Dementia is a long standing, progressive disease which is characterized by cognitive deficits mainly in the domain of memory.
As well as it will disturbing the functions of below processes.
- Memory
- Thinking
- Orientation
- Comprehension
- Calculation
- Learning capacity
- Language
- Judgement.
It is not completely due to process of normal aging and the disease effects the independence of a person’s performance of activities of daily living. This can further be defined as an acquired brain syndrome which is attributable for a neurological or medical condition that affects the brain, trauma, nutritional deficiency, chronic use of specific substances or medications, or exposure to heavy metals or other toxins.
Diagnostic Criteria
According to ICD-11, dementia is diagnosed by a decline from a previous level of cognitive functioning with impairment in two or more cognitive domains (as memory, executive functions, attention, language, social cognition and judgment, psychomotor speed, visuoperceptual or visuospatial abilities).
Etiology and Epidemiology
Onset of disease increases with aging. Prevalence of disease doubles every 5 years between ages of 65-85. Commonest type of dementia is the Alzheimer type which is common among females which shows evidence of genetic etiology. Second commonest type of dementia is Vascular dementia which is commoner in males. Causative factors for vascular dementia are multiple cerebral infarcts and single infarcts while risk factors are obesity, hypercholesterolemia, smoking and hypertension.
Clinical Presentations
- Memory impairment – Short-term memory impairment is prominent than the long-term memory impairment. Initial, complaints of a patient will be forgetting the location of the keys, money or forgetting the shopping list. When the disease progresses the patient becomes unable to recall recent events, and recognize known people which later on progresses as being unable to recognize family members or recall personal details such as address and birthdays.
- Difficulty in naming objects and finding words
- In advanced disease can cause incomprehensible speech
- Poor judgement, difficulty in handling money and hardness in taking rational decisions
- In initial stages patient can get lost in unfamiliar surroundings while in advanced stages can get lost even in familiar surroundings.
- Previous personality traits are exaggerated causing continuous quarrels, socially unacceptable behavior.
- Due to forgetfulness, they can accuse others of stealing patient’s belongings.
- Behavioral changes as agitation, wandering, poor sleep and repetition of meaningless words
Management
After establishing the diagnosis, cause of dementia must be identified whether a treatable cause or not. Some treatable causes of dementia are
- Cerebral tumors
- Subdural haematomas
- Hypothyroidism
- Tertiary syphilis
As the next step in management severity of illness must be assessed for which
- Mini Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MoCA) can be used.
Next the capacity of the patient to understand
- Data and retain them
- Believe in them
- Weigh them
- Arrive at an informed choice must be assessed as it effects the patient’s capability to give informed consent and manage money
- The patient and family must be educated regarding the disease
- Social support must be arranged for the patient
They must be described that dementia causes impairment of brain function due to gradual atrophy and early treatment can slow the rate of progression of cognitive impairment.
- Carers must be educated about maintaining
- Quality of life
- Minimizing risks
- Managing behavioral problems
- Maintaining good health in patients
If the patient is still in the early phase of illness, encourage patient and carers to address financial and legal issues before further cognitive deterioration occurs. Carers must be prepared for future as progression of disease can make the patient more dependent. An occupational therapist should assess the home environment and advice on possible interventions to minimize the risk as providing good lighting to reduce the risk of accidents and falls.
Pharmacological Management
Effective drugs in the treatment of mild to moderate dementia while NMDA receptor antagonist as Memantine is recommended for treatment of moderate to severe dementia.
- Cholinesterase inhibitors as Rivastigmine
- Donepezil
- Galantamine
References
- ICD -11, Classification of Mental and Behavioral Disorders- Diagnostic Criteria for Research
- Shorter Oxford Textbook of Psychiatry – 7th Edition – Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel
- Handbook of Clinical Psychiatry – A Practical Guide- Second Edition – Varuni De Silva, Raween Hanwella
