Clinical Notes : Mental Health

84. Dementia

 

Dementia is not a specific disease.

Dementia describes a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily functioning.

Though dementia generally involves memory loss, Memory loss has different causes. Memory loss alone does not constiute dementia.

Alzheimer's disease is the most common cause of a progressive dementia in older adults, but there are a number of causes of dementia.

Depending on the cause, some dementia symptoms can be reversed.

Symptoms

 

People with dementia usually present first to their family physician, although an estimated 39% present to specialist clinics (neurologists, psychiatrists and geriatricians).

 

The GP is often the first physician to observe patients with possible dementia and often the only physician involved in making the diagnosis.

Dementia symptoms vary depending on the cause, but common signs and symptoms include:

 

Cognitive changes :

  • Memory loss, which is usually noticed by a spouse or someone else

  • Difficulty communicating or finding words

  • Difficulty reasoning or problem-solving

  • Difficulty handling complex tasks

  • Difficulty with planning and organizing

  • Difficulty with coordination and motor functions

  • Confusion and disorientation

 

Psychological changes :

  • Personality changes

  • Depression

  • Anxiety

  • Inappropriate behavior

  • Paranoia

  • Agitation

  • Hallucinations

Difficulty making a diagnosis may necessitate referral to a specialist, such as a geriatrician, neurologist, or psychiatrist, or require the request for further investigations to be completed by a neuropsychologist.

For those with mild or questionable impairment, more comprehensive standardized cognitive assessments can be useful to assist with establishing a firm diagnosis; these are normally undertaken as part of a specialist assessment after referral.

Risk factors

Many factors can eventually lead to dementia.

Some factors, such as age, can't be changed. Others can be addressed to reduce risk.

 

Risk factors that can't be changed :

  • Age

    • The risk rises after age 65.

    • However, dementia isn't a normal part of aging, and dementia can occur in younger people.

  • Family history. .

    • Having a family history of dementia puts individuals at greater risk of developing the condition.

    • However, many people with a family history never develop symptoms, and many people without a family history do.

    • Tests for specific genetic mutations are available

  • Down syndrome.

    • By middle age, many people with Down syndrome develop early-onset Alzheimer's disease.

  • Mild cognitive impairment.

    • This involves difficulties with memory but without loss of daily function. It puts people at higher risk of dementia.

 

Risk factors that can be changed :

  • Heavy alcohol use.

    • Consumption of large amounts of alcohol, has a higher risk of dementia.

    • Some studies, however, have shown that moderate amounts of alcohol might have a protective effect.

  • Cardiovascular risk factors.

    • Hypertension), hypercholesterolemia, atherosclerosis and obesity.

  • Depression.

    • Although not yet well-understood, late-life depression might indicate the development of dementia.

  • Diabetes.

    • Increased risk of dementia, especially if it's poorly controlled.

  • Smoking.

  • Smoking 

  • Sleep apnea.

 
 

Minimum clinical assessment of patients with dementia.

 

  • Anamnesis:

    • medical history collected or at least confirmed by the principal caregiver or a person who knows the history

    • beware of risk of underestimation of the symptom in older cognitively compromised

  • Objective examination:

    • patient visit in order to capture significant clinical signs

    • beware of underlying organic disease not reported or underestimated by the patient and the family

  • Pharmacological anamnesis:

    • drug history of the patient

    • beware of many drugs that may cause side effects, especially when OTC and/or self-administered

  • Vital signs:

    • for better understanding of the patient's general condition

    • minimum determination of blood pressure, heart rate, oxygen saturation (blood gas, or), body temperature, and glycemia

In the OOH setting the first challenge is to differentiate the presenting symptoms from Delirium and Depression.

Patients with dementia generally tend to sub-report symptoms of organic disease, and therefore may be at increased risk of hiding somatic disease until it presents in a more dramatic acute fashion, often as sudden increase in frequency and severity of BPSD (behavioral and psychological symptoms of dementia), such as agitation, insomnia, delirium, or hallucinations..

