dementia

(di-men′chă)

[L. dementia, madness]
A progressive, irreversible decline in mental function.
SYN: neurocognitive disorder (e.g., vascular dementia = vascular neurocognitive disorder)

INCIDENCE
In the U.S., 4.5 million people are afflicted by dementia. The prevalence is esp. high in the very older; about 20% to 40% of those over 85 have dementia. Dementia is somewhat more common in women than in men. It must be distinguished by careful clinical examination from delirium, psychosis, depression, and the effects of medications.

CAUSES
Dementia may result from many illnesses, including AIDS, chronic alcoholism, Alzheimer disease, vitamin B₁₂ deficiency, carbon monoxide poisoning, cerebral anoxia, hypothyroidism, subdural hematoma, or multiple brain infarcts (vascular dementia).

SYMPTOMS AND SIGNS
Dementia is characterized by impairments in reasoning, judgment, abstract thought, registration, comprehension, learning, task execution, and the use of language. The cognitive impairments diminish a person’s social, occupational, and intellectual abilities. The onset of primary dementia may be slow, taking months or years. Memory deficits, impaired abstract thinking, poor judgment, and clouding of consciousness and orientation are not present until the terminal stages; depression, agitation, sleeplessness, and paranoid ideation may be present. Patients become dependent on others for activities of daily living and often die from complications of immobility in the terminal stage.

DIAGNOSIS
Dementia is diagnosed by clinical assessment. Tests to exclude other illnesses (such as structural diseases of the brain; hypothyroidism, or vitamin deficiencies) should be performed before concluding that a patient has dementia.

PREVENTION
Maintaining an active lifestyle with physical, mental, and social activities appears to affect the onset of dementia. The use of toxins like cigarette smoke and excessive alcohol intake adversely affect mental capacities. Abstaining from these toxins may delay the onset of dementia.

TREATMENT
Some medications, e.g., donepezil or tacrine, improve cognitive function in some patients.

PATIENT CARE
Demented patients deserve courtesy and respectful care at all stages of their disease. Caregivers assist the demented with activities of daily living and with the cognitive and behavioral changes that accompany the disease. A variety of nursing interventions may reduce the risk of inadvertently precipitating behavioral symptoms. Health care professionals should reinforce the patient's abilities and successes rather than their disabilities and failures. Caregivers can help the patient make optimal use of his or her abilities by reducing the adverse effects of other health conditions, sensory impairments, and cognitive defects while maximizing social and environmental factors that support functional capacity. Daily routines should be adjusted to focus on the person rather than the task, e.g., the comfort of bathing rather than the perceived need to bathe in a certain way at a certain time.

Alterations in the home environment (or the environment of the care facility) that may improve patient behaviors include limiting clutter and visual complications, labeling important or frequently used objects, limiting noise and other distractions, installing adequate illumination, and placing arrows or signs that suggest where important functions (like eating or toileting) are performed. Providing tasks to patients may prove useful so long as the tasks chosen are well organized and patient-centered. For instance, asking a demented patient to install software on a computer might be unfamiliar or frustrating, but having the patient sort clothing by color or separate towels from other clothes may engage the patient and provide structure.

Interaction and communication strategies should be adjusted to ensure that the message delivered is the one perceived: obtain attention, make eye contact, speak directly to the person, match nonverbal communication and gestures to the message, slow the pace of speech, use declarative sentences, and use nouns instead of pronouns. Avoid commands that begin with “don’t” or questions that begin with “why.” Tasks should be broken down into manageable steps. Reassurance and encouragement are provided to assist the patient to act more independently. Criticizing the patient, using a harsh or gruff tone of voice, or raising one's voice may backfire and cause or escalate challenging behaviors. Reality grounding is not always necessary; thus, if the patient asks to see his mother (who is dead), reminding the patient of her death may reinforce the pain of that loss. It may be better to redirect the conversation, asking the patient to talk about his mother, instead. Written agreements and reminders may not be as useful as they would be in the care of other patients because a demented patient may not remember what has been talked about and agreed upon in the past. Setting limits on daytime sleep may improve nocturnal sleep habits, as may other elements of sleep hygiene. Similarly, participation in afternoon exercise programs, or enrolling patients in adult day care (to provide daytime activities and enhance socialization may help to reduce a patient's boredom, disruptiveness, or injury). Home safety may be further enhanced by consulting occupational therapists, who may identify potential hazards to the patient. Caregivers often find participation in educational programs helpful both to them and to the demented. Caregivers must be aware that the patient will have moments of lucidity, which should be treasured but not considered evidence that the patient is exaggerating or feigning his or her disease to obtain attention. Family members who provide care must be aware that they, too, have emotional needs and can become angry, frustrated, and impatient and that they need help to learn to forgive themselves as well as the loved one they are caring for. Finally, such caregivers must learn how to accept help and should not fear to admit that they cannot carry the burden of care by themselves.
SEE: Alzheimer disease; SEE: Huntington chorea; SEE: Parkinson disease; SEE TABLE: Prevalence of Dementia, by Patient Age
Prevalence of Dementia, by Patient Age

