Dementia is an acquired persistent and progressive impairment in intellectual function, with compromise of memory and at least one other cognitive domain. The key features of dementia include progressive decline in intellectual functions over months to years, loss of short term memory and at least one other cognitive deficit, no disturbance of consciousness, deficits severe enough to cause impairment in daily functioning, and not being in a state of delirium. Dementia can be categorized into reversible or partially reversible dementias and nonreversible dementias. Nonreversible dementias include Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementias. Treatment involves acetylcholinesterase inhibitors, memantine, managing behavioral problems non-

1. Dementia
Nyreese N. Castro MPH, CPH, BS.

2.  Dementia is a clinical syndrome involving a
sustained loss of intellectual functions and
memory of sufficient severity to cause dysfunction
in daily living. Its key features include:
 Progressive decline of intellectual (usually over
months to years)
 Loss of short-term memory and at least one other
cognitive deficit
 No disturbance of consciousness
 Deficit severe enough to cause impairment of
function
 Not delirious

3.  Dementia in the geriatric population can be
grouped into two broad categories:
 Reversible or partially reversible dementias
 Nonreversible dementias

5. Causes of Nonreversible Dementias

6.  Dementia is an acquired persistent and progressive
impairment in intellectual function, with compromise of
memory and at least one other cognitive domain,
most commonly:
 language impairment
 apraxia (inability to perform motor tasks, such as
cutting a loaf of bread, despite intact motor function)
 agnosia (inability to recognize objects)
 impaired executive function (poor abstraction, mental
flexibility, planning, and judgment).
 The diagnosis of dementia requires a significant
decline in function that is severe enough to interfere
with work or social life.

7.  Depression and delirium are also common in
elders, may coexist with dementia, and may also
present with cognitive impairment.
 Depression is a common concomitant of early
dementia. A patient with depression and cognitive
impairment whose intellectual function improves
with treatment of the mood disorder has an
almost fivefold greater risk of suffering irreversible
dementia later in life.
 Delirium, characterized by acute confusion,
occurs much more commonly in patients with
underlying dementia.

8. Clinical Findings
 Screening:
 1. Cognitive Impairment
 2. Decision Making Capacity

9. Cognitive Impairment
 Although there is no consensus at present on
whether older patients should be screened for
dementia, the benefits of early detection include
identification of potentially reversible
causes, planning for the future (including
discussing values and completing advance care
directives), and providing support and counseling
for the caregiver.

10.  The combination of a clock drawing task with a three-
item word recall (also known as the "mini-cog") is a
simple screening test that is fairly quick to administer.
Although a number of different methods for
administering and scoring the clock draw test have
been described, pre-drawing a four inch circle on a
sheet of paper and instructing the patient to "draw a
clock" with the time set at 10 minutes after 11.
 Scores are classified as normal, almost normal, or
abnormal.
 When a patient is able to draw a clock normally and
can remember all 3 objects, dementia is unlikely.
 When a patient fails this simple screen, further
cognitive evaluation with the Folstein Mini Mental
State Exam (MMSE) or other instruments is
warranted.

11.  It is common for a cognitively impaired elder to face a
serious medical decision and for the clinicians involved in
his care to ascertain whether the capacity exists to make
the choice. There are five components of a thorough
assessment:
 (1) ability to express a choice
 (2) understanding relevant information about the risks and
benefits of planned therapy and the alternatives, in the
context of one's values, including no treatment
 (3) comprehension of the problem and its consequences
 (4) ability to reason
 (5) consistency
 A patient's choice should follow rationally from an
understanding of the consequences.

12.  Cultural sensitivity must be used in applying
these five components to people of various
cultural backgrounds.
 Decision-making capacity varies over time:
 A delirious patient may regain his capacity after
an infection is treated, and so reassessments are
often appropriate.
 The capacity to make a decision is a function of
the decision in question.
 A woman with mild dementia may lack the
capacity to consent to coronary artery bypass
grafting yet retain the capacity to designate a

13. Signs and Symptoms
 The clinician can gather important information about
the type of dementia that may be present by asking
about:
 (1) the rate of progression of the deficits as well as
their nature (including any personality or behavioral
change)
 (2) the presence of other neurologic symptoms,
particularly motor problems
 (3) risk factors for HIV
 (4) family history of dementia
 (5) medications, with particular attention to recent
changes.
 Work-up is directed at identifying any potentially
reversible causes of dementia. However, such cases
are indeed rare.

14.  AD typically presents with early problems in memory
and visuospatial abilities (eg, becoming lost in familiar
surroundings, inability to copy a geometric design on
paper), yet social graces may be retained despite
advanced cognitive decline.
 Personality changes and behavioral difficulties
(wandering, inappropriate sexual behavior, agitation)
may develop as the disease progresses.
 Hallucinations may occur in moderate to severe
dementia. End-stage disease is characterized by
near-mutism; inability to sit up, hold up the head, or
track objects with the eyes; difficulty with eating and
swallowing; weight loss; bowel or bladder
incontinence; and recurrent respiratory or urinary
infections.

15. "Subcortical" dementias
 (eg, the dementia of Parkinson disease, and
some cases of vascular dementia) are
characterized by psychomotor slowing, reduced
attention, early loss of executive function, and
personality changes.

16. Dementia with Lewy bodies
 may be confused with delirium, as fluctuating
cognitive impairment is frequently observed.
 Rigidity and bradykinesia are the primary
signs, and tremor is rare.
 Response to dopaminergic agonist therapy is
poor.
 Complex visual hallucinations—typically of people
or animals—may be an early feature that can
help distinguish dementia with Lewy bodies from
AD.
 These patients demonstrate a hypersensitivity to
neuroleptic therapy, and attempts to treat the
hallucinations may lead to marked worsening of
extrapyramidal symptoms.

