Dementia is an acquired impairment of intellectual function caused by organic lesion of the brain. It can be a consequence of a disease or have a pluricausal nature (senile dementia). It may develop in vascular diseases, Alzheimer’s disease, traumas, neoplasms of the brain, alcoholism, drug addiction, infections of the central nervous system and some other diseases. The patients present persistent intellect disorders, affective impairs and decrease in willpower. The diagnosis is established on the basis of clinical criteria and instrumental studies (brain CT, MRI). Treatment is carried out taking into account the etiological form of dementia.
Dementia is a persistent disorder of higher nervous activity, accompanied by a loss of acquired knowledge and skills and a decreased ability to learn. Currently, there are more than 35 million patients with dementia in the world.
The prevalence of the disease increases with age. According to statistics, severe dementia is detected in 5%, mild – in 16% of people older than 65. Clinicians expect that in the future the number of patients will grow. This is due to the increase in life expectancy and the improvement of the quality of medical care, which helps to prevent death, even in severe cerebral injuries and brain diseases.
In most cases, acquired dementia is irreversible, so the most important task for physicians is the timely diagnosis and treatment of diseases that can cause dementia, as well as the stabilization of the pathological process in patients with already acquired dementia. Specialists in the field of psychiatry in collaboration with neurologists, cardiologists, endocrinologists and physicians of other specialties are engaged in the treatment of dementia.
Causes of dementia
Dementia occurs with organic damage to the brain as a result of trauma or disease. Currently, there are more than 200 pathological conditions that can trigger the development of dementia. The most common cause of acquired dementia is Alzheimer’s disease, which accounts for 60-70% of the total number of cases of dementia. Vascular dementias caused by hypertension, atherosclerosis and other similar diseases are on the second place (near 20%). Several diseases provoking acquired dementia are often found in patients suffering from senile dementia.
In young and middle age, dementia can be observed in people with alcoholism, drug addiction, craniocerebral trauma, benign or malignant neoplasms. In some patients, acquired dementia is detected in infectious diseases: AIDS, neurosyphilis, chronic meningitis or viral encephalitis. Sometimes dementia develops with severe diseases of internal organs, endocrine pathology and autoimmune diseases.
Classification of dementia
In view of the primary lesion of certain parts of the brain, there are four types of dementia:
- Cortical dementia. Mostly the cortex of the cerebral hemispheres is affected. It is observed with alcoholism, Alzheimer’s disease and Pick’s disease (frontotemporal dementia).
- Subcortical dementia. Subcortical structures are affected. It is accompanied by neurological disorders (tremor, muscle stiffness, gait disorders, etc.). Occurs in Parkinson’s disease, Huntington’s disease and white matter hemorrhages.
- Cortical-subcortical dementia. It affects both the cortex and the subcortical structures. It is observed in vascular pathology.
- Multifocal dementia. Multiple areas of necrosis and degeneration are formed in different departments of the central nervous system. Neurological disorders are very diverse and depend on the localization of lesions.
Depending on the extent of the lesion, there are two forms of dementia: total and lacunar. Lacunar dementia affects the structures responsible for certain types of intellectual activity. The leading role in the clinical presentation is usually played by short-term memory disorders. Patients forget where they are, what they planned to do, or what they agreed on just a few minutes ago. Criticism to its state is still preserved, and emotional-volitional violations are weakly expressed. There may be signs of asthenia: tearfulness, emotional instability. Lacunar dementia is observed in many diseases, including at the initial stage of Alzheimer’s disease.
In total dementia, there is a gradual disintegration of the personality. The intellect decreases, the cognitive function is lost, the emotional-volitional sphere suffers. The circle of interests is narrowing, shame disappears, and the former moral standards become insignificant. Total dementia develops with mass lesions and circulatory disorders in the frontal lobes.
The high prevalence of dementia in the elderly led to the creation of a classification of senile dementia:
- Atrophic (Alzheimer’s-like) type is provoked by primary degeneration of neurons of the brain.
- Vascular type: lesion of nerve cells occurs secondarily, due to violations of the blood supply to the brain in vascular pathology.
- Mixed type: mixed dementia, which is a combination of atrophic and vascular dementia.
Symptoms of dementia
Clinical manifestations of dementia are determined by the cause of acquired dementia, the size and localization of the affected area. In view of the severity of the symptoms and the patient’s abilities for social adaptation, three stages of dementia are distinguished. In mild dementia, the patient remains critical to what is happening and to their own condition. They retain the ability to self-service (washing, cooking, cleaning, wash dishes, etc.).
With moderate degree of dementia, the critic to patient own condition is partially impaired. When communicating with such patient, a marked decrease in intelligence is noticeable. Patients have difficulty servicing themselves or using household appliances and mechanisms: they cannot answer a phone call, open or close a door. Care and supervision are necessary. Severe dementia is accompanied by complete decay of personality. Patients cannot get dressed, wash, eat or go to the toilet. Constant monitoring is required.
