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DEMENTIA
EPIDEMIOLOGY, ECONOMIC-IMPACT AND CLINICAL’S ASPECT
Rusdi Lamsudin
Department of Neurology Faculty of Medicine
Indonesian Islamic UniversityYogyakarta, INDONESIA
Overview
Epidemiology Economic Impacts Definition Clinical presentation Diagnosis Differential Diagnosis Etiology Workup Non-pharmacologic Treatments Drug Treatments Terminal Care
EPIDEMIOLOGY
Epidemiology
Dementia affects 17–25 million people worldwide Estimated 4 million in the US and an estimated
800,000 people in the UK [Ritchie, 1995; Keefover, 1996].
It affects predominantly elderly people, The prevalence of dementia in people over the age of 65 is 5% and in people over 80, it is 20%.
It has been estimated that 26% of women and 21% of men over the age of 85 have some form of dementia, of whom approximately 50% have Alzheimer’s disease (AD) [Melzer, 1997].
Epidemiology
In case of AD:- Age specific prevalence rates almost double
with every additional 5 years of age from 1% of 65, rising to about 8-10% at age 80 and 30-40%at age 90
- African-Americans and Hispanics may have a higher risk than Caucasians-Americans. It also occurs less frequently in Asians than Americans
Growth of numbers of people with dementia
The World Alzheimer Report (2009) estimated:
35.6 million people living with dementia worldwide in 2010
Increasing to 65.7 million by 2030
115.4 million by 2050
Economic Impact
Worldwide cost of dementia
The societal cost of dementia is already enormous.
Dementia is already significantly affecting every health and social care system in the world.
The economic impact on families is insufficiently appreciated.
The total estimated worldwide costs of dementia are US$604 billion in 2010.
These costs are around 1% of the world’s GDP
0.24% in low income1.24% in high income
Worldwide costs of dementia
The World Alzheimer Report (2010) estimated that:
If dementia care were a country, it would be the world’s 18th largest economy
Definition
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Definition
a syndrome characterized by progressive decline of intellectual ability from a previously attained level
the decline in mental inability usually involves variable deterioration in
- speech - memory- judgment - mood
without alteration of consciousness
Definition Multiple Cognitive Deficits:
Memory dysfunction especially new learning, a prominent early
symptom At least one additional cognitive deficit
aphasia, apraxia, agnosia, or executive dysfunction
Cognitive Disturbances: Sufficiently severe to cause impairment of
occupational or social functioning and Must represent a decline from a previous level of
functioning
Clinical Presentation
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Clinical Presentation
onset of dementia it is usually insidious
dementia is often progressive (degenerative disease) but may be static (post-traumatic brain injury)
initial presentation may include slight forgetfulness, attention and concentration deficits, and increasing repetitiousness or inconsistencies in usual behavior
later presentation may display impaired judgment, inability to abstract or generalized, and personality change with rigidity, perseveration, irritability, and confusion; affective disturbances may be prominent with loss of personality and self-care
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Impairment of 2 or more cognitive domain
Memory loss
Language
Abstract thinking & Judgment
Praxis (learned motor behavior)
Spatial processing
32
1
4
7 Social conduct
Personality65
Risk Factors for Dementia
Gender: male Age: 60-70 years Prior stroke Hardening of the
arteries Heart disease High blood
pressure Diabetes
• Cholesterol problems
• Atrial fibrillation• Smoking• Education• Race• Family history
(CADASIL-cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy )
17
Most common causes of dementia
• Alzheimer’s disease• Vascular dementia• Lewy body dementia• Frontotemporal dementia
18
Established risk factors for dementia
• Age• Female sex• Head trauma• Low level of education
19
• Coronary artery disease
• High dietary saturated
fat and cholesterol• Serum cholesterol• Hyperhomocysteine
mia
• Smoking• Diabetes
mellitus• Hypertension• Apolipoprotein
E status
All these are vascular risk factors!
