Dementia

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Description/Definition

Dementia refers to a group of symptoms associated with a decline in mental ability. It is caused by disorders affecting the brain, and are described by a collection of symptoms affecting the brain. Dementia has an effect on thinking, behaviour and social interaction, as well as functional abilities.

Clinically relevant anatomy

Hippocampus:

• Center of memory and learning
• Cells in this region are normally first to be damaged, resulting in the most common symptom of memory loss

Epidemiology & Etiology

Epidemiology

Dementia is more common in the population above 65.

Etiology

Damage to brain cells causes changes to cognitive, behavioural and emotional functions, causing dementia

Different types of dementia has different causes. Common types of dementia are:

• Alzheimer's disease (most common type):
  • 60-80% of cases
• Vascular dementia (second most common type):
  • After a cerebrovascular accident
• Dementia with Lewy bodies
• Fronto-temporal lobar degeneration
• Huntington's disease
• Alcohol related dementia (Korsakoff's syndrome)
• Creutzfeldt-Jacob disease

Clinical presentation

Early signs of dementia are normally subtle, and not always obvious. It can include:

• Progressive and frequent memory loss (mostly short-term)
• Confusion
• Personality change
• Apathy and withdrawal
• Loss of functional abilities to perform activities of daily living

Although some cases of dementia are reversible (e.g. hormonal or vitamin deficiencies), most are progressive, with a slow, gradual onset. Certain symptoms, mostly behavioural and psychological, can result from drug interactions, environmental factors, unreported pain and other illnesses.

Diagnostic procedures

There are no clear test to diagnose dementia. To make the diagnosis of dementia, at least two of the core mental functions need to be significantly impaired:

• Memory
• Communication and language skills
• Concentration and focus
• Reasoning and judgment
• Visual perception

Certain types of dementia is diagnosed by medical history, physical examination, blood tests, and characteristic changes in thinking, behaviour and the effect on performance of activities of daily living. The diagnosis of dementia itself is relatively straight-forward to make, but a lot of times it is difficult to diagnose the exact type, as a lot of the symptoms and brain changes overlap. Neurologists or gero-psychologist normally assist in the diagnosis of the specific types of dementia.

Differential diagnosis

Dementia can have different causes, and the following causing conditions can improve with treatment:

• Vitamin deficiencies
• Hormone deficiencies (e.g. thyroid problems)
• Depression
• Medication side-effects
• Alcohol abuse
• Overmedication
• Infections
• Brain tumours

Outcome Measures

add links to outcome measures here (see Outcome Measures Database)

Medical management

Medical management should be obtained as soon as symptoms start appearing, as some of the causes are treatale, and early diagnosis and management can slow down or treat the disease process to allow most benefit from available treatments.

Medication

Antidepressants

Effectiveness is normally only seen after 2-3 weeks.

• Types:
  • Tricyclic (amitriptyline, imipramine or dothiepin)
    • Side-effects:
      • Worsening confusion
      • Dry mouth
      • Blurry vision
      • Constipation
      • Dizziness in upright position (thus not recommended in Alzheimer's disease, as it can cause falls and injuries)
      • Difficulty with urination
  • Newer types of antidepressants have less side-effects
    • First line treatment: Fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram and escitalopram
    • Side-effect
      • Headaches
      • Nausea

• Commonly prescribed:
  • Antidepressants:
    • Amitriptyline (Endep) 
    • Citalopram (Cipramil, also Celapram, Ciazil, Talam, Talohexal) 
    • Dothiepin (Prothiaden, also Dothep) 
    • Doxepin (Sinequan, also Deptran)
    • Escitalopram (Lexapro) 
    • Fluoxetine (Prozac, also Lovan, Auscap, Fluohexal, Fluoxebell, Zactin) 
    • Fluvoxamine (Faverin, also Movax, Luvox, Voxam) 
    • Imipramine (Tofranil, also Tolerade) 
    • Mirtazipine (Avanza, Axit, Mirtazon, Remeron) 
    • Nortriptyline (Allegron) 
    • Paroxetine (Aropax, Paxtine, Oxetine) 
    • Reboxetine (Edronax) 
    • Sertraline (Zoloft, Xydep, Eleva, Concorz) 
    • Venlafaxine (Efexor)
    • Lithium carbonate (Lithicarb, Quilonum) - mood stabilizer

Antipsychotics

• Neuroleptics/major tranquillisers such as:
  • Amisulpride (Solian) 
  • Chlorpromazine (Largactil)  
  • Fluphenazine (Modecate) 
  • Haloperidol (Haldol, Serenace) 
  • Moclobemide (Auroix) 
  • Olanzapine (Zyprexa) 
  • Promazine (Promazine) 
  • Quetiapine (Seroquel) 
  • Risperidone (Risperdal) 
  • Sulpiride (Dolmatil, Sulparex, Sulpitil) 
  • Trifluoperazine (Stelazine) 
  • Zuclopenthixol (Clopixol)

• Treats agitation, aggression and psychotic symptoms
• Side-effects:
  • Sedation
  • Dizziness
  • Unsteadiness
  • Shakiness, slowless, stiffness of limbs (resembles Parkinson's disease)

Hypnotics

• Treatment of sleep disturbances
• Side-effects:
  • Excessive sedation
  • Increased confusion
  • Unsteadiness
  • Long-term use: Tardive dyskinesia

• Commonly prescribed:
  • Chloral hydrate (Welldorm) 
  • Clomethiazole (Heminevrin) 
  • Flurazepam (Dalmane) 
  • Nitrazepam (Mogadon also Alodorm) 
  • Temazepam (Femaze, Temtabs, Normison) 
  • Zopiclone (Imrest, Imovane) 
  • Zolpidem (Stilnoct)

Anxiety-relieving drugs

• Benzodiazepine - short periods of anxiety
  • Short duration: Lorazepam, oxazepam
  • Long duration: Chlordiazepoxide, diazepam
• Long term use not recommended
• Side-effects:
  • Excessive sedation
  • Unsteadiness
  • Accentuation of confusion and memory deficits

• Commonly prescribed:
  • Alprazolam (Xanax, also Alprax, Kalma, Zamahexal) 
  • Buspirone (Buspar) 
  • Diazepam (Valium also Antenex, Valpam, Ducene) 
  • Lorazepam (Ativan) 
  • Oxazepam (Alepam, Serepax, Minelax)

Anticonvulsants

• Commonly prescribed:
  • Sodium valproate (Epilim also Valpro) 
  • Carbamazepine (Tegretol)

• Reduce aggression and agitation

Cholinesterase inhibitors

• Donepezil, galantamine, rivastigmine
• Effects:
  • Improve memory and ability to perform activities of daily living (especially in Alzheimer's disease)
  • Slight effect on behavioural symptoms, mood, confidence, delusions, hallucinations
• Side-effects (high dosages):
  • Increased agitation
  • Insomnia with nightmares

Lifestyle modifications

• Regular exercise/active lifestyle:
  • Very effective in the management of the depression component of dementia
• Stimulating daily activities

Resources 

• Help sheets