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dementia is an umbrella term that
describes a progressive
neurodegenerative disease characterized
by cognitive decline causing an
impairment in Daily functioning under
this umbrella we have multiple subtypes
including Alzheimer's vascular dementia
dementia with louisi bodies and frontal
temporal dementia neurod degeneration
means that cells in the nervous system
stop working and eventually die this
happens naturally as we age but in
dementia there are abnormal changes that
increase how many cells are lost this
loss of neurons and their connections
results in the symptoms described as
cognitive decline which is quite a
general term it means an impairment in
one of memory executive function
language attention or Vis spatial
functions like recognizing faces or
environments since dementia is
Progressive these can be seen to be
getting worse over time in the earliest
stage called the pre-dementia stage
there can be subtle symptoms such as
anosmia which is the loss of sense of
smell this can occur as far back as 10
years before the first clinical signs of
dementia there can be mild cognitive imp
impairment but it does not impair daily
functioning which is a defining feature
of dementia examples could be some
difficulty in finding occasional words
or some
forgetfulness once the symptoms are
profound enough to cause impairment in
Daily function it is called early stage
dementia here symptoms are apparent to
other people such as forgetting to take
medication misplacing objects difficulty
in accomplishing tasks around the house
managing finances as well as planning and
and
organizing in the middle stage people
tend to lose the ability to acquire new
information particularly in Alzheimer's
it's also here that they begin to
require assistance with personal care
and hygiene and there can be more
behavioral disturbances like
restlessness aggression and
repetitiveness they may also demonstrate
a lack of insight into their condition
and problems with orientation also
become more
apparent in the latest stages people
will believe that they are in a
different time commonly an earlier time
in their life this is called time
shifting and patients may ask for people
who are no longer alive the ability to
speak may be lost regressing only to a
few words depression and anxiety become
more common in the later stages and
hallucinations also to become more
prominent restlessness is very common at
this stage and aggression may be more
present as it is more difficult for
patients to express their needs dangers
like hot stoves May no longer be
recognized and faces or places also no
longer recognized there can also be
physical difficulties walking becomes
more difficult leading to more time in
chairs or in a bed which predisposes to
Venus thrombo embolism nutrition is
challenging as swallowing difficulties
often develop which can result in
aspiration and ultimately pneumonia the
duration of the timeline varies but
tends to be roughly 2 years in each
stage once functionally
impaired the most common subtype of
dementia is Alzheimer's disease which
makes up around 70% of cases worldwide
as with most subtypes Alzheimer's is the
result of accumulation of ins soluble
proteins in the brain there are two in
particular involved in Alzheimer's the
first is beta ameloid which forms
extracellular plaqu also known as
extracellular scile pla the second is
hyper phosphorated TOA protein which
accumulates inside neurons to form neuro fibrillary
fibrillary
Tangles beta ameloid comes from the
breakdown of a normal transmembrane
protein called ameloid precursor protein
protein it is cleaved by alpha beta and
gamma secretes and is normally broken
down but if the beta secretas acts first
and is Then followed by gamma secretas
this generates beta ameloid and leads to
the formation of the plaques these
proteins lead to dysfunction and death
of the neurons they are found in normal
brains however in Alzheimer's there is a
significantly higher quantity and
they're found in more particular
locations specifically the hippocampus
parietal and temporal lobes although
dementia symptoms can generally be
similar the subtypes can have slightly different
different
presentations Alzheimer's often presents
with short-term memory loss and
difficulty finding words Visos spatial
impairment is also fairly common for
example getting lost and problems with
Insight meaning they do not realize that
they have problems with their memory
vascular dementia makes up around 15% of
cases and generally involves disturbance
in the blood supply to the brain leading
to ischemia and loss of cells if the
blood supply to the brain is interrupted
causing the neurons to die this could be
called a stroke and it is thought that
in vascular dementia there could be a
series of small Strokes which alone are
not evident but as they increase in
Number the symptoms then develop this is
known as multi- infa
dementia subcortical dementia is another
common type of vascular dementia in
which the smaller penetrating vessels
are affected sometimes called small
vessel disease because of the close link
to Strokes it's no surprise to have a
stroke related subtype of vascular
dementia with up to 30% of patients with
es schic Strokes estimated to go on and
develop vascular dementia in the periods
between events there may be little to no
decline followed by sudden decline when
new insults occur this gives vascular
dementia the characteristic stepwise
progression risk factors include smoking
diabetes atrial fibrillation
dyslipidemia hypertension and age with
the risk doubling every 5 years in
vascular dementia impairments in
planning organizing and judgment and
noticeable early on Lou body dementia is
seen in around 10% of cases Louis bodies