Risk factors for dementia
Diagnosis and Diffeerential Diagnosis
Differential Diagnosis:TopTen (commonly used mnemonic device: AVDEMENTIA)
1. Alzheimer Disease (pure ~40%, + mixed~70%)
2. Vascular Disease, MID (5-20%)3. Drugs, Depression, Delirium
4. Ethanol (5-15%)5. Medical / Metabolic Systems
6. Endocrine (thyroid, diabetes), Ears, Eyes, Environ.
7. Neurologic (other primary degenerations, etc.)
8. Tumor, Toxin, Trauma9. Infection, Idiopathic, Immunologic10. Amnesia, Autoimmune, Apnea, AAMI
Comparison of the Clinical Features
Dementia Depression Delirium
Insidious/slow and often unrecognized; depends on cause
Coincides with major life changes; often abrupt, but can be
gradual
Sudden/abrupt; depends on cause; often at twilight or in
darkness
Clinical Features: ONSET
COURSE, PROGRESSION, ATTENTION, MEMORY, THINKING
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Neurologic Diseases Associated with Intellectual DysfunctionDISEASE PHYSICAL SIGNS CLINICAL FEATURES
Creutzfeldt-Jakob Myoclonus , cerebellar signs, Subacute course; EEG has specific abnormalities,
eye movement abnormalities brain biopsy diagnostic
Huntington's disease Choreiform movements, Often positive family history; caudate atrophy
corticospinal signs by CT or MRI
Multiple sclerosis Brainstem signs, optic atrophy, Usually long-standing disease; episodic illness
corticospinal signs with remissions; often extensive white matter
abnormalities by MRI
Wilson's disease Extrapyramidal signs , hepatic Onset in adolescence or young adult life, dysfunction, Kayser-Fleischer psychiatric disordersrings
Progressive Failure of vertical downgaze, Eye movement abnormalities; differentiate fromsupranuclear extrapyramidal signs Parkinson's disease; unresponsive or onlypalsy transiently responsive to levodopa
* = invariably present; all other physical signs are neither invariably present nor pathognomonic.
Etiologic Diagnosis of Progressive Dementias in Adults Neurodegenerative
Diseases Alzheimer’s disease Parkinson’s disease Diffuse Lewy body disease Progressive supranuclear palsy Multisystem atrophy Huntington’s disease Frontotemporal dementias – e.g. Pick’s disease
Structural Disease or Trauma Normal pressure hydrocephalus Neoplasms Dementia pugilistica
Vascular Disease Vascular dementia Vasculitis
Heredometabolic Disease Wilson’s disease Other late-onset lysosomal storage diseases
Etiology contd.
Demyelinating or Dysmyelinating Disease Multiple sclerosis
Infectious Disease Human immunodeficiency virus, type 1 Tertiary syphilis Creutzfeldt-Jakob disease Progressive multifocal leukoencephalopathy Whipple’s disease Chronic meningitis – e.g. Cryptococcal
Etiology contd.
Acute brain dysfunction characterized by: Global symptoms (affecting both cerebral
hemispheres) including impairment of consciousness and attention
Primary physiological changes with potential for reversibility
‘waxing and waning’ symptoms – usually worse in evening
Life-threatening conditions underlying the syndrome
DELIRIUM
Symptoms of Delirium
Common symptoms of a delirium include: Waxing and waning levels of
consciousness Poor attention and disorientation Disturbed memory (long and short term) Psychosis Sleep dysregulation Fearfulness with agitation and
aggression Seriously impaired insight and judgment
Epidemiology of DeliriumEpidemiology of Delirium
Very Common - 10-15% med/surg inpatients (30%+ if elderly)
30% of Adult Burn Patients 80%of delirious patients have pre-
existing dementia Predisposing Factors:
old age, postcardiotomy, s/p burns prexisting brain damage drug withdrawal states AIDS
Causes of Delirium
Often multifactorial Infections, trauma, brain diseases Cardiac diseases, lung disease,
hypoxia, hypoglycemia Toxins, or intoxications Medication effects Substance withdrawals (e.g. DTs) Endocrinopathies In elderly dementia patients: UTI,
