. Moreover, recent research indicates that dementia in many patients has overlapping causes, so that it is not always easy to assess the true rates of occurrence of the different types. For example, AD and MID are found together in about 15%20% of cases.

Alzheimer's disease

AD is by far the most common cause of dementia in the elderly, accounting for 60%80% of cases. It is estimated that four million adults in the United States suffer from AD. The disease strikes women more often than men, but researchers don't know yet whether the sex ratio simply reflects the fact that women in developed countries tend to live longer than men, or whether female sex is itself a risk factor for AD. One well-known long-term study of Alzheimer's in women is the Nun Study, begun in 1986 and presently conducted at the University of Kentucky.

Multi-infarct dementia

MID is responsible for between 15% and 20% of cases of dementia (not counting cases in which it coexists with AD). Unlike AD, MID is more common in men than in women. Diabetes, high blood pressure, a history of smoking, and heart disease are all risk factors for MID. Researchers in Sweden have suggested that MID is underdiagnosed, and may coexist with other dementias more frequently than is presently recognized.

Dementia with Lewy bodies

Dementia with Lewy bodies is now thought to be the second most common form of dementia after Alzheimer's disease. But because researchers don't completely understand the relationship between Lewy bodies, AD, and Parkinson's disease, the demographic distribution of this type of dementia is also unclear.

Other dementias

FLD, Pick's disease, Huntington's disease, Parkinson's disease, HIV infection, alcoholism, head trauma, etc. account for about 10% of all cases of dementia. In FLD and Pick's dementia, women appear to be affected slightly more often than men.

Diagnosis

In some cases, a patient's primary physician may be able to diagnose the dementia; in many instances, however, the patient will be referred to a neurologist or a gerontologist (specialist in medical care of the elderly). Distinguishing one disorder from other similar disorders is a process called differential diagnosis . The differential diagnosis of dementia is complicated because of the number of possible causes; because more than one cause may be present at the same time; and because dementia can coexist with such other conditions as depression and delirium . Delirium is a temporary disturbance of consciousness marked by confusion, restlessness, inability to focus one's attention, hallucinations, or delusions. In elderly people, delirium is frequently a side effect of surgery, medications, infectious illnesses, or dehydration. Delirium can be distinguished from dementia by the fact that delirium usually comes on fairly suddenly (in a few hours or days) and may vary in severity it is often worse at night. Dementia develops much more slowly, over a period of months or years, and the patient's symptoms are relatively stable. It is possible for a person to have delirium and dementia at the same time.

Another significant diagnostic distinction in elderly patients is the distinction between dementia and ageassociated memory impairment (AAMI), which is sometimes called benign senescent forgetfulness. Older people with AAMI have a mild degree of memory loss; they do not learn new information as quickly as younger people, and they may take longer to recall a certain fact or to balance their checkbook. But they do not suffer the degree of memory impairment that characterizes dementia, and they do not get progressively worse.

Clinical interview

The doctor will begin by taking a full history, including the patient's occupation and educational level as well as medical history. The occupational and educational history allows the examiner to make a more accurate assessment of the extent of the patient's memory loss and other evidence of intellectual decline. In some cases, the occupational history may indicate exposure to heavy metals or other toxins. A complete medical history allows the doctor to assess such possibilities as delirium, depression, alcohol-related dementia, dementia related to head injury, or dementia caused by infection. It is particularly important for the doctor to have a list of all the patient's medications, including over-the-counter and alternative herbal preparations, because of the possibility that the patient's symptoms are related to side effects of these substances.

Whenever possible, the examiner will consult the patient's family members or close friends as part of the history-taking process. In many cases, friends and relatives can provide more detailed information about the patient's memory problems and loss of function.

Mental status examination

A mental status examination (MSE) evaluates the patient's ability to communicate, follow instructions, recall information, perform simple tasks involving movement and coordination, as well as his or her emotional state and general sense of space and time. The MSE includes the doctor's informal evaluation of the patient's appearance, vocal tone, facial expressions, posture, and gait as well as formal questions or instructions. A common form that has been used since 1975 is the so-called Folstein Mini-Mental Status Examination, or MMSE. Questions that are relevant to diagnosing dementia include asking the patient to count backward from 100 by 7s, to make change, to name the current President of the United States, to repeat a short phrase after the examiner (such as, "no ifs, ands, or buts"); to draw a clock face or geometric figure, and to follow a set of instructions involving movement (such as, "Show me how to throw a ball" or "Fold this piece of paper and place it under the lamp on the bookshelf.") The examiner may test the patient's abstract reasoning ability by asking him or her to explain a familiar proverb ("People who live in glass houses shouldn't throw stones," for example) or test the patient's judgment by asking about a problem with a common-sense solution, such as what one does when a prescription runs out.

Neurological examination

A neurological examination includes an evaluation of the patient's cranial nerves and reflexes. The cranial nerves govern the ability to speak as well as sight, hearing, taste, and smell. The patient will be asked to stick out the tongue, follow the examiner's finger with the eyes, raise the eyebrows, etc. The patient is also asked to perform certain actions (such as touching the nose with the eyes closed) that test coordination and spatial orientation. The doctor will usually touch or tap certain areas of the body, such as the knee or the sole of the foot, to test the patient's reflexes. Failure to respond to the touch or tap may indicate damage to certain parts of the brain.

Laboratory tests

Blood and urine samples may be collected in order to rule out such conditions as thyroid deficiency, niacin or vitamin B12deficiency, heavy metal poisoning, liver disease, HIV infection, syphilis, anemia, medication reactions, or kidney failure. A lumbar puncture (spinal tap) may be done to rule out neurosyphilis.

Diagnostic imaging

The patient may be given a computed tomography (CT) scan or magnetic resonance imaging (MRI) to detect evidence of strokes, disintegration of the brain tissue in certain areas, blood clots or tumors, a buildup of spinal fluid, or bleeding into the brain tissue. Positron-emission tomography (PET) or single-emission computed tomography (SPECT) imaging is not used routinely to diagnose dementia, but may be used to rule out Alzheimer's disease or frontal lobe degeneration if a patient's CT scan or MRI is unrevealing.

Treatments

Reversible and responsive dementias

Some types of dementia are reversible, and a few types respond to specific treatments related to their causes. Dementia related to dietary deficiencies or metabolic disorders is treated with the appropriate vitamins or thyroid medication. Dementia related to HIV infection often responds well to zidovudine (Retrovir), a drug given to prevent the AIDS virus from replicating. Multi-infarct dementia is usually treated by controlling the patient's blood pressure and/or diabetes; while treatments for these disorders cannot undo damage already caused to brain tissue, they can slow the progress of the dementia. Patients with alcohol-related dementia often improve over the long term if they are able to stop drinking. Dementias related to head injuries, hydrocephalus, and tumors are treated by surgery.

It is important to evaluate and treat elderly patients for depression, because the symptoms of depression in older people often mimic dementia. This condition is sometimes called pseudodementia. In addition, patients who suffer from both depression and dementia often show some improvement in intellectual functioning when the depression is treated. The medications most often used for depression related to dementia are the selective serotonin reuptake inhibitors (SSRIs) paroxetine and sertraline . The mental status examination should be repeated after six12 weeks of antidepressant medication.

Irreversible dementias

As of 2001, there are no medications or surgical techniques that can cure Alzheimer's disease, the frontal lobe dementias, MID, or dementia with Lewy bodies. There are also no "magic bullets" that can slow or stop the progression of these dementias. There is, however, one medication, Aricept, that is being used to halt the progression of Alzheimer's disease. In addition, another medication called galantamine (Reminyl) is also being used to treat the symptoms of Alzheimer's disease. Patients may be given medications to ease the depression, anxiety, sleep disturbances, and other behavioral symptoms that accompany dementia, but most physicians prescribe relatively mild dosages in order to minimize the troublesome side effects of these drugs. Dementia with Lewy bodies appears to respond better to treatment with the newer antipsychotic medications than to treatment with such older drugs as haloperidol (Haldol).

Patients in the early stages of dementia can often remain at home with some help from family members or other caregivers, especially if the house or apartment can be fitted with safety features (handrails, good lighting, locks for cabinets containing potentially dangerous products, nonslip treads on stairs, etc.). Patients in the later stages of dementia, however, usually require skilled care in a nursing home or hospital.

Prognosis

The prognosis for reversible dementia related to nutritional or thyroid problems is usually good once the cause has been identified and treated. The prognoses for dementias related to alcoholism or HIV infection depend on the patient's age and the severity of the underlying disorder.

The prognosis for the irreversible dementias is gradual deterioration of the patient's functioning ending in death. The length of time varies somewhat. Patients with Alzheimer's disease may live from two20 years with the disease, with an average of seven years. Patients with frontal lobe dementia or Pick's disease live on average between five and 10 years after diagnosis. The course of Creutzfeldt-Jakob disease is much more rapid, with patients living between five and 12 months after diagnosis.

Prevention

The reversible dementias related to thyroid and nutritional disorders can be prevented in many cases by regular physical checkups and proper attention to diet. Dementias related to toxic substances in the workplace may be prevented by careful monitoring of the work environment and by substituting less hazardous materials or substances in manufacturing processes. Dementias caused by infectious diseases are theoretically preventable by avoiding exposure to the prion, spirochete, or other disease agent. Multi-infarct dementia may be preventable in some patients by attention to diet and monitoring of blood pressure. Dementias caused by abnormalities in the structure of the brain are not preventable as of 2002.

With regard to genetic factors, tests are now available for the APOE gene implicated in late-onset Alzheimer's, but these tests are used primarily in research instead of clinical practice. One reason is that the test results are not conclusive; about 20% of people who eventually develop AD do not carry this gene. Another important reason is the ethical implications of testing for a disease that presently has no cure. These considerations may change, however, if researchers discover better treatments for primary dementia, more effective preventive methods, or more reliable genetic markers.

See also Respite care

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

"Dementia." The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, M.D., and Robert Berkow, M.D. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Lyon, Jeff, and Peter Gorner. Altered Fates: Gene Therapy and the Retooling of Human Life. New York and London: W. W. Norton & Co., Inc., 1996.

Marcantonio, Edward, M.D. "Dementia." Chapter 40 in The Merck Manual of Geriatrics, edited by Mark H. Beers, M.D., and Robert Berkow, M.D. Whitehouse Station, NJ: Merck Research Laboratories, 2000.

Morris, Virginia. How to Care for Aging Parents. New York: Workman Publishing, 1996. A good source of information about caring for someone with dementia as well as information about dementia itself.

PERIODICALS

"Alzheimer's Disease: Recent Progress and Prospects." Harvard Mental Health Letter (Parts 1, 2, and 3) 18 (OctoberDecember 2001).

ORGANIZATIONS

Alzheimer's Association. 919 North Michigan Avenue, Suite 1000, Chicago, IL 60611. (800) 272-3900.

Alzheimer's Disease International. 45/46 Lower Marsh, London SE1 7RG, United Kingdom. (+44 20) 7620 3011. E-mail: adi@alz.co.uk. <www.alz.co.uk>.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov>.

National Institute of Neurological Disorders and Stroke (NINDS). Building 31, Room 8A06, 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-5751. <www.ninds.nih.gov>.

National Institute on Aging Information Center. P.O. Box 8057, Gaithersburg, MD 20898. (800) 222-2225 or (301) 496-1752.

National Organization for Rare Disorders (NORD). P. O. Box 8923, New Fairfield, CT 06812. (800) 447-6673 or (203) 746-6518.

OTHER

Alzheimer's Disease Education and Referral (ADEAR). <www.alzheimers.org>.

The Nun Study. <www.coa.uky.edu/nunnet>.

Rebecca J. Frey, Ph.D.

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Dementia

Dementia


Dementia (from the Latin de mens—from the mind) is not a specific disease itself, but rather a group of psychological and behavioral symptoms associated with a variety of diseases and conditions that affect the brain (Rabins, Lyketsos, and Steele 1999). Generally, dementia is characterized as the loss or impairment of mental abilities. With dementia, these cognitive losses (e.g., in reasoning, memory, and thinking) are severe enough to interfere with a person's daily life. Additionally, such losses are noticeable in a person who is awake and alert—the term dementia does not apply to cognitive problems caused by drowsiness, intoxication or simple inattention (American Psychiatric Association 1994).

Although often associated with later life, the symptoms of dementia can affect people of any age. Before age sixty-five, however, the incidence of dementia is low—affecting one-half to 1 percent of the population (Rabins et al. 1999). As people get older, the risk of dementia rises. While variation in measurement across countries makes it difficult to determine the world-wide prevalence of dementia, it is estimated that dementia affects less than 10 percent of the sixty-five-and-over population globally (Ikels 1998). In the United States, approximately 5 to 8 percent of people over the age of sixty-five suffer from dementia (Tinker 2000). For the oldest old (age seventy-five and over), the risk of dementia is much greater. Approximately 18 to 20 percent of those over the age of seventy-five have dementia and between 35 to 40 percent of people eighty-five years of age or older are affected (Ikels 1998; Rabins et al. 1999; Tinker 2000).

Signs and Symptoms

As a diagnostic category, dementia is comprised of several symptoms of which the most notable is memory loss. Additional symptoms include impairment of judgment (including social appropriateness), abstract reasoning, sense of time, speech and communication, and physical coordination. Changes in emotional responses may also be seen (American Psychiatric Association 1994). Since dementia results from many different diseases, an individual's symptoms may progress at varying rates and in different ways. Additionally, losses in dementia can be uneven, with one ability (e.g., comprehension) being lost before another (e.g., reading) (Rabins et al. 1999).

