INTRODUCTION

“Dementia” is the word taken from Latin, originally meaning "madness", from de- "without",
ment means "mind". it is a serious loss of cognitive ability in a previously unimpaired person,
beyond what might be expected from normal aging. It may be static, the result of a unique global
brain injury, or progressive, resulting in long-term decline due to damage or disease in the body.
Although dementia is far more common in the geriatric population, it can occur before the age of
65, in which case it is termed "early onset dementia"The word dementia has been in use for at
least 200 years, in 1874, Maudesley used the term “Dementia” in relation to memory
impairment.

Dementia is not a single disease or dementia is not a disease itself but a clinical syndrome a
collection of symptoms that can occur with many types of diseases.

but rather a non-specific illness syndrome (i.e., set of signs and symptoms) in which affected
areas of cognition may be memory, attention, language, intellectual function , problem solving
ability ,judgment, reasoning, orientation and by inappropriate behaviour. Personality changes and
behavioural problems such as agitation , delusions, and hallucination may result.. It is normally
required to be present for at least 6 months to be diagnosed. In all types of general cognitive
dysfunction, higher mental functions are affected first in the process.

In fully developed dementia the higher cortical, functions affected include memory thinking,
orientation, and comprehension, calculation, learning capacity, language and judgment.

DEFINITION

“Dementia is a chronic organic mental disorder and it is a syndrome due to disease of brain,
chronic or progressive nature. Dementia is characterized by generalized Psychological
dysfunction of higher cortical functions, with out impairment of consciousness.”

Dementia as a syndrome due to disease of the brain usually of chronic or progressive in nature. In
which, there is disturbances of multiple higher cortical functions including memory, thinking,
orientation, comprehension, calculating, learning, capacity, language and judgment, and
consciousness in not clouded. Occasionally deterioration in emotional control social behaviour or
motivation also seen.

Dementia can be considered as a global impairment of intelligence, memory and personality in

clear consciousness . It can occur at any age but become more frequent with age, with a
prevalence of 5% - 10% in the over 65s and 20% in the over 80s. It is seen more frequently in
women, due to their increased longevity

INCIDENCE
Dementia is essentially a disease of older people. About 5 percent of every one who reaches age
65 has dementia of the Alzheimer’s type, compared with 15% to 25% of everyone age 85 or older
patients with dementia of Alzheimer’s type occupy more than 50 percent of nursing home beds.
Over 2 million person with dementia are cared for in these homes. The risk factors for the
development of dementia of the Alzheimer’s type include being female, having a first degree
relative with the disorder, and having a history of head injury. Down’s syndrome is also
characteristically associated with the development of dementia of the Alzheimer'’ type.

Alzheimer’s type generally occurs in late life, most commonly in the 60s, 70s and 80s and
beyond , but in rare instances the disorder appears in the 40s and 50s (known as early-onset
dementia). The incidence of Alzheimer's disease also increase with age and it is estimated at:-

0.5 % Per year from age 65 to 69

1 % Per year from age 70 to 74
2 % per year from age 75 to 79
3 % Per year from age 80 to 84
8 % Per year from age 85 onwards.

Progression is gradual but steadily downward, with an average duration from onset of symptoms
to death of 8 to 10 years. Plateaus may occur, but progression generally resume after 1 to several
years.

The second most common type of dementia is vascular dementia, which is causally related to
cerebrovascular diseases. Hypertension predisposes a person to the disease. Vascular dementia
accounts for 15 to 30% of all dementia cases. Vascular dementia is most common in people
between the ages of 60 and 70 and is more common in men than in women. Approximately 10 to
15% percent of patients have coexisting vascular dementia of the Alzheimer’s type.

Other common causes of dementia, each representing 1 to 5 percent of all cases, include head
trauma, alcohol related dementias, and various movement disorder related dementia’s such as
Huntington’s disease and Parkinson’s disease. Because dementia is a fairly general syndrome. It
has many causes and clinicians must embark on a careful clinical workup of a patient with
dementia to establish its cause. The current annual cost of caring for patients with dementia is 15
billion, which is likely to increase. By the year 2030, an estimated 20% of the population will be
older than age 65.

In India
In 2010, there are 3.7 million Indians with dementia. In India the number of people with
Alzheimer‟s Disease and other dementias is increasing every year because of the steady growth
in the older population and stable increment in life expectancy and it is expected to increase two-
fold by 2030 and three-fold by 2050

CAUSES OF DEMENTIA

Dementias may result from primary diseases of the brain or other conditions
The most common types of dementia are Alzheimer's disease, vascular dementia, Lewy body
dementia, frontotemporal dementias, and HIV-associated dementia. Dementia also occurs in
patients with Parkinson's disease, Huntington's disease, progressive supranuclear palsy,
Creutzfeldt-Jakob disease, other prion disorders, and neurosyphilis. Patients can have > 1 type
(mixed dementia).

Some structural brain disorders (eg, normal-pressure hydrocephalus, subdural hematoma),

metabolic disorders (eg, hypothyroidism, vitamin B12 deficiency), and toxins (eg, lead) cause a
slow deterioration of cognition that may resolve with treatment. This impairment is sometimes
called reversible dementia, but some experts restrict the term dementia to irreversible cognitive
deterioration.

A. Degenerative diseases of the central Nervous System.

 Senile dementia
 Alzheimer’s disease

 Pick’s disease

 Huntington’s chorea

 Parkinson’s disease

 Creutzfeldt Jakob disease

 Normal pressure hydrocephalus

 Multiple sclerosis

 Lewy body disease

B. Intra Cranial Causes

 Space – occupying lesions

 Tumors

 chronic subdural haematomas

 chronic abscesses

 aneurysm

C. Vascular causes –

 Multi-infarct dementia.
 Occlusion of the carotid artery

 Stroke

 Hypertension
  Cranial arthritis

D. Metabolic and endocrine disorders :-

 Endocrinopathies – Addison’s disease, Cushing’s syndrome, Hyperinsulinism,

 Hypothyroidsm, Hyporupituitatism, Hypoparathyrodism, Hyperparathyrodism.

 Hepatic failure

 Renal failure

 Renal dialysis

 Respiratory failure

 Hypoxia

 Chronic uraemia.

 Chronic electrolyte imbalance.

 Hypocalcaemia

 Hypercalcaemia

 Hypokalaemia

 Hyponatraemia

 Hypernatraemia

 Remote effect of Carcinoma or Lymphoma.

E. Nutritional Causes :-

1. Sustained lack of B12 pernicious anemia

b) Niacin – Pellagra
c) Thiamine – Wernicke – Korsakoffs syndrome
2. Vitamin intoxication – vitamin A , Vitamin D – Paget’s disease

F. Traumatic Causes :-

1. Severe single head injury

2. Repeated head injuries in boxers and others.

G. Infections and related conditions: -

 Encephalitis of any cause

 Neurosyphilic

 Chronic Meningitis
  Cerebral Sarcoidosis

 Cysticercosis

 AIDS and AIDS related complex.

H. Toxic Causes :

1.Alcohol
2. Poisoning with heavy metals – lead, arsenic, thallium, mercury, carbon monoxide.
3. Drug and alcohol withdrawal of anxiolytic sedative drugs, amphetamine.

