An acquired decline in memory and in at least one other cognitive function such as language, visual-spatial or executive and sufficient to affect the daily life of an alert person.
Defined by chronic, acquired loss of two or more cognitive abilities caused by brain disease or injury.
About 3% of people between the ages of 65 and 74, 19% between 75 and 84, and nearly half of those over 85 years of age have dementia.
There is an estimated 6.7 million people over 65 years of age in the US living with dementia.
Worldwide, more than 55 million people have dementia, and 10 million people new cases are diagnosed each year.
The most common causes of dementia: Alzheimer’s disease, dementia with Lewy bodies, Parkinson’s disease Dementia, Vascular The Dementia and Frontal temporal dementia may be associated with hallucinations and delusions.
The syndrome of dementia related psychosis causes behavioral disturbances, decreased quality of life, nursing home placement, and more rapid cognitive decline.
Typical and atypical antipsychotic agents to manage psychotic symptoms are used cautiously in patients with Lewy bodies owing to the risk of worsening parkinsonism and other side effects.
Antipsychotics in Dementia have modest short-term advocacy and may be associated with worsening cognition, extraparametal effects, sedation, falls, and metabolic abnormalities.
Refers to any disorder with significant decline from one’s previous level of cognition causes interference in work, domestic, or socialization.
Describes a decline in mental abilities including: memory, language, and logical thinking there that is severe enough to affect daily living.
A global epidemic, with 50 million people affected and estimated economic cost of approximately $1 trillion per year globally.
In the study of 1,869,090 patients with the mean age of 69.4 years the incidence of dementia per 1000 person years were 14.2 for American Indian or Alaskan native patients, 12.4 for Asian patients, 19.4 for black patients, 20.7 Hispanic patients, and 11.5 for White patients (Kornblith et Al).
As a comorbidities, dementia increases the cost of care by 50% when it coexist with chronic conditions.
Pervasive impairment of cognitive function, including memory, language, and personality are characteristic of dementia.
Defined as a progressive deterioration in cognition, behavior, or both, without impaired consciousness, that is severe enough to impair activities of daily living.
Causes include neurodegenerative, vascular, infectious, inflammatory, neoplastic, toxic or metabolic, hydro- cephalic and psychiatric disorders.
Most cases are due to Alzheimer’s disease.
Alzheimer’s disease and related dementia affect nearly 10% of adults older than 65 years.
Considered in acquired syndrome, with multiple possible clauses, rather than a specific disease itself.
With aging population the prevalence is likely to increase.
Besides Alzheimer pathology with amyloid and tau protein deposition there is increasing evidence vascular pathologies such as stroke, subclinical infarct, and ischemic white matter changes contribute to dementia.
Alzheimer’s disease and vascular dementia are not reversible.
Differentiating Alzheimer’s disease from other causes of dementia is more easily done in the early stage of disease, as dementias in the late stage of disease have similar manifestations.
There is evidence that cerebrovascular insults may even trigger Alzheimer disease pathology.
Aries or patterns of reduce glucose metabolism are often seen in brain scans of patients with Alzheimer’s disease and other dimentias.
The risk of dementia doubles with mild hearing, triples with moderate hearing loss and is five times higher for severe hearing loss (Lin FR).
It is estimated that up to 35% of dementia cases potentially preventable hearing loss is considered the largest modifiable risk factor.
Individuals who avoid smoking, are physically active, drink alcohol in moderation, and have a healthy diet have a lower dementia risk.
Rapid progressive onset dementia occurring in a matter of weeks to months are associated with prion diseases, including sporadic Creutzfeldt-Jakob disease, acquired Creutzfeldt Jakob disease, and genetic prion disease, other neurodegenerative diseases such as frontotemporal dementia, corticobasal degeneration, progressive supranuclear palsy, dementia with Lewy bodies, atypical Alzheimer’s disease, autoimmune encephalopathy, and uncommonly vascular, infectious, neoplastic, toxic, metabolic, and psychiatric conditions.
Neuroimaging should be considered in every patient with dementia.
More than 5 million demented patients in the U.S.
Worldwide approximately 47 million people have dementia.
Estimated that the cost of healthcare in 2012, including long-term care and hospice services, for individual 65 years and older who had dementia was expected to be around $200 billion.
