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Dementia: symptoms,diagnosis and management
Rasha Salama
Rasha Salama is a Senior Lecturer in School of health and Life Sciences, De Montfort University, Leicester.Email: RSalama00@dmu.ac.uk 
 Abstract
his article provides an overview of dementia.It looks at the incidence of dementia, the threemain types of this condition and the suggestedclinical management guidelines for Alzheimer’sdisease dementia, with specific focus onthe main pharmacological approach to thiscondition. The management is discussed withspecific reference to the National Institute ofHealth and Clinical Excellence (NICE) guidelinesreleased in 2006 with regards to Alzheimer’sdisease dementia.
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Pharmacology
D
ementia is a generic term that is used to describea progressive and irreversible syndrome. Itsmain characteristics include a gradual progressivedeterioration o intellectual capacity, and inability to carry out day-to-day activities, which areaccompanied in later stages by changes in socialbehaviour. Te progressive nature o this conditioncan result in complexity o issues or carers andsocial care staf with problems such as aggressivebehaviour, restlessness, wandering, eating problems,incontinence, delusions, hallucinations and mobility problems, which can leadto alls and ractures (MeReC bulletin 2007).
How common is it?
Globally, dementia afects 24.3 million people, withthe numbers o cases increasing every year (Husbandand Worsley, 2006). In the UK there are currently around 700 000 cases o dementia (Alzheimer’s Society,2006) Dementia afects around 5% o the those agedover 65 years, rising to 20% o the over 80s, but to amuch lesser extent in those under 65 years. Tere is agreater prevalence in emales than males (NICE-SCIGguidelines, 2006). Tis is thought to be due mainly tolongevity, but may also be due to education and, tosome extent, hormonal inuences.
Types of dementia
Tere are many types o dementia, but the commonesttypes seen in clinical practice include: Alzheimer’sdisease;, vascular dementia; and dementia with Lewy bodies.
 Alzheimer’s disease
Alzheimer’s disease is the most common type o dementia, accounting or 60% o all cases (NICE-SCIG guidelines, 2006). Alzheimer’s disease presentsinsidiously with a very gradual progression, where asuferer would initially experience short-term memory loss and language decits and little dysphasia. Withprogression o the disease, complex psychomotorsymptoms appear, and at end stages the suferermay not be able to recognize their amily. On aphysiological basis, the brain is thought to developabnormal structures known as neurobrillary tanglesand amyloid plaques, with chronic inammationin nervous tissues (neurons and synapses) leadingto a neurovascular dysunction (Tomas, 2001).Cholinergic decits, i.e. a decit in the transmissiono the cholinergic pathways and the neurotransmitteracetylcholine, are thought to be involved thepathogenesis o this condition. Acetylcholine is aneurotransmitter that is involved in learning, memory and attention. Tis theory is based on autopsy data, which showed high levels o destruction inthe cholinergic neurons in brains o patient withAlzheimer’s disease.
 Vascular dementia
Vascular dementia accounts or 20% o dementiacases. As the name suggests, it is associated withinarcts or small vessel disease. Vascular dementiacovers dementia caused by ischaemic or haemorrhagiccerebrovascular lesions, where multi-inarctdementia resulting rom a series o small strokesis the most common type. Vascular dementia ismore common in males than emales, and it has asudden onset compared to dementia associated withAlzheimer’s disease. Te risk actors or vascular
 
