Dementia

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Dimentia
Classification and external resources
ICD-10 F00.-F07.
ICD-9 290-294
DiseasesDB 29283
MedlinePlus 000739

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Dementia

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Editor-in-Chief: Angela Botts, M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [1]

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Overview

Dementia (from Latin de- "apart, away" + mens (genitive mentis) "mind") is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal ageing.

Particularly affected areas may be memory, attention, language, and problem solving. Especially in the later stages of the condition, affected persons may be disoriented in time (not knowing what day of the week, day of the month, month, or even what year it is), in place (not knowing where they are), and in person (not knowing who they are).

Symptoms of dementia can be classified as either reversible or irreversible depending upon the etiology of the disease. Less than 10 percent of cases of dementia have been reversed. Dementia is a non-specific term encompassing many disease processes, just as fever is attributable to many etiologies.

Without careful assessment, delirium can easily be confused with dementia and a number of other psychiatric disorders because many of the signs and symptoms are also present in dementia (as well as other mental illnesses including depression and psychosis).[1]

Epidemiology

The prevalence of dementia is rising as the global life expectancy is rising. Particularly in Western countries, there is increasing concern about the economic impact that dementia will have in future, older populaces. In Australia, the 2006 estimated prevalence of dementia is 1.03% of the population as a whole. Though reports of some of the longest living people claim them to be free of it (e.g. Yone Minagawa), it is a disease which is strongly associated with age; 1% of those aged 60-65, 6% of those aged 75-79, and 45% of those aged 95 or older suffer from the disease.[2]

Types

Cortical dementias

Subcortical dementias

Dementia and early onset dementia have been associated with neurovisceral porphyrias. Porphyria is listed in textbooks in the differential diagnosis of dementia. Because acute intermittent porphyria, hereditary coproporphyria and variegate porphyria are aggravated by environmental toxins and drugs the disorders should be ruled out when these etiologies are raised.

Diagnosis

The final diagnosis of dementia is made on the basis of the clinical picture, increasingly with neuroimaging results for backup. For research purposes, the diagnosis depends on both a clinical diagnosis and a pathological diagnosis (i.e., based on the examination of brain tissue, usually from autopsy).

Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist. However, there are some brief (5-15 minutes) tests that have good reliability and can be used in the office or other setting to evaluate cognitive status. Examples of such tests include the abbreviated mental test score (AMTS), the mini mental state examination (MMSE), Modified Mini-Mental State Examination (3MS)[3], the Cognitive Abilities Screening Instrument (CASI)[4], and the clock drawing test[5].

An AMTS score of less than six (out of a possible score of ten) and an MMSE score under 24 (out of a possible score of 30) suggests a need for further evaluation. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances (for example, a person in great pain will not be expected to do well on many tests of mental ability).

Mini-mental state examination

Main article: Mini-mental state examination

The U.S. Preventive Services Task Force (USPSTF) reviewed tests for cognitive impairment and concluded [6]:

sensitivity 71% to 92%
specificity 56% to 96%

A copy of the MMSE can be found in the appendix of the original publication.[7]

Modified Mini-Mental State examination (3MS)

A copy of the 3MS is online.[8] A meta-analysis concluded that the Modified Mini-Mental State (3MS) examination has:[9]

sensitivity 83% to 94%
specificity 85% to 90%

Abbreviated mental test score

Main article: abbreviated mental test score

A meta-analysis concluded:[9]

sensitivity 73% to 100%
specificity 71% to 100%

Other examinations

Many other tests have been studied [10][11] [12] including the clock-drawing test example form). Although some may emerge as better alternatives to the MMSE, presently the MMSE is the best studied. However, access to the MMSE is now limited by enforcement of its copyright (details).

Further evaluation includes retesting at another date, and administration of other (and sometimes more complex) tests of mental function, such as formal neuropsychological testing.

