dementia

More about Dementia: Causes and symptoms Diagnosis Treatment Alternative treatment Prognosis Prevention Resources

Definition

Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.

Description

Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. While the over-whelming number of people with dementia are elderly, it is not an inevitable part of aging. Instead, dementia is caused by specific brain diseases. Alzheimer's disease (AD) is the most common cause, followed by vascular or multi-infarct dementia.

The prevalence of dementia has been difficult to determine, partly because of differences in definition among different studies, and partly because there is some normal decline in functional ability with age. Dementia affects 5–8% of all people between ages 65 and 74, and up to 20% of those between 75 and 84. Estimates for dementia in those 85 and over range from 30–47%. Between two and four million Americans have AD; that number is expected to grow to as many as 14 million by the middle of the twenty-first century as the population as a whole ages.

The cost of dementia can be considerable. While most people with dementia are retired and do not suffer income losses from their disease, the cost of care is often enormous. Financial burdens include lost wages for family caregivers, medical supplies and drugs, and home modifications to ensure safety. Nursing home care may cost several thousand dollars a month or more. The psychological cost is not as easily quantifiable but can be even more profound. The person with dementia loses control of many of the essential features of his life and personality, and loved ones lose a family member even as they continue to cope with the burdens of increasing dependence and unpredictability.

— Richard Robinson

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n.

1. Deterioration of intellectual faculties, such as memory, concentration, and judgment, resulting from an organic disease or a disorder of the brain. It is sometimes accompanied by emotional disturbance and personality changes.
2. Madness; insanity. See synonyms at insanity.

[Latin dēmentia, madness, from dēmēns, dēment-, senseless. See dement.]

demential de·men'tial adj.

For more information on dementia, visit Britannica.com.

Definition

The term dementia refers to symptoms, including changes in memory, personality, and behavior, that result from a change in the functioning of the brain. These declining changes are severe enough to impair the ability of a person to perform a function or to interact socially. This operating definition encompasses 70–80 different types of dementia. They include changes due to diseases (Alzheimer's and Creutzfeld-Jakob diseases), changes due to a heart attack or repeated blows to the head (as suffered by boxers), and damage due to long-term alcohol abuse.

Dementia is not the same thing as delirium or mental retardation. Delirium is typically a brief state of mental confusion often associated with hallucinations. Mental retardation is a condition that usually dates from childhood and is characterized by impaired intellectual ability; mentally retarded individuals typically have IQ (intelligence quotient) scores below 70 or 75.

Description

The absent-mindedness and confusion about familiar settings and tasks that are hallmarks of dementia used to be considered as part of a typical aging pattern in the elderly. Indeed, dementia historically has been called senility. Dementia is now recognized not to be a normal part of aging. The symptoms of dementia can result from different causes. Some of the changes to the brain that cause dementia are treatable and can be reversed, while other changes are irreversible.

Demographics

An estimated two million people in the United States alone have severe dementia. Up to five million more people in the United States have milder forms of cognitive impairment of the dementia type. The elderly are most prone to dementia, particularly those at risk for a stroke. The historical tendency of women to live longer than men has produced a higher prevalence of dementia in older women. However, women and men are equally prone to dementia. Over age 80, more than 20% of people have at least a mild form of dementia.

Causes and symptoms

Dementia is especially prominent in older people. The three main irreversible causes are Alzheimer's disease, dementia with Lewy bodies, and multi-infarct dementia (also called vascular dementia).

Degenerative forms of dementia are long lasting (chronic) and typically involve a progressive loss of brain cell function. In disorders like Alzheimer's and Creutzfeld-Jakob diseases, this can involve the presence of infectious agents that disturb the structure of proteins that are vital for cell function. Other forms of dementia are chemically based. For example, Parkinson's disease involves the progressive loss of the ability to produce the neurotransmitter dopamine. Interrupted transmission of nerve impulses causes the progressive physical and mental deterioration. Huntington's disease is an inherited form of dementia that occurs when neurons (brain cells) degenerate.

Alzheimer's disease is the most common cause of dementia. The progressive death of nerve cells in the brain is associated with the formation of clumps (amyloid plaques) and tangles of protein (neurofibrillary tangles) in the brain. The loss of brain cells with time is reflected in the symptoms; minor problems with memory become worse, and impairment in normal function can develop. Alzheimer's patients also have a lower level of a chemical that relays nerve impulses between nerve cells. As the brain damage progresses, other complications can ensue from the damage and these can prove fatal. Put another way, people die with Alzheimer's, not from it.

Dementia resulting from the abnormal formation of protein in the brain (Lewy bodies) is the second most common form of dementia in the elderly. It is unclear whether these structures are related to the brain abnormalities noted in Alzheimer's patients. Lewy body formation differs from Alzheimer's in that the speed of brain functions is affected more so than memory.

In multi-infarct dementia, blood clots can dislodge and impede the flow of blood in blood vessels in the brain. The restricted flow of blood can lead to death of brain cells and a stroke.

Dementias that are caused by the blockage of blood vessels are generally known as vascular dementia. This type of dementia can sometimes be reversed if the blood-vessel blockage can be alleviated. In contrast, the dementia associated with Alzheimer's disease is non-reversible.

Less common causes of dementia include Binwanger's disease (another vascular type of dementia), Parkinson's disease, Pick's disease, Huntington's disease, Creutzfeldt-Jakob disease, and acquired immunodeficiency syndrome (AIDS).

A study published in 2002 documented a link between elevated levels of an amino acid called homocysteine in the blood and the risk of developing dementia, likely vascular dementia. As homocysteine concentration can be modified by diet, the finding holds the potential that one risk factor for dementia may be controllable.

