Introduction (Psychology and Mental Health)
Dementia is usually characterized as a gradual, progressive decline in cognitive function that affects speech, memory, judgment, and mood. However, it may also be an unchanging condition that results from an injury to the brain. Initially, individuals may be aware of a cognitive decline, but over time they no longer notice. The insidious and progressive nature of dementia may make early diagnosis difficult because cognitive changes may appear as only slight declines in memory, attention, and concentration or rare episodes of inconsistencies in behavior that are attributed to aging. Over time, increased confusion and irritability in unfamiliar environments, poor judgment, difficulty in abstract thinking, and personality changes may be seen.
Delirium is a transient alteration in mental status that is a common feature of dementia. Signs and symptoms of delirium develop over a short period of time. Once the underlying causes of delirium, such as medical problems, stress, and medications, are identified and ministered to, delirium can be reversed. Visual and auditory hallucinations, paranoia, and delusions of persecution may be observed. Memory loss is another symptom of dementia. People with dementia often forget how to perform activities of daily living (ADLs), such as dressing, cleaning, and cooking, that they have been performing for years. They may repeatedly ask the same questions, have the same conversations, forget simple...
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Prevalence and Impact (Psychology and Mental Health)
Dementia may occur at all ages, but its incidence increases with advanced age. Dementia is most frequent in those older than age seventy-five. There are an estimated 600,000 cases of advanced dementia in the United States, and milder degrees of altered mental status are common in the elderly. The prevalence of dementia increases from 1 percent at age sixty to 40 percent at age eighty-five. The expense of long-term care at home or in a nursing facility has been estimated at 40 billion dollars per year for people age sixty-five and older. The prevalence of dementia is expected to continue to increase as a result of increased life expectancy and an aging population of baby boomers. Many of the problems caused by dementia are due to memory loss.
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Causes (Psychology and Mental Health)
Dementia may be reversible or irreversible. Reversible causes include brain tumors; subdural hematoma; slowly progressive or normal-pressure hydrocephalus; head trauma; endocrine conditions (such as hypothyroidism, hypercalcemia, hypoglycemia); vitamin deficiencies (of thiamin, niacin, or vitamin B12); thyroid disease; ethanol abuse; infections; metabolic abnormalities; effects of medications; renal, hepatic, and neurological conditions; and depression. Irreversible dementia is more common in the elderly. Irreversible causes of dementia include diseases of the brain such as Alzheimer’s, Parkinson’s, Pick’s, Creutzfeldt-Jakob, and Huntington’s diseases; human immunodeficiency virus (HIV) infection; vascular dementia; and head trauma.
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Types of Dementia (Psychology and Mental Health)
Alzheimer’s disease is the most common form of dementia and is responsible for 50 percent of all dementias. No direct cause has been identified, but it is thought that viruses, environmental toxins, and family history are involved. Definitive diagnosis of Alzheimer’s disease can be made only on autopsy when neurofibrillary tangles are found in the brain.
Parkinson’s disease is an insidious, slow, progressive neurological condition that begins in middle to late life. It is characterized by tremor, rigidity, bradykinesia, and postural instability. Dementia is also present in 20 percent to 60 percent of those with Parkinson’s disease. It is characterized by diminishing cognitive function, diminishing motor and executive function, and memory impairment.
Lewy body disease is similar to Alzheimer’s disease. Visual hallucinations and Parkinson-like features progress quickly. Lewy bodies are found in the cerebral cortex. Patients exhibit psychotic symptoms and have a sensitivity to antipsychotic medications.
Vascular dementia is less common after age seventy-five. It is estimated that 8 percent of individuals over sixty years old who have a stroke develop dementia within one year. Early treatment of hypertension and vascular disease may prevent further progression of dementia.
Pick’s disease and other frontal lobe dementias are rare and are identified by changes in personality and emotions,...
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Risk Factors and Diagnosis (Psychology and Mental Health)
Risk factors for dementia include a family history of dementia, head trauma, lower educational level, and gender (women are more prone to dementia). Alcohol and drug abuse, infections, cardiovascular disease, and head injuries are also causes for the development of dementia.
