[guide.chat] Dementia by wickapedia article
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Dementia
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For other uses, see Dementia (disambiguation).
Dementia
Classification and external resources
ICD-10
F00-F07
ICD-9
290-294
DiseasesDB
29283
MedlinePlus
000739
MeSH
D003704
Dementia (taken from Latin, originally meaning "madness", from de-
"without" + ment, the root of mens "mind") is a serious loss of global
cognitive ability in a previously unimpaired person, beyond what might
be expected from normal aging. It may be static, the result of a unique
global brain injury, or progressive, resulting in long-term decline due
to damage or disease in the body. Although dementia is far more common
in the geriatric population, it can occur before the age of 65, in which
case it is termed "early onset dementia".[1]
Dementia is not a single disease, but rather a non-specific illness
syndrome (i.e., set of signs and symptoms) in which affected areas of
cognition may be memory, attention, language, and problem solving. It is
normally required to be present for at least 6 months to be
diagnosed;[2] cognitive dysfunction that has been seen only over shorter
times, in particular less than weeks, must be termed delirium. In all
types of general cognitive dysfunction, higher mental functions are
affected first in the process.
Especially in the later stages of the condition, affected persons may be
disoriented in time (not knowing what day of the week, day of the month,
or even what year it is), in place (not knowing where they are), and in
person (not knowing who they, or others around them, are). Dementia,
though often treatable to some degree, is usually due to causes that are
progressive and incurable as observed in primary progressive aphasia
(PPA).[3][4][5]
Symptoms of dementia can be classified as either reversible or
irreversible, depending upon the etiology of the disease. Fewer than 10%
of cases of dementia are due to causes that may presently be reversed
with treatment. Causes include many different specific disease
processes, in the same way that symptoms of organ dysfunction such as
shortness of breath, jaundice, or pain are attributable to many etiologies.
Delirium can be easily confused with dementia due to similar symptoms.
Delirium is characterized by a sudden onset, fluctuating course, a short
duration (often lasting from hours to weeks), and is primarily related
to a somatic (or medical) disturbance. In comparison, dementia has
typically an insidious onset (except in the cases of a stroke or
trauma), slow decline of mental functioning, as well as a longer
duration (from months to years).[6] Some mental illnesses, including
depression and psychosis, may produce symptoms that must be
differentiated from both delirium and dementia.[7]
There are many specific types (causes) of dementia, often showing
slightly different symptoms. However, the symptom overlap is such that
it is impossible to diagnose the type of dementia by symptomatology
alone, and in only a few cases are symptoms enough to give a high
probability of some specific cause. Diagnosis is therefore aided by
nuclear medicine brain scanning techniques. Certainty cannot be attained
except with brain biopsy during life, or at necropsy in death.
Some of the most common forms of dementia are: Alzheimer's disease,
vascular dementia, frontotemporal dementia, semantic dementia and
dementia with Lewy bodies. It is possible for a patient to exhibit two
or more dementing processes at the same time, as none of the known types
of dementia protects against the others. Indeed, about ten per cent of
people with dementia have what is known as "mixed dementia", which may
be a combination of Alzheimer's disease and multi-infarct dementia.[8][9]
Contents [hide]
1 Signs and symptoms
1.1 Comorbidities
1.2 Risk to self and others
2 Causes
2.1 Fixed cognitive impairment
2.2 Slowly progressive dementia
2.3 Rapidly progressive dementia
2.4 Dementia as a feature of other conditions
3 Diagnosis
3.1 Cognitive testing
3.2 Laboratory tests
3.3 Imaging
4 Prevention
5 Management
5.1 Medications
5.1.1 Off label
5.2 Pain
5.3 Services
5.4 Feeding tubes
6 Epidemiology
7 History
8 References
9 External links
[edit]
Signs and symptoms
[edit]
Comorbidities
Dementia is not merely a problem of memory. It reduces the ability to
learn, reason, retain or recall past experience and there is also loss
of patterns of thoughts, feelings and activities (Gelder et al. 2005).
