Dementia refers to a group of symptoms involving progressive impairment of brain function.

Disorders that cause dementia include conditions that impair the vascular (blood vessels) or neurologic (nerve) structures of the brain. Some causes of dementia are treatable. These include normal pressure hydrocephalus, brain tumors, and dementia due to metabolic causes and infections. Unfortunately, most disorders associated with dementia are progressive, irreversible, and degenerative.

The two major degenerative causes of dementia are Alzheimer's disease and vascular dementia (loss of brain function due to a series of small strokes). The two conditions often occur together, and vascular dementia may speed the progression of Alzheimer's disease. Neither condition can be diagnosed definitively until autopsy.

Dementia may be diagnosed when two or more brain functions are impaired. These functions include language, memory, visual-spatial perception, emotional behavior or personality, and cognitive skills (such as calculation, abstract thinking, or judgment). Dementia usually appears first as forgetfulness. Other symptoms may be apparent only with neurologic examination or cognitive testing.

Dementia progresses slowly from decreased problem solving and language skills to difficulty with ordinary daily activities to severe memory loss and complete disorientation with withdrawal from social interaction.

• Progressive memory loss
• Inability to concentrate
• Decrease in problem-solving skills and judgment capability
• Confusion, severe
• Hallucinations and delusions
• Altered sensation or perception
• Impaired recognition (agnosia)
  • Impaired recognition of familiar objects or persons
  • Impaired recognition through the senses
• Altered sleep patterns
  • Insomnia
  • Need for increased sleep
  • Disturbance or change in sleep-wake cycle
• Motor system impairment
  • Impaired skilled motor function (apraxia)
    • Inability to reproduce geometric figures
    • Inability to mimic hand positions
    • Inability to dress self
  • Gait changes
  • Inappropriate movements
  • Other motor system impairment
• Disorientation
  • Person, place, time disorientation
  • Visual-spatial disorientation
  • Inability to interpret environmental cues
• Specific disorders of problem-solving or learning
  • Inability to generalize
  • Loss of abstract thinking
  • Impaired calculating ability
  • Inability to learn
• Memory deficit
  • Short-term memory problems (can't remember new things)
  • Long-term memory problems (can't remember past)
• Absent or impaired language ability (aphasia)
  • Inability to comprehend speech
  • Inability to read
  • Inability to write
  • Inability to speak, without muscle paralysis
  • Inability to form words
  • Inability to name objects
  • Poor enunciation
  • Inappropriate speech; use of jargon or wrong words
  • Inability to repeat a phrase
  • Persistent repetition of phrases
  • Other language impairment
• Personality changes
  • Irritability
  • Poor temper control
  • Anxiety
  • Depression
  • Indecisiveness
  • Self-centeredness
  • Inflexibility
  • No observable mood (flat affect)
  • Inappropriate mood or behavior
  • Withdrawal from social interaction
  • Inability to function or interact in social or personal situations
  • Inability to maintain employment
  • Decreased ability to care for oneself
  • Decreased interest in daily living activities
• Lack of spontaneity

• Swallowing problems
• Incontinence

A neurologic examination may reveal abnormalities. Early signs of dementia include mild problems with memory or attention. Over time, the following cognitive difficulties may appear:

• Language problems
• Disorientation
• Personality changes
• Visual or spatial problems
• Slow thinking
• Impaired skilled motor function (apraxia)
• Impaired recognition (agnosia)
• Difficulty with planning and organizing
• Weakness
• Incontinence
• Falling

The extent of damage and cause of dementia may be indicated by tests and procedures that include, but are not limited to, the following:

• Serum electrolytes
• Blood chemistry (chem-20)
• Serum calcium
• Glucose test
• Thyroid stimulating hormone level
• Thyroid function tests
• Liver function tests
• Blood ammonia levels
• B-12 level
• Drug or alcohol levels (toxicology screen)
• Urinalysis
• Blood gas analysis
• EEG (electroencephalograph)
• Head CT
• MRI of head
• CSF (cerebrospinal fluid) analysis

• Anti-psychotics, given at night
• Serotonin-affecting drugs (trazodone, buspirone)
• Dopamine blockers (haloperidol, Risperidal, olanzapine, clozapine)
• Cholinesterase inhibitors [donepezil (aricept), rivastigmine (exelon), or the newly approved galantamine (reminyl) for Alzheimer's-type dementia]
• Fluoxetine, imipramine, or Celexa to help stabilize mood
• Stimulant drugs (such as methylphenidate) to increase activity and spontaneity
• Vitamin E

Sensory function should be evaluated regularly and hearing aids, glasses, or cataract surgery should be provided as needed.

Formal psychiatric treatment such as psychotherapy or group therapy is seldom helpful because it may overload the limited cognitive resources in the person with dementia.

LONG-TERM TREATMENT:

Providing a safe environment, controlling aggressive or agitated behavior, and meeting the physiologic needs of a person with dementia may require monitoring and assistance in the home or in an institutionalized setting. Possible options include in-home care, boarding homes, adult day care, and convalescent homes.

Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may help in caring for the person with dementia. In some communities, support groups may be available (see elder care - support group), and family counseling can help family members cope with home care.

In any care setting, there should be familiar objects and people. Lights can be left on at night to reduce disorientation. The activity schedule should be simple. Behavior modification may help some people to control unacceptable or dangerous behavior. This consists of rewarding appropriate behaviors and ignoring inappropriate ones (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may also help reduce disorientation.

Legal advice may be appropriate early in the course of the disorder, before the person with dementia becomes too incapacitated to make decisions. Advance directives, power of attorney, and other legal actions may make it easier to decide about the care of the person with dementia.

• Loss of ability to function or care for self
• Loss of ability to interact
• Increased infections anywhere in the body
• Reduced life span
• Abuse by an overstressed caregiver
• Side effects of medications used to treat the disorder

• Call your health care provider if dementia develops or a sudden change in mental status occurs.
• Call your health care provider if the condition of a person with dementia deteriorates and you are unable to cope with caring for that person in the home.