17. Frontotemporal dementias
 are a group of diseases that include Pick
disease, dementia associated with amyotrophic lateral
sclerosis, and others.
 Patients manifest personality change
(euphoria, disinhibition, apathy) and compulsive
behaviors (often peculiar eating habits or
hyperorality).
 In contrast to AD, visuospatial function is relatively
preserved.
 Dementia in association with motor findings, such as
extrapyramidal features or ataxia, may represent a
less common disorder (eg, progressive supranuclear
palsy, corticobasal ganglionic
degeneration, olivopontocerebellar atrophy).

18. Physical Examination
 The neurologic examination emphasizes
assessment of mental status but should also
include evaluation for sensory deficits, possible
previous strokes, parkinsonism, or peripheral
neuropathy.
 The remainder of the physical examination should
focus on identifying comorbid conditions that may
aggravate the individual's disability.

19. Laboratory Findings
 Laboratory studies should include a complete
blood
count, electrolytes, calcium, creatinine, glucose, t
hyroid-stimulating hormone (TSH), and vitamin
B12 levels.
 HIV testing, RPR (rapid plasma reagin)
test, heavy metal screen, and liver biochemical
tests may be informative in selected patients but
should not be considered part of routine testing.

20. Imaging
 Most patients should receive neuroimaging as
part of the diagnostic work-up to rule out subdural
hematoma, tumor, previous stroke, and
hydrocephalus (usually normal pressure).
 Those who are younger and those who have
focal neurologic symptoms or signs, seizures, gait
abnormalities, and an acute or subacute onset
are most likely to yield positive findings and most
likely to benefit from MRI scanning.
 In older patients with a more classic picture of AD
in whom neuroimaging is desired, a noncontrast
CT scan is sufficient.

21. Treatment
 Soon after diagnosis, patients and families should be
made aware of the Alzheimer's Association
(http://www.alz.org) as well as the wealth of helpful
community and online resources and publications
available.
 Caregiver support, education, and counseling can
prevent or delay nursing home placement.
 Education should include the manifestations and
natural history of dementia as well as the availability
of local support services such as respite care.
 Collaborative care models and disease management
programs appear to improve the quality of care for
patients with dementia.

22. Cognitive Impairment
 Demented patients have greatly diminished
cognitive reserve, they are at high risk for
experiencing acute cognitive or functional decline
in the setting of new medical illness.
 Consequently, fragile cognitive status may be
best maintained by ensuring that comorbid
diseases such as congestive heart failure and
infections are detected and treated.

23.  Acetylcholinesterase inhibitors:
 The majority of experts recommend considering a
trial of acetylcholinesterase inhibitors
(eg, donepezil, galantamine, rivastigmine) in most
patients with mild to moderate AD.
 Memantine
 In clinical trials, patients with more advanced
disease have been shown to have statistical
benefit from the use of memantine, an N- methyl-
D-aspartate (NMDA) antagonist, with or without
concomitant use of an acetylcholinesterase
inhibitor.

24. Behavioral Problems:
Nonpharmacologic approaches
 Behavioral problems in demented patients are often
best managed with a nonpharmacologic approach.
Initially, it should be established that the problem is
not unrecognized delirium, pain, urinary
obstruction, or fecal impaction.
 Caregivers are taught to use simple language when
communicating with the patient, to break down
activities into simple component tasks, and to use a
"distract, not confront" approach when the patient
seems disturbed by a troublesome issue.
 Additional steps to address behavioral problems
include the discontinuation of all medications except
those considered absolutely necessary and
correction, if possible, of sensory deficits.

25. Behavioral Problems: Pharmacologic
approaches
 Patients with depressive symptoms may show
improvement with antidepressant therapy.
 Patients with dementia with Lewy bodies have shown
clinically significant improvement in behavioral symptoms
when treated with rivastigmine (3–6 mg orally twice daily).
 For those with AD and agitation, no agents, including
acetylcholinesterase inhibitors and antipsychotics, have
demonstrated consistent efficacy. Despite the lack of
strong evidence, antipsychotic medications have remained
a mainstay for the treatment of behavioral
disturbances, largely because of the lack of alternative
agents.
 The newer atypical antipsychotic agents
(risperidone, olanzapine, quetiapine, aripiprazole, clozapin
e, ziprasidone) are reported to be better tolerated than
older agents but should be avoided in patients with
vascular risk factors due to an increased risk of stroke and

26. Prognosis
 Life expectancy after a diagnosis of AD is
typically 3–15 years.
 Other neurodegenerative dementias, such as
dementia with Lewy bodies, show more rapid
decline.
 Hospice is often appropriate for patients with end-
stage dementia.

27. When to Refer
 Referral for neuropsychological testing may be
helpful in the following circumstances: to
distinguish dementia from depression, to
diagnose dementia in persons of very poor
education or very high premorbid intellect, and to
aid diagnosis when impairment is mild.

28. Question 1
 ___________ is an acquired persistent and
progressive impairment in intellectual function,
with compromise of memory and at least one
other cognitive domain.
 A. Depression
 B. Dementia
 C. Delirium
 D. Immobility

29.  B. Dementia

30. Question 2
 The clinician can gather important information
about the type of dementia that may be present
by asking about which of the following, except:
 A. the rate of progression of the deficits as well as
their nature (including any personality or
behavioral change)
 B. the presence of other neurologic
symptoms, particularly motor problems
 C. risk factors for Syphilis
 D. family history of dementia
 E. all of the above

31.  C. risk factors for Syphilis