Dementia is a condition that results in a gradual insidious and constant loss of cognitive ability.
There are many types of dementia, presenting different types of symptoms, which make it difficult to accurately diagnose a dementia. (Stuss & Levine, 1996).
Another major problem is the decline in cognitive ability with increasing age. Normal loss or decline in cognitive functions can mask the early stages of dementia, as memory impairment, difficulty recalling names and increasing reaction time are common symptoms for healthy older people. The degree of cognitive ability in the elderly population varies, which can easily lead to a misdiagnosis of dementia in people with normal cognitive impairment (Martin, 2006) The American Psychiatric Society's Diagnostic and Statistical Manual of Mental Disorders (5thedition, 2013) lists the main clinical and behavioral symptoms that should occur when diagnosing dementia. Still, it records all major diagnostic springs. Which are:
- Alzheimer’s type dementia
- Vascular dementia
- HIV dementia
- Dementia due to head injury
- Dementia due to Parkinson's disease
- Dementia due to Huntington's disease
- Dementia due to Pick's disease
- Dementia due to Creutzfeldt-Jacob's disease
- Dementia due to other general medical conditions
- Persistent dementia caused by substances
- Dementia due to multiple reasons
- Dementia not otherwise specified’
The diagnosis of dementia is made based on a number of predefined clinical, histopathological and adaptive factors.
According to DSM-V (Diagnostic and Statistical Manual of Mental Disorders (2013), diagnostic criteria for asthma are the following:
An obvious reduction in both short-term and long-term memory, impairment of memory / cognitive ability that interferes with work, social activities, and relationships. The above are indications of a 'causal' organic factor in the disorder and at least one of the Symptoms below:
impaired thinking, critical thinking, disorders of higher cortical functions, such as aphasia, inactivity and ignorance or personality change.
Differential diagnosis of dementia can be made by examining the location and histology of dementia, both of which contribute to determining the type of dementia the patient presents with. Histopathological examination is perhaps the criterion that the least degree of human interpretation is possible because the molecular and chemical evidence is clear. For this reason, the only absolute confirmation of the diagnosis of dementia can be obtained by autopsy or biopsy
(Mc Khannetal., 1984).
Different types of dementia also affect different brain systems and exhibit slightly different clinical symptoms. Alzheimer's degenerative disease (Alzheimer disease, AD) is the most known cause of dementia occurring in approximately 45% of dementia patients in the US (Cunnings & Benson, 1992) and has a worldwide prevalence of 3.75 million cases (Stuss & Levine, 1996).
The disease was named after Alois Alzheimer, who in 1907 reported the case of a 56-year-old patient with abnormal formations in her brain called parietal plaques and knots. He presented a prominent form of prenatal dementia, to which he gave his name. (dementia of the Alzheimer type, DAT), (Martin, 2006).
Alzheimer’s type dementia
Alzheimer’s dementia is characterized by:
- Cognitive impairment of memory (learning new information and recalling previous ones) and one or more problems of aphasia, inactivity, ignorance and executive functioning
- Symptoms that cause a significant reduction from a previous level of functionality
- Gradual onset and continuous cognitive decline
- Symptoms not due to other progressive CNS disease or dementia conditions
Clinical Symptoms of Alzheimer’s Dementia
The most serious cognitive problem in Alzheimer’s disease (AD) is memory loss. This loss is gradual and occurs within the bounds of a normal level of consciousness, with no other CNS disorders that could explain these symptoms. The most typical memory deficits include:
An inability to retrieve autobiographical information from long-term memory (eg information about people, events and conversations). It is the most important feature of the disease and is one of those that occurs early in the development of the disorder.
- Reduced recall of previously learned information and sometimes memory for conceptual or information
- Patient quickly forgets
- Oblique memory (or non-explicit memory is retained)
- Shortage of short- and long-term memory
- There is a tendency for the primary effect to be lacking but the effect of temporal proximity occurs where the patient recalls more correct data at the end of a list than at the beginning (Bayley, 2000).
- Intervention / contribution from previous learned information when learning new material
- Impaired attention and working memory
- Semantic memory impairment, inability to recall already known information
- Fencing and fencing errors
- Impairment of delayed memory recall – this appears to be a criterion to distinguish Alzheimer’s dementia patients from healthy (Zakzanisetal. 1999).
Greene and Hodges (1996b) compared public memory (such as the ability to identify famous persons and names) and autobiographical memory (such as reporting events that occurred during childhood), in 24 Alzheimer’s dementia patients over the course of a year found that, although public and autobiographical memory had been affected in patients, only the public had worsened over time. This finding is indicative that the distinction of long-term memory exists in segments.
One of the neuropathological features of Alzheimer’s disease is the degeneration of the tonsils and other brain structures involved in emotional processing (Callen, 2001). The psychological implication of this would be that because the main cognitive symptom of dementia is memory impairment, emotional memory can be particularly vulnerable.