In the early stages of dementia, it may be hard to distinguish "normal" behavior (such as forgetfulness) from pathological (or illness based) changes. Since a person rarely uses their full capacities for daily functioning, a person in the early stages of dementia may be able to compensate for some of their losses by developing a variety of coping strategies (Mace and Rabins 1999). While some of these strategies (e.g., leaving oneself notes) can be helpful for a while, others may lead to additional behavioral and psychological symptoms that can add to the person's confusion and pose significant challenges for their caregivers.

An example of this may be seen in regard to impairments in a person's emotional responses. Often such changes are characterized by a lack of emotional involvement. On the other hand, persons with dementia might also demonstrate heightened emotional responses. Such reactions, where a person may become excessively upset or combative over something they might have earlier perceived as trivial, are referred to as catastrophic reactions (Mace and Rabins 1999). Sometimes catastrophic reactions can be confused with obstinacy when they are really a response to too much stimulation. A person may cry or even strike out to cover up their confusion or frustration. Such reactions can be particularly trying for caregivers. Recognizing and removing the triggers for such outbursts (e.g., by removing an offending noise or breaking down a confusing task into simpler steps) may help to reduce their occurrence.

Another example of behavioral symptoms may be seen in the strategies used for communication. Two distinct communication challenges for persons with dementia are making themselves understood and understanding others. With regard to being understood, common communication issues include word substitution; incomplete or incoherent thoughts; making up information to fill in the gaps (confabulation); and frequent repetition of a response (perseveration). In regard to understanding others, it is important to note that reading and understanding are not the same skill. Thus, a person may be able to read words but not understand the content. Also, persons with dementia may only catch part of what is being said, and thus fill in (often inaccurately) the rest on their own. This can lead to confusion and frustration for all involved (Small, Geldart, and Gutman 2000).


Types and Causes of Dementia

There are close to 100 different diseases associated with the clinical symptoms of dementia. While the causes of some are known (e.g., traumatic injury, stroke, brain tumors, infection, vitamin deficiencies, and nervous system toxicity from substances such as alcohol, cocaine, opiates, marijuana, inhalants, and heavy metals), the causes of many dementia producing diseases are still being sought. Ongoing research continues to advance our understanding of these disorders. This is particularly true of the most common dementia producing disorder, Alzheimer's disease, which accounts for approximately 50 to 70 percent of all cases of dementia in old age (or about 3–5% of the U.S. population over the age of 65) (Rabins et al. 1999). First described in 1907, Alzheimer's disease is a degenerative brain disorder characterized by amyloid plaques and neurofibrillary tangles in the brain. Early stages of Alzheimer's disease include memory problems, followed by impairments in language and the ability to do daily tasks. In later stages, impairments in memory, communication, and physical ability become quite severe. While some progress has been made in slowing memory losses in the early stages of Alzheimer's disease, treatments to prevent or cure the disease are not yet available (National Institute on Aging and National Institute on Health 1999).

Another leading cause of dementia, cerebrovascular disease, is associated with vascular dementia (also referred to as multi-infarct dementia) (Ringholz 2000). Sometimes mistaken for Alzheimer's disease, vascular dementia may appear to have a more sudden or step-wise onset than Alzheimer's disease. Also, in contrast to Alzheimer's disease and most of the other dementia-producing diseases discussed here, the progression of vascular dementia may be slowed or stopped by addressing the underlying cause of the damage (e.g., strokes or other brain damage due to cerebrovascular disease) (Rabins et al. 1999; Ringholz 2000).

Also often mistaken for Alzheimer's disease, Lewy body disease is receiving increased attention as a significant cause of dementia in later life (Brown 1999). First described as a distinct disorder in the mid-1990s, Lewy body disease is an irreversible degenerative disorder associated with protein deposits in the brain called Lewy bodies. Symptoms vary depending on where the deposits are located, but typically include problems with motor coordination similar to those seen in Parkinson's disease (McKeith and Burn 2000). In early stages, forgetfulness, walking instability, and depression may be seen. In the middle stages, cognitive impairments seem to fluctuate but become more frequent at night. The final stage is characterized by rapid cognitive decline, delusions, and hallucinations.

In addition to the most widely known disorders described above, there are a number of less common dementia producing diseases. For example, frontotemporal degeneration is a group of dementia-producing disorders in which there is degeneration in the frontal and temporal lobes of the brain. Frontotemporal degeneration has been known by a number of different names, including frontal lobe dementia and Pick's disease. Frontotemporal degeneration usually begins with changes in personality and behaviors such as the ability to follow social rules and think abstractly. Prevalence of frontotemporal dementia is thought to be fairly low (up to 3% of all patients with dementia). Since it is associated with an earlier onset (around age fifty-four), it may account for closer to 10 percent of those who die with dementia before age seventy (Rabins et al. 1999).


Huntington's disease (formerly known as Huntington's Chorea), is a rare, inherited degenerative disorder which can produce slurred speech and problems with physical movement in addition to the progressive symptoms of dementia. When the gene for Huntington's disease is inherited, there is almost certain that the disease will occur. Onset of the disease is variable, ranging from age two to age seventy, although it is mostly a disease of adulthood (average onset is in the late thirties to forties). Due to the physical disturbances, early stages of Huntington's disease may be mistaken for alcoholism (Rabins et al. 1999; Siemers 2001).

Prion dementias represent an even more rare group of diseases. Known as spongiform encephalopathy because of the characteristic degeneration of the neurons and a spongy appearance of the brain's gray matter, prion dementia was first described in 1921. Although Bovine Spongiform Encephalopathy (BSE), also known as "mad cow disease," is the most widely known form of the disease, two additional forms of spongiform encephalopathy (Creutzfeld-Jakob disease and Gerstman-Straussler-Scheinker syndrome) are associated with dementia in humans. With spongiform encephalopathy, the progression of symptoms is rapid and change can occur over weeks. Prion dementia is very rare—literally one in a million (Nguyen and Rickman 1997).

In addition to the disorders described above, several forms of dementia have been associated with outside agents. Some involve exposure to toxins such as alcohol or heavy metals (e.g., lead, arsenic, or mercury). Others are associated with infectious agents such as syphilis and human immunodeficiency virus (HIV). The growing body of research on HIV/AIDS (acquired immunodeficiency syndrome) suggests that AIDS dementia complex (also known as HIV-associated dementia) may affect up to 60 percent of patients with AIDS before their death (Brew 1999; Rabins et. al 1999).


Diagnosing Dementia

Diagnosing the specific diseases that cause dementia can be difficult because of the number of potential causes, overlapping symptoms, and current technological limitations. Many diseases can not yet be definitively diagnosed without an autopsy. Declining abilities of the patient, and fear of what might lie ahead may also delay diagnosis. Many other highly treatable disorders (e.g., depression, malnutrition, drug reactions, or thyroid problems), however, can mimic the symptoms of dementia. Thus, a complete and thorough evaluation is important in order to understand the nature of a person's illness; whether the condition can be treated and or reversed; the extent of the impairment; the areas in which a person may still function successfully; whether the person has other health problems that need treatment; the social and psychological needs and resources of the patient and family; and the changes which might be expected in the future (Mace and Rabins 1999).

Impact of Dementia

Dementia poses considerable medical, social, and economic concerns as it impacts individuals, families, and health-care systems throughout the world (National Institute on Aging and National Institutes of Health 1999; O'Shea and O'Reilly 2000). Not surprisingly, increasing attention and resources have been directed toward the medical aspects of dementia—with the goal of better understanding the various causes, treatments, and possible cures for the diseases that produce dementia's debilitating symptoms.

Greater attention is being directed as well toward the concerns of families of persons with dementia. Previously known as the "hidden victims," family caregivers gained considerable attention throughout the 1980s and 1990s. With the majority of persons with dementia being cared for in the community, it has been suggested that the coping mechanisms and resources of families may be severely tested (Dunkin and Anderson-Hanley 1998; O'Shea and O'Reilly 2000). During the prolonged care period characteristic of Alzheimer's disease and other demential conditions, caregivers face the potential for social isolation; financial drain; and physical duress (Clyburn et al. 2000). Women are particularly vulnerable, as they make up the majority of care providers (Gwyther 2000).

With the development and expansion of programs including support groups, respite care, adult day care, and a growing number of specialized care facilities, assistance for families is increasingly available. Use of such assistance, however, varies widely depending upon availability, cost, quality, and simply knowing that these resources exist. Family expectations and guilt can also play a role in their use, as do cultural attitudes about both dementia and caregiving obligations (Ikels 1998; Yamamoto-Mitani et al. 2000). Additionally, the use of such services does not necessarily alleviate the strains of caregiving. The decision to use outside services can pose its own challenges, and, especially in the case of moving a person with dementia into a care facility, the decision-making process is often a stressful and contentious one. Even after institutionalization, much of the family's experience of caregiving burden may remain (Levesque, Ducharme, and LaChance 2000).

In addition to the medical and caregiving aspects of dementia, new interest is being directed toward the social needs of persons with dementia. Some advancements have focused on developing supportive environments for persons with dementia (Day, Carreon, and Stump 2000). Others have focused on behavior management (Kaplan and Hoffman 1998) and modes of effective communication and interpersonal interaction (Feil 1993; Zgola 1999). Very little attention, however, has focused on understanding the personal and emotional experiences of having dementia. One exception is Diana Friel McGowin's (1993) account of her experiences with Alzheimer's disease. Another is the call to mental health professionals for person-centered therapies for persons with dementia (Cheston and Bender 1999).

As the population of older adults—and thus the number of persons affected by dementia— increases, it is expected that the subjective experiences of persons with dementia will garner even greater interest. Overall, our knowledge and understanding of the diseases that produce dementia is expanding at a rapid rate. To those affected by dementia, however, these advances can not come soon enough.

See also:Acquired Immunodeficiency Syndrome (AIDS); Alzheimer's Disease; Caregiving: Formal; Caregiving: Informal; Chronic Illness; Disabilities; Elder Abuse; Elders; Health and Families; Hospice; Respite Care: Adult


Bibliography

american psychiatric association (1994). diagnostic andstatistical manual of mental disorders, 4th edition. washington, dc: american psychiatric association.

brew, b. (1999). "aids dementia complex." neurologicclinics 17(4):861–881.

brown, d. f. (1999). "lewy body dementia." annals ofmedicine 31(3):188–196.

cheston, r., and bender, m. (1999). understanding dementia: the man with the worried eyes. philadelphia: jessica kingsley.

clyburn, l.; stones, m.; hadjistavropoulos, t.; andtuokko, h. (2000). "predicting caregiver burden and depression in alzheimer's disease." journal of gerontology: social sciences 55b(1):s2–13.

day, k.; carreon, d.; and stump, c. (2000). "the therapeutic design of environments for people with dementia: a review of the empirical literature." the gerontologist 40(4):397–416.

dunkin, j., and anderson-hanley, c. (1998). "dementiacaregiving burden: a review of the literature and guidelines for assessment and intervention." neurology 51(1):s53–s60.

feil, n. (1993). the validation breakthrough: simple techniques for communicating with people with "alzheimer's-type dementia." baltimore, md: health professions.

gwyther, l. (2000). "family issues in dementia: finding a new normal." neurologic clinics 18(4):993–1010.

ikels, c. (1998). "the experience of dementia in china."culture, medicine and psychiatry 22(4):257–283.

kaplan, m., and hoffman, s., eds. (1998). behaviors in dementia: best practices for successful management. baltimore, md: health professions press.

levesque, l.; ducharme, f.; and lachance, l. (2000). "aone-year follow-up study of family caregivers of institutionalized elders with dementia." american journal of alzheimer's disease 15(4):229–238.

mace, n., and rabins, p. (1999). the 36-hour day: a family guide to caring for persons with alzheimer's disease, related dementing illness and memory loss in later life, 3rd edition. baltimore, md: johns hopkins university press.

mcgowin, d. f. (1993). living in the labyrinth: a personal journey through the maze of alzheimer's. new york: delacorte.

mckeith, i., and burn, d. (2000). "spectrum of parkinson'sdisease, parkinson's dementia, and lewy body dementia." neurologic clinics 18(4):865–883.

national institute on aging, and national institute onhealth (1999). progress report on alzheimer's disease, 1999. silver spring, md: alzheimer's disease education and referral center.

nguyen, s., and rickman, l. (1997). "understandingcreutzfeldt-jakob disease." journal of gerontological nursing 23(11):22–27.

o'shea, e., and o'reilly, s. (2000). "the economic andsocial costs of dementia in ireland." international journal of geriatric psychiatry 15:208–218.

rabins, p.; lyketsos, c.; and steele, c. (1999). practicaldementia care. new york: oxford university press.

ringholz, g. (2000). "diagnosis and treatment of vasculardementia." topics in stroke rehabilitation 7(3):38–46.

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small, j.; geldart, k.; and gutman, g. (2000). "communication between individuals with dementia and their caregivers during activities of daily living." american journal of alzheimer's disease and other dementias 15(5):200–209.

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zgola, j. (1999). care that works: a relationship approach to persons with dementia. baltimore, md: johns hopkins university press.

rona j. karasik

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Dementia

Dementia

Definition

Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.

