What is dementia?What are the types of dementia?

What are the stages? Treatment?

Dementia: The Basics

Normal Aging…or Symptoms of Mental Illness …or

an Age-Related Disease Process?There are widespread misconceptions about what

happens to us cognitively as we age.

We have all heard that forgetfulness is an inevitable consequence of aging –but the facts do not support this, and this myth exerts a powerful bias on the views of lay people as well as those of us in health care.

Memory function as measured by delayed recall of newly learned information is not substantially decreased for most people as they age. Older persons do experience a decline in processing speed and rote memory. However, in regard to information that they are allowed sufficient time to acquire, older persons experience no more memory loss over time of newly learned material than do young people. Numerous studies document that aging in and of itself does not degrade memory; disease does.

Normal Aging…or Symptoms of Mental Illness …or

an Age-Related Disease Process?

It is true that memory function fails in everyone, of every age, every day. Because memory failures are so common, it is easy for observers to overlook genuine memory lapses in developing dementia.

Conversely normal memory failures can mislead persons with normal brain function into thinking that they are developing a dementia such as Alzheimer ’s disease.

Additionally, other problems such as depression and anxiety which are common in elders can also cause memory and other cognitive deficits mimicking dementia, and often incorrectly diagnosed as Alzheimer’s dementia.

Dementia vs Delirium vs Depression vs Mild Cognitive Impairment

Other problems such as depression and anxiety which are common in elders can also cause memory and other cognitive deficits mimicking dementia, and often incorrectly diagnosed as Alzheimer’s dementia.

Physical changes, acute medical illness such as urinary infection can result in cognitive changes that mimic dementia but may be better understood and need to be evaluated for delirium.

Mild cognitive impairments are sometimes present and do not necessarily indicate presence of dementia process.

Dementia DefinedDementia is a permanent and progressive loss in the ability

to make new memories and general cognitive decline ultimately resulting in death. There are many types of dementia with varying causes such as Alzheimer’s disease, HIV, cardio-vascular disease, Parkinson’s disease, to name just a few.

 Diagnosis of Dementia requires: a significant memory impairment and a significant impairment in another cognitive domain.

Cognitive Domains : Inability to learn, retain, and retrieve newly acquired information

(memory) Inability to comprehend and express verbal information (language) Inability to manipulate and synthesize nonverbal, geographic, or

graphic information / or inability to carry out motor activities despite intact motor functioning (psycho-motor functioning)

Inability to perform abstract reasoning, solve problems, plan for future events, mentally manipulate more than one idea at a time, maintain mental focus in the face of distraction, or shift mental effort easily (executive functioning)

DeliriumDelirium is an acute decline in mental status that can be

resolved and is primarily a disturbance of consciousness, with change in cognition (memory deficit, disorientation, language disturbance) or perceptual disturbance that is the direct physiological consequence of a medical condition. Delirium should be considered any time there is an acute change in mental status.

Abrupt onset (hours to days) Fluctuating level of consciousness (altered sleep/wake

cycle) Perceptual disturbances (hallucinations, sensory

misinterpretations) Disordered thoughts Disorientation, memory impairment, inattention,

decreased concentration and attentionChanges in psychomotor activity  

Delirium continued…Delirium is a medical emergency which

may indicate a serious medical illness. Treatment of delirium consists of correcting

the underlying cause and treatment of symptoms. Risk factors for delirium include: increasing age, pre-existing cognitive impairment and polypharmacy (especially Rx with a high anti-cholinergic load).

Suspect delirium if psychosis is suddenly present in a resident who previously did not have psychotic symptoms.

Mild Cognitive Impairment MCI is a decline in at least 1 cognitive domain that is

noticeable, but not significant enough to warrant a diagnosis of dementia.

People with MCI typically function independently in their daily affairs.

The most frequently encountered MCI is the amnesic type defined as subjective and objective memory impairment with the other cognitive functions and activities of daily living preserved.

While in many instances people with MCI demonstrate progressive decline ultimately being diagnosed with dementia, many do not progress to such severity.

Depression (Pseudo-Dementia)Pseudo-dementia is not a discreet diagnostic category;

rather it represents a constellation of symptoms that mimic the cognitive impairment normally associated with dementia (especially memory and executive functioning deficits).

Some reports suggest that as many as 20%-50% of elderly patients are misdiagnosed with degenerative dementia when they are instead experiencing cognitive decline associate with another psychiatric disorder usually depression.

The highest rates of depression are found among nursing home populations. Symptoms of depression can be found in 44%-68% of nursing home residents. Rate of Major Depression among nursing home residents is 9%-38%. Depressed patients have higher risks of morbidity and mortality.

Types of DementiaAlzheimer’s Dementia: Alzheimer's disease is the underlying

cause of -- of all dementia cases. Research indicates that the disease is associated with plaques and tangles in the brain. Alzheimer’s dementia tends to be slow and is always progressive, although some cases are more aggressive.

Vascular Dementia: The second most common form of dementia, vascular dementia is caused by poor blood flow to the brain, which deprives brain cells of the nutrients and oxygen they need to function normally. One of the ten dementia types, vascular dementia can result from any number of conditions which narrow the blood vessels, including stroke, diabetes and hypertension.

Mixed Dementia: Sometimes dementia is caused by more than one medical condition. This is called mixed dementia. The most common form of mixed dementia is caused by both Alzheimer's and vascular disease.

