Dementia- Evaluation, Treatment

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Last week, I discussed the seven stages of dementia. Dementia is a term used to describe a decline in mental abilities including memory, language, and logical thinking that is severe enough to affect daily living. When these symptoms appear in older people, concern about Alzheimer’s disease is common. Alzheimer’s disease is a neurodegenerative dementia, meaning that there is a loss of brain tissue that is not reversible. Another irreversible cause of dementia is vascular dementia, in which poor blood flow to the brain causes the death of brain cells. Vascular dementia and Alzheimer’s disease may occur together.

There are many other conditions that can affect a person’s memory, language, and logical thinking. Some of these conditions may be temporary or reversible. Delirium is one condition that may cause symptoms similar to dementia. Delirium may be caused by the side effects of medication, recreational drug and alcohol use, toxins, endocrine disorders such as severe hypothyroidism (myxedema), metabolic disorders like hyponatremia (low serum sodium). Other causes of delirium include depression, sleep disturbances, hearing and vision loss, deficiencies in nutrients such as vitamin B12, folic acid, and thiamine (pernicious anemia causes low B12 levels, and chronic alcoholism may cause low levels of folic acid and thiamine), normal pressure hydrocephalus (excessive brain fluid), chronic infections like neurosyphilis or HIV/AIDS, brain tumors, subdural hematomas (blood clot in the brain, often following head trauma), autoimmune encephalitis (brain inflammation), and cerebral vasculitis (inflammation of the brain’s blood vessels).

When evaluating a patient for memory loss, it is important to determine when the symptoms first started, how severe they are, and how they affect the patient’s everyday activities. Often, with the patient’s permission of course, family members and friends may be helpful in obtaining this information. Medication use should be documented, and a screening test for depression may be appropriate, as may be oral and/or written tests to evaluate the patient’s cognitive function. Laboratory tests and brain imaging are usually part of the evaluation, which may also include vision and hearing screening, neuropsychiatric testing, or a psychological assessment.

Treatment options for dementia depend on its cause. For example, depression can be treated with antidepressants, B12 levels can be corrected, as can low folic acid and thiamine levels. Alcohol use should be curtailed, thyroid hormone replacement can be given, and vision and hearing can be improved. Although it should never be assumed that an older person with memory loss has Alzheimer’s disease or another irreversible neurodegenerative dementia without considering reversible causes of dementia, unfortunately all to often irreversible dementia is the diagnosis. However, the progress of irreversible dementia can be slowed down. Cholinesterase inhibitors (Aricept, Exelon, Razadyne), which increase levels of chemical messengers in the brain, may be helpful, as may glutamate (Namenda), which raises levels of other brain messengers. Occupational therapy can help with coping behaviors and making the home safer. Modifying the home environment, for example reducing clutter and trip hazards and hiding knives and car keys, is also helpful. Monitoring systems to detect wandering are available. Lastly, keeping a light on in the bedroom prevents sundowning, which is worsening of disorientation due to darkness.

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By Peter Galvin, MD

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