Dementia

Cause

Dementia is caused by damage to or changes in the brain.

Common causes of dementia are:

• Alzheimer's disease. This is the most common cause of dementia.
• Vascular dementia. This may occur in people who have long-term high blood pressure, severe hardening of the arteries, or several small strokes. Strokes are the second most common cause of dementia.
• Parkinson's disease. Dementia is common in people with this condition.
• Dementia with Lewy bodies. It can cause short-term memory loss.
• Frontotemporal dementia, a group of diseases that includes Pick's disease.
• Severe head injury.

Less common causes of dementia include:

• Huntington's disease.
• Leukoencephalopathies, which are diseases that affect the deeper, white-matter brain tissue.
• Creutzfeldt-Jakob disease, a rare and fatal condition that destroys brain tissue.
• Brain injuries from accidents or boxing.
• Some cases of multiple sclerosis (MS) or amyotrophic lateral sclerosis (ALS).
• Multiple-system atrophy (a group of degenerative brain diseases affecting speech, movement, and autonomic functions).
• Infections such as late-stage syphilis. Antibiotics can effectively treat syphilis at any stage, but they cannot reverse the brain damage already done.

Inherited dementia

Some disorders that cause dementia can run in families. Doctors often suspect an inherited cause if someone younger than 50 has symptoms of dementia. For more information, see the topic Alzheimer's Disease.

Symptoms

Symptoms of dementia vary depending on the cause and the area of the brain that is affected. Symptoms include:

• Memory loss. This is usually the earliest and most noticeable symptom.
• Trouble recalling recent events or recognizing people and places.
• Trouble finding the right words.
• Problems planning and carrying out tasks, such as balancing a checkbook, following a recipe, or writing a letter.
• Trouble exercising judgment, such as knowing what to do in an emergency.
• Trouble controlling moods or behaviors. Depression is common, and agitation or aggression may occur.
• Not keeping up personal care such as grooming or bathing.

Some types of dementia cause particular symptoms:

• People who have dementia with Lewy bodies often have highly detailed visual hallucinations. And they may fall frequently.
• The first symptoms of frontotemporal dementia may be personality changes or unusual behavior. People with this condition may not express any caring for others, or they may say rude things, expose themselves, or make sexually explicit comments.

Symptoms of dementia that come on suddenly suggest vascular dementia or possibly delirium, which is short-term confusion caused by a new or worsening illness.

It is important to know that memory loss can be caused by conditions other than dementia, such as depression, and that those conditions can be treated. Also, occasional trouble with memory (such as briefly forgetting someone's name) can be a normal part of aging. But if you are worried about memory loss or if a loved one has memory loss that is getting worse, see your doctor.

What Happens

How quickly dementia progresses depends on what is causing it and the area of the brain that is affected. Some types of dementia progress slowly over several years. Other types may progress more rapidly. If vascular dementia is caused by a series of small strokes, the loss of mental skills may be gradual. If it is caused by a single stroke in a large blood vessel, loss of function may occur suddenly.

The course of dementia varies greatly from one person to another. Early diagnosis and treatment with medicines may help for a while. Even without these medicines, some people remain stable for months or years, while others decline rapidly.

Many people with dementia are not aware of their mental decline. They may deny their condition and blame others for their problems. Those who are aware may mourn their loss of abilities and become hopeless and depressed.

Depending on the type of dementia, the person's behavior may eventually become out of control. The person may become angry, agitated, and combative or clingy and childlike. He or she may wander and become lost. These problems can make it difficult for family members or others to continue providing care at home. Palliative care can offer families a lot of support and assistance, which is why getting palliative care early is so important.

Even with the best care, people with dementia tend to have a shorter life span than the average person their age. The progression varies depending on the disease causing the dementia and whether the person has other illnesses such as diabetes or heart disease. Death usually results from lung or kidney infections caused by being bedridden.

What to think about

Many older people have a slight loss of mental skills (usually recent memory) that doesn't affect their daily functioning. This is called mild cognitive impairment by some. People who have mild impairment may be in the early stage of dementia, or they may stay at their present level of ability for a long time.

What Increases Your Risk

Aging is the main risk factor for all types of dementia. Some diseases that cause dementia (such as early-onset Alzheimer's disease and some frontotemporal dementias) may run in families.

You have a greater chance of developing vascular dementia if you:

• Are male.
• Have high blood pressure.
• Have had a heart attack.
• Have atherosclerosis, a buildup of fat and calcium in the arteries, which can lead to coronary artery disease.
• Have diabetes.
• Have high cholesterol.
• Have had a stroke or transient ischemic attack (TIA).

When To Call

Call 911 or other emergency services immediately if signs of a stroke or transient ischemic attack (TIA) develop suddenly. These may include:

• Numbness, weakness, or inability to move the face, arm, or leg, especially on one side of the body.
• Vision problems in one or both eyes, such as dimness, blurring, double vision, loss of vision, or feeling like a shade is being pulled down over your eyes.
• Confusion, or trouble speaking or understanding.
• Trouble walking, dizziness, or loss of balance or coordination.
• Severe headache with no known cause.