Associated Conditions

Criteria for Diagnosis

  • Amnesia
  • Impairment of abstract thinking
  • Limited judgment ability
  • Orientation disturbances
  • Impairment of higher cognitive functions:

Severity of Dementia

  • Mild: Independet personal hygiene and judgment are retained, but a reduced performance in social activities or household activities is noticed
  • Medium: Some monitoring necessary, living independently is dangerous
  • Severe: Permanent care and monitoring absolutely necessary, serious loss of independence

History and Symptoms

  • Medication history
  • Abbreviated mental status examination
  • Thorough history needs to be performed to rule out any underlying disease etiology

Laboratory Findings

Electrolyte and Biomarker Studies

Other Diagnostic Studies

  • Genetic testing
  • Cerebrospinal fluid (CSF) analysis is suggested in some cases

Imaging

A CT scan or magnetic resonance imaging (MRI scan) is commonly performed, although these modalities (as is noted below) may not have optimal sensitivity for the diffuse metabolic changes associated with dementia in a patient who 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 can yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. Recently, the functional neuroimaging modalities of SPECT and PET have shown quite similar ability to diagnose dementia as clinical exam (PMID 16785801). SPECT's ability to differentiate vascular type from Alzheimer disease types of dementias appears to be superior to clinical exam (PMID 15545324).

Complete List of Differential Diagnoses

Most Common Causes

Less Common Causes

Treatment

Except for the treatable types listed above, there is no cure to this illness, although scientists are progressing in making a type of medication that will slow down the process. Cholinesterase inhibitors are often used early in the disease course. Cognitive and behavioral interventions may also be appropriate. Educating and providing emotional support to the caregiver (or carer) is of importance as well (see also elderly care).

A Canadian study found that a lifetime of bilingualism has a marked influence on delaying the onset of dementia by an average of four years when compared to monolingual patients. The researchers determined that the onset of dementia symptoms in the monolingual group occurred at the mean age of 71.4, while the bilingual group was 75.5 years. The difference remained even after considering the possible effect of cultural differences, immigration, formal education, employment and even gender as influences in the results. [13]

  • Treat all reversible causes
  • Identify and treat nonreversibly disease etiologies
  • Treat risk factors for those patients with vascular dementia

Pharmacotherapy

Snoezelen rooms that provide patients with a soothing and stimulating environment of light, color, music and scent have been used in the therapy of dementia patients.

Medications

Tacrine (Cognex), donepezil (Aricept), galantamine (Reminyl), and rivastigmine (Exelon) are approved by the United States Food and Drug Administration (FDA) for treatment of dementia induced by Alzheimer disease. They may be useful for other similar diseases causing dementia such as Parkinsons or vascular dementia.[14]

  • N-methyl-D-aspartate Blockers

Drugs within the class known as N-methyl-D-aspartate (NMDA) blockers include memantine (Namenda), which has been approved by the FDA for the treatment of moderate-to-severe dementia.

Acute Pharmacotherapies

Off label

  • Amyloid deposit inhibitors

Minocycline and Clioquinoline, antibiotics, may help reduce amyloid deposits in the brains of persons with Alzheimer disease.[15]

  • Antipsychotic drugs

Haloperidol (Haldol), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) are frequently prescribed to help manage psychosis and agitation. Treatment of dementia-associated psychosis or agitation is intended to decrease psychotic symptoms (for example, paranoia, delusions, hallucinations), screaming, combativeness, and/or violence.[16][17]

Depression is frequently associated with dementia and generally worsens the degree of cognitive and behavioral impairment. Antidepressants may be helpful in alleviating cognitive and behavior symptoms by reuptaking neurotransmitter regulation through reuptake of serotonin, noradrenaline and dopamine.

  • Antianxiety 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 or are too sedating. Buspirone (Buspar) is often initially tried for mild-to-moderate anxiety.

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.

