2. Dementia Progressive deterioration of intellect,behavior and
personality as a consequence of diffuse disease of the brain
hemispheres, maximally affecting the cerebral cortex and
hippocampus. Dementia is a symptom of disease rather than a single
disease entity!!! 3.
- Memorymust be impaired to make the diagnosis of dementia.
- Loss of memory for recent events is theearlist feature of
- Subsequent symptomsinclude abnormal behavior, loss of
intellect, mood changes, and difficulty coping with ordinary
- Insightmay be retained initially, but is then usually
- Ultimately , there is loss of self-care, wandering,
incontinence, and often paranoia.
4. Dementia has to be distinguished fromdeliriumwhich is an
acute disturbance of cerebral function with impaired conscious
level, hallucinations and autonomic overactivity as a consequence
of toxic, metabolic or infective conditions. Depressioncan mimic
the initial phases of dementia and it is termed pseudodementia
(which is amenable to antidepressant medication). 5. Dementia may
occur at any age but ismore common in the elderly , accounting for
40% of long-term psychiatric in-patients over the age of 65 years.
Theprevalencein persons aged between 50 and 70 years is about 1%
and in those approaching 90 years reaches 50%. An annual incidence
rate is 190/100 000 persons. 6. Clinical course: The rate of
progression depends upon the underlying cause. The duration of
history helps establish the cause of dementia:Alzheimers disease is
slowly progressive over years, whereas encephalitis may be rapid
over weeks. Dementia due to cerebrovascular disease appears to
occur stroke by stroke. 7. Dementias classification Based on
- Alzheimers disease(~60% of all dementias)
- Cerebrovascular(multiinfarct state, subcortical small vessel,
- Neurodegenerative(DLB, Picks disease, Huntingtons chorea,
- Infectious(Creutzfeld-Jakob disease, HIV infection, progressive
- Normal pressure hydrocephalus TREATABLE!
- Nutritional(thiamine deficiency in alcoholics!, B 12deficiency,
- Metabolic(hepatic disease, thyroid d., parathyroid d., Cushings
- Chronic inflammatory(MS, )
- Trauma(head injury, Punch drunk syndrome)
- Tumour(e.g. subfrontal meningioma)
8. Dementias classification Based on site 9. Dementias history
and clinical examination
- When obtaining a historyfrom a demented person and relative,
establish: rate of intellectual decline, impairment of social
function, general health and relevant disorders (e.g. stroke, head
injury), nutrition status, drug history, family history of
- Tests to assess intellectual functionare designed to check:
memory, abstract thought, judgement, specific focal cortical
- The Mini Mental State Examination (MMSE)
- On neurological examinationnote: focal signs, involuntary
movements, pseudobulbar signs, gait disorder.
10. Dementias further investigation
- Blood tests(to exclude hypothyroidism, vitamin B 12 , thiamine
and folate deficiency, Lyme disease, HIV infection, metabolic
disorders and inflammatory diseases).
- Cranial imaging(CT or/and MRI) (tu, NPH)
- EEG(slowing in AD, normal in pseudodementia, periodic complexes
- Genetic testing(rarely Huntington mutation, apolipoprotein E4
mutation in AD)
- Brain biopsy(if treatable cause is suspected)
11. Alzheimer's disease
- The commonest cause of dementia.
- The disorder rarely occurs under the age of 45 years.
- The incidence increases with age.
- The cause of AD is not known(neurodegenerative d.) .
- Up to 30% of cases are familial(the loci were found on
chromosome 21 and 19).
- Pathology the presence of senile plaques and neurofibrillary
tangles in the brain.
- Diagnosis of AD may be established during life by early memory
failure, slow progression and exclusion of other causes.
12. Alzheimer's disease
- CT scanningaids diagnosis by excluding multiple infarction or a
- MRIshows bilateral temporal lobe atrophy.
- SPECTusually shows temporoparietal hypoperfusion.
13. Alzheimer's disease - treatment
- -Acetylcholinesterase inhibitors(Donepezil [Aricept],
Rivastigmine [Exelon], Galantamine [Reminyl]) have been shown to
enhance cognitive performance in early disease. Memantine
[Ebixa,Axura, Namenda ] is approved for moderate disease.However
they do not cure!
- Treat concurrent depression, anxiety and sleep disorders.
Neuroleptic use may be required for behavioral disturbance.
- Mangement of AD requires careful advice and counseling of the
patient and family and shared care involving the family,
caregivers, GPs, hospital specialist, and community psychiatric
- Long-term residential care is ofte required.
14. Multi-infarct dementia (MID)
- This is anoverdiagnosed conditionwhich accounts for less than
10% of cases of dementia.
