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Dementia: The Basics
What is dementia?
What are the types of dementia?
What are the stages?
Treatment?
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 Defined
 Dementia 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)
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Delirium
 Delirium is an acute decline in mental status that can be resolved and is
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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 attention
Changes 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 Dementia
 Alzheimer’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 WernickeKorsakoff 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 & Progression
 The 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 cerebralvascular 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 Dementia
Early Stages: mild cognitive decline
 The 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 Dementia
Middle Stages: moderate cognitive decline
 At 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
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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 Dementia
Late 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 Dementia
 In 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.
Treatment
 Effective 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.