Dementia – an acquired impairment in mental and functional capabilities – is common in the elderly. It is often progressive and may eventually result in nursing home placement due to incapacitation. Doctors need to make an accurate and early diagnosis of dementia to provide the patient the best treatment options.

About 5 to 15 percent of people 65 and older suffer from some form of dementia – the most common of which is Alzheimer’s disease. As people age, the risk of dementia increases. Moderate to severe dementia is found in three percent of those aged 65 to 74 and in 30 percent of those 85 and older.

Dementia accounts for a growing share of health care expenses and medical resources. Decline in thinking abilities often requires increased supervision and support systems – usually at a great expense.

Detecting signs of dementia at an earlier stage and starting appropriate treatments immediately appears to reduce the rate of mental decline, increase independence in day-to-day activities, reduce health care costs, and improve quality of life.

For more information on dementia, please visit the website of the Memory Disorders Clinic at The Ohio State University:

Signs of Dementia

The good news is that while dementia has many causes, most are treatable. It is important to get a patient’s complete medical history, including any psychiatric care he or she has received.

• Forgetfulness, memory loss, repeating questions
• Problems with spatial awareness; such as impairment in drawing skills or getting turned around
• Word finding problems
• Disorientation
• Changes in personality and emotional states
• Impaired decision making and problem solving
• Decreased insight

The physical exam for dementia should include a search for systemic illness (sickness that affects the entire body) looking for conditions affecting the endocrine system (which secretes hormones for use throughout the body); and a complete neurological exam, which includes looking for both physical and cognitive (thinking) abnormalities in the brain.

Some Types of Dementia

Alzheimer’s disease. Alzheimer’s accounts for 50 to 60 percent of all causes of dementia. It typically starts after age 50 and occurs more commonly as a person grows older. Death usually occurs six to 12 years after the onset of the disease. Alzheimer’s disease often runs in families (genetic predisposition). There are several mutations located on three separate chromosomes (numbers 21, 14, and 1) that scientists have found that will cause early-onset Alzheimer’s disease (usually starting in the late 30’s to early 50’s). The APOE e4 gene has been linked to increased risk of later onset (over age 60) Alzheimer’s disease. Alzheimer’s starts insidiously and progresses slowly. Early warning signs include difficulty with language (word finding problems), memory (not remembering things recently learned such as recent events or conversations) and visuospatial abilities (trouble drawing objects or finding one’s ways).

Family members usually notice the impairments more than the patient. As the disease progresses, so do the symptoms. Judgment and problem solving become impaired. Patients start needing assistance with finances, medication management, cooking, and other activities of daily living. As the disease progresses, so do the symptoms, and eventually the person has difficulty performing even simple tasks. Behavioral symptoms are common. About 70 percent of patients with the disease experience delusions (false beliefs) of some sort, while depression affects about 40 percent.

Drugs currently approved for treating the cognitive and memory aspects of Alzheimer’s disease are cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) and NMDA antagonists (memantine). A cholinesterase inhibitor and an NMDA antagonist are best used in combination. They appear effective for mild, moderate, and the initial severe stages of the disease. They provide modest improvement in thinking and functioning for about 12 months and continue to provide benefit compared to the natural course of decline for approximately 7 years on the average. For best effect, they should be started early and not stopped prematurely. Disease-modifying treatments with great potential benefit are currently under investigation and available only through clinical trial participation.

For more information, please see Medications Used to Control Dementia.

Vascular dementia, or multiple strokes. Vascular dementia could be caused by a large stroke or many small strokes and is another common cause of dementia. As more small strokes occur, the patient becomes neurologically impaired (especially giat disturbance) and demented. Usually there are contributing factors, such as a history of hypertension, heart disease, diabetes or cigarette smoking. Physical symptoms include weakness, tremors and difficulty walking. Memory is impaired, depression is frequent, and personality changes may occur. CT or MRI scans of the brain are helpful for diagnosis. Controlling the risk factors of stroke – such as hypertension, diabetes, being overweight, elevated cholesterol, smoking – is critical. Aspirin for stroke prevention is often prescribed.

Binswanger’s disease.  This is a form of vascular dementia that affects tiny blood vessels deep inside the brain. Dementia comes gradually with this disease. Symptoms include gait instability, memory problems, mood changes and poor judgment.

Parkinson’s disease with dementia.  Parkinson’s disease typically causes tremors, slow movements, stiffness, and gait disturbance. Dementia is obvious in about 40 percent of patients with the disease, while an additional 50 percent have subtle signs of memory loss. Dementia is most common in Parkinson’s patients with noticeable posture problems and walking difficulties. Dementia is least common in patients with the characteristic tremors.  Rivastigmine is approved for mild to moderate disease.

