Prepared by:


Prepared to:

Dra. Dianna Mendoza

A. Definitions/Distinctions 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. B. Prevalence 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. C. Risk Factors 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

Alzheimer¶s disease 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. Characteristics: Alzheimer¶s disease may be characterized by a diffuse pattern of cortical deficits including:
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Aphasia ± loss or impairment of language caused by brain dysfunction Apraxia ± inability to execute learned movements on command Agnosia ± inability to recognize or associate meaning to a sensory perception Acalculia ± inability to perform arithmetical calculations Agraphia ± inability to write Alexia ± inability to read 

Vascular dementia 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.

Characteristics: Vascular dementia is characterized by three elements:
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Presence of clinical dementia Evidence of cerebrovascular disease Exclusion of other conditions capable of producing dementia 

Dementia with Lewy bodies 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.

Clinical features: Dementia of six months¶ duration with:
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Periods of confusion Fluctuations in cognition (especially attention and alertness) Visual hallucinations Spontaneous extrapyramidal signs such as rigidity or slowing (mild parkinsonism) Bradykinesia (paucity of movement) 

Fronto-temporal dementia 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 State Examination (MMSE) 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. Presenting features of FTD include:
y Insidious onset and slow progression y Preservation of memory to late-stage disease making diagnosis difficult y Early and prominent personality changes (eg, apathy, irritability, jocularity, euphoria,

y y y y y y y

loss of personal and social awareness) Loss of tact and concern Impaired judgement and insight Mental rigidity and inflexibility Hypochondriasis Unrestrained exploration of objects and the environment (hypermetamorphosis) Distractability and impulsivity, depression and anxiety Language difficulties (eg, problems with word recall, circumlocution, word repetition ± also known as gramophone syndrome)

y Inertia 

Other dementias 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: Head injury and trauma o Brain tumours

Hydrostatic causes o Bacterial and viral infections o Toxic, endocrine and metabolic causes
o o


A number of potentially reversible causes of dementia include thyroid deficiency or excess, vitamin B12 deficiency, abnormal calcium levels and intracranial space-occupying lesions.


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

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

Symptoms at the later stage include the following:
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Lose all cognitive ability Become entirely incapable of self-care, including eating, bathing, and so on Neglect personal hygiene, and will become incontinent Lose weight gradually, walk unsteadily and become confined to bed.

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 (MMSE)'. 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:
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an MMSE score of 20 to 24 indicates mild dementia a score of 10 to 20 suggests moderate dementia 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.

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. Medicines Alzheimer's disease medicines If you have moderate Alzheimer's disease, your doctor may prescribe one of the following medicines:
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donepezil galantamine rivastigmine

These can temporarily slow down the progression of symptoms in some people. There are several medicines that are also licensed in the UK 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 NHS can only prescribe medicines recommended by NICE. NICE hasn't recommended the use of these medicines even though they are licensed in the UK. Licensing involves proving that a medicine is safe to use and isn't based on its effectiveness. Medicines for other symptoms 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.

Talking therapies You may find other therapies helpful, such as:
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group activities and discussions - these aim to stimulate your mind (this is sometimes referred to as cognitive stimulation therapy) 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

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