Additional mental and behavioral problems often affect people who have
dementia, and may influence quality of life, caregivers, and the need
for institutionalization. As dementia worsens individuals may neglect
themselves and may become disinhibited and may become incontinent.
(Gelder et al. 2005).
Depression affects 20-30% of people who have dementia, and about 20%
have anxiety.[10] Psychosis (often delusions of persecution) and
agitation/aggression also often accompany dementia. Each of these needs
to be assessed and treated independently of the underlying dementia.[11]
[edit]
Risk to self and others
Globe icon.
The examples and perspective in this article may not represent a
worldwide view of the subject. Please improve this article and discuss
the issue on the talk page. (December 2010)
The Canadian Medical Association Journal has reported that driving with
dementia could lead to severe injury or even death to self and others.
Doctors should advise appropriate testing on when to quit driving.[12]
In the United States, Florida's Baker Act allows law enforcement and the
judiciary to force mental evaluation for those suspected of suffering
from dementia or other mental incapacities.[citation needed]
In the United Kingdom, as with all mental disorders, where a person with
dementia could potentially be a danger to themselves or others, they can
be detained under the Mental Health Act 1983 for the purposes of
assessment, care and treatment. This is a last resort, and usually
avoided if the patient has family or friends who can ensure care.
The United Kingdom DVLA (Driving & Vehicle Licensing Agency) states that
people with dementia who specifically suffer with poor short term
memory, disorientation, lack of insight or judgment are almost certainly
not fit to drive-and in these instances, the DVLA must be informed so
said license can be revoked. They do however acknowledge low-severity
cases and those with an early diagnosis, and those drivers may be
permitted to drive pending medical reports.
Behaviour may be disorganized, restless or inappropriate. Some people
become restless or wander about by day and sometimes at night. When
people suffering from dementia are put in circumstances beyond their
abilities, there may be a sudden change to tears or anger (a
"catastrophic reaction").[13]
David Cameron has described dementia as being a "national crisis",
affecting 800, 000 people in the United Kingdom.[14] A competition by
the Design Council found that the smell of a bakewell tart, wrist bands
that could help and guide dogs for the mind[clarification needed] were
all suggestions for ideas to help people with dementia.[15] German
nursing homes have installed fake bus stops so patients with dementia
will "wait" for a bus there instead of wandering farther away.[16]
[edit]
Causes
[edit]
Fixed cognitive impairment
Various types of brain injury, occurring as a single event, may cause
irreversible but fixed cognitive impairment. Traumatic brain injury may
cause generalized damage to the white matter of the brain (diffuse
axonal injury), or more localized damage (as also may neurosurgery). A
temporary reduction in the brain's supply of blood or oxygen may lead to
hypoxic-ischemic injury. Strokes (ischemic stroke, or intracerebral,
subarachnoid, subdural or extradural hemorrhage) or infections
(meningitis and/or encephalitis) affecting the brain, prolonged
epileptic seizures and acute hydrocephalus may also have long-term
effects on cognition. Excessive alcohol use may cause alcohol dementia,
Wernicke's encephalopathy and/or Korsakoff's psychosis, and certain
other recreational drugs may cause substance-induced persisting
dementia; once overuse ceases, the cognitive impairment is persistent
but not progressive.[citation needed]
[edit]
Slowly progressive dementia
Dementia which begins gradually and worsens progressively over several
years is usually caused by neurodegenerative disease; that is, by
conditions affecting only or primarily the neurons of the brain and
causing gradual but irreversible loss of function of these cells. Less
commonly, a non-degenerative condition may have secondary effects on
brain cells, which may or may not be reversible if the condition is treated.