Description

Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and behavior. While the overwhelming number of people with dementia are elderly, it is not an inevitable part of aging. Instead, dementia is caused by specific brain diseases. Alzheimer's disease (AD) is the most common cause, followed by vascular or multi-infarct dementia.

The prevalence of dementia has been difficult to determine, partly because of differences in definition among different studies, and partly because there is some normal decline in functional ability with age. Dementia affects 5-8% of all people between ages 65 and 74, and up to 20% of those between 75 and 84. Estimates for dementia in those 85 and over range from 30-47%. Between two and four million Americans have AD; that number is expected to grow to as many as 14 million by the middle of the twenty-first century as the population ages.

The cost of dementia can be considerable. While most people with dementia are retired and do not suffer income losses from their disease, the cost of care often is enormous. Financial burdens include lost wages for family caregivers, medical supplies and drugs, and home modifications to ensure safety. Nursing home care may cost several thousand dollars a month or more. The psychological cost is not as easily quantifiable but can be even more profound. The person with dementia loses control of many of the essential features of his life and personality, and loved ones lose a family member even as they continue to cope with the burdens of increasing dependence and unpredictability.

Causes and symptoms

Causes

Dementia usually is caused by degeneration in the cerebral cortex, the part of the brain responsible for thoughts, memories, actions and personality. Death of brain cells in this region leads to the cognitive impairment that characterizes dementia.

The most common cause of dementia is AD, accounting for one-half to three-fourths of all cases. The brain of a person with AD becomes clogged with two abnormal structures, called neurofibrillary tangles and senile plaques. Neurofibrillary tangles are twisted masses of protein fibers inside nerve cells, or neurons. Senile plaques are composed of parts of neurons surrounding a group of proteins called beta-amyloid deposits. Why these structures develop is unknown. Current research indicates possible roles for inflammation, blood flow restriction, and toxic molecular fragments known as free radicals. Several genes have been associated with higher incidences of AD, although the exact role of these genes still is unknown.

Vascular dementia is estimated to cause from 5-30% of all dementias. It occurs from decrease in blood flow to the brain, most commonly due to a series of small strokes (multi-infarct dementia). Other cerebrovascular causes include: vasculitis from syphilis, Lyme disease, or systemic lupus erythematosus; subdural hematoma; and subarachnoid hemorrhage. Because of the usually sudden nature of its cause, the symptoms of vascular dementia tend to begin more abruptly than those of Alzheimer's dementia. Symptoms may progress stepwise with the occurrence of new strokes. Unlike AD, the incidence of vascular dementia is lower after age 75.

Other conditions that may cause dementia include:

  • AIDS
  • Parkinson's disease
  • Lewy body disease
  • Pick's disease
  • Huntington's disease
  • Creutzfeldt-Jakob disease
  • brain tumor
  • hydrocephalus
  • head trauma
  • multiple sclerosis
  • prolonged abuse of alcohol or other drugs
  • vitamin deficiency: thiamin, niacin, or B12
  • hypothyroidism
  • hypercalcemia

Symptoms

Dementia is marked by a gradual impoverishment of thought and other mental activities. Losses eventually affect virtually every aspect of mental life. The slow progression of dementia is in contrast with delirium, which involves some of the same symptoms, but has a very rapid onset and fluctuating course with alteration in the level of consciousness. However, delirium may occur with dementia, especially since the person with dementia is more susceptible to the delirium-inducing effects of may types of drugs.

Symptoms include:

  • Memory losses. Memory loss usually is the first symptom noticed. It may begin with misplacing valuables such as a wallet or car keys, then progress to forgetting appointments, where the car was left, and the route home, for instance. More profound losses follow, such as forgetting the names and faces of family members.
  • Impaired abstraction and planning. The person with dementia may lose the ability to perform familiar tasks, to plan activities, and to draw simple conclusions from facts.
  • Language and comprehension disturbances. The person may be unable to understand instructions, or follow the logic of moderately complex sentences. Later, he or she may not understand his or her own sentences, and have difficulty forming thoughts into words.
  • Poor judgment. The person may not recognize the consequences of his or her actions or be able to evaluate the appropriateness of behavior. Behavior may become rude, overly friendly, or aggressive. Personal hygiene may be ignored.
  • Impaired orientation ability. The person may not be able to identify the time of day, even from obvious visual clues; or may not recognize his or her location, even if familiar. This disability may stem partly from losses of memory and partly from impaired abstraction.
  • Decreased attention and increased restlessness. This may cause the person with dementia to begin an activity and quickly lose interest, and to wander frequently. Wandering may cause significant safety problems, when combined with disorientation and memory losses. The person may begin to cook something on the stove, then become distracted and wander away while it is cooking.
  • Behavioral changes and psychosis. The person with dementia may lose interest in once-pleasurable activities, and become more passive, depressed, or anxious. Delusions, suspicion, paranoia, and hallucinations may occur later in the disease. Sleep disturbances may occur, including insomnia and sleep interruptions.

Diagnosis

Since dementia usually progresses slowly, diagnosing it in its early stages can be difficult. However, prompt intervention and treatment has been shown to help slow the effects of dementia, so early diagnosis is important. Several office visits over several months or more may be needed. Diagnosis begins with a thorough physical exam and complete medical history, usually including comments from family members or caregivers. A family history of either AD or cerebrovascular disease may provide clues to the cause of symptoms. Simple tests of mental function, including word recall, object naming, and number-symbol matching, are used to track changes in the person's cognitive ability.

Depression is common in the elderly and can be mistaken for dementia; therefore, ruling out depression is an important part of the diagnosis. Distinguishing dementia from the mild normal cognitive decline of advanced age also is critical. The medical history includes a complete listing of drugs being taken, since a number of drugs can cause dementia-like symptoms.

Determining the cause of dementia may require a variety of medical tests, chosen to match the most likely etiology. Cerebrovascular disease, hydrocephalus, and tumors may be diagnosed with x rays, CT or MRI scans, and vascular imaging studies. Blood tests may reveal nutritional deficiencies or hormone imbalances.

Treatment

Treatment of dementia begins with treatment of the underlying disease, where possible. The underlying causes of nutritional, hormonal, tumor-caused and drug-related dementias may be reversible to some extent. Treatment for stroke-related dementia begins by minimizing the risk of further strokes, through smoking cessation, aspirin therapy, and treatment of hypertension, for instance. No therapies can reverse the progression of AD. Aspirin, estrogen, vitamin E, and selegiline have been evaluated for their ability to slow the rate of progression. However, none of these have been proven effective. In fact, in 2002 and 2003, research revealed that non-steroidal anti-inflammatory agents (NSAIDs) did not help prevent AD and dementia. In the same two years, the Women's Health Initiative, a large clinical trial, was halted because of detrimental effects of combined estrogen and progestigin therapy, or hormone replacement therapy (HRT). Not only was HRT found to increase risk of breast cancer, stroke, and other heart disease, but the risk of probable dementia was twice that for women taking HRT than for those taking a placebo. Further, those taking HRT had a substantial and clinically important decline in indicators of cognitive ability. Studies still debate the effects of vitamin E on slowing the progression of moderately severe AD.

Care for a person with dementia can be difficult and complex. The patient must learn to cope with functional and cognitive limitations, while family members or other caregivers assume increasing responsibility for the person's physical needs. In progressive dementias such as AD, the person may ultimately become completely dependent. Education of the patient and family early in the disease progression can help them anticipate and plan for inevitable changes.

Symptoms of dementia may be treated with a combination of psychotherapy, environmental modifications, and medication. Drug therapy can be complicated by forgetfulness, especially if the prescribed drug must be taken several times daily.

Behavioral approaches may be used to reduce the frequency or severity of problem behaviors, such as aggression or socially inappropriate conduct. Problem behavior may be a reaction to frustration or over-stimulation; understanding and modifying the situations that trigger it can be effective. Strategies may include breaking down complex tasks, such as dressing or feeding, into simpler steps, or reducing the amount of activity in the environment to avoid confusion and agitation. Pleasurable activities, such as crafts, games, and music, can provide therapeutic stimulation and improve mood.

Modifying the environment can increase safety and comfort while decreasing agitation. Home modifications for safety include removal or lock-up of hazards such as sharp knives, dangerous chemicals, and tools. Child-proof latches or Dutch doors may be used to limit access as well. Lowering the hot water temperature to 120 °F (48.9 °C) or less reduces the risk of scalding. Bed rails and bathroom safety rails can be important safety measures, as well. Confusion may be reduced with simpler decorative schemes and presence of familiar objects. Covering or disguising doors (with a mural, for example) may reduce the tendency to wander. Positioning the bed in view of the bathroom can decrease incontinence.

Two drugs, tacrine (Cognex) and donepezil (Aricept), are commonly prescribed for AD. These drugs inhibit the breakdown of acetylcholine in the brain, prolonging its ability to conduct chemical messages between brain cells. They provide temporary improvement in cognitive functions for some patients with mild to moderate AD and help delay disease progression.

Psychotic symptoms, including paranoia, delusions, and hallucinations, may be treated with antipsychotic drugs, such as haloperidol, chlorpromazine, risperidone, and clozapine. Side effects of these drugs can be significant. Antianxiety drugs such as Valium may improve behavioral symptoms, especially agitation and anxiety, although BuSpar has fewer side effects. The anticonvulsant carbamazepine also is sometimes prescribed for agitation. Depression is treated with antidepressants, usually beginning with selective serotonin reuptake inhibitors (SSRIs) such as Prozac or Paxil, followed by monoamine oxidase inhibitors or tricyclic antidepressants. In general, medications should be administered cautiously to demented patients, in the lowest possible effective doses, to minimize side effects. Supervision of taking medications is generally required.

Long-term institutional care may be needed for the person with dementia, as profound cognitive losses often precede death by a number of years. Early planning for the financial burden of nursing home care is critical. Useful information about financial planning for long-term care is available through the Alzheimer's Association.

Family members or others caring for a person with dementia often are subject to extreme stress, and may develop feelings of anger, resentment, guilt, and hopelessness, in addition to the sorrow they feel for their loved one and for themselves. Depression is an extremely common consequence of being a full-time caregiver for a person with dementia. Support groups can be an important way to deal with the stress of caregiving. The location and contact numbers for caregiver support groups are available from the Alzheimer's Association; they may also be available through a local social service agency or the patient's physician. Medical treatment for depression may be an important adjunct to group support.

Alternative treatment

Several drugs are currently being tested for their ability to slow the progress of AD. These include acetyl-l-carnitine, which acts on the cellular energy structures known as mitochondria; propentofylline, which may aid circulation; milameline, which acts similarly to tacrine and donezepil; and ginkgo extract.

Ginkgo extract, derived from the leaves of the Ginkgo biloba tree, interferes with a circulatory protein called platelet activating factor. It also increases circulation and oxygenation to the brain. Ginkgo extract has been used for many years in China and is widely prescribed in Europe for treatment of circulatory problems. A 1997 study of patients with dementia seemed to show that gingko extract could improve their symptoms, though the study was criticized for certain flaws in its method.

Prognosis

The prognosis for dementia depends on the underlying disease. On average, people with Alzheimer's disease live eight years past their diagnosis, with a range from one to 20 years. Vascular dementia usually is progressive, with death from stroke, infection, or heart disease.

Prevention

There is no known way to prevent Alzheimer's disease, although several drugs under investigation may reduce its risk or slow its progression. The risk of developing multi-infarct dementia may be reduced by reducing the risk of stroke. Various studies continue to determine ways to lower risk of AD and dementia. For example, a 2003 study in the New England Journal of Medicine reported that people over age 75 who participated in leisure activities such as playing board games, reading, dancing, and playing musical instruments were less likely to have dementia after five years than others their age.

KEY TERMS

Donepezil A drug commonly prescribed for Alzheimer's disease that provides temporary improvement in cognitive functions for some patients with mild-to-moderate forms of the disease.

Ginkgo extract Made from the leaves of the Ginkgo biloba tree, this extract, used in other countries to treat circulatory problems, may improve the symptoms of patients with dementia.

Neurofibrillary tangles Abnormal structures, composed of twisted masses of protein fibers within nerve cells, found in the brains of people with Alzheimer's disease.

Senile plaques Abnormal structures, composed of parts of nerve cells surrounding protein deposits, found in the brains of people with Alzheimer's disease.

Tacrine A drug commonly prescribed for Alzheimer's disease that provides temporary improvement in cognitive functions for some patients with mild-to-moderate forms of the disease.

Resources

PERIODICALS

"Antioxidants Don't Prevent Dementia." JAAPAJournal of the American Academy of Physicians Assistants, May 2003: 25.

MacReady, Norra. "Prompt Intervention May Help Slow Dementia." Clinical Psychiatry News, May 2003: 38.

"Research Breifs: Play Keeps Dementia Away." GP, June 23, 2003: 04.

"Risks of Hormone Treatment." The Lancet, May 31, 2003: 1877.

ORGANIZATIONS

Alzheimer's Association. 919 North Michigan Ave., Suite 1000, Chicago, IL 60611. (800) 272-3900. http://www.alz.org.

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Robinson, Richard; Odle, Teresa. "Dementia." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 28 Jun. 2016 <http://www.encyclopedia.com>.

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Robinson, Richard; Odle, Teresa. "Dementia." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved June 28, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600494.html

Dementia

Dementia

Definition

Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.

Description

Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. While the over-whelming number of people with dementia are elderly, it is not an inevitable part of aging . Instead, dementia is caused by specific brain diseases. Alzheimer's disease is the most common cause, followed by vascular or multi-infarct dementia.