are spherical deposits with surrounding
fibers found in the cytoplasm of neurons
the center of the deposit is formed from
Alpha sincan and ubiquitin Aggregates
Louis bodies are also a primary brain
abnormality in Parkinson's disease
dementia Louis body dementia has core
symptoms such as fluctuating cognition
visual hallucinations and parkinsonian
symptoms like Brad kinesia which is the
slowing of movements Cog wheel rigidity
a predisposition to Falls and autonomic
disturbances like orthostatic
hypotension incontinence and
constipation it also has suggestive
symptoms like REM sleep disturbance or
antipsychotic sensitivity one or more
core with one or more suggestive
symptoms is enough for a probable
diagnosis while having only one or more
suggestive gives a possible
diagnosis the second most common
Dementia in people under the age of 65
is frontal temporal dementia just behind
early Alzheimer's with the mean age of
onset being 53 experts believe that
there are two main disease processes
involving transactive DNA binding
protein tdp43
and the microtubule Associated tow
protein behavioral variant type is the
most common subtype characterized by
personality changes and behavioral
changes like disinhibition and social
withdrawal occurring early on in the
process spherical collections of TOA
fibrils can be found in the cytoplasm
called pick bodies which is why frontal
temporal dementia was in the past called
PX disease semantic variant manifests
with language difficulties including
difficulties in finding words as well as
impairments in
comprehension this variant features a
form of fluent
Aphasia non-fluent primary Progressive
Aphasia features labored hesitant speech
rather than fluency and these two are
under the category of primary Progressive
Progressive
Aphasia increasing age is generally the
largest risk factor at age 65 there is a
2% prevalence while at 85 it is as high as
as
40% genetics also has a role for example
a family history of a first-degree
relative with Alzheimer's increases the
risk by between 10 and
30% early onset dementia is defined as
dementia affecting people under the age
of 65 which makes up around 5% of all
cases triom 21 or Down syndrome is a
significant risk factor for developing
early onset Alzheimer's there are three
chromosomes instead of two which could
mean more amalo precursor protein and
therefore more beta ameloid being
produced in Alzheimer there can be
autosomal dominant transmission with
near complete
penetrance this is the case in around 5%
of all cases and in most cases of early
onset Alzheimer's for the early on on
set variant the three genes in
particular are ameloid precursor protein
on chromosome 21 prein 1 and two on
chromosomes 14 and 1 for later onset
Alzheimer's APO lipoprotein e genes play
a larger role it is a regulator of lipid
metabolism and can interact with beta
ameloid the E4 variant is thought to
produce a 50% risk of developing
Alzheimer's while having two aliot is
thought to produce a 90% risk dementia
in general is more common in women but
this may be because women tend to live
longer than men cognitive Reserve is
another Factor it is the extent of
neuronal loss that can be tolerated
before function is impaired people who
are socially isolated or left education
early or have low job complexity
typically have a lower reserve and are
therefore form more likely to develop
dementia we've also already mentioned
risk factors for vascular dementia the
only conclusive diagnostic test for
Alzheimer's is a brain biopsy and
histological Confirmation which is
rarely done in living people some
Imaging techniques like positron
emission tomography or pet scans are
being developed that can detect these
hystological findings
non-invasively therefore the clinical
history along alongside a largely normal
neurological exam is most commonly how
dementia is suspected a mental state
examination is done to evaluate
cognition examples being the mini mental
state exam and the Montreal cognitive
assessment blood tests are usually
normal however there are some reversible
causes of cognitive impairment that can
be detected such as vitamin B12 or
folate deficiency
hypothyroidism electroly disturbance
like hypocalcemia and even infective
causes like Lim's disease and neuros
syphilis CT Imaging can help to rule out
other causes of cognitive impairment and
may also reveal cerebral atrophy meaning
a shrinking in the brain volume although
this is suggestive it is not specific
for dementia genetic tests are not
routinely done and this is mostly
reserved for rare familial forms
no cure currently exists for dementia
the 1-year mortality is 30 to 40% while
the 5-year mortality is around
65% the most common cause of death is
pneumonia which may be because
swallowing problems can predispose to
aspiration and subsequently
pneumonia some medications are used to
reduce the symptoms such as colon
esteras Inhibitors which prevent the
enzyme colon esteras from breaking down
acetyl choline a neurotransmitter
involved in cognition and memory
examples include Don episil galantamine and
and
rasine nmda receptor antagonists like
memantine are also used these two
classes have been found to slow the
cognitive decline but the effect on
overall survival is not yet conclusive
in vascular dementia a key part of
management is addressing identified risk
factors which may help in slowing the
progression behavioral and environmental
approaches are encouraged for example
maintaining a familiar environment
monitoring personal comfort and
redirecting attention people with
dementia are also prone to developing
anxiety depression or even psychosis and
it is also important to treat these
symptoms as well regular aerobic
exercise has been found to slow down the
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