Symptoms of dementia include repeatedly asking the same question; loss of familiarity with surroundings; increasing difficulty in following directions; difficulty in keeping track of time, people, and locations; loss of memory; changes in personality or emotion; and neglect of personal care. Not everyone displays all symptoms. Indeed, symptoms vary based on the cause of the dementia. Also, symptoms can progress at different rates in different people.

Diagnosis

Diagnosis of dementia typically involves a medical examination, testing of mental responses (such as memory, problem solving, and counting), and knowledge of the patient's medical history (e.g., prescription and non-prescription drug use, nutrition, results of a physical examination, and medical history). Testing of the composition of the blood and urine can be helpful in ruling out specific causes such as thyroid disease or a deficiency in vitamin B₁₂. Some blood tests can help alert clinicians to the possibility of dementia. For example, persons infected with the human immunodeficiency virus (HIV) have distinct proteins in their blood that are often associated with the presence of dementia.

Visual examination of the brain can reveal structural abnormalities associated with dementia. Tests that are typically performed are computerized tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). While accurate, such tests are not commonplace, and are rarely encountered outside of the research setting. Neuroimaging (CT or MRI scans) can be useful in excluding the possibility that dementia has resulted from an occlusion of a blood vessel, as in a stroke or due to the presence of a tumor.

Treatment team

Family physicians, medical specialists such as neurologists and psychiatrists, physical therapists, counselors, personal caregivers, and family members can all be part of the treatment team for someone afflicted with dementia.

Treatment

Drugs can help delay the progression of symptoms, particularly for Alzheimer's disease. The high blood pressure that is associated with multi-infarct dementia can also be controlled by drug therapy. Other stroke risk factors that can be treated include cholesterol level, diabetes, and smoking. Medicines such as antidepressants, antipsychotics, and anxiolytics can also be used to treat behaviors associated with dementia, including insomnia, anxiety, depression, and nervousness.

Other treatments that do not involve drugs are the maintenance of a healthy diet, regular exercise, stimulating activities and social contacts, and making the home as safe as possible. Hobbies can help keep the mind occupied and stimulated. "Things-to-do" lists can be a helpful memory prompt for persons with early dementia. With more advanced disease, a facility specializing in Alzheimer's treatment often provides a stimulating modified environment along with meeting increasing medical and personal care needs.

Recovery and rehabilitation

Irreversible causes of dementia reduce or eliminate the chances of recovery and rehabilitation. Stimuli such as favorite family photographs and calendars provide clues to cognitive orientation, while devices such as walkers help maintain mobility for as long as possible.

Clinical trials

As of early 2004, there are 64 clinical trials for dementia study and treatment in the United States that are recruiting subjects. The trials range from improved strategies of care and telephone support to active interventions in the outcome of various forms of dementia. The bulk of the trials are concerned with Alzheimer's disease. Information about the trials can be found at the National Institutes of Health (NIH) sponsored clinical trials website.

Prognosis

For those with irreversible progressive dementia, the outlook often includes slow deterioration in mental and physical capacities. Eventually, help is often required when swallowing, walking, and even sitting become difficult. Aid can consist of preparing special diets that can be more easily consumed and making surroundings safe in case of falls. Lift assists in areas such as the bathroom can also be useful.

For those with dementia, the expected lifespan is often reduced from that of a healthy person. For example, in Alzheimer's disease, deterioration of areas of the brain that are vital for body functions can threaten survival.

Special concerns

Caring for an individual with dementia almost always challenges family resources. Licensed social service providers at hospitals and facilities for the elderly can provide information and referrals regarding support groups, mental health agencies, community resources, and personal care providers to assist families in caring for a person with dementia.

Resources

BOOKS

Bird, T. D. "Memory Loss and Dementia." In Harrison's Principles of Internal Medicine, 15th edition. Edited by A. S. Franci, E. Daunwald, and K. J. Isrelbacher. New York: McGraw Hill, 2001.

Castleman, Michael, et al. There's Still a Person in There: The Complete Guide to Treating and Coping With Alzheimer's. New York: Perigee Books, 2000.

Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life. New York: Warner Books, 2001.

PERIODICALS

Sullivan, S. C., and K. C. Richards. "Special Section—Behavioral Symptoms of Dementia: Their Measurement and Intervention." Aging and Mental Health (February 2004): 143–152.

Seshadri, S., et al. "Plasma Homocysteine as a Risk Factor for Dementia and Alzheimer's Disease." New England Journal of Medicine (February 2002): 476–483.

OTHER

Mayo Clinic. Dementia: It's Not Always Alzheimer's. December 23, 2003 (March 30, 2004). http://www.mayoclinic.com/invoke.cfm?id=AZ00003.

National Institute on Aging. Forgetfulness: It's Not Always What You Think. December 23, 2003 (March 30, 2004). http://www.niapublications.org/engagepages/forgetfulness.asp.

ORGANIZATIONS

Alzheimer's Association. 919 Michigan Avenue, Suite 1100, Chicago, IL 60611-1676. (312) 335-8700 or (800) 272-3900; Fax: (312) 335-1110. info@alz.org. http://www.alz.org.

Alzheimer's Disease Education and Referral Center. P. O. Box 8250, Silver Spring, MD 20907-8250. (301) 495-3334 or (800) 438-4380. adear@alzheimers.org. http://www.alzheimers.org.

National Institute on Aging. 31 Center Drive, MSC 2292, Building 31, Room 5C27, Bethesda, MD 20892. (301) 496-1752 or (800) 222-2225. karpf@nia.nih.gov. http://www.nia.nih.gov.

National Institute for Neurological Disorders and Stroke. P. O. Box 5801, Bethesda, MD 20824. (301) 496-5761 or (800) 352-9424. http://www.ninds.nih.gov.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (866) 615-6464; Fax: (301) 443-4279. nimhinfo@nih.gov. http://www.nimh.nih.gov.