The prevalence of dementia has been difficult to determine, partly because of differences in definition among different studies, and partly because there is some normal decline in functional ability with age. Dementia affects 58% of all people between ages 65 and 74, and up to 20% of those between 75 and 84. Estimates for dementia in those 85 and over range from 3047%. Between two and four million Americans have Alzheimer's disease; that number is expected to grow to as many as 14 million by the middle of the twenty-first century as the population as a whole ages.

The cost of dementia can be considerable. While most people with dementia are retired and do not suffer income losses from their disease, the cost of care is often enormous. Financial burdens include lost wages for family caregivers, medical supplies and drugs, and home modifications to ensure safety. Nursing home care may cost several thousand dollars a month or more. The psychological cost is not as easily quantifiable but can be even more profound. The person with dementia loses control of many of the essential features of his life and personality, and loved ones lose a family member even as they continue to cope with the burdens of increasing dependence and unpredictability.

Causes & symptoms

Causes

Dementia is usually caused by degeneration of brain cells in the cerebral cortex, the part of the brain responsible for thoughts, memories, actions, and personality. Death of brain cells in this region leads to the cognitive impairment that characterizes dementia.

The most common cause of dementia is Alzheimer's disease (AD), accounting for half to three quarters of all cases. The brain of a person with AD becomes clogged with two abnormal structures, called neurofibrillary tangles and senile plaques. Neurofibrillary tangles are twisted masses of protein fibers inside nerve cells, or neurons. Senile plaques are composed of parts of neurons surrounding a group of proteins called beta-amyloid deposits. Why these structures develop is unknown. Current research indicates possible roles for inflammation, blood flow restriction, and accumulation of aluminum in the brain and toxic molecular fragments known as free radicals or oxidants.

Several genes have been associated with higher incidences of AD, although the exact role of these genes is still unknown. In 2001, investigators discovered a rare mutation in the amyloid precursor protein (APP) that is linked to early-onset Alzheimer's. The discovery points scientists to new ideas for targeting and treating the disease.

Vascular dementia is estimated to cause from 530% of all dementias. It occurs from a decrease in blood flow to the brain, most commonly due to a series of small strokes (multi-infarct dementia). Other cerebrovascular causes include: vasculitis from syphilis, Lyme disease , or systemic lupus erythematosus ; subdural hematoma; and subarachnoid hemorrhage. Because of the usually sudden nature of its cause, the symptoms of vascular dementia tend to begin more abruptly than those of Alzheimer's dementia. Symptoms may progress stepwise with the occurrence of new strokes. Unlike AD, the incidence of vascular dementia is lower after age 75.

Other conditions which may cause dementia include:

  • AIDS
  • Parkinson's disease
  • Lewy body disease
  • Pick's disease
  • Huntington's disease
  • Creutzfeldt-Jakob disease
  • brain tumor
  • hydrocephalus
  • head trauma
  • multiple sclerosis
  • prolonged abuse of alcohol or other drugs
  • vitamin deficiency: thiamin, niacin , or B12
  • hypothyroidism
  • hypercalcemia

Symptoms

Dementia is marked by a gradual impoverishment of thought and other mental activities. Losses eventually affect virtually every aspect of mental functioning. The slow progression of dementia is in contrast with delirium, which involves some of the same symptoms, but has a very rapid onset and fluctuating course with alteration in the level of consciousness. However, delirium may occur with dementia, especially since the person with dementia is more susceptible to the delirium-inducing effects of may types of drugs.

Symptoms include:

  • Memory losses. Short-term memory loss is usually the first symptom noticed. It may begin with misplacing valuables such as a wallet or car keys, then progress to forgetting appointments, where the car was left, and the route home, for instance. More profound losses may eventually follow, such as forgetting the names and faces of family members.
  • Impaired abstraction and planning. The person with dementia may lose the ability to perform familiar tasks, to plan activities, and to draw simple conclusions from facts.
  • Language and comprehension disturbances. The person may be unable to understand instructions, or follow the logic of moderately complex sentences. Later, he or she may not understand his or her own sentences, and have difficulty forming thoughts into words.
  • Poor judgment. The person may not recognize the consequences of his or her actions or be able to evaluate the appropriateness of behavior. Behavior may become crude or offensive, overly-friendly, or aggressive. Personal hygiene may be ignored.
  • Impaired orientation ability. The person may not be able to identify the time of day, even from obvious visual clues; or may not recognize his or her location, even if familiar. This disability may stem partly from losses of memory and partly from impaired abstraction.
  • Decreased attention and increased restlessness. This may cause the person with dementia to begin an activity and quickly lose interest, and to wander frequently. Wandering may cause significant safety problems, when combined with disorientation and memory losses. The person may begin to cook something on the stove, then become distracted and wander away while it is cooking.
  • Personality changes and psychosis. The person may lose interest in once-pleasurable activities, and become more passive, depressed, or anxious. Delusions, suspicion, paranoia, and hallucinations may occur later in the disease. Sleep disturbances may occur, including insomnia and sleep interruptions.

Diagnosis

Since dementia usually progresses slowly, diagnosing it in its early stages can be difficult. Several office visits over several months or more may be needed. Diagnosis begins with a thorough physical exam and complete medical history, usually including comments from family members or caregivers. A family history of either Alzheimer's disease or cerebrovascular disease may provide clues to the cause of symptoms. Simple tests of mental function, including word recall, object naming, and number-symbol matching, are used to track changes in the person's cognitive ability. Recent studies suggest that positron emissions tomography (PET) scans of the brain might be able to identify those at risk for Alzheimer's. As these tests become more widely available, they may offer hope for earlier detection of dementia.

Depression is common in the elderly and can be mistaken for dementia; therefore, ruling out depression is an important part of the diagnosis. Distinguishing dementia from the mild normal cognitive decline of advanced age is also critical. The medical history includes a complete listing of drugs being taken, since a number of drugs can cause dementia-like symptoms.

Determining the cause of dementia may require a variety of medical tests, chosen to match the most likely etiology. Cerebrovascular disease, hydrocephalus, and tumors may be diagnosed with x rays, CT or MRI scans, and vascular imaging studies. Blood tests may reveal nutritional or metabolic deficiencies or hormone imbalances.

Treatment

Nutritional supplements

Some nutritional supplements may be helpful, especially if dementia is caused by deficiency of these essential nutrients:

  • Acetyl-L-carnitine: improves brain function and increases attention span, enhances ability to concentrate and increases energy in patients with Alzheimer's disease.
  • Antioxidants (vitamin E, vitamin C , beta-carotene, or selenium ): may slow down disease progression by preventing the damaging effects of free radicals.
  • B-complex vitamins and vitamin B12: may significantly improve mental function in patients who have low levels of these essential nutrients.
  • Coenzyme Q10: helps deliver more oxygen to the brain
  • DHEA: may increase brain function in old people.
  • Magnesium : may be helpful if the dementia is caused by magnesium deficiency and/or accumulation of aluminum in the brain
  • Phosphotidylserine: Deficiency of this nutrient may decrease mental function and cause depression.
  • Zinc: may boost short-term memory and increase attention span

Herbal treatment

Herbal remedies that may be helpful in treating dementia include Chinese or Korean ginseng, Siberian ginseng, gotu kola , and Ginkgo biloba. Of these, ginkgo biloba is the most well-known and widely accepted by Western medicine. Ginkgo extract, derived from the leaves of the Ginkgo biloba tree, interferes with a circulatory protein called platelet-activating factor. It also increases circulation and oxygenation to the brain. Ginkgo extract has been used for many years in China and is widely prescribed in Europe for treatment of circulatory problems. A 1997 study of patients with dementia appeared to show that gingko extract could improve their symptoms. Some scientists believe that, taken early enough in the process, Ginkgo biloba can delay the onset of Alzheimer's, but this claim has not yet been sufficiently backed by enough supportive studies.

Homeopathy

A homeopathic physician may prescribe patient-specific homeopathic remedies to alleviate symptoms of dementia.

Acupressure

This form of therapy uses hands to apply pressure on specific acupressure points to improve blood circulation and calm the nervous system.

Aromatherapy

Aromatherapists use essential oils as inhalants or in baths to improve mental performances and to calm the nerves.

Chelation therapy

This is a controversial treatment that may provide symptomatic improvement in some patients. However, its effectiveness has not been supported by clinical studies. In addition, this form of therapy may cause kidney damage. Therefore, it should only be given under watchful eyes of a qualified physician.

Allopathic treatment

There are no therapies that can reverse the progression of Alzheimer's disease. Therefore, treatment of dementia begins with treatment of the underlying disease when possible. Aspirin, estrogen, vitamin E, selegiline, propentofylline and milameline are currently being evaluated for their ability to slow the rate of progression.

Care for a person with dementia can be difficult and complex. The patient must learn to cope with functional and cognitive limitations, while family members or other caregivers assume increasing responsibility for the person's physical needs.

Symptoms of dementia may be treated with a combination of psychotherapy , environmental modifications and medication. Behavioral approaches may be used to reduce the frequency or severity of problem behaviors, such as aggression or socially inappropriate conduct.

Modifying the environment can increase safety and comfort while decreasing agitation. Home modifications for safety include removal or lock-up of hazards such as sharp knives, dangerous chemicals, and tools. Child-proof latches or Dutch doors may be used to limit access as well. Lowering the hot water temperature to 120°F (48.9°C) or less reduces the risk of scalding. Bed rails and bathroom safety rails can be important safety measures, as well. Confusion may be reduced with simpler decorative schemes and presence of familiar objects. Covering or disguising doors (with a mural, for example) may reduce the tendency to wander. Positioning the bed in view of the bathroom can decrease incontinence.

Two drugs, tacrine (Cognex) and donepezil (Aricept), are commonly prescribed for Alzheimer's disease. These drugs inhibit the breakdown of acetylcholine in the brain, prolonging its ability to conduct chemical messages between brain cells. They provide temporary improvement in cognitive functions for about 40% of patients with mild-to-moderate AD. Hydergine is sometimes prescribed as well, though it is of questionable benefit for most patients. Other drugs that are frequently used in dementia patients include antianxiety (for agitation and anxiety ) and antipsychotics (for paranoia, delusions or hallucinations) and antidepressants (for depressive symptoms). Evaluation of any medical side effects from the medications should be ongoing.

Long-term institutional care may be needed for the person with dementia, as profound cognitive losses often precede death by a number of years. Early planning for the financial burden of nursing home care is critical. Useful information about financial planning for long-term care is available through the Alzheimer's Association.

Expected results

The prognosis for dementia depends on the underlying disease. On average, people with Alzheimer's disease live eight years past their diagnosis, with a range from one to twenty years. Vascular dementia is usually progressive, with death from stroke , infection, or heart disease .

Prevention

There is no known way to prevent Alzheimer's disease, although several of the drugs under investigation may reduce its risk or slow its progression. Nutritional supplements, including antioxidants, may also help protect against Alzheimer's disease. New studies also show that use of nonsteroidal anti-inflammatory agents (overthe-counter pain relievers like ibuprofen and naproxen) may lower risk of Alzheimer's. The risk of developing multi-infarct dementia may be reduced by reducing the risk of stroke. Sources of aluminum, which can be found in aluminum cookware, canned sodas, and certain antacids and deodorants, should be avoided.

Resources

BOOKS

Halpern, Georges. Ginkgo: A Practical Guide. Garden City Park, NY: Avery Publishing Group, 1998.

Jacques, Alan. Understanding Dementia. New York: Churchill Livingstone, 1992.

Mace, Nancy L. and Peter V. Rabins. The 36-Hour Day. Baltimore: Johns Hopkins University Press, 1995.

Murray, Michael and Joseph Pizzorno. "Alzheimer's Disease." In Encyclopedia of Natural Medicine. 2nd ed. Rocklin, CA: Prima Publishing, 1998.

Zand, Janet, Allan N. Spreen, and James B. LaValle. "Alzheimer's Disease." In Smart Medicine for Healthier Living: A Practical A-to-Z Reference to Natural and Conventional Treatments for Adults. Garden City Park, NY: Avery Publishing Group, 2000.

PERIODICALS

Gottlieb, Scott R."NSAIDs Can Lower Risk of Alzheimer's." British Medical Journal 323 no.7324 (December 1, 2001):1269.

Mitka M."PET and Memory Impairment." JAMA, Journal of the American Medical Association 286 no. 16 (October 24, 2001):1961.

Stephenson Joan. "Alzheimer Treatment Target?" JAMA, Journal of the American Medical Association 286 no. 14 (October 10, 2001):1704.

ORGANIZATION

Alzheimer's Association. 919 North Michigan Ave., Suite 1000, Chicago, IL 60611. (800) 272-3900 (TDD: (312) 335-8882). http://www.alz.org/.

Mai Tran

Teresa G. Odle

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Tran, Mai; Odle, Teresa. "Dementia." Gale Encyclopedia of Alternative Medicine. 2005. Retrieved June 28, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3435100254.html

Dementia

Dementia

Definition

The term dementia refers to symptoms, including changes in memory, personality, and behavior, that result from a change in the functioning of the brain. These declining changes are severe enough to impair the ability of a person to perform a function or to interact socially. This operating definition encompasses 7080 different types of dementia. They include changes due to diseases (Alzheimer's and Creutzfeld-Jakob diseases), changes due to a heart attack or repeated blows to the head (as suffered by boxers), and damage due to long-term alcohol abuse.