The causes of dementia depend on the age at which symptoms begin. In the
elderly population (usually defined in this context as over 65 years of
age), a large majority of cases of dementia are caused by Alzheimer's
disease, vascular dementia or both. Dementia with Lewy bodies is another
fairly common cause, which again may occur alongside either or both of
the other causes.[17][18][19] Hypothyroidism sometimes causes slowly
progressive cognitive impairment as the main symptom, and this may be
fully reversible with treatment. Normal pressure hydrocephalus, though
relatively rare, is important to recognize since treatment may prevent
progression and improve other symptoms of the condition. However,
significant cognitive improvement is unusual.
Dementia is much less common under 65 years of age. Alzheimer's disease
is still the most frequent cause, but inherited forms of the disease
account for a higher proportion of cases in this age group.
Frontotemporal lobar degeneration and Huntington's disease account for
most of the remaining cases.[20] Vascular dementia also occurs, but this
in turn may be due to underlying conditions (including antiphospholipid
syndrome, CADASIL, MELAS, homocystinuria, moyamoya and Binswanger's
disease). People who receive frequent head trauma, such as boxers or
football players, are at risk of chronic traumatic encephalopathy[21]
(also called dementia pugilistica in boxers).
In young adults (up to 40 years of age) who were previously of normal
intelligence, it is very rare to develop dementia without other features
of neurological disease, or without features of disease elsewhere in the
body. Most cases of progressive cognitive disturbance in this age group
are caused by psychiatric illness, alcohol or other drugs, or metabolic
disturbance. However, certain genetic disorders can cause true
neurodegenerative dementia at this age. These include familial
Alzheimer's disease, SCA17 (dominant inheritance); adrenoleukodystrophy
(X-linked); Gaucher's disease type 3, metachromatic leukodystrophy,
Niemann-Pick disease type C, pantothenate kinase-associated
neurodegeneration, Tay-Sachs disease and Wilson's disease (all
recessive). Wilson's disease is particularly important since cognition
can improve with treatment.
At all ages, a substantial proportion of patients who complain of memory
difficulty or other cognitive symptoms are suffering from depression
rather than a neurodegenerative disease. Vitamin deficiencies and
chronic infections may also occur at any age; they usually cause other
symptoms before dementia occurs, but occasionally mimic degenerative
dementia. These include deficiencies of vitamin B12, folate or niacin,
and infective causes including cryptococcal meningitis, HIV, Lyme
disease, progressive multifocal leukoencephalopathy, subacute sclerosing
panencephalitis, syphilis and Whipple's disease.
[edit]
Rapidly progressive dementia
Creutzfeldt-Jakob disease typically causes a dementia which worsens over
weeks to months, being caused by prions. The common causes of slowly
progressive dementia also sometimes present with rapid progression:
Alzheimer's disease, dementia with Lewy bodies, frontotemporal lobar
degeneration (including corticobasal degeneration and progressive
supranuclear palsy).
On the other hand, encephalopathy or delirium may develop relatively
slowly and resemble dementia. Possible causes include brain infection
(viral encephalitis, subacute sclerosing panencephalitis, Whipple's
disease) or inflammation (limbic encephalitis, Hashimoto's
encephalopathy, cerebral vasculitis); tumors such as lymphoma or glioma;
drug toxicity (e.g. anticonvulsant drugs); metabolic causes such as
liver failure or kidney failure; and chronic subdural hematoma.
[edit]
Dementia as a feature of other conditions
There are many other medical and neurological conditions in which
dementia only occurs late in the illness, or as a minor feature. For
example, a proportion of patients with Parkinson's disease develop
dementia, though widely varying figures are quoted for this
proportion.[citation needed] When dementia occurs in Parkinson's
disease, the underlying cause may be dementia with Lewy bodies or
Alzheimer's disease, or both.[22] Cognitive impairment also occurs in
the Parkinson-plus syndromes of progressive supranuclear palsy and
corticobasal degeneration (and the same underlying pathology may cause
the clinical syndromes of frontotemporal lobar degeneration). Chronic
inflammatory conditions of the brain may affect cognition in the long
term, including Behçet's disease, multiple sclerosis, sarcoidosis,
Sjögren's syndrome and systemic lupus erythematosus. Although the acute
porphyrias may cause episodes of confusion and psychiatric disturbance,
dementia is a rare feature of these rare diseases.