Brian Douglas Hoyle, PhD

…Last scene of all,
That ends this strange eventful history,
Is second childishness, and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything

[Shakespeare, As You Like It]

We all fear disintegration of the mind, and rightly so; it robs us of our dignity. Bereft of reason we cannot contribute to society, vote, write a will, nor with time care for our basic needs. The disintegration of the mind, or dementia, is a familiar occurrence in the elderly but can occur at any age and result from a vast array of diseases. The loss of acquired intellectual skills — the characteristic feature of dementia — is distinct from developmental failure, which results in learning difficulties of variable severity. We may also be robbed of our senses by sleep or inebriation, and so the term ‘dementia’ is restricted to individuals who are awake and alert. Similarly, patients with a restricted cognitive deficit such as impairment of language following a stroke may have a very different prognosis, with preservation of other intellectual functions, when compared with the widespread disintegration commonly seen with the dementing diseases. A definition of dementia has thus emerged to describe an individual who is alert but who suffers impairment in more than one cognitive domain, of sufficient severity to impair social function. A difficulty in applying the definition is to decide what is a specific cognitive domain. Impairment of memory is considered essential, or more specifically impairment of event memory: that which allows us to recall day-to-day events and maintains our sense of continuity; impairment of memory is a salient feature of Alzheimer's disease, the commonest cause of dementia. Other cognitive domains may include language; visuospatial and visuoperceptual functions, which allow interpretation of our visual world; and so-called ‘frontal executive skills’, which allow us to plan and select appropriate responses to our environment.

It is important to emphasize that dementia is a syndrome and not a disease. The challenge to the clinician is to identify the underlying cause, of which there are many. Alzheimer's disease is the commonest, particularly in the elderly; it is thus the main cause of ‘senile dementia’, a term that is becoming obsolete. It was described in 1906 by Alois Alzheimer, and was considered a rarity occurring in relatively young people (‘pre-senile dementia’), until the 1960s, when it was recognized that the microscopic abnormalities described by Alzheimer were also found in the demented elderly. This led to an apparent epidemic as patients were reassigned from the categories of ‘just old age’ or ‘senile dementia’ to Alzheimer's disease.

Alzheimer had exploited the newly-discovered silver staining method for microscopic examination of nerve tissue, to visualize abnormal cellular changes in the brain. He studied the brain of a 51-year-old patient, Auguste D., whom he had seen whilst working in Frankfurt and who died at the age of 54 years with severe dementia. He reported the hallmark features: ‘neurofibrillary tangles’ and ‘senile plaques’. Recent research has shown that the neurofibrillary tangle results from a collapse of the ‘internal skeleton’ of brain cells (the neuronal cytoskeleton). Senile plaques consist of disrupted neuronal connections, axons, and dendrites, around a core of abnormal deposits of a protein called beta amyloid. This protein undergoes a change in shape that renders it harmful to the cell; exactly how and why these changes occur is the subject of intense research aimed at finding effective treatments.

Alzheimer's disease is the prototypic dementia, characteristically starting with mild forgetfulness and a tendency to repetition in conversation: memory failure worsens, with appointments and recent events forgotten. Losing their way, at first in unfamiliar and then in familiar surroundings, patients become increasingly bemused and testy. Failure of language follows, with increasing difficulty in making sense of the world around them. Dressing, feeding, and toiletting all require help before the final stage ‘sans everything’.

A variety of other degenerative diseases have been, and are being, identified as causes of dementia, including Creutzfeldt Jakob disease and Pick's disease. The latter was described as long ago as 1894. Arnold Pick, a neurologist from Prague, reported a patient with loss of language who was found to have circumscribed shrinkage or atrophy of the temporal lobe, the area of the brain involved with language function. Pick reported the case to disprove the prevailing dogma that all senile atrophies inevitably involved the whole brain. It was Alzheimer's subsequent analysis of such cases that identified silver-stained ‘Pick bodies’ as distinct from the neurofibrillary tangles of his own eponymous disease. Pick's disease is rare and cannot be reliably diagnosed without examination of brain tissue after death, and so is generally swept up in the wider diagnostic category of the fronto-temporal degenerations. Reflecting the areas of the brain affected, such patients present with impairment of language or of social behaviour; whilst at first the symptoms may be confined to one cognitive domain, other functions decline and the clinical picture becomes that of a dementia.

Before the demonstration that the changes of Alzheimer's disease were the common accompaniment of dementia in old age, it used to be thought that such cases were due to a failure of the blood supply, starving the brain of oxygen. There is no evidence that this is so, but multiple strokes can result in dementia, as can multiple haemorrhages into the brain. These are subsumed within the broad category of vascular dementia, which represents the second commonest cause of cognitive impairment, according to some reports.

The ‘use it or lose it’ school of thought argues that education may in part protect us from Alzheimer's disease. But no one is exempt. Scholars, scientists, artists, and statesmen have all succumbed. The publicity surrounding Ronald Reagan's diagnosis of Alzheimer's disease has done much to focus research funding, whereas the same diagnosis in Finland's President may have affected his ability to govern in the last few years of office in the early 1980s.

A small minority of dementias are eminently treatable, and vascular dementia is anticipated to become less common with better management of risk factors such as heart disease, hypertension, and smoking. The major challenge is Alzheimer's disease, and the challenge is a global one, with a predicted 34 million affected individuals by the year 2025. Most will be in the emerging nations, where life expectancy is increasing. In China this is combined with a policy of one child per family, such that the future work force will have to provide for a disproportionate dependent population; the solution will owe as much to politics as to medicine.

The conceptual shift in our understanding of dementia has been profound; no longer is it seen as an inevitable concomitant of old age. Instead we can view Alzheimer's disease, the major cause of late life dementia, as a disease with distinct physical changes, which should be amenable to treatment. However, we should not confuse this with the inevitable changes of ageing. We cannot run as fast at 90 as at 20, nor can we think as fast. We can, though, anticipate the preservation of wisdom and knowledge; to exploit the latter is a challenge for society, to preserve them and avoid dementia is a challenge for medicine.

