Procedure

Dementia Management- Neurology, Sleep Studies

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Dementia is a neurological disorder characterized by a progressive decrease in the intellectual and mental function of the brain, leading to physical disability and eventual death. It is not a disease but a symptom that can result from several types of disorders.

Epidemiology

In 2015, ~47 million people globally developed dementia. This figure is projected to increase to ~130 million by 2050. It is more commonly observed in people above 65 years of age. In the US, ~15% of people aged over 68 years develop dementia. Females are more likely to be affected than males.

Types and clinical features

Dementia can be grouped into different types. The major groupings include Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, frontotemporal dementia, and mixed dementia.

Alzheimer’s disease: It is the most common type, observed in ~60% of individuals with dementia. It is characterized by the accumulation of amyloid plaques (proteins) in and around neurons (nerves) of the brain. This leads to the death of neurons and inability to transmit signals to the brain. The following symptoms can be observed:

  • Loss of memory (e.g., difficulty in managing finances, paying bills, recollecting events).
  • Repeating questions and conversations.
  • Change in behavior and language.
  • Poor sense of judgment and a decrease in the ability to perform tasks.
  • Neuropsychiatric symptoms such as depression, anxiety, delusions, hallucinations, aggression, and changes in eating habits.

Vascular dementia: It affects ~15% of individuals suffering from dementia. The presence of single or multiple infarcts (dead tissues) in the blood vessels can impair the supply of blood to specific areas in the brain, resulting in vascular dementia. It has a high mortality rate due to cardiovascular and cerebrovascular causes.

Signs and symptoms include:

  • Impaired cognitive functions followed by loss of memory.
  • Difficulty in paying attention and processing information.
  • Loss of control over language.
  • Neuropsychiatric symptoms (similar to Alzheimer’s disease), particularly lack of interest and depression.

Dementia with Lewy bodies: This constitutes ~10-20% of all the cases of dementia. It is caused by high accumulation of protein (Lewy bodies) in the neurons controlling the functions of memory, behavior, and movement in the brain, leading to degeneration and impaired functioning of neurons. It is characterized by:

  • Alternating periods of impaired intellectual abilities and normal behavior.
  • Neuropsychiatric symptoms such as hallucination, anxiety, loss of interest, sleep disturbances, and depression.
  • Motor function disorders such as stiffness of limbs, tremors, disturbance in the gait, reduced movement of limbs, and fainting.

Frontotemporal dementia (or Pick’s disease): This type of dementia is found in younger individuals. This is caused by degeneration of nerves in different parts of the brain (including both frontal and temporal regions).

The following changes are observed:

  • Change in the personality and social conduct of the individual.
  • Neuropsychiatric symptoms: Display of extreme behaviors such as lethargy, inactiveness, excessive talking, laughing, singing, aggression, or sadness.
  • Overall decrease in personal hygiene, altered food habits, overeating, stiffness of muscles.
  • Display of inappropriate physical, verbal, or sexual behavior, or lack of emotional outlook.
  • No changes are exhibited with cognitive behavior, memory, language, and processing of information.

Mixed type: It comprises of features of more than one type of dementia.

Special note: Reversible dementia: It is a temporary loss of cognitive function due to causes such as psychiatric disorders, Vitamin B12 deficiency, deficiency of folic acid, hypothyroidism, alcohol abuse, increased toxin levels (e.g., mercury, lead poisoning), and depression.

Etiology:

There are multiple factors involved in causing the disease:

Genetic factors:

  • Autosomal dominant genes—responsible for a family history of Alzheimer’s or Vascular dementia—increase the risk of developing the condition in an individual.
  • Abnormalities in the chromosomes are also associated with frontotemporal dementia and late-onset Alzheimer’s disease.

Environmental factors:

  • Age: Aging increases the risk of developing dementia.
  • Gender: Dementia is more-commonly observed in females.
  • Systemic health: Factors such as high blood pressure, diabetes, smoking, and high lipid levels pose a high risk for several heart and brain related disorders, leading to dementia. Individuals with Parkinson’s disease have a higher risk of developing Lewy bodies dementia
  • Mental health: Research suggests that individuals with a previous history of psychiatric disorders, schizophrenia, or depression are at higher risk of developing dementia.
  • Trauma: Severe brain injuries may cause development of Alzheimer’s disease.
  • Lifestyle: Individuals with physically, socially, and intellectually active lifestyles are less prone to developing dementia.
  • Other factors: Deficiency of thyroid, Vitamin B12 deficiency, folate deficiency, alcohol abuse, etc. can lead to dementia which gets corrected once the definitive treatment is given.

Diagnosis:

  • Initial examination and case history: This include identification of signs and symptoms by the physician based on the patient’s history, cognitive function, patient’s behavior, past medical history, family history, personal history, and the record of daily activities.
  • Physical examination: It is performed to evaluate the motor function and identify neurological signs.
  • Cognitive function test: Several tests are performed to evaluate the cognitive functions of the individual.
  • Laboratory examinations: Several blood tests are recommended to rule out the possibilities of disorders such as anemia, vitamin B12 deficiency, diabetes, endocrine disorders, HIV, viral infections, and liver and kidney disease.
  • Genetic testing: It can help diagnose Alzheimer’s disease.
  • Brain imaging (CT or MRI): This aids in the identification of several intracranial abnormalities.
  • CSF testing: Cerebrospinal fluid protein test (using fluid from the brain) is useful to detect biomarkers and the presence of Creutzfeldt-Jakob disease.

