Understanding Dementia and the Disease Process

Dementia is a progressive loss of memory, reasoning and cognitive functions impairing the abilities to perform normal day-to-day activities like household chores, driving and personal care like bathing, dressing and feeding, otherwise known as Activities of Daily Living (ADLs).  People suffering from dementia experience a reduction in most areas of intellectual functioning such as usage of language, numbers, orientation, judgment, reasoning ability, problem solving and ability to think abstractly impairing a persons ability to function independently.

Types of Dementia

A diagnosis is based upon common features.

Cortical Dementia is caused due to damage to the cortex or outer layer, which tends to cause problems with memory, language, thinking and social behavior.

Subcortical Dementia affects parts of the brain below the cortex, which causes changes in emotions and movement, in addition to, problems with memory.

Progressive Dementia, as the name indicates, worsens over a period of time, interfering with cognitive abilities.

Primary Dementia does not result from any other disease, such as: Alzheimer's disease.

Secondary Dementia is caused due to a physical disease or injury.

Common Diagnosis of Dementia that fall into the above types of dementia are:

Alzheimer's Disease, the most common form of dementia, is caused due to irreversible progressive deterioration of brain cells (especially the cerebral cortex and hippocampus) causing loss of cognitive functions such as memory, movement coordination, pattern recognition, judgment and reasoning.

Vascular Dementia, the second most common form of dementia, is caused by damage to the brain due to cerebralvascular or cardiovascular strokes or inflammation of the blood vessel system (Vasculitis) due to low blood pressure or lesions from a brain hemorrhage.

Multi Infarct Dementia (MID) is caused by a number of small strokes leading to multiple damaged areas and lesions in the white matter or nerve fibers of the brain. Dementia from a single stroke damages either the left side of the brain or hippocampus and is called Single Infarct Dementia. It is important to note that not all strokes cause dementia but in some cases, a single stroke can damage the brain enough to cause dementia.

Lewy Body Dementia (LBD) is caused due to the death of cells in the cortex and mid-brain area of the brain. The remaining mid-brain nerve cells contain abnormal structures called Lewy Bodies. A protein called alpha-synuclein contained in these Lewy Bodies cause several disorders collectively called Synucleinopathies. Symptoms of LBD overlap with those of Alzheimer's disease and typically include visual hallucinations, parkinsonian symptoms and day-to-day fluctuations in the severity of symptoms.

Frontal Temporal Dementia (FTD) (aka: Frontal Lobe Dementia, Pick's Disease) is a group of diseases caused by the degeneration of nerve cells in the frontal and temporal lobes of the brain. There is an abnormal formation of tau protein in these regions of the brain accumulating into neurofibrillary tangles and disrupting normal cell activities and thus, ultimately leading to death of the nerve cells.  Symptoms, such as: loss of speech, language, compulsive or repetitive behavior, increased appetite and motor problems (stiffness and balance) are common in FTD.

Causes

• Diseases that affect the heart, kidneys, liver, lungs, and blood vessels, such as with a stroke, heart attack, renal disease, etc.

• Chronic and excessive consumption of alcohol and drugs.

• Metabolic problems and endocrine abnormalities that cause deficiencies in vitamin B12, folate, vitamin B6, thiamine (vitamin B1), etc. such as; thyroid problems, hypoglycemia, inadequate or excessive sodium or calcium levels.

• Malnutrition.

• Infections.

• Accumulation of fluid (Hydrocephalus) in the brain caused by developmental abnormalities, injuries, infections and/or brain tumors.

• A single (or several) head injuries such as: Subdural Hematoma.

• Diminished supply of oxygen to cells in the brain, such as: Anoxia or Hypoxia. Symptoms often seen during recovery of diminished oxygen supplies include various psychological and neurological abnormalities, which may cause dementia or psychosis.

• Exposure to poison.

Signs & Symptoms

Memory Loss. Forgets recent events, experiences and information. Asks repetitive questions.  Misplaces items.  Misinterprets objects.

Disorientation. Forgets familiar surroundings.  Forgets how to complete simple tasks.  Forgets names of grandchildren.  Forgets the year.

Communication.  Forgets simple words.  Uses irrelevant words during conversation, thus making it difficult for the listener to understand the conversation.  Tunes out when listening to a conversation.  Repeats self.

Abstract Thinking. People suffering from dementia have trouble carrying out simple calculations such as adding and subtracting numbers. And in later stages of dementia, forgets the purpose of numbers and calculation.

Poor Judgment.  Unaware of own cognitive impairments or physical limitations.  Lacks safety awareness.  Reacts poorly during an emergency.

Completion of Tasks.  Unable to perform activities of daily living, such as: preparing a meal, operating a stove or making a telephone call.

Personality (Mood or Behavioral) Changes. People suffering from dementia exhibit tearful, anxious and/or angry moods for no apparent reason.

