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1. Dementia is a clinical syndrome of cognitive deficits that involves both memory
impairments and a disturbance in at least one other area of cognition (e.g., aphasia,
apraxia, agnosia) and disturbance in executive functioning.
2. In addition to disruptions in cognition, dementias are commonly associated with
changes in function and behavior.
3. The most common forms of progressive dementia are Alzheimer's disease, vascular
dementia, and dementia with Lewy bodies; the pathophysiology for each is poorly
understood.
4. Differential diagnosis of dementing conditions is complicated by the fact that
concurrent disease states (i.e., co-morbidities) often coexist.
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1. Dementia affects about 5% of individuals 65 and older.
2. Four to five million Americans have Alzheimer's disease (AD)
3. 13.2 million are projected to have AD by 2050.
4. Global prevalence of dementia is about 24.3 million, with 6 million new cases every
year.
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1. Advanced age
2. Mild cognitive impairment
3. Cardiovascular disease
4. Genetics: family history of dementia, Parkinson's disease, cardiovascular disease,
stroke, presence of ApoE4 allele on chromosome 19
5. Environment: head injury, alcohol abuse

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Alzheimer¶s disease is the most common type of dementia. In patients aged 65
years or older, who have some kind of cognitive decline, it accounts for over 50% of
cases. Progression to full dementia may take several years following the signs of mild
cognitive impairment (MCI) at the early stage of AD.

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Alzheimer¶s disease may be characterized by a diffuse pattern of cortical deficits
including:

yc Aphasia ± loss or impairment of language caused by brain dysfunction


yc Apraxia ± inability to execute learned movements on command
yc Agnosia ± inability to recognize or associate meaning to a sensory perception
yc Acalculia ± inability to perform arithmetical calculations
yc Agraphia ± inability to write
yc Alexia ± inability to read

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Vascular dementia is the second most common cause of dementia. It results from
vascular or circulatory lesions or from diseases of the cerebral vasculature leading to
ischaemia or infarction.
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Vascular dementia is characterized by three elements:

yc Presence of clinical dementia


yc Evidence of cerebrovascular disease
yc Exclusion of other conditions capable of producing dementia

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Dementia with Lewy bodies (DLB) is an increasingly recognized cause of
dementia in elderly patients. The typical presenting features of DLB include fluctuating
dementia with prominent deficits in attention, frontal executive tasks and visuospatial
abilities. The cognitive profile of DLB contains both cortical and subcortical features.

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Dementia of six months¶ duration with:

yc Periods of confusion
yc Fluctuations in cognition (especially attention and alertness)
yc Visual hallucinations
yc ‘pontaneous extrapyramidal signs such as rigidity or slowing (mild
parkinsonism)
yc Bradykinesia (paucity of movement)

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Fronto-temporal dementia (FTD) ± sometimes called Pick¶s complex ± is


characterized by focal frontal atrophy with personality and behavioural disturbances, or
temporal atrophy with either progressive aphasia or semantic dementia [Hodges, 1992;
Neary, 1998]. Onset of FTD is observed in a younger age group than other dementias and
diagnosis may be difficult in the early stages of disease.
Routine neuropsychological assessment procedures such as the Mini-Mental ‘tate
Examination (MM‘E) are usually insensitive at detecting frontal abnormalities, therefore
more extensive neuropsychological testing is required to establish frontal deficit in
patients suspected with FTD. The clock drawing test may be helpful.

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yc Insidious onset and slow progression


yc Preservation of memory to late-stage disease making diagnosis difficult
yc Early and prominent personality changes (eg, apathy, irritability, jocularity, euphoria,
loss of personal and social awareness)
yc Loss of tact and concern
yc Impaired judgement and insight
yc Mental rigidity and inflexibility
yc Hypochondriasis
yc ñnrestrained exploration of objects and the environment (hypermetamorphosis)
yc Distractability and impulsivity, depression and anxiety
yc Language difficulties (eg, problems with word recall, circumlocution, word repetition
± also known as gramophone syndrome)

yc Inertia

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More than 100 types of dementias have been documented and reviewed [Perry, 1990;
Cummings, 1992; Pryse-Phillips W; Morris, 1994]. Apart from the four main types
discussed above, other less common dementias result from:

yc Head injury and trauma


xc Brain tumours
xc Hydrostatic causes
xc Bacterial and viral infections
xc Toxic, endocrine and metabolic causes
xc Anoxia

A number of potentially reversible causes of dementia include thyroid deficiency or excess,


vitamin B12 deficiency, abnormal calcium levels and intracranial space-occupying lesions.

