History

Fact Explanation
Gradual and progressive onset of memory impairment Dementia is a chronic progressive disease characterized by multiple cognitive deficits. It is a disease of the elderly. Cognitive functions that could be affected are memory, orientation, comprehension, learning ability, judgement etc. Onset of symptoms is gradual and is progressive.
Memory impairment Memory impairment initially manifests with forgetfulness of keys, money and the location of personal items. This may progress to inability to recognize familiar people, forgetfulness of recent events and inability to remember personal details. Unawareness of memory impairment is common among dementia patients and may be influenced by social and cultural factors.[1]
Language difficulties/ aphasia The patient may present with difficulty in naming familiar objects and finding words.
Inability to perform learned purposeful movements - apraxia Difficulty in performing complex tasks such as dressing, cooking etc.
Disturbance in executive functions Inability understand and arrive at rational conclusions/decisions - handling money, planning events etc. Poor judgement.
Visuospatial impairment In early disease the patient will find it difficult to navigate through unfamiliar surroundings. In advance disease the patient will be unable to identify familiar surroundings and may get lost.
Behavioral symptoms The patient may wander aimlessly, behave inappropriately in public, be agitated, have poor sleep and engage in meaningless repetition of words. Previous personality traits may be exaggerated - frequent quarreling.
Psychiatric symptoms Suspiciousness is a common symptom among dementia patients. The patient may be persistently worried about others harming or stealing from him/her. In addition rarely the patient may develop depression, suicidal ideas, delusions and hallucinations.
Varies causes of dementia can be differentiated by history. Pattern of disease progression may be suggestive of the aetiology - In Alzheimer's disease memory loss is the earliest feature. It is insidious in onset and slowly progressive. Apraxia, dis-inhibition, aphasia follows. Disorientation is a late feature. In vascular dementia the onset may be abrupt. It may be caused by a single large infarct or by multiple small infarcts, hence it progresses in a stepwise manner.[2] In addition to cognitive function abnormalities, personality changes and emotional symptoms may be prominent. The patient usually has history of cardiovascular risk factors. Dementia with Lewy bodies presents with prominent visual hallucinations. Parkinson's disease dementia characteristically presents with motor features of parkinsonism.[3]
Exclude reversible causes of dementia Clinical information should be used to exclude potentially reversible causes of dementia - depressive pseudo dementia, space occupying lesion, normal pressure hydrocephalus, Vit B12 deficiency, excess alcohol usage, Endocrine & metabolic causes (hypothyroidism, uraemia, hepatic encephalopathy), infections(tertiary syphilis, HIV) and vasculitis.[4]
Risk factors for dementia Vascular dementia results from multiple cerebral infarcts. The patient may be a chronic smoker and have a long standing history of cardiovascular risk factors such as diabetes, hypertension and hyperlipidaemia.
References
  1. MOGRABI DC, FERRI CP, SOSA AL, STEWART R, LAKS J, BROWN R, MORRIS RG. Unawareness of memory impairment in dementia: a population-based study. Int Psychogeriatr [online] 2012 Jun, 24(6):931-9 [viewed 23 July 2014] Available from: doi:10.1017/S1041610211002730
  2. AMAR K., WILCOCK G.. Fortnightly Review: Vascular dementia. BMJ [online] 1996 January, 312(7025):227-231 [viewed 23 July 2014] Available from: doi:10.1136/bmj.312.7025.227
  3. BOEVE BF. A review of the non-Alzheimer dementias. J Clin Psychiatry [online] 2006 Dec, 67(12):1985-2001; discussion 1983-4 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17194279
  4. REISBERG B. Dementia: a systematic approach to identifying reversible causes. Geriatrics [online] 1986 Apr, 41(4):30-46 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3949165