Dementia is not the same thing as delirium or mental retardation . Delirium is typically a brief state of mental confusion often associated with hallucinations. Mental retardation is a condition that usually dates from childhood and is characterized by impaired intellectual ability; mentally retarded individuals typically have IQ (intelligence quotient) scores below 70 or 75.

Description

The absent-mindedness and confusion about familiar settings and tasks that are hallmarks of dementia used to be considered as part of a typical aging pattern in the elderly. Indeed, dementia historically has been called senility. Dementia is now recognized not to be a normal part of aging. The symptoms of dementia can result from different causes. Some of the changes to the brain that cause dementia are treatable and can be reversed, while other changes are irreversible.

Demographics

An estimated two million people in the United States alone have severe dementia. Up to five million more people in the United States have milder forms of cognitive impairment of the dementia type. The elderly are most prone to dementia, particularly those at risk for a stroke . The historical tendency of women to live longer than men has produced a higher prevalence of dementia in older women. However, women and men are equally prone to dementia. Over age 80, more than 20% of people have at least a mild form of dementia.

Causes and symptoms

Dementia is especially prominent in older people. The three main irreversible causes are Alzheimer's disease, dementia with Lewy bodies, and multi-infarct dementia (also called vascular dementia).

Degenerative forms of dementia are long lasting (chronic) and typically involve a progressive loss of brain cell function. In disorders like Alzheimer's and Creutzfeld-Jakob diseases, this can involve the presence of infectious agents that disturb the structure of proteins that are vital for cell function. Other forms of dementia are chemically based. For example, Parkinson's disease involves the progressive loss of the ability to produce the neurotransmitter dopamine. Interrupted transmission of nerve impulses causes the progressive physical and mental deterioration. Huntington's disease is an inherited form of dementia that occurs when neurons (brain cells) degenerate.

Alzheimer's disease is the most common cause of dementia. The progressive death of nerve cells in the brain is associated with the formation of clumps (amyloid plaques) and tangles of protein (neurofibrillary tangles) in the brain. The loss of brain cells with time is reflected in the symptoms; minor problems with memory become worse, and impairment in normal function can develop. Alzheimer's patients also have a lower level of a chemical that relays nerve impulses between nerve cells. As the brain damage progresses, other complications can ensue from the damage and these can prove fatal. Put another way, people die with Alzheimer's, not from it.

Dementia resulting from the abnormal formation of protein in the brain (Lewy bodies) is the second most common form of dementia in the elderly. It is unclear whether these structures are related to the brain abnormalities noted in Alzheimer's patients. Lewy body formation differs from Alzheimer's in that the speed of brain functions is affected more so than memory.

In multi-infarct dementia, blood clots can dislodge and impede the flow of blood in blood vessels in the brain. The restricted flow of blood can lead to death of brain cells and a stroke.

Dementias that are caused by the blockage of blood vessels are generally known as vascular dementia. This type of dementia can sometimes be reversed if the blood-vessel blockage can be alleviated. In contrast, the dementia associated with Alzheimer's disease is non-reversible.

Less common causes of dementia include Binwanger's disease (another vascular type of dementia), Parkinson's disease, Pick's disease, Huntington's disease, Creutzfeldt-Jakob disease , and acquired immunodeficiency syndrome (AIDS ).

A study published in 2002 documented a link between elevated levels of an amino acid called homocysteine in the blood and the risk of developing dementia, likely vascular dementia. As homocysteine concentration can be modified by diet, the finding holds the potential that one risk factor for dementia may be controllable.

Symptoms of dementia include repeatedly asking the same question; loss of familiarity with surroundings; increasing difficulty in following directions; difficulty in keeping track of time, people, and locations; loss of memory; changes in personality or emotion; and neglect of personal care. Not everyone displays all symptoms. Indeed, symptoms vary based on the cause of the dementia. Also, symptoms can progress at different rates in different people.

Diagnosis

Diagnosis of dementia typically involves a medical examination, testing of mental responses (such as memory, problem solving, and counting), and knowledge of the patient's medical history (e.g., prescription and non-prescription drug use, nutrition, results of a physical examination, and medical history). Testing of the composition of the blood and urine can be helpful in ruling out specific causes such as thyroid disease or a deficiency in vitamin B12. Some blood tests can help alert clinicians to the possibility of dementia. For example, persons infected with the human immunodeficiency virus (HIV) have distinct proteins in their blood that are often associated with the presence of dementia.

Visual examination of the brain can reveal structural abnormalities associated with dementia. Tests that are typically performed are computerized tomography (CT), magnetic resonance imaging (MRI) , and positron emission tomography (PET) . While accurate, such tests are not commonplace, and are rarely encountered outside of the research setting. Neuroimaging (CT or MRI scans) can be useful in excluding the possibility that dementia has resulted from an occlusion of a blood vessel, as in a stroke or due to the presence of a tumor.

Treatment team

Family physicians, medical specialists such as neurologists and psychiatrists, physical therapists, counselors, personal caregivers, and family members can all be part of the treatment team for someone afflicted with dementia.

Treatment

Drugs can help delay the progression of symptoms, particularly for Alzheimer's disease. The high blood pressure that is associated with multi-infarct dementia can also be controlled by drug therapy. Other stroke risk factors that can be treated include cholesterol level, diabetes, and smoking. Medicines such as antidepressants, antipsychotics, and anxiolytics can also be used to treat behaviors associated with dementia, including insomnia, anxiety, depression , and nervousness.

Other treatments that do not involve drugs are the maintenance of a healthy diet, regular exercise , stimulating activities and social contacts, and making the home as safe as possible. Hobbies can help keep the mind occupied and stimulated. "Things-to-do" lists can be a helpful memory prompt for persons with early dementia. With more advanced disease, a facility specializing in Alzheimer's treatment often provides a stimulating modified environment along with meeting increasing medical and personal care needs.

Recovery and rehabilitation

Irreversible causes of dementia reduce or eliminate the chances of recovery and rehabilitation. Stimuli such as favorite family photographs and calendars provide clues to cognitive orientation, while devices such as walkers help maintain mobility for as long as possible.

Clinical trials

As of early 2004, there are 64 clinical trials for dementia study and treatment in the United States that are recruiting subjects. The trials range from improved strategies of care and telephone support to active interventions in the outcome of various forms of dementia. The bulk of the trials are concerned with Alzheimer's disease. Information about the trials can be found at the National Institutes of Health (NIH) sponsored clinical trials website.

Prognosis

For those with irreversible progressive dementia, the outlook often includes slow deterioration in mental and physical capacities. Eventually, help is often required when swallowing, walking, and even sitting become difficult. Aid can consist of preparing special diets that can be more easily consumed and making surroundings safe in case of falls. Lift assists in areas such as the bathroom can also be useful.

For those with dementia, the expected lifespan is often reduced from that of a healthy person. For example, in Alzheimer's disease, deterioration of areas of the brain that are vital for body functions can threaten survival.

Special concerns

Caring for an individual with dementia almost always challenges family resources. Licensed social service providers at hospitals and facilities for the elderly can provide information and referrals regarding support groups, mental health agencies, community resources, and personal care providers to assist families in caring for a person with dementia.

Resources

BOOKS

Bird, T. D. "Memory Loss and Dementia." In Harrison's Principles of Internal Medicine, 15th edition. Edited by A. S. Franci, E. Daunwald, and K. J. Isrelbacher. New York: McGraw Hill, 2001.

Castleman, Michael, et al. There's Still a Person in There: The Complete Guide to Treating and Coping With Alzheimer's. New York: Perigee Books, 2000.

Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life. New York: Warner Books, 2001.

PERIODICALS

Sullivan, S. C., and K. C. Richards. "Special SectionBehavioral Symptoms of Dementia: Their Measurement and Intervention." Aging and Mental Health (February 2004): 143152.

Seshadri, S., et al. "Plasma Homocysteine as a Risk Factor for Dementia and Alzheimer's Disease." New England Journal of Medicine (February 2002): 476483.

OTHER

Mayo Clinic. Dementia: It's Not Always Alzheimer's. December 23, 2003 (March 30, 2004). <http://www.mayoclinic.com/invoke.cfm?id=AZ00003>.

National Institute on Aging. Forgetfulness: It's Not Always What You Think. December 23, 2003 (March 30, 2004). <http://www.niapublications.org/engagepages/forgetfulness.asp>.

ORGANIZATIONS

Alzheimer's Association. 919 Michigan Avenue, Suite 1100, Chicago, IL 60611-1676. (312) 335-8700 or (800) 272-3900; Fax: (312) 335-1110. info@alz.org. <http://www.alz.org>.

Alzheimer's Disease Education and Referral Center. P. O. Box 8250, Silver Spring, MD 20907-8250. (301) 495-3334 or (800) 438-4380. adear@alzheimers.org. <http://www.alzheimers.org>.

National Institute on Aging. 31 Center Drive, MSC 2292, Building 31, Room 5C27, Bethesda, MD 20892. (301) 496-1752 or (800) 222-2225. karpf@nia.nih.gov. <http://www.nia.nih.gov>.

National Institute for Neurological Disorders and Stroke. P. O. Box 5801, Bethesda, MD 20824. (301) 496-5761 or (800) 352-9424. <http://www.ninds.nih.gov>.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (866) 615-6464; Fax: (301) 443-4279. nimhinfo@nih.gov. <http://www.nimh.nih.gov>.

Brian Douglas Hoyle, PhD

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Dementia

Dementia

BIBLIOGRAPHY

Although there is growing understanding of dementia, it remains a poorly understood condition that continues to be associated with negative attitudes and stigmas. Dementia is not a disease but a clinical syndrome, meaning a set of symptoms relating to the breakdown of intellectual (cognitive) functions. Operational diagnostic criteria for dementia stipulate (1) an impairment in memory; (2) an impairment in at least one other cognitive domain (e.g., language, visuospatial, knowledge and understanding, executive functions, control over social and emotional behaviors); (3) that the impairment represents a decline from the persons previous levels of ability; and (4) that the impairments are severe enough to interfere with the persons everyday life.

The main risk factor for the development of dementia is age. Prevalence rises from 1 in 1,000 for those aged 45 to 65; to 1 in 5 for those aged 80 to 90; to 1 in 3 among those over age 90. Until the late twentieth century, dementia in an elderly person (defined to be someone over 65 years of age) was commonly diagnosed as senility or senile dementia. These terms, however, are no longer recommended because they have been used with a lack of diagnostic rigor and there is a lack of scientific evidence to justify the diagnostic distinction between prese-nile dementia (dementia in someone under age 65) and senile dementia (identical symptoms in someone age 65 or more). Furthermore, the term senility carries negative connotations and implies that the dementia syndrome is an inevitability of old age. This implication is not supported by the evidence and leads to poor recognition of dementia syndrome. The symptoms of dementia in elderly people often get dismissed on the basis that these are just signs of old age, although dementia in middle-aged people is commonly misdiagnosed as a functional psychiatric disorder.

Most causes of dementia are slowly progressing neurodegenerative diseases with Alzheimers disease being the most common cause, accounting for 50 to 60 percent of all cases. Dementia is typically thought of as progressing from a mild stage, characterized by slips of the memory and confusion in complex situations, through a moderate stage, during which the degree of cognitive impairment intensifies to affect an increasing number of activities of daily living (e.g., use of language, ability to recognize friends and relatives, ability to make sense of the visual world, ability to use household objects or appliances effectively and safely, ability to dress and attend to personal hygiene). The severe stage of dementia is characterized by serious disability in which the person is likely to have limited language and understanding and to be totally dependent upon others for all their physical needs (eating, drinking, toileting).

However, typical schemes of dementia symptoms and progression need to be treated with extreme caution. The precise symptoms a person experiences will depend upon the particular cause of that persons dementia and the parts of the brain that were damaged. Also, the symptoms of dementia must be understood as complex interplay between neurological damage and psychological and social variables, such as the persons life history, personality, and quality of the care environment. These considerations are particularly important when assessing the non-cognitive symptoms of dementia, such as apathy, anxiety, wandering, or aggression. Such behaviors may reflect the individuals personality or coping style, or they may be a valid response to an environment in which the persons needs and personhood are being overlooked or neglected.

With over two hundred possible causes of dementia there is still a lot to be learned about how specific causes manifest. The stages of dementia outlined are strongly influenced by the specific characteristics of Alzheimers disease. Other forms of dementia are known to have different characteristics and growing knowledge of these differences is stimulating a move away from the generic criteria for dementia toward operational criteria for specific diagnoses (e.g., dementia of the Alzheimer type, vascular dementia). In particular, early memory loss is often cited as the key feature of dementia but this symptom has a specific link with Alzheimers disease and there are forms of dementia in which memory loss is not a central feature (e.g., frontotemporal and Lewy body dementia).

After Alzheimers disease, vascular dementia is the next most common form of primary dementia, accounting for 20 percent of all dementias. The blood supply to the brain can become fragile in old age and the term vascular dementia covers all forms of dementia that result from cerebrovascular pathologies. Lewy body disease, frontotemporal atrophy, alcohol abuse, and the AIDS complex are also significant causes of dementia. Some dementias are due to reversible causes (e.g., depression, hypothyroidism, vitamin B deficiency) and are called secondary dementias. It is important that the diagnostic procedure fully investigates secondary causes for dementia before diagnosing a primary (irreversible) cause.