I. Anoxia:-

1. Anemia
2. Post – anesthesia
3. Cardiac arrest
4. Chronic respiratory failure

Potentially reversible causes of dementia

 Infection
 Neurosyphyllis
 Meningitis
 Encephalitis
 Normal pressure hydrocephalus
 Chronic subdural hematoma
 Nutritional deficiencies
Cobalamine deficiency
Thiamine deficiency
Pellagra chronic drug intoxication
 Alcohol
 Sedatives
 Metabolic disorders
 Thyroid abnormalities
 Chronic hepatic encephalopathy
 Cerebral vasculitis
 Sarcoidosis
 Some type of tumor
 Pseudo dementia of depression
 Medication side effects
Anticholinergics
Antihypertensives
Antihistamines

Irreversible causes of dementia

  Neurodegenerative disorders
 Alzheimer’s disease
 Dementia with Lewy bodies
 Fronto temperoal dementia
 Pick’s disease
 Huntington’s disease
 Parkinson’s disease
 Vascular dementia
 Post encephalitic dementia
 Dementia associated with HIV

Strategic single infract

B. Intra Cranial Causes

 Space – occupying lesions

 Tumors

 chronic subdural haematomas

 chronic abscesses

 aneurysm

C. Vascular causes –

 Multi-infarct dementia.
 Occlusion of the carotid artery

 Stroke

 Hypertension

 Cranial arthritis

D. Metabolic and endocrine disorders :-

 Endocrinopathies – Addison’s disease, Cushing’s syndrome, Hyperinsulinism,

Hypothyroidsm, Hyporupituitatism, Hypoparathyrodism, Hyperparathyrodism.
 Hepatic failure

 Renal failure

 Renal dialysis

 Respiratory failure

 Hypoxia

 Chronic uraemia.
  Chronic electrolyte imbalance.

Hypocalcaemia, Hypercalcaemia , Hypokalaemia, Hyponatraemia Hypernatremia

 Remote effect of Carcinoma or Lymphoma.

E. Nutritional Causes :-

1. Sustained lack of B12 pernicious anemia

b) Niacin – Pellagra
c) Thiamine – Wernicke – Korsakoffs syndrome
2. Vitamin intoxication – vitamin A , Vitamin D – Paget’s disease

F. Traumatic Causes :-

1. Severe single head injury

2. Repeated head injuries in boxers and others.

G. Infections and related conditions: -

 Encephalitis of any cause

 Neurosyphilic

 Chronic Meningitis

 Cerebral Sarcoidosis

 Cysticercosis

 AIDS and AIDS related complex.

H. Toxic Causes :

1.Alcohol
2. Poisoning with heavy metals – lead, arsenic, thallium, mercury, carbon monoxide.
3. Drug and alcohol withdrawal of anxiolytic sedative drugs, amphetamine.

I. Anoxia:-

1. Anemia
2. Post – anesthesia
3. Cardiac arrest
4. Chronic respiratory failure

Irreversible causes

The main irreversible causes of dementia are described here. These damage brain cells in both
cortical and subcortical areas. Treatment focuses on slowing progress of the underlying condition
and relieving symptoms.
 Alzheimer disease: This is the most common cause of dementia, accounting for about
half of all cases. Alzheimer disease is at least partly hereditary in that it tends to run in
families. (Just because a relative has Alzheimer disease, however, does not mean that
another family member will have the disease.) In this disease, abnormal protein deposits
in the brain destroy cells in the areas of the brain that control memory and mental
functions. People with Alzheimer disease also have lower-than-normal levels of brain
chemicals called neurotransmitters that control important brain functions. Alzheimer
disease is not reversible, and no known cure exists. However, certain medications can
slow its progress.

 Vascular dementia: This is the second most common cause of dementia, accounting for as
many as 40% of cases. This dementia is caused by atherosclerosis, or "hardening of the
arteries," in the brain. Deposits of fats, dead cells, and other debris form on the inside of
arteries, partially (or completely) blocking blood flow. These blockages cause multiple
strokes, or interruptions of blood flow, to the brain. Because this interruption of blood
flow is also called "infarction," this type of dementia is sometimes called multi-infarct
dementia. One subtype whose origin is not well understood is Binswanger
disease. Vascular dementia is related to high blood pressure, high cholesterol, heart
disease, diabetes, and related conditions. Treating those conditions can slow the progress
of vascular dementia, but functions do not come back once they are lost. 

 Parkinson disease: People with this disease typically have limb stiffness (which causes
them to shuffle when they walk), speech problems, and tremor(shaking at rest). Dementia
may develop late in the disease, but not everyone with Parkinson disease has dementia.
Reasoning, memory, speech, and judgment are most likely to be affected. 

 Lewy body dementia: This is caused by abnormal microscopic deposits of protein, called

Lewy bodies, which destroy nerve cells. These deposits can cause symptoms typical of
Parkinson disease, such as tremor and muscle rigidity, as well as dementia similar to that
of Alzheimer disease. Lewy body dementia affects thinking, attention, and concentration
more than memory and language. Like Alzheimer disease, Lewy body dementia is not
reversible and has no known cure. The drugs used to treat Alzheimer disease also benefit
some people with Lewy body disease. 

 Huntington disease: This inherited disease causes wasting of certain types of brain cells
that control movement as well as thinking. Dementia is common and occurs in the late
stages of the disease. Personality changes are typical. Reasoning, memory, speech, and
judgment may also be affected. 

 Creutzfeldt-Jakob disease: This rare disease occurs most often in young and middle-aged
adults. Infectious agents called prions invade and kill brain cells, leading to behavior
changes and memory loss. The disease progresses rapidly and is fatal. 
  Pick disease (frontotemporal dementia): This is another rare disorder that damages cells
in the front part of the brain. Behavior and personality changes usually precede memory
loss and language problems. 

 Parkinson disease and Huntington disease begin in subcortical areas. They cause the
subcortical type of dementia.

Treatable conditions

The dementia in these conditions may be reversible or partially reversible, even if the underlying
disease or damage is not.

 Head injury: This refers to brain damage from accidents, such as motor vehicle wrecks
and falls; from assaults, such as gunshot wounds or beatings; or from activities such as
boxing without protective gear. The resulting damage of brain cells can lead to dementia. 

 Infections: Infections of brain structures, such as meningitis and encephalitis, are primary

causes of dementia. Other infections, such as HIV/AIDS and syphilis, can affect the brain
in later stages. In all cases, inflammation in the brain damages cells. 

 Normal pressure hydrocephalus: The brain floats in a clear fluid called cerebrospinal
fluid. This fluid also fills internal spaces in the brain called cerebral ventricles. If too
much fluid collects outside the brain, it causes hydrocephalus. This condition raises the
fluid pressure inside the skull and compresses brain tissue from outside. It may cause
severe damage and death. If fluid builds up in the ventricles, the fluid pressure remains
normal ("normal pressure hydrocephalus"), but brain tissue is compressed from within. 

 Simple hydrocephalus: Simple hydrocephalus may cause typical dementia symptoms or

lead to coma. In normal pressure hydrocephalus, people have trouble walking and
become incontinent (unable to control urination) at the same time they start to lose mental
functions, such as memory. If normal pressure hydrocephalus is diagnosed early, the
internal fluid pressure may be lower able by putting in a shunt. This can stop the
dementia, the gait problems, and the incontinence from getting worse.

