Dementia
Dementia refers to a group of disorders characterized by progressive deterioration of mental capacity,
specifically in forming new memories. (dementia classification tables) Many affected individuals
eventually develop behavioral disturbances and lose the ability to care for themselves.
Although knowledge of the different types of dementia is important it is immensely more important to
recognize other conditions that mask as dementia but are entirely reversible. Some of these conditions
include depression, medications side effects, low blood pressure, fluctuating blood sugar levels.
Common medications that suppress bran activity and can produce a condition similar to dementia
include all pain medications, all blood pressure medications and anti-seizure medications.
Alzheimer's disease (AD) accounts for up to 80 percent of all cases of dementia, affecting up to 4
million Americans today. Other common forms of dementia include vascular dementia, HIV dementia,
Parkinson’s disease and Huntington’s disease. Diagnosis is based mostly on typical history in a
patient at risk, poor performance on cognitive testing, lack of abnormal findings on neurological and
laboratory examinations. A definitive diagnosis can only be made on autopsy where abnormal protein
deposits can be demonstrated.
Who’s at Risk?
Age over 60- 10% of all over 65 and 50% of all those over 85 years of age
Heredity, especially with close relatives with dementia onset prior to age 60
Hypertension and high cholesterol
Previous brain injury
Low education level
History of depression
Environmental heavy metal exposure (Aluminum)
Typical Early Findings
According to the National Institute on Aging, losing the ability to balance a checkbook, relying on others
to make decisions, and repeating questions or stories over and over are three of the major warning
signs of Alzheimer’s disease. Furthermore, several small studies are suggestive of the loss of sense of
smell as a harbinger of serious memory loss.
Dangers
Driving- Patients with Alzheimer’s diagnosis, regardless of stage, are at increased risk for driving
accidents and driving performance errors. The patient should not drive an automobile unless an on-
road evaluation of driving ability conducted by the state driver's licensing authority deems it
appropriate.
Cooking- Fire hazard because demented patients tend to forget they have started cooking a meal.
Falls- Patients are at increased risk for fall due to lack of safety awareness.
Wandering- demented patients tend to forget where they are and sometimes revert back to childhood
and youth and visit their old neighborhoods and hometowns.
Aggression- demented patients may exhibit aggressive behavior most commonly towards their
caretakers.
Sun-downing- all patients with dementia regardless of the type are prone to having nightly
exacerbation of symptoms called sun-downing. This is believed to be due to decrease in sensory
stimulation and cues that normally keep them stimulated and ware of their whereabouts.
Hospital psychosis- This occurs commonly with patients who are hospitalized or who otherwise
spend time in unfamiliar settings. It is easier to lose orientation and become confused in new and
intimidating environments stimulating aggressive or inappropriate behavior. Decompensation during a
hospitalization is a clear risk factor for development of future dementia and may be an early sign of
sub-clinical disease.
Depression- Some forms of dementia are “insight preserving”. Namely the patient is periodically
aware of their progressive cognitive loss. Alzheimer’s is not an insight preserving dementia. However,
in any kind of dementia depression can be a complicating factor. Furthermore, in any condition
associated with loss of cognitive ability depression must be considered and ruled out as it can cause
significant mental slowing and mimic dementia.
Prevention
No clearly advantageous intervention has been identified that can prevent progression of dementia. A
regimen of low dose anti-inflammatory agents (Motrin 200 mg once a day) plus vitamin E 400 IU daily
is benign and is being recommended by some clinician.
Treatment
Treatment and slowing the progress of dementia is difficult, expensive and often unrewarding. Gauging
the effectiveness of therapy is difficult and often tainted by caretakers’ desire to see a response.
Available medications include:
MedicationSupplement $/month
Aricept
(donepezil) 128
Exelon (Rivastigmine) 137
Reminyl (Galantamine) 139
Cognex
(Tacrine) 155
Namenda
(Memantine) 130
Membrin (combination of
Gingko Biloba, Huperazin, 22
Vinopectin)
The most reasonable course of therapy for any stage of Alzheimer’s for patients and families that
desire a drug trial is to begin therapy and assess its effectiveness in 6-12 weeks. Because there are
no concrete criteria about measuring response assessment and decision making about continuation
of drug therapy is difficult. Drugs in general do not improve or reverse the disease but only slow the
progression. In our experience patients who have been stable on these medications for some time
deteriorate quickly upon cessation of medical therapy.
