What is the psychology of dementia?
Dementia, which has been renamed major neurocognitive disorder (NCD) and mild NCD by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (2013). 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 words, or use incorrect words when speaking. They may become disoriented to time and place and become lost in familiar surroundings. Problems with abstract thinking may make solving math problems and balancing a checkbook impossible. People with dementia may misplace items and be unable to find them because the items were put in unaccustomed places. Mood swings and drastic personality changes, such as sudden, unexpected swings from calm and happiness to tears and anger, are not uncommon in those with dementia.
Depression may be mistaken for dementia. Symptoms of depression include feelings of profound sadness, difficulty in thinking and concentrating, feelings of despair, and apathy. Severe depression brings with it an inability to concentrate and a poor attention span. As the person with dementia tries to conceal memory loss and cognitive decline, appetite loss, apathy, and feelings of uselessness may ensue. In combined dementia and depression, intellectual deterioration can be extreme. An older adult who is depressed may also show signs of confusion and intellectual impairment even though dementia is not present. These individuals are identified as having pseudodementia. Depression, alone or in combination with dementia, is treatable.
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.
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.
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, executive dysfunction, deterioration of social skills, inappropriate behavior, and language problems. Pick’s disease is most common between ages fifty and sixty. It progresses rapidly and may be accompanied by apathy, extreme agitation, severe language difficulties, attention deficits, and inappropriate behavior. Pick’s disease can be confirmed only on autopsy when Pick’s inclusion bodies are found.
Another disorder that can lead to progressive dementia is Huntington’s disease, a genetic disorder that usually occurs in middle age. The basal ganglia and subcortical structures in the brain are affected, causing spasticity in body movements. Personality, memory, intellect, speech, and judgment are altered.
Creutzfeldt-Jakob disease (spongiform encephalopathy) is a rare and fatal brain disorder caused by a virus that converts protein into infectious, deadly molecules. Early symptoms may be memory loss and changes in behavior. Creutzfeldt-Jakob disease progresses into mental deterioration, muscle spasms, weakness in the extremities, blindness, and coma.
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-5 (2013) for the diagnosis of dementia, which this edition classifies under the general diagnosis of major neurocognitive disorder (NCD) or mild NCD, require the presence of multiple cognitive deficits in addition to memory impairment. The diagnosis of major NCD 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. Cognitive deficits must also not be attributable to another mental disorder such as schizophrenia or major depressive disorder. Mild NCD, on the other hand, is diagnosed when an individual exhibits a modest decline in cognitive function or performance as reported by the individual, a concerned third party, or a clinician. The decline is measured via test performance or a clinical evaluation. Cognitive deficits in mild NCD do not interfere with independence or social or occupational functioning and must occur exclusive of other mental disorders. 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 studies, electroencephalogram, lumbar puncture, and computed tomography (CT) scans of the head are done in relation to the presenting symptoms.
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.
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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