 Brain tumors: Tumors can cause dementia symptoms in a number of ways. A tumor can
press on structures such as the hypothalamus or pituitary gland, which
control hormone secretion. They can also press directly on brain cells, damaging them.
Treating the tumor, either medically or surgically, can reverse the symptoms in some
cases. 

 Toxic exposure: People who work around solvents or heavy metal dust and fumes (lead
especially) without adequate protective equipment may develop dementia from the
damage these substances can cause to brain cells. Some exposures can be treated, and
avoiding further exposure can prevent further damage. 

 Metabolic disorders: Diseases of the liver, pancreas or kidneys can lead to dementia by

disrupting the balances of salts and other chemicals in the blood. Often, these changes
occur rapidly and affect the person's level of consciousness. This is called delirium.
 Although the person with delirium, like the person with dementia, cannot think well or
remember, treatment of the underlying disease may fully reverse the condition. If the
underlying disease persists, however, brain cells may die, and the person will have
dementia. 

 Hormone disorders: Disorders of hormone-secreting and hormone-regulating organs such

as the thyroid gland, the parathyroid glands, the pituitary gland, or the adrenal glands can
lead to hormone imbalances, which can cause dementia if not corrected. 

 Poor oxygenation (hypoxia): People who do not have enough oxygen in their blood may
develop dementia because the blood brings oxygen to the brain cells, and brains cells
need oxygen to live. The most common causes of hypoxia are lung diseases such
as emphysema or pneumonia. These limit oxygen intake or transfer of oxygen from the
airways of the lungs to the blood.Cigarette smoking is a frequent cause of emphysema. It
can worsen hypoxicbrain damage by damaging the lungs and also by increasing the levels
of carobon monoxide in the blood. Heart disease leading to congestive heart failure may
also lower the amount of oxygen in the blood. Sudden, severe hypoxia may also cause
brain damage and symptoms of dementia. Sudden hypoxia may occur if someone is
comatose or has to be resuscitated.

 Drug reactions, overuse, or abuse: Some drugs can cause temporary problems with
memory and concentration as side effects in elderly people. Misuse of prescription drugs
over time, whether intentional or accidental, can cause dementia. The most common
culprits are sleeping pills and tranquilizers. Other drugs that cause dry
mouth, constipation, and sedation ("anticholinergic side effects") may cause dementia or
dementia symptoms. Illegal drugs, especially cocaine (which affects circulation and may
cause small strokes) and heroin (which is very anticholinergic) may also cause dementia,
especially in high doses, if taken for long periods, or in older people. The withdrawal of
the drug usually reverses the symptoms. 

 Nutritional deficiencies: Deficiencies of certain nutrients, especially B vitamins, can

cause dementia if not corrected. 

 Chronic alcoholism: Dementia in people with chronic alcoholism is believed to result

from other complications such as liver disease and nutritional deficiencies.

Risk factors
Many factors can eventually lead to dementia. Some, such as age, can't be changed. Others can
be addressed to reduce your risk.

Risk factors that can't be changed

 Age. The risk of Alzheimer's disease, vascular dementia and several other dementias
increases significantly with age. However, dementia isn't a normal part of aging.
  Family history. People with a family history of dementia are at greater risk of developing
it. However, many people with a family history never develop symptoms, and many
people without a family history do. If you have specific genetic mutations, you're at
significantly greater risk of developing certain types of dementia. Tests to determine
whether you have such genetic mutations are available, but only for the disorders in which
the specific mutation is known, for example, Huntington's disease.
 Down syndrome. By the time they reach middle age, most people with Down syndrome
develop the plaques and tangles characteristic of Alzheimer's disease, according to studies.
Many, but not all, also develop dementia.

Risk factors you can change

To reduce your risk of dementia, you can take steps to control the following factors.

 Alcohol use. Consuming large amounts of alcohol appears to increase the risk of
dementia. Although studies have shown that moderate amounts of alcohol — one drink a
day for women and two for men — especially red wine, have a protective effect, abuse of
alcohol puts you at increased risk of developing dementia.
 Atherosclerosis. This buildup of fats and other substances in and on your artery walls
(plaques) is a significant risk factor for vascular dementia because it interferes with blood
flow to your brain. This can lead to stroke. Studies have also shown a possible link
between atherosclerosis and Alzheimer's disease.
 Blood pressure. Blood pressure that's too high, and also possibly too low, can put you at
risk of developing Alzheimer's disease and vascular dementia.
 Cholesterol. High levels of low-density lipoprotein (LDL) cholesterol, the "bad"
cholesterol, can significantly increase your risk of developing vascular dementia. Some
research has also linked it to an increased risk of developing Alzheimer's disease.
 Depression. Although not yet well understood, late-life depression, especially in men,
may be an indication for the development of Alzheimer's-related dementia.
 Diabetes. If you have type 2 diabetes, you're at increased risk of developing both
Alzheimer's disease and vascular dementia.
 High estrogen levels. High levels of total estrogen in women have been associated with
greater risk of developing dementia. This can be determined through a blood test.
 Homocysteine blood levels. Elevated blood levels of homocysteine — a type of amino
acid produced by your body — may increase your risk of developing Alzheimer's disease
and vascular dementia. When working properly, your body breaks down homocysteine
using vitamins B-6, B-12 and folic acid. If this isn't happening properly, it may be because
you don't metabolize these vitamins well, or you don't have enough of them in your diet.
Blood tests can determine whether you have elevated homocysteine levels.
 Smoking. Smoking likely increases the risk of developing dementia because it puts you at
a higher risk of atherosclerosis and other types of vascular disease.
TYPES OF DEMENTIA

Based on site

A. CORTICAL AND SUB CORTICAL DEMENTIA

Dementia may be associated with multiple sub cortical or cortical infarcts and clinical features
vary according to that. Non-Alzheimer’s dementia basically means sub-cortical dementia. Some
distinguishing features of sub cortical and cortical dementia are as follows:

Sub cortical dementia Cortical dementia

1. Language No aphasia Aphasia early
2.. Memory Impaired recall>recognition Recall and recognition
impaired equally
3. Attention and immediate Impaired Impaired
recall & visuospatial skills
4. Calculation Preserved until late Involved early
5. Frontal system abilities Disproportionately affected Degree of impairment
(executive function) consistent with other
involvement
6. Speed of cognitive Slowed early Normal until late in disease
processing
7. Personality Apathetic inert Unconcerned
8. Mood Depressed Euthymic
9. Speech Dysarthric Articulate until late
10. Posture Bowed or extended Upright
11. Co-ordination Impaired Normal until later
12. Motor speed and control Slowed Normal
13. Adventitiois movements Chorea, tremor, tics, dystonia Absent (Alzheimer’s
dementia: some myoclonus).

B. REVERSIBLE AND NON-REVERSIBLE DEMENTIA

REVERSIBLE DEMENTIA :

Is a term used to describe a dementia that as a specific treatable cause. In the past, dementia has
implied a progressive or irreversible course.