Call a doctor now if a person suddenly becomes confused or emotionally upset or doesn't seem to know who or where they are. These are signs of delirium, which can be caused by a reaction to medicines or a new or worsening medical condition.

Call a doctor if you or a person you are close to has new and troubling memory loss that is more than an occasional bout of forgetfulness. This may be an early sign of dementia.

Watchful waiting

Occasional forgetfulness or memory loss can be a normal part of aging. But any new or increasing memory loss or problems with daily living should be reported to a doctor. Learn the warning signs of dementia, and talk to a doctor if you or a family member shows any of these signs. They include increased trouble finding the right words when speaking, getting lost going to familiar places, and acting more irritable or suspicious than usual.

Exams and Tests

Doctors diagnose the cause of dementia by asking questions about the person's medical history and doing a physical exam, a mental status exam, and lab and imaging tests.

Tests can help the doctor learn whether the loss of mental abilities is caused by a treatable condition. Even for causes that cannot be treated, knowing the type of dementia a person has can help the doctor prescribe medicines or other treatments that may improve mood and behavior and help the family.

Medical history

During a medical history and physical exam, the doctor will ask the affected person and a close relative or partner about recent illnesses or other life events that could cause memory loss or other symptoms such as behavioral problems. The doctor may ask the person to bring in all medicines he or she takes. This can help the doctor find out if the problem might be caused by the person being overmedicated or having a drug interaction.

Although a person may have more than one illness causing dementia, symptoms sometimes can distinguish one form from another. For example, early in the course of frontotemporal dementia, people may display a lack of social awareness and develop obsessions with eating.

Mental status exam

A doctor or other health professional will conduct a mental status exam. This test usually involves such activities as having the person tell what day and year it is, repeat a series of words, draw a clock face, and count back from 100 by 7s.

Lab tests

Many medical conditions can cause mental impairment. During a physical exam, the doctor will look for signs of other medical conditions and have lab tests done to find any treatable condition. Routine tests include:

• Thyroid hormone tests to check for an underactive thyroid.
• Vitamin B12 blood test to look for a vitamin deficiency.

Other lab tests that may be done include:

• Complete blood count, or CBC, to look for infections.
• ALT or AST, blood tests that check liver function.
• Chemistry screen to check the level of electrolytes in the blood and to check kidney function.
• Glucose test to check the level of sugar in the blood.
• HIV testing to look for AIDS.
• Erythrocyte sedimentation rate, a blood test that looks for signs of inflammation in the body.
• Toxicology screen, which examines blood, urine, or hair to look for drugs that could be causing problems.
• Antinuclear antibodies, a blood test used to diagnose autoimmune diseases.
• Testing for heavy metals in the blood, such as a lead test.
• A lumbar puncture to test for certain proteins in the spinal fluid. This test may also be done to rule out other causes of symptoms.

Imaging tests

Brain imaging tests such as CT scans and MRI may also be done to make sure another problem isn't causing the symptoms. These tests may rule out brain tumors, strokes, normal-pressure hydrocephalus, or other conditions that could cause a loss of mental abilities.

MRI and CT scan also can show evidence of strokes from vascular dementia.

Single photon emission CT (SPECT) and PET scan can help identify several forms of dementia, including vascular dementia and frontotemporal dementia.

Other tests

In some cases, electrical activity in the brain may be measured using an electroencephalogram (EEG). Doctors seldom use this test to diagnose dementia, but they may use it to distinguish dementia from delirium and to look for unusual brain activity found in Creutzfeldt-Jakob disease, a rare cause of dementia.

After death

After death, an autopsy may be done to find out for sure what caused dementia. This information may be helpful to family members concerned about genetic causes.

Treatment Overview

Medicines may slow down dementia, but they don't cure it. They may help improve mental function, mood, or behavior.

Palliative care

Palliative care is a kind of care for people who have a serious illness. It's different from care to cure the illness. Its goal is to improve a person's quality of life—not just in body but also in mind and spirit.

Care may include:

• Tips to help the person be independent and manage daily life as long as possible. For more information, see Home Treatment.
• Medicine. While medicines cannot cure dementia, they may help improve mental function, mood, or behavior.
• Support and counseling. A diagnosis of dementia can create feelings of anger, fear, and anxiety. A person in the early stage of the illness should seek emotional support from family, friends, and perhaps a counselor experienced in working with people who have dementia.

Planning for the future

If possible, make decisions while your loved one is able to take part in the decision making. These are difficult but important conversations. Questions include:

• What kind of care does he or she need right now?
• Who will take care of him or her in the future?
• What can the family expect as the disease progresses?
• What kind of financial and legal planning needs to be done?

