Jump to content

Dementia

From Wikipedia, the free encyclopedia

This is an old revision of this page, as edited by 76.106.58.112 (talk) at 04:39, 28 April 2009. The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

For other uses, see Dementia (disambiguation).
Dementia
SpecialtyPsychiatry, neurology Edit this on Wikidata
Frequency3.8—4% (Asia), 6.1—6.3% (Europe), 6.4—6.6% (Americas), 2.5—2.7% (Africa)

Dementia (from Latin de- "apart, away" + mens "mind") is the progressive decline in cognitive function due to damage or disease in the body beyond what might be expected from normal aging. Although dementia is far more common in the geriatric population, it may occur in any stage of adulthood. This age cutoff is defining, as similar sets of symptoms due to organic FAT [citation needed] brain dysfunction are given different names in populations younger than adult.

Dementia is a non-specific illness syndrome (set of signs and symptoms) in which affected areas of cognition may be memory, attention, language, and problem solving. Higher mental functions are affected first in the process. Especially in the later stages of the condition, affected persons may be disoriented in time (not knowing what day of the week, day of the month, or even what year it is), in place (not knowing where they are), and in person (not knowing who they are or others around them).

Symptoms of dementia can be classified as either reversible or irreversible, depending upon the etiology of the disease. Less than 10 percent of cases of dementia are due to causes which may presently be reversed with treatment. Causes include many different specific disease processes, in the same way that symptoms of organ dysfunction such as shortness of breath, jaundice, or pain are attributable to many etiologies. Without careful assessment of history, the short-term syndrome of delirium can easily be confused with dementia, because they have many symptoms in common. Some mental illnesses, including depression and psychosis, may also produce symptoms which must be differentiated from both delirium and dementia.[1]

Diagnosis

Proper differential diagnosis between the types of dementia (cortical and subcortical - see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist.[citation needed] However, there exist some brief tests (5–15 minutes) that have reasonable reliability and can be used in the office or other setting to screen cognitive status for deficits which are considered pathological. Examples of such tests include the abbreviated mental test score (AMTS), the mini mental state examination (MMSE), Modified Mini-Mental State Examination (3MS),[2] the Cognitive Abilities Screening Instrument (CASI),[3] and the clock drawing test.[4] An AMTS score of less than six (out of a possible score of ten) and an MMSE score under 24 (out of a possible score of 30) suggests a need for further evaluation. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances; for example, a person highly depressed or in great pain will not be expected to do well on many tests of mental ability.

Mini-mental state examination

Main article: Mini-mental state examination

The U.S. Preventive Services Task Force (USPSTF) reviewed tests for cognitive impairment and concluded:[5]

  • MMSE
sensitivity 71% to 92%
specificity 56% to 96%

Modified Mini-Mental State examination (3MS)

A copy of the 3MS is online.[6] A meta-analysis concluded that the Modified Mini-Mental State (3MS) examination has:[7]

sensitivity 83% to 93.5%
specificity 85% to 90%

Abbreviated mental test score

Main article: abbreviated mental test score

A meta-analysis concluded:[7]

sensitivity 73% to 100%
specificity 71% to 100%

Other examinations

Many other tests have been studied[8][9][10] including the clock-drawing test (example form). Although some may emerge as better alternatives to the MMSE, presently the MMSE is the best studied. However, access to the MMSE is now limited by enforcement of its copyright.[citation needed]

Another approach to screening for dementia is to ask an informant (relative or other supporter) to fill out a questionnaire about the person's everyday cognitive functioning. Informant questionnaires provide complementary information to brief cognitive tests. Probably the best known questionnaire of this sort is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).[11]

Further evaluation includes retesting at another date, and administration of other (and sometimes more complex) tests of mental function, such as formal neuropsychological testing.

Laboratory tests

Routine blood tests are also usually performed to rule out treatable causes. These tests include vitamin B12, folic acid, thyroid-stimulating hormone (TSH), C-reactive protein, full blood count, electrolytes, calcium, renal function, and liver enzymes. Abnormalities may suggest vitamin deficiency, infection or other problems that commonly cause confusion or disorientation in the elderly. The problem is complicated by the fact that these cause confusion more often in persons who have early dementia, so that "reversal" of such problems may ultimately only be temporary.

