the Clinical Features of Dementia
is a chronic impairment of intellectual functioning of sufficient
severity to interfere with social or occupational functioning. Patients
with dementia manifest multiple cognitive deficits manifested by
memory impairment (impaired to learn new information or to recall
previously learned information)and one (or more) of the following
cognitive disturbances: aphasia (language disturbance), apraxia
(impaired ability to carry out motor activities despite intact motor
function), agnosia (failure to recognize or identify objects despite
intact sensory function), and disturbance in executive functioning,
(i.e., planning, organization, sequencing, abstracting). Additionally,
the diagnosis of Alzheimer's type dementia requires that illness
have a gradual onset over one or two years and progressive course
and that the cognitive deficits are not due to other conditions.
The diagnosis of vascular dementia necessitates the presence of
focal neurological signs and symptoms or laboratory evidence of
cerebrovascular disease judged to be etiologically related to the
is the Pattern of Progression of Dementia?
the earliest stages of dementia, patients manifest loss of higher
order functional skills such as the capacity to perform social or
work activities outside the home. Impaired memory, particularly
for new events, is usually the reason for initial consultation with
a physician. In the moderate stages of dementia, visual-spatial
impairment becomes prominent as indicated by the patient's inability
to draw geometric figures. Clinically, visual-spatial impairment
may impair driving abilities. As the disease progresses, word-finding
difficulties, personality alterations, hallucinations and delusions
may occur as well as behavioral disturbances including wandering,
sleep disturbances and combativeness. At this stage, loss of some
of the basic self care functions occur such as the inability to
groom and dress appropriately. In the late stages of dementia overt
aphasia may result in impaired communication and gait disturbances
and urinary incontinence occur. Eventually the patient becomes chair
or bedbound. Finally, the patient experiences an inability to eat
and swallow properly, instead holding food for long periods in the
oral cavity resulting in undernutrition and the risk of aspiration.
The duration from onset of symptoms to the bedridden non-communicative
state is variable but usually develops over five to seven years.
are the Common Causes of Dementia?
it must be understood that senility is not synonymous with dementia.
Whereas senescence and senility refer to the normal aging process,
dementia denotes a pathological process. Most often, dementia is
caused by Alzheimer's Disease, a diffuse degenerative process, or
by multi-infarct dementia (MID), due to multiple small subcortical
or cortical infarcts or lacunes. Symptoms suggestive of MID include:
history of hypertension, history of stroke or transient ischemic
attack, sudden onset, stepwise deterioration, and focal neurological
symptoms and signs. Other causes of dementia are important because
of their potential for palliation or rarely, for complete reversibility.
Longitudinal studies have pointed out that less than 4% of patients
with dementia, exclusive of depression, have a completely reversible
illness. Drugs, metabolic abnormalities, and subdural hematomas,
though less common than Alzheimer's disease, may be causative of
dementia. Structural or mass lesions due to brain tumors, and normal
pressure hydrocephalus may also present as a dementing illness.
are the principal historical facts to elicit in diagnosing dementia?
history should focus on acuity of onset, duration, course of the
illness over time, severity as indicated by functional status, presence
of the underlying organic illnesses, use of drugs associated with
these disorders, and the patients support system. Other questions
are directed at specific cognitive deficits that result in confusion:.
What was the patient's premorbid mental status? Is there a remote
or recent history of memory, orientation, or speech impairment?
Have there been periods of lethargy or stupor? When did the process
begin? Have the patient's symptoms fluctuated? Is there a history
of falls, head trauma, focal neurologic symptoms, seizures, alcohol
or other drugs of abuse? What prescription and over-the-counter
medications does the patient take?
the Components of the Physical and Mental Status Examination?
should be tested by observing the patient's responses to routine
history-taking and by asking the patient to perform specific tasks:
performing serial subtractions backward, spelling words backwards,
and, for patients whose level of education is a barrier to tests
of spelling and math, reciting the days of the week backward. Disorientation
to time is tested by asking questions related to the day, date,
month, and year while disorientation to place is tested by asking
about the city, state, country, and name of the hospital where the
patient is being examined. In testing memory, registration is first
tested by asking the patient to immediately repeat the names of
three objects, such as hat, car, and tree. Three minutes later ask
the patient to repeat the same objects. Remote memory should be
tested by asking about events with which the patient should be familiar:
city of birth, age and birthdates of children, wedding anniversary,
and other similar questions. The nature of the patient's speech
should also be observed. Is the patient drowsy, stuporous, or comatose?
Does the patient demonstrate restlessness, tremulousness, or paucity
is the Value of Neuropsychologic Testing?
tests of cognition and affect have received considerable attention
over the past decade because of their brevity and because they offer
specific instructions for physicians with limited experience in
mental status testing. Among these tests are the Mini- mental State
Examination (MMSE) and the Blessed Tomlinson Scale used to assess
cognition and the Geriatric Depression Scale used to assess affect.
Although beneficial in following the course of illness, they are
not a substitute for a detailed clinical mental status history and
examination or a substitute for formal neuropsychologic testing.