— Martin Rossor

See also ageing; memory; psychological disorders; senility.

noun

Serious mental illness or disorder impairing a person's capacity to function normally and safely: brainsickness, craziness, derangement, disturbance, insaneness, insanity, lunacy, madness, mental illness, psychopathy, unbalance. Psychiatry mania. Psychology aberration, alienation. See sane/insane.

n

Definition: mental illness
Antonyms: sanity

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n

A progressive, organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment or control of memory, judgment, and impulses (for example, senile psychosis, also associated with AIDS).

Definition

Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.

Description

Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. While the over-whelming number of people with dementia are elderly, it is not an inevitable part of aging. Instead, dementia is caused by specific brain diseases. Alzheimer's disease is the most common cause, followed by vascular or multi-infarct dementia.

The prevalence of dementia has been difficult to determine, partly because of differences in definition among different studies, and partly because there is some normal decline in functional ability with age. Dementia affects 5–8% of all people between ages 65 and 74, and up to 20% of those between 75 and 84. Estimates for dementia in those 85 and over range from 30–47%. Between two and four million Americans have Alzheimer's disease; that number is expected to grow to as many as 14 million by the middle of the twenty-first century as the population as a whole ages.

The cost of dementia can be considerable. While most people with dementia are retired and do not suffer income losses from their disease, the cost of care is often enormous. Financial burdens include lost wages for family caregivers, medical supplies and drugs, and home modifications to ensure safety. Nursing home care may cost several thousand dollars a month or more. The psychological cost is not as easily quantifiable but can be even more profound. The person with dementia loses control of many of the essential features of his life and personality, and loved ones lose a family member even as they continue to cope with the burdens of increasing dependence and unpredictability.

Causes & Symptoms

Causes

Dementia is usually caused by degeneration of brain cells in the cerebral cortex, the part of the brain responsible for thoughts, memories, actions, and personality. Death of brain cells in this region leads to the cognitive impairment that characterizes dementia.

The most common cause of dementia is Alzheimer's disease (AD), accounting for half to three quarters of all cases. The brain of a person with AD becomes clogged with two abnormal structures, called neurofibrillary tangles and senile plaques. Neurofibrillary tangles are twisted masses of protein fibers inside nerve cells, or neurons. Senile plaques are composed of parts of neurons surrounding a group of proteins called beta-amyloid deposits. Why these structures develop is unknown. Current research indicates possible roles for inflammation, blood flow restriction, and accumulation of aluminum in the brain and toxic molecular fragments known as free radicals or oxidants.

Several genes have been associated with higher incidences of AD, although the exact role of these genes is still unknown. In 2001, investigators discovered a rare mutation in the amyloid precursor protein (APP) that is linked to early-onset Alzheimer's. The discovery points scientists to new ideas for targeting and treating the disease.

Vascular dementia is estimated to cause from 5–30% of all dementias. It occurs from a decrease in blood flow to the brain, most commonly due to a series of small strokes (multi-infarct dementia). Other cerebrovascular causes include: vasculitis from syphilis, Lyme disease, or systemic lupus erythematosus; subdural hematoma; and subarachnoid hemorrhage. Because of the usually sudden nature of its cause, the symptoms of vascular dementia tend to begin more abruptly than those of Alzheimer's dementia. Symptoms may progress stepwise with the occurrence of new strokes. Unlike AD, the incidence of vascular dementia is lower after age 75.

Other conditions which may cause dementia include:

• AIDS
• Parkinson's disease
• Lewy body disease
• Pick's disease
• Huntington's disease
• Creutzfeldt-Jakob disease
• brain tumor
• hydrocephalus
• head trauma
• multiple sclerosis
• prolonged abuse of alcohol or other drugs
• vitamin deficiency: thiamin, niacin, or B₁₂
• hypothyroidism
• hypercalcemia

Symptoms

Dementia is marked by a gradual impoverishment of thought and other mental activities. Losses eventually affect virtually every aspect of mental functioning. The slow progression of dementia is in contrast with delirium, which involves some of the same symptoms, but has a very rapid onset and fluctuating course with alteration in the level of consciousness. However, delirium may occur with dementia, especially since the person with dementia is more susceptible to the delirium-inducing effects of may types of drugs.

Symptoms include:

• Memory losses. Short-term memory loss is usually the first symptom noticed. It may begin with misplacing valuables such as a wallet or car keys, then progress to forgetting appointments, where the car was left, and the route home, for instance. More profound losses may eventually follow, such as forgetting the names and faces of family members.
• Impaired abstraction and planning. The person with dementia may lose the ability to perform familiar tasks, to plan activities, and to draw simple conclusions from facts.
• Language and comprehension disturbances. The person may be unable to understand instructions, or follow the logic of moderately complex sentences. Later, he or she may not understand his or her own sentences, and have difficulty forming thoughts into words.
• Poor judgment. The person may not recognize the consequences of his or her actions or be able to evaluate the appropriateness of behavior. Behavior may become crude or offensive, overly-friendly, or aggressive. Personal hygiene may be ignored.
• Impaired orientation ability. The person may not be able to identify the time of day, even from obvious visual clues; or may not recognize his or her location, even if familiar. This disability may stem partly from losses of memory and partly from impaired abstraction.
• Decreased attention and increased restlessness. This may cause the person with dementia to begin an activity and quickly lose interest, and to wander frequently. Wandering may cause significant safety problems, when combined with disorientation and memory losses. The person may begin to cook something on the stove, then become distracted and wander away while it is cooking.
• Personality changes and psychosis. The person may lose interest in once-pleasurable activities, and become more passive, depressed, or anxious. Delusions, suspicion, paranoia, and hallucinations may occur later in the disease. Sleep disturbances may occur, including insomnia and sleep interruptions.