Examination

Fact Explanation
Mental state examination : Appearance The general appearance of the patient is usually normal. The patient will be well groomed and dressed appropriately. In advance disease when the patient looses ability conduct his/her daily functions, signs of self neglect may be seen. The mood is normal and sometimes may have a depresses appearance. Social behavior will be normal in early disease. In advance disease disinhibition in social situations may be noted. Abnormal motor activity will not be seen.
Mental state examination : Speech Speech will be spontaneous with normal rate and volume. The patient may exhibit difficulty in finding words or naming certain objects.
Mental state examination : Mood The patients are usually euthymic. Variations of mood are normal with no liability or incongruity of mood. Depression is a differential diagnosis for dementia.[1] Observe the patient for low mood, reduced variation of mood and blunt affect.
Mental state examination : Thoughts The form of thought is normal. In long standing disease the patient may have delusions, suicidal ideas and suspicious thoughts.
Mental state examination : Perceptions Hallucinations of any form are rare in dementia. The presence of visual hallucinations may indicate the possibility of delirium which needs to excluded in dementia patients.[2]
Mental state examination : Cognitive functions The patient is usually oriented in time, place and person up to the terminal stages. In contrast disorientation is a prominent feature in delirium. The patients attention and concentration is usually normal. Significant impairment in both short and long term memory may be seen. The short term memory is affected more in comparison. Intelligence is not affected but poor memory span may influence findings on intelligence.
Physical examination Perform physical examination to rule out reversible causes of dementia. Examine for features of hypothyroidism and uremia. Examine for features of liver failure. Examine for neurological symptoms of space occupying lesions.
References
  1. RABINS PV, MERCHANT A, NESTADT G. Criteria for diagnosing reversible dementia caused by depression: validation by 2-year follow-up. Br J Psychiatry [online] 1984 May:488-92 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6733372
  2. WEBSTER R, HOLROYD S. Prevalence of psychotic symptoms in delirium. Psychosomatics [online] 2000 Nov-Dec, 41(6):519-22 [viewed 23 July 2014] Available from: doi:10.1176/appi.psy.41.6.519

Differential Diagnoses

Fact Explanation
Normal aging Aging is associated with a certain degree of deterioration of cognitive functions. The presentation may mimic early dementia. Progressive deterioration of memory beyond what is expected for that age is suggestive of dementia. The presence of multiple cognitive deficits : language difficulty, apraxia, agnosia and deterioration of executive functions is rarely seen with the normal aging process and supports a diagnosis of dementia.
Delirium An important differential diagnosis of dementia is delirium. Delirium/ acute confusional syndrome is the impairment of cognitive functions and consciousness secondary to systemic/physical dysfunction. Delirium is common among the elderly. A specific aetiology is usually found : infections, severe trauma, organ failure, medications and toxins etc. Disorientation and visual hallucinations are common in delirium. In comparison to dementia, symptoms are acute in onset and may fluctuate, being worst at night.[1]
Depression Depressive pseudo dementia is a potentially reversible cause of dementia. Loss of memory, impaired attention span and concentration can occur in depressive disorder.[2] The onset of symptoms are usually more acute than in dementia. The patient may also exhibit features of depressive disorder such as depressed demeanor, low mood, decreased energy, loss of interest/pleasure, lack of sleep and diminished appetite. A specific aetiology for depression may found in the clinical history. Once the patient recovers from depression the symptoms of cognitive impairment usually improve.
Mild cognitive impairment (MCI) In MCI the degree of cognitive impairment is between normal aging and dementia. MCI is considered a to represent a pre-dementia state. The patient presents with mild changes in memory and rate of information processing. The ability to recall daily events is impaired. The patients daily functions are not affected. Physical examination and investigations are normal.[3] Montreal Cognitive Assessment (MoCA) is a sensitive tool for diagnosis of MCI.
References
  1. INOUYE SHARON K.. Delirium in Older Persons. N Engl J Med [online] 2006 March, 354(11):1157-1165 [viewed 22 July 2014] Available from: doi:10.1056/NEJMra052321
  2. LAMBERTY GJ, BIELIAUSKAS LA. Distinguishing between Depression and Dementia in the Elderly: A Review of Neuropsychological Findings. Archives of clinical neuropsychology, 1993, 8, 149-170.
  3. PETERSEN RONALD C.. Mild Cognitive Impairment. N Engl J Med [online] 2011 June, 364(23):2227-2234 [viewed 22 July 2014] Available from: doi:10.1056/NEJMcp0910237

