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Overview |
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Definition |
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According to DSM-IV, dementia is characterized by multiple cognitive deficits
that are severe enough to cause significant impairment in social or occupational
functioning. These deficits must show evidence of decline from previous levels
of functioning, include memory impairment, and at least one other cognitive
disturbance (aphasia, apraxia, agnosia, or a disturbance in executive
functioning). The rate of occurrence is higher in later life; the highest
prevalence is above age 85. Dementia is classified as being progressive, static,
or remitting. The subtypes of dementia are listed below.
- Dementia of the Alzheimer's type
(DAT)—deterioration of higher cortical function (this
is the most common form)
- Vascular dementia—one form is multi-infarct
dementia (MID), which is secondary to atherosclerosis
- Dementia due to other general medical conditions, including infection
with the human immunodeficiency virus (HIV), traumatic brain injury, Parkinson's
disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease,
normal-pressure hydrocephalus, hypothyroidism, brain tumor, and vitamin B
deficiencies
- Substance-induced persisting dementia due to drug or alcohol abuse,
medication, or toxin exposure
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Etiology |
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Alzheimer's disease is the most common cause of dementia. Other causes
include biologic factors (e.g., neurofibrillary tangles); nutritional
deficiencies (e.g., the B vitamins); physiological effects of general medical
conditions (e.g., Creutzfeldt-Jakob disease); persisting effects of a substance
(e.g., alcohol or medications); and multiple etiologies (e.g., the combination
of Alzheimer's disease and cerebrovascular disease). |
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Risk Factors |
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- Family history of Alzheimer's disease and other dementias
- Down's syndrome
- Head trauma (especially with loss of consciousness)
- Other factors sometimes associated with dementia include age (onset
at age 65 and above); late maternal age; history of depression; strokes,
especially with a history of hypertension; alcohol or drug abuse; and history of
CNS infection.
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Signs and Symptoms |
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- Memory impairment
- Language deterioration (aphasia)
- Motor activities impairment (apraxia)
- Impaired ability to recognize objects (agnosia)
- Inability to think abstractly, i.e., to plan, initiate, sequence,
monitor, and stop complex behavior (disturbances in executive
functioning)
- Spatial disorientation
- Suicidal behavior
- Motor disturbances
- Disinhibited behavior
- Anxiety, mood, and sleep disturbances
- Hallucinations
- Increased susceptibility to physical stressors such as illness or
bereavement that worsen intellectual deficits and other problems
- Incontinence
- Tremor
- Seizures
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Differential
Diagnosis |
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- Mental retardation
- Other cognitive disorders (delirium, amnesic disorder)
- Substance abuse
- Psychiatric disorders (e.g., schizophrenia)
- Major depressive disorder
- Malingering and factitious disorder
- Aging (e.g., age-related cognitive
decline)
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Diagnosis |
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Laboratory Tests |
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There is no accepted diagnostic test for Alzheimer's disease available in
blood, cerebrospinal fluid, or other tissue. Underlying medical conditions
(e.g., cerebellar atrophy focal or focal brain lesions) may be determined via
neurological imaging. The "gold standard" for diagnosing dementia is
neuropathological findings made at autopsy. However, there are potential
biomarkers for Alzheimer's disease, including characteristics of the
beta-amyloid protein found in senile plaques.
Routine laboratory evaluations should include CBC count, sedimentation rate,
stool for occult blood, thyroid functions, electrolytes, BUN, calcium,
phosphorus, urinalysis and culture, B12 liver function, blood sugar, syphilis
serology, chest radiograph, and electrocardiogram. |
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Pathology/Pathophysiology |
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Several microscopic changes in brain tissue have been identified in
Alzheimer's disease, principally the formation of senile or neuritic plaques and
neurofibrillary tangles. |
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Imaging |
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Neuroimaging, including CT, MRI, PET, or SPECT scans, may aid in the
differential diagnosis of dementia. |
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Other Diagnostic
Procedures |
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There are no objective tests, but the Dementia Questionnaire is often
applied.
