Causes and symptoms

Diagnosis

Since dementia usually progresses slowly, diagnosing it in its early stages can be difficult. However, prompt intervention and treatment has been shown to help slow the effects of dementia, so early diagnosis is important. Several office visits over several months or more may be needed. Diagnosis begins with a thorough physical exam and complete medical history, usually including comments from family members or caregivers. A family history of either AD or cerebrovascular disease may provide clues to the cause of symptoms. Simple tests of mental function, including word recall, object naming, and number-symbol matching, are used to track changes in the person's cognitive ability.

Depression is common in the elderly and can be mistaken for dementia; therefore, ruling out depression is an important part of the diagnosis. Distinguishing dementia from the mild normal cognitive decline of advanced age also is critical. The medical history includes a complete listing of drugs being taken, since a number of drugs can cause dementia-like symptoms.

Determining the cause of dementia may require a variety of medical tests, chosen to match the most likely etiology. Cerebrovascular disease, hydrocephalus, and tumors may be diagnosed with x rays, CT or MRI scans, and vascular imaging studies. Blood tests may reveal nutritional deficiencies or hormone imbalances.

Treatment

Treatment of dementia begins with treatment of the underlying disease, where possible. The underlying causes of nutritional, hormonal, tumor-caused and drug-related dementias may be reversible to some extent. Treatment for stroke-related dementia begins by minimizing the risk of further strokes, through smoking cessation, aspirin therapy, and treatment of hypertension, for instance. No therapies can reverse the progression of AD. Aspirin, estrogen, vitamin E, and selegiline have been evaluated for their ability to slow the rate of progression. However, none of these have been proven effective. In fact, in 2002 and 2003, research revealed that non-steroidal anti-inflammatory agents (NSAIDs) did not help prevent AD and dementia. In the same two years, the Women's Health Initiative, a large clinical trial, was halted because of detrimental effects of combined estrogen and progestigin therapy, or hormone replacement therapy (HRT). Not only was HRT found to increase risk of breast cancer, stroke, and other heart disease, but the risk of probable dementia was twice that for women taking HRT than for those taking a placebo. Further, those taking HRT had a substantial and clinically important decline in indicators of cognitive ability. Studies still debate the effects of vitamin E on slowing the progression of moderately severe AD.

Care for a person with dementia can be difficult and complex. The patient must learn to cope with functional and cognitive limitations, while family members or other caregivers assume increasing responsibility for the person's physical needs. In progressive dementias such as AD, the person may ultimately become completely dependent. Education of the patient and family early in the disease progression can help them anticipate and plan for inevitable changes.

Symptoms of dementia may be treated with a combination of psychotherapy, environmental modifications, and medication. Drug therapy can be complicated by forgetfulness, especially if the prescribed drug must be taken several times daily.

Behavioral approaches may be used to reduce the frequency or severity of problem behaviors, such as aggression or socially inappropriate conduct. Problem behavior may be a reaction to frustration or overstimulation; understanding and modifying the situations that trigger it can be effective. Strategies may include breaking down complex tasks, such as dressing or feeding, into simpler steps, or reducing the amount of activity in the environment to avoid confusion and agitation. Pleasurable activities, such as crafts, games, and music, can provide therapeutic stimulation and improve mood.

Modifying the environment can increase safety and comfort while decreasing agitation. Home modifications for safety include removal or lock-up of hazards such as sharp knives, dangerous chemicals, and tools. Child-proof latches or Dutch doors may be used to limit access as well. Lowering the hot water temperature to 120°F (48.9°C) or less reduces the risk of scalding. Bed rails and bathroom safety rails can be important safety measures, as well. Confusion may be reduced with simpler decorative schemes and presence of familiar objects. Covering or disguising doors (with a mural, for example) may reduce the tendency to wander. Positioning the bed in view of the bathroom can decrease incontinence.

Two drugs, tacrine (Cognex) and donepezil (Aricept), are commonly prescribed for AD, though four drugs are available as of 2003. These drugs inhibit the breakdown of acetylcholine in the brain, prolonging its ability to conduct chemical messages between brain cells. They provide temporary improvement in cognitive functions for some patients with mild to moderate AD and help delay disease progression.

Psychotic symptoms, including paranoia, delusions, and hallucinations, may be treated with antipsychotic drugs, such as haloperidol, chlorpromazine, risperidone, and clozapine. Side effects of these drugs can be significant. Antianxiety drugs such as Valium may improve behavioral symptoms, especially agitation and anxiety, although BuSpar has fewer side effects. The anticonvulsant carbamazepine also is sometimes prescribed for agitation. Depression is treated with antidepressants, usually beginning with selective serotonin reuptake inhibitors (SSRIs) such as Prozac or Paxil, followed by monoamine oxidase inhibitors or tricyclic antidepressants. In general, medications should be administered cautiously to demented patients, in the lowest possible effective doses, to minimize side effects. Supervision of taking medications is generally required.

Long-term institutional care may be needed for the person with dementia, as profound cognitive losses often precede death by a number of years. Early planning for the financial burden of nursing home care is critical. Useful information about financial planning for long-term care is available through the Alzheimer's Association.

Family members or others caring for a person with dementia often are subject to extreme stress, and may develop feelings of anger, resentment, guilt, and hopelessness, in addition to the sorrow they feel for their loved one and for themselves. Depression is an extremely common consequence of being a full-time caregiver for a person with dementia. Support groups can be an important way to deal with the stress of caregiving. The location and contact numbers for caregiver support groups are available from the Alzheimer's Association; they may also be available through a local social service agency or the patient's physician. Medical treatment for depression may be an important adjunct to group support.

Alternative treatment

Several drugs are currently being tested for their ability to slow the progress of AD. These include acetyl-l-carnitine, which acts on the cellular energy structures known as mitochondria; propentofylline, which may aid circulation; milameline, which acts similarly to tacrine and donezepil; and ginkgo extract.

Ginkgo extract, derived from the leaves of the Ginkgo biloba tree, interferes with a circulatory protein called platelet activating factor. It also increases circulation and oxygenation to the brain. Ginkgo extract has been used for many years in China and is widely prescribed in Europe for treatment of circulatory problems. A 1997 study of patients with dementia seemed to show that gingko extract could improve their symptoms, though the study was criticized for certain flaws in its method.

Prognosis

The prognosis for dementia depends on the underlying disease. On average, people with Alzheimer's disease live eight years past their diagnosis, with a range from one to 20 years. Vascular dementia usually is progressive, with death from stroke, infection, or heart disease.

Prevention

There is no known way to prevent Alzheimer's disease, although several drugs under investigation may reduce its risk or slow its progression. The risk of developing multi-infarct dementia may be reduced by reducing the risk of stroke. Various studies continue to determine ways to lower risk of AD and dementia. For example, a 2003 study in the New England Journal of Medicine reported that people over age 75 who participated in leisure activities such as playing board games, reading, dancing, and playing musical instruments were less likely to have dementia after five years than others their age.

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