Clinical types for dementia
Alzheimer’s disease was described in 1906 by the German psychiatrist Alois Alzheimer. Until 1977, such diagnosis was made only in cases of early dementia (at the age of 45-65 years), and with the appearance of symptoms over the age of 65, senile dementia was diagnosed. Later it was found that the pathogenesis and clinical manifestations of the disease are the same regardless of age. Currently, Alzheimer’s disease is diagnosed regardless of the age of appearance of the first clinical signs of acquired dementia. The risk factors include age, familial history with relatives who suffered from the disease, atherosclerosis, hypertension, overweight, diabetes mellitus, low motor activity, chronic hypoxia, craniocerebral trauma and lack of mental activity throughout life. Women are affected more often than men.
The first symptom is a pronounced impairment of short-term memory while preserving the critique of one’s own condition. Subsequently, memory disorders are aggravated, while there is a backward movement in time, as the patient gradually forgets the recent events, and then what happened in the past. The patients cease to recognize their children, accept them for long-dead relatives, do not know what they did this morning, but can tell in detail about the events of their childhood, as if they had happened quite recently. In place of lost memories, confabulations can occur. Criticism to their condition is reduced.
In the developed stage of Alzheimer’s disease, the clinical presentation is supplemented by emotional-volitional disorders. Patients become grouchy and uncomfortable, often demonstrate discontent with the words and actions of others, are annoyed by any trivial matters, etc. Later, there may be a delusion of detriment. Patients claim that the loved ones deliberately leave them in dangerous situations, pour poison into their food to poison them and take possession of their apartment, talk foul things about them to spoil the reputation and leave without the protection of the public, etc. Such a delusional system involves not only family members, but also neighbors, social workers and other people interacting with the patients. Other behavior disorders can also be detected: vagrancy, intemperance and indiscrimination in food and sex, meaningless disorderly actions (for example, shifting objects from place to place). Speech is simplified and impoverished, there are paraphases (use of other words instead of forgotten ones).
At the final stage of Alzheimer’s disease, delusions and behavioral disorders are leveled due to a pronounced decrease in intelligence. Patients become passive, inactive. The need for liquid and food disappears. The speech is almost completely lost. As the disease worsens, the ability to chew food and self-walking is gradually lost. Due to complete helplessness, such patients need constant professional care. Lethal outcome occurs as a result of typical complications (pneumonia, pressure sores, etc.) or progression of concomitant somatic pathology.
Diagnosis of Alzheimer’s disease is made on the basis of clinical symptoms. Treatment is symptomatic. Currently, there are no medications and non-medicinal methods that can cure patients with Alzheimer’s disease. Dementia progresses steadily and ends with complete disintegration of mental functions. The average life expectancy after diagnosis is less than 7 years. The earlier the first symptoms appeared, the faster dementia is aggravated.
There are two types of vascular dementia, the first occurs after a stroke and develops as a result of chronic insufficiency of the blood supply to the brain. With post-stroke acquired dementia, focal disorders (speech, paresis, and paralysis) usually prevail in the clinical presentation. The nature of the neurological disorders depends on the location and size of the hemorrhage or the site with the impaired blood supply, the quality of the treatment in the first hours after the stroke and some other factors. With chronic disorders of the blood supply, symptoms of dementia predominate, and neurological symptoms are rather monotonous and less pronounced.
Most often vascular dementia occurs with atherosclerosis and hypertension, less often with severe diabetes and some rheumatic diseases, even less often with embolisms and thromboses due to skeletal injuries, increased coagulability of blood and peripheral veins diseases. The likelihood of developing acquired dementia increases with diseases of the cardiovascular system, smoking and overweight.
The first sign of the disease is difficulty in trying to concentrate, distracted attention, fast fatigue, some stiffness of mental activity, difficulty in planning, and reduced ability to analyze. Memory disorders are less pronounced than in Alzheimer’s. There is some forgetfulness, but with an impulse in the form of a suggestive question or suggesting several options of the answer, the patient easily recalls the necessary information. Many patients experience emotional instability, mood is down, depression and subdepression are also possible.
Neurological disorders include dysarthria, dysphonia, changes in gait (shuffling, shortening of the step length, sticking of the soles to the ground), slowing down of movements, impairment of gestures and mimicry. Diagnosis is made on the basis of clinical picture, USDG and MRA of cerebral vessels and other studies. To assess the severity of the underlying pathology and make a scheme of pathogenetic therapy, patients are referred for consultations to the appropriate specialists: therapist, endocrinologist, cardiologist, phlebologist. Treatment: symptomatic therapy, therapy of the underlying disease. The rate of development of dementia is determined by the features of the course of the main pathology.
The cause of alcoholic dementia is a continuous (for 15 years or more) abuse of alcohol. Along with the direct destroying effect of alcohol on the brain cells, the development of dementia is caused by the disruption of the activity of various organs and systems, gross metabolic disorders and vascular pathology. For alcoholic dementia, typical personality changes (coarsening, loss of moral values, social degradation) are combined with total reduction of mental abilities (distraction of attention, reduced ability to analyze, plan and abstract thinking, and memory disorders).