Aside from those mentioned above, inherited conditions which may cause
dementia alongside other features include:[23]
?Alexander disease
?Canavan disease
?Cerebrotendinous xanthomatosis
?DRPLA
?Fatal Familial Insomnia
?Fragile X-associated tremor/ataxia syndrome
?Glutaric aciduria type 1
?Krabbe's disease
?Maple syrup urine disease
?Niemann Pick disease type C
?Kufs' disease
?Neuroacanthocytosis
?Organic acidemias
?Pelizaeus-Merzbacher disease
?Urea cycle disorders
?Sanfilippo syndrome type B
?Spinocerebellar ataxia type 2
[edit]
Diagnosis
Proper differential diagnosis between the types of dementia (cortical
and subcortical) will require, at the least, referral to a specialist,
e.g., a geriatric internist, geriatric psychiatrist, neurologist,
neuropsychologist or geropsychologist.[citation needed] Duration of
symptoms must evident for at least six months for a diagnosis of
dementia or organic brain syndrome to be made (ICD-10).
[edit]
Cognitive testing
Sensitivity and specificity of common tests for dementia
Sensitivity and specificity of common tests for dementia
Test
Sensitivity
Specificity
Reference
MMSE
71%-92%
56%-96%
[24]
3MS
83%-93.5%
85%-90%
[25]
AMTS
73%-100%
71%-100%
[25]
There exist some brief tests (5-15 minutes) that have reasonable
reliability and can be used in the office or other setting to screen
cognitive status. Examples of such tests include the abbreviated mental
test score (AMTS), the mini mental state examination (MMSE), Modified
Mini-Mental State Examination (3MS),[26] the Cognitive Abilities
Screening Instrument (CASI),[27] the Trail-making test.[28] and the
clock drawing test.[29] Scores must be interpreted in the context of the
person's educational and other background, and the particular
circumstances; for example, a person highly depressed or in great pain
will not be expected to do well on many tests of mental ability.
While many tests have been studied,[30][31][32] and some may emerge as
better alternatives to the MMSE, presently the MMSE is the best studied
and most commonly used.
Another approach to screening for dementia is to ask an informant
(relative or other supporter) to fill out a questionnaire about the
person's everyday cognitive functioning. Informant questionnaires
provide complementary information to brief cognitive tests. Probably the
best known questionnaire of this sort is the Informant Questionnaire on
Cognitive Decline in the Elderly (IQCODE).[33] On the other hand the
General Practitioner Assessment Of Cognition combines both, a patient
assessment and an informant interview. It was specifically designed for
the use in the primary care setting and is also available as a web-based
test.
Further evaluation includes retesting at another date, and
administration of other tests of mental function.
Increasingly, clinical neuropsychologists provide diagnostic
consultation following administration of a complex full battery of
cognitive testing, often lasting several hours, to determine functional
patterns of decline associated with varying types of dementia. Tests of
memory, executive function, processing speed, attention, and language
skills are relevant, as well as tests of emotional and psychological
adjustment. These tests assist with ruling out other etiologies and
determining relative cognitive decline over time or from estimates of
prior cognitive abilities.
[edit]
Laboratory tests
Routine blood tests are also usually performed to rule out treatable
causes. These tests include vitamin B12, folic acid, thyroid-stimulating
hormone (TSH), C-reactive protein, full blood count, electrolytes,
calcium, renal function, and liver enzymes. Abnormalities may suggest
vitamin deficiency, infection or other problems that commonly cause
confusion or disorientation in the elderly. The problem is complicated
by the fact that these cause confusion more often in persons who have
early dementia, so that "reversal" of such problems may ultimately only
be temporary.[citation needed]
Testing for alcohol and other known dementia-inducing drugs may be
indicated.