6th leading cause of death in the US among persons 65 years or older.
Estimated to affect 8% of adults over the age of 50 years.
In general, the prevalence rates for dementia are estimated to double every five years after the age of 65.
Global estimates are up to 7% of individuals above the age of 65 years, with a 8 to 10% prevalence in developed countries due to longer lifespans.
Prevalence in the US is 15% in people older than 68 years.
Community studies indicate that the rates of dementia increase from 30% for persons aged 85 through 89 years to 50% for persons aged 90-94 years, to 74% for those 95 years or older (Graves AB).
The incidence of dementia is decreasing throughout the developed world, but the number of individuals developing dementia annually continues to increase due to advancing age.
Decline in dementia has been ascribed to improved control of cardiovascular risk factors, better education, increased wealth, and greater use of anti-inflammatory drugs.
Stroke, advancing age, genetic profile and systemic vascular disease are major risk factors.
The oldest old, 90 years of age or older, account for half of all persons with dementia.
Most cases due to Alzheimer’s disease but other frequent causes include vascular dementia, either alone or in combination with Alzheimer’s disease (10-20%), dementia with Lewy bodies (10-15%), and frontotemporal dementia (5-15%).
Dementia due solely to cerebral ischemic in hemorrhagic injury, i.e. vascular dementia is the second most common neuropathic substrate of cognitive failure after Alzheimer’s disease.
Autopsy studies demonstrate that this problem is a convergent phenotype from three common diseases, Alzheimer’s disease, vascular brain injury, and Lewy body disease: and these diseases, variably combine to produce dementia.
Most cases arise from a combination of Alzheimer and cerebrovascular pathology, not Alczheimer changes alone.
Diminished cerebral reserve by ischemic brain injury is sufficient to substantially accelerate the symptomatic consequences of Alzheimer’s related amyloid plaques, tau neurofibrillary tangle deposits, and multiregional synaptic loss.
Traumatic brain injury is associated with an increased risk of dementia both compared with people without a history of TBI and with people with non-TBI trauma.
Alzheimer’s disease accounts for more than 70% of all cases of dementia.
The risk ratio of the association between diabetes and dementia is between 1.43 and 1.62.
The younger the age of diabetes onset the higher risk for subsequent development of dementia.
Vascular factors contribute to cognitive impairment and dementia in old age.
Risk of dementia increases after stroke, with prevalence rates ranging from 13.6 to 32% within 3 months to 1 year after stroke; and incidence rates of new onset dementia ranging from 24% within 3 years to 33.3% within 5 years.
10% of patients develop new onset dementia after a first stroke, and more than 1/3 developed dementia after recurrent stroke.
Atrial fibrillation is associated with a twofold increase in the risk of developing post stroke dementia.
Patient’s with cardiovascular risk factors and history of stroke have an increased risk of both vascular dementia and Alzheimer’s disease.
Fluctuations in cognition, and variability and cognitive test results in neurodegenerative diseases, cerebrovascular disease, and psychiatric conditions, as well as with medications alzh affecting cognition.
With cognitive decline evaluation includes a complete blood count, measurement of vitamin B-12 levels, assessment of thyroid functions.
Advanced dementia is characterized by progressive functional and cognitive impairments, with 86% of patients develop an eating problem, often leading to malnutrition, recurrent infections and hospitalizations before death.
Modifiable risk factors for all-cause dementia include hypertension, diabetes, diet, limited cognitive, physical, and social activities.
Additional preventable dementia risk factors include: head injuries, excessive alcohol consumption, and air pollution exposure.
Decreasing air pollution may slow cognitive decline.
Shortens life expectancy with estimates of median survival from the onset of symptoms varying from 5 years to 9.3 years.
Advanced dementia associated with recurrent infections, hospitalizations, eating and swallowing difficulties.
Persons with COPD are at increased risk of developing dementia.
Administering oxygen therapy to patients with COPD reduced the risk of developing dementia.
Reduced risk of dementia associated with walking and physically active lifestyles.
Risk associated with hypertension.
Sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal blood pressure are associated with increased risk for dementia (Walker K).
Higher levels of physical activity over 2 years in the Nurses’ Health Study associated with improved cognitive function.