dehydration and pneumonia are the most common causes
DELIRIUM - TREATMENTDELIRIUM - TREATMENT
• Must look for medical cause(s) and treat• Symptoms can be helped by
antipsychotic drugs such as haldoperidol or risperidone (especially psychosis, agitation)
• Consider anticholinesterases for anticholinergic delirium
• Comfort measures include reorientation strategies, reducing stimulation, frequent reassurance
General rules of thumb: Delirium Dementia
acute chronic
reversible irreversible
physiological structural
primary attention primary memory
deficits deficits
Delirium and dementia can coexist; in fact delirium is very common in demented patients
Delirium vs Dementia(summary)
Work-up
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Workup
History Physical Examination Laboratory studies
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History - etiology
the most important component of the initial evaluation
adequate history with help of a family member is critical description of
cognitive, memory, and behavior problems effect on daily life - difficulty with driving, work, or family
relationships details on temporal course of illness
chronic progressive (Alzheimer or other neurodegenerative
disease) stepwise (multi-infarct) static (traumatic injury, episode of severe hypotension)
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History - treatable causes Vascular dementia - presence of cardiovascular risk
factors (smoking, HTN, chol, diabetes) Normal pressures hydrocephalus - triad of dementia,
gait, incontinence with a prior history of meningitis or subarachnoid hemorrhage
Mass lesion - history of head trauma, unexplained focal neurologic deficit, unilateral headache worsening over time
Parkinson’s disease - resting tremor and rigidity Wilson’s disease - hepatocellular disease and dementia HIV and neurosyphilis - high-risk sexual behavior hereditary - family history dementia, Down’s syndrome,
psychiatric disorders
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History - treatable causes B12 deficiency - previous gastric surgery
B12, thiamin, niacin deficiency - inadequate nutrition, alcohol abuse
medications - opiates, sedative-hypnotics, analgesics, anticholinergics, anticonvulsants, corticosteroids, centrally acting anti-hypertensives, psychotropics
symptoms of hypothyroidism, pituitary insufficiency occupational history - exposure to toxic substances
(aniline dyes, heavy metals)
Diagnostic Criteria For Dementia Of The Alzheimer Type (DSM-IV, APA, 1994)
A. Multiple Cognitive Deficits1. Memory Impairment 2. Other Cognitive Impairment
B. Deficits Impair Social/Occupational
C. Course Shows Gradual Onset And Decline
D. Deficits Are Not Due to:1. Other CNS Conditions2. Substance Induced Conditions
E. Do Not Occur Exclusively during Delirium
F. Not Due to Another Psychiatric Disorder
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Mental Status Examination
Examination should be geared to both the detection of focal lesions and to signs of general brain dysfunction immediate memory testing (three object recall, recite
digits forward and backward, recall a short story) remote memory testing (recall of historical events,
family milestones, or recent local or international news)
reproducible drawings discern similarities among objects decision-requiring tasks (finding a stamped letter or
seeing a fire in a theater)
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Mini-Mental Status Tests
Score
Recall:
3 Ask for 3 objects repeated above. Give one point for each. Language:
2 Name a pencil and watch (2 points).
1 Repeat the following: "No ifs ands or buts."
3 Follow a 3-stage command: "Take a paper in your right hand:
fold it in half, and put it on the floor." (3 points).