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dementia include hypertension, atrial brillation,hypercholesterolaemia, smoking and diabetes(Husband and Worsley, 2006). Te course andmanagement o vascular dementia is diferent romAlzheimer’s disease, where the average survival is4–5 years as patients die rom cardiovascularor cerebrovascular events.
Dementia with Lewy bodies
Tis type o dementia accounts or 15–20% o alldementia cases. Lewy bodies are eatures o many neurodegenerative diseases, o which dementia is aprimary example. Dementia with Lewy bodies hascommon eatures o both Alzheimer’s disease andParkinson’s disease. Similar to Alzheimer’s disease, thistype o dementia has a slow progression. Dementiawith Lewy bodies can be diferentiated clinically romAlzheimer’s disease based on specic clinical eaturesthat will not be covered in this article. Lewy bodies areintracytoplasmic, eosinophilic, round-to-elongatedinclusions ound in vacuoles o injured or ragmentedneurons, present in the subcortical and corticalregions o the brain. Te presence o Lewy bodiesis accompanied with decits o both dopaminergicand cholinergic neuronal transmission. Tere are nodrugs available to treat or slow down the progress o dementia with Lewy bodies; treatments are used toimprove the quality o lie.
Other types of dementia
Other types o dementia include rontotemporaldementia, Huntington’s disease, HIV dementia(associated with patients inected with HIV) and many others. Generally the pathophysiology o dementia isunclear, and the number o drugs available to managedementia is very limited. Te drugs currently availablein the UK market or managing dementia targetthe cholinergic decit theory o dementia but ullunderstanding o this condition and its managementis not yet known.
Diagnosis
Diagnosis o dementia must be carried out by aspecialist, and is based on taking a medical history,observations, and testing intellectual unction andmemory. Symptoms o dementia may be conused withother conditions because many conditions can presentwith cognitive impairment. In addition, symptomsdifer between the diferent types o dementia.Dementia is under-diagnosed and it is estimatedthat only a third o people with dementia receiveormal diagnosis at any time during their illness. Latediagnosis oen happens, at which stage those suferingorm the condition are incapable o making inormedchoices. One o the main tests used to assess patientsto aid diagnosis o dementia is the mini mental stateexamination (MMSE) (see
Box 1)
. Tis is a series o tests on orientation, memory, attentionand calculation, language, writing and drawing,is commonly used. Accurate diagnosis o the typeo dementia is important to guide themanagement approaches.
Knowing about dementia
Dementia is generally not well understood andproessional approaches to its management are not very clear. Tereore in November 2006, the NationalInstitute or Health and Clinical Excellence (NICE)in collaboration with the Social Care Institute orExcellence (SCIE) issued clinical guidelines to aid
Box 1. Summary of Mini Mental StateExamination (MMSE)
MMSE consists of a series of tests that look at five areasof mental assessment. These are:
n
 
Orientation
n
 
Memory test 1 (looking at remembering three objects)
n
 
 Attention and calculation
n
 
Memory test 2 (remembering questions from memory test 1)
n
 
Language, writing and drawing
MMSE has a maximum score of 30 points. Classification ofdementia is as follows:
n
 
21–26: mild dementia
n
 
10–20: moderate dementia
n
 
<10: severe dementia
Dementia afects over 24 million people worldwide.
 
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health and social care services to support thesepatients (NICE-SCIE guidelines, 2006).Dementia is a progressive condition, andinterventions aim to relieve some o the symptomsand improve the quality o lie o patients and theircarers. Other behavioural and psychological symptomso dementia such as agitation, hallucinations andaggression, may also be present. Tese symptomsrequire urther drug management as they can causeproblems to both patients and carers.
Prevention of dementia
Te evidence or preventing dementia is inconclusive.Vascular dementia may be prevented by maintaininga healthy liestyle and to reduce cardiovascular risks(NHS Direct, 2007). Among the drugs researchedto prevent dementia are the statins, hormonereplacement therapy, vitamin E, and non-steroidalanti-inammatory drugs. Te NICE-SCIE guidelines(2006) have indicated that none o above mentionedtherapies should be used specically or primary prevention o dementia because o a lack o goodclinical trial evidence. Gingko biloba was alsoconsidered to prevent and treat the symptoms o dementia, but there is no conclusive evidence itsbenets, (Mantle et al, 2000; McCarney et al, 2008).
Non-drug treatments
Psychological interventions have been researched inthe management o dementia. Tese interventionstarget symptoms o cognitive impairment andpsychotic symptoms and behavioural disturbances,e.g. agitation, anxiety, depression, and aggression.Research is inconclusive in this area because o a lack o established, randomized controlled trials (RCs).Although this is based on the little evidence present,NICE-SCIE highlighted that cognitive stimulationwas one o the main interventions with conclusiveevidence. Patients enrol onto cognitive stimulationprogrammes. For the non-cognitive symptoms, e.g.psychotic disturbances, NICE-SCIE recommends thatindividual patients are assessed early and individualcare plans are prepared. A systematic review o diferent psychological approaches to managing
Pharmacology
Drug Indication Dosing schedule
Donepezil (Aricept) Mild to moderate 5 mg once daily; increasedementia in Alzheimer’s disease after one month to10 mg once daily Galantamine (Reminyl) Mild to moderate 4 mg twice daily, increased todementia in Alzheimer’s 8 mg twice daily for 4 weeks,disease maintenance 8-12 mg twice dailyGalantamine XL Mild to moderate 8 mg once daily for 4 weeks, 24 hours(once-daily preparation) dementia in Alzheimer’s disease increased to 10 mg once for 4 weeks,maintenance 16-24 mg dailyRivastigmine (Exelon) Mild to moderate dementia 1.5 mg twice daily, increased in stepsin Alzheimer’s disease or of 1.5 mg twice daily at intervals of atin Parkinson’s disease least 2 weeks, maximum 6 mg twice dailyMemantine (Ebixa) Moderate to severe 5 mg in the morning, increaseddementia in Alzheimer’s disease in steps of 5 mg weekly intervals,up to a maximun of 10 mg twice daily
*One month at usual dose
Table 1. Summary of the four available drugsfor managing dementia
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