Prevention

Main article: Prevention of dementia

Since there is no cure for dementia, the best an individual can do is to prevent it from developing in the first place.

The main method to prevent dementia is to live an active life, both mentally and physically. It appears that the regular moderate consumption of alcohol (beer, wine or distilled spirits) may reduce risk. [18]

Furthermore, there are medications which might contribute to prevent the onset of dementia, including hypertension medications, anti-diabetic drugs and NSAIDs[19].

Risk to self & others

Driving with Dementia could lead to severe injury or even death to self and others. Doctors should advise appropriate testing and on when to quit driving[20].

Services

Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Adult daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers.

Mnemonics to remember causes

Dementia: treatable causes

DEMENTIA:

  • Drug toxicity
  • Emotional (depression, anxiety, OCD, etc.)
  • Metabolic (electrolytes, liver dz, kidney dz, COPD)
  • Eyes/ Ears (peripheral sensory restrictions)
  • Nutrition (vitamin, iron deficiencies/ NPH [Normal Pressure Hydrocephalus]
  • Tumors/ Trauma (including chronic subdural hematoma)
  • Infection (meningitis, encephalitis, pneumonia, syphilis)
  • Arteriosclerosis and other vascular disease

Dementia: some common causes

DEMENTIA:

  • Diabetes
  • Ethanol
  • Medication
  • Environmental (eg CO poisoning)
  • Nutritional
  • Trauma
  • Infection
  • Alzheimer's

Dementia: reversible dementia causes

DEMENTIA:

  • Drugs / Depression
  • Elderly
  • Multi-infarct/ Medication
  • Environmental
  • Nutritional
  • Toxins
  • Ischemia
  • Alcohol

