Dementia= Loss of memory and other intellectual abilities serious enough to interfere with daily life. An acquired complex of intellectual deterioration which affects at least two areas of cognitive function. Dementia is a broad umbrella term used to describe symptoms of a loss in cognitive abilities. A medical diagnosis is required to determine the underlying cause or causes of symptoms. In the past, terms like “senility” and “hardening of the arteries” were commonly used to describe dementia but do not accurately explain the disease processes at work. Dementia typically unfolds gradually over a period of many years but it can begin abruptly.
It affects some or all of the following brain functions:
Memory= The hallmark of dementia is impairment with respect to recent events, what is often referred to as “working memory.” Forgetting appointments, conversations, and the like typically herald the onset of dementia. New learning becomes defective whereas memories from the distant past may be intact.
Orientation =The inability to know one’s place and time may also be indicative of dementia - for example, getting lost outside one’s home or not knowing the month or year.
Language = Word finding difficulty is also typically seen among persons with dementia. Comprehension of spoken language may also be impaired. Rules of syntax and grammar may be impaired although speech itself may be intact.
Judgment= Reasoning skills, especially with respect to abstract tasks, are often impaired resulting in poor judgment.
Visuospatial skills= Distortions in interpreting one’s environment may also be seen in dementia. Although eyesight itself may be well preserved, the brain’s ability to accurately interpret what one is seeing may be impaired.
Concentration= The ability to pay attention or concentrate may also be impaired. This may be seen in difficulty with making change or balancing a checkbook.
Ability to sequence tasks= Performing any task requires the ability to put a series of steps together in the right order. Someone with dementia may forget the steps in preparing a meal or shopping for groceries.
Reversible Dementias :
There are numerous causes of dementia including reversible conditions and other conditions that may be stabilized. These include:
Medications=Older adults are often on complex medication regimens. Dementia can be related to toxic effects of these medications or drug-food interactions. Moreover, many classes of drugs are known to affect mental status such as psychotropics, anticonvulsants, antibiotics, and antihypertensives.
Infections= An infection in one’s blood or central nervous system can cause dementia. Laboratory tests usually reveal such infections causing dementia.
Metabolic disorders= There are numerous metabolic disturbances associated with dementia. These include vitamin deficiencies, chronic kidney failure, thyroid, liver and pancreatic disorders.
Depression = Depression is a psychiatric disorder with the principal symptoms of sadness, difficulty in thinking and concentration, decreased activity, feelings of helplessness and hopelessness, and sometimes suicidal ideation. Many severely depressed people will have some cognitive deficits, like poor concentration and attention, which can mimic a dementia. This condition is sometimes called pseudodementia. These people may not receive treatment for their depression unless it is differentiated from the symptoms of dementia. Depression is treatable but requires prompt evaluation and treatment. Another challenge is the presence of both dementia and depression. In this situation, the intellectual presentation may be more extreme for the stage of the dementia. A skilled diagnosis by a psychiatrist, neurologist, or geriatrician is important to sort out this complex clinical picture. Depression is treatable, whether alone or in combination with dementia.
Brain tumor and subdural hematoma= The presence of a brain tumor or traumatic brain injury can result in dementia depending on the location of the mass or injury in the brain. These problems are diagnosed using brain imaging techniques such as a CT scan or MRI.
Normal pressure hydrocephalus= Normal pressure hydrocephalus (NPH) is a relatively uncommon brain disorder that involves an obstruction in the normal flow of cerebral spinal fluid. This blockage causes a buildup of cerebral spinal fluid in the ventricle (space) in the brain. The clinical symptoms of NPH are urinary incontinence, poor balance and gait, and dementia. NPH is sometimes treatable with a neurosurgical procedure in which a shunt is inserted to divert the cerebral spinal fluid away from the brain.
Irreversible Dementias:
Most dementias are irreversible in nature. Sometimes two or more types of these dementias may occur together as a “mixed dementia.” There are several dozen causes, but the major types are listed below:
Alzheimer’s Disease= a progressive brain disorder that gradually destroys brain cells and affects a person’s memory, ability to learn, make judgments, communicate, and carry out basic daily activities.
More than four million Americans have Alzheimer's disease (AD), the leading cause of dementia in older adults. By the year 2050, it is estimated that 14 million Americans will be afflicted. The characteristics of AD are progressive loss of working memory, disorientation, and confusion. The stages of AD will be noted later as well as possible causes and treatments.
Multi-Infarct Dementia= Multi-infarct dementia or vascular dementia is caused by multiple, tiny infarcts or strokes in the brain. A stroke is an injury to a blood vessel (either a clot in the vessel or the tearing of the vessel wall) that results in bleeding into brain tissue. In either case, there is death to the area of brain tissue immediately around the infarct. When the stroke is in an area responsible for learning and memory, then symptoms of memory loss and thinking problems are evident. This form of dementia is not reversible or curable, but if an underlying treatable cause of the strokes can be determined (e.g., hypertension), then treating the cause may decrease the risk of future infarcts. Instead of the gradual decline associated with AD, someone with MID usually has an abrupt, stepwise decline.