Presentation 

The diseases that most often drive the elderly to apply for an urgent evaluation are :

 

  • Medical emergency

    •  Cardiovascular diseases (angina, heart failure, arrhythmias, syncope)

    •  Respiratory (acute exacerbation of chronic bronchitis, bronchial asthma, pneumonia)

    •  Cancer (cancer of the lung, breast, large bowel)

    •  Neurological diseases (acute cerebrovascular disease, altered state of consciousness)

 

  • Surgical emergency

    •  Trauma and fractures

 

  • Clinical emergency

    • dehydration,

    • urinary tract infections,

    • intestinal sub-ileus,

    • delirium, behavioral disturbances

    • acute respiratory failure from respiratory infection,

    • acute myocardial infarction,

    • sepsis

    • clinical problems related to an incorrect home management

    • oversedation from psychopharmacological treatment, side effects from medications (iatrogenic hypotension, hypoglycemia jatrogena)

 
 

Management

Management in the OOH setting is focused on treatment of the precipitating conditions identified.

Agitated or aggresive individuals are treated in a manner similar to those in delirium.

 

Follow-up by the patient's own GP is mandatory in all cases, with a view to :

  • review of precipitating condition

  • review of co-morbidities and their management

  • medication review

  • referral for further specialist assessment and management

  • formulation of an acute care management plan (instructions for family or nursing home staff for emergencies)

  • formulation of a chronic care management plan (instructions for family or nursing home staff for coping with activities of daily living and for monitoring and management of individual features of dementia)

 
 

Types of dementia :

 

Dementia involves damage of nerve cells in the brain, which can occur in several areas of the brain.

Dementia affects people differently, depending on the area of the brain affected.

Dementias are often grouped by what they have in common, such as the part of the brain that's affected or whether they worsen over time (progressive dementias).

Some dementias, such as those caused by a reaction to medications or vitamin deficiencies, might improve with treatment.

Progressive dementias

Types of dementias that progress and aren't reversible include:

  • Alzheimer's disease.

    • In people age 65 and older, Alzheimer's disease is the most common cause of dementia.

    • Although the cause of Alzheimer's disease isn't known, plaques and tangles are often found in the brains of people with Alzheimer's. Plaques are clumps of a protein called beta-amyloid, and tangles are fibrous tangles made up of tau protein.

    • Certain genetic factors might make it more likely that people will develop Alzheimer's.

 

  • Vascular dementia.

    • This second most common type of dementia occurs as a result of damage to the vessels that supply blood to the brain.

    • Blood vessel problems can be caused by stroke or other blood vessel conditions.

 

  • Lewy bodies dementia.

    • Lewy bodies are abnormal clumps of protein that have been found in the brains of people with Lewy body dementia, Alzheimer's disease and Parkinson's disease.

    • This is one of the more common types of progressive dementia.

 

  • Frontotemporal dementia.

    • This is a group of diseases characterized by the breakdown (degeneration) of nerve cells in the frontal and temporal lobes of the brain, the areas generally associated with personality, behavior and language.

    • As with other dementias, the cause isn't known.

 

  • Mixed dementia.

    • Autopsy studies of the brains of people 80 and older who had dementia indicate that many had a combination of Alzheimer's disease, vascular dementia and Lewy body dementia.

    • Studies are ongoing to determine how having mixed dementia affects symptoms and treatments.

 

Other disorders linked to dementia

 

  • Huntington's disease.

    • Caused by a genetic mutation, this disease causes certain nerve cells in the brain and spinal cord to waste away.

    • Signs and symptoms, including a severe decline in thinking (cognitive) skills usually appear around age 30 or 40.

 

  • Traumatic brain injury.

    • This condition is caused by repetitive head trauma, such as experienced by boxers, football players or soldiers.

    • Depending on the part of the brain that's injured, this condition can cause dementia signs and symptoms, such as depression, explosiveness, memory loss, uncoordinated movement and impaired speech, as well as slow movement, tremors and rigidity (parkinsonism).

    • Symptoms might not appear until years after the trauma.

 

 

  • Creutzfeldt-Jakob disease.

    • This rare brain disorder usually occurs in people without known risk factors.

    • This condition might be due to an abnormal form of a protein.

    • Creutzfeldt-Jakob disease can be inherited or caused by exposure to diseased brain or nervous system tissue.

    • Signs and symptoms of this fatal condition usually appear around age 60.