The criteria in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (rev. 4th ed., 2000) for the diagnosis of dementia require the presence of multiple cognitive deficits in addition to memory impairment. The diagnosis of dementia is based on cognitive deficits that are severe enough to cause impairment in occupational or social functioning and must represent a decline from a previous level of functioning. The nature and degree of impairment are variable and often depend on the particular social setting of the individual. Standardized mental status tests are a baseline for evaluation for dementia. Examples of some short tests are the Mini-Mental Status Test, the Blessed Information-Memory-Concentration Test, and the Short Portable Mental Status Questionnaire. A standardized mental status test score should be used to confirm the results of a history and a physical examination. Standardized mental status tests should not be the single deciding factor for the diagnosis of dementia. Some tests such as blood evaluations, urinalysis, chest radiography, carotid ultrasound, Doppler flow...
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Treatment (Psychology and Mental Health)
The goals of treating dementia are improving mental function and maintaining the highest level of function possible. Many families care for family members with dementia at home. A structured home environment and established daily routines are important as the person with dementia begins to experience difficulty learning and remembering new activities. Establishing simple chores to enhance a sense of usefulness, such as watering plants, dusting, and setting the table, is helpful. It is essential to provide a safe home environment. This includes maintaining uncluttered surroundings and removing potentially dangerous items such as matches, lighters, knives, scissors, and medications. In later stages of dementia, stoves, ovens, and other cooking items may need to be disabled to prevent fires. Clocks, calendars, television, magazines, and newspapers are good ways to help to preserve orientation in those with dementia. As functioning decreases, nursing home placement may be necessary.
It is important that the families who care for members with dementia at home are made aware of community services that can assist them in locating support groups and social service agencies to access day care, counseling, home care, and respite care and group therapy services.
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Pharmaceutical Therapies (Psychology and Mental Health)
Successfully treating some of these causes of dementia may reverse the condition: brain tumors; subdural hematoma; slowly progressive or normal-pressure hydrocephalus; head trauma; hypothyroidism; hypercalcemia; hypoglycemia; deficiency of thiamine, niacin, or vitamin B12; thyroid disease; ethanol abuse; infections; metabolic abnormalities; effects of medications; renal, hepatic, and neurological conditions; and depression.
Nerve growth factor, antioxidant therapy, and other drugs are being investigated for the management of dementia. Psychotrophic medications such as carbamazepine, desipramine, haloperidol, lorazepam, and thioridazine are used to control symptoms of agitation, anxiety, confusion, delusions, depression, and hallucinations in patients with dementia. Unfortunately, some of the medications used to improve patients’ quality of life may not work, worsen memory deficits, or cause neurological effects such as irreversible tremors (tardive diskinesia).
It is important to reduce cerebrovascular risk factors such as hypertension, diabetes, smoking, hyperlipidemia, and coronary artery disease in patients with vascular dementia. Dementia resulting from neurologic conditions (Parkinson’s disease, normal-pressure hydrocephalus, brain lesions, carotid artery disease) requires a neurological workup. Dementia related to a hereditary condition requires referral for genetic counseling.
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Sources for Further Study (Psychology and Mental Health)
Epstein, David, and James Gonnor. “Dementia in the Elderly: An Overview.” Generations 23, no. 3 (1999): 9-17. Presents an overview of various types of dementia and their treatments.
Kuhn, Daniel, and Jane Verity. The Art of Dementia Care. Clifton Park, N.Y.: Thomson Delmar Learning, 2008. The authors use examples from common clinical situations to show caregivers how to promote the strengths and abilities of those suffering from dementia.
Rabins, Peter V., Constantine G. Lyketsos, and Cynthia Steele. Practical Dementia Care. New York: Oxford University Press, 2006. Written primarily for medical professionals. Covers definitions, evaluation, diseases causing dementia, care for the patient and the family, treatment options, terminal care, and ethical and legal issues.
Schindler, Rachel. “Late-Life Dementia.” Geriatrics 55, no. 10 (2000): 55-57. Discusses American Psychiatric Association guidelines for detecting and treating dementia.