Diagnosis

Since dementia usually progresses slowly, diagnosing it in its early stages can be difficult. Several office visits over several months or more may be needed. Diagnosis begins with a thorough physical exam and complete medical history, usually including comments from family members or caregivers. A family history of either Alzheimer's disease or cerebrovascular disease may provide clues to the cause of symptoms. Simple tests of mental function, including word recall, object naming, and number-symbol matching, are used to track changes in the person's cognitive ability. Recent studies suggest that positron emissions tomography (PET) scans of the brain might be able to identify those at risk for Alzheimer's. As these tests become more widely available, they may offer hope for earlier detection of dementia.

Depression is common in the elderly and can be mistaken for dementia; therefore, ruling out depression is an important part of the diagnosis. Distinguishing dementia from the mild normal cognitive decline of advanced age is also critical. The medical history includes a complete listing of drugs being taken, since a number of drugs can cause dementia-like symptoms.

Determining the cause of dementia may require a variety of medical tests, chosen to match the most likely etiology. Cerebrovascular disease, hydrocephalus, and tumors may be diagnosed with x rays, CT or MRI scans, and vascular imaging studies. Blood tests may reveal nutritional or metabolic deficiencies or hormone imbalances.

Treatment

Nutritional Supplements

Some nutritional supplements may be helpful, especially if dementia is caused by deficiency of these essential nutrients:

• Acetyl-L-carnitine: improves brain function and increases attention span, enhances ability to concentrate and increases energy in patients with Alzheimer's disease.
• Antioxidants (vitamin E, vitamin C, beta-carotene, or selenium): may slow down disease progression by preventing the damaging effects of free radicals.
• B-complex vitamins and vitamin B₁₂: may significantly improve mental function in patients who have low levels of these essential nutrients.
• Coenzyme Q₁₀: helps deliver more oxygen to the brain
• DHEA: may increase brain function in old people.
• Magnesium: may be helpful if the dementia is caused by magnesium deficiency and/or accumulation of aluminum in the brain
• Phosphotidylserine: Deficiency of this nutrient may decrease mental function and cause depression.
• Zinc: may boost short-term memory and increase attention span

Herbal Treatment

Herbal remedies that may be helpful in treating dementia include Chinese or Korean ginseng, Siberian ginseng, gotu kola, and Ginkgo biloba. Of these, ginkgo biloba is the most well-known and widely accepted by Western medicine. Ginkgo extract, derived from the leaves of the Ginkgo biloba tree, interferes with a circulatory protein called platelet-activating factor. It also increases circulation and oxygenation to the brain. Ginkgo extract has been used for many years in China and is widely prescribed in Europe for treatment of circulatory problems. A 1997 study of patients with dementia appeared to show that gingko extract could improve their symptoms. Some scientists believe that, taken early enough in the process, Ginkgo biloba can delay the onset of Alzheimer's, but this claim has not yet been sufficiently backed by enough supportive studies.

Homeopathy

A homeopathic physician may prescribe patient-specific homeopathic remedies to alleviate symptoms of dementia.

Acupressure

This form of therapy uses hands to apply pressure on specific acupressure points to improve blood circulation and calm the nervous system.

Aromatherapy

Aromatherapists use essential oils as inhalants or in baths to improve mental performances and to calm the nerves.

Chelation Therapy

This is a controversial treatment that may provide symptomatic improvement in some patients. However, its effectiveness has not been supported by clinical studies. In addition, this form of therapy may cause kidney damage. Therefore, it should only be given under watchful eyes of a qualified physician.

Allopathic Treatment

There are no therapies that can reverse the progression of Alzheimer's disease. Therefore, treatment of dementia begins with treatment of the underlying disease when possible. Aspirin, estrogen, vitamin E, selegiline, propentofylline and milameline are currently being evaluated for their ability to slow the rate of progression.

Care for a person with dementia can be difficult and complex. The patient must learn to cope with functional and cognitive limitations, while family members or other caregivers assume increasing responsibility for the person's physical needs.

Symptoms of dementia may be treated with a combination of psychotherapy, environmental modifications and medication. Behavioral approaches may be used to reduce the frequency or severity of problem behaviors, such as aggression or socially inappropriate conduct.

Modifying the environment can increase safety and comfort while decreasing agitation. Home modifications for safety include removal or lock-up of hazards such as sharp knives, dangerous chemicals, and tools. Child-proof latches or Dutch doors may be used to limit access as well. Lowering the hot water temperature to 120°F (48.9°C) or less reduces the risk of scalding. Bed rails and bathroom safety rails can be important safety measures, as well. Confusion may be reduced with simpler decorative schemes and presence of familiar objects. Covering or disguising doors (with a mural, for example) may reduce the tendency to wander. Positioning the bed in view of the bathroom can decrease incontinence.

Two drugs, tacrine (Cognex) and donepezil (Aricept), are commonly prescribed for Alzheimer's disease. These drugs inhibit the breakdown of acetylcholine in the brain, prolonging its ability to conduct chemical messages between brain cells. They provide temporary improvement in cognitive functions for about 40% of patients with mild-to-moderate AD. Hydergine is sometimes prescribed as well, though it is of questionable benefit for most patients. Other drugs that are frequently used in dementia patients include antianxiety (for agitation and anxiety) and antipsychotics (for paranoia, delusions or hallucinations) and antidepressants (for depressive symptoms). Evaluation of any medical side effects from the medications should be ongoing.

Long-term institutional care may be needed for the person with dementia, as profound cognitive losses often precede death by a number of years. Early planning for the financial burden of nursing home care is critical. Useful information about financial planning for long-term care is available through the Alzheimer's Association.