Chronic use of substances such as alcohol can also predispose the patient to cognitive changes suggestive of dementia.

Imaging

A CT scan or magnetic resonance imaging (MRI scan) is commonly performed, although these modalities (as is noted below) do not have optimal sensitivity for the diffuse metabolic changes associated with dementia in a patient who shows no gross neurological problems (such as paralysis or weakness) on neurological exam. CT or MRI may suggest normal pressure hydrocephalus, a potentially reversible cause of dementia, and can yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. However, the functional neuroimaging modalities of SPECT and PET have shown similar ability to diagnose dementia as clinical exam.[12] The ability of SPECT to differentiate the vascular cause from the Alzheimer disease cause of dementias, appears to be superior to differentiation by clinical exam.[13]

Types

Cortical dementias

Cortical dementias arise from a disorder affecting the cerebral cortex, the outer layers of the brain that play a critical role in cognitive processes such as memory and language.

Subcortical dementias

Subcortical dementias result from dysfunction in the parts of the brain that are beneath the cortex. Usually, the memory loss and language difficulties that are characteristic of cortical dementias are not present. Rather, people with subcortical dementias, such as Huntington's disease, Parkinson's Disease, and AIDS dementia complex, tend to show changes in their personality and attention span, and their thinking slows down.

Dementia and early onset dementia have been associated with neurovisceral porphyrias. Porphyria is listed in textbooks in the differential diagnosis of dementia. Because acute intermittent porphyria, hereditary coproporphyria and variegate porphyria are aggravated by environmental toxins and drugs the disorders should be ruled out when these etiologies are raised.

Treatment

Except for the treatable types listed above, there is no cure to this illness, although scientists are progressing in making a type of medication that will slow down the process.[citation needed] Cholinesterase inhibitors are often used early in the disease course. Cognitive and behavioral interventions may also be appropriate. Educating and providing emotional support to the caregiver (or carer) is of importance as well (see also elderly care).

A Canadian study found that a lifetime of bilingualism has a marked influence on delaying the onset of dementia by an average of four years when compared to monolingual patients. The researchers determined that the onset of dementia symptoms in the monolingual group occurred at the mean age of 71.4, while the bilingual group was 75.5 years. The difference remained even after considering the possible effect of cultural differences, immigration, formal education, employment and even gender as influences in the results.[14]

Some studies worldwide have found that Music therapy may be useful in helping patients with dementia.[15][16][17][18][19]

Medications

Tacrine (Cognex), donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon) are approved by the United States Food and Drug Administration (FDA) for treatment of dementia induced by Alzheimer disease. They may be useful for other similar diseases causing dementia such as Parkinsons or vascular dementia.[20]

  • N-methyl-D-aspartate Blockers. Memantine (Namenda) is a drug representative of this class. It can be used in combination with acetylcholinesterase inhibitors.[citation needed]

Off label

  • Amyloid deposit inhibitors

Minocycline and Clioquinoline, antibiotics, may help reduce amyloid deposits in the brains of persons with Alzheimer disease.[21]

Depression is frequently associated with dementia and generally worsens the degree of cognitive and behavioral impairment. Antidepressants may be helpful in alleviating cognitive and behavior symptoms by reuptaking neurotransmitter regulation through reuptake of serotonin, noradrenaline and dopamine.[citation needed]

Many patients with dementia experience anxiety symptoms. Although benzodiazepines like diazepam (Valium) have been used for treating anxiety in other situations, they are often avoided because they may increase agitation in persons with dementia and are likely to worsen cognitive problems or are too sedating. Buspirone (Buspar) is often initially tried for mild-to-moderate anxiety.[citation needed]

Selegiline, a drug used primarily in the treatment of Parkinson's disease, appears to slow the development of dementia. Selegiline is thought to act as an antioxidant, preventing free radical damage. However, it also acts as a stimulant, making it difficult to determine whether the delay in onset of dementia symptoms is due to protection from free radicals or to the general elevation of brain activity from the stimulant effect.[citation needed]

Contraindicated

  • Antipsychotic drugs

Both typical antipsychotics (such as Haloperidol) and atypical antipsychotics such as (risperidone) increases the risk of death in dementia-associated psychosis.[22] Antipsychotics are therefore not indicated for the treatment of dementia-related psychosis.[23] This means that any use of antipsychotic medication for dementia-associated psychosis is off-label, and should only be considered after discussing the risks and benefits of treatment with these drugs, and after other treatment modalities have failed.