Stages of Alzheimer’s disease
Cummings and Benson (1992) suggest that Alzheimer’s dementia develops in 3 stages
In the first phase (within three years), the memory of recent (and some distant) events is reduced and the learning of new information is impaired. The patient feels tired, anxious, apathetic and sometimes sad.
In the second stage (within 2 to 10 years), memory deficits accrue, with the recent and long-term memory impairment weakened and malfunctions such as dyspraxia and ignorance occur. The judgment and the capacity for abstract thought disappear. Patients have anomaly and have difficulty understanding speech.
In the third and final phase (between eight and twelve years), all mental function is disrupted. Complete lifting of emotional blockages and disorientation occurs and the former personality is lost. Patients get to the point where they can’t recognize relatives, or even themselves in a mirror.
Behaviorally, patients with Alzheimer’s dementia can be socially withdrawn and apathetic, and depression is a commonly experienced disorder. There may still be paranoia and examples of misidentification syndrome, considering a caregiver a fraud.
7 stages of dementia / Symptoms and course
It is common for health professionals to analyze dementia in ‘stages’, which refer to how much dementia a person has advanced. Setting the stage of an illness helps physicians decide the best therapeutic approach and facilitates communication between health care providers and caregivers.
One of the most widely used dementia scales is the GDS (Global Deterioration Scale for Assessment Of Primary Degenerative Dementia), which divides the disease process into 7 stages based on the “amount” of cognitive decline. GDS refers to most people with Alzheimer’s dementia, since other types of dementia (e g, frontotemporal dementia) do not always have memory loss.
|Diagnosis Stages Signs and Symptoms|
|Non-Diagnosed||Dementia Stage 1: No Cognitive Impairment |
At this stage the person is functioning normally, has no memory loss, is mentally healthy. All people without dementia can join stage 1.
|Non-diagnosable dementia||Stage 2: Very mild cognitive decline |
This stage is used to describe memory retardation associated with aging. For example, to forget a person’s names and places where objects were left. Symptoms are not present in relatives and in the treating physician.
|Non-diagnosable dementia||Stage 3: Mild cognitive impairment||This stage involves higher levels of memory retention, relatively difficult concentration, and poor work performance. People sometimes tend to get lost or find the right words to express themselves. At this point in time, relatives will start to notice some mental decline. Average duration: 7 years before dementia begins|
|Early stage||Stage 4: Mild cognitive impairment||This stage includes difficulty concentrating, reduced memory of recent events, difficulty managing finances, and difficulty traveling alone to new locations. Problems in completing complex activities consistently and adequately may be in denial about symptoms. There may be withdrawal from family and friends because socializing is now a difficult task. At this point in time, the doctor may notice clear cognitive problems during a diagnostic test. Average duration: 2 years|
|Medium stage||Stage 5: Moderately severe cognitive impairment||People at this stage have severe memory deficits and need partial help in completing their daily activities (dressing, bathing, preparing meals). Mnemonic loss is a prominent symptom and may contain important areas of recent life. B.C. People do not remember their address or phone number and may not know the time and day or where they are. Average life span: 1.5 years|
|Medium Stage||Stage 6: Severe Cognitive Impairment||Stage 6 individuals require extensive assistance in performing daily activities. They begin to forget the names of important family members and have little recollection of recent events. Many people can only remember a few details of their early life. They also have difficulty counting down to 10 and completing activities. They have incontinence. The ability to speak falls. The personality changes, for example, delusions, believing that something is true, while in reality it is not. They experience abuses, repeating a behavior such as cleaning. They have stress and irritability. Average life span: 2.5 years|
|Advanced stage||Stage 7: Very serious cognitive impairment||In essence, people at this stage cannot speak and communicate. Support is required in every activity (feeding, restroom ..) Loss of psychomotor skills, such as the ability to walk. Average life span: 2.5 years|
(Reisberg, et al., 1982; DeLeon and Reisberg, 1999)
Pharmaceutical treatment of Alzheimer’s disease
Most treatments already in place have focused on the treatment of memory disorders. Cholinergic treatment of the disease has led to the development of drugs that specifically aim to restore the loss of cholinergic neurons and neurotransmitters. The mechanism of action of these drugs is the inhibition of the acetylcholinesterase enzyme, which divides its neurotransmitter receptors (Bullock, 2002). Three ingredients used this time are donepezil, or rivastigmine and galantamine.
Patients who have been treated with either donepezil or ribastigmine have shown some improvement in memory performance (Cameronetal. 2000; Evanset. Al.2000). Other medicines under consideration are anti-inflammatory drugs (because the incidence of Alzheimer’s disease is low in rheumatoid arthritis patients taking these medicines) and antioxidants such as vitamin E. Perhaps the most innovative therapeutic treatment that is still under consideration involves vaccinating the individual, thereby giving him an antibody to remove the amyloid protein that causes cell degeneration. Mice trials are effective in relieving the symptoms of Alzheimer’s disease and preventing plaque growth, but there is no such vaccine for humans yet.