Types of Dementia continued…

Dementia with Lewy Bodies: Parkinson’s Disease can lead to is one type of dementia with Lewy Body involvement. Sometimes referred to as Lewy Body Disease, this type of dementia is characterized by abnormal protein deposits called Lewy bodies, which appear in nerve cells in the brain stem. These deposits disrupt the brain's normal functioning, impairing cognition and behavior and can also cause tremors.

Frontotemporal Dementia: Pick’s Disease is one type of frontal lobe

dementia., it is a rare disorder which causes damage to brain cells in the frontal and temporal lobes. Pick's disease affects the individual's personality significantly, usually resulting in a decline in social skills, coupled with emotional apathy. Unlike other types of dementia, Pick's disease typically results in behavior and personality changes manifesting before memory loss and speech problems.

Creutzfeldt-Jacob Dementia: CJD is a degenerative neurological disorder, which is also known as mad cow disease. The incidence is very low, occurring in about one in one million people. There is no cure. Caused by viruses that interfere with the brain's normal functioning, dementia due to CJD progresses rapidly, usually over a period of several months. Symptoms include memory loss, speech impairment, confusion, muscle stiffness and twitching, and general lack of coordination, making the individual susceptible to falls. Occasionally, blurred vision and hallucinations are also associated with the condition.

Types of Dementia continued… Wernicke-Korsakoff Syndrome: Wernicke-Korsakoff syndrome is

caused by a deficiency in thiamine (Vitamin B1) and often occurs in alcoholics, although it can also result from malnutrition, cancer which have spread in the body, abnormally high thyroid hormone levels, long-term dialysis and long-term diuretic therapy (used to treat congestive heart failure). The symptoms of dementia caused by Wernicke-Korsakoff syndrome include confusion, permanent gaps in memory, and impaired short-term memory. Hallucinations may also occur.

Huntington's Disease: Huntington's disease is an inherited progressive dementia that affects the individual's cognition, behavior and movement. The cognitive and behavioral symptoms of dementia due to Huntington's include memory problems, impaired judgment, mood swings, depression and speech problems (especially slurred speech). Delusions and hallucinations may occur. In addition, the individual may experience difficulty ambulating, and uncontrollable jerking movements of the face and body.

Others: There are other types of dementia but those noted above are some of the most well known. Comprehensive evaluation is often needed for proper differential diagnosis of cognitive decline.

Course & ProgressionThe various types of dementia have varying rates of

progression and course. For example, the rate of progression for vascular dementia is highly variable depending on re-occurring cerebral-vascular events, and the progression is step-wise.

Alzheimer’s type dementia tends to have a slow and progressive course and the stages tend to be demarcated by a regular constellations of symptoms. However, even though the stages in Alzheimer’s dementia tend to follow a fairly regular course the effect on each individual is idiosyncratic and while many patients with Alzheimer’s will show significant problems with mental calculations by the middle stages, many will not especially if math was always a strength for them. Thus, testing is required for accurate differential diagnosis.

Stages of Alzheimer’s DementiaEarly Stages: mild cognitive declineThe person may feel as if he or she is having

memory lapses such as forgetting familiar words or the location of everyday objects. Alternatively, they may have no awareness of changes, but friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration.

Common difficulties include:

Noticeable problems coming up with the right word or name

Trouble remembering names when introduced to new people Having noticeably greater difficulty performing tasks in social

or work settings Forgetting material that one has just read Losing or misplacing a valuable object Increasing trouble with planning or organizing May demonstrate some spatial disorientation

Stages of Alzheimer’s DementiaMiddle Stages: moderate cognitive declineAt this point, cognitive changes are more overt., and at times

personality changes may also become evident. Individuals in the middle stages will begin needing help with activities of daily living.

Common difficulties include:

Impaired ability to perform challenging mental arithmetic — for example, counting backward from 100 by 7s

Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances

Memory impairments become more obvious, and some forgetfulness about one's own personal history may be observed

Becoming moody or withdrawn, especially in socially or mentally challenging situations

Confusion about where they are or what day it is Hygiene and personal grooming may decline Important autobiographical memories are generally still intact. Need help

handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly)

Stages of Alzheimer’s DementiaLate Stages: severe cognitive decline Memory continues to worsen, personality changes may take place or

worsen, individuals need extensive help with daily activities.

Difficulties Include: Lose awareness of recent experiences as well as of their

surroundings Remember their own name, but have difficulty remembering their

personal history Distinguish familiar and unfamiliar faces but have trouble

remembering the name of a spouse or caregiver Need help dressing properly and may, without supervision, make

mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet

Experience major changes in sleep patterns — sleeping during the day and becoming restless at night

Have increasingly frequent trouble controlling their bladder or bowels

Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding

Stages of Alzheimer’s DementiaIn the final stage of this disease, individuals lose

the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases. At this stage, individuals need help with much of their daily personal care, including eating or using the toilet. They may also lose the ability to smile, to sit without support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid. Swallowing can be impaired.

TreatmentEffective treatment for dementia, regardless of the type, is

dependent on proper diagnosis, good understanding of cognitive and adaptive functioning, and management of physical health.

Research is clear that the best treatment for patients with dementia includes a combination of psychotherapy, medical management, occupational and physical therapy, and recreation.

The specific type of psychotherapy should be determined by idiosyncratic needs and functioning of each patient but can include, talk therapy, cognitive-behavioral treatment, behavioral treatment aimed at assessing and managing environmental factors, narrative therapy, supportive treatment, and family therapy.

Medical management includes managing physical and health related issues as well as psychopharmacological management of psychiatric symptoms associated with dementia.