1 Read and obey the following: "Close your eyes."
1 Write a sentence.
1 Copy design.
Total Score: [ ] Maximum Score: 30
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Physical and Neurologic Examinations Check for focal evidence of neovascular risk
factors - carotid bruits, signs of alcoholism, hepatocellular injury, renal insufficiency, other systemic illnesses
specific neurologic abnormalities frontal lobe release signs (grasp, suck, snout, root) visual field cut and extraocular movement limitations abnormal pupillary reactions extrapyramidal features (carditis dyskinesis, tumors,
asterixis, Korea, monoclonal disc, it) sensory deficit and gait disorder
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Screening Laboratory Studies
1. Complete blood count and sedimentation rate 2. Chemistry panel (electrolytes, calcium, albumin,
BUN, creatinine, transaminase) 3. Thyroid-stimulating hormone (TSH) 4. VDRL test for syphilis 5. Urinalysis 6. Serum B12 and folate levels
7. Chest x-ray 8. Electrocardiogram 9. Head computed tomography (CT)
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Neuroimaging
Head CT or MRI is appropriate in the presence of1) history suggestive of a mass lesion2) focal neurologic signs or symptoms3) dementia of abrupt onset4) history of seizures5) history of stroke
MRI with gadolinium contrast enhancement is superior to CT for the diagnosis of multi-infarct dementia and problems referrable to the posterior fossa
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Other Ancillary Studies
Lumbar puncture routine LP for initial evaluation of dementia
is not justified may be indicated when other clinical
findings suggest an active infection or vasculitis and as part of the evaluation of normal pressure hydrocephalus
sugar, protein, cell count, cultures, gamma globulins, the serology for stiffness should be obtained
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Other Ancillary Studies
Electroencephalogram (EEG) usually normal or with nonspecific rhythm slowing indicated in patients with episodic altered
consciousness and in whom seizures may be suspected
may occasionally raise suspicion of a particular etiology: focal, delta slowing is seen with tumor unilateral attenuation of voltage may suggest an
extracranial mass such as subdural hematoma excessive beta activity may be consistent with drug
ingestion Creutzfeldt-Jakob disease has a highly specific EEG pattern
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Other Ancillary Studies
Formal neuropsychologic evaluation appropriate for more specific information when the
diagnosis is in doubt also helpful in providing additional information about
the nature of impairment following focal brain injury
Speech analysis may improve patient and family communication with
therapy
Formal psychiatric assessment may be desirable if depression in addition to
dementia is suspected
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Studies of Limited or Uncertain Utility Cerebral blood flow and metabolism measurements
PET and SPECT scans have no routine use at present
Brain biopsy rarely justified for non-neoplastic or noninfectious diseases Progressive multifocal leukoencephalopathy or Creutzfeldt-
Jakob disease is diagnosed by biopsy
Noninvasive neurovascular studies (carotid ultrasound, Doppler flow studies) if MRI or CT demonstrates infarction, or clinical course or physical examinations is suggestive of
cerebralvascular disease
Treatment
General Treatment Principles For Dementia Treatment Of Underlying
Disease Process (Primary Treatment)
Management Of Behaviors and Symptoms (Secondary Treatment)
Caregiver Support and Education
Primary Treatment Strategies(for progressive dementias)
Primary Treatment Strategies(for progressive dementias) 1. Prevention Identify risks and mitigate Develop neuroprotective strategies for those at risk
2. Slow or halt progression of illness Understanding pathophysiology leads to treatment ideas 5 year delay in onset ---> 1/3 decrease in prevalence Delaying institutionalization by 1 month saves $1.2 billion/yr
3. Reverse symptoms Compensate through augmentation of remaining neurons or
other systems Reversal of destructive processes & regeneration of tissue
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Symptomatic Management and Counseling
Improving mental functioning
Management of confusion and agitation
Maintaining the patient at home
Risk factor reduction and attention to underlying etiologies
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Improving Mental Functioning
no established treatment for Alzheimer’s disease or for patients with multi-infarct dementia