[edit]
Imaging
A CT scan or magnetic resonance imaging (MRI scan) is commonly
performed, although these modalities do not have optimal sensitivity for
the diffuse metabolic changes associated with dementia in a patient that
shows no gross neurological problems (such as paralysis or weakness) on
neurological exam. CT or MRI may suggest normal pressure hydrocephalus,
a potentially reversible cause of dementia, and can yield information
relevant to other types of dementia, such as infarction (stroke) that
would point at a vascular type of dementia.
The functional neuroimaging modalities of SPECT and PET are more useful
in assessing long-standing cognitive dysfunction, since they have shown
similar ability to diagnose dementia as a clinical exam.[34] The ability
of SPECT to differentiate the vascular cause from the Alzheimer's
disease cause of dementias, appears to be superior to differentiation by
clinical exam.[35]
Recent research has established the value of PET imaging using carbon-11
Pittsburgh Compound B as a radiotracer (PIB-PET) in predictive diagnosis
of various kinds of dementia, in particular Alzheimer's disease. Studies
from Australia have found PIB-PET to be 86% accurate in predicting which
patients with mild cognitive impairment would develop Alzheimer's
disease within two years. In another study, carried out using 66
patients seen at the University of Michigan, PET studies using either
PIB or another radiotracer, carbon-11 dihydrotetrabenazine (DTBZ), led
to more accurate diagnosis for more than one-fourth of patients with
mild cognitive impairment or mild dementia.[36]
[edit]
Prevention
Main article: Prevention of dementia
A study done at the University of Bari in Italy, found that a group
drinking alcoholic beverages moderately had a slower progression to
dementia. In a group of 1,566 elderly Italians, 1,445 had no cognitive
impairment and 121 had suffered mild cognitive impairment, the study
found that that over the duration of 3.5 years the people with MCI who
drank less than one alcoholic beverage a day progressed to dementia at a
rate that was 85% slower than those who drank no alcoholic beverages.
However, the authors of the study commented that since it was
epidemiologic, the findings might only be a marker of lifestyle, showing
that "moderate lifestyle" in general is associated with slower
dementia-progression.[37] A study failed to show a conclusive link
between high blood pressure and developing dementia. The study,
published in the Lancet Neurology journal July 2008, found that blood
pressure lowering medication did not reduce dementia but that meta
analysis of the study data combined with other data suggested that
further study could be warranted.[38]
Brain-derived neurotrophic factor (BDNF) expression is associated with
prevention of some dementia types.[39][40][41]
A Canadian study found that a lifetime of bilingualism delays the onset
of dementia by an average of four years when compared to monolingual
patients. [42][43][44]
[edit]
Management
Except for the treatable types listed above, there is no cure to this
illness. Cholinesterase inhibitors are often used early in the disease
course. Cognitive and behavioral interventions may also be appropriate.
Educating and providing emotional support to the caregiver (or carer) is
of importance as well (see also elderly care).