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‘ymptoms at the c $ include the following:

yc Forget recent events and distant memory also fades as the disease progresses
yc Experience difficulty in reasoning, calculation, and accepting new things
yc Become confused over time, place and direction
yc Affect the activity of daily living
yc wudgment will be reduced
yc Personality will be changed
yc Become passive and lose initiative.
‘ymptoms at the c $ include the following:

yc Lose cognitive ability, such as the ability to learn, judge, and reason
yc Become emotionally unstable, and easily lose temper or become agitated
yc Need help from his or her family with activities of daily living
yc Confuse night and day, and disturb the family's normal sleeping time.

‘ymptoms at the  c $cinclude the following:

yc Lose all cognitive ability


yc Become entirely incapable of self-care, including eating, bathing, and so on
yc Neglect personal hygiene, and will become incontinent
yc Lose weight gradually, walk unsteadily and become confined to bed.

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If you think you may be developing dementia, visit your GP. It's very important to seek help
early so you can get the support you need.

Your GP will ask about your symptoms and examine you. He or she may also ask you about
your medical history. Your GP may do blood and urine tests to rule out the possibility of other
conditions that could cause symptoms similar to dementia.

You may also have a memory test - one that is often used to help find out if you have dementia is
the 'mini mental state examination (MM‘E)'. In this test, your GP will ask you some questions
and test your attention and ability to remember words. How you score in this test indicates how
serious your condition is, for example:

yc an MM‘E score of 20 to 24 indicates mild dementia


yc a score of 10 to 20 suggests moderate dementia
yc a score below 10 implies severe dementia

Your GP will refer you to a specialist doctor or assessment centre for more detailed tests. This
will help to determine what type of dementia you have. You may also be asked to have a brain
scan, such as a CT scan.
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There isn't a cure for dementia. However, for some types of dementia there are medicines that
can treat your symptoms and prevent them coming on as quickly. The treatment you're offered
will depend on which type of dementia you have.

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If you have moderate Alzheimer's disease, your doctor may prescribe one of the following
medicines:

yc donepezil
yc galantamine
yc rivastigmine

These can temporarily slow down the progression of symptoms in some people.

There are several medicines that are also licensed in the ñ to treat mild Alzheimer's disease.
However, they aren't currently recommended by the National Institute for Health and Clinical
Excellence (NICE), which provides national guidance on treatment.

NICE doesn't currently recommend these medicines to treat other types of dementia. More
research is needed to determine whether or not they are effective.

Another medicine called memantine works in a different way and is only used in severe
dementia. NICE doesn't recommend that you're prescribed this unless you're taking part in a
clinical trial to test its effectiveness.

It's important to be aware that doctors working for the NH‘ can only prescribe medicines
recommended by NICE. NICE hasn't recommended the use of these medicines even though they
are licensed in the ñ . Licensing involves proving that a medicine is safe to use and isn't based
on its effectiveness.

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There is a range of other medicines to treat the symptoms of dementia, such as tranquilisers if
you feel aggressive or restless, medicines to treat anxiety and antidepressants.
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You may find other therapies helpful, such as:

yc group activities and discussions - these aim to stimulate your mind (this is sometimes
referred to as cognitive stimulation therapy)
yc reminiscence therapy - discussing past events in groups, usually using photos or familiar
objects to jog your memory, although there are conflicting opinions on whether this is
effective


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It's possible that aromatherapy will help you to feel less agitated. However, there is only a small
amount of evidence to support this.