Differential diagnosis:

Diseases which display symptoms similar to dementia-related disorders:

  • Cerebral causes: Chronic subdural hematomas (pooling of blood in the brain due to injury), normal-pressure hydrocephalus (fluid build-up in the brain), and slow-growing tumors.
  • Cardiovascular causes: Cerebral Vasculopathies (disease affecting vessels supplying blood to the brain).
  • Endocrine hormone-related: Hypothyroidism or hyperthyroidism, hyperparathyroidism, Cushing’s disease, and Addison’s disease.
  • Other causes: Hyponatremia (decreased sodium levels), hypercalcemia (increased calcium levels), chronic hepatic failure, and renal failure.

Management

Management for dementia includes both non-medicinal and medicinal interventions:

Non-medicinal: These interventions largely include the behavioral changes in patients.

  • Cognitive training: Regular reading, playing games (e.g., chess), listening to music, and reminiscing old memories help improve the cognitive function and psychological well-being.
  • Physical training: Physical exercises such as walking, swimming, cardio, and resistance training help improve the overall health (especially in case of blood pressure, diabetes, and stroke risks).
  • Social activities: Participating in social activities, get-togethers with friends and family, and interacting with pets can be beneficial. Intake of a Mediterranean diet (e.g., nuts, berries, fish) and adequate sleep is also good for the brain’s health.
  • Support of the family or caregiver: Family members or a caregiver should be educated about the disease and its consequences. He or she should be trained to deliver primary care such as maintenance of personal hygiene of individuals, providing a safe environment inside or outside the home, regulating medicine intake, assisting in financial aspects, and tracking improvements in signs and symptoms of the disease.

Medicinal: Several drugs can help improve cognitive functions.

  • Acetylcholinesterase inhibitors: The presence of acetylcholinesterase prevents transmission of signals or messages to the brain. Acetylcholinesterase inhibitors block the action of this chemical and increase acetylcholine levels, which helps in uninterrupted transmission of signals. Examples of the drug include Donepezil Rivastigmine and Galantamine. These drugs are taken orally.
  • Memantine: It is used to treat moderate to severe types of Alzheimer’s disease. It is taken orally. This can be used alone or in combination with acetylcholinesterase inhibitors.
  • Psychostimulants: Medications such as levodopa and dopamine agonist aid in the improvement of cognitive functions.
  • Neuroleptics: Neuroleptics such as clozapine, quetiapine, and risperidone are useful in reducing delusions and agitations.
  • Serotonin reuptake inhibitors: These medications are effective against symptoms such as depression and anxiety.
  • Antidepressants: Antidepressants such as mirtazapine and trazodone help improve sleep and depression.

Sources:

  • Doody, R. (2010). Dementia. Neurology Secrets, 235–246. doi:10.1016/b978-0-323-05712-7.00014-3
  • O’Brien, J. T., & Thomas, A. (2015). Vascular dementia. The Lancet, 386(10004), 1698–1706. doi:10.1016/s0140-6736(15)00463-8
  • Mosimann UP, McKeith IG. Dementia with lewy bodies--diagnosis and treatment. Swiss medical weekly. 2003 Mar 8;133(9-10):131-42.
  • Neary, D., Snowden, J., & Mann, D. (2005). Frontotemporal dementia. The Lancet Neurology, 4(11), 771–780. doi:10.1016/s1474-4422(05)70223-4
  • Gouras, G. K. (2014). Dementia. Reference Module in Biomedical Sciences. doi:10.1016/b978-0-12-801238-3.00159-8
  • Falk N, Cole A, Meredith TJ. Evaluation of suspected dementia. American family physician. 2018 Mar 15;97(6):398-405.
  • Arvanitakis, Z., Shah, R. C., & Bennett, D. A. (2019). Diagnosis and Management of Dementia: Review. JAMA, 322(16), 1589. doi:10.1001/jama.2019.4782
  • Grossman H, Bergmann C, Parker S. A Brief Review. The Mount Sinai journal of medicine. 2006 Nov;73(7):985.
  • Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D, et al. Dementia prevention, intervention, and care. The Lancet. 2017 Dec 16;390(10113):2673-734.
  • National Collaborating Centre for Mental Health (UK. Dementia. InDementia: A NICE-SCIE Guideline on Supporting People with Dementia and Their Carers in Health and Social Care 2007. British Psychological Society.
About the Author:
Dr. Shilpy Bhandari is an experienced dental surgeon, with specialization in periodontics and implantology. She received her graduate and postgraduate education from Rajiv Gandhi University of Health Sciences in India. Besides her private practice, she enjoys writing on medical topics. She is also interested in evidence-based academic writing and has published several articles in international journals.
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