- Clinician interview—assessment of symptoms
and degree of severity of dementia; includes (1) focused history emphasizing
mode of onset (abrupt versus gradual); (2) progression (stepwise versus
continuous decline; worsening versus fluctuating versus improving), duration of
symptoms; (3) medical history; (4) family history; (5) social and cultural
history; (6) medication history; and (7) informant reports
- Neurological assessment—CT scan; EEG for
suspected seizure disorder or Creutzfeldt-Jakob disease; MRI scan for suspected
Huntington's disease
- Genetic Testing—Recent studies show that
genetic testing may be useful, especially for the ApoE-e4 allele and mutations
in the presenilin 1 gene in Alzheimer's disease.
- Use of standardized instruments such as the Dementia Mood Assessment
Scale developed for Alzheimer's
patients
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Treatment Options |
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Treatment Strategy |
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Treatments are aimed at the arrest and reversal of the disease or the
reduction of symptoms, including those listed below.
- Pharmacotherapy
- Psychotherapy, including psychosocial, interpersonal, environmental,
and psychoeducational interventions
- Environmental interventions (e.g., fostering a secure and predictable
environment with a minimum of sensory stimulation)
- Medication management
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Drug Therapies |
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- Acetylcholinesterase inhibitors (antidementia treatment), such as
tacrine (Cognex, 10 to 40 mg qid) and donepezil (Aricept, 5 to 10 mg/day)
increase precursor substances and acetylcholine in synapses; slow degradation of
acetylcholine, direct activation of the postsynaptic receptor, and deactivation
of inhibiting impulses on cholinergic systems; side effects include elevated
serum alanine aminotransferase levels; contraindicated for patients who
currently have or have a history of liver disease
- Neuroleptics (behavior problems), such as haloperidol (Haldol, 0.5 to
5 mg/day) and trifluoperazine (Stelazine, 1 to 20 mg/day); side effects, even at
low doses, include extrapyramidal signs (e.g., parkinsonism and
akathisia)
- Benzodiazepines (agitation), such as lorazepam (Ativan, 0.5 to 2 mg,
one to three/day) and clonazepam (Klonopin, 0.5 to 1 mg bid); side effects
include sedation and falls.
- Selective serotonin reuptake inhibitors (SSRIs) (depressive
symptoms), such as paroxetine (Paxil, 10 to 40 mg/day) and sertraline (Zoloft,
25 to 200 mg/day) block serotonin reuptake. Anticholinergic side effects include
dry mouth, constipation, urinary retention, atrioventricular conduction delay,
and orthostatic hypotension.
- Estrogen therapy may help to maintain connections between neurons and
reduce development of Alzheimer's disease in postmenopausal
women.
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Complementary and Alternative
Therapies |
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Alternative therapies may offer great promise in treating dementia without
the side effects of the commonly prescribed pharmaceuticals. Treatment with
nutrition can provide rapid results in those with deficiencies. Herbal treatment
is widely used in Europe with promising results. |
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Nutrition |
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- Antioxidants are a key component, with emphasis on both water and fat
soluble antioxidants—vitamin E (400 to 800 IU/day),
vitamin C (1,000 mg tid), and coenzyme Q10 (10 to 50 mg tid)
- Vitamins: biotin (300 mcg); B vitamins are often depleted in
dementia: B1 (50 to 100 mg), B2 (50 mg), B6 (50 to 100 mg), B12 (100 to 1,000
mcg). B12 may need to be administered IM for optimum results.
- Minerals: calcium/magnesium (1,000/500 mg/day), zinc (30 to 50
mg/day); excess of manganese and copper can increase the risk for
dementia
- IV chelating agents such as ethylenediaminetetraacetic acid (EDTA)
may help to restore normal circulation in the brain, remove calcium plaques and
heavy metals from brain arteria.
- Essential fatty acids regulate platelet aggregation, stabilize
arterial walls and are anti-inflammatory. Dietary manipulation includes reducing
animal fats and increasing fish.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Choose four to six herbs from the most appropriate category and use 1 cup or
30 to 60 drops tid.