Formal neuropsychologic tests are most useful in the mildly impaired
patient suspected of dementia because of subtle cognitive deficits
but prior to the onset of overt functional deficits. Administered
by a psychologist, this examination typically consists of two to
four hours of tests designed to assess brain function in several
dimensions: general intelligence, verbal and visual memory, attention
and concentration, language, fine motor skills and visual spatial
skills. Although performance on one examination may suggest impairment,
the administration of two are more tests at six to nine month intervals
is more useful in that the magnitude and pattern of deficits as
they change over time can be suggestive of Alzheimer's Disease versus
Laboratory and Radiological Tests Should be Ordered?
suspected of dementia should always undergo the following tests:
complete blood count, electrolyte panel, metabolic panel, serologic
tests for syphilis, thyroid function tests, B 12 and folate levels,
urinalysis, electrocardiogram and chest radiograph. Other tests
should be obtained when specific diseases are suspected. For example,
the sedimentation rate is warranted when symptoms suggest giant
cell arteritis or another form of vasculitis. Tests of lyme disease
should be considered in adults with dementia accompanied by rheumatic,
cardiac or peripheral neurologic findings. An EEG cannot reliably
distinguish dementia from normal aging and is therefore of little
value as a routine test in the evaluation of dementia. Computerized
Tomography or Magnetic Resonance Imaging of the brain is useful
in selected patients when in or out subdural hematomas, mass lesions,
or normal pressure hydrocephalus when suggested by specific clinical
features: onset in less than six months, history of malignancy,
focal neurologic deficits, and recent onset of a seizure disorder.
are the Elements of Nonpharmacologic Treatment of Dementia?
most instances, dementia is due to Alzheimer's or Multiple infarcts.
In these patients, treatment is palliative rather than curative.
However, over 30% of patients with dementia have more than one illness
contributing to the dementia state. Treatment of these concomitant
disorders provides temporary improvement in 28% of 200 patients
and improvement is sustained for at least one year in 14%. Thus
patients with irreversible dementia due to Alzheimer's and MID may
improve in function with comprehensive management, although their
cognitive status continues to inexorably deteriorate. In the case
of Alzheimer's Disease, practitioners should assist the patient's
family in providing a supportive environment to compensate for the
patient's disabilities, minimize the cognitive side effects of medications,
and maximize function of organs other than the brain by treating
concomitant illnesses. Maintenance of nutrition, and exercise are
vital, as is social stimulation. Additionally, one must assist and
counsel caregivers, by providing respite when needed as well as
consultation on the legal and ethical issues that arise over the
course of dementia.
and caregiver counseling is a critical component of he management
of the demented patient. Families must be advised of the community
support services and day care centers and other forms of respite.
To avoid crises, families should be given advance notice of potential
legal and ethical issues that arise over the course of dementia.
Therefore, issues of durable power of attorney and other forms of
advance directives should be discussed early in the illness. One
of the difficult but predictable issues for families is whether
to use artifical feeding when the demented patient progresses to
the point that oral intake is insufficient or unsafe because of
aspiration. The physician should try to get the caregivers to decide
whether artifical feeding will be used before a decision has to
are Useful in Treating Dementia?
useful in treatment of dementia fall in to two categories: drugs
aimed at managing behavioral problems, such as combativeness, agitation
and sleeplessness; and drugs aimed at improving cognition. A review
of controlled trial of neuroleptic treatment in dementia showed
that 18% of dementia patients benefited but only modestly. No single
neuroleptic is superior. Although there is little scientific evidence
for the widespread use of these agents, neuroleptics are superior
to placebo in controlling anxiety, suspiciousness, uncooperativenes
and hallucinatory behaviors. It is safest to use these drugs only
if signs and symptoms of psychosis or significant excitement and
agitation complicate management. On the contrary, repetitive behaviors
such as aimless wandering, pacing and calling out are usually less
responsive to neuroleptics and they have little effect on poor self
care, social withdrawal, wandering and cognition. In these instances,
the adverse effects of neuroleptics (sedation, orthostatis, Parkinsonism,
falls and urinary retention) may reduce functional status outweighing
any benefit. When antipsychotic agents are used, butyrophenones
or other high potency agents rather than the more sedating phenothiazine
agents are indicated. The latter may be preferable if sedation is
needed. Other psychotropics including benzodiazepines, betablockers
and the antidepressant, trazodone, have been used also to induce
sleep and control agitation. In summary, agents for behavioral control
should be used as a last resort. When used, the practitioner should
avoid combining more than of these agents concurrently.
aimed at altering the progressive cognitive decline in dementia
have been the subject of multiple clinical trials. In multi-infarct
dementia (MID), the principal aim is to prevent further brain infarcts
by use of aspirin and antihypertensives, though data to support
efficacy are lacking. Vasodilators in MID have shown little benefit.
Recently attention has been directed at developing effective therapy
for Alzheimer's Disease. Categories of medications proposed to treatment
Alzheimer's include cholinomimetics to restore deficiencies of acetyl
choline in the brain; neuropeptides to induce cortical interneuronal
transmission, nootropic agents to stimulate neuron metabolic activity;
vascular agents to improve blood flow; calcium blockers to prevent
the accumulation of calcium in injured neurons; and miscellaneous
agents including nerve growth factors and cell membrane stabilizers.
What is the
Benefit of Acetylcholine Esterase Inhibitors?
clinical use, most progress in the treatment of Alzheimer's Disease
has been made with acetylcholine esterase inhibitors. Tetrahydroaminoacridine
(Tacrine), recently released in the United States, has been marketed
for patients with mild to moderate disease. Recent randomized trials
of tacrine in England, Canada, and the United States provide a basis
for using this medication in some patients. Of note, patients studied
have had mild to moderate dementia (mean Mini-Mental State Examination
score of 16 to 18). When seen, improvements have been in cognitive
rather than in behavioral function. In summary, studies show that
tacrine in doses of 40 to 160 mg per day :
a small subgroup of patients with Alzheimer's Disease;
cognition or slows rate of cognitive decline over a short period,
but the magnitude of the improvement is small ;
causes hepatotoxicity that is usually reversible; and most important,
use requires a clear commitment from patients, caregivers, and
clinicians because of the need for careful monitoring.
the other hand, the duration of the effect of Tacrine is unknown
since studies have been of short duration and because study populations
have been highly selected, its effectiveness in severe dementia
or in demented patients with co-morbidities is unknown.