findings of degeneration of cholinergic neurons and depletion of choline-acetyl transferase in Alzheimer's disease have led to attempts at improving cholinergic transmission lecithin supplements (dietary choline repletion) tacrine (a centrally active, reversible cholinesterase
inhibitor) There is no evidence to support the use of: restorative
therapy with nerve growth factor, protective therapy with antioxidants, preventive therapy with drugs that inhibit beta amyloid formation, and “cerebral vasodilators” (papaverine, dihydroergotoxine) to improve memory
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Management of Confusion and Agitation The chronic use of sedatives and psychoactive
agents in the confused patient should be avoided unless persistent extreme agitation hampers care
The lowest possible doses should be used and for the shortest time possible thioridazine (10 to 25 mg qhs) haloperidol (0.5 to 1 mg bid or tid )
often a first choice in the setting of delusions and hallucinations; must be careful to avoid long-term use because of the risk of inducing tardive dyskinesia
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Management of Confusion and Agitation Avoid regular use of sedative/hypnotic agents
for sleep Beta-blocking agents and anticholinergics may
exacerbate confusion Patients with depression may improve with a
tricyclic compound with low anticholinergic side effects
- desipramine (25 to 50 mg qhs) A recent study of nursing home patients
demonstrated substantial improvement in many patients when chronically prescribed psychotropic drugs were discontinued or reduced in dose
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Maintaining the Patient at Home
An important task is helping the family maintain and care for the patient at home
The goal is to sustain the highest level of function possible: facilitate and promote an orderly home situation regular routine use of calendars, television,
newspapers, and other means of orientation limit the use of potentially dangerous appliances provide convenient toilet facilities advice against driving when early impairment of
judgment and spatial concepts is present
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Maintaining the Patient at Home
Families can often find help in local support groups, day care and group therapy services, and social service agencies
When care at home begins to exhaust and strain the family, sensitive counseling can do much to help a family cope with the difficult decision regarding institutionalization
some dementing diseases are infectious (eg, HIV infection) and that the bodily fluids and tissues of such patients require special handling to avoid transmission. It is particularly important to emphasize when home care is rendered by lay persons
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Risk factor reduction and attention to underlying etiologies
Central to an effective outcome :
control of cerebrovascular risk factors as hypertension, diabetes mellitus, smoking , hyperlipidemia , and coronary artery disease
endarterectory deserves consideration when a vascular etiology is strongly suspected and a significant stenosis is found
Avoidance of toxins, correction of vitamin deficiencies, discontinuation of causative drugs, initiation of hormonal replacement therapy in cases of deficiency, and treatment of underlying infectious etiologies
• Who are the AD Caregivers? (slide 37)
• Demands of Caregiving (slide 38)
• Technology and Caregiving (slide 39)
• National Support for Caregivers (slide 40)
• How to Contact the ADEAR Center (slide 41)
Improving Support for Families and Other Caregivers
Slide 36
Demands of Caregiving
AD takes a huge physical and emotional toll. Caregivers must deal with changes in a loved one’s personality and provide constant attention for years. Thus, caregivers are especially vulnerable to physical and emotional stress.• Peer support programs can
help link caregivers with trained volunteers. Other support programs can offer services geared to caregivers dealing with different stages of AD.
Support for Caregivers
Slide 38
Treatment of AD…
Tacrine
Cholinesterase inhibitor 1 systematic review with 5 RCTs,
1434 people, 1-39 weeks No difference in overall clinical
improvement Some clinically insignificant
improvement in cognition Significant risk of LFT
abnormalities: NOT USED
Donepezil
Aricept Cholinesterse inhibitor Easy titration (start 5/day, then
10) Side effects: GI (nausea,
diarrhea) Can be associated with
bradycardia… Main effect seems to be
lessening of rate of decline, delayed time to needing nursing home/more intensive care
Other agents…
Rivastigmine Galantamine Cholinesterase inhibitors ?more side effects, more titration
required Future directions:
Prevention of delirium in at risk patients (cholinergic theory of delirium)
Behavioral effects in those with severe dementia?