Potentially reversible dementia syndromes include those arising from inflammatory processes
e.g. encephalopathy caused by systemic lupus erythematosus (SLE) , infections such as syphilis ;
or toxic conditions (e.g. Alcohol abuse) that produce memory loss and abnormal frontal lobe
functions (Cummings 1987). Metabolic related dementia such as hypothyroidism or
hyperthyroidism and nutritional syndromes such as Vitamin B12 and rotate deficiencies may also
be reversible with appropriate therapy.
It is estimated that 30% to 40% of persons with memory disturbances have a reversible and there
fore treatable dementia. Although most of the patients will have physical disorders, Psychiatric
disturbances such as depression are a significant challenge in the differential diagnosis.
Treatment of such conditions as depression, drug – induced dementia, infections and metabolic
disturbances leads to complete restoration off functioning with prompt diagnosis and appropriate
treatment the dementia can be reversed.

NON-REVERSIBLE DEMENTIA:

When a reversible cause of intellectual impairment can’t be identified, the clinical diagnosis is
presumed to be a irreversible dementia many diseases can produce a progressive and irreversible
dementia . Most of these are rare and can affect adults of all ages with older individuals more
likely to be affected when dementia does occur in a younger person it have been associated with
suicide . The most common irreversible dementia are Alzheimer’s disease, Parkinson’s disease,
Huntington’s disease, pick’s disease, Creutzfeldt– Jakob disease and multi – infarct dementia.
transient ischemic attack (TIAs) are included in the category because they can lead to a disabling
cerebral infarction.

C. PRE-SENILE AND SENILE DEMENTIA

PRE–SENILE DEMENTIA – It resembles that of senile dementia except that disorders occurs
in younger age group . the onset of disease occurs in people of 40s and 50s and people with this
disease live an average 11 years after the onset of disease.

SENILE DEMENTIA: It occurs usually after the age of 65 yrs. Due to degenerative bring
changes as accompanied by a clinical picture of mental deterioration. The types of senile
dementia are already mentioned previously.

D. TYPES OF DEMENTIA ACCORDING TO UNDERLYING ETIOLOGY

1, DEMENTIA IN ALZHEIMER’S DISEASE

Alzheimer’s disease is a primary degenerative cerebral disease of unknown etiology, with

characteristic neuropathological and neurochemical features. The onset can be in middle adult
life or even earlier but the incidence is higher in later life. In cases with onset before the age of
65-70 years. There is the likelihood of a family history of dementia, a more rapid course and
prominence of features of parietal and temporal lobe damage, including dysphasia or dyspraxia,
general impairment of higher cortical function.

There are characteristic changes in the brain: a marked reduction in the population of neuron,
particularly in the hippocampus, appearance of neurofibrillary tangles, neurotic plagues, which
consist largely of amyloid. Marked reduction in the enzyme chorine acetyl transference in
acetylcholine it self.

Pathophysiology
Typically, extracellular β-amyloid deposits, intracellular neurofibrillary tangles (paired helical
filaments), and senile plaques develop, and neurons are lost. Cerebrocortical atrophy is common,
and use of cerebral glucose is reduced, as is perfusion in the parietal lobe, temporal cortices, and
prefrontal cortex.

Other common abnormalities include increased brain and CSF concentrations of the tau protein
(a component of neurofibrillary tangles and β-amyloid) and reduced levels of choline
acetyltransferase and various neurotransmitters (eg, somatostatin).

a). Dementia in Alzheimer’s disease with early onset

 Dementia in Alzheimer’s disease beginning before the age of 65 years

 Evidence of relatively rapid onset and progression.

 In addition to memory impairment, there must be rapid deterioration, disorders of the

higher cortical functions, Aphasia, Agraphia, Alexia and Aparaxia occur relatively early
onset of dementia.

b). Dementia in Alzheimer’s disease with late onset

Dementia in Alzheimer’s disease with late on set where the clinically observable onset in after
the age of 65 years and usually in the late 70s or there after with a slow progression and usually
with memory impairment as the principal feature.

c). Dementia in Alzheimer’s disease, a typical or mixed type

This term and code should be used for dementia that have important atypical features or that fulfil criteria for
both early – and late onset types of Alzheimer’s disease.

Four A’s of Alzheimer’s Disease

1. Amnesia: inability to learn new information or to
recall previously learned information.

2. Agnosia: failure to recognize or identify objects

despite intact sensory function

3. Aphasia: language disturbances that can manifest

in both understanding and expressing the spoken
word.

4. Apraxia: inability to carry out motor activities

despite intact motor function (e.g. ability to grab a
doorknob but not knowing what to do with it.)

Sign and symptoms

  Insidious onset with slow deterioration while the onset usually seems difficult to pinpoint
in time, realization by others that the defects exist may come suddenly.
 Absence of clinical evidence of findings from special investigation

 Absence of a sudden, apoplectic onset, or have neurological signs of focal damage such as
hemi paresis, sensory loss, visual field defects, and in coordination occurring early in the
illness.

2). VASCULAR DEMENTIA

Vascular dementia which includes multi-infarct dementia, is distinguished from dementia in

Alzheimer’s type by history of onset. There is a history of transient ischemic attacks with brief
impairment of consciousness, fleeting pareses or visual loss. Cerebrovascular accidents cause
impairment of memory and thinking becomes apparent. Onset in later life can be abrupt in
ischemic episode or gradual emergences. The dementia is result of infraction of brain due to
vascular disease including hypertensive cerebrovascular disease.

Vascular dementia is the second commonest type of dementia. This disorder arises earlier
between 50 – 60 years of age, but more prevalent between ages 60-70 years. It is slightly more
common in male than in females.

a). Vascular Dementia of acute onset

This dementia develops rapidly (i.e. usually within one month but with in no longer

than 3 months) after a succession of strokes or a single large infarction.

b). Multi-infract dementia:

This is more gradual in onset than the acute form , following a number of minor ischemic
episodes which produce an accumulation of infarcts in the cerebral parenchyma.

c). Subcortical vascular dementia

There may be a history of hypertension. There is evidence of foci of ischemic destruction in the
deep white matter of the cerebral hemispheres. Which can be suspected on clinical groups and
demonstrated on computerized cortex is preserved and this contrasts with the clinical picture,
which may closely resemble that of dementia in Alzheimer’s disease.

d). Mixed cortical and sub cortical vascular dementia.

Mixed cortical and sub cortical components of the vascular dementia may be suspected from the
clinical features, the results of investigation (including autopsy) or both.

Clinical Features
  The patient develops multiple episodes of cerebral ischemia which may or may not be
apparent.
 Impairment of cognitive function.

 Memory disturbances.

 Intellectual deficits

 Focal Neurological sign changes.

 There may be aphasias, dysarthria, and dysphagia.

 There may be headache, dizziness, faintness , weakness, sleep disturbance and personality
changes.

 Insight and judgment may be preserved.

 An abrupt onset or a step wise deterioration.

 Seizure occurs in 20 percent of cases.

3). DEMENTIA IN OTHER DISEASES

Cases of dementia due to cause other than Alzheimer’s disease or vascular disease. Onset may be
at any time in life, rarely in old age.

a). Dementia in Huntington’s disease.

Huntington’s disease is an autosomal dominant disorder caused by a gene which has been
localized to the most distal band of the short arm of chromosome 4. Therefore 50% of the
children of one affected parent can develop this disorder. Spontaneous mutations can also give
rise to sporadic cases in which there is no known family history.

Clinical features:-

 Males and females are affected equally by Huntington’s disease and the average age of
onset is in the 30s.
 Insidious onset of involuntary choreiform movement disorder.

 Involuntary choreiform movements in face, hands, shoulder or in the gait.