  • Parkinson's disease.

    • Many people with Parkinson's disease eventually develop dementia symptoms (Parkinson's disease dementia).

 

Dementia-like conditions that can be reversed

Some causes of dementia or dementia-like symptoms can be reversed with treatment. They include:

 

  • Infections and immune disorders.

    • Dementia-like symptoms can result from fever or other side effects of your body's attempt to fight off an infection.

    • Conditions such as multiple sclerosis that result from the body's immune system attacking nerve cells also can cause dementia.

  • Metabolic problems and endocrine abnormalities.

    • People with thyroid problems, low blood sugar (hypoglycemia), too little or too much sodium or calcium, or an impaired ability to absorb vitamin B-12 can develop dementia-like symptoms or other personality changes.

  • Nutritional deficiencies.

    • Not drinking enough liquids (dehydration); not getting enough thiamin (vitamin B-1), which is common in people with chronic alcoholism; and not getting enough vitamins B-6 and B-12 in your diet can cause dementia-like symptoms.

  • Reactions to medications.

    • A reaction to a medication or an interaction of several medications can cause dementia-like symptoms.

  • Subdural hematomas.

    • Bleeding between the surface of the brain and the covering over the brain, which is common in the elderly after a fall, can cause symptoms similar to dementia.

 

  • Poisoning.

    • Exposure to heavy metals, such as lead, and other poisons such as pesticides, as well as alcohol abuse or recreational drug use can lead to symptoms of dementia.

    • Symptoms might resolve with treatment.

  • Brain tumors.

    • Rarely, dementia can result from damage caused by a brain tumor.

 

  • Anoxia.

    • This condition, also called hypoxia, occurs when organ tissues aren't getting enough oxygen.

    • Anoxia can occur due to severe asthma, heart attack, carbon monoxide poisoning or other causes.

  • Normal-pressure hydrocephalus.

    • This condition, which is caused by enlarged ventricles in the brain, can cause walking problems, urinary difficulty and memory loss

 

Complications

 

Dementia can lead to:

  • Inadequate nutrition.

    • Many people with dementia eventually reduce or stop their intake of nutrients.

    • Ultimately, they may be unable to chew and swallow.

  • Pneumonia.

    • Difficulty swallowing increases the risk of choking or aspirating food into the lungs, which can block breathing and cause pneumonia.

  • Inability to perform self-care tasks.

    • As dementia progresses, it can interfere with Activities of Daily Living (ADLs) such as bathing, dressing, brushing hair or teeth, using the toilet independently and taking medications accurately.

  • Personal safety challenges.

    • Some day-to-day situations can present safety issues for people with dementia, including driving, cooking and walking alone.

 

  • Death.

    • Late-stage dementia results in coma and death, often from infection.

 

Prevention

There's no sure way to prevent dementia, but there is evidence that it might be beneficial to do the following:

  • Keep your mind active.

    • Mentally stimulating activities, such as reading, solving puzzles and playing word games, and memory training might delay the onset of dementia and decrease its effects.

  • Be physically and socially active.

    • Physical activity and social interaction might delay the onset of dementia and reduce its symptoms. 

  • Quit smoking.

    • Some studies have shown smoking in middle age and beyond may increase the risk of dementia and blood vessel (vascular) conditions. 

  • Get enough vitamin D.

    • Research suggests that people with low levels of vitamin D in their blood are more likely to develop Alzheimer's disease and other forms of dementia.

  • Lower blood pressure.

    • High blood pressure might lead to a higher risk of some types of dementia. 

  • Maintain a healthy diet.

    • Eating a healthy diet is important for many reasons, but a diet such as the Mediterranean diet — rich in fruits, vegetables, whole grains and omega-3 fatty acids, commonly found in certain fish and nuts — might promote health and lower the risk of developing dementia.

 
 
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Dementia: assessment, management and support for people living with dementia and their carers

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James E. Galvin, MD, MPH and  Carl H. Sadowsky, MD..

J Am Board Fam Med May-June 2012 vol. 25 no. 3 367-382

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Royal Australian & New Zealand College of Psycjhiatrists

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Diagnosing dementia with confidence by GPs.

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Fam Pract 2007;24:616–21.

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