Treatment of Lewy Body dementia Treatment of mixed Vascular/AD
dementia
Comments about cholinesterase inhibitor studies…
Highly selected patients (mild-moderate dementia)
?QOL improvements… Not known: severe dementia and
mild CI
Memantine
NEJM april 2003 Moderate to severe AD (MMSE 3-
14) N-methyl D aspartate (NMDA)
receptor antagonist; theory that overstimulation of NMDA receptor by glutamate leads to progressive neurodegenerative damage
28 week, double blinded, placebo controlled study; 126 in each group; 67% female, mean age 76, mean MMSE 7.9
Memantine…
Found less decline in ADL scores, less decline in MMSE (-.5 instead of –1.2)
Problem: significant drop outs (overall 28% dropout rate) in both groups; data analyzed did not account for drop outs, followed those “at risk”
Selegiline
Unclear benefit Less than 10mg day, selective
MAO B inhibitor Small studies, not very
conclusive
Vitamin E (alpha tocopherol)
NEJM 1997: selegiline, vit E, both , placebo for tx of AD
Double blind, placebo controlled, RCT with mod AD; 341 patients
Primary outcome: time to death, institutionalization, loss of ADLS, severe dementia
Baseline MMSE higher in placebo group No difference in Primary outcomes;
adjusted for MMSE differences at baseline and found delay in time to NH from 670 days with vit E to 440 days with placebo
Ginkgo Biloba
1 systematic review of 9 double blind RCTs with AD, vascular, or mixed dementia
Heterogeneity, short durations High withdrawal rates; best
studies have shown no sig change in clinician’s global impression scores
Other treatments
NO good evidence to support estrogens or NSAIDS
Other treatments…
Behavioral/agitation: Nonpharmacologic strategies Reasons for NH placement:
Agitation Incontinence Falls Caregiver stress
?Antipsychotics
NO data to support any significant benefit for treating behavioral symptoms of dementia with antipsychotic agents
Small group of patients with active psychoses, disturbing hallucinations, or aggressive behaviors who may have some benefit
Antipsychotics:
Side Effects: Sedation Anticholinergic effects Prolonged QT Edema Orthostasis Weight gain Confusion
Warnings: FDA black box warning for increased
mortality (OR 1.5- 1.7), and increased ?increased stroke risk
Prevention?
HTN and DM linked to future development of ALL types of dementia (not just vascular)…
Large initial studies of treating systolic hypertension in the elderly (SHEPS and others) demonstrated decreased risk of development of cognitive impairment over time in those patients in the original treatment group!
Decreased risk included vascular AND alzheimer type
dementias…
Cholinesterase inhibitors seem to work as well (or as poorly) for both vascular and alzheimer type of dementias…
What is the link? Both common in elderly, may be that one “unmasks” the other…
Conclusion International studies make it clear that dementia
occurs in every country of the world. Dementia affects 1 in 20 people over the age of 65 and 1 in 5 over age of 80
Worldwide there are an estimated 35.6 million people with dementia. By 2050 the number will rise to over 115 million. For at least the last 15 years, the majority of people with dementia worldwide have been living in developing regions of the world. They account already for over 60% of all cases. By 2040 this portion will have risen to 71%.
Conclusion cont’
The worldwide cost of dementia will exceed 1 per cent of global GDP in 2010, at US$604 billion. If dementia care a country, it would be the world’s 18th largest economy
The costs of caring for people with dementia are likely to rise even faster than the prevalence-especially in the developing world, as more formal social care systems emerge, and rising incomes lead to higher opportunity costs.
Conclusion cont’
Dementia is a progressive, degenerative brain syndrome that affects memory, thinking, behavior and emotion
The progressive syndrome of dementia is define as loss of memory plus impairment in at least one other cognitive function, such as aphasia, apraxia, agnosia and disturbance in executive function, which is severe enough to interfere with activities of daily living and represent decline (DSM-IV, 1994
Conclusion cont’
Dementia presents with variety of clinical manifestations regardless of aetiology, and in most cases it caused by organic barain disease. It characterized by three main symptomatic domains as; 1) activities-inability to perform activities of daily life, 2) behaviours-psychiatric symtoms/behavioural disturbances and 3) cognition-neuropsychological impairment
Conclusion cont’
There are four main types of dementia: 1) Alzheimer’s disease (60% of cases), 2) Vascular dementia (30-40%; including about 20% where dual pathology exists), 3) Dementia with Lewy bodies (15% of cases), and 4) Fronto-temporal dementia (5% of cases).
Conclusion cont’
The treatments options for dementia include both pharmacological and nonpharmacological therapeutic approaches. These can be further subdivided into therapies for cognitive impairment and neuropsychiatric disturbances (psychiatric symptoms and behavioural disturbances).
Conclusion cont’
The quality of life patients with dementia is paramount and long-term care of the patient requires continued education and communication with clinicians, primary carers, care staff and family members.