Pharmacological treatments for primary dementias are limited. A number of anti-cholinesterases are available that aim to alleviate some of the cognitive and functional symptoms of dementia by boosting levels of the neurotransmitter acetylcholine. These drugs were designed to specifically target the Alzheimers disease process, although there is evidence that they may be beneficial in other forms of dementia, particularly vascular dementia and Lewy body dementia. Memantine is an alternative drug that aims to protect undamaged nerve cells from the toxic effects of high levels of the neurotransmitter glutamate, which is released in excessive amounts when cells are damaged. Both types of drug are aimed at damage limitation; neither can stop the underlying disease processes themselves. The evidence suggests anti-cholinesterases and memantine provide some benefit, but it is modest.

It is also important to support drug interventions with non-pharmacological interventions (e.g., reminiscence therapies, sensory therapies, support and discussion groups). These interventions will also not cure the problem but will protect well-being and ensure that the symptoms of dementia are not exacerbated through poor care, inappropriate expectations, and lack of support. The person with dementias well-being is critically dependent upon that of their care giver. When care givers are not properly supported there is a high risk that their own mental and physical health will be affected, leading to a poor outcome for both the care giver and patient.

In terms of prevention, control of vascular risk, particularly cholesterol levels and hypertension, is emerging as the main preventative strategy for both vascular dementia and Alzheimers disease. People can control their vascular risk either through diet or pharmaceuticals. An increased risk for dementia has also been associated with low education or intelligence, socioeconomic disadvantage, stress, and dietary factors (particularly the B vitamins) but untangling the direction of causation among this complex set of factors remains a significant challenge. For example, the well-established correlation between low intelligence and risk for dementia has been interpreted in terms of compensation, such that the effects of pathology are masked by higher ability, but some recent prospective studies, most notably the nun studies organized by David Snowden, suggest that low intelligence in early life may be directly involved in the pathogenesis of Alzheimers disease. Similarly, low intake of vitamin B12 and folate are associated with elevated levels of homocysteine, another vascular risk factor which has been associated with risk for Alzheimers disease. However, it is less clear whether increasing the dietary intake of vitamin B12 and folate has any protective effect.

SEE ALSO Alzheimer’s Disease; Gerontology; Madness; Medicine; Memory in Psychology; Mental Illness; Neuroscience; Psychopathology; Psychotherapy; Stigma

BIBLIOGRAPHY

Burns, Alistair, John OBrien, and David Ames. 2005. Dementia. 3rd ed. London: Hodder Arnold.

Kitwood, Tom. 1997. Dementia Reconsidered. Buckingham, U.K.: Open University Press.

Sabat, Steven R. 2001. The Experience of Alzheimers Disease: Life Through a Tangled Veil. Oxford: Blackwell.

Snowden, David. 2001 Aging with Grace: The Nun Study and the Science of Old Age. London: Fourth Estate.

Elizabeth J. Anderson

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dementia

dementia …Last scene of all,
That ends this strange eventful history,
Is second childishness, and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything
[ Shakespeare , As You Like It]


We all fear disintegration of the mind, and rightly so; it robs us of our dignity. Bereft of reason we cannot contribute to society, vote, write a will, nor with time care for our basic needs. The disintegration of the mind, or dementia, is a familiar occurrence in the elderly but can occur at any age and result from a vast array of diseases. The loss of acquired intellectual skills — the characteristic feature of dementia — is distinct from developmental failure, which results in learning difficulties of variable severity. We may also be robbed of our senses by sleep or inebriation, and so the term ‘dementia’ is restricted to individuals who are awake and alert. Similarly, patients with a restricted cognitive deficit such as impairment of language following a stroke may have a very different prognosis, with preservation of other intellectual functions, when compared with the widespread disintegration commonly seen with the dementing diseases. A definition of dementia has thus emerged to describe an individual who is alert but who suffers impairment in more than one cognitive domain, of sufficient severity to impair social function. A difficulty in applying the definition is to decide what is a specific cognitive domain. Impairment of memory is considered essential, or more specifically impairment of event memory: that which allows us to recall day-to-day events and maintains our sense of continuity; impairment of memory is a salient feature of Alzheimer's disease, the commonest cause of dementia. Other cognitive domains may include language; visuospatial and visuoperceptual functions, which allow interpretation of our visual world; and so-called ‘frontal executive skills’, which allow us to plan and select appropriate responses to our environment.

It is important to emphasize that dementia is a syndrome and not a disease. The challenge to the clinician is to identify the underlying cause, of which there are many. Alzheimer's disease is the commonest, particularly in the elderly; it is thus the main cause of ‘senile dementia’, a term that is becoming obsolete. It was described in 1906 by Alois Alzheimer, and was considered a rarity occurring in relatively young people (‘pre-senile dementia’), until the 1960s, when it was recognized that the microscopic abnormalities described by Alzheimer were also found in the demented elderly. This led to an apparent epidemic as patients were reassigned from the categories of ‘just old age’ or ‘senile dementia’ to Alzheimer's disease.

Alzheimer had exploited the newly-discovered silver staining method for microscopic examination of nerve tissue, to visualize abnormal cellular changes in the brain. He studied the brain of a 51-year-old patient, Auguste D., whom he had seen whilst working in Frankfurt and who died at the age of 54 years with severe dementia. He reported the hallmark features: ‘neurofibrillary tangles’ and ‘senile plaques’. Recent research has shown that the neurofibrillary tangle results from a collapse of the ‘internal skeleton’ of brain cells (the neuronal cytoskeleton). Senile plaques consist of disrupted neuronal connections, axons, and dendrites, around a core of abnormal deposits of a protein called beta amyloid. This protein undergoes a change in shape that renders it harmful to the cell; exactly how and why these changes occur is the subject of intense research aimed at finding effective treatments.

Alzheimer's disease is the prototypic dementia, characteristically starting with mild forgetfulness and a tendency to repetition in conversation: memory failure worsens, with appointments and recent events forgotten. Losing their way, at first in unfamiliar and then in familiar surroundings, patients become increasingly bemused and testy. Failure of language follows, with increasing difficulty in making sense of the world around them. Dressing, feeding, and toiletting all require help before the final stage ‘sans everything’.

A variety of other degenerative diseases have been, and are being, identified as causes of dementia, including Creutzfeldt Jakob disease and Pick's disease. The latter was described as long ago as 1894. Arnold Pick, a neurologist from Prague, reported a patient with loss of language who was found to have circumscribed shrinkage or atrophy of the temporal lobe, the area of the brain involved with language function. Pick reported the case to disprove the prevailing dogma that all senile atrophies inevitably involved the whole brain. It was Alzheimer's subsequent analysis of such cases that identified silver-stained ‘Pick bodies’ as distinct from the neurofibrillary tangles of his own eponymous disease. Pick's disease is rare and cannot be reliably diagnosed without examination of brain tissue after death, and so is generally swept up in the wider diagnostic category of the fronto-temporal degenerations. Reflecting the areas of the brain affected, such patients present with impairment of language or of social behaviour; whilst at first the symptoms may be confined to one cognitive domain, other functions decline and the clinical picture becomes that of a dementia.

Before the demonstration that the changes of Alzheimer's disease were the common accompaniment of dementia in old age, it used to be thought that such cases were due to a failure of the blood supply, starving the brain of oxygen. There is no evidence that this is so, but multiple strokes can result in dementia, as can multiple haemorrhages into the brain. These are subsumed within the broad category of vascular dementia, which represents the second commonest cause of cognitive impairment, according to some reports.

The ‘use it or lose it’ school of thought argues that education may in part protect us from Alzheimer's disease. But no one is exempt. Scholars, scientists, artists, and statesmen have all succumbed. The publicity surrounding Ronald Reagan's diagnosis of Alzheimer's disease has done much to focus research funding, whereas the same diagnosis in Finland's President may have affected his ability to govern in the last few years of office in the early 1980s.

A small minority of dementias are eminently treatable, and vascular dementia is anticipated to become less common with better management of risk factors such as heart disease, hypertension, and smoking. The major challenge is Alzheimer's disease, and the challenge is a global one, with a predicted 34 million affected individuals by the year 2025. Most will be in the emerging nations, where life expectancy is increasing. In China this is combined with a policy of one child per family, such that the future work force will have to provide for a disproportionate dependent population; the solution will owe as much to politics as to medicine.

The conceptual shift in our understanding of dementia has been profound; no longer is it seen as an inevitable concomitant of old age. Instead we can view Alzheimer's disease, the major cause of late life dementia, as a disease with distinct physical changes, which should be amenable to treatment. However, we should not confuse this with the inevitable changes of ageing. We cannot run as fast at 90 as at 20, nor can we think as fast. We can, though, anticipate the preservation of wisdom and knowledge; to exploit the latter is a challenge for society, to preserve them and avoid dementia is a challenge for medicine.

Martin Rossor


See also ageing; memory; psychological disorders; senility.

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Dementia

DEMENTIA

The word dementia comes from Latin and means "out of the mind." It is used to describe an acquired, persistent, global impairment of cognition/intellectual processes, which is sufficiently severe to interfere with social or occupational function. Dementia, like delirium, is known as a syndrome, that is, it is a collection of symptoms and signs, whose presence can be diagnosed, but the diagnosis does not in and of itself suggest a cause. For example, the syndrome of dementia has a number of causes, including Alzheimer's disease, Lewy body dementia, and fronto-temporal dementia.

Each of the words in the definition is important both for what it says and what it leaves out. Thus "acquired" differentiates dementia, which is usually seen in late life, from lifelong conditions of diminished intellect encountered in people who have grown older. Such people would still be described by their original diagnosis (e.g., cerebral palsy) even after they have become elderly. The most common exception to this general rule is with Down's syndrome, where a genetic abnormality that gives rise to increased amounts of the protein beta-amyloid increases the likelihood that individuals will develop Alzheimer's disease as they grow older. In consequence, the designation of the syndrome describing their cognitive impairment can properly be termed, once they have developed Alzheimer's disease, as a dementia. In other cases, however, the description of the lifelong disorder, if stable, is not described as a dementia.

The word chronic (some definitions use the word persistent ) is meant to distinguish dementia from delirium. While delirium is another cause of global cognitive impairment in elderly people, it typically comes on acutely, and generally resolves quickly. Note, however, that an acute onset does not rule out dementia. For example, the dementia seen following stroke can begin suddenly. Similarly, there are other dementias, particularly Creutzfeldt-Jakob disease, and dementia with Lewy bodies, which can seem as though they came on almost out of the blue. Although it is often not stated, chronic generally implies progressive, that is, it is usually the case that the dementia gets worse over time. While there are some dementias (notably the dementia following stroke) that can have prolonged periods of plateau, most dementias follow a characteristic pattern of decline. The pattern of deficits seen as the decline progresses forms the basis of staging the dementia.

The word "global" in the definition of dementia is meant to imply that the dementia cannot be diagnosed when only one aspect of higher cortical function is impaired. Thus, for example, people with language problems (aphasia), even though they typically have great difficulty in expressing themselves, would not meet the criteria for dementia as long as other functions (such as memory) were not impaired.

Impairment of cognition may seem self-evident for a diagnosis of dementia, but its demonstration sometimes is difficult, particularly where the impairment is mild. The special challenge here is the diagnosis of cognitive impairment, which may begin to meet the dementia criteria in someone who is highly educated. Most highly educated people do well on most tests of cognition until a dementia becomes established.

One way to distinguish mild cognitive impairment from the cognitive impairment that is more likely consistent of dementia is to determine the extent to which this impairment interferes with social or occupational function. For example, although many people find as they get older that their memory is not as good as it once was, this does not imply dementia unless the memory loss impairs job performance or social roles.

Impairment of function also underlies the usual method of staging the course of dementia. While a number of formal staging systems exist, most agree on a "pre-dementia" stage, followed by mild, moderate, and then severe dementia. In the pre-dementia stage, the rough rule of thumb is that the cognitive impairment, while giving rise to symptoms, does not yet impair function. By contrast, mild dementia is diagnosed with somewhat greater confidence when impairment in instrumental activities of daily living (such as driving, balancing a check book, following a recipe) is present. Moderate dementia is diagnosed when patients begin to need prompting to carry out their personal care. Typically, prompting is required for them to change their clothes or maintain their grooming. Severe dementia is heralded when, even with prompting, people are no longer able to carry out basic activities of daily living, such as dressing, grooming, and feeding.

Dementia is a common problem among older people, affecting about 10 percent of the population over age sixty. Although dementia is age-related, it is distinct from the normal aging of the brain. Dementia increases the risk of delirium, and is often seen in the face of depression. Patients with severe dementia need to be cared for in nursing homes or in long-term care institutions. Between one-third and one-half of all people with dementia are in institutional long-term care. These facilities are quite costly and make dementia among the most expensive of medical conditions.

People with dementia necessarily have impairment of their cognitive function. Given that good cognitive function is necessary to be competent, a number of ethical issues arise when a person's competence is not assured at the same time that important decisions about the future course need to be made.

While some causes of dementia can be treated, cure is rare, and many types of dementia have no effective treatment. In consequence, in each of these ways discussed abovepersonal, medical, social, economic, and ethicaldementia poses a considerable challenge to an aging society.

Kenneth Rockwood

See also Alzheimer' s Disease; Creutzfeld-Jakob Disease; Dementia: Ethical Issues; Dementia with Lewy Bodies; Fronto-Temporal Dementia; Memory; Psychiatric Disease in Relation to Physical Illness; Retrogenesis; Vascular Dementia.