Teitel, Rosette, and Marc Gordon. The Handholder’s Handbook: A Guide to Caregivers of People with Alzheimer’s or Other Dementias. New Brunswick, N.J.: Rutgers University Press, 2001. A guide to practical and emotional issues for caregivers of dementia patients. Chapters provide checklists of topics that caregivers should deal with or cover as they adjust to their role.
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Dementia (Encyclopedia of Genetic Disorders)
Dementia is not a specific disorder or disease. It is a syndrome (group of symptoms) associated with a progressive loss of memory and other intellectual functions that is serious enough to interfere with the tasks of daily life. Dementia can occur to anyone at any age from an injury or oxygen deprivation, although it is most commonly associated with aging.
The definition of dementia has become more inclusive over the past several decades. Whereas earlier descriptions of dementia emphasized memory loss, the last two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R in 1987 and DSM-IV in 1994) define dementia as an overall decline in intellectual function, including difficulties with language, simple calculations, planning and judgment, and motor (muscular movement) skills as well as loss of memory. Although dementia is not caused by aging itselfost researchers regard it as resulting from injuries, infections, brain diseases, tumors, or other disorderst is quite common in older people. Common estimates are that over 15% of people in North America over the age of 65 suffer from dementia, and 40% of people over 80. Surveys indicate that dementia is the condition most feared by older adults in the...
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Dementia (Encyclopedia of Medicine)
Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.
Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. While the over-whelming number of people with dementia are elderly, it is not an inevitable part of aging. Instead, dementia is caused by specific brain diseases. Alzheimer's disease (AD) is the most common cause, followed by vascular or multi-infarct dementia.
The prevalence of dementia has been difficult to determine, partly because of differences in definition among different studies, and partly because there is some normal decline in functional ability with age. Dementia affects 5% of all people between ages 65 and 74, and up to 20% of those between 75 and 84. Estimates for dementia in those 85 and over range from 307%. Between two and four million Americans have AD; that number is expected to grow to as many as 14 million by the middle of the twenty-first century as the population as a whole ages.
The cost of dementia can be...
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Dementia (Encyclopedia of Neurological Disorders)
The term dementia refers to symptoms, including changes in memory, personality, and behavior, that result from a change in the functioning of the brain. These declining changes are severe enough to impair the ability of a person to perform a function or to interact socially. This operating definition encompasses 700 different types of dementia. They include changes due to diseases (Alzheimer's and Creutzfeld-Jakob diseases), changes due to a heart attack or repeated blows to the head (as suffered by boxers), and damage due to long-term alcohol abuse.
Dementia is not the same thing as delirium or mental retardation. Delirium is typically a brief state of mental confusion often associated with hallucinations. Mental retardation is a condition that usually dates from childhood and is characterized by impaired intellectual ability; mentally retarded individuals typically have IQ (intelligence quotient) scores below 70 or 75.
The absent-mindedness and confusion about familiar settings and tasks that are hallmarks of dementia used to be considered as part of a typical aging pattern in the elderly. Indeed, dementia historically has been called senility. Dementia is now recognized not to be a normal part of aging. The symptoms of dementia can result from different causes. Some of the...
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Dementia (Encyclopedia of Mental Disorders)
Dementia is not a specific disorder or disease. It is a syndrome (group of symptoms) associated with a progressive loss of memory and other intellectual functions that is serious enough to interfere with performing the tasks of daily life. Dementia can occur to anyone at any age from an injury or from oxygen deprivation, although it is most commonly associated with aging. It is the leading cause of institutionalization of older adults.
The definition of dementia has become more inclusive over the past several decades. Whereas earlier descriptions of dementia emphasized memory loss, the last three editions of the professional's diagnostic handbook, Diagnostic and Statistical Manual of Mental Disorders(also known as the DSM) define dementia as an overall decline in intellectual function, including difficulties with language, simple calculations, planning and judgment, and motor (muscular movement) skills as well as loss of memory. Although dementia is not caused by aging itself- most researchers regard it as resulting from injuries, infections, braindiseases, tumors, or other disorders- it is quite common in older people. The prevalence of dementia increases rapidly with age; it doubles every five years...
(The entire section is 4224 words.)