Investigations - for Diagnosis

Fact Explanation
Dementia is diagnosed by history and mental state examination Gradually progressive deterioration of cognitive functions as identified in clinical history and metal state examination aid in the diagnosis. The DSM 4 criteria for diagnosis of dementia : Multiple cognitive deficits manifested by both memory impairment and one/ more of the following cognitive disturbances - agnosia, aphasia, apraxia and deficits in executive function.
Mini–mental state examination (MMSE) The MMSE is a score designed to quantitatively measure the cognitive status. It includes tests for orientation, attention, memory and language. Each test is given a scoring system adding up to a total of 30 points. Dementia can be classified as mild (21-24), moderate (10-20) and severe (<9) according to MMSE. Use of the MMSE alone for diagnosis of dementia is not recommended.[1] MMSE is mainly used as a screening test and to monitor disease progression periodically.
CT scan/ MRI of the brain CT brain and MRI may aid in identifying the subtype of dementia. In vascular dementia MRI and CT may show evidence of ischemic changes - small or large infarcts. In early Alzheimer's disease the MRI may detect hippocampal atrophy. In advance disease ventricular enlargement and diffuse cerebral atrophy may be seen in both CT scan and MRI.[2]
Neuro-imaging - CT scan and MRI Investigations to identify reversible causes of dementia should be carried out since specific therapy will improve the cognitive functions of the patient. Neuroimaging can be used to identify cerebral tumors, chronic subdural hematomas and normal pressure hydrocephalus.[3]
Thyroid function tests Exclude hypothyroidism.[4]
Liver function tests Hepatic encephalopathy is reversible cause of dementia.
Full blood count/ Blood film/ Serum Vit B-12 levels Presence of macrocytic anemia with hyper-segmented neutrophils is a feature of Vitamin B-12 deficiency.[4]
Blood urea, serum creatinine and serum electrolytes Exclude chronic renal failure and uremia.
VDRL and HIV screening HIV and tertiary syphilis is a treatable cause of dementia.
Antinuclear antibody (ANA) and Anti- ds DNA antibody To exclude Systemic lupus erythematosus (SLE).
References
  1. TOMBAUGH TN, MCINTYRE NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc [online] 1992 Sep, 40(9):922-35 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1512391
  2. FRISONI GB, FOX NC, JACK CR JR, SCHELTENS P, THOMPSON PM. The clinical use of structural MRI in Alzheimer disease Nat Rev Neurol [online] 2010 Feb, 6(2):67-77 [viewed 23 July 2014] Available from: doi:10.1038/nrneurol.2009.215
  3. ISHIKAWA E, YANAKA K, SUGIMOTO K, AYUZAWA S, NOSE T. Reversible dementia in patients with chronic subdural hematomas. J Neurosurg [online] 2002 Apr, 96(4):680-3 [viewed 23 July 2014] Available from: doi:10.3171/jns.2002.96.4.0680
  4. TRIPATHI M, VIBHA D. Reversible dementias Indian J Psychiatry [online] 2009 Jan, 51(Suppl1):S52-S55 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038529

Management - General Measures

Fact Explanation
Establish safety measures to reduce injury/ harm to the patient Make changes to the home environment – Add railings to the staircase, improving lighting of the house particularly at night, provide the patient with a safe room, remove dangerous electrical appliances from the vicinity of the patient etc. If the house is close to the road or railway establish measures to prevent wandering of the patient. The patient should have contact numbers to call in an emergency. Arrange for measures to avoid elder abuse.
Stimulation of the patient Frequent stimulation of the dementia patients may slow the rate of disease progression and help preserve cognitive functions. Sensory stimulation may be provided with music therapy and leisure activities. Arrange the patient to get involved in the household activities and provide opportunities for social interactions.
Measures to improve sleep among patients A common problem among dementia patients is disturbed sleep. Improve the sleeping environment of the patient – less noisy room, less lighting, cool. Arrange for a set time and place for sleeping. Avoid factors which prevent sleep – excessive caffeine at night, heavy meals. Advise the patient to avoid using the bed for other activities such as watching television, reading. Increased physical activity and social activity promotes adequate sleep.[1] These factors improve sleep hygiene. Use of hypnotic should be avoided if possible.
Caring for the caretakers As dementia progresses the patient gradually loses ability to perform his/her daily functions and becomes dependent on the caregivers. Managing a dementia patient in the home environment puts a significant burden on the family. Hence the caregivers should be provided support.[2] Arranging for shared care of the patient may reduce the burden on one caretaker. Involve all family members in caring for the patient. Family members can divide responsibilities among themselves. Arrange for counseling sessions and provide psychological support. Caretakers are prone to develop psychiatric problems such as depression, anxiety and anger.
References
  1. DESCHENES CL, MCCURRY SM. Current Treatments for Sleep Disturbances in Individuals With Dementia Curr Psychiatry Rep [online] 2009 Feb, 11(1):20-26 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649672
  2. BURNS R, NICHOLS LO, MARTINDALE-ADAMS J, GRANEY MJ, LUMMUS A. Primary care interventions for dementia caregivers: 2-year outcomes from the REACH study. Gerontologist [online] 2003 Aug, 43(4):547-55 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12937333