Physical activity provided cognitive benefits in older adults with mild cognitive impairment at 6 months and persisted for at least 12 months after such activities were discontinued (Lautenschlager).
Men that walk 2 miles per day are 1.8 times less likely than sedentary men to develop dementia (Abbott).
Habitual exercise protects individuals from cognitive decline, and all cause dementias.
Aerobic exercise may be useful in slowing cognitive changes in aging.
Exercise may be useful in slowing clinical progression from mild cognitive impairment to dementia.
A Swedish study demonstrated that women who exercise vigorously in middle-age have a 65% reduction in the prevalence of dementia, and those with a low level of fitness experience at increased risk of about 35% (Horder H).
A Finish study demonstrated the use of a sauna was associated with the 66% reduction in the prevalence of dementia.
Green tea consumption in Japan demonstrated 50% reduction in elderly individuals who consume 2 cups of green tea per day.
A study from Norway evaluated participants’ CRF at two points in time to evaluate if changes in physical fitness would have an impact on cognitive outcomes and mortality: It was estimated that participants who increased their estimated CRF over time gained 2.2 dementia-free years, and 2.7 years of life when compared with those who remained unfit at the two assessments.
There is a lack of association between CRF and white matter as opposed to gray matter with CRF.
Swedish military conscript study found low fitness at age 18 years is associated with early-onset dementia.
Modifiable factors include neuropsychiatric symptom management, participation in mental activities and caregiving.
Care can delay institutionalization and reduce neuropsychiatric symptoms.
There is a protective association between seafood consumption and dementia.
Dementia patients have as many or more serious comorbidities of more medications than comparably aged individuals.
Comorbid illnesses implements progression of dementia and illnesses can accelerate functional decline.
Exacerbations of acute and chronic comorbid illnesses. Frequently associated with delirium indicating vulnerability of the demented patients ran the biologic distresses.
Patients suffering with dementia may have significant functional decline is urinary tract infections, URIs, or exposure to minimal anesthesia routine procedures.
Patients with dementia more likely to require hospitalization for UTI, pneumonia, dehydration, and drug induced delirium.
Depression in diabetics associated with increased risk of dementia.
The development of dementia is related to age, and is more likely if one is obese, diabetic, hypertensive or has a disturbed microbiome, or impaired immune system, liver, or kidney function.
Individuals with central obesity in middle-age have nearly twice the lifetime risk of developing dementia than those who do not.
Diabetes increases the risk of dementia by 70%.
At least 20% of patients with dementia develop a depressive syndrome.
Associated with atrial fibrillation.
Atrial fibrillation increases risk of dementia by 40% independent of the occurrence of clinical stroke.
Dementia associated with AF May be due to hypoperfusion, inflammation, brain atrophy, genetic factors.
Cerebral infarction, including silent stroke in AF play a central role in dementia.
Moderate to severe cognitive deficiency associated with an increase in 5-year survival equivalent to the diagnosis of cancer.
Delay in diagnosis averages 3-5 years.
Fewer than 50% of individuals receive a formal diagnosis.
Patients 70 years or older that are found to have cognitive impairment on screening tests have half the survival of similar patients with negative screening results, 41.8 versus 93.5 months, respectively.
In elderly a majority develop aggression and delusions during their illness and require antipsychotic medications.
Use of atypical antipsychotic agents in this setting of dementia associated with increase risks of stroke.
Use of antipsychotic medications is associated with a modest increase in the risk of MI among community dwelling older patients with treated dementia.
The increased risk of myocardial infarction occurs at the beginning of treatment with anti-psychotic agents in patients with elderly who have dementia.
In the elderly many conditions other than Alzheimer’s disease or vascular dementia can affect a persons memory, language in logical thinking; Some of these processes are temporary while others may be permanent.
In the elderly memory impairment considerations include degenerative diseases, medication side effects, recreational drug use, toxins, endocrine disorders, metabolic processes, depression hearing and vision loss, deficiencies of vitamin B 12, folic acid, and thiamine, alcohol misuse, normal pressure hydrocephalus, chronic infections, HIV/AIDS, brain masses, subdural hematoma, autoimmune encephalitis, and cerebral vasculitis.
Progression is highly variable, with as many as one third of cases progressing very little after five years of observation (Tshantz et al).