Education of the family and other caregivers is critical to successfully caring for someone who has dementia. If you are or will be a caregiver, start learning what you can expect and what you can do to manage problems as they arise. For more information, see Home Treatment.

Treatment as dementia gets worse

The goal of ongoing treatment for dementia is to keep the person safely at home for as long as possible and to provide support and guidance to the caregivers.

Routine follow-up visits to a health professional (every 3 to 6 months) are necessary to monitor medicines and the person's level of functioning.

Eventually, the family may have to consider whether to place the person in a care facility that has a dementia unit.

Taking care of a person with dementia is stressful. If you are a caregiver, seek support from family members or friends. Take care of your own health by getting breaks from caregiving. Counseling, a support group, and adult day care or respite care can help you through stressful times and bouts of burnout.

Prevention

Dementia is hard to prevent, because what causes it often is not known. But people who have dementia caused by stroke may be able to prevent future declines by lowering their risk of heart disease and stroke. Even if you don't have these known risks, your overall health can benefit from these strategies:

• Don't smoke.
• Stay at a healthy weight.
• Get plenty of exercise.
• Eat healthy food.
• Manage health problems including diabetes, high blood pressure, and high cholesterol.
• Stay mentally alert by learning new hobbies, reading, or solving crossword puzzles.
• Stay involved socially. Attend community activities, church, or support groups.
• If your doctor recommends it, take aspirin.

Self-Care

Home treatment for dementia involves teamwork among health professionals and caregivers to create a safe and comfortable environment and to make tasks of daily living as easy as possible. People who have mild dementia can be involved in planning for the future and organizing the home and daily tasks.

Tips for caregivers

Work with the team of health professionals to:

• Make sure your home is safe.
• Keep the person eating well.
• Manage bladder and bowel control problems.
• Manage driving privileges.

The team can also help you learn how to manage behavior problems. For example, you can learn ways to:

• Make the most of remaining abilities. Reinforce and support the person's efforts to remain independent, even if tasks take more time or aren't done perfectly.
• Help the person avoid confusion.
• Understand behavior changes.
• Manage agitation.
• Manage wandering.
• Communicate clearly.

Caregivers should remember to seek support from other family and friends. For more information, see the topic Caregiver Tips.

Nursing home placement

Even with the best care, a person with progressive dementia will decline, perhaps to the point where the caregiver is no longer physically, emotionally, or financially able to provide care.

Making the decision about nursing home placement is often very difficult. Every family needs to consider its own financial situation, emotional capacity, and other issues.

Medicines

Doctors use medicines to treat dementia in the following ways:

• To maintain mental functioning for as long as possible
• To prevent further strokes in people who have dementia caused by stroke (vascular dementia)
• To manage mood or behavior problems, such as depression, insomnia, hallucinations, and agitation

Medicine choices

Medicines to help maintain mental function

• Cholinesterase inhibitors such as donepezil, galantamine, and rivastigmine.
  • These drugs were developed to treat Alzheimer's disease, but they may be tried in other dementias, especially vascular dementia.
  • It is not clear how long these medicines will work.
  • Side effects include nausea, vomiting, diarrhea, and weight loss.
• Memantine. This medicine is used to treat symptoms of Alzheimer's disease, but may also help with mild to moderate vascular dementia.

Medicines to help control mood or behavior problems

Many behavior problems can be managed without medicines. For more information, see Home Treatment.

In some cases, the doctor may prescribe:

• Antipsychotic drugs , such as olanzapine (Zyprexa) and risperidone (Risperdal).
• Antidepressants, especially selective serotonin reuptake inhibitors.

Medicines to prevent future strokes

• The doctor may prescribe medicines for high blood pressure and high cholesterol, since these conditions are risk factors for vascular dementia. These drugs can't reverse existing dementia, but they may prevent future strokes and heart disease that can lead to further brain damage.

Other Treatment

• Ginkgo biloba. Many people take ginkgo biloba to improve or preserve memory. But studies have not shown that ginkgo biloba helps improve memory or prevent dementia.^{footnote 1}
• Other medicines. Research is ongoing to look at the usefulness of nonsteroidal anti-inflammatory drugs (NSAIDS), antioxidants, and supplements such as citicoline. Be safe with medicines. Read and follow all instructions on the label.
• Reality orientation. People who have dementia may benefit from a structured group program that encourages them to focus on a variety of topics and to think creatively within their limits. This type of program, sometimes called reality orientation or cognitive stimulation therapy, is offered in some day care and residential settings.
• Validation therapy. A person who has dementia may say things that don't make sense. A caregiver's response may be to correct or disagree with him or her. This can be frustrating for everyone. Validation therapy is a way to talk to someone with empathy. It can help to give the person with dementia a feeling of control or calmness. It recognizes his or her feelings and emotions.
• Occupational therapy. Occupational therapists focus on a person's ability to perform daily tasks and take part in social activities.