It is important to recognize that since dementia impairs normal
communication due to changes in receptive and expressive language, as
well as the ability to plan and problem solve, agitated behaviour is
often a form of communication for the person with dementia and actively
searching for a potential cause, such as pain, physical illness, or
overstimulation can be helpful in reducing agitation. [45] Additionally,
using an "ABC analysis of behaviour" can be a useful tool for
understanding behavior in patients with dementia. It involves looking at
the antecedants (A), behavior (B), and consequences (C) associated with
an event to help define the problem and prevent further incidents that
may arise if the person's needs are misunderstood. [46]
[edit]
Medications
Currently, there are no medications that are clinically proven to be
preventative or curative of dementia.[47] Although some medications are
approved for use in the treatment of dementia, these treat the
behavioural and cognitive symptoms of dementia, but have no effect on
the underlying pathophysiology.[48]
?Acetylcholinesterase inhibitors: Tacrine (Cognex), donepezil (Aricept),
galantamine (Razadyne), and rivastigmine (Exelon) are approved by the
United States Food and Drug Administration (FDA) for treatment of
dementia induced by Alzheimer's disease. They may be useful for other
similar diseases causing dementia such as Parkinsons or vascular
dementia.[48] Acetylcholinesterase inhibitors aim to increase the amount
of the neurotransmitter acetylcholine, which is deficient in people with
dementia.[49] This is done by inhibiting the action of the enzyme
acetylcholinesterase, which breaksdown acetylcholine as part of normal
brain function.[50] Though these medications are commonly prescribed, in
a minority of patients these drugs can cause side effects including
bradycardia and syncope.[51]
?N-methyl-D-aspartate (NMDA) receptor blockers: Memantine is marketed
under several names by different pharmaceutical companies including:
Abixa, Akatinol, Axura, Ebixa, Memox and Namenda.[52] In dementia, NMDA
receptors are over-stimulated by glutamate, which creates problems for
neurotransmission (and thus cognition) and also leads to damage to
neurons through excitotoxicity. Memantine is thought to work by
improving the "signal-to-noise" ratio and preventing excitotoxic
damage.[53] Hence, due to their differing mechanisms of action memantine
and acetylcholinesterase inhibitors can be used in combination with each
other.[54][55]
[edit]
Off label
"Off label" use of a drug is one that is a use that is not formally
approved for the drug by the FDA, but is still legal at a doctor's
discretion. Due to lack of formal FDA approval studies in the patient
population to be treated, off label use of drugs is common in medical
practice. In treating children, the mentally ill, and also persons with
dementia, off label drug use is even more common, since lack of informed
consent for the treatment group in studies makes these more expensive
and difficult (since it must be done by proxy), so that for off-patent
pharmaceuticals treatment studies are less often done, due to lack of
funding.
Drugs sometimes used off-label to treat underlying causes of dementia,
or symptoms of dementia, include:
?Antidepressant drugs: Depression is frequently associated with dementia
and generally worsens the degree of cognitive and behavioral impairment.
Antidepressants effectively treat the cognitive and behavioral symptoms
of depression in patients with Alzheimer's disease,[56] but evidence for
their use in other forms of dementia is weak.[57]
?Anxiolytic drugs: Many patients with dementia experience anxiety
symptoms. Although benzodiazepines like diazepam (Valium) have been used
for treating anxiety in other situations, they are often avoided because
they may increase agitation in persons with dementia and are likely to
worsen cognitive problems or are too sedating. Buspirone (Buspar) is
often initially tried for mild-to-moderate anxiety.[citation needed]
There is little evidence for the effectiveness of benzodiazepines in
dementia, whereas there is evidence for the effectivess of
antipsychotics (at low doses).[58]
?Selegiline, a drug used primarily in the treatment of Parkinson's
disease, appears to slow the development of dementia. Selegiline is
thought to act as an antioxidant, preventing free radical damage.
However, it also acts as a stimulant, making it difficult to determine
whether the delay in onset of dementia symptoms is due to protection
from free radicals or to the general elevation of brain activity from
the stimulant effect.[59]
?Antipsychotic drugs: Both typical antipsychotics (such as Haloperidol)
and atypical antipsychotics such as (risperidone) increase the risk of
death in dementia-associated psychosis.[60] This means that any use of
antipsychotic medication for dementia-associated psychosis is off-label
and should only be considered after discussing the risks and benefits of
treatment with these drugs, and after other treatment modalities have
failed. In the UK around 144,000 people with dementia are unnecessarily
prescribed antipsychotic drugs, around 2000 patients die as a result of
taking the drugs each year.[61]
[edit]
Pain
See also: Assessment in nonverbal patients
As people age, they experience more health problems, and most health
problems associated with aging carry a substantial burden of pain; so,
between 25% and 50% of older adults experience persistent pain. Seniors
with dementia experience the same prevalence of conditions likely to
cause pain as seniors without dementia.[62] Pain is often overlooked in
older adults and, when screened for, often poorly assessed, especially
among those with dementia since they become incapable of informing
others that they're in pain.[62][63] Beyond the issue of humane care,
unrelieved pain has functional implications. Persistent pain can lead to
decreased ambulation, depressed mood, sleep disturbances, impaired
appetite and exacerbation of cognitive impairment,[63] and pain-related
interference with activity is a factor contributing to falls in the
elderly.[62][64]
Although persistent pain in the person with dementia is difficult to
communicate, diagnose and treat, failure to address persistent pain has
profound functional, psychosocial and quality of life implications for
this vulnerable population. Health professionals often lack the skills
and usually lack the time needed to recognize, accurately assess and
adequately monitor pain in people with dementia.[62][65] Family members
and friends can make a valuable contribution to the care of a person
with dementia by learning to recognize and assess their pain.