Age	Prevalence
<60	0.1%
60-64	∼1%
>65	3%-11%
>85	25%-47%

AIDS dementia

SEE: AIDS-dementia complex.

alcoholic dementia

A form of toxic dementia in which there is loss of memory and problem-solving ability after many years of alcohol abuse.

dementia of the Alzheimer type

ABBR: DAT
SEE: Alzheimer disease

apoplectic dementia

Sudden loss of cognitive or intellectual function due to a stroke.

Binswanger dementia

SEE: Binswanger disease.

dialysis dementia

A neurological disturbance in patients who have been on dialysis for several years. Symptoms include slurring of speech, tremors and myoclonus, cognitive impairment, and seizures. The causative agent is presumed to be aluminum in the dialysate.
SYN: SEE: dialysis encephalopathy

epileptic dementia

An infrequent complication of epilepsy, presumed to result from injury to neurons during uncontrolled seizures.

frontotemporal dementia

A general term for any of four types of dementia: frontotemporal lobar degeneration; Pick disease; primary progressive aphasia; or semantic dementia. Symptoms include personality changes, psychiatric decompensation, apathy, compulsive or repetitive behavior, lack of social inhibition, and deterioration in planning and language use.

Heller dementia

SEE: Regressive autism.

HIV-associated dementia

SEE: HIV-associated neurocognitive disorder.

dementia with Lewy bodies

A common neurodegenerative disease characterized by gradual and progressive loss of intellectual abilities combined with a movement disorder that resembles Parkinson disease. Those affected often have marked fluctuations in their ability to stay alert and awake; they also experience visual hallucinations. The disease is characterized pathologically by deposits of Lewy bodies. The dementia is treated symptomatically.

mixed dementia

Dementia in which elements of both Alzheimer disease and vascular dementia are found.

multi-infarct dementia

Dementia resulting from multiple small strokes. After Alzheimer disease, it is the most common form of dementia in the U.S. It has a distinctive natural history. Unlike Alzheimer disease, which develops insidiously, the cognitive deficits of multi-infarct dementia appear suddenly, in stepwise fashion. The disease is rare before middle age and is most common in patients with hypertension, diabetes mellitus, or other risk factors for generalized atherosclerosis. Brain imaging in patients with this form of dementia shows multiple lacunar infarctions.
SYN: SEE: vascular dementia

paralytic dementia

An obsolete term for tertiary syphilis.

dementia paralytica

An obsolete term for tertiary syphilis.

postfebrile dementia

Dementia following a severe febrile illness.

presenile dementia

Dementia beginning in middle age, usually resulting from cerebral arteriosclerosis or Alzheimer disease. The symptoms are apathy, loss of memory, and disturbances of speech and gait.

primary dementia

Dementia associated with Alzheimer disease.

dementia pugilistica

Traumatic dementia (encephalopathy or an organic brain syndrome) caused by a closed head injury. It is sometimes called colloquially boxer's brain.

rapidly progressive dementia

Dementia that develops over a few weeks or months, rather than years.

semantic dementia

Any of a group of brain disorders marked by nearly complete losses in the understanding of word meanings, spelling, and identification or recognition of facts, faces, or objects. The disease is marked pathologically by local atrophy in the neocortex of the temporal lobe of the brain.

senile dementia of the Alzheimer type

ABBR: SDAT SEE: Alzheimer disease.

subcortical vascular dementia