Following 323 nursing home residents with advanced dementia over a period of 18 months: 54.8% of the residents died, and the probability of pneumonia was 41.1%, a febrile episode 52.6% and an eating problem of 85.8% ( Mitchell).
In the Mitchell, study the six-month mortality rate for residents who had pneumonia was 46.7%, a febrile episode was 44.5% and an eating problem of 38.6%.
In the Mitchell study, 40.7% of residents had one or more hospitalizations, or emergency room visit, or feeding treatment in the last three months of their lives.
In the Mitchell study the adjusted median survival was 478 days and the probability of death within six months was 24.7%.
Advanced dementia is associated with a life expectancy similar to that of metastatic breast cancer and stage 4 congestive heart failure.
Deaths from dementia are steadily increasing.
Lower plasma β amyloid 42/40 is associated with greater cognitive decline among elderly persons without dementia over nine years, and this is associated with those with low measures of cognitive reserve (Yaffe K et al).
In a study of 3019 participants 65 years and older without dementia in the Adult Changes of Thought study with 490 for developing dementia during the course of study: the average annual admission hospital rate for those who developed dementia was 419 per thousand person-years, more than twice the rate of 200 per 1000 person-years in persons without dementia (Phelan EA etr al).
In the above study the admission rate for circulatory, genitourinary infections, neurologic, and pulmonary processes was higher for patients with dementia, with a ratio of 1.41.
With progressive cognitive and functional impairment the 86% develop eating problems that can lead to malnutrition, recurrent infections, hospitalizations and deaths.
With advanced dementia feeding tubes do not improve survival or prevent aspiration pneumonia.
Feeding tubes are not associated with prevention or healing of pressure ulcers (Teno JM et al).
Evidence suggests that the physical and mental activity can improve cognitive function in the short-term and may lower the risk of developing dementia over the long term.
Older adults engaged in mental physical activity are less likely to experience cognitive decline or develop dementia.
Mental activity interventions in healthy adults and in individuals with mild cognitive impairment benefit in domain specific improvements, which benefits the specific cognitive activities with little evidence of generalization to other activities or domains.
Exercise interventions in healthy older adults and individuals with mild cognitive impairment with aerobic exercise and resistance training have small to moderate improvements in cognitive function particularly in measures of attention, speed of processing and executive function.
The Mental Activity and eXercise (MAX) trial studied 126 inactive community residing older adults with cognitive impairment and participants engaged in home-based mental activities plus class based physical activities for 12 weeks and were randomized to either mental activity intervention or mental activity control plus exercising intervention or exercise control: There was significant improvement in global cognitive functions with no evidence of difference between intervention and active control groups suggesting that the amount of activity is more important than the type of activities in this population (Barnes DE et al).
Young onset dementia is defined as that type of dementia occurring before age 65 years.
Because of the young age of those effective with young onset dementia it is associated with severe consequences relating to employment, social life and roles as parents and as guardians.
There are nine independent risk factors for young onset dementia and include: alcohol and other drug intoxications, stroke, hypertension, low overall cognitive function, low height, dementia in father, depression, and use of neuroleptics (Nordstrom P et al).
Management goals including reducing suffering caused by the cognitive decline and accompanying symptoms such as mood and behavior changes, while delaying progressive cognitive decline.
Non-pharmacological approaches to dementia include:
Cognitively stimulating activities
Physical exercise
Social interactions with others
Healthy diet
Adequate sleep
Proper personal hygiene
Physical exercise may positively affect cognitive and physical function, however randomized trials show no effect of exercise on cognition.
Sleep training may reduce nighttime awakenings and depressive symptoms.
Social activities may be beneficial.
Eating a brain healthy diet of nuts, berries, leafy greens, and fish, or a Mediterranean diet is recommended.
The Nurse Health Study revealed the women who consume blueberries or strawberries twice a week at a substantial reduction in cognitive decline compared to women who did not consume berries.
In the Copenhagen heart study the risk of dementia in wine drinkers was reduced by about 50% in both genders.
Combining diet, exercise, and cognitive training may improve cognition in people at risk for cognitive decline.
Caregiver education they improve outcomes for patients with dementia.
Safety measures controlling medication intake, limiting access to firearms and other weapons, and monitoring for elder abuse.