Dementia is when the brain gradually loses its ability to think. Thinking means learning new information, remembering old information, and putting information together to function. When this ability is lost all of a sudden, and the person becomes newly confused, the term is “Delirium,” which is always due to an acute medical illness (occasionally psychiatric). We send such patients right to an emergency room, sometimes by ambulance.
Dementia is most common over 85-years-old. At that age, families almost expect it, & sometimes don’t seek care. When the same illnesses begin younger, it’s obviously much more tragic. Of course, a person with chronic dementia can develop a medical illness that causes new confusion, needing rapid diagnosis and treatment.
People with Dementia don’t complain about losing their memory; actually, they don’t even realize what’s happening. It’s their family and friends who bring them for care. Diagnosis is outlined under topic Memory Loss. Basically, we:
- Get a sense of the things they forget, and how it affects their life in general
- Perform a general examination & order basic lab tests, maybe images (x-rays, etc.), to be sure there’s no medical illness causing the problem
- Perform various memory tests
- Refer to a Neurologist if families / patients want confirmation, and a specific diagnosis of what disease is the cause
There are various causes of Dementia:
1. Alzheimer’s Disease. This is caused by abnormal protein plaques (made of “amyloid”) forming in the brain. Nobody knows why it occurs, except that it’s much more common with older age (5% of people over 65, but the great majority of them are over 85). Some younger people get it for genetic reasons. A variety of factors may increase risk a tiny bit in studies (some medications & diseases, smoke, pollution, etc.), but none are clear causes.
There’s no cure, and the disease keeps getting worse over a few years. Half of those diagnosed at age 65 live at least 9 more years, only 3 more if diagnosed at age 90. Medications don’t work well at all, nor does rehab. Treatment is “supportive,” meaning assuring good nutrition. exercise, and especially safety, while avoiding alcohol & sedating medications.
The earliest symptoms are loss of recent memory — things newly learned. The easiest test is to ask patients to remember three words 5 minutes later (after rehearsing the words a few times at first). Patients may have trouble multi-tasking, & become more disorganized; eventually they are unable to dress or groom themselves. A Brief Questionnaire for family and friends can help with diagnosis.
Even though the disease may run in families, it’s impossible to estimate the chance of it occurring in a specific person. Genetic tests may be relatively accurate only among the rare families in which members developed Alzheimer’s at a very early age. For persons whose elderly relatives have the illness, tests are not at all useful.
More information is available from the Alzheimer’s Association (1-800-272-3900, or http://www.alz.org).
2. Lewy-body Dementia. Lewy bodies are abnormal particles inside brain cells that can be seen by a microscope. Nobody knows why they occur, but almost all patients are over 50 (average age 75), men affected more than women. The actor Robin Williams seems to have committed suicide because of it.
As opposed to Alzheimer’s, memory loss is not the earliest symptom. Instead, people have unexplainable problems with actions like driving, or at work. These tend to come and go, with good days & bad days. There may be weird visual hallucinations, and stiff movements on-and-off that look like Parkinson’s. There may be sleep problems, frequent falls, and blacking out spells (like staring blankly).
Diagnosis is made clinically, by a good history, and then Neuropsychiatric Testing (complex tests of memory and thought, takes several hours, administered by psychologists). The main problem is that clinicians aren’t aware of the possibility, so they don’t refer. There’s no treatment other than general measures (see above). The Alzheimer’s Association can offer information (see above).
3. Fronto-Temporal Dementia (FTD). Once thought to be rare, this form of dementia, which occurs relatively early compared to other types (average age 60), is becoming more recognized. The cause is unknown. Memory problems are not as obvious; it’s usually a change in behavior that families & friends notice. Patients themselves aren’t aware.
Patients may have personality changes, become apathetic, or lose their inhibitions (doing embarrassing things in public). Eating habits often change, patients may stop caring about loved ones or pets, and can become compulsive (like always watching the clock). Some patients simply forget words & then lose their speech, without seeming to care about it.
Diagnosis is best made by a neurologist, especially since this begins at an early age. There’s no specific treatment, though psychiatric medications sometimes help symptoms. The disease tends to progress somewhat faster than other forms of dementia, with death usually occurring within 10 years. Fronto-Temporal Dementia is somewhat more inheritable than other forms of dementia. If family members are concerned, they should request referral to a genetic counselor.
4. Vascular Dementia. Previously called “multi-infarct dementia,” this is the second most common cause of dementia after Alzheimer’s, and is caused by Strokes. Sometimes the stroke comes from blockage of a large artery and is obvious. But often, there may be repeated small strokes in small deep arteries, so there’s no sudden onset noticeable.
In the latter case, symptoms develop subtly. Memory loss may be mild, with difficulty functioning overall. There may be falls and trouble walking, funny facial twitching or grimacing, or urinary changes not due to bladder infection or disease. Personality may become apathetic, mood may seem depressed, actions may be slow and seemingly uninterested.
Vascular Dementia can be differentiated from Alzheimer’s if there’s an abrupt onset, if disability waxes and wanes but keeps worsening, or if there are abnormalities on physical exam (the neurologic exam). Patients usually have risks for strokes, like hypertension, diabetes, or high cholesterol, although advanced age by itself is a major risk. MRI is able to diagnose presence of strokes; sometimes a CT scan can also. The main treatment is to prevent future Strokes. We try to lower blood pressure, keep diabetes under control, treat high cholesterol, and help smokers quit. If dementia becomes profound, general protective measures as for Alzheimer’s are important (see above).
5. Parkinson’s Disease can also cause dementia. Click link for the topic.