Dementia

There are seven stages of dementia.

• Dementia is a broad description that includes many different symptoms, including memory loss, word-finding difficulties, impaired judgment, and problems with day-to-day activities, which are caused by injury or loss of brain cells (neurons). In the U.S., one in 10 people over 65 years of age have dementia according to a 2016 study.
• Signs and symptoms of dementia are varied but typically include the following:
  • Memory loss
  • Problems with speaking or communicating (word-finding difficulties, repetition)
  • Problems focusing
  • Impairments in judgment
  • Struggles completing tasks
  • Has difficulty comprehending what is seen
• Causes of dementia are factors that lead to damage to neurons. Once the brain cells are injured, they lose their ability to communicate with other cells, leading to dysfunction.
• The types of dementia include Lewy body dementia, vascular dementia, and frontotemporal dementia. Other types include dementia associated with Parkinson's disease or Huntington's disease. Senile dementia (senility) is a term that was once used to describe all dementias; this term is no longer used as a diagnosis.
• The stages of dementia are used when progressive dementia has been diagnosed. The stages include the following:
  • Stage 1: No impairment. The patient has no problems.
  • Stage 2: Questionable impairment. The patient begins to have some difficulty but can still function independently.
  • Stage 3: Mild impairment. The patient has obvious, but still mild difficulty with daily activities.
  • Stage 4: Moderate impairment. The patient needs help with caring for him or herself as well as with carrying out daily activities.
  • Stage 5: Moderate to severe impairment
  • Stage 6: Severe Impairment; patients are unable to function independently.
  • Stage 7: Very severe impairment. Body and mental functions begin to fail.

• Risk factors for dementia include the following:
  • Age
  • Family history
  • Heavy alcohol use
  • Hardening of the arteries
  • High blood pressure
  • Diabetes
  • High cholesterol
  • Smoking
• Dementia is diagnosed after a series of assessments, including a physical evaluation and determination of the history of any problems. Memory tests, imaging studies, and blood work may exclude other problems which might mimic dementia. The diagnosis of dementia can take a long time.
• The treatment for dementia is primarily supportive. Prescription medications cannot reverse or stop the process. Environmental changes, a structured schedule, regular exercise, and staying engaged with others can all be beneficial.
• Home care for dementia can be beneficial for patients and families, as a way for patients to remain close to family members. However, caregivers should confirm that they have helped to avoid burnout.
• Prescription drugs to treat dementia include donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda). A new combination of donepezil and memantine (Namzaric) was recently approved by the FDA.
• Although there is no way to prevent dementia, modifying the risk factors of high blood pressure, high cholesterol, alcohol intake, and keeping diabetes as well-controlled as possible, as well as exercising regularly can help.
• The prognosis for a person with dementia is individual. Some patients have a rapidly progressive course, while others progress very slowly. Factors that contribute to the progression of dementia haven't been fully identified.

Dementia is often one of the most misunderstood conditions in medicine today. Some people believe that senility or senile dementia is an inevitable result of aging, and never seek evaluation for family members who show signs of memory loss. Others believe that any evidence of forgetfulness is evidence of dementia. Neither of these conclusions is accurate.

Additionally, many questions have been raised about dementia. Does dementia differ from Alzheimer's disease or are all forms of dementia Alzheimer's disease? If someone has memory loss associated with another condition, does that turn into Alzheimer's disease? What can be expected if someone has been diagnosed with dementia?

Many patients with early signs of dementia are unaware that they have any problems.

Early signs of dementia may include the following:

• Simple forgetfulness
• Losing items
• Problems performing tasks or activities that were previously done without effort.
• Difficulty with learning new material is frequently one of the earliest signs of dementia.

Many patients with early Alzheimer's disease or other types of dementia are unaware that they have any problems. As the disease progresses, behavioral changes can become evident.

• Patients have difficulty performing basic tasks, such as getting dressed or using the bathroom.
• Some patients begin to forget pieces of information about themselves, including their address or telephone number, or even their date of birth.
• They may have difficulty understanding what is occurring around them.
• Some patients have problems remembering to eat and may develop pronounced weight loss.
• In the late stages of dementia, patients often cannot recognize family members, and their ability to communicate effectively is markedly impaired.
• They are no longer able to effectively care for themselves and require assistance for all activities of daily living.
• Over time, patients can forget how to walk or even how to sit up.

Dementia is a broad term that covers many different conditions, including Alzheimer's disease, vascular dementia, frontotemporal dementia, and other disorders.

Simple forgetfulness is not enough to lead to a diagnosis of dementia, as there needs to be evidence of problems in at least two areas of cognition (brain function) to confirm this diagnosis.

Possible symptoms or signs of dementia include the following:

• Memory loss
• Problems with speaking include difficulty completing sentences or finding the right word to say
• Difficulty completing tasks
• Difficulty recognizing items or people
• Showing signs of poor judgment
• People with dementia may have problems preparing food
• Performing household chores
• Paying bills

They may repeat questions or stories regularly, or forget appointments. They may get lost in familiar environments. Personality changes, including irritability or agitation, may also occur. In some cases, people with dementia develop hallucinations (or see things that aren't really there).

1. Alzheimer's dementia/Alzheimer's disease (AD) is the most common form of dementia. The cause has not yet been identified. While patients with AD have amyloid plaques (an accumulation of an abnormal protein) identified in certain areas of their brain, it is unclear if these plaques are the cause of the disease or a result of the disease. Although most cases of Alzheimer's disease begin after the age of 65, in some cases symptoms begin when someone is in their 40s or 50s. This early-onset Alzheimer's disease can progress more rapidly than later-onset AD.
2. Vascular dementia is the second most common cause of dementia and is due to multiple strokes occurring within the brain. Often, these strokes may have been unnoticed and patients may not have any associated symptoms such as weakness, visual loss, or numbness. Patients with untreated high blood pressure or heart disease may be at risk of developing vascular dementia.
3. Frontotemporal dementia is associated with pronounced atrophy or shrinkage of the frontal and temporal lobes in the brain. In addition to forgetfulness and word-finding problems, patients may have marked personality changes, impulsivity, or poor judgment. Some patients with frontotemporal dementia can develop incoordination or stiffness of their muscles.

• Normal pressure hydrocephalus is an abnormal enlargement of the ventricles, or fluid-filled spaces within the brain, that causes pressure on areas of the brain. This leads to problems with walking, memory, and the ability to control urine flow (incontinence). Although this can be identified with imaging of the brain (MRI or CT scan), further testing may be required to confirm the diagnosis. If diagnosed, this condition can be treated with the placement of a shunt to drain the extra fluid.
• Huntington's disease causes characteristic abnormal movements, called chorea, in affected individuals. The movements are the hallmark of the diagnosis. However, in some cases, problems with memory can precede the development of the chorea by many years.
• Alcoholic dementia is caused when patients drink heavily and develop a deficiency in one of the B vitamins. When this happens, brain cells are unable to function normally and memory loss can occur. This is called Korsakoff syndrome. Although it is most commonly seen in alcoholics, patients who are malnourished from other causes are also at risk of developing this disorder.
• Traumatic brain injury (concussion)/dementia) pugilistic can lead to memory problems, as we have learned in recent years. In some cases, recurrent brain injuries or repeated concussions can contribute to the underlying changes identified in Alzheimer's disease.

• Lewy body dementia/Lewy body disease is caused by Lewy bodies, which are abnormal clumps of certain proteins, accumulating inside of neurons. Forgetfulness and other signs of cognitive decline are the primary features of this condition, but patients can also develop prominent hallucinations which seem very real to them. Some patients with Lewy body disease develop symptoms that look like Parkinson's disease, such as tremors and slowness.
• Creutzfeldt-Jakob disease is a rare condition where an abnormal protein leads to the destruction of brain cells and dementia. While most cases occur without an underlying cause, in some patients there is a family history of this disorder. Even less often, patients might be exposed to the abnormal protein. Mad cow disease is one example of external exposure. This condition tends to progress rapidly, over only a few years and is often associated with abnormal muscle movements.
• Mixed dementia refers to patients who have evidence of two (or more) types of dementia. They are often described as having mixed dementia. Alzheimer's disease and vascular dementia are the most common causes of mixed dementia.

The stages of dementia are loosely grouped into mild, moderate, and severe categories by some doctors. However, there is another system of staging for dementia.

• Stage 1: No cognitive decline.
• Stage 2: Mild cognitive decline.
• Stage 3: Moderate cognitive decline, for example, dementia impairment like memory lapses, and losing objects daily.
• Stage 4: Moderately severe cognitive decline, for example, poor short-term memory, forgetting personal details, and difficulty with basic math. This is usually the longest stage of dementia.
• Stage 5: Moderately severe cognitive decline, for example, increasing problems planning or organizing, disorientation, and may no longer be able to live alone.
• Stage 6: Severe cognitive decline, for example, problems recognizing friends and family members, and memory loss that worsens.
• Stage 7: Very severe cognitive decline. This is the final stage of dementia. Body systems decline, and communication is limited.

Patients may seem to fall into two different stages at the same time, depending on what symptoms they are experiencing. The different stages of dementia cannot be used to predict how rapidly someone's condition might progress and patients may remain in one stage for many years or for only a few months. Every patient has a different progression of their disease.

The risk factors for developing dementia include age and family history. Age and a family history of dementia are non-modifiable risk factors.

• Abnormal genes which are associated with Alzheimer's disease have been identified, but are only rarely involved in the development of Alzheimer's disease.
• Conditions such as high blood pressure, high cholesterol, or diabetes increase the risks of developing either Alzheimer's disease or multi-infarct dementia.
• Some medications can lead to memory problems that look like dementia.

To diagnose dementia, testing is performed by doctors. While in-office screening assessments are sometimes enough to confirm a diagnosis, at other times a more in-depth evaluation is required. Blood testing and imaging studies are often completed to confirm that reversible conditions such as thyroid disease or certain vitamin deficiencies are not present.

Treatment options for Alzheimer's disease and other dementia are limited.

• While there are medications available to try to improve the symptoms of Alzheimer's disease, the effect of these medications is limited.
• Physical exercise has been shown to be of some benefit in helping to maintain cognition.
• Staying engaged and participating in social events may also be of some help.
• To date, no treatment which can reverse the process of Alzheimer's disease has been identified.

There is no cure for dementia.

• Although Alzheimer's disease is listed as the 6th most common cause of death in the U.S. Patients with Alzheimer's disease most commonly die due to infections caused by a lack of mobility.
• Pneumonia, bladder infections, bedsores, and other causes can lead to more widespread infection and subsequent death.
• Patients with dementia have widely varying life expectancies, depending on the underlying cause of their dementia. Life expectancy can range from only 1-2 years to more than 15 years; the average duration of the disease is between 4-8 years after diagnosis.

It is important for someone who is the primary caregiver of a patient with dementia to have a strong network of support. This is needed both to aid in caring for the patient and to give the caregiver some intermittent relief. In the early stages, many caregivers function more as a helper or guides, providing reminders for different tasks. Later in the disease, caregivers may have to supply basic care to the patient, including assistance with bathing, dressing, and going to the bathroom.

Obtaining power of attorney status for financial and medical matters and determining when a patient is no longer able to perform certain activities, such as driving, are difficult but necessary actions. Local Alzheimer's Association chapters are often helpful in completing these tasks. Enlisting the help of a patient's physician or mandating an on-the-road driving assessment can place the responsibility of determining when a patient is no longer safe to drive on someone other than a caregiver or family member, as driving is often an action that many patients attempt to perform far past the time when it is safe to continue. There are many sources of assistance for caregivers of patients with dementia:

Alzheimer's and Dementia Caregiver Center
Alzheimer's Association

While there is no way to absolutely prevent the development of dementia, different activities have been identified which might decrease the risk. These include the following:

• Maintaining optimal health, including normal blood pressure, normal cholesterol, and normal blood sugars
• Staying physically active, avoiding tobacco use or excessive alcohol intake, maintaining a healthy weight, and preventing head injuries are also recommended.