Educational resources (such as the Understand Pain and Dementia
tutorial) and observational assessment tools are available.[62][66][67]
[edit]
Services
Adult daycare centers as well as special care units in nursing homes
often provide specialized care for dementia patients. Adult daycare
centers offer supervision, recreation, meals, and limited health care to
participants, as well as providing respite for caregivers.
In addition, Home care can provide one-on-one support and care in the
home allowing for more individualized attention that is needed as the
disease progresses.
While some preliminary studies have found that music therapy may be
useful in helping patients with dementia, their quality has been low and
no reliable conclusions can be drawn from them.[68]
Psychiatric nurses can make a distinctive contribution to people's
mentalness. The four main premises upon which psychiatric nursing is
based are:
?The nursing is an interactive, developmental human activity that is
more concerned with the future development of the person than the origins.
?The experience of mental distress related to the psychiatric disorder
is represented through disturbances or reports of private events that
are known only to the person concerned.
?Nurses and the people in care are engaged in a relationship based on
mutual influence.
?The experience of psychiatric disorder is translated into problems of
everyday living and the nurse notes the human responses to the
psychiatric distress, not the disorder.[69]
[edit]
Feeding tubes
The risks associated with the use of tubes are not well known.[70]
However, the risks include agitation and the patient pulling out the
feeding tube, tubes becoming dislodged, clogged, or malpositioned. There
is about a 1% fatality rate directly related to the procedure [71] with
a 3% major complication rate [72]
[edit]
Epidemiology
File:Alzheimer_and_other_demen?
Disability-adjusted life year for Alzheimer and other dementias per
100,000 inhabitants in 2002.
<100
100-120
120-140
140-160
160-180
180-200
200-220
220-240
240-260
260-280
280-300
300
Evidence from well-planned, representative epidemiological surveys is
scarce in many regions, particularly in low-income countries. However, a
2009 study by Alzheimer Disease International estimated the global
prevalence of dementia will almost double every 20 years, from 35.6
million in 2010, to 65.7 million by 2030 and 115.4 million by 2050.[73]
Around two thirds of individuals with dementia live in low and middle
income countries, where the sharpest increases in numbers are
predicted.[74] A recent survey done by Harvard University School of
Public Health and the Alzheimer's Europe consortium revealed that the
second leading health concern (after cancer) among adults is Dementia.[75]
[edit]
History
Main articles: Dementia praecox and Alzheimer's disease
Up to the end of the 19th century, dementia was a much broader clinical
concept, which included mental illness and any type of psychosocial
incapacity, including those which could be reversed.[76] Dementia at
this time simply referred to anyone who had lost the ability to reason,
and was applied equally to psychosis of mental illness, "organic"
diseases like syphilis which could destroy the brain, and to the
dementia associated with old age, which was held to be caused by
"hardening of the arteries."
Dementia when seen in the elderly was called senile dementia or senility
and viewed as a normal and somewhat inevitable aspect of growing old,
rather than as being caused by any specific diseases. At the same time,
in 1907, a specific organic dementing process of early onset, called
Alzheimer's disease, had been described. This was associated with
particular microscopic changes in the brain, but was seen as a rare
disease of middle age.