Dementia (Encyclopedia of Science)
Dementia is a decline in a person's ability to think and learn. It is an irreversible mental condition. Occurring mainly in older people, dementia is characterized by memory loss, the inability to concentrate and make judgments, and the general loss of other intellectual abilities.
The two most common forms of dementia are senile dementia and Alzheimer's disease. Senile dementia, or senility, is the loss of mental capacities as a result of old age. It is considered a normal part of the aging process, and generally occurs very late in life. Alzheimer's disease, on the other hand, is not a normal result of aging and can begin in late middle age.
The deterioration of brain tissue occurs much more quickly in those people suffering from Alzheimer's disease than in those suffering from senility. Alzheimer's disease is marked first by forgetfulness, followed by memory loss and disorientation, then by severe memory loss, confusion,
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Dementia (Encyclopedia of Psychology)
A gradual deterioration of mental functioning affecting all areas of cognition, including judgment, language, and memory.
Dementia generally occurs in the elderly, although it can appear at any age. Several substantial studies have been done to determine its prevalence, and in 1991 a major study was conducted which found that dementia occurred in just over 1 percent of the population aged 65 to 74; in approximately 4 percent in ages 75 to 84; and more than doubling to 10.14 percent in persons 85 and over. Other studies have concluded that many as 47 percent of people over 85 suffer from some form of dementia. Prevalence rates tend to be comparable between the sexes and across sociocultural barriers, such as education and class. It is also worth noting that, despite what is often commonly thought, dementia is not an inevitable consequence of aging.
Researchers have identified many types of dementia, including dementia resulting from Alzheimer's disease, vascular dementia, substance induced dementia, dementia due to multiple etiologies, dementia due to other general medical conditions, and dementia not otherwise specified. More than half of the persons diagnosed with dementia are classified as having dementia resulting from Alzheimer's disease. This type of dementia occurs in more than half of dementia cases in the United...
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Dementia (Encyclopedia of Alternative Medicine)
Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.
Dementia is a group of symptoms caused by gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. While the over-whelming number of people with dementia are elderly, it is not an inevitable part of aging. Instead, dementia is caused by specific brain diseases. Alzheimer's disease is the most common cause, followed by vascular or multi-infarct dementia.
The prevalence of dementia has been difficult to determine, partly because of differences in definition among different studies, and partly because there is some normal decline in functional ability with age. Dementia affects 5% of all people between ages 65 and 74, and up to 20% of those between 75 and 84. Estimates for dementia in those 85 and over range from 307%. Between two and four million Americans have Alzheimer's disease; that number is expected to grow to as many as 14 million by the middle of the twenty-first century as the population as a whole ages.
The cost of dementia can...
(The entire section is 2299 words.)
Dementia (Encyclopedia of Nursing & Allied Health)
Dementia is a condition characterized by a progressive, irreversible decline in mental ability, accompanied by changes in behavior and personality. There is commonly a loss of memory and skills that are required to carry out activities of daily living.
Dementia is a group of symptoms caused by the gradual death of brain cells. The loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and personality. Dementia can occur at any age and may affect younger people as the result of disease such as AIDS, hypoxia (a deficiency of oxygen reaching the tissues of the body), or injury. However, it is primarily a disease of the elderly, affecting more than 15% of those over 65 years of age, and as many as 40% of those over the age of 80. The condition is somewhat more common among women than men. Some studies suggest that the risk for dementia is higher for African Americans and Hispanic Americans than it is for Caucasians. More than half of all nursing home admissions occur because of dementia.
While the overwhelming majority of people with dementia are elderly, it is not an inevitable part of aging. One of the challenges for health care professionals is to differentiate the early-stage cognitive deficits of dementia from normal age-related memory impairment. Persons with age-related memory impairment may tend to learn new information more slowly; but, if they are given additional time, their cognitive performance is usually adequate. Other problems that may be mistakenly labeled dementia include delirium, psychosis, depression, and the side effects of various medications.