Dementia with Lewy bodies. This is a form of dementia where the person looks like they have Parkinson’s, yet their progressive dementia is similar to that found in Alzheimer’s. Patients often appear rigid and slow in their movement and may have frequent sleep disturbances (acting out dreams or sleep talking) and visual hallucinations. Tremors occur less often. The disease usually appears after age 60. Lewy bodies are abnormal proteins that accumulate in the brain.

Frontotemporal Dementia. This dementia typically starts between ages 40 to 60. Cognitive decline and personality trait changes are often the first recognized clinical signs.  Many patients display apathy, disinhibition, inappropriate disrobing, obsessive behaviors such as rewashing hands repeatedly, verbal dysdecorum, and lack of insight into their present condition. Some develop a progressive language disturbance, and others have prominent problems with memory, planning, organization, decision-making, and problem solving. Current treatments focus on the behavioral issues.

Toxic-metabolic dementia. Prescribed drugs can cause dementia in the elderly. Looking over the patient’s medication regimen may reveal a reversible cause of dementia. Almost any drug can cause problems with mental function, but drugs in the following categories are particularly likely to cause problems: anticholinergic drugs, analgesics, antihypertensive agents, anticonvulsants, psychotropic agents, and benzodiazepines. Prescription drugs aside, alcohol can also cause dementia. An alcoholic loses memory capability, mental processes slow down and attention span decreases.

Other causes of toxic-related dementia include: Korsakoff’s syndrome or thiamine deficiency (more common in alcoholics), intoxication by industrial solvents and heavy metals after prolonged exposure. Common causes of metabolic-related dementia include: nutritional deficiencies (B1, B6, B12, folate, niacin, or E vitamins), decreased oxygen to the brain, end stage kidney or liver disease, low blood counts, and thyroid, adrenal, or parathyroid disorders.

Infectious dementia. A number of infectious agents can cause dementia in the elderly: viruses, fungi, and parasites. Dementia can also occur with illnesses such as HIV and Lyme disease.

Depression and Dementia. Certain patients with depression may show symptoms similar to dementia. The onset of dementia is gradual, and it is reversible with the successful treatment of the mood disorder typically with antidepressant medications. Symptoms include a depressed mood, anxiety, agitation, a slowing of mental processes, and poor memory.

Other Dementia Conditions. Trauma, brain cancer, multiple sclerosis, systemic lupus erythematosus, inflammatory brain conditions, and hydrocephalus (obstruction of the cerebrospinal fluid) can all be causes of a dementia syndrome.

Intervention

Dementia brings with it many levels of disability. Patients with memory loss tend to underreport their symptoms, so other physical illnesses may be overlooked. Infection (typically urinary tract infections or pneumonia) and dehydration are quite common, as are adverse reactions to medications (particularly drug interactions). Patients may need supervision to prevent falls, medication errors or poor eating habits. Caregivers should prevent social and sensory deprivation by spending time with the patient. Support groups, family counseling and legal and social services can educate and help caregivers.

Behavioral Management

Doctors can treat changes in behaviors caused by dementia. However, it is important to tailor the treatment to the individual based on their other medical problems and the medications that they take. If a patient’s behavior changes, check for infections and dehydration. It’s a good idea to maintain a routine, avoid unfamiliar places, and relieve any pain the patient may have. Ways to modify a patient’s behavior include being calm and gentle, using non-verbal communication, speaking slowly and simply, giving reassurance, acknowledging the patient’s concerns, not bossing, using distraction and bribes, keeping triggers to behaviors out of their sight, and avoiding over-stimulation. Patients that tend to move excessively – characterized by feeling restless, wandering, pacing or hiding objects – are best managed by providing a safe, contained environment and encouraging regular exercise.

If drugs need to be used for behaviors, it is best to start medications at a low dose and gradually increase to their optimal levels. Just remember that medications should be reviewed frequently and discontinued or reduced in dosage if necessary. Treatment depends on the types of behaviors a patient exhibits. When behaviors don’t disturb the patient or the caregiver, then no treatment may be necessary. Otherwise, low-dose psychotropic medications may be helpful. For significant suspiciousness, false beliefs, hallucinations, and aggression a low dose of an antipsychotic medication could be used. Depression or anxiety is best treated with antidepressants. Mood Lability, intrusiveness, and hypomania can be treated with mood stabilizers.

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