Lacks Initiative.  People suffering from dementia may become passive in social groups, withdrawn from others or uninterested in own daily hygiene.

Stages of Dementia

1.  No impairment of normal function.  No signs of memory loss are visible to a medical professional, nor does the patient experience any symptoms.

2.  Very mild cognitive decline.  The patient attends to own activities of daily living:  bathing, toileting, dressing, cooking, finances, shopping.  The patient may experience some memory loss such as, forgetting familiar words, names, or location of wristwatch, eyeglasses or any objects of daily use. Family and friends may notice the patient is forgetful.  The patient continues to drive.

3.  Mild cognitive decline.  The patient requires verbal reminders to complete activities of daily living; dressing, cooking, finances, shopping.  The patient has trouble remembering new information and recalling some past life events.  The patient has difficulty finding the words to express a thought.  The patient has difficulty recalling the name of a familiar family member. The patient has difficulty in paying attention and displays less retention from articles read in a newspaper or magazine.  The patient misplaces every day items (glasses, dentures, hearing aide) and loses valuable objects (wallet, car keys, portable phone).  The patient displays decreased ability to plan or organize. Family and friends begin to call patient at home to ensure patient is safe and healthy.  Family members begin to provide some type of assistance: grocery shopping, paying the bills, laundry, cooking.  Family members begin to visit patient weekly to ensure safety and provide socialization.  The patient continues to drive and family members question if this privilege should be removed permanently.

4.  Moderate cognitive decline.  The patient requires verbal reminders and assistance with activities of daily living DAILY: bathing schedule, dressing appropriately, cooking stove top meals, balancing checkbook, paying bills, shopping, and driving.  The patient is unable to recall recent events.  The patient is unable to perform challenging mental arithmetic, such as, counting backwards from say 100 by 7s.  The patient is unable to plan, manage, or organize complex tasks such as paying bills, driving to the grocery store, relay important information to the primary care physician during appointments, etc.  The patient is socially withdrawn at family events and silent in challenging situations.  Family members begin to visit patient daily to ensure safety and the activities of daily living are addressed.  Family members recognize the patient should not drive and offer to transport patient to and from everywhere.

5.  Moderately severe cognitive decline.  The patient requires 24 hr supervision and physical assistance with activities of daily living: taking a bath, urinating, dressing appropriately for the present season, cooking.  The patient is unable to recall current address, telephone number, location, date, day of the week, season, etc. Generally, the patient retains substantial knowledge and is aware of own name, name of spouse or children. The patient can eat independently.  The patient fails to perform even lesser challenging mental arithmetic, such as, counting backwards from 40 by 4s.  The patient relies on family members to manage all complex tasks in their life.  Family members are visiting for longer periods of time every day.  Family members are attending to all aspects of patient's life.  The patient may have suffered a fall with or without injury, an infection, dehydration, or malnutrition.  The patient may have required hospitalization and rehabilitation.  Personality and behavioral changes emerge including anger, anxiety, fearful, tearful.  Family members are beginning to show signs of distress.  Family members look for assistance from home care agencies and local organizations.  Family members recognize patient may have to be removed from the home.

6.  Severe cognitive decline.  The patient requires 24hr supervision and physical assistance with all activities of daily living: flushing a toilet, wiping properly, and even proper disposal of tissue paper.  There are increasing episodes of urinary or fecal incontinence. The patient experiences a disturbance in normal sleep-waking cycle.  The patient is unaware of their surroundings. The patient is unable to recall personal history or most recent experiences. The patient needs assistance with eating.  The patient is aware of their name. The patient can distinguish familiar faces from unfamiliar faces. The patient communicates basic needs and understands simple directions.  Personality and behavioral changes emerge including suspicion of family members and others, delusions such as; accusations that a caregiver is as an impostor, hallucinations, repetitive behavior such as, hand wringing.  The patient tends to wander and become lost.  The patient is dependent upon family members for hygiene, meals, and socialization.  The primary caregiver displays signs of emotional and physical distress.  If family members relocated patient to an assisted living facility or nursing home, then the patient is adjusting to nursing home staff and routines.  Family members are displaying relief and guilt simultaneously, while trying to adjust to the patients new environment and trust nursing home staff.

7.  Very severe cognitive decline.  The patient requires 24hr physical care with bathing, toileting, dressing, and eating.  The patient is unaware of self, environment, or time. The patient is unable to communicate basic needs and desires in recognizable speech. A caregiver must bath, toilet and feed the patient daily. The patient is unable to walk without support.  The patient's muscles become rigid.  The patient has difficulty swallowing food.  The patient utilizes a wheelchair for transportation.  The patient is at end of life.  Hospice services are a beneficial service for this stage of dementia for the patient and the family members.