Dementia
Dementia refers to a group of disorders characterized by progressive deterioration of mental capacity,
specifically in forming new memories. (dementia classification tables) Many affected individuals eventually
develop behavioral disturbances and lose the ability to care for themselves.
Alzheimer's disease (AD) accounts for up to 80 percent of all cases of dementia, affecting up to 4 million
Americans today. Other common forms of dementia include vascular dementia, HIV dementia, Parkinson’s
disease and Huntington’s disease. Diagnosis is based mostly on typical history in a patient at risk, poor
performance on cognitive testing, lack of abnormal findings on neurological and laboratory examinations. A
definitive diagnosis can only be made on autopsy where abnormal protein deposits can be demonstrated.
Who’s at Risk?
Age over 60- 10% of all over 65 and 50% of all those over 85 years of age
Heredity, especially with close relatives with dementia onset prior to age 60
Hypertension and high cholesterol
Previous brain injury
Low education level
History of depression
Environmental heavy metal exposure (Aluminum)
Typical Early Findings
According to the National Institute on Aging, losing the ability to balance a checkbook, relying on others to make
decisions, and repeating questions or stories over and over are three of the major warning signs of Alzheimer’s
disease.
Dangers
Driving- Patients with Alzheimer’s diagnosis, regardless of stage, are at increased risk for driving accidents and
driving performance errors. The patient should not drive an automobile unless an on-road evaluation of driving
ability conducted by the state driver's licensing authority deems it appropriate.
Cooking- Fire hazard because demented patients tend to forget they have started cooking a meal.
Falls- Patients are at increased risk for fall due to lack of safety awareness.
Wandering- demented patients tend to forget where they are and sometimes revert back to childhood and
youth and visit their old neighborhoods and hometowns.
Aggression- demented patients may exhibit aggressive behavior most commonly towards their caretakers.
Sun-downing- all patients with dementia regardless of the type are prone to having nightly exacerbation of
symptoms called sun-downing. This is believed to be due to decrease in sensory stimulation and cues that
normally keep them stimulated and ware of their whereabouts.
Hospital psychosis- This occurs commonly with patients who are hospitalized or who otherwise spend time in
unfamiliar settings. It is easier to lose orientation and become confused in new and intimidating environments
stimulating aggressive or inappropriate behavior. Decompensation during a hospitalization is a clear risk factor
for development of future dementia and may be an early sign of sub-clinical disease.
Depression- Some forms of dementia are “insight preserving”. Namely the patient is periodically aware of their
progressive cognitive loss. Alzheimer’s is not an insight preserving dementia. However, in any kind of dementia
depression can be a complicating factor. Furthermore, in any condition associated with loss of cognitive ability
depression must be considered and ruled out as it can cause significant mental slowing and mimic dementia.
Prevention
No clearly advantageous intervention has been identified that can prevent progression of dementia. A regimen
of low dose anti-inflammatory agents (motrin 200 mg once a day) plus vitamin E 400 IU daily is benign and is
being recommended by some clinician.
Treatment
Treatment and slowing the progress of dementia is difficult, expensive and often unrewarding. Gauging the
effectiveness of therapy is difficult and often tainted by caretakers’ desire to see a response. Available
medications include:
Medication $/month
Aricept
(donepezil) 128
Exelon (Rivastigmine) 137
Reminyl (Galantamine) 139
Cognex
(Tacrine) 155
Namenda
(Memantine) 130
The most reasonable course of therapy for any stage of Alzheimer’s for patients and families that desire a drug
trial is to begin therapy and assess its effectiveness in 6-12 weeks. Because there are no concrete criteria
about measuring response assessment and decision making about continuation of drug therapy is difficult.
Drugs in general do not improve or reverse the disease but only slow the progression. In our experience
patients who have been stable on these medications for some time deteriorate quickly upon cessation of
medical therapy.
Medications for Behavioral Problems
The most effective therapies for controlling behavioral manifestations of Alzheimer’s include the use of anti-
convulsant, sedating and anti-psychotic medications for relieving symptoms of agitation and aggression. There
is no report or indication that any of these medications will curtail the wandering, spontaneous vocalization, or
apathy associated with advanced stages of Alzheimer’s or otherwise hinder disease progression. These
medications are no more than band-aids on a problem that is best dealt with by providing a supportive
environment designed to minimize confusion and polypharmacy.
Medication $/month
Haldol
(Haloperodiol) 8
Tegretol
(Carbamazepine) 12
Risperidone 200
Alternative Treatments
Alternative means for controlling the progression or the symptoms of Alzheimer’s are in use by various
practitioners and institutions that specialize in treating patients with dementia. They include Vitamin E, Ginko
Biloba, music therapy, anti-inflammatory agents such as aspirin and advil, hormones such as estrogen and
progesterone, music therapy, reorientation therapy, validation therapy. Several recent trials have demonstrated
benefit in using cholesterol lowering medications in patinets with Alzheimer's. Animal studies have revealed
some regression of brain cells abnormalities (neurofibrillary tangles) in brains of animals with Alzheimer's after
treatment with cholesterol lowering drugs.
Probably the most important aspect of caring for someone with dementia is their home environment. Not all
facilities are appropriate for dementia care. Staying home is not always the best option. Many patients with
dementia are unsafe at home and the desire to keep them at home places undue stress upon the families as
well as the exposing the patients to unnecessary risks, misery and loneliness. Patients with dementia require
appropriate, specialized care in familiar, safe, non-threatening settings. They require caretakers with experience
treating patients with dementia and social setting with supervised activities and appropriate stimulation. Visual
cues in the environment such as colorful plates, respect for their independence and attention to their specific
likes and dislikes are all parts of what makes a successful environment for allowing patients with dementia to
flourish. Sydney Creek is the premier choice of such a facility in San Luis Obispo County.
Consultation by Specialists (Neurologist or Psychiatrist)
In general dementia is diagnosed and treated by primary care providers. Sub-specialty evaluation,
neuropsychiatric testing and treatment of dementia is indicated based on the following:
Cognitive loss is early-onset (before the age of 60)
Strong Family history
Diagnosis is complex or remains unclear after basic work-up
Primary care provider can not rule out depression, substance use or systemic disease as the main cause of
cognitive changes
Movement disorders suggest atypical dementia such as Huntington’s or Parkinson’s