Dementia presents a major health problem for the United States because of its huge impact on individuals and their families, the health care system, and society overall. The costs of dementia are considerable. While most people with the disease are retired and do not suffer income losses, the cost of care is often enormous. Financial burdens include lost wages for family caregivers, medical supplies and drugs, and home modifications to ensure safety. Nursing home care may cost several thousand dollars a month or more. As of 1998, the cost of caring for Alzheimer's dementia patients alone was estimated to be slightly over $50 billion. The psychological costs are not as easily quantifiable, but can be even more profound. The person with dementia loses control of many of the essential features of life and personality, and loved ones lose a family member even as they continue to cope with the burdens of increasing dependence and unpredictability.
Causes and symptoms
Dementia is usually caused by degeneration in the cerebral cortex, the part of the brain responsible for thoughts, memories, actions, and personality. Death of brain cells in this region leads to the cognitive impairment that characterizes dementia. Dementia may be caused by a variety of illnesses.
The most common cause of dementia is Alzheimer's disease (AD), accounting for half to three-quarters of all cases.
Vascular dementia accounts for 50% of all dementias in the United States. It occurs from a decrease in blood flow to the brain, most commonly due to a series of small strokes (multi-infarct dementia). Other cerebrovascular causes include vasculitis from syphilis, Lyme disease, or systemic lupus erythematosus; subdural hematoma; and subarachnoid hemorrhage. Because of the usually sudden nature of its cause, the symptoms of vascular dementia tend to appear more abruptly than those of Alzheimer's dementia. Symptoms may progress with the occurrence of new strokes. Unlike AD, the incidence of vascular dementia decreases after the age of 75.
Other conditions that may cause dementia include:
- Parkinson's disease
- Lewy body disease
- Pick's disease
- Huntington's disease
- Creutzfeldt-Jakob disease
- brain tumors
- head trauma
- prolonged abuse of alcohol or other drugs
- vitamin B12 deficiency
Dementia is marked by a gradual decline of thought and other mental activities. The onset may be slow, occurring over months or years. The slow progression of dementia is in contrast with delirium, which involves some of the same symptoms, but has a very rapid onset and fluctuating course with alteration in the level of consciousness. However, delirium may occur along with dementia, especially since the person with dementia is more susceptible to the delirium-inducing effects of many types of drugs.
Symptoms of dementia may include:
- Memory losses: Memory loss is usually the first symptom noticed. It may begin with misplacing valuables such as a wallet or car keys, then progress to situations such as forgetting appointments, where the car was left, or the route home. More profound losses follow, such as forgetting the names and faces of family members.
- Impaired abstraction and planning: The person with dementia may lose the ability to perform familiar tasks, to plan activities, and to draw simple conclusions from facts.
- Language and comprehension disturbances: The person may be unable to understand instructions, or follow the logic of moderately complex sentences. Later, the individual may not be able to understand his or her own sentences, and have difficulty forming thoughts into words.
- Poor judgment: The person may not recognize the consequences of his or her actions or be able to evaluate the appropriateness of behavior. Behavior may become ribald, overly friendly, or aggressive. Personal hygiene may be ignored.
- Impaired orientation: The person may not be able to identify the time of day, even from obvious visual clues; or may not recognize a location, even if familiar. This disability may stem partly from losses of memory and partly from impaired abstraction.
- Decreased attention and increased restlessness: These symptoms may cause the person with dementia to begin an activity and quickly lose interest, and to wander frequently. Wandering may cause significant safety problems, when combined with disorientation and memory losses. The person may begin to cook something on the stove, then become distracted and wander away while it is cooking.
- Personality changes and psychosis: The person may lose interest in once pleasurable activities, and become more passive, depressed, or anxious. Delusions, suspicion, paranoia, and hallucinations may occur later in the disease. Sleep disturbances may occur, including insomnia and sleep interruptions.
Since dementia usually progresses slowly, diagnosing it in the early stages can prove difficult. However, as the elderly population grows and the prevalence of dementia increases, the importance of recognizing the early symptoms has become imperative.
Dementia may be suspected by the health care professional if memory deficits are exhibited during an examination or assessment. Information from the family members, friends, and caregivers may point to dementia as well. Diagnosis begins with a thorough physical exam and complete medical history. A family history of either Alzheimer's disease 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. If dementia is suspected, a complete review of medications and an assessment for chronic disease processes are indicated. If the patient shows no improvement after eliminating unnecessary medications and treating the chronic disease, then other tests are warranted. Physical examination and a variety of laboratory tests may rule out potentially treatable causes of dementia. These may include hearing or visual deficits, hypothyroidism, vitamin B12 deficiency, and depression. Some of the laboratory tests that might be performed include a complete blood cell count and urinalysis (to rule out infection), serum electrolytes, glucose and calcium levels, and kidney and liver function tests.
