Dementia

Definition
Dementia is a condition characterized by a
progressive,
irreversible decline in mental ability, accompanied
by changes in behavior and personality. There is
commonly
a loss of memory and skills that are required to
carry out activities of daily living.
Description
Dementia is a group of symptoms caused by the
gradual death of brain cells. The loss of cognitive
abilities that occurs with dementia leads to
impairments in memory, reasoning, planning, and
personality. Dementia can occur at any age and may
affect younger people as the result of disease such as
AIDS, hypoxia (a deficiency of oxygen reaching the
tissues of the body), or injury. However, it is
primarily a disease of the elderly, affecting more than
15% of those over 65 years of age, and as many as
40% of those over the age of 80. The condition is
somewhat more common among women than men.
Some studies suggest that the risk for dementia is
higher or African Americans and Hispanic
Americans than it is for Caucasians. More than half
of all nursing home admissions occur because of
dementia. while the overwhelming majority of people
with dementia are elderly, it is not an inevitable part
of aging. One of the challenges for health care
professionals is to differentiate the early-stage
cognitive deficits of dementia from normal age-
related memory impairment. Persons with age-related
memory impairment may tend to learn new
information more slowly; but, if they are given
additional time, their cognitive performance is
usually adequate. Other problems that may be
mistakenly labeled dementia include delirium,
psychosis, depression, and the side effects of various
medications. Dementia presents a major health
problem for the United States because of its huge
impact on individuals and their families, the health
care system, and society overall. The costs of
dementia are considerable. While most people with
the disease are retired and do not suffer income
losses, 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.
As of 1998, the cost of caring for Alzheimers
dementia patients alone was estimated to be slightly
over $50 billion. The psychological costs are not as
easily quantifiable, but can be even more profound.
The person with dementia loses control of many of
the essential features of 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 is usually 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. Dementia
may be caused by a variety of illnesses.
The most common cause of dementia is Alzheimers
disease (AD), accounting for half to three-quarters of
all cases. Vascular dementia accounts for 530% of
all dementias in the United States. 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 appear more abruptly than those of
Alzheimers dementia. Symptoms may progress with
the occurrence of new strokes. Unlike AD, the
incidence of vascular dementia decreases after the
age of 75.
Other conditions that may cause dementia include:
AIDS
Parkinsons disease
Lewy body disease
Picks disease
Huntingtons disease
Creutzfeldt-Jakob disease
brain tumors
hydrocephalus
head trauma
prolonged abuse of alcohol or other drugs
vitamin B12 deficiency
hypothyroidism
hypercalcemia
Symptoms
Dementia is marked by a gradual decline of thought
and other mental activities. The onset may be slow,
occurring over months or years. 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 along with
dementia, especially since the person with dementia
is
more susceptible to the delirium-inducing effects of
many types of drugs.
Symptoms of dementia may include:
Memory losses: Memory loss is usually the first
symptom
noticed. It may begin with misplacing valuables
Dementia
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HEALTH 657
such as a wallet or car keys, then progress to
situations
such as forgetting appointments, where the car was
left,
or the route home. 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, the
individual
may not be able to 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
ribald, overly friendly, or aggressive. Personal
hygiene
may be ignored.
Impaired orientation: The person may not be able to
identify the time of day, even from obvious visual
clues; or may not recognize a location, even if
familiar.
This disability may stem partly from losses of
memory
and partly from impaired abstraction.
Decreased attention and increased restlessness:
These
symptoms 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 the early stages can prove difficult. However, as
the elderly population grows and the prevalence of
dementia increases, the importance of recognizing the
early symptoms has become imperative.
Dementia may be suspected by the health care
professional
if memory deficits are exhibited during an
examination or assessment. Information from the
family
members, friends, and caregivers may point to
dementia
as well. Diagnosis begins with a thorough physical
exam
and complete medical history. A family history of
either
Alzheimers 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 persons cognitive ability. If dementia is
suspected,
a complete review of medications and an assessment
for
chronic disease processes are indicated. If the patient
shows no improvement after eliminating unnecessary
medications and treating the chronic disease, then
other
tests are warranted. Physical examination and a
variety
of laboratory tests may rule out potentially treatable
causes
of dementia. These may include hearing or visual
deficits, hypothyroidism, vitamin B12 deficiency, and
depression. Some of the laboratory tests that might be
performed include a complete blood cell count and
urinalysis (to rule out infection), serum
electrolytes,
glucose and calcium levels, and kidney and liver
function
tests.