References

  1. ↑ American Family Physician, March 1, 2003 Delirium
  2. ↑ Dementia Estimates and Projections: Australian States and Territories. Alzheimer's Australia (2005-02-01). Retrieved on 2006-10-04.
  3. ↑ Teng E L, Chui H C. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 1987;48:314–18. PMID 3611032
  4. ↑ Teng E L, Hasegawa K, Homma A, et al. The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr 1994;6:45–58. PMID 8054493
  5. ↑ Royall, D.; Cordes J.; & Polk M. (1998). "CLOX: an executive clock drawing task". J Neurol Neurosurg Psychiatry 64 (5): 588-94. PMID 9598672.
  6. ↑ Boustani, M.; Peterson, B.; Hanson, L.; Harris, R.; & Lohr, K. (2003). "Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force". Ann Intern Med 138 (11): 927-37. PMID 12779304.
  7. ↑ Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of psychiatric research 12 (3): 189-98. doi:10.1016/0022-3956(75)90026-6. PMID 1202204.
  8. ↑ Appendix: The Modified Mini-Mental State (3MS). Retrieved on 2007-09-06.
  9. ↑ 9.0 9.1 Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):790-9. Epub 2006 Dec 18. PMID 17178826
  10. ↑ Sager, M.; Hermann, B.; La Rue, A.; & Woodard, J. (2006). "Screening for dementia in community-based memory clinics". WMJ 105 (7): 25-9. PMID 17163083.
  11. ↑ Fleisher, A.; Sowell B.; Taylor C.; Gamst A.; Petersen R.; & Thal L.. "Clinical predictors of progression to Alzheimer disease in amnestic mild cognitive impairment". Neurology. PMID 17287448.
  12. ↑ Karlawish, J. & Clark, C. (2003). "Diagnostic evaluation of elderly patients with mild memory problems". Ann Intern Med 138 (5): 411-9. PMID 12614094.
  13. ↑ Bilingualism Has Protective Effect In Delaying Onset Of Dementia By Four Years, Canadian Study Shows. Medical News Today (2007-01-11). Retrieved on 2007-01-16.
  14. ↑ Lleo A, Greenberg SM, Growdon JH. Current pharmacotherapy for Alzheimer's disease. Annu Rev Med. 2006;57:513-33. Review. PMID 16409164
  15. ↑ Choi, Y., Kim, H.S., Shin, K.Y., Kim, E.M., Kim, M., Kim, H.S., Park, C.H., Jeong, Y.H., Yoo, J., Lee, J.P., Chang K.A., Kim S., & Suh, Y.H. Related Minocycline Attenuates Neuronal Cell Death and Improves Cognitive Impairment in Alzheimer's Disease Models. Neuropsychopharmacology. 2007 Apr 4; PMID 17406652
  16. ↑ Wei, Z., Mousseau, D.D., Dai, Y., Cao, X., Li, X.M. (2006). Haloperidol induces apoptosis via the sigma2 receptor system and Bcl-XS. Pharmacogenomics J. 6(4):279-88. Epub 2006 Feb 7. PMID 16462815
  17. ↑ Wang, H., Xu, H., Dyck, L.E., & Li, X.M. (2005). Olanzapine and quetiapine protect PC12 cells from beta-amyloid peptide(25-35)-induced oxidative stress and the ensuing apoptosis. Journal Neuroscience Res, 81(4):572-80. PMID 15948179
  18. ↑ Mulkamal, K.J., et al. Prospective study of alcohol consumption and risk of dementia in older adults. Journal of the American Medical Association, 2003 (March 19), 289, 1405-1413; Ganguli, M., et al. Alcohol consumption and cognitive function in late life: A longitudinal community study. Neurology, 2005, 65, 1210-12-17; Huang, W., et al. Alcohol consumption and incidence of dementia in a community sample aged 75 years and older. Journal of Clinical Epidemiology, 2002, 55(10), 959-964; Rodgers, B., et al. Non-linear relationships between cognitive function and alcohol consumption in young, middle-aged and older adults: The PATH Through Life Project. Addiction, 2005, 100(9), 1280-1290; Anstey, K. J., et al. Lower cognitive test scores observed in alcohol are associated with demographic, personality, and biological factors: The PATH Through Life Project. Addiction, 2005, 100(9), 1291-1301; Espeland, M., et al. Association between alcohol intake and domain-specific cognitive function in older women. Neuroepidemiology, 2006, 1(27), 1-12; Stampfer, M.J., et al'. Effects of moderate alcohol consumption on cognitive function in women. New England Journal of Medicine, 2005, 352, 245-253; Ruitenberg, A., et al. Alcohol consumption and risk of dementia: the Rotterdam Study. Lancet, 2002, 359(9303), 281-286; Scarmeas, N., et al. Mediterranean diet and risk for Alzheimer’s disease. Annals of Neurology, 2006 (published online April 18, 2006).
  19. ↑ West Virginia Department of Health and Human Resources (with further links to experiments respectively)
  20. ↑ Drivers with dementia a growing problem, MDs warn, CBC News, Canada, September 19, 2007