The use of computed tomography (CT) or magnetic resonance imaging (MRI) to rule out vascular disease is somewhat controversial, since even if a cause is discovered, less than 11% of patients with cognitive decline have partially or fully reversible disease.
Treatment of dementia starts 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, including smoking cessation, aspirin therapy, and treatment of hypertension. There are no known therapies that can reverse the progression of Alzheimer's disease.
Early intervention may allow the patient to compensate for the alterations in functioning, help to minimize complications, and have an improved quality of life. It may also allow the patient and family to plan for the future and to identify resources.
Periodically, new drugs are studied for the treatment of dementia. The only drugs currently approved for the symptomatic treatment of AD are tacrine (Cognex) and donepazil (Aricept). These drugs act by slowing down the degradation of neurotransmitters. They may provide temporary improvement in cognitive functioning for about 40% of patients with mild-to-moderate AD. However, drug therapy can be complicated by forgetfulness, especially if the drug must be taken several times a day.
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. Anti-anxiety drugs such as Valium may improve behavioral symptoms, especially agitation and anxiety, although BuSpar has fewer side effects. The anticonvulsant carbamazepine is also sometimes prescribed for agitation. Depression is treated with antidepressants, usually beginning with selective serotonin reuptake inhibitors (SSRIs) such as Prozac or Paxil.
In general, medications should be administered very cautiously to demented patients, in the lowest possible effective doses, to minimize side effects. Supervision of taking medications is generally required.
The primary goals of treatment for progressive dementia are to preserve as much functioning and independence as possible, and to maintain quality of life as long as possible. It is important that the patient and caregivers are aware that caring 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 may need to assume increasing responsibility for the person's physical needs. The patient and family should be educated early on in the disease progression to help them anticipate and plan for inevitable changes.
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 over-stimulation. 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. Childproof latches may be used to limit access as well. Bed rails and bathroom safety rails can be important safety measures. Confusion may be reduced with the use of simpler decorative schemes and the presence of familiar objects. Covering or disguising doors may reduce the tendency to wander. Positioning the bed in view of the bathroom can decrease incontinence.
Long-term institutional care may be required 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 are often subject to extreme stress, and may develop feelings of anger, resentment, guilt, and hope-lessness, 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. Contact numbers are available from the Alzheimer's Association; they may also be available through a local social service agency.
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 is usually progressive, with death resulting from stroke, infection, or heart disease.
Health care team roles
Any member of the health care team may work with patients with dementia. The physician normally makes the diagnosis. Laboratory technicians may obtain laboratory tests, and radiology technicians may perform imaging studies, if ordered. Nurses assess patients and how dementia affects their functioning. Patient education is very important in managing dementia and is a nursing responsibility.
There is no known way to prevent AD, although several drugs under investigation may reduce its risk or slow its progression. The risk of developing multi-infarct dementia may be avoided by reducing the overall risk for strokes.
Amyloid plaquesbnormal structures composed of parts of nerve cells surrounding protein deposits, found in the brains of persons with Alzheimer's disease.
Neurofibrillary tanglesbnormal structures composed of twisted masses of protein fibers within nerve cells, found in the brains of persons with Alzheimer's disease.
Beers, Mark H., and Robert Berkow. The Merck Manual of Diagnosis and Therapy, 17th ed. Whitehouse Station, NJ: Merck and Company, Inc., 1999.
"Progress Report on Alzheimer's Disease." National Institute on Aging, National Institutes of Health (1999).
Santacruz, Karen S., and Daniel Swagerty. "Early Diagnosis of Dementia." American Family Physician (February 15,2001): 703.
Alzheimer's Association. 919 North Michigan Ave., Suite 1000, Chicago, IL 60611. (800) 272-3900. <<a href="http://www.alz.org">http://www.alz.org>.