 Slurring of speech, extra pyramidal rigidity and epilepsy.

 Psychiatric features include depression, increased risk of suicide and schizophreniform

and delusional disorders.

 Insight tends to be retained until a late stage.

 Death usually occurs within 15 years of the onset of symptoms.

b). Dementia in pick’s disease:-

It occurs in middle life usually between 50 and 60 years, characterized by slowly progressing
changes of character and social at deterioration, memory impairment, impairment of intellect and
language functions with apathy, euphoria and extra pyramidal phenomena. There will be atrophy
of the frontal and temporal lobes, but with out the occurrence of neuritic plaques and
neurofibrillary tangus in excess of that seem in normal aging.

Signs ad symptoms

 Onset is slow with steady deterioration.

 A predominance of frontal lobe involvement is evidenced by two or more of the
following.

 Emotional blunting

 Coarsening of social behaviour

 Disinhibition

 Apathy or restlessness

 Aphasia

 Behavioural manifestations which precede memory impairment.

c). Dementia in Creutzfeldt – Jakob disease

Creutzfeldt– Jakob disease with extensive neurological signs due to specific neuropathological
changes that are presumed to be caused by a transmissible agent, onset is middle age or later age
typically in the fifth decade, but may be at any adult age. The course is sub acute, leading to
death within 1-2 years.

Signs and symptoms

There is very rapid progression of dementia with disintegration of virtually all higher cerebral
functions. One or more of the following types of neurological symptoms and signs emerge,
usually after or simultaneously with the dementia.

 Pyramidal symptoms
 Extra pyramidal symptoms

 Cerebellar symptoms

 Aphasia

 Visual impairment

d). Dementia in Parkinson’s disease

Parkinson’s disease is a disorder of a nucleus of norm cell, deep in the centre of the brain , called
the substantianigra. Because of the death of cells in this nucleus there is a reduction in the
neurotransmitter dopamine and cause the typical symptoms. The dementia in Parkinsonism
develop is thought to be due to reduction in acetylcholine and the evidence in affected of cell
death in the nucleus of Meynert.

Signs and Symptoms:

 Rigidity
 Shuffling gait

 Mask like face

 Mumbling of speech

 Hypokinesia

 Difficulty in co-ordination

e). Dementia in Human Immunodeficiency Virus (HIV) disease.

A disorder characterized by cognitive deficits meeting the clinical diagnostic criteria for
dementia. HIV dementia presents with complaints of forgetfulness, slowness, poor concentration
and difficulties with problem solving and reading, Apathy, reduced spontaneity and social
withdrawal are common and in significant minority of affected disorder, psychosis or seizure.
Tremor, impaired rapid, repetitive movements, imbalance, ataxia, hypertonia, generalized, hyper
reflexia.

Positive frontal release signs and impaired pursuit and saccadic eye movement, children also
develop and HIV associated neuro developmental disorder characterized by developmental delay,
hypertonia, microcephaly and basal ganglia calcification.

f). Alcoholism Dementia

Chronic alcoholics develop a specific recent memory loss called Korsakoff’s syndrome. This is
progressive if the person continues to drink or as after a head injury or stroke, some recovery of
function may be possible over months or even years. Since it does not affect the over all
functions of the cerebrum, Korsakoff’s syndrome is not strictly speaking a dementia. There is
evidence that some alcoholics develop a more generalized shrinking of the brain which shows up
on CT scanning. This shrinkage is a sign of developing general dementia.

PATHOPHYSIOLOGY

Pathologically, Dementia Lewy Body is characterized by the development of abnormal

proteinaceous (alpha-synuclein) cytoplasmic inclusions, called Lewy bodies, throughout the
brain. These inclusions have similar structural features to "classical" Lewy bodies seen
subcortically in Parkinson's disease, additionally, there is a loss of dopamine-producing neurons
(in the substantia nigra) similar to that seen in Parkinson's disease, and a loss of acetylcholine-
producing neurons (in the basal nucleus of Meynert and elsewhere) similar to that seen in
Alzheimer's disease. Cerebral atrophy (or shrinkage) also occurs as the cerebral cortex
degenerates. Autopsy series have revealed that the pathology of DLB is often concomitant with
the pathology of Alzheimer's disease. That is, when Lewy body inclusions are found in the
cortex, they often co-occur with Alzheimer's disease pathology found primarily in the
hippocampus, including: senile plaques (deposited beta-amyloid protein), and granulovacuolar
degeneration (grainy deposits within, and a clear zone around hippocampal neurons).
Neurofibrillary tangles (abnormally phosphorylated tau protein) are less common in DLB,
although they are known to occur. It is presently not clear whether DLB is an Alzheimer's variant
or a separate disease entity. Unlike Alzheimer's Disease, the brain may appear grossly normal
with no visible signs of atrophy.

CLINICAL FEATURES

The major defects in dementia involve orientation, memory, perception, intellectual functioning
and reasoning and all these functions become progressively affected as the disease process
advance. Affective and behavioural changes, such as defective control of impulses and liability of
mood, are frequent, as are accentuations and alterations of premorbid personality traits.

1) Intellectual deterioration with failure of: -

a) Memory:- Memory impairment is typically an early and prominent feature in dementia,

especially in dementias involving the cortex, such as dementia of the Alzheimer’s type. Early in
the course of dementia, memory impairment is mild and is usually most marked for recent events;
people forget telephone numbers, conversations and events of the day. As the course of dementia
progresses, memory impairment becomes severe and only the earliest learned information is
retained.

b) Orientation:- In as much as memory is important for orientation to person, place and time,
orientation can be progressively affected during the course of a dementing illness. For example,
patients with dementia may forget how to get back to their rooms after going to the bathroom. No
matter how severe the disorientation seems, how every, patients show no impairment in their
level of consciousness.

c) Language:- Dementing processes that affect the cortex, primarily dementia of the Alzheimer’s
type and vascular dementia, can affect patient’s language abilities. Aphasia is one of the
diagnostic criteria of dementia . The language difficulty may be characterized by a vague,
stereotyped, imprecise or circumstantial locution, and patients may also have difficulty in naming
objects.

d) Thinking & Judgment:- Thinking becomes slower with reduced flow of ideas and impaired
concentration; Judgment is impaired from early on and leads to poor insight; Paranoid thoughts
and ideas of reference are common and may develop into delusions.
e) Comprehension of Learning Capacity:- The brains ability to process incoming information
is impaired.

f) Calculation:- This cognitive skill is usually impaired from early on dementia.

g) Reduced Concentration

2) Emotional Changes :- Emotions become too easily stimulated, and have reduced control over
laughter or tears.

3) Deterioration of personality:-

a. Increasing tendency to selfishness.

b. Lack of consideration for other people’s feelings.
c. Personal habits, table manners, toilet, habits and hygiene deteriorate.
d. Sexual offences may be committed.

Changes in the personality of a person with dementia are especially disturbing for the families of
affected patients. Pre existing personality traits may be accentuated during the development of a
dementia. Patients with dementia may also become introverted and may seem to be less
concerned than they previously were about the effects of their behavior on others. People with
dementia who have paranoid delusions are generally hostile to family members and caretakers.
Patients with frontal and temporal involvement are likely to have marked personality changes ad
may be irritable and explosive.