BIBLIOGRAPHY

Dunitz, M. Clinical Diagnosis and Management of Alzheimer's Disease. Edited by S. Gauthier. London: Martin Dunitz, Ltd., 2001.

Rockwood, K., and MacKnight, C. Understanding Dementia. Halifax: Pottersfield, 2001.

Wilcock, G. K.; Bucks, R.; and Rockwood, K. Diagnosis and Management of Dementia. Oxford, U.K.: Oxford University Press, 1999.

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Dementia

DEMENTIA

Dementia is a condition characterized by a chronic decline in cognitive functions contrasted with a person's usual state of functioning. It is seen most often in people sixty-five years and older, and the incidence increases with age. Dementia occurs in a stable level of consciousness and sensorium, unlike delirium. There are various causes and types of dementia, but they have certain characteristics in common. Persons with dementia often have problems with short-term memory, such as forgetting names and recent events. They may have trouble with visuospatial processing, such as getting lost in familiar places. Language may be affected, causing difficulty in finding the right word to use in a sentence. The affected person may have difficulty with activities of daily living, such as balancing the checkbook or forgetting to turn off the stove when cooking. This condition may also be accompanied by alterations in personality and behavior. Persons with dementia often become depressed, irritable, or have unreasonable fears. They may also say or do inappropriate things in social situations. Visual or auditory hallucinations sometimes occur.

The onset of dementia is usually insidious. Recognition of the condition is often delayed due to lack of insight on the part of the affected person, who often does not notice that anything is wrong. Families are also slow to recognize the condition and sometimes deny that there is a problem. There is a common false myth that aging is synonymous with poor memory. Although aging results in mild slowing for some cognitive functions, normal aging does not cause significant memory loss. In many cases, the deterioration is progressive. However, some dementias have reversible causes, and this possibility must be investigated thoroughly when the person comes for treatment. Physicians should regularly screen patients who are sixty-five years and older for dementia.

Alzheimer's disease is the most common type of dementia in North America and Europe (5060 percent of dementias). It is characterized by slow onset and gradual impairment of recent memory. Long-term memory usually remains more intact. This impairment progresses until death. It is thought to be caused by the accumulation of certain proteins in the brain. It is not clear what causes this condition to occur. Alzheimer's disease is usually diagnosed clinically by cognitive testing rather than using laboratory tests.

Dementia may also be caused by problems with the vascular system, such as cerebrovascular accident (stroke), hypertension, and atherosclerosis. This is thought to make up 15 to 20 percent of dementias in North America and Europe. These disorders are characterized by abrupt onset of cognitive dysfunction that progressively worsens in a step-wise pattern as multiple strokes recur and damage to the brain accumulates.

There are many other causes of dementia, including trauma, metabolic imbalances, hereditary illness, drugs (e.g., alcohol), toxins, and infections (e.g., HIV [human immunodeficiency virus], syphilis). Some of these causes are reversible with medical treatment. Unlike Alzheimer's disease, these conditions usually have rapid onset and progression. Whenever dementia is diagnosed, these reversible causes must be ruled out promptly.

Parkinson's disease is a movement disorder characterized by tremor, slow unsteady gait, and a mask-like face. Decreased levels of a chemical called dopamine in the brain cause this condition. Approximately 30 percent of persons with Parkinson's disease also have dementia. This dementia is characterized by fluctuations in alertness and cognitive abilities. It is also associated with visual hallucinations. It can be treated with medications that increase the levels of dopamine in the brain.

Psychiatric disorders like depression may cause a dementia-like impairment of memory and concentration called pseudodementia. Depression is a common condition in the elderly. People with depression often have problems with sleep, guilt, appetite, sexual drive, low mood, low energy, and loss of interest in activities, and they may be suicidal. They are more likely to be pessimistic and complain of poor memory than a person with true Alzheimer's disease, who usually tries to deny any problems. Pseudodementia improves after the depression is treated, usually by psychotherapy, medications, or social support. Depression may occur in some individuals with dementia as the person becomes aware of the cognitive decline. Treatment of depression may still be very helpful in such cases.

Diagnosis of dementia requires a thorough physical, neurological, and psychiatric exam. Neuropsychological testing consists of a battery of cognition tests and helps determine what functions are specifically impaired. Laboratory tests are required as part of the medical evaluation. Occasionally, brain imaging is used if a brain tumor or head injury is suspected.

Betty Tzeng

Stuart J. Eisendrath

(see also: Alzheimer's Disease; Stroke )

Bibliography

Kaplan, H., and Sadock, B., eds. (1995). Comprehensive Textbook of Psychiatry, Vol. 1, 6th edition. Baltimore, MD: Williams and Willkins.

Knopman, D. (1998). "The Initial Recognition and Diagnosis of Dementia." The American Journal of Medicine 104 (April):2S12S.

Tierney L.; McPhee, S.; and Papadakis, M. (1999). "Dementia." In Current Medical Diagnosis and Treatment, 38th edition. Stamford, CT: Appleton and Lange.

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Dementia

Dementia

A gradual deterioration of mental functioning affecting all areas of cognition, including judgment, language, and memory.

Dementia generally occurs in the elderly, although it can appear at any age. Several substantial studies have been done to determine its prevalence, and in 1991 a major study was conducted which found that dementia occurred in just over 1 percent of the population aged 65 to 74; in approximately 4 percent in ages 75 to 84; and more than doubling to 10.14 percent in persons 85 and over. Other studies have concluded that many as 47 percent of people over 85 suffer from some form of dementia. Prevalence rates tend to be comparable between the sexes and across sociocultural barriers, such as education and class. It is also worth noting that, despite what is often commonly thought, dementia is not an inevitable consequence of aging .

Researchers have identified many types of dementia, including dementia resulting from Alzheimer's disease , vascular dementia, substance induced dementia, dementia due to multiple etiologies, dementia due to other general medical conditions, and dementia not otherwise specified. More than half of the persons diagnosed with dementia are classified as having dementia resulting from Alzheimer's disease. This type of dementia occurs in more than half of dementia cases in the United States. There is no definitive method in diagnosing this kind of dementia until after the patient's death and an autopsy can be performed on the brain . Alzheimer-related dementia is characterized by slow deterioration in the initial stages, but the rate of cognitive loss speeds up as the disease progresses. Patients with this type of dementia can generally be expected to live eight years.

Vascular dementia is the second most common type of dementia and is caused by damage to the blood vessels that carry blood to the brain, usually by stroke. Because the area of the brain that is affected differs from person to person, the pattern of cognitive deterioration in this type of dementia is unpredictable. Other diseases that can cause dementia include human immunodeficiency virus (HIV), Parkinson's disease , Huntington's disease, Pick's disease, and Creutzfeldt-Jakob disease. The kind of dementia induced by these diseases is known as subcortical, meaning they affect mainly the interior structures of the brain, as opposed to cortical dementia (Alzheimer's and vascular) which affect the outer layers of the brain. Many of these subcortical diseases have been known for some time to result in dementia, but HIV-related dementia has only recently been described and diagnosed. Recent studies have indicated that between 29 to 87 percent of people with AIDS show significant signs of dementia.

Generally speaking, dementia has a gradual onset and can take different routes in different people. All sufferers, however, are eventually impaired in all areas of cognition . Initially, dementia can appear in memory loss, which may result in being able to vividly remember events from many years past while not being able to remember events of the very recent past. Other symptoms of dementia are agnosia, which is the technical term for not being able to recognize familiar objects, facial agnosia, the inability to recognize familiar faces, and visiospatial impairment, the inability to locate familiar places.

Along with cognitive deterioration, sufferers of dementia often experience related emotional disorders as they recognize their deterioration and experience anxiety about its continuation and worsening. Typical among reactions are depression , anxiety, aggression , and apathy. Psychologists are uncertain to what extent these symptoms are direct results of dementia or simply responses to its devastation. Dementia progressively deteriorates the brain and eventually sufferers are completely unable to care for themselves and, ultimately, the disease results in death.

Further Reading

Cooper, James W. Jr. "The Effects of Dementia." American Druggist (April 1993): 59.

Crystal, Howard. "Treating Severe Clinical Memory Disorders." Newsweek (3 May 1993): S6.

"Dementia: When You Suspect a Loved One's Problem." Mayo Clinic Health Letter (November 1995): 6

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Dementia

DEMENTIA

Dementia has been defined in two very different ways. The first definition, which came into use in the nineteenth century with the establishment of a nosographic framework for the psychoses, culminated in the concept of dementia praecox in the work of Emil Kraepelin. The second definition concerns altered states in memory and ideation following injury to the brain.

The word dementia, which first appeared in a psychiatric sense in Philippe Pinel's work contrasting mania and dementia, underwent changes in meaning during the nineteenth century. In 1911 Eugen Bleuler, in his discussion of the concept of schizophrenia, centered around dissociation or splitting (Spaltung ), proposed bringing together the old notion of "vesanic dementia" (the culmination of psychotic development) and Kraepelin's three forms of dementia praecox: hebephrenic, catatonic, and paranoid.

Sigmund Freud approved of Kraepelin's approach but he criticized the term dementia praecox, as well as the term schizophrenia. This despite the fact that he felt it important to distinguish between the two, writing, in "Psycho-Analytical Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)" (1911 c[1910]): ". . . we shall hope later on to find clues which will enable us to trace back the differences between the two disorders (as regards both the form they take and the course they run) to corresponding differences in the patients' dispositional fixations" (p. 62). In reality, he continued to use both terms indiscriminately. He focused his study of the psychoses on paranoia in the essay cited above. After "On Narcissism: An Introduction," (1914) he proposed to distinguish among the neuroses, the psychoses, and the perversions. In Freudian theory, dementia praecox consists of a withdrawal of object libido onto the ego through regression and fixation. Freud later went on to specify its linguistic characteristics (words are subjected to the primary process) and its functioning (reality testing is no longer operant; verbal delusions are an attempt at healing), but essentially it was Freud's successors who developed a psychoanalytic theory of the psychoses.

In current usage, the term dementia refers to erosion of the intelligence caused by many different kinds of damage to the brain: degenerative dementias (dominated by Alzheimer's disease), vascular diseases, infectious diseases, toxic conditions, or metabolic disorders. Clinical treatment of dementia from a psychoanalytic perspective runs up against problems of theoretical elaboration. Psychoanalysis has limited applications for these conditions and is used mainly in the early stages of illness. The goal is to limit the breakdown of identity for a certain time. The gradual erosion of the capacity for symbolization and the work of representation owing to memory loss, the weakening of repression and the breaking through of the protective shield, and the instinctual flooding that ensues, has led to reliance on a therapeutic approach focusing on the reconstitutive function of the affects as the basis for mental activity, since, as Michèle Grosclaude suggested in Le Statut de l'affect dans la psychothérapie des démences (The status of the affects in the psychotherapy of dementia; 1997), verbal therapies are among the first to be affected by the degenerative process. Denial, projective delusions, and heightened anxiety are all typical of these conditions.

Richard Uhl

See also: Ego; Infantile psychosis; Infantile schizophrenia; Narcissism, secondary; Organic psychoses; Paranoid psychosis; Paraphrenia; "Psycho-Analytic Notes on Autobiographical Account of a Case of Paranoia (Dementia Paranoides)"; Schizophrenia; "Unconscious, The"

Bibliography

Freud, Sigmund. (1911c [1910]). Psycho-analytical notes on autobiographical account of a case of paranoia (dementia paranoides). SE, 12, 9-82.

. (1914). On narcissism: an introduction. SE, 14, 73-102.

. (1915). The unconscious. SE, 14, 166-204.

Grosclaude, Michèle. (1997). Le Statut de l'affect dans la psychothérapie des démences. Psychothérapie des démences. Montrouge, France: John Libbey Eurotext.

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Uhl, Richard. "Dementia." International Dictionary of Psychoanalysis. 2005. Encyclopedia.com. 28 Jun. 2016 <http://www.encyclopedia.com>.

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Dementia

Dementia

Dementia is a decline in a person's ability to think and learn. It is an irreversible mental condition. Occurring mainly in older people, dementia is characterized by memory loss, the inability to concentrate and make judgments, and the general loss of other intellectual abilities.

The two most common forms of dementia are senile dementia and Alzheimer's disease. Senile dementia, or senility, is the loss of mental capacities as a result of old age. It is considered a normal part of the aging process, and generally occurs very late in life. Alzheimer's disease, on the other hand, is not a normal result of aging and can begin in late middle age.

The deterioration of brain tissue occurs much more quickly in those people suffering from Alzheimer's disease than in those suffering from senility. Alzheimer's disease is marked first by forgetfulness, followed by memory loss and disorientation, then by severe memory loss, confusion,

and delusions. There is no effective treatment or cure for the disease and its cause is unknown.

Dementia may result from several other conditions characterized by progressive deterioration of the brain. The three most common of these are Pick's disease, Parkinson's disease, and Huntington's disease.

Like Alzheimer's disease, Pick's disease affects the brain's cortexthe outer part where most of the higher mental functions take place. However, Pick's disease affects different parts of the cortex than does Alzheimer's disease. This influences the order in which symptoms appear. The earliest symptoms of Pick's disease include personality changes such as loss of tact (politeness) and concern for others. Loss of language skills occurs afterward, while memory and knowledge of such things as where one is and the time of day are preserved until much later.