- Ginkgo (Ginkgo biloba) is specific for preventing and treating
Alzheimer's and senile dementia from cerebral vascular insufficiency; regulates
platelets, may exacerbate peripheral edema, clotting times may need to be
checked. May be taken as a single herb in a standardized extract of 40 to 50 mg
tid. Monitor carefully with concurrent use of anticoagulants.
- Hawthorn (Crataegus
monogyna)—circulatory stimulant, cardiac
tonic
- Rosemary (Rosmarinus
officinalis)—circulatory stimulant, digestive
bitter, antidepressant
- Siberian ginseng (Eleutherococcus
senticosus)—increases endurance, increases cerebral
circulation, may be contraindicated in hypertension.
- Lemon balm (Melissa
officinalis)—carminative, spasmolytic;
anti-anxiety, insomnia
- Ginger (Zingiber
officinale)—carminative, vasodilator; general
weakness
- St. John's wort (Hypericum
perforatum)—depression,
anxiety
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Alumina for dullness of mind, vagueness, slow answers to
questions, especially with constipation
- Argentum nitricum for dementia with irritability, especially
when lack pf control over impulses
- Cicuta for dementia after head injuries, especially with
convulsions
- Helleborus for stupefaction, person answers questions slowly
and stares vacantly
- Silica for mental deterioration with anxiety over small
details
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Patient Monitoring |
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Patients should be monitored closely due to the combination of age and
presence of neurologic disorder, which drastically increases sensitivity to the
side effects of pharmacologic agents. Smaller initial doses, longer titration
intervals, and lower final doses are recommended. |
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Other
Considerations |
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Prevention |
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Preventive measures for specific dementias are effective (e.g., abstinence
for alcoholic dementia; safety measures for postconcussive dementia; lowering
blood pressure, treating cardiac disease, and preventing atherosclerosis or
embolization for multi-infarct dementia). Caregiver and patient education
focusing on knowledge of the disease, health, and the patient's well-being
result in better patient care. Exercise, both physical and mental, may prevent
or slow dementia. |
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Complications/Sequelae |
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- Drug interactions or drug overdose can be severe.
- Malnutrition
- General hygiene problems
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Prognosis |
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Dementia may be progressive, static, or remitting. The underlying pathology
and application of effective treatment in a timely manner plays a large role in
its reversibility and manageability. |
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References |
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American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association;
1994.
Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:214, 376.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:136, 138, 197.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:967-968, 1101-1102,
1219-1220, 1229-1230.
Hofferberth B. The efficacy of EGb 761 in patients with senile dementia of
the Alzheimer type: a double-blind, placebo-controlled study on different levels
of investigation. Hum Psychopharmacol. 1994;9:215-222.
Kanowski S, Hermann WM, Stephan K, Wierich W, Horr R. Proof of efficacy of
the Ginkgo biloba special extract EGb 761 in outpatients suffering from mild to
moderate dementia of the Alzheimer's type or multi-infarct dementia.
Pharmacopsychiatry. 1996;29:47-56.
Le Bars, et al. A placebo-controlled, double-blind, randomized trial of an
extract of Gingko biloba for dementia. JAMA. 1997;278:1327-1332.
Maurer K, et al. Clinical efficacy of Gingko biloba special extract EGb 761
in dementia of the Alzheimer type. J Psychiatr Res. 1997;31:645-655.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:17-18, 32-33, 124-125,
176-177, 248-249.
Morris JC, ed. Handbook of Dementing Illnesses. New York, NY: Marcel
Dekker Inc; 1994.
National Institutes of Health. Available at http://text.nlm.nih.gov/.
Perry EK, Pickering AT, Wang WW, Houghton P, Perry NS. Medicinal plants and
Alzheimer's disease: integrating ethnobotanical and contemporary scientific
evidence. J Altern Complement Med. 1998;4:419-428.
Rai GS, Shovlin C, Wesnes KA. A double-blind, placebo controlled study of
Ginkgo biloba extract in elderly patients with mild to moderate memory
impairment. Curr Med Res Opin. 1991;12:350-355.
Rakel RE. Conn's Current Therapy 1997: Latest Approved Methods of
Treatment for the Practicing Physician. Philadelphia, Pa: WB Saunders Co;
1997.
Werbach, M. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing; 1988:149-154. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |