Dementia

What is Dementia?

Dementia is a brain disease that is usually chronic and progressive and causes a gradual decline of memory, thinking capacity, and communication to the extent that it affects an individual's daily functioning.

Is Dementia a Medical Emergency?

Dementia is not a medical emergency. But, severe agitation, violent behaviour, suicidal ideations, or delirium can occur in dementia, which are emergencies. 

Types

Dementia may be of the following types:

• Alzheimer's disease: Alzheimer’s disease is the cause of Dementia in most cases. Symptoms include recent memory impairment, followed by remote memory loss. Immediate memory, like attention and concentration, remains intact until later stages. Word-finding difficulties, getting lost, requiring frequent repetitions, and difficulty with problem-solving.
• Vascular Dementia: This type is caused due to reduced blood supply to the brain. Blood vessels in the brain get damaged due to trauma or stroke. Symptoms include slow thinking, difficulty focusing, and difficulty in problem-solving. Often, abrupt onset and step ladder progression of memory loss are seen. 
• Parkinson’s disease Dementia: 80% of Parkinson’s patients have dementia, and the mean duration of dementia is about 10 years after the onset of typical motor symptoms. Along with forgetfulness, difficulty in thinking, orientation, language, and comprehension, there may be depression, hallucination, and delusion. 
• Lewy body Dementia: Clumps of protein get deposited in the brain's nerve cells and cause symptoms of visual hallucinations and Parkinsonism (slow movements, tremors, and rigid muscles). Other symptoms include problems with attention and focus.
• Frontotemporal Dementia: This type is caused by damage to nerve cells in the front and temporal lobes of the brain. Symptoms include personality and behavioral changes like apathy, loss of empathy for others, disinhibition, language difficulties, difficulty thinking, planning and judgment.

There are several other types of dementia which are less common.

Causes

Dementia can be caused as a result of some diseases, such as:

• Alzheimer's disease 
• Huntington's disease
• Traumatic brain injury (TBI)
• Creutzfeldt-Jakob disease
• Parkinson's disease
• stroke

Various conditions can cause dementia-like symptoms that can be resolved with treatment. They are the following:

• Endocrine problems like thyroid and low blood sugar
• Vitamin deficiencies. Lack of adequate vitamins like B1, B6, B12, and E
• Exposure to substances like pesticides, lead metal, recreational drugs, and heavy alcohol intake
• Subdural hematomas
• Brain tumors
• Normal-pressure hydrocephalus
• Due to the side effects of some medications

Risk factors

Factors that influence the development of dementia include the following:

• Advanced age
• Family history of Dementia
• Down Syndrome
• High blood pressure, high cholesterol, and overweight
• Diabetes, High blood pressure
• Depression and social isolation
• Smoking and heavy alcohol consumption
• Hearing loss: A greater degree of hearing loss can increase the risk of developing Dementia
• Deficiencies of vitamins and nutrients like vitamin D, B6, B12, and folate may increase of risk of developing senility

Signs & Symptoms

Signs and symptoms of Dementia consist of behavioural and neuropsychiatric symptoms. They include the following:

• Speech and language abnormality
• Inability in problem-solving and reasoning
• Inability to perform a complex task
• Confusion
• Wandering and restlessness
• Memory difficulties like thinking an old memory is a new one
• Agitation and irritability
• Depression and anxiety
• Inappropriate behaviour
• Loss of balance and coordination
• Hallucination and delusions

Investigations

Investigation tests include the following:

• Laboratory tests: These include blood tests to determine any vitamin deficiencies, infections, and other problems that can cause disorientation and confusion. Spinal fluid tests are also done to rule out infections.
• Cognitive and neuropsychological tests: These tests evaluate memory, orientation, attention, language, reasoning, and judgment skills.
• Neurological evaluation: A neurological evaluation evaluates memory, attention, balance, senses, problem-solving, reflexes, language, etc.
• Psychiatric evaluation: A mental health examination is performed to check for depression or other disorder that is contributing to confusion and disorientation
• Imaging tests: Brain scans like CT and MRI are done to identify any stroke, tumor, or bleeding in the brain. PET scans are done to identify any cognitive dysfunction

Diagnosis

A diagnosis of dementia is made based on the findings of the neurological evaluation, psychiatric evaluation, medical and physical examination, family history, and the investigation results.

Course/ Stages

Dementia progresses gradually and can be divided into the following stages depending on the severity of the symptoms:

• Mild cognitive impairment: The starting stage of Dementia is called mild cognitive impairment (MCI). Initial symptoms are very minute. MCI later progresses to Dementia.
• Early-stage: Symptoms are noticeable and interfere with daily activities. They include memory difficulty, getting lost in new places, word-finding problems, repeating things, and difficulty handling finances.
• Middle stage: As Dementia progresses, the symptoms vary from individual to individual. Individuals will be unable to function outside the home, require assistance for personal care and hygiene, and be impaired in solving problems.
• Last stage: In the last stage, people will require assistance and 24-hour supervision. They lose balance and fall and maybe incontinent of stools or urine. They have complete forgetfulness, loss of appetite, and difficulty sleeping.

Treatment options

Treatment of dementia focuses on managing the symptoms. Treatment options include medications as well as therapies.

Medical treatment

Medical management of dementia includes:

• Cholinesterase inhibitors: These medications include donepezil, rivastigmine, and galantamine. They improve memory and judgment.
• Memantine: This drug improves memory and learning

Interventional treatment including surgery and indications for surgery/ Surgical treatment

Therapies that are implemented in the treatment of dementia include the following:

• Psychological therapies like reminiscence therapy: This therapy uses senses (smell, touch, taste, sight, and sound) to help the individual remember past events, places, and people
• Occupational therapy: Occupational therapy helps to manage daily tasks like cooking, walking, driving, etc., and helps to prevent falls
• Modifying the tasks and modifying the environments: A less noisy environment can help in better focus and functioning. Tasks like bathing and grooming can be simplified and performed better.
• Cognitive and behavioural interventions: Focus or maximize a few areas of problem, reality orientation, and Cognitive restructuring. This therapy helps to improve thinking capacity and problem-solving 
• Stimulation oriented therapy: Recreational activity like playing with a or closeness to a child, a pet, art/ music therapy, social benefit group, providing proper learning and relearning environment.
• Emotion Oriented therapy: Supportive psychotherapy, Validation therapy ( reciprocal communication, acknowledgement, respecting, hearing, even when the patient is wrong), Simulated presence therapy ( Playing an old recording, old family picture photos, things that remind the presence of a friend or relative), Sensory integration therapy. 

Do’s and Don’t’s while communicating with a Dementia Patient

• Never ‘Argue’, instead ‘Agree’
• Never ‘Reason’, instead ‘Divert’
• Never ‘Shame’, instead ‘Distract’
• Never ‘Lecture’, instead ‘ Reassure’ 
• Don’t say ‘I told you', instead ‘ Repeat’
• Never ‘ Demand’, instead ‘Ask’ 
• Never ‘Force’, instead ‘ Enforce’ 
• Never ‘Shout at', rather, ‘Encourage’

Role of Diet/ Exercise/ Lifestyle changes/ Preventive measures

Preventive measures include:

• Being socially active
• Engaging in activities
• Controlling high blood pressure and blood sugar
• Cessation of smoking tobacco
• Maintaining a healthy diet and weight
• Having adequate sleep
• Engaging in physical activity and exercise

Complications

Dementia can affect the quality of life and can lead to several complications such as:

• Inability to care for self and requiring assistance for eating, dressing, toileting, and bathing
• Difficulty eating and swallowing leading to malnutrition and dehydration
• Incontinence of stool and urine
• Increased infections in the body
• Change in sleep patterns
• Behavioural changes like irritability, arguing and striking out behaviours
• Having hallucinations, delusions, depression, and agitation
• Forgetting long-term events as well as recent events and conversations
• Inability to recognize faces, familiar routes, and inability to predict danger
• Difficulty problem solving, performing basic tasks like cooking, driving, or balancing finances
• Difficulties with language, reading, writing, and speaking confusing sentences or inappropriate sentences
• Reduced lifespan

Prognosis

The prognosis of dementia varies from individual to individual, depending upon the person's age, type of disease, and severity of the condition.

When to contact the doctor? / How to identify the complications?

A medical consultation is recommended after observing any changes in memory, attention, behaviour or personality. 

Indications for hospitalization if required

As Dementia progresses, hospitalization may be required for appropriate care and management.

Screening methods

Screening methods include the following:

• Mini-mental status examination (MMSE)
• Abbreviated mental test score (AMTS)
• Modified mini-mental state examination (3MS)
• Cognitive Abilities Screening Instrument (CASI)
• The trail-making test and the clock drawing test
• MoCA (Montreal Cognitive Assessment)
• Informant questionnaire on cognitive decline in the elderly (IQCODE)
• Alzheimer’s disease caregiver questionnaire
• General practitioner assessment of cognition
• Depression screening, such as the neuropsychiatric inventory and geriatric depression scale

Suggested clinical specialists/ Departments to consult for this condition

Neurology
Psychiatry