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

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).

• 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.

• 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

• 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)

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.

Several microscopic changes in brain tissue have been identified in Alzheimer's disease, principally the formation of senile or neuritic plaques and neurofibrillary tangles.

Neuroimaging, including CT, MRI, PET, or SPECT scans, may aid in the differential diagnosis of dementia.

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

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

• 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.

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.

• 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.

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

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

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.

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.

• Drug interactions or drug overdose can be severe.
• Malnutrition
• General hygiene problems

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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