Alzheimer's Disease Education and Referral Center (ADEAR). P.O. Box 8250, Silver Spring, MD 20907-8250. (800) 438-4380. <<a href="http://www.alzheimers.org">http://www.alzheimers.org>.
Deanna M. Swartout-Corbeil, R.N.
Dementia (Encyclopedia of Public Health)
Dementia is a condition characterized by a chronic decline in cognitive functions contrasted with a person's usual state of functioning. It is seen most often in people sixty-five years and older, and the incidence increases with age. Dementia occurs in a stable level of consciousness and sensorium, unlike delirium. There are various causes and types of dementia, but they have certain characteristics in common. Persons with dementia often have problems with short-term memory, such as forgetting names and recent events. They may have trouble with visuospatial processing, such as getting lost in familiar places. Language may be affected, causing difficulty in finding the right word to use in a sentence. The affected person may have difficulty with activities of daily living, such as balancing the checkbook or forgetting to turn off the stove when cooking. This condition may also be accompanied by alterations in personality and behavior. Persons with dementia often become depressed, irritable, or have unreasonable fears. They may also say or do inappropriate things in social situations. Visual or auditory hallucinations sometimes occur.
The onset of dementia is usually insidious. Recognition of the condition is often delayed due to lack of insight on the part of the affected person, who often does not notice that anything is wrong. Families are also slow to recognize the condition and sometimes deny that there is a problem. There is a common false myth that aging is synonymous with poor memory. Although aging results in mild slowing for some cognitive functions, normal aging does not cause significant memory loss. In many cases, the deterioration is progressive. However, some dementias have reversible causes, and this possibility must be investigated thoroughly when the person comes for treatment. Physicians should regularly screen patients who are sixty-five years and older for dementia.
Alzheimer's disease is the most common type of dementia in North America and Europe (500 percent of dementias). It is characterized by slow onset and gradual impairment of recent memory. Long-term memory usually remains more intact. This impairment progresses until death. It is thought to be caused by the accumulation of certain proteins in the brain. It is not clear what causes this condition to occur. Alzheimer's disease is usually diagnosed clinically by cognitive testing rather than using laboratory tests.
Dementia may also be caused by problems with the vascular system, such as cerebrovascular accident (stroke), hypertension, and atherosclerosis. This is thought to make up 15 to 20 percent of dementias in North America and Europe. These disorders are characterized by abrupt onset of cognitive dysfunction that progressively worsens in a step-wise pattern as multiple strokes recur and damage to the brain accumulates.
There are many other causes of dementia, including trauma, metabolic imbalances, hereditary illness, drugs (e.g., alcohol), toxins, and infections (e.g., HIV [human immunodeficiency virus], syphilis). Some of these causes are reversible with medical treatment. Unlike Alzheimer's disease, these conditions usually have rapid onset and progression. Whenever dementia is diagnosed, these reversible causes must be ruled out promptly.
Parkinson's disease is a movement disorder characterized by tremor, slow unsteady gait, and a mask-like face. Decreased levels of a chemical called dopamine in the brain cause this condition. Approximately 30 percent of persons with Parkinson's disease also have dementia. This dementia is characterized by fluctuations in alertness and cognitive abilities. It is also associated with visual hallucinations. It can be treated with medications that increase the levels of dopamine in the brain.
Psychiatric disorders like depression may cause a dementia-like impairment of memory and concentration called pseudodementia. Depression is a common condition in the elderly. People with depression often have problems with sleep, guilt, appetite, sexual drive, low mood, low energy, and loss of interest in activities, and they may be suicidal. They are more likely to be pessimistic and complain of poor memory than a person with true Alzheimer's disease, who usually tries to deny any problems. Pseudodementia improves after the depression is treated, usually by psychotherapy, medications, or social support. Depression may occur in some individuals with dementia as the person becomes aware of the cognitive decline. Treatment of depression may still be very helpful in such cases.
Diagnosis of dementia requires a thorough physical, neurological, and psychiatric exam. Neuropsychological testing consists of a battery of cognition tests and helps determine what functions are specifically impaired. Laboratory tests are required as part of the medical evaluation. Occasionally, brain imaging is used if a brain tumor or head injury is suspected.
STUART J. EISENDRATH
(SEE ALSO: Alzheimer's Disease; Stroke)
Kaplan, H., and Sadock, B., eds. (1995). Comprehensive Textbook of Psychiatry, Vol. 1, 6th edition. Baltimore, MD: Williams and Willkins.
Knopman, D. (1998). "The Initial Recognition and Diagnosis of Dementia." The American Journal of Medicine 104 (April):2S2S.
Tierney L.; McPhee, S.; and Papadakis, M. (1999). "Dementia." In Current Medical Diagnosis and Treatment, 38th edition. Stamford, CT: Appleton and Lange.
Dementia (International Dictionary of Psychoanalysis)
Dementia has been defined in two very different ways. The first definition, which came into use in the nineteenth century with the establishment of a nosographic framework for the psychoses, culminated in the concept of dementia praecox in the work of Emil Kraepelin. The second definition concerns altered states in memory and ideation following injury to the brain.
The word dementia, which first appeared in a psychiatric sense in Philippe Pinel's work contrasting mania and dementia, underwent changes in meaning during the nineteenth century. In 1911 Eugen Bleuler, in his discussion of the concept of schizophrenia, centered around dissociation or splitting (Spaltung), proposed bringing together the old notion of "vesanic dementia" (the culmination of psychotic development) and Kraepelin's three forms of dementia praecox: hebephrenic, catatonic, and paranoid.
Sigmund Freud approved of Kraepelin's approach but he criticized the term dementia praecox, as well as the term schizophrenia. This despite the fact that he felt it important to distinguish between the two, writing, in "Psycho-Analytical Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)" (1911 c): ". . . we shall hope later on to find clues which will enable us to trace back the differences between the two disorders (as regards both the form they take and the course they run) to corresponding differences in the patients' dispositional fixations" (p. 62). In reality, he continued to use both terms indiscriminately. He focused his study of the psychoses on paranoia in the essay cited above. After "On Narcissism: An Introduction," (1914) he proposed to distinguish among the neuroses, the psychoses, and the perversions. In Freudian theory, dementia praecox consists of a withdrawal of object libido onto the ego through regression and fixation. Freud later went on to specify its linguistic characteristics (words are subjected to the primary process) and its functioning (reality testing is no longer operant; verbal delusions are an attempt at healing), but essentially it was Freud's successors who developed a psychoanalytic theory of the psychoses.
In current usage, the term dementia refers to erosion of the intelligence caused by many different kinds of damage to the brain: degenerative dementias (dominated by Alzheimer's disease), vascular diseases, infectious diseases, toxic conditions, or metabolic disorders. Clinical treatment of dementia from a psychoanalytic perspective runs up against problems of theoretical elaboration. Psychoanalysis has limited applications for these conditions and is used mainly in the early stages of illness. The goal is to limit the breakdown of identity for a certain time. The gradual erosion of the capacity for symbolization and the work of representation owing to memory loss, the weakening of repression and the breaking through of the protective shield, and the instinctual flooding that ensues, has led to reliance on a therapeutic approach focusing on the reconstitutive function of the affects as the basis for mental activity, since, as Michèle Grosclaude suggested in Le Statut de l'affect dans la psychothérapie des démences (The status of the affects in the psychotherapy of dementia; 1997), verbal therapies are among the first to be affected by the degenerative process. Denial, projective delusions, and heightened anxiety are all typical of these conditions.
See also: Ego; Infantile psychosis; Infantile schizophrenia; Narcissism, secondary; Organic psychoses; Paranoid psychosis; Paraphrenia; "Psycho-Analytic Notes on Autobiographical Account of a Case of Paranoia (Dementia Paranoides)"; Schizophrenia; "Unconscious, The"
Freud, Sigmund. (1911c ). Psycho-analytical notes on autobiographical account of a case of paranoia (dementia paranoides). SE, 12, 9-82.
. (1914). On narcissism: an introduction. SE, 14, 73-102.
. (1915). The unconscious. SE, 14, 166-204.
Grosclaude, Michèle. (1997). Le Statut de l'affect dans la psychothérapie des démences. Psychothérapie des démences. Montrouge, France: John Libbey Eurotext.