Reduced speed in nerve conduction, increased confusion with physical illness and loss of
environmental cues , reduced cerebral circulation causes slower to respond and react, learning
takes longer , becomes confused, complaints of forgetfulness and frequent falls.

4). Special Senses :-

Vision: Diminished ability to focus on close objects , inability to tolerate glare, difficulty in
adjusting changes of light intensity , decreased ability to distinguish colors. As a result holds
objects for away from face, complaints of glare , complaints of poor night vision and confusion
co lour.

Hearing: Decreased ability to hear high frequency sounds Results in inappropriate responses,
asks people to repeat words .Strains forward to hear .
Taste and smell: Decreased ability to taste and smell, results in excessive use of sugar and salt.

6). Hallucinations and Delusions:-

As estimated 20 to 30 percent of patients with dementia , primarily patients with dementia of the
Alzheimer’s type , have hallucinations and 30 to 40 percent have delusions , primarily of a
paranoid or persecutory and unsystematized nature, although complex, sustained and well
systematized delusions are also reported by these patients. Physical aggression and other forms of
violence are common in demented patients who also have psychotic symptoms.
7). Other Sign and Symptoms:-

Psychiatric: 40 to 50 percent of patients with dementia are having anxiety and depression , in
addition to psychosis and personality changes patients with dementia may also exhibit
pathological laughter or crying , extremes of emotions – with no apparent provocation .

Neurological: In addition to the aphasias in patients with dementia, apraxias and agnosias are
common other neurological signs that can be associated with dementia are seizures, seen in
approximately 10 percent of patients with dementia of Alzheimer’s type and in 20 percent of
patients with vascular dementia ,and atypical neurological presentations , such as non-dominant
parietal lobe syndromes, primitive reflex – such as the grasp , snout , suck , tonic – may be
present on neurological examination and myoclonic jerks are present in 5 to 10% of patients..

Headaches, dizziness, faintness, weakness, focal, neurological signs and sleep disturbance are
some of the additional neurological symptoms in-patient with vascular dementia.
Cerebrovascular disease pseudobulbar palsy, dysarthria and dysphagia are also more common in
vascular dementia than in other dementing conditions.

Catastrophic reaction: Patients with dementia also exhibit reduced ability in abstract attitude
patients have difficulty in generalizing from a single instance , in forming concepts and in
grasping similarities and differences among concepts. Catastrophic reaction marked by agitation
secondary to the subjective awareness of intellectual deficits under stressful circumstances.

Sundown syndrome: This is characterized by drowsiness, confusion ataxia and accidental falls.
It occurs in older people who are overly sedated and in patients with dementia who reach
adversely to even a small dose of a psychoactive drug. The syndrome also occurs in demented
patients when external stimuli, such as light and interpersonal orienting cues are diminished. It
most commonly occurs as a result of benzodiazepines.

DIAGNOSTIC STUDIES

Distinguishing type or cause of dementia can be difficult; definitive diagnosis often requires
postmortem pathologic examination of brain tissue. Thus, clinical diagnosis focuses on
distinguishing dementia from delirium and other disorders and identifying the cerebral areas
affected and potentially reversible causes.

Dementia must be distinguished from the following:

 Delirium:
Distinguishing between dementia and delirium is crucial (because delirium is usually reversible
with prompt treatment) but can be difficult. Attention is assessed first. If a patient is inattentive,
the diagnosis is likely to be delirium, although advanced dementia also severely impairs attention.
Other features that suggest delirium rather than dementia .
 Age-associated memory impairment:
This impairment is not severe enough to affect daily function. If affected people are given enough
time to learn new information, their intellectual performance is good.
 Mild cognitive impairment:
Memory is impaired, but other cognitive domains and daily function are not affected.
 Dementia of depression:
This cognitive disturbance resolves with treatment of depression. Depressed older patients may
experience cognitive decline, but unlike patients with dementia, they tend to exaggerate their
memory loss and rarely forget important current events or personal matters. Neurologic
examinations are normal except for signs of psychomotor slowing. When tested, patients with
depression make little effort to respond, but those with dementia often try hard but respond
incorrectly. When depression and dementia coexist, treating depression does not fully restore
cognition.

Clinical criteria:

 The best screening test for dementia is a short-term memory test (eg, registering 3 objects and
recalling them after 5 min); patients with dementia forget simple information within 3 to 5 min.
Another test assesses the ability to name objects within categories (eg, lists of animals, plants, or
pieces of furniture). Patients with dementia struggle to name a few; those without dementia easily
name many.

In addition to loss of short-term memory, diagnosis of dementia requires at least one of the
following cognitive deficits:

 Aphasia
 Apraxia
 Agnosia
 Impaired ability to plan, organize, sequence, or think abstractly (executive dysfunction)
Each cognitive deficit must substantially impair function and represent a significant decline from
a previous level of functioning. Also, the deficits must not occur only during delirium.

A formal mental status examination should be done. The Mini-Mental Status Examination is

often used. When delirium is absent, the presence of multiple deficits, particularly in patients
with an average or a higher level of education, suggests dementia.
Practice recommendations for the diagnosis of dementia published by the quality standards
subcommittee of the American Academy of neurology include both lab evaluations and imaging
of the brain

None of the imaging test are of sufficient sensitivity or specificity to diagnose thew specific
cause of the dementia, and is most cases, they are used to exclude other disorders.

1. Lab tests : to rule out infection, anemia, vitamin deficiencies, or metabolic causes of
dementia.

Recommended tests

 CBC
 Serum electrolytes including calcium
 Glucose
 BUN/ creatinine
 LFT
 Thyroid function tests
 Vitamin B12 levels

Optional

 Syphilis serology
 ESR
 Serum folate
 HIV (CDC protocol)

Brain imaging

Recommended

 Structural imaging
 Non contrast CT
 MRI

Optional

 Functional imaging
 SPECT
 PET Fundus examination – Evidence of atherosclerosis

Other tests

 EEG
 Carotid ultrasound

Computed tomography
A CT scan or magnetic resonance imaging (MRI scan) is commonly performed, although these
modalities do not have optimal sensitivity for the diffuse metabolic changes associated with
dementia in a patient that shows no gross neurological problems (such as paralysis or weakness)
on neurological exam. CT or MRI may suggest normal pressure hydrocephalus, a potentially
reversible cause of dementia and establish patterns of atrophy or shrinkage of the brain( eg;
medial temporal atrophy or enlarged ventricles). Enlarged ventricles, out of proportion to the
degree of atrophy, and can yield information relevant to other types of dementia, such as
infarction (stroke) that would point at a vascular type of dementia. Atrophy in the temporal and
parietal areas of the brain with pronounced hippocampus atrophy is typically seen in Alzheimer’s
disease.

PET / SPECT

The functional neuroimaging modalities of SPECT and PET are more useful in assessing long-
standing cognitive dysfunction, since they have shown similar ability to diagnose dementia as a
clinical exam. The ability of SPECT to differentiate the vascular cause from the Alzheimer's
disease cause of dementias, appears to be superior to differentiation by clinical exam.

To identify decreased glucose metabolism or hypo perfusion in the temporal and parietal regions
of brain, which is commonly seen in AD, or experimental scans that demonstrate beta amyloid
deposits.

MANAGEMENT

The assessment should also include search for treatable, often minor, medical conditions that are
associated rather primary causes. Treatment of these conditions can reduce distress and disability.