After completely giving up alcohol and treating alcoholism, partial recovery is possible, however, such cases are very rare. Because of the pronounced pathological craving for alcoholic beverages, the reduction of strong-willed qualities and lack of motivation, most patients cannot stop taking ethanol-containing liquids. The prognosis is unfavorable, and the cause of death is usually somatic diseases caused by alcohol use. Often, such patients die as a result of criminal incidents or accidents.
Diagnosis of dementia
The diagnosis of dementia is made in the presence of five mandatory signs. The first is memory disorders, which are revealed on the basis of a conversation with the patient, a special study and a survey of relatives. The second is at least one symptom, indicating an organic lesion of the brain. Among these symptoms – the 3A syndrome: aphasia (speech disturbances), apraxia (loss of ability to purposeful actions while maintaining the ability to commit elementary motor acts), agnosia (perception disorders, loss of ability to recognize words, people and objects with intact touch, hearing and vision); reducing criticism to their own state and surrounding reality; personal disorders (causeless aggression, rudeness, lack of shame).
The third diagnostic sign of dementia is an impairment of family and social adaptation. The fourth is the absence of symptoms typical for delirium (loss of orientation in place and time, visual hallucinations and delusions). The fifth is the presence of an organic defect confirmed by data from instrumental studies (brain CT and MRI). The diagnosis of dementia is made only if all of the listed signs persist for six months or more.
Dementia often has to be differentiated with depressive pseudo-dementia and functional pseudo-dementia arising from avitaminosis. If a depressive disorder is suspected, the psychiatrist takes into account the severity and nature of affective disorders, the presence or absence of diurnal mood swings and a feeling of painless insensibility. If a clinician suspects a vitamin deficiency, they will study the anamnesis (malnutrition, severe intestinal lesions with prolonged diarrhea) and exclude the symptoms characteristic of a deficiency of certain vitamins (anemia with a deficiency of folic acid, polyneuritis in the absence of thiamine, etc.).
Prognosis for dementia
The prognosis for dementias is determined by the underlying disease. With acquired dementia, which has occurred as a result of craniocerebral injuries or mass lesions (tumors, hematomas), the process does not progress. Partial and, more rarely, complete reduction of symptoms due to compensatory capabilities of the brain are often observed. In an acute period, it is very difficult to predict the degree of recovery, the outcome of extensive damage can be good compensation with retention of work capacity, and the outcome of a small injury is severe dementia with access to disability and vice versa.
With dementias caused by progressive diseases, the symptoms are steadily worsening. Clinicians can only slow down the process, carrying out adequate treatment of the underlying pathology. The main tasks of therapy in such cases are the preservation of self-service skills and adaptive abilities, prolonging life, providing proper care and eliminating unpleasant manifestations of the disease. Death occurs as a result of a serious impairment of vital functions associated with the immobility of patients, their inability to elementary self-care and the development of complications characteristic of bedridden patients.
How to treat dementia at home
At its initial stage, the treatment of dementia is possible at home. However, you must first seek your doctor’s consultation. You must not take antidepressants and other medicines on your own, as it can aggravate the situation. The patient is not able to remember how and in what dosage he should take the drugs, so relatives should monitor this process. With complicated dementia, a person can no longer move and it is difficult to interact with him or her. In addition, sometimes these patients may become danger to themselves and others.
The choice of drugs depends on the type of dementia and the cause that caused it. Vascular dementia is treated with the following medicines:
- Antidementia. One of the most popular is Memantine. It has a neuroprotective effect, prevents the destruction of neurons and improves memory.
- Metabolism improvement. Phosphatidylcholine slightly improves the work of brain neurons.
- Hypotensive. Maintains a normal blood pressure level (Captopril, Kapoten).
- Disaggregants. Prevent platelets from clumping and clotting of blood. Usually Aspirin cardio is prescribed.
- Antisclerotic. Reduces cholesterol (statins).
- Improve the blood supply to the brain (Cerebrolysin, Actovegin).
- Corticosteroid. Prescribed in the case of blood vessels inflammatory lesions (vasculitis).
Also it is necessary to carry out symptomatic treatment of dementia to somewhat reduce the negative manifestations of the disease. For this, the following drugs are used:
- Antidepressants. Prescribed in the case of progressive depressive states, accompanied by suicidal thoughts. Most popular: Fluoxetine, Mianserin.
- Sleeping pills. Used to improve sleep in patients with insomnia.
Antidepressants and hypnotics are contraindicated in people with heart problems. You should also be careful with the use of neuroleptics as these can trigger an increase in aggression.
Patients with dementia are also prescribed vitamins:
- Omega 3. Improves the memory and other cognitive functions in vascular dementia. This supplement should be taken continuously.
- Vitamin E. The properties of the vitamin have been shown to relieve the symptoms of dementia, however, this remedy is contraindicated in cardiac pathologies.
- Coenzyme Q10 is an antioxidant that improves the functioning of the heart and brain.