Demenita

Dementia

Dementia is the general term used to describe a progressive decline in cognitive function. This refers to a patient of normal intellect who is experiencing difficulties with thought and memory.

There are a number of potential causes of dementia. Many confuse the terms dementia and Alzheimer disease. Alzheimer disease is just one potential cause of dementia.

It is important to have a neurologist evaluate anyone experiencing difficulties with thought. While some of these patients with turn out to have Alzheimer disease, others may have a different explanation of their symptoms. Some causes of dementia are potentially curable, while others can be managed with medication. Some forms of dementia are resistant to therapy.

Several potential causes of dementia include:

Most types of dementia are nonreversible (degenerative). Nonreversible means the changes in the brain that are causing the dementia cannot be stopped or turned back. Alzheimer's disease is the most common type of dementia.Lewy body disease is a leading cause of dementia in elderly adults. People with this condition have abnormal protein structures in certain areas of the brain.

Dementia also can be due to many small strokes. This is called vascular dementia.

The following medical conditions also can lead to dementia:

Parkinson's disease
Multiple sclerosis
Huntington's disease
Pick's disease
Progressive supranuclear palsy
Infections that can affect the brain, such as HIV/AIDS and Lyme disease

Some causes of dementia may be stopped or reversed if they are found soon enough, including:

Brain tumors
Changes in blood sugar, sodium, and calcium levels (see: Dementia due to metabolic causes)
Low vitamin B12 levels
Normal pressure hydrocephalus
Use of certain medications, including cimetadine and some cholesterol-lowering medications
Chronic alcohol abuse

Dementia usually occurs in older age. It is rare in people under age 60. The risk for dementia increases as a person gets older.

Symptoms:

Dementia symptoms include difficulty with many areas of mental function, including:

Language
Memory
Perception
Emotional behavior or personality
Cognitive skills (such as calculation, abstract thinking, or judgment)

Dementia usually first appears as forgetfulness.

Mild cognitive impairment is the stage between normal forgetfulness due to aging and the development of dementia. People with MCI have mild problems with thinking and memory that do not interfere with everyday activities. They are often aware of the forgetfulness. Not everyone with MCI develops dementia.

Symptoms of MCI include:

Forgetting recent events or conversations
Difficulty performing more than one task at a time
Difficulty solving problems
Taking longer to perform more difficult mental activities

The early symptoms of dementia can include:

Language problems, such as trouble finding the name of familiar objects
Misplacing items
Getting lost on familiar routes
Personality changes and loss of social skills
Losing interest in things you previously enjoyed, flat mood
Difficulty performing tasks that take some thought, but that used to come easily, such as balancing a checkbook, playing games (such as bridge), and learning new information or routines

As the dementia becomes worse, symptoms are more obvious and interfere with the ability to take care of yourself. The symptoms may include:

Forgetting details about current events
Forgetting events in your own life history, losing awareness of who you are
Change in sleep patterns, often waking up at night
More difficulty reading or writing
Poor judgment and loss of ability to recognize danger
Using the wrong word, not pronouncing words correctly, speaking in confusing sentences
Withdrawing from social contact
Having hallucinations, arguments, striking out, and violent behavior
Having delusions, depression, agitation
Difficulty doing basic tasks, such as preparing meals, choosing proper clothing, or driving

People with severe dementia can no longer:

Understand language
Recognize family members
Perform basic activities of daily living, such as eating, dressing, and bathing

Other symptoms that may occur with dementia:

Incontinence
Swallowing problems

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Stages of Alzheimers

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As part of the visit at Armstrong Neurology, we endeavor to provide comprehensive care and to address a wide variety of issues that frequently impact patients with cognitive impairment.

Issues that will commonly be addressed in patients who have cognitive impairment:

1. An overall care plan
   - This will involve the patient, family members, and other caregivers
   - Identification of a caregiver and individual with power of attorney for the patient
   - Advanced care planning

2. Preventive care and screening
   - Identification of factors that may put the patient at risk
- Evaluation of mood disturbances and depression
   - Completion of the Beck Depression Inventory
   - If indicated, a plan to address depression and other behavioral issues will be formulated

Beck Depression Inventory

Hamilton Depression Rating Scale

3. Staging of dementia
- Functional Assessment Staging Tool
- Dementia Severity Rating Scale will be completed annually at follow up visits

Functional Assessment Staging Tool

Dementia Severity Rating Scale

Mini-Mental State Examination

4. Cognitive assessment
- A number of assessment tools are available including formal neuropsychiatric testing
- Completion of the Montreal Cognitive Assessment