The assessment should also include search for treatable, often minor, medical conditions that are
associated rather primary causes. Treatment of these conditions can reduce distress and disability.

Goals are :

o Treat the underline cause of dementia.

Conditions such as B12 deficiency, low thyroid function, drug toxicity and brain tumor are
treatable. The treatment may reverse or improve the dementia.

o Manage the problematic behaviors

eg: agitation sleep disorders and wandering. If agitations and wandering behaviors are present
interventions designed to address the underlying cause of this problems must be implemented.
Interventions may include cognitive therapy , drug therapy and combination of both.

3. Identify and treat depression

Although the depression is most common psychiatric illness in the older people, it is often under
diagnosed, especially when concurrent physical illness is present. There are serious implications
for the misdiagnosing of dementia as depression. Inappropriate treatment for nonexistent
depression in a person with progressive dementia may exacerbate dementia antidepressants they
 have anti cholinergic properties may worsen confusion and memory impairment. Therefore
assessment for depression is an important component of the initial evaluation.

4.Prepare the patient and the family for the future in a supportive and sensitive manner.

Type and extent of preparation depend on the diagnosis. The patient and the family should
receive anticipatory guidance about what to expect in the future and the rate of the decline that is
geared to the underlying cause of dementia.

5. Help the patient in maintain highest quality of life as long as possible.

Monitoring should be conducted every 3 to 6 months to re evaluate the patient’s and family care
givers functional level and to identify new problems that can be addressed to support the patient
and family.

6. Treating specific symptoms and complications 

Some symptoms and complications of dementia can be relieved by medical treatment, even if no
treatment exists for the underlying cause of the dementia.

 Behavioral disorders may improve with individualized therapy aimed at identifying and
changing specific problem behaviors.

 Mood swings and emotional outbursts may be treated with mood-stabilizing drugs.

 Agitation and psychosis (hallucinations and delusions) may be treated

withantipsychotic medication or, in some cases, anticonvulsants.

 Seizures usually require anticonvulsant medication.

 Sleeplessness can be treated by changing certain habits and, in some cases, by taking

medication.

 Infections require treatment with antibiotics.

 Dehydration and malnutrition may be treated with rehydration and supplements or with

behavioral therapies.

 Aspiration, pressure sores, and injuries can be prevented with appropriate care.

 Some cases of dementia are regarded as treatable because the dysfunctional brain tissue
may retain the capacity for recovery if treatment is timely.
 A complete medical history. Physical examination , and laboratory tests, including
appropriate brain imaging, should be undertaken as soon as the diagnosis is suspected .
  If a patient is suffering from a treatable cause of dementia, therapy is directed toward
treating the underlying disorder.

The general treatment approach to patients with dementia is to provide:

 supportive medical care,

 emotional support for the patients and their families and

 pharmacological treatment for specific symptoms, including disruptive behaviour.

Symptomatic treatment also includes

 the maintenance of a nutritious diet,

 proper exercise,

 recreational and activity therapies,

 attention to visual and auditory problems,

 treatment of infections such as urinary tract infections, decuibtus ulcers, and

cardiopulmonary dysfunctions.

 Hypertension

 Hyperlipidemia

 Obesity

 cardiac disease

 diabetes

 alcohol dependence

Patients who smoke should be encouraged to stop smoking cessation is associated with improved
cerebral perfusion and cognitive functioning.

1). Hospitalization

Clear indication for hospitalization are:

 a history of rapidly deteriorating symptoms

 diagnostic uncertainty

 failure of usual support system

 unmanageable at home

 advances towards other people

 associated medical illness.

History taking : History of both patients and families are very important.

a). The patient’s history

 More important memories may be maintained in dementia because they have

 been rehearsed often over the years that they are very fixed. Patient returns to these
memories when the present and recent past are fading. In the earliest stages she will be
able to given quite a full account of her life up to recent times, this information must be
checked for memories become incomplete and time sequences muddled. These more or
less muddled memories are important in understanding how the patient reacts to her/his
illness.

b). The Relative’s History

 From relative’s history we can obtain more information about patients previous
personality, attitudes, level of activity, interests, social functioning and self care.
 It is important to help the relatives separate recent events, from events that happened
before dementia.

This information will provide clear evidence of how much changes has occurred and also helps in
understanding what new problems that family is having to cope with and so helps to explain their
reactions.

MEDICAL MANAGEMENT

Currently, there are no medications that are clinically proven to be preventative or cu rative of
dementia. Although some medications are approved for use in the treatment of dementia, these
treat the behavioural and cognitive symptoms of dementia, but have no effect on the underlying
pathophysiology. Pharmacologic interventions are used primarily to delay progression of the
syndrome and improve its symptoms. In most cases, dementia affects cognition, behaviour,
functional activities, and caregiver burden; these are key targets for the therapeutic interventions.

Pharmacologic treatments are available to help manage associated symptoms and behaviours that
can be common in all dementias. Although the non pharmacological management is the first
treatment considered for the management of behavioural disturbances, pharmacological therapies
may be necessary for the brief period of time if non pharmacological approaches do not provide
adequate symptom relief . When necessary this medication should be started at low doses and
slowly titrated as needed to achieve the desired effect.

Acetylcholinesterase inhibitors: Tacrine (Cognex), donepezil (Aricept), galantamine

(Razadyne), and rivastigmine (Exelon) are approved by the United States Food and Drug
Administration (FDA) for treatment of dementia induced by Alzheimer's disease. They may be
useful for other similar diseases causing dementia such as Parkinsons or vascular dementia.
Acetylcholinesterase inhibitors aim to increase the amount of the neurotransmitter acetylcholine,
which is deficient in people with dementia. [46] This is done by inhibiting the action of the enzyme
acetylcholinesterase, which breaksdown acetylcholine as part of normal brain function. Though
these medications are commonly prescribed, in a minority of patients these drugs can cause side
effects including bradycardia and syncope

N-methyl-D-aspartate (NMDA) receptor blockers: Memantine is marketed under several

names by different pharmaceutical companies including: Abixa, Akatinol, Axura, Ebixa, Memox
and Namenda. In dementia, NMDA receptors are over-stimulated by glutamate, which creates
problems for neurotransmission (and thus cognition) and also leads to damage to neurons through
excitotoxicity. Memantine is thought to work by improving the “signal-to-noise” ratio and
preventing excitotoxic damage. Hence, due to their differing mechanisms of action memantine
and acetylcholinesterase inhibitors can be used in combination with each other.

Antidepressant drugs: Depression is frequently associated with dementia and generally worsens
the degree of cognitive and behavioral impairment. Antidepressants effectively treat the cognitive
and behavioral symptoms of depression in patients with Alzheimer's disease, but evidence for
their use in other forms of dementia is weak.

Anxiolytic drugs: Many patients with dementia experience anxiety symptoms. Although
benzodiazepines like diazepam (Valium) have been used for treating anxiety in other situations,
they are often avoided because they may increase agitation in persons with dementia and are
likely to worsen cognitive problems or are too sedating. Buspirone (Buspar) is often initially tried
for mild-to-moderate anxiety. There is little evidence for the effectiveness of benzodiazepines in
dementia, whereas there is evidence for the effectivess of antipsychotics (at low doses).