Prevention

Main article: Prevention of dementia

It appears that the regular moderate consumption of alcohol (beer, wine, or distilled spirits) and a Mediterranean diet may reduce risk.[24][25][26][27] A study has shown a link between high blood pressure and developing dementia. The study, published in the Lancet Neurology journal July 2008, found that blood pressure lowering medication reduced dementia by 13%.[28][29]

There has been much research showing capability for psychoactive ingredients in Cannabis preventing and helping reverse damage from dementia. Compounds in Cannabis (cannabinoids), specifically ∆9THC and Cannabidol, are neuroprotective antioxidents that stimulate neurogenesis. The existence of CB1 and CB2 receptors (cannabinoid receptors) in the hippocampus and other important area's of the brain, allow for the possibility of preventing dementia.--Blankcortex (talk) 18:28, 18 April 2009 (UTC)--

Risk to self and others

Driving with dementia could lead to severe injury or even death to self and others. Doctors should advise appropriate testing on when to quit driving.[30]

Florida's Baker Act allows law enforcement and the judiciary to force mental evaluation for those suspected of suffering from dementia or other mental incapacities.[citation needed]

Services

Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Adult daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers.

See also

References

Notes

  1. ^ American Family Physician, March 1, 2003 Delirium
  2. ^ Teng E L, Chui H C. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 1987;48:314–18. PMID 3611032
  3. ^ Teng E L, Hasegawa K, Homma A, et al. The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr 1994;6:45–58. PMID 8054493
  4. ^ Royall, D.; Cordes J.; & Polk M. (1998). "CLOX: an executive clock drawing task". J Neurol Neurosurg Psychiatry. 64 (5): 588–94. doi:10.1136/jnnp.64.5.588. PMID 9598672.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ^ Boustani, M.; Peterson, B.; Hanson, L.; Harris, R.; & Lohr, K. (2003). "Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force". Ann Intern Med. 138 (11): 927–37. PMID 12779304. {{cite journal}}: Unknown parameter |day= ignored (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  6. ^ "Appendix: The Modified Mini-Mental State (3MS)". Retrieved 2007-09-06.
  7. ^ a b Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry. 2007 Aug;78(8):790-9. Epub 2006 Dec 18. PMID 17178826
  8. ^ Sager, M.; Hermann, B.; La Rue, A.; & Woodard, J. (2006). "Screening for dementia in community-based memory clinics". WMJ. 105 (7): 25–9. PMID 17163083.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Fleisher, A.; Sowell B.; Taylor C.; Gamst A.; Petersen R.; & Thal L. (2007). "Clinical predictors of progression to Alzheimer disease in amnestic mild cognitive impairment". Neurology. 68: 1588. doi:10.1212/01.wnl.0000258542.58725.4c. PMID 17287448.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Karlawish, J. & Clark, C. (2003). "Diagnostic evaluation of elderly patients with mild memory problems". Ann Intern Med. 138 (5): 411–9. PMID 12614094.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Jorm, A.F. (2004). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): A review. International Psychogeriatrics, 16, 1-19.
