Dementia describes a syndrome caused by chronic and/or progressive brain disease affecting higher cortical function.
It is estimated that the prevalence of Alzheimer's disease will triple by 2050.
Mild cognitive impairment (MCI) may be described as a transition phase between cognitive changes from normal aging and dementia.
Dementia is an umbrella term that includes:
Damage to the brain includes development of plaque, neurofibrillary tangles, synaptic loss, neuronal atrophy
Clinical manifestations may include impairment of memory, functional impairment, apraxia, aphasia, agnosia, executive function dysfunction
Accounts for 33% of dementias
History or presence of cerebrovascular accident with positive radiologic infarct finding
Progression may be both rapid and related to stroke-like event or stepwise delayed recall
Concomitant depression is common
Pathology of frontal and anterior temporal areas; frontotemporal lobar degeneration
Early age of onset
Early behavioral changes are a red flag: disinhibition, apathy, hyperorality, inappropriate social interaction
Poor execute and language function and relatively spared memory
Parkinson Disease Dementia
Typical subcortical pattern: impairments in attention, executive function and visuospatial function
Variable rates of progression
Depression is very prevalent (some estimates up to 50%)
Dementia with Lewy Bodies
Triad of symptoms – fluctuating cognition, Parkinson-like symptoms and visual hallucination
Other symptoms may include REM sleep disorders and frequent falls
Risk factors include:
Family history and genetics
History of psychiatric disorders
History of head trauma
Cardiovascular disease and related risk factors
Alcohol misuse, drug misuse, and toxins
Assess for delirium before dementia. The CAM is a recommended screening tool:
Some comparative facts include
Comparing Dementia and Delirium
Insidious, with an uncertain starting point
Rapid, usually with a certain starting point
Loss of memory, particularly for a recent event(s)
May be related to an underlying brain disorder, such as Alzheimer disease, vascular dementia, or Lewy body dementia
Nearly always related to underlying acute change, such as dehydration, infection, or starting or stopping medications
Level of consciousness
May be normal until advanced stages
Fluctuates from being lethargic to hyperalert
May be problematic with word choices
Slowed or rapid speech, frequently with incoherent and/or inappropriate language
Slowly progresses, gradually but eventually greatly impairing all mental functions
Causes variations in mental function- people are alert one moment and sluggish and drowsy the next
Fluctuates; days to weeks to months
Needed but less urgently; slows progression but does not cure
Immediate; usually reversible
Once delirium is ruled out, the next steps are:
The evaluation of a patient with suspected dementia should focus upon the history.
Family members or other informants who know the patient well are invaluable resources for providing an adequate history of cognitive and behavioral changes.
Adequate time should be arranged for a full assessment of cognitive function, followed by a complete physical examination, including neurologic examination.
Ask simple yes or no questions
Cognitive screening tests- St. Louis University Mental Status (SLUMS) or the Mini-Cog
Depression screening tests – Geriatric Depression Scale (GDS) or Hamilton Depression Rating Scale (HDRS)
Functional Level of Independence – Katz Index of Activities of Daily Living (ADL) or Lawton Instrumental Activities of Daily Living Scale (IADL)
Laboratory evaluation – Complete blood count, complete metabolic panel, thyroid screen, Vitamin B12 and folate, C reactive protein, RPR, Lipid panel, HIV screen, sedimentation rate and other test as indicated by the history and physical
Neuroimaging, MRI (preferred) or CT to rule out potentially treatable intracerebral lesions (Normal Pressure Hydrocephalus, subdural hematoma) and to rule out cortical and subcortical infarcts, white matter changes, localized atrophy.
Other investigations – CSF fluid evaluation, genetic testing, and EEG
Dependent on stage and type of dementia
Stabilize cognitive ability
Effective future planning
Interprofessional team interventions include both non-pharmacologic and pharmacologic strategies.
Alzheimer's Association (2012). 2012 Alzheimer's Disease Facts and Figures - Alzheimer's Association. Retrieved from http://www.merck.com/mmhe/sec06/ch083/ch083a.html
Alzheimer's Association (2012). Basics of Alzheimer 's disease: What is it and what you can do. Retrieved from http://www.alz.org/national/documents/brochure_basicsofalz_low.pdf . Accessed November 1, 2013.
American Medical Association (2013). Dementia. Retrieved from http://www.ama-assn.org//ama/pub/physician-resources/public-health/promoting-healthy-lifestyles/geriatric-health/dementia.page Accessed November 1, 2013.
Feldman, H.H., Jacova, C., & Robillard, A. (2009). Diagnosis and Treatment of Dementia. Canadian Medical Association Journal; 178(7):825-836.
Lawton, M.P., & Brody, E.M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9:179.
Sheikh, J.L. Yesavage, J.A. (1986) Geriatric Depression Scale (GDS): Recent evidence and development of shorter version. Clinical Gerontologist, 5:165.
U.S. Preventive Services Task Force (2003). Screening for dementia: recommendations and rationale. Annals of Internal Medicine; 138: 925-926. http://www.preventive services.ahrq.gov