Parkinson’s Disease= Parkinson’s disease, a progressive neurological disorder that affects about one million Americans, is the result of the loss of dopamine-producing brain cells. The central nervous system needs the neurotransmitter dopamine to control motor activity. The classic symptoms of the disease are resting tremors, rigidity of limbs and joints, mask-like facial expressions, speech and swallowing difficulties, and difficulty initiating movement. Late in the disease, symptoms of dementia occur in 20 to 30 percent of cases. The relationship between Parkinson’s disease and AD is an area of great interest to researchers today.
Lewy Body Disease= Also known as Dementia with Lewy Bodies, it typically presents with a combination of motor difficulties and dementia, similar to the symptoms of Parkinson’s disease and Alzheimer’s disease. Behavioral disturbances including delusions and hallucinations are often part of the presentation.
Creutzfeldt-Jakob Disease= This is a rare transmissible brain disease that is rapidly progressive in most cases that also includes motor difficulties and dementia.
Pick’s Disease= Pick’s disease is a rare brain disorder, which is usually difficult to diagnose at first since it is usually associated with psychiatric conditions. Disturbances in personality, behavior, and orientation may precede and initially be more severe than memory defects. A definitive diagnosis can only be determined at autopsy. The brain shows unusual shrinkage of the frontal cortex, the region involved in reasoning and other higher mental functions as well as unusual protein deposits (Pick bodies). The condition is more common in women than men, and most sufferers develop it between age 40 and 60. It is rare in people over 75 years of age.
Huntington’s Disease= Huntington’s is a hereditary disease that usually strikes in one’s 20s and 30s. Symptoms include a pronounced movement disorder and dementia. Although the specific genetic defect responsible for this disease has been identified on Chromosome 6, there are no effective treatments at this time.
AIDS Dementia Complex= HIV infection can also cause dementia, especially in the later stages of AIDS. In rare cases, dementia is seen in the early stages of AIDS.
Progressive Aphasia=Progressive aphasia is another rare brain disorder, marked by gradual loss of the abilities to speak and write. The person may not express any other symptoms except loss of the ability to speak. At present, the cause for this disorder is not known, and no treatment or cure exists.
The Early Stage of Alzheimer’s Disease:
AD is slowly progressive and may last three to 20 years. The rate of progression varies from person to person. The disease tends to advance according to stages of severity. It unfolds in subtle ways, not unlike normal absent-mindedness, except with regularity. Early stage symptoms may be imperceptible until the patient or family notices that a pattern has developed or a stressor such as acute illness make symptoms more apparent. Forgetting appointments, misplacing things, difficulty managing a checkbook, word finding problems, and loss of initiative are typical changes at this stage. Symptoms may be inconsistent, with “good days” and “bad days” making life unpredictable for all concerned. One’s ability to manage self-care tasks is usually not compromised at this point but reminders and supervision are needed with certain activities of daily living (ADLs) such as cooking, shopping, and paying bills.
Early Stage Symptoms
Memory Recent memory loss much of the time
Language Mild aphasia
Orientation Seeks the familiar and avoids the unfamiliar
Motor Some difficulty writing and using objects
Mood and Behavior Apathy, depression
Activities of Daily Living (ADLs) Needs reminders with some ADLs
The Middle Stage of Alzheimer’s Disease:
As AD progresses to the middle stage, the symptoms are more obvious. Memory loss and disorientation worsen, expressive and receptive language difficulties increase, and independence with activities of daily living is compromised. The patient’s ability to make autonomous health care and financial decisions is questionable and others must assume the role of surrogate decision-makers. At this point, difficulty with self-care tasks usually arises.
Middle Stage Symptoms
Memory Routine loss of recent memory
Language Moderate aphasia
Orientation May get lost at times, even inside the home
Motor Repetitive actions, apraxia
Mood and Behavior Possible mood and behavioral disturbances
ADLs Needs reminders and help with most ADLs
The Late Stage of Alzheimer’s Disease:
Late in AD, all cognitive functions are severely impaired and the person is completely dependent on others for most or all ADLs. Even long-term memory is significantly compromised at this point. Individuals may misidentify familiar people, places and objects. Constant supervision is required for the sake of safety and care.
Late Stage Symptoms
Memory Mixes up past and present
Language Expressive and receptive aphasia
Orientation Misidentifies familiar persons and places
Motor Bradykinesia, falls
Mood and Behavior Greater incidence of mood and behavioral disturbances
ADLs Needs help with all ADLs
The Terminal Stage of Alzheimer’s Disease:
In the final stage of AD, there is little or no language, little purposeful movement, and total dependence on others. Death usually results from sepsis or pneumonia at this stage. At any point in the disease, co-existing medical problems can exacerbate symptoms and hasten decline if not properly treated.
Terminal Stage Symptoms
Memory No apparent link to past or present
Language Mute or few incoherent words
Orientation Mostly oblivious to surroundings
Motor Little spontaneous movement, dysphagia, myoclonus, seizures
Mood and Behavior Generally passive
ADLs Needs total care