Management - Specific Treatments

Fact Explanation
Educate the patient and family Provide information about the natural course of the disease, aetiology, risks and treatment options available. The family should be educated and counseled about the need for continuous care of the patient.
Minimizing risks to the patient Dementia patients are prone to environmental risks.[1] Patients with forgetfulness may ingest an overdose of medicine, forget to switch off electrical appliances. In advance disease the patient may find it difficult to navigate through the house and have the risk of injury and falls. The patient may wander out of the house. The family should make changes in the house to avoid such risks. Ideally an occupational therapist should evaluate the house environment and suggest changes.
Pharmacological therapy: Combined Cholinesterase inhibition and NMDA receptor antagonist The two main classes of drugs used to treat dementia are cholinesterase inhibitors and NMDA receptor antagonists.[2] Monotherapy or combinations of both may be used.
Pharmacological therapy : Cholinesterase inhibitor therapy The commonly used drugs are galantamine, donepezil and rivastigmine. These drugs are commonly used to treat mild-moderate dementia.[3] Cholinesterase inhibitors improve cognitive functions, activities of daily living and behavior. Initiate drug therapy promptly after diagnosis. The drugs have been shown to be effective against most subtypes of dementia- Alzheimer's dementia, vascular dementia and Parkinson's dementia.[4] Monitor the progression of the disease by 3/6 monthly cognitive assessments.
Pharmacological therapy : NMDA receptor antagonists NMDA receptor antagonist - Memantine is indicated for moderate to severe dementia.[5] These drugs reduces neuropsychiatric symptoms, help maintain skills and slows cognitive deterioration. The starting dose is 5mg daily which can be increased up to a maximum of 10mg bd.
Managing behavioral problems Behavioral problems are usually arise due to distress within the patient. Boredom, sensory deprivation, hunger, loneliness can cause behavioral problems. These can be avoided by involving the patient in the household work, improving social contact and planning the day of the patient. The carers should actively involve in providing emotional support to the patient. Pharmacological therapy for behavioral problems should be used as a last resort. Depression is treated with SSRIs. Antipsychotics may be indicated for treatment of delusions and hallucinations.
Ensure optimum quality of life The basic needs such as food, clothing, hygiene and medications should be provided by the carers. Improve social interactions of the patient. Encourage the patient to engage in exercise, music therapy and leisure activities which promote pleasure. Help the patient in financial and legal matters. During the terminal stages of disease the patient may be totally dependent upon the carers for daily activities of living.
Manage concomitant medical conditions Elderly patients are at higher risk of having multiple comorbidities such as diabetes, hypertension, cardiovascular disease. These conditions need to be appropriately managed. Ensure regular follow-up. Poor vision and poor hearing is common among the elderly. These sensory deficits may predispose to falls, injury, and may interfere with social interaction. Arrange for appropriate measures to improve patient functioning.
References
  1. DOODY RS, STEVENS JC, BECK C, DUBINSKY RM, KAYE JA, GWYTHER L, MOHS RC, THAL LJ, WHITEHOUSE PJ, DEKOSKY ST, CUMMINGS JL. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology [online] 2001 May 8, 56(9):1154-66 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11342679
  2. QASEEM A, et al. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med, 2008, 148, 370-378.
  3. RAINA P, SANTAGUIDA P, ISMAILA A, PATTERSON C, COWAN D, LEVINE M, BOOKER L, OREMUS M. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline. Ann Intern Med [online] 2008 Mar 4, 148(5):379-97 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18316756
  4. BIRKS J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev [online] 2006 Jan 25:CD005593 [viewed 22 July 2014] Available from: doi:10.1002/14651858.CD005593
  5. MCSHANE R, AREOSA SASTRE A, MINAKARAN N. Memantine for dementia. Cochrane Database Syst Rev [online] 2006 Apr 19:CD003154 [viewed 22 July 2014] Available from: doi:10.1002/14651858.CD003154.pub5