Montreal Cognitive Assessment

5. Functional status assessment
- An assessement of the patient's ability to perform basic and instrumental aspects of daily living

Barthel ADL Index

6. Neuropsychiatric symptom assessment

This includes evaluation of potential activity disturbances:

Agitation
Wandering
Purposeless hyperactivity
Verbal or physical aggressiveness
Resistiveness to care
Apathy

Mood disturbances:

Anxiety
Dysphoria

Thought and perceptual disturbances:

Having fixed false beliefs
Hearing or seeing non-present entities
(hallucinations)

Socially inappropriate behaviors
Appetite
Eating disturbances
Sleep disorders
Diurnal / sleep-wake cycle disturbances
Repetitive behavior / Impulsiveness

Irritability
Mood lability / fluctuations
Euphoria

Paranoia

Neuropsychiatric Inventory

7. Management of neuropsychiatric symptoms

Management of BPSD

Behavioral and Psychological Symptoms

8. Counseling regarding safety concerns:
- A variety of options will be discussed to ensure patient safety
- Home safety evaluations may be ordered
- Supervision options will be considered

Fall risk
Gait / balance
Financial management
Home safety risks (cooking / smoking)
Suicidality
Physical aggression
Wandering

Being left alone
Inability to respond rapidly to crisis / household emergencies
Driving
Operation of hazardous equipment
Abuse / neglect
Access to potentially dangerous materials
Access to firearms or other weapons

9. Counseling regarding the risks of driving:

Driving Risks

Driving Counseling

10. Caregiver education and support
- Extensive resources are available here on the Armstrong Neurology site

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Resources to assist patients with dementia:

There a number of positive interventions that can be taken to help patients who are experiencing difficulties with their cognitive function. The more active and involved the patient is in various activities of daily living the better.

Many patients benefit from having an "activity table". Consider having a dedicated space for the patient. A large desk or banquet table would be ideal. This could be an activity area and personal space just for the patient. Items that could be included in this space might be; a personal computer / iPad, cell phone, activities, hobbies, puzzles, and games.

Here are some additional ideas that may be helpful:

Alzheimer / Dementia: Nutrition and Lifestyle

Activities for patients with dementia: I

Activities for patients with dementia: II

Memory Games I

Memroy Games II

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Imaging:

MRI or CT of the brain is part of the standard evaluation. Other imaging options such as the amyloid PET scan may be considered in certain circumstances.

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CSF and plasma Abeta42/40 ratios:

These tests may be helpful as an adjunct to the diagnosis of dementia due to Alzheimer disease, but they have limitations:

"In theory, the results of these studies indicate that if ABeta42 were to be used in a specialist clinic in a group of 1000 people, where 520 (52%) have Alzheimer's dementia, an estimated 602 would have an ABeta42 result. This would indicate that Alzheimer's dementia is present. Of these, 192 (32%) would be incorrectly classified as having Alzheimer's disease. Of the 398 people with a result indicating that Alzheimer's disease is not present, 110 (28%) would be incorrectly classified as not having Alzheimer's disease. The included studies used different levels of ABeta42 to make the diagnosis of Alzheimer's disease, and the accuracy of the test depended on the level of ABeta42 used."

https://www.cochrane.org/CD010945/DEMENTIA_how-accurate-abeta42-test-distinguishing-alzheimers-disease-other-types-dementia-patients-seen

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Medical Therapy:

Galantamine Exelon

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Internet Resources to assist in the care of patients with cognitive impairment:

Safety Issues

Safety Information: II

Alzheimer association safety information

Guides for caring for a patient with dementia

Dementia Today

Bright Focus Foundation

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Dr. Roger Rosenberg is a highly respected professor of neurology at Southwestern and was a mentor for Dr. Armstrong during his residency training.

Link to the Alzheimer Association website:

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A Brief History of Alzheimer Disease

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Lewy body dementia

Lewy Body Dementia (also called Dementia with Lewy bodies) is a form of dementia that shares characteristics with both Alzheimer's and Parkinson's diseases. Lewy Body dementia (LBD) symptoms resemble other diseases but LBD is especially challenging to diagnose correctly.

As a caregiver, you may feel discouraged in the face of this dementia, however, you can make the life of someone with LBD safer and more comfortable. By more fully understanding LBD and by using strategies that help you can also bring more hope and purpose into your own life.