External links


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v • d • e
WHO ICD-10 mental and behavioural disorders (F · 290–319)
Neurological/symptomaticDementia (Alzheimer's disease, multi-infarct dementia, Pick's disease, Creutzfeldt-Jakob disease, Huntington's disease, Parkinson's disease, AIDS dementia complex, Frontotemporal dementia) · Delirium · Post-concussion syndrome
Psychoactive substanceIntoxication (drunkenness) · Physical dependence (alcohol dependence, opioid dependency, cocaine dependence) · Withdrawal (benzodiazepine withdrawal, delirium tremens) ·
Amnesic: (Korsakoff's syndrome)
Psychotic disorderSchizophrenia (disorganized schizophrenia) · Schizotypal personality disorder · Delusional disorder · Folie à deux · Schizoaffective disorder
Mood (affective)Mania · Bipolar disorder · Clinical depression · Cyclothymia · Dysthymia
Neurotic, stress-related
and somatoform		Agoraphobia · Anxiety disorder · Panic disorder · Generalized anxiety disorder · Social Anxiety Disorder · OCD · Acute stress reaction · PTSD · Adjustment disorder · Conversion disorder (Ganser syndrome) · Somatoform disorder · Somatization disorder · Neurasthenia
Physiological/physical
behavioural		Eating disorder (anorexia nervosa, bulimia nervosa) · Sleep disorder (dyssomnia, insomnia, hypersomnia, parasomnia, night terror, nightmare) ·
Sexual dysfunction (erectile dysfunction, premature ejaculation, vaginismus, dyspareunia, hypersexuality) · Postpartum depression
Adult personality
and behaviour		Personality disorder · Passive-aggressive behavior · Kleptomania · Trichotillomania · Voyeurism · Factitious disorder · Munchausen syndrome · Ego-dystonic sexual orientation
Mental retardationMental retardation
Psychological development
(developmental disorder)		Specific: speech and language (expressive language disorder, aphasia, expressive aphasia, receptive aphasia, Landau-Kleffner syndrome, lisp) · Scholastic skills (dyslexia, dysgraphia, Gerstmann syndrome) · Motor function (developmental dyspraxia)
Pervasive: Autism · Rett syndrome · Asperger syndrome
Behavioural and emotional,
childhood and adolescence onset		ADHD · Conduct disorder · Oppositional defiant disorder · Separation anxiety disorder · Selective mutism · Reactive attachment disorder · Tic disorder · Tourette syndrome · Speech (stuttering · cluttering)
v • d • e
WikiDoc Research Resources for Dementia
Articles on DementiaMost recent articles on Dementia • Most cited articles on Dementia • Review articles on Dementia • Articles on Dementia in N Eng J Med, Lancet, BMJ
Media (Slides, Video, Images, MP3) on DementiaPowerpoint slides on Dementia • Images of Dementia • Photos of Dementia • Podcasts & MP3s on Dementia • Videos on Dementia
Evidence Based Medicine Regarding DementiaCochrane Collaboration on Dementia • Bandolier on Dementia • TRIP on Dementia
Cost Effectiveness of DementiaCost Effectiveness of Dementia
Clinical Trials Involving DementiaOngoing Trials on Dementia at Clinical Trials.gov • Trial results on Dementia • Clinical Trials on Dementia at Google
Guidelines / Policies / Government Resources (FDA/CDC) Regarding DementiaUS National Guidelines Clearinghouse on Dementia • NICE Guidance on Dementia • NHS PRODIGY Guidance • FDA on Dementia • CDC on Dementia
Textbook Information on DementiaBooks and Textbook Information on Dementia
Pharmacology Resources on DementiaDosing of Dementia • Drug interactions with Dementia • Side effects of Dementia • Allergic reactions to Dementia • Overdose information on Dementia • Carcinogenicity information on Dementia • Dementia in pregnancy • Pharmacokinetics of Dementia •
Genetics, Pharmacogenomics, and Proteinomics of DementiaGenetics of Dementia • Pharmacogenomics of Dementia • Proteomics of Dementia
Newstories on DementiaDementia in the news • Be alerted to news on Dementia • News trends on Dementia
Commentary on DementiaBlogs on Dementia
Patient Resources on DementiaPatient resources on Dementia • Discussion groups on Dementia • Patient Handouts on Dementia • Directions to Hospitals Treating Dementia • Risk calculators and risk factors for Dementia
Healthcare Provider Resources on DementiaSymptoms of Dementia • Causes & Risk Factors for Dementia • Diagnostic studies for Dementia • Treatment of Dementia
Continuing Medical Education (CME) Programs on DementiaCME Programs on Dementia
International Resources on DementiaDementia en Espanol • Dementia en Francais
Business Resources on DementiaDementia in the Marketplace • Patents on Dementia
Informatics Resources on DementiaList of terms related to Dementia

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Acknowledgement and Attribution Regarding Sources of Content

Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .

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