- MID is caused by multiple strokes - SILENT STROKES
- Dementia occursstroke by stroke,with progressive focal loss of
- Clinical features of stroke profile hypertension, diabetes,
etc. are present. More often in males.
- Diagnosis is obtained from the history and confirmed byCT or
MRI scan (the presence of multiple areas ofinfarction).
- Treatment : Maintain adequate bloodpressure control,
15. Frontotemporal dementia (Pick's disease)
- This progressive condition accounts for 5% of all
- Usually sporadic, it more commonly affect women between 40 and
- Personality and behaviour are initially more affected than
- Frontal lobe dysfunction predominates with apathy, lack of
initiative and personality changes.
- CT or MRI scans show frontal (and/or temporal) atrophy, often
- SPECT reveal anterior hypoperfusion, EEG is usually
- The disorder is characterized pathologically by argyrophylic
inclusion bodies within the cytoplasm of cells of the
- There is no treatment, death occuring within 2-3 years of the
16. Primary progressive aphasia
- This condition is one of a group of disorders characterized by
asymmetrical cortical degeneration.
- Dominant hemisphere perisylvian atrophy is associated with loss
of language, which, after many years, becomes a more widespread
- Pathologically non-specific cell loss, Picks pathology or
spongiform changes are described.
- MRI and SPECT confirm focal changes.
17. Dementia with Lewy bodies (DLB)
- One of the most common types of progressive dementia.
- Progressive cognitive decline, combined with three additional
defining features: (1) pronounced fluctuations in alertness and
attention; (2) recurrent visual hallucinations, and (3)
parkinsonian motor symptoms, such as rigidity and the loss of
- The symptoms of DLB are caused by the build-up of Lewy bodies
accumulated bits of alpha-synuclein protein - inside the nuclei of
neurons in areas of the brain that control particular aspects of
memory and motor control. Lewy bodies are often also found in the
brains of people with Parkinson's and Alzheimers diseases.These
findings suggest that either DLB is related to these other causes
of dementia or that an individual can have both diseases at the
- DLB usually occurs sporadically, in people with no known family
history of the disease. However, rare familial cases have
occasionally been reported.
18. Normal pressure hydrocephalus
- = term applied to the triad of:
- occuring in conjunction with hydrocephalus and normal
- NPH with a preceding cause (SAH, meningitis, trauma,
- NPH with no known preceding cause idiopathic (50%).
19. Normal pressure hydrocephalus
- It is presumed that at some preceding period, impedence to
normal SCF flow causes raised intraventricular pressure and
ventricular dilatation. Compensatory mechanisms permit a reduction
in CSF pressure yet the ventricular dilatation persists and causes
20. Normal pressure hydrocephalus
- Diagnosis is based on clinical picture plus CT scan/MRI
evidence of ventricular enlargement.
- NPH must be differentiated from pts whose ventricular
enlargement is merely the result of shrinkage of the surrounding
brain, e.g. AD. These pts do not respond to CSF shunting, whereas a
proportion of NPH pts (but not all) show a definitive improvement
with ventriculo-peritoneal shunting.
21. AIDS dementia complex
- Approximately two-thirds of persons with AIDS develop dementia,
mostly due to AIDS dementia complex.
- In some patients HIV is found in the CNS at postmortem. In
others an immune mechanism or an unidentified pathogen is
- Dementia is initially of a "subcortical " type.
- CT - atrophy; MRI - increased T2 signal from white matter.
- Treatment with Zidovudine (AZT) halts and partially revers
- Reduction of intellectual function is common after severe head
- Chronic subdural haematoma can also present as progressive
dementia, especially in the elderly.
- Punch-drunk encephalopathy(dementia pugilistica) is the
cumulative result of repeated cerebral trauma. It occurs in both
amateur and professional boxers and it manifests by dysarthria,
ataxia and expy signs associated with subcortical dementia. There
is no treatment for this progressive syndrome.
- Dementia rarely may be due to intracranial tumour, especially
when tumours occur in certain anatomical sites.
- Mental or behavioral changes occur in 50-70% of all brain
tumours as distinct from dementia which is associated with frontal
lobe tumours, III ventricle tumours and corpus callosum
- Cognitive impairment also occurs as a non metastatic
complication of systemic malignancy.
24. Dementia diagnostic approach 25. Mild cognitive impairment
- MCI is a relatively recent term, used to describe people who
have someproblems with their memorybut do not actually have
- Some people (80%?) will be in the early stages of Alzheimers
disease or another dementia. Others, however, will have MCI as a
result of stress, anxiety, depression, physical illness or just an
- It is estimated that15% of the populationmay be experiencing
- Currentlyextensive researchon MCI is ongoing.
- At the moment there is not enough evidence to recommend any