  12. ^ Bonte, FJ (2006). "Tc-99m HMPAO SPECT in the differential diagnosis of the dementias with histopathologic confirmation". Clinical Nuclear Medicine. 31 (7): 376–8. doi:10.1097/01.rlu.0000222736.81365.63. PMID 16785801. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  13. ^ Dougall, NJ (2004). "Systematic review of the diagnostic accuracy of 99mTc-HMPAO-SPECT in dementia". The American Journal of Geriatric Psychiatry. 12 (6): 554–70. doi:10.1176/appi.ajgp.12.6.554. PMID 15545324. {{cite journal}}: |access-date= requires |url= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  14. ^ "Bilingualism Has Protective Effect In Delaying Onset Of Dementia By Four Years, Canadian Study Shows". Medical News Today. 2007-01-11. Retrieved 2007-01-16.
  15. ^ Aldridge, David, Music Therapy in Dementia Care, London : Jessica Kingsley Publishers, November 2000. ISBN 1853027766
  16. ^ Tuet, R.W.K.; Lam, L.C.W. (September 2006) "A preliminary study of the effects of music therapy on agitation in Chinese patients with dementia", Hong Kong Journal of Psychiatry, Volume 16, Number 3
  17. ^ Watanabe, Tomoyuki; et al., "Effects of music therapy for dementia: A systematic review", (in Japanese) Aichi University of Education Research Reports, v.55, pp. 57-61, March, 2005
  18. ^ Koger, Susan M.; Chapin Kathyn; Brotons, Melissa, "Is Music Therapy an Effective Intervention for Dementia? : A Meta-Analytic Review of Literature", Journal of Music Therapy 36(1), February 1999, pp.2-15.
  19. ^ Remington, Ruth, "Calming Music and Hand Massage With Agitated Elderly", Nursing Research 51(5): 317-323, September/October 2002.
  20. ^ Lleo A, Greenberg SM, Growdon JH. Current pharmacotherapy for Alzheimer's disease. Annu Rev Med. 2006;57:513-33. Review. PMID 16409164
  21. ^ Choi, Y., Kim, H.S., Shin, K.Y., Kim, E.M., Kim, M., Kim, H.S., Park, C.H., Jeong, Y.H., Yoo, J., Lee, J.P., Chang K.A., Kim S., & Suh, Y.H. Related Minocycline Attenuates Neuronal Cell Death and Improves Cognitive Impairment in Alzheimer's Disease Models. Neuropsychopharmacology. 2007 Apr 4; PMID 17406652
  22. ^ "FDA MedWatch - 2008 Safety Alerts for Human Medical Products". FDA.
  23. ^ "FDA MedWatch - 2008 Safety Alerts for Human Medical Products". FDA.
  24. ^ Mukamal KJ, Kuller LH, Fitzpatrick AL, Longstreth WT, Mittleman MA, Siscovick DS (2003). "Prospective study of alcohol consumption and risk of dementia in older adults". JAMA. 289 (11): 1405–13. doi:10.1001/jama.289.11.1405. PMID 12636463. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  25. ^ Ganguli M, Vander Bilt J, Saxton JA, Shen C, Dodge HH (2005). "Alcohol consumption and cognitive function in late life: a longitudinal community study". Neurology. 65 (8): 1210–7. doi:10.1212/01.wnl.0000180520.35181.24. PMID 16247047. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  26. ^ Huang W, Qiu C, Winblad B, Fratiglioni L (2002). "Alcohol consumption and incidence of dementia in a community sample aged 75 years and older". J Clin Epidemiol. 55 (10): 959–64. doi:10.1016/S0895-4356(02)00462-6. PMID 12464371. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  27. ^ Sofi F, Cesari F, Abbate R, Gensini GF, Casini A (2008). "Adherence to Mediterranean diet and health status: meta-analysis". BMJ. 337: a1344. doi:10.1136/bmj.a1344. PMC 2533524. PMID 18786971.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  28. ^ Fillit H, Nash DT, Rundek T, Zuckerman A (2008). "Cardiovascular risk factors and dementia". Am J Geriatr Pharmacother. 6 (2): 100–18. doi:10.1016/j.amjopharm.2008.06.004. PMID 18675769. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  29. ^ Peters R, Beckett N, Forette F; et al. (2008). "Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial". Lancet Neurol. 7 (8): 683–9. doi:10.1016/S1474-4422(08)70143-1. PMID 18614402. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  30. ^ Drivers with dementia a growing problem, MDs warn, CBC News, Canada, September 19, 2007
Retrieved from "https://en.wikipedia.org/w/index.php?title=Dementia&oldid=286587393"