Antipsychotic drugs: Both typical antipsychotics (such as Haloperidol) and atypical

antipsychotics such as (risperidone) increase the risk of death in dementia-associated psychosis.
This means that any use of antipsychotic medication for dementia-associated psychosis is off-
label and should only be considered after discussing the risks and benefits of treatment with these
drugs, and after other treatment modalities have failed.

Selegiline: a drug used primarily in the treatment of Parkinson's disease, appears to slow the
development of dementia. Selegiline is thought to act as an antioxidant, preventing free radical
damage. However, it also acts as a stimulant, making it difficult to determine whether the delay
in onset of dementia symptoms is due to protection from free radicals or to the general elevation
of brain activity from the stimulant effect.

CHANGES THAT MAY SUGGEST THE NEED FOR DEMENTIA WORK UP

1.Cognitive changes

Impaired memory (forgets address ,phone numbers)forgetfulness , confusion, difficulty in

understanding the written and spoken words, lack of knowledge about current activities, poor
concentration, difficulty in recognizing faces and common objects.

2.Change in daily function

Self care and grooming neglect, difficulties in managing finances and completing home
activities( cooking and cleaning) difficulty with shopping, using the telephone and simple
problem solving skill, making mistake in usual work or volunteer activities.

3.Personality changes

Social withdrawal mood swings , losss of appropriate social behavior. Easily frusturated and
explosive spells, crying spells.

4.Problematic and psychiatric behavior

Agitation restlessness demanding uncooperative wandering sleeplessness outburst sexual

aggressiveness, verbal and physical abusiveness safety concerns such as forgetting to turn off the
stove losing things such as keys apathy depression anxiety fearfulness paranoia hallucination
insomnia

NURSING MANAGEMENT OF PATIENTS WITH DEMENTIA

The Nursing care should be given according to its cause, onset of illness and severity. The main
aim of nursing care is to make the patients life easier and pleasant. There is no effective treatment
of cerebral pathology but we can help the patient in adjustment to life and coping with stress.

PROBLEMS OF THE CARER

The carer, often a spouse is likely to also be elderly and possibly with poor physical health. If the
carer is a child they may have family responsibilities such as dependent children, producing
divided loyalties and some times marital conflict. The carer may live a distance away and suffer
financial problems from travel expenses. There may be embarrassment caused by the reversal of
roles, especially if caring for the personnel hygiene of a parent of the opposite sex. Lack of
insight and knowledge of the progress of dementia, which symptoms can be modified and how to
obtain help, can all be remedied by introducing the carer to a support group such as Age concern
and the Alzheimer’s Disease society.

Help of Carer

Carer giving is hard work and is usually considered a professional activity. Amateur careers are
untrained so it is not surprising they makes mistakes such as using restrain to prevent behaviour
(e.g.: locked doors or request for sedation) rather than environmental or Psychological
management Brodaty (1992) Suggests that, training should be comprehensive, tailored to
Individual needs, and continuing through the different phases of the illness. A joint report by the
RCP (1989) suggests that for the massive issue of Dementia, the emphasis should be on support
of carer. Attention should be given to “Those aspects which wear careers down such as
restlessness, aggression, disturbed nights and in continence “together with complicating problems
such as depression in patient of career. The report describes the role of the community

Psychiatric Nurse as monitoring and support, counseling, helping with practical, financial and
emotional difficulties and advocacy on behalf of the patient and families. How ever one must
beware the tendency for paternalistic control. Where a patient is in capable of consent, relatives
should be consulted closely at every stage of treatment. But when a patient is capable of making
certain decisions

1) In the Home: - The home help service can reduce the amount of work necessary in the
house, leaving the carer more time to spent with the patient. Some district run schemes where
paid or voluntary carers come to the house and stay with the demented patient while the carer
with the demented patient while the career goes out, or take the patient out for some hours
giving the career since alone in the home.

2) Outings: Many voluntary and statutory groups are able to arrange outings, either day trips
or even holidays, for the carer and patient, to give interest and stimulation to them both.

3) Day Care: - Social service department and voluntary service run day care scheme in all
areas. It is usually possible for transport to collect and return the patient, although sometimes
a carer may do this, if there are major problems with physically dependency or behaviour
such as aggression day care may be provided by the psycho geriatric day hospital, which has a
higher number of staff, including nurses to deal with such problems.

Journal

A study was conducted by Department of Epidemiology & Biostatistics, Erasmus Medical

Center, Rotterdam, The Netherlands. About “incidence of dementia: does gender make a
difference?

Result:

Several studies suggested that women are at higher risk of dementia than men. However, that was
based on rather limited data. We investigated possible gender differences in the incidence of
dementia, Alzheimer's disease and vascular dementia, in the Rotterdam Study, a large population
based prospective cohort study in the Netherlands of 7,046 persons aged 55 years and older, free
of dementia at baseline. In 40,441 person-years of follow-up (mean 5.7 years) we identified 395
new cases of dementia (overall incidence: 9.8 per 1,000 person-years). Alzheimer's disease was
the most frequent subtype of dementia (293 cases; 7.2 per 1,000). Vascular dementia was
diagnosed in 57 participants (1.5 per 1,000). Overall, dementia incidence was similar for men and
women
CONCLUSION

Dementia is irreversible psychiatric disorder characterized by the global impairment of higher

cortical function including, memory, the capacity to solve the problems of day to day living, the
performance of learned percept motor skills, the correct use of social skill and control of
emotional reactions, in the absence of clouding of consciousness. The condition is often
irreversible and progressive.

The clinical diagnosis of dementia is arrived at by the information obtained from a detailed
longitudinal history and a mental status examination, supplemented by a thorough physical
examination, once the diagnosis of dementia is established the choice of investigation should be
done. Basic screening test is necessary for proper diagnosis.

After diagnosis psychosocial management, institutionalization, treatment of concurrent

psychiatric disorder and various medical interventions purposed to improve cognitive functions
assume importance. Nursing care is also ever important for demented patient according to its
cause, onset of illness and severity. The main aim of nursing care is to make the patients life
easier and pleasant. It also provides safe environment for the patient. Fulfill his basic needs and
emotional needs. Demented patients can be treated in community mental health centres. The team
members visit the home and teach patient and family members and educational, recreational and
social activities are planned and provided.

Demented patient can also be placed in dementia centres and geriatric nursing homes. In India
also emphasis is being given good care to dementia patients. There are provisions to treat these
cases in the Dementia centres in India, Example Kerala, Madras, Vellor, and Bangalore etc.

REFERENCE

BOOKS

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Publishers.

 Smelter,C.S. Brenda,B (2004).Medical Surgical Nursing (10 th.ed.).Philadelphia :Lippincott

Williams and Wilkins Publishers Ltd.

 Nicolas,A.B. Colledge,N.R Brian.R.B (2007).Davidson Principle and practice of medicine

(20th.ed.).Philadelphia :Elseviers Publishers Ltd.

 Barker Ellen (2002) .Neuroscience nursing A Spectrum of care(3 rd ed).mosby publication:

USA

 Adams and Victors (2009) . Principles of Neurology. (9th ed). Megraw Hill companies.
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Journal

Medical surgical nursing, vol.2o/N 1- Jan/Feb. 2011

ON LINE REFERENCE

1. http://www.emedicine/ dementia.com
2. http://pub med/dementia.org
3. http://www.scibid//dementia/vascular.org