Medications for Behavioral Problems
The most effective therapies for controlling behavioral manifestations of Alzheimer’s include the use of
anti-convulsant, sedating and anti-psychotic medications for relieving symptoms of agitation and
aggression. There is no report or indication that any of these medications will curtail the wandering,
spontaneous vocalization, or apathy associated with advanced stages of Alzheimer’s or otherwise
hinder disease progression. These medications are no more than band-aids on a problem that is best
dealt with by providing a supportive environment designed to minimize confusion.
Medication $/month
Haldol
(Haloperodiol) 8
Tegretol
(Carbamazepine) 12
Risperidone >150
Seroquel >200
Alternative Treatments
Reducing medications in often helpful in the older more forgetful patient. Poly-pharmacy is a major
contributor to medical problems in older patients. It is in part the result of doctors seeing their roles as
"fixers" and patients hearing a little too much about "making sure they mention everything to the
doctor". It is true that there is a pill for every problem but taking that pill may open a whole new
Pandora's Box of problems in place of the one it solves.
A major correctable cause of memory loss in the elderly is cerebral hypo-perfusion, lack of
appropriate circulation to the brain. The most common cause of this problem is over treatment with
medications for high blood pressure. Tolerating blood pressure levels up to 160 in order to avoid
lowering the diastolic blood pressure below 60 is often the most gratifying intervention that can be
made in the treatment of memory loss and fatigue in older patients.
Hormone replacement is another potential way of improving cognition, strength and metabolism.
Nutritional interventions are increasingly recognized as ways to help improve patient status and reduce
deposits of beta amyloid felt to be in part responsible for the development of Alzheimer's.
Alternative means for controlling the progression or the symptoms of Alzheimer’s are in use by various
practitioners and institutions that specialize in treating patients with dementia. They include Vitamin E
(which unfortunately increases mortality), Ginko Biloba (with variable results in large clinical trials),
music therapy, anti-inflammatory agents such as aspirin and advil, hormones such as estrogen and
progesterone, testosterone, music therapy, re-orientation therapy, validation therapy. Several recent
trials have demonstrated minor benefits in using cholesterol lowering medications in patients with
dementia. Animal studies have revealed some regression of brain cells abnormalities (neurofibrillary
tangles) in brains of animals with Alzheimer's after treatment with cholesterol lowering drugs.
Probably the most important aspect of caring for someone with dementia is their home environment.
Not all facilities are appropriate for dementia care. Staying home is not always the best option. Many
patients with dementia are unsafe at home and the desire to keep them at home places undue stress
upon the families as well as the exposing the patients to unnecessary risks, misery and loneliness.
Patients with dementia require appropriate, specialized care in familiar, safe, non-threatening settings.
They require caretakers with experience treating patients with dementia and social setting with
supervised activities and appropriate stimulation. Visual cues in the environment such as colorful
plates, respect for their independence and attention to their specific likes and dislikes are all parts of
what makes a successful environment for allowing patients with dementia to flourish.
Care for the demented patient is best provided by knowledgeable caregivers. Providing care to those
with advanced dementia can be quite challenging and frustrating. Specialized care is available at
several dementia facilities in the area as well as in 6 bed facilities where personalized care can be
provided by experienced staff.
Consultation by Specialists (Neurologist or Psychiatrist)
In general dementia is diagnosed and treated by primary care providers. Sub-specialty evaluation,
neuropsychiatric testing and treatment of dementia is indicated based on the following:
Cognitive loss is early-onset (before the age of 60)
Strong Family history
Diagnosis is complex or remains unclear after basic work-up
Primary care provider can not rule out depression, substance use or systemic disease as the main
cause of cognitive changes
Movement disorders suggest atypical dementia such as Huntington’s or Parkinson’s
PET scanning, assessing brain metabolism and function rather than just structure is available and
effective in identifying unusual causes of dementia. This modality can identify those who will not benefit
from intervention and can help guide therapy of those who will benefit.