Expected Results

The prognosis for dementia depends on the underlying disease. On average, people with Alzheimer's disease live eight years past their diagnosis, with a range from one to twenty years. Vascular dementia is usually progressive, with death from stroke, infection, or heart disease.

Prevention

There is no known way to prevent Alzheimer's disease, although several of the drugs under investigation may reduce its risk or slow its progression. Nutritional supplements, including antioxidants, may also help protect against Alzheimer's disease. New studies also show that use of nonsteroidal anti-inflammatory agents (overthe-counter pain relievers like ibuprofen and naproxen) may lower risk of Alzheimer's. The risk of developing multi-infarct dementia may be reduced by reducing the risk of stroke. Sources of aluminum, which can be found in aluminum cookware, canned sodas, and certain antacids and deodorants, should be avoided.

Resources

Books

Halpern, Georges. Ginkgo: A Practical Guide. Garden City Park, NY: Avery Publishing Group, 1998.

Jacques, Alan. Understanding Dementia. New York: Churchill Livingstone, 1992.

Mace, Nancy L. and Peter V. Rabins. The 36-Hour Day. Baltimore: Johns Hopkins University Press, 1995.

Murray, Michael and Joseph Pizzorno. "Alzheimer's Disease." In Encyclopedia of Natural Medicine. 2nd ed. Rocklin, CA: Prima Publishing, 1998.

Zand, Janet, Allan N. Spreen, and James B. LaValle. "Alzheimer's Disease." In Smart Medicine for Healthier Living: A Practical A-to-Z Reference to Natural and Conventional Treatments for Adults. Garden City Park, NY: Avery Publishing Group, 2000.

Periodicals

Gottlieb, Scott R."NSAIDs Can Lower Risk of Alzheimer's." British Medical Journal 323 no.7324 (December 1, 2001):1269.

Mitka M."PET and Memory Impairment." JAMA, Journal of the American Medical Association 286 no. 16 (October 24, 2001):1961.

Stephenson Joan. "Alzheimer Treatment Target?" JAMA, Journal of the American Medical Association 286 no. 14 (October 10, 2001):1704.

Organization

Alzheimer's Association. 919 North Michigan Ave., Suite 1000, Chicago, IL 60611. (800) 272-3900 (TDD: (312) 335-8882). http://www.alz.org/.

[Article by: Mai Tran; Teresa G. Odle]

Dementia is a condition characterized by a chronic decline in cognitive functions contrasted with a person's usual state of functioning. It is seen most often in people sixty-five years and older, and the incidence increases with age. Dementia occurs in a stable level of consciousness and sensorium, unlike delirium. There are various causes and types of dementia, but they have certain characteristics in common. Persons with dementia often have problems with short-term memory, such as forgetting names and recent events. They may have trouble with visuospatial processing, such as getting lost in familiar places. Language may be affected, causing difficulty in finding the right word to use in a sentence. The affected person may have difficulty with activities of daily living, such as balancing the checkbook or forgetting to turn off the stove when cooking. This condition may also be accompanied by alterations in personality and behavior. Persons with dementia often become depressed, irritable, or have unreasonable fears. They may also say or do inappropriate things in social situations. Visual or auditory hallucinations sometimes occur.

The onset of dementia is usually insidious. Recognition of the condition is often delayed due to lack of insight on the part of the affected person, who often does not notice that anything is wrong. Families are also slow to recognize the condition and sometimes deny that there is a problem. There is a common false myth that aging is synonymous with poor memory. Although aging results in mild slowing for some cognitive functions, normal aging does not cause significant memory loss. In many cases, the deterioration is progressive. However, some dementias have reversible causes, and this possibility must be investigated thoroughly when the person comes for treatment. Physicians should regularly screen patients who are sixty-five years and older for dementia.

Alzheimer's disease is the most common type of dementia in North America and Europe (50–60 percent of dementias). It is characterized by slow onset and gradual impairment of recent memory. Long-term memory usually remains more intact. This impairment progresses until death. It is thought to be caused by the accumulation of certain proteins in the brain. It is not clear what causes this condition to occur. Alzheimer's disease is usually diagnosed clinically by cognitive testing rather than using laboratory tests.

Dementia may also be caused by problems with the vascular system, such as cerebrovascular accident (stroke), hypertension, and atherosclerosis. This is thought to make up 15 to 20 percent of dementias in North America and Europe. These disorders are characterized by abrupt onset of cognitive dysfunction that progressively worsens in a step-wise pattern as multiple strokes recur and damage to the brain accumulates.

There are many other causes of dementia, including trauma, metabolic imbalances, hereditary illness, drugs (e.g., alcohol), toxins, and infections (e.g., HIV [human immunodeficiency virus], syphilis). Some of these causes are reversible with medical treatment. Unlike Alzheimer's disease, these conditions usually have rapid onset and progression. Whenever dementia is diagnosed, these reversible causes must be ruled out promptly.

Parkinson's disease is a movement disorder characterized by tremor, slow unsteady gait, and a mask-like face. Decreased levels of a chemical called dopamine in the brain cause this condition. Approximately 30 percent of persons with Parkinson's disease also have dementia. This dementia is characterized by fluctuations in alertness and cognitive abilities. It is also associated with visual hallucinations. It can be treated with medications that increase the levels of dopamine in the brain.

Psychiatric disorders like depression may cause a dementia-like impairment of memory and concentration called pseudodementia. Depression is a common condition in the elderly. People with depression often have problems with sleep, guilt, appetite, sexual drive, low mood, low energy, and loss of interest in activities, and they may be suicidal. They are more likely to be pessimistic and complain of poor memory than a person with true Alzheimer's disease, who usually tries to deny any problems. Pseudodementia improves after the depression is treated, usually by psychotherapy, medications, or social support. Depression may occur in some individuals with dementia as the person becomes aware of the cognitive decline. Treatment of depression may still be very helpful in such cases.

Diagnosis of dementia requires a thorough physical, neurological, and psychiatric exam. Neuropsychological testing consists of a battery of cognition tests and helps determine what functions are specifically impaired. Laboratory tests are required as part of the medical evaluation. Occasionally, brain imaging is used if a brain tumor or head injury is suspected.

(SEE ALSO: Alzheimer's Disease; Stroke)

Bibliography

Kaplan, H., and Sadock, B., eds. (1995). Comprehensive Textbook of Psychiatry, Vol. 1, 6th edition. Baltimore, MD: Williams and Willkins.

Knopman, D. (1998). "The Initial Recognition and Diagnosis of Dementia." The American Journal of Medicine 104 (April):2S–12S.

Tierney L.; McPhee, S.; and Papadakis, M. (1999). "Dementia." In Current Medical Diagnosis and Treatment, 38th edition. Stamford, CT: Appleton and Lange.

— BETTY TZENG; STUART J. EISENDRATH

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Dementia has been defined in two very different ways. The first definition, which came into use in the nineteenth century with the establishment of a nosographic framework for the psychoses, culminated in the concept of dementia praecox in the work of Emil Kraepelin. The second definition concerns altered states in memory and ideation following injury to the brain.

The word dementia, which first appeared in a psychiatric sense in Philippe Pinel's work contrasting mania and dementia, underwent changes in meaning during the nineteenth century. In 1911 Eugen Bleuler, in his discussion of the concept of schizophrenia, centered around dissociation or splitting (Spaltung), proposed bringing together the old notion of "vesanic dementia" (the culmination of psychotic development) and Kraepelin's three forms of dementia praecox: hebephrenic, catatonic, and paranoid.

Sigmund Freud approved of Kraepelin's approach but he criticized the term dementia praecox, as well as the term schizophrenia. This despite the fact that he felt it important to distinguish between the two, writing, in "Psycho-Analytical Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)" (1911 c[1910]): ". . . we shall hope later on to find clues which will enable us to trace back the differences between the two disorders (as regards both the form they take and the course they run) to corresponding differences in the patients' dispositional fixations" (p. 62). In reality, he continued to use both terms indiscriminately. He focused his study of the psychoses on paranoia in the essay cited above. After "On Narcissism: An Introduction," (1914) he proposed to distinguish among the neuroses, the psychoses, and the perversions. In Freudian theory, dementia praecox consists of a withdrawal of object libido onto the ego through regression and fixation. Freud later went on to specify its linguistic characteristics (words are subjected to the primary process) and its functioning (reality testing is no longer operant; verbal delusions are an attempt at healing), but essentially it was Freud's successors who developed a psychoanalytic theory of the psychoses.

In current usage, the term dementia refers to erosion of the intelligence caused by many different kinds of damage to the brain: degenerative dementias (dominated by Alzheimer's disease), vascular diseases, infectious diseases, toxic conditions, or metabolic disorders. Clinical treatment of dementia from a psychoanalytic perspective runs up against problems of theoretical elaboration. Psychoanalysis has limited applications for these conditions and is used mainly in the early stages of illness. The goal is to limit the breakdown of identity for a certain time. The gradual erosion of the capacity for symbolization and the work of representation owing to memory loss, the weakening of repression and the breaking through of the protective shield, and the instinctual flooding that ensues, has led to reliance on a therapeutic approach focusing on the reconstitutive function of the affects as the basis for mental activity, since, as Michèle Grosclaude suggested in Le Statut de l'affect dans la psychothérapie des démences (The status of the affects in the psychotherapy of dementia; 1997), verbal therapies are among the first to be affected by the degenerative process. Denial, projective delusions, and heightened anxiety are all typical of these conditions.

Bibliography

Freud, Sigmund. (1911c [1910]). Psycho-analytical notes on autobiographical account of a case of paranoia (dementia paranoides). SE, 12, 9-82.

——. (1914). On narcissism: an introduction. SE, 14, 73-102.

——. (1915). The unconscious. SE, 14, 166-204.

Grosclaude, Michèle. (1997). Le Statut de l'affect dans la psychothérapie des démences. Psychothérapie des démences. Montrouge, France: John Libbey Eurotext.

—RICHARD UHL

This is defined by W. A. Lishman (1978) as 'an acquired global impairment of intellect, memory, and personality but without impairment of consciousness'. Although often considered to be an irreversible condition, recent studies have shown that about 10 per cent of patients with dementia have conditions for which treatment can reverse the otherwise inexorable decline of mental function. The progressive dementias are most often diagnosed in the elderly under the headings of senile dementia of the Alzheimer type and multi-infarct dementia. The former is caused by widespread degeneration of nerve cells in the brain and their replacement by elements known as plaques and neurofibrillary tangles. Post-mortem studies of the brains of patients who have died from senile dementia have enabled correlation of the numbers of these elements with the degree of mental impairment shown by psychometric testing during life. Multi-infarct dementia, which is less common than senile dementia, is caused by loss of brain substance following repeated closure of small or large blood vessels, incidents that cause minor or major strokes. The older term, arteriosclerotic dementia, has now been superseded.

These areas of degeneration may be widespread and scattered, or concentrated in certain areas of the brain. If the latter, the mental changes will be much more severe in some functions than in others. For instance, the person may lose his speech (developing aphasia) but not his memory, or vice versa. One of the last things usually to be affected is his basic personality, and some of the last skills to be lost are the social ones. Hence some demented persons will retain the major features of personality, remaining well mannered, considerate, and responsive if these were the former characteristics. On the other hand, blunting of emotion and loss of control of social behaviour may lead to episodes of petulant and irritable behaviour or tactless and inappropriate remarks which would not have been uttered before the onset of the illness.

The difference between dementia and the more limited losses of mental ability due to focal injuries is that the demented person can seldom make compensations for his disabilities in the way the others do, and, indeed, very often seems to be unaware of them. He tends to live his life entirely for the present moment, although the present for him may be an era from his own distant past.

Although it is characteristic of the truly demented person that he has little insight into his defects, inability to cope with his environment may make him severely perplexed, or trigger off a condition described by Kurt Goldstein (1878–1965) and called by him the 'catastrophic reaction'. The individual becomes tearful and angry; he may repeat non-adaptive stereotyped movements in a repetitive manner, or start sweating and becoming restless. The 'emotional lability' that accompanies dementia is one of its outstanding characteristics and helps to differentiate it from true depression, in which the individual remains sad and retarded no matter how his circumstances alter. Dementia must also be differentiated from another, much less common form of emotional disorder: that accompanying bulbar palsy, in which the individual may respond to any sudden stimulus or strong effort by screwing up his face and bursting into tears, without any of the unhappiness that usually causes such outbursts. 'I just can't help crying,' he may be able to tell you between spasms. 'Don't pay any attention to me.' In contrast to both of these, the emotional state of the demented person seems to reflect exactly the situation of the moment. If he is faced with a problem too difficult for him to solve, he shows all the signs of distress, but if this is removed and he is presented with a simpler one, the next moment he will be laughing and cheerful. It follows that even severe dementia may not necessarily cause its sufferer any personal pain, depending on where and how he is cared for. If his environment is simple, cheerful, and constant (i.e. unchanging) he may to all outward appearances (and on his own admission) be perfectly cheerful and contented.

It is important to distinguish dementia from the other disorders which commonly affect the elderly, as, although there is, as yet, no known method of retarding or reversing dementia, many of the other conditions are fully treatable. In the speech disorders of dementia, comprehension is usually just as badly affected as expression, whereas in the aphasia due to focal lesions this is very rare. Moreover, the errors made when trying to name objects are rather different. The aphasic person usually manages to indicate that he knows perfectly well what the object is even though he cannot find its name, but the demented person often seems to fail to recognize the object too. If asked to name different parts of his body, the aphasic person can usually name those parts that are commonly mentioned (such as feet, hands, and arms) but not those less frequently so (knuckles, eyebrows, ankles); in the demented there is seldom any difference.

The failure of memory seen in senile dementia is also different from that seen in normal old age (see ageing) or in the organic amnesic conditions. In the latter, cues or prompts very often help, but in the demented they seem rather to do the opposite. If one considers recall as being like searching for an item in a vast territory, a cue for the amnesic narrows the field of search and directs his attention to a specific area; for the demented, it seems to direct him to a new part of the field. For instance, if the target is the word 'cart', a useful cue for an amnesic would be the words 'Horse and — — '. A case of senile dementia might respond by saying, 'Horse? Yes, I remember we had many horses when I was a child, one particular one ... '.

The ability to handle and manipulate objects is usually little impaired in dementia. Those motor skills which were learned in the past are well retained, but since he is inclined to forget what he is aiming to achieve before he has half done it, the demented person gets himself into difficulties. At first appearance he may seem to be suffering from apraxia (the loss of such skills due to focal lesions), but closer study will reveal differences. For example, both apraxic and demented individuals often have difficulty dressing themselves, but in the case of the apraxic the difficulty is due to 'forgetting' how to tie knots, do up buttons, or put an arm into a sleeve; in the demented it is due to forgetting whether he is supposed to be getting dressed or undressed at the time. When preparing meals — even such a simple task as making a pot of tea — the apraxic forgets how to put tea into the pot or stir it with a spoon; the demented can do all these things, if reminded constantly of the task in hand, but if distracted at all is liable to lose track of how far he has got and has to start from the beginning again.

Finally, there are two conditions that may be easily mistaken for dementia. The first is a severe depressive illness which may produce the condition sometimes called pseudodementia which only a skilled psychiatrist can distinguish from true dementia, but which responds to appropriate antidepressant treatment. The second is a delirious state, triggered off in an old person by physical disorder such as pneumonia, a heart attack, or hypothermia. Unlike dementia, which usually comes on slowly over a long period, delirious states are likely to appear suddenly and will be accompanied by severe disorientation and even hallucinations. These symptoms, however, clear up completely once the underlying physical disorder is rectified, and in former days it was quite common for an old person to 'wake up' after such an illness and find himself in a mental hospital labelled, to his great consternation, a case of senile dementia.

(Published 1987)

— Moyra Williams

Bibliography
• Lishman, W. A. (1978). Organic Psychiatry.
• Miller, E. (1977). Abnormal Ageing.
• Ritchie, K., and Lovestone, S. (2002). 'The dementias'. Lancet, 360.
• Roth, M., and Iverson, L. L. (eds.) (1986). 'Alzheimer's disease and related disorders'. British Medical Bulletin, 42.
• Williams, M. (1979). Brain Damage, Behaviour and the Mind.

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Loss of intellectual capacity accompanied usually by irrational behavior.

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Dansk (Danish)
n. - demens, sløvsind

Nederlands (Dutch)
dementie (ouderdomsziekte)

Français (French)
n. - démence

Deutsch (German)
n. - Schwachsinn, Wahnsinn

Ελληνική (Greek)
n. - (παθολ.) άνοια

Italiano (Italian)
demenza

Português (Portuguese)
n. - demência (f)

Русский (Russian)
слабоумие

Español (Spanish)
n. - demencia

Svenska (Swedish)
n. - dementi

中文（简体）(Chinese (Simplified))
痴呆

中文（繁體）(Chinese (Traditional))
n. - 癡呆

한국어 (Korean)
n. - 치매

日本語 (Japanese)
n. - 痴呆, 狂気

العربيه (Arabic)
‏(الاسم) اختلال عقلي شديد بسبب مرض في الدماغ او إصابه‏

עברית (Hebrew)
n. - ‮טירוף‬

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