Both Parkinson's disease and Huntington's disease initially affect deeper brain structures, those that control muscular movements. Symptoms of Parkinson's disease, which begins in middle to later life, include trembling of the lips and hands, loss of facial expression, and muscular rigidity. In later stages, about 50 percent of patients with the disease develop some degree of dementia. Huntington's disease, which strikes in middle age, is first marked by involuntary muscular movements. Shortly after, patients suffering from the disease begin to have trouble thinking clearly and remembering previous events. In later stages of the illness, Huntington patients cannot walk or care for themselves.

[See also Alzheimer's disease; Nervous system ]

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dementia

dementia (dĬmĕn´shə) [Lat.,=being out of the mind], progressive deterioration of intellectual faculties resulting in apathy, confusion, and stupor. In the 17th cent. the term was synonymous with insanity, and the term dementia praecox was used in the 19th cent. to describe the condition now known as schizophrenia. In recent years, the term has generally been used to describe various conditions of mental deterioration occurring in middle to later life. Dementia, in its contemporary usage, is an irreversible condition, and is not applied to states of mental deterioration that may be overcome, such as delirium. The condition is generally caused by deterioration of brain tissue, though it can occassionally be traced to deterioration of the circulatory system. Major characteristics include short- and long-term memory loss, impaired judgement, slovenly appearance, and poor hygiene. Dementia disrupts personal relationships and the ability to function occupationally. Senility (senile dementia) in old age is the most commonly recognized form of dementia, usually occurring after the age of 65. Alzheimer's disease can begin at a younger age, and deterioration of the brain tissue tends to happen much more quickly. Individuals who have experienced cerebrovascular disease (particularly strokes) may develop similar brain tissue deterioration, with symptoms similar to Alzheimer's disease and senile dementia. Other types of dementia include Huntington's disease, Parkinson's disease, and Pick's disease. Some forms of familial Alzheimer's disease are caused by specific dominant gene mutations.

See L. L. Heston and J. White, The Vanishing Mind (1991).

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dementia

dementia (di-men-shă) n. a chronic and progressive deterioration of behaviour and higher intellectual function due to organic brain disease, which is usually a condition of old age (senile d.) but can occur in youth or middle age. It is marked by memory disorders, changes in personality, deterioration in personal care, impaired reasoning ability, and disorientation. d. with Lewy bodies the second most common cause of dementia after Alzheimer's disease. See Lewy bodies. multi-infarct d. dementia resulting from the destruction of brain tissue by a series of small strokes. See Alzheimer's disease, Pick's disease.
www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/index.htm Information about dementia from the Alzheimer's Society

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Dementia

Dementia

Why Doesnt Grandpa Recognize Me?

What Are the Symptoms of Dementia and Who Is Affected?

What Causes Dementia?

How Is Dementia Diagnosed and Is It Treatable?

When a Loved One Has Dementia

Resources

Dementia (dee-MEN-shuh) is a decline in mental ability that usually progresses slowly, causing problems with thinking, memory, and judgment. It is most often seen in the elderly and is caused by deterioration in parts of the brain. A person with dementia eventually has difficulty with the activities of everyday living, such as balancing a checkbook, reading, and working.

KEYWORDS

for searching the Internet and other reference sources

Brain tumor

Geriatrics

Head injuries

Huntington disease

Neurology

Parkinson disease

Why Doesnt Grandpa Recognize Me?

As Jacob sat in the hospital waiting room, he reminisced about this same day last year; Grandpa had taken him to the Baltimore Orioles home opener to celebrate his eleventh birthday. Since then, his grandfather had experienced a few small strokes, or blockages in the blood vessels that supply oxygen and nutrients to his brain. The resulting loss of oxygen caused damage to parts of Grandpas brain, and now he could barely talk or make any decisions for himself. Grandpa was 70 years old, but he almost seemed like a little kid.

During todays visit, Grandpa did not seem to know that it was Jacobs twelfth birthday. In fact, Grandpa did not even seem to know who Jacob was. Seeing his grandfather in this state made Jacob very sad and a little bit angry. He did not understand why his grandfather did not recognize him. Grandpas doctor saw Jacob sitting in the waiting room and knew he was upset. She sat beside him and explained that Grandpa did not recognize people because he had a condition called dementia, which was a result of the brain damage caused by the strokes. She said that only time would tell if Grandpas condition would improve, but in the meantime Jacob should keep visiting him, talking to him, and including him in special occasions. She told Jacob that even though Grandpa might act differently in many ways, there was still a part of the old Grandpa inside, and that Jacobs presence could still bring enjoyment to him.

What Are the Symptoms of Dementia and Who Is Affected?

People who develop dementia typically experience changes in personality, frequent confusion, and a lack of energy. Thinking, reasoning, memory, and judgment are often affected, and a person with dementia might also have trouble with language and motor (movement) skills.

Dementia is mostly a disease of the elderly. It is estimated to affect more than 15 percent of people (about 1 in 7) over age 65 but as many as 40 percent of people (2 out of 5) over age 80. It is one of the most common reasons for nursing home admissions in the United States, and it is a condition that many older people fear. When dementia affects young people, it is usually the result of an injury or some other condition that causes brain damage.

What Causes Dementia?

Dementia can result from any damage that interferes with the normal functioning of the brain. This damage may be permanent or temporary, and it can have a variety of causes that are usually classified into three categories:

  1. Structural: a problem with the structure of the brain.
  2. Infectious (in-FEK-shus): a bacterium or virus causes an infection that interferes with brain function.
  3. Metabolic* or toxic: a problem with the substances in the blood that are needed to nourish the brain.
* metabolic
(meh-tuh-BALL-ik) pertains to the process in the body (metabolism) that converts food into energy and waste products.

Structural causes of dementia

The most common cause of dementia is Alzheimer (ALZ-hy-mer) disease, a condition in which abnormal structures (called plaques and tangles) accumulate in the brain over time and interfere with nerve cell connections. Alzheimer disease leads to a gradually worsening loss of mental abilities, including memory, judgment, and abstract thinking, as well as to changes in personality. This disease usually affects people over age 65, and doctors are not sure of the causes.

Successive strokes are the second most common cause of dementia. Strokes, or blockages in some of the blood vessels that feed the brain, gradually destroy areas of brain tissue that normally are fed by the blocked blood vessels. People who develop this condition often have a history of high blood pressure* and/or diabetes*.

* high blood pressure
or hyper-tension, is a condition in which the pressure of the blood in the arteries is above normal. Arteries are the blood vessels that carry blood from the heart through the entire body.
* diabetes
(dy-a-BEE-teez) is a condition in which the body is unable to take up and use sugar from the bloodstream normally to produce energy. It is caused by low levels of insulin (the hormone that controls this process) or the inability of the body to respond to insulin normally.

Other structural causes of dementia include:

  • A brain tumor, which is a mass of abnormal cells growing in the brain. As the tumor grows, it presses on certain areas of the brain and causes personality change and problems with thinking, movement, and other functions. Severe or repeated milder head injuries can lead to dementia, also.
  • Parkinson disease is a slowly progressing, degenerative* disorder of the nervous system that leads to shaking, difficulties with movement, and muscle stiffness. About 15 to 20 percent of people who have it also develop dementia. Former Attorney General Janet Reno, boxer Muhammad Ali, and actor Michael J. Fox are three well-known people who have Parkinson disease.
* degenerative
[dee-JEN-er-uhtiv] means progressive deterioration. A degenerative disease results in diminished function or impaired structure of a tissue or organ
  • Huntington disease is a rare inherited disease in which people in midlife begin having occasional jerks or spasms that are caused by a gradual loss of brain cells. People with Huntington disease eventually develop uncontrolled movements and mental deterioration.

Dementia caused by infectious diseases People who have Acquired Immunodeficiency Syndrome* (AIDS) sometimes experience dementia because the virus that causes AIDS can infect the brain. Another dementia-causing condition is Creutzfeldt-Jakob Disease (CJD), a very rare, rapidly progressing disease that affects the brain. Doctors are not sure what causes CJD, although in some cases it appears to have been passed from human to human by contaminated surgical instruments. One form of the disease has been found in humans who have eaten beef from a cow that has mad cow disease. Yet another cause of dementia is viral encephalitis [en-sef-uh-LIGHT-us], an inflammation of the brain that can be caused by certain viruses, particularly those transmitted to humans by the bite of a mosquito.

* Acquired Immunodeficiency Syndrome
AIDS, or AIDS, is a viral disease that damages the immune system, leaving a person at high risk for many life-threatening infections.

Metabolic causes of dementia

Having too much or too little of certain substances in the body can damage the brain enough to cause dementia. For example, anoxia (too little oxygen reaching the brain), vitamin B12 deficiency, and hypoglycemia (hy-po-gly-SEE-mee-uh; a lower than normal amount of sugar in the bloodstream) are conditions that can lead to dementia if left untreated. People with severe alcoholism can also develop dementia, due to a condition known as Wernicke-Korsakoff syndrome. This syndrome occurs when a persons body has too little of a vitamin called thiamine, which plays a key role in helping the brain process sugar for energy; over time, a thiamine deficiency can cause mental confusion and memory loss. People who are malnourished or do not get enough of certain other nutrients from their diet have also been known to develop Wernicke-Korsakoff syndrome.

Get To Know The Scientists

Many dementia-causing conditions are named after the physicians or scientists who discovered them:

  • Alois Alzheimer was the German physician who published an article on a new disease of the cortex (the outermost or reasoning portion of the brain) in 1907. The disease is now called Alzheimer disease.
  • James Parkinson was the English physician who published Essay on the Shaking Palsy in 1817. This was one of the first articles on the disease now named for him.
  • George Huntington was an American doctor from Ohio whose 1872 paper on hereditary chorea (kor-EE-uh; a condition of uncontrolled, rapid movements) made him famous because of its accurate and complete descriptions of this disease. The condition is now better known as Huntington chorea or Huntington disease.
  • Hans Gerhard Creutzfeldt and Alfons Jakob were two German physicians who, in the 1920s, first described the brain disease now known by their names.
  • Carl Wernicke was a German physician whose 1881 Textbook of Brain Disorders first described a nervous system condition caused by insufficient amounts of a vitamin known as thiamine.
  • Sergei Korsakov was a nineteenth-century Russian psychiatrist who studied and described the connections among alcoholism, nerve inflammation, and mental symptoms.

How Is Dementia Diagnosed and Is It Treatable?

The process of diagnosing dementia usually begins when the person and/or family members begin to notice that the person is experiencing increasing forgetfulness, lapses in memory, or problems with everyday tasks. The doctor may give the patient a mental status test by asking a series of questions that require memory of everyday events or by asking the patient to perform simple tasks like counting backwards. The doctor also will try to determine whether there is some underlying cause of the persons symptoms. Blood tests and scans of the brain can help the doctor see whether there is an imbalance of certain substances in the body or a structural problem in the brain. The doctor also will ask for a complete description of the persons symptoms, his or her family medical history, current medications, and about the presence of any other medical conditions (such as high blood pressure or diabetes).

In most cases, dementia cannot be cured; rather, it is more likely to worsen over time, especially when a progressive disease such as Alzheimer disease or Parkinson disease is the cause. However, in some cases the worsening of dementia can be slowed and sometimes the symptoms can actually improve if the underlying cause can be addressed. For example, controlling blood pressure and quitting smoking can slow or stop progressive dementia associated with blockages in blood vessels within the brain. Stopping excessive alcohol intake or correcting a vitamin deficiency can also help, if that is what is causing the problem.

When a Loved One Has Dementia

Dementia is especially hard on family members and loved ones who remember the person as he or she once was. The loss of memory, increased helplessness, and personality changes can be especially difficult to witness and accept. However, family and friends can play an important role in helping the person deal with dementia. The presence of familiar faces, regular exercise, and maintaining a bright, cheerful, familiar environment have been shown to help people with dementia. Caregivers can also help the person establish a routine, take part in low-stress activities, and get good nutrition and exercise on a regular basis. Large calendars and clocks can help the person keep track of the day and time. Reminders from family, friends, or other caregivers about what is going on, who they are, and where the person is can also be helpful.

See also

Alzheimer Disease

Brain Chemistry (Neurochemistry)

Brain Injuries

Resources

Organizations

Alzheimers Association, 919 North Michigan Avenue, Suite 1100, Chicago, IL 60611-1676. The Alzheimers Association is a support organization for people with Alzheimer disease and their families. Telephone 800-272-3900 http://www.alz.org

The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118. The American Geriatrics Society website features information on dementia and dementia-related conditions. Telephone 212-308-1414 http://www.americangeriatrics.org

U.S. National Institute of Neurological Diseases and Stroke (NINDS), Bethesda, MD 20824. NINDS posts fact sheets about dementia and dementia-related conditions at its website; a keyword search for dementia calls up a range of information. http://www.ninds.nih.gov

Family Caregiver Alliance, 690 Market Street, Suite 600, San Francisco, CA 94104. The Family Caregiver Alliance offers information helpful to people who are caring for loved ones with dementia. Telephone 415-434-3388 http://www.caregiver.org

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dementia

dementia Deterioration of personality and intellect that can result from disease of or damage to the brain. It is characterized by memory loss, impaired mental processes, personality change, confusion, lack of inhibition and deterioration in personal hygiene. Dementia can occur at any age, although it is more common in the elderly. See also Alzheimer's disease

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dementia

de·men·tia / diˈmenshə/ • n. Med. a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning.

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dementia

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