The use of computed tomography (CT) or magnetic
resonance imaging (MRI) to rule out vascular
disease is
somewhat controversial, since even if a cause is
discovered,
less than 11% of patients with cognitive decline
have partially or fully reversible disease.
Treatment
Treatment of dementia starts with treatment of the
underlying disease, where possible. The underlying
causes
of nutritional, hormonal, tumor-caused, and
drugrelated
dementias may be reversible to some extent.
Treatment for stroke-related dementia begins by
minimizing
the risk of further strokes, including smoking
cessation,
aspirin therapy, and treatment of hypertension.
There are no known therapies that can reverse the
progression
of Alzheimers disease.
Early intervention may allow the patient to
compensate
for the alterations in functioning, help to minimize
complications, and have an improved quality of life.
It
may also allow the patient and family to plan for the
future and to identify resources.
Periodically, new drugs are studied for the treatment
of dementia. The only drugs currently approved for
the
symptomatic treatment of AD are tacrine (Cognex)
and
donepazil (Aricept). These drugs act by slowing
down the
degradation of neurotransmitters. They may provide
temporary
improvement in cognitive functioning for about
40% of patients with mild-to-moderate AD.
However,
drug therapy can be complicated by forgetfulness,
especially
if the drug must be taken several times a day.
Psychotic symptoms, including paranoia, delusions,
and hallucinations, may be treated with
antipsychotic
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ALLIED HEALTH
drugs such as haloperidol, chlorpromazine,
risperidone,
and clozapine. Side effects of these drugs can be
significant.
Anti-anxiety drugs such as Valium may improve
behavioral symptoms, especially agitation and
anxiety,
although BuSpar has fewer side effects. The
anticonvulsant
carbamazepine is also sometimes prescribed for
agitation.
Depression is treated with antidepressants, usually
beginning with selective serotonin reuptake inhibitors
(SSRIs) such as Prozac or Paxil.
In general, medications should be administered very
cautiously to demented patients, in the lowest
possible
effective doses, to minimize side effects. Supervision
of
taking medications is generally required.
The primary goals of treatment for progressive
dementia are to preserve as much functioning and
independence
as possible, and to maintain quality of life as
long as possible. It is important that the patient and
caregivers
are aware that caring 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 may need to
assume
increasing responsibility for the persons physical
needs.
The patient and family should be educated early on in
the
disease progression to help them anticipate and plan
for
inevitable changes.
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
Dementia
KEY TERMS
Amyloid plaquesAbnormal structures
composed
of parts of nerve cells surrounding protein
deposits, found in the brains of persons with
Alzheimers disease.
Neurofibrillary tanglesAbnormal structures
composed of twisted masses of protein fibers
within
nerve cells, found in the brains of persons with
Alzheimers disease.
for safety include removal or lock-up of hazards such
as
sharp knives, dangerous chemicals, and tools.
Childproof
latches may be used to limit access as well. Bed rails
and
bathroom safety rails can be important safety
measures.
Confusion may be reduced with the use of simpler
decorative
schemes and the presence of familiar objects.
Covering or disguising doors may reduce the
tendency to
wander. Positioning the bed in view of the bathroom
can
decrease incontinence.
Long-term institutional care may be required 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
longterm
care is available through the Alzheimers
Association.
Family members or others caring for a person with
dementia are often 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.
Contact numbers are available from the Alzheimers
Association; they may also be available through a
local
social service agency.
Prognosis
The prognosis for dementia depends on the
underlying
disease. On average, people with Alzheimers disease
live eight years past their diagnosis, with a range
from
one to 20 years. Vascular dementia is usually
progressive,
with death resulting from stroke, infection, or heart
disease.
Health care team roles
Any member of the health care team may work with
patients with dementia. The physician normally
makes
the diagnosis. Laboratory technicians may obtain
laboratory
tests, and radiology technicians may perform imaging
studies, if ordered. Nurses assess patients and how
dementia affects their functioning. Patient
education is
very important in managing dementia and is a
nursing
responsibility.
Prevention
There is no known way to prevent AD, although
several
drugs under investigation may reduce its risk or slow
its progression. The risk of developing multi-infarct