Much like other diseases associated with aging, dementia was rare before
the 20th century, although by no means unknown, due to the fact that it
is most prevalent in people over 80, and such lifespans were uncommon in
preindustrial times. Conversely, syphilitic dementia was widespread in
the developed world until largely being eradicated by the use of
penicillin after WWII.
By the period of 1913-20, schizophrenia had been well-defined in a way
similar to today, and also the term dementia praecox had been used to
suggest the development of senile-type dementia at a younger age.
Eventually the two terms fused, so that until 1952 physicians used the
terms dementia praecox ("precocious dementia") and schizophrenia
interchangeably. The term "precocious dementia" for a mental illness
suggested that a type of mental illness like schizophrenia (including
paranoia and decreased cognitive capacity) could be expected to arrive
normally in all persons with greater age (see paraphrenia). At the same
time, the beginning use of dementia to describe both what we now
understand as schizophrenia and senile dementia, after about 1920, acted
to give the word "dementia" a more limited role, as one of describing a
type of permanent mental deterioration which was not expected to be
reversible. This is the beginning of the more recognizable use of the
term today.
In 1976, neurologist Robert Katzmann suggested a link between "senile
dementia" and Alzheimer's disease.[77] Katzmann suggested that much of
the senile dementia occurring (by definition) after the age of 65, was
pathologically identical with Alzheimer's disease occurring before age
65 and therefore should not be treated differently. He noted that the
fact that "senile dementia" was not considered a disease, but rather
part of aging, was keeping millions of aged patients experiencing what
otherwise was identical with Alzheimer's disease from being diagnosed as
having a disease process, rather than simply considered as aging
normally.[78] Katzmann thus suggested that Alzheimer's disease, if taken
to occur over age 65, is actually common, not rare, and was the 4th or
5th leading cause of death, even though rarely being reported on death
certificates in 1976.
This suggestion opened the view that dementia is never normal, and must
always be the result of a particular disease process, and is not part of
the normal healthy aging process, per se. The ensuing debate led for a
time to the proposed disease diagnosis of "senile dementia of the
Alzheimer's type" (SDAT) in persons over the age of 65, with
"Alzheimer's disease" diagnosed in persons younger than 65 who had the
same pathology. Eventually, however, it was agreed that the age limit
was artificial, and that Alzheimer's disease was the appropriate term
for persons with the particular brain pathology seen in this disease,
regardless of the age of the person with the diagnosis. A helpful
finding was that although the incidence of Alzheimer's disease increased
with age (from 5-10% of 75-year-olds to as many as 40-50% of
90-year-olds), there was no age at which all persons developed it, so it
was not an inevitable consequence of aging, no matter how great an age a
person attained. Evidence of this is shown by numerous documented
supercentenarians (people living to 110+) that experienced no serious
cognitive impairment.
Also, after 1952, mental illnesses like schizophrenia were removed from
the category of "organic brain syndromes," and thus (by definition)
removed from possible causes of "dementing illnesses" (dementias). At
the same, however, the traditional cause of senile dementia- "hardening
of the arteries" - now returned as a set of dementias of vascular cause
(small strokes). These were now termed "multi-infarct dementias" or
vascular dementias.
In the 21st century, a number of other types of dementia have been
differentiated from Alzheimer's disease and vascular dementias (these
two being the most common types). This differentiation is on the basis
of pathological examination of brain tissues, symptomatology, and by
different patterns of brain metabolic activity in nuclear medical
imaging tests such as SPECT and PETscans of the brain. The various forms
of dementia have differing prognoses (expected outcome of illness), and
also differing sets of epidemologic risk factors. The causal etiology of
many of them, including Alzheimer's disease, remains unknown, although
many theories exist such as accumulation of protein plaques as part of
normal aging, inflammation, inadequate blood sugar, and traumatic brain
injury.
[edit]
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