Dementia

Description

Dementia is an umbrella term for various diseases that have in common the decline of mental capacity and a change in personality.

Alzheimer's disease is the most common representative of dementia.

In the foreground is the decreasing performance of memory and thinking. It becomes increasingly difficult to take in new information and to reproduce it. Forgetting alone does not constitute dementia!

Difficulties with orientation and judgement increase (Where am I now? What is going on?). Language and arithmetic gradually deteriorate. All this happens at the same time as a personality change. Everyday life can only be mastered to a limited extent. Activities such as shopping or housework become more difficult, until they are no longer possible at all. Sufferers develop aggressiveness and disinhibition, seem depressed or moody, which is a challenge for relatives and caregivers.

With increasing years of life, the risk of developing dementia rises sharply.

In the 65-69 age group, 2% are affected. In comparison, 10-17% of 80-84 year olds are already affected. The front runners are the over 90 year olds with more than 30%.

The number of people suffering from dementia will double by 2050, as the proportion of older people in the total population continues to rise. Currently, dementia is already the most frequent reason for moving into a nursing home.

Dementia is an umbrella term for various diseases that negatively affect mental performance and personality due to changes in the brain.

Alzheimer's disease

Today, Alzheimer's disease is considered the most common cause of dementia. In 1906, this disease was described by the neuropsychiatrist and pathologist Alois Alzheimer and subsequently named after him. Nerve cells of the brain lose their normally very close connection to each other, which leads to a reduction in brain and memory performance.

Disturbed blood circulation

The brain substance can also change due to insufficient blood flow. In a so-called vascular dementia, there is a spontaneous impairment of brain and memory performance. This is accompanied by symptoms of a stroke such as speech disorders. More rarely, these changes may progress slowly.

Other causes

There are also other diseases that involve degrading processes similar to Alzheimer's disease. This can be, for example, a "dementia with Lewy bodies". It ranks third among the most common types of dementia.

Other reasons for the development of dementia can be:

• metabolic disorders (e.g. vitamin B-12 deficiency, thyroid disease)
• chronic poisoning (e.g. alcohol dependence)
• Spatial damage in the brain (e.g. tumours)
• Infections of the brain (e.g. AIDS, Creutzfeld-Jakob disease)

If one of these causes can be found, dementia can usually be treated. Often, however, it is not just one cause. Widespread diseases such as hypertension (high blood pressure) or diabetes mellitus (diabetes) can worsen an already existing dementia or even cause it by damaging brain vessels.

The first sign of the onset of dementia is often an impairment of short-term memory. Gradually, abilities such as concentration, language and thinking skills are also reduced. Those affected feel increasingly tired.

In the early stages, symptoms of depression often become apparent, especially when the person affected notices the deterioration themselves. However, many sufferers do not notice these changes, which applies to the majority of dementia types and is also called anosognosia.

The further course is characterized by an intensification of the symptoms. Forgetfulness increases, orientation becomes difficult and everyday life becomes more of a hurdle. Independent dressing, household chores or cooking are no longer possible. In the final stage of the disease, those affected often fall silent (dementia-related speech decline). Bedriddenness and complete dependence on help set in.

The following are some of the symptoms that can occur at the same time, but do not necessarily have to:

• Forgetfulness
• impaired concentration and thinking
• Problems with complex tasks (e.g. planning a party, packing suitcases)
• disorientation
• impaired speech
• impaired judgement
• change of personality
• listlessness

All of the above symptoms are not specific to dementia, but can be due to other mental or brain disorders.

In order to be able to determine the progress and cause of a dementia disease, neurologists, psychiatrists and geriatricians become necessary. There are already own memory outpatient clinics or memory clinics, which have specialized in the diagnosis and consultation of dementia diseases. There, all basic examination methods are available, which brings a clear time advantage in the diagnosis.

Relatives

Patients and their relatives are asked about their medical history, which is how the anamnesis is taken. Since the affected persons usually do not notice changes themselves or conceal them due to shame, the relatives are enormously important. This is followed by internal neurological examinations and a blood test, after which the attending physician determines the further course of action.

Neuropsychological tests

The first important step is to distinguish mild forgetfulness from dementia. Neuropsychological tests (e.g. SKT - Syndrom-Kurz-Test, MMST - Mini-Mental-Status-Test) are suitable for this purpose. With their help, the degree of forgetfulness and other possibly disturbed brain functions can be assessed. If there is any uncertainty, usually in the early stages, a specially trained neuropsychologist should carry out a detailed neuropsychological diagnosis.

Furthermore, it is important to exclude depression. Although it can be a symptom of dementia, it can also occur independently of it and generally has nothing to do with it.

In the further course, other internal or psychological diseases and other causes must also be excluded.

Imaging procedures

If dementia is suspected, imaging procedures such as computer or magnetic resonance tomography provide information about the brain structure. In unclear cases, changes in performance can be shown with the help of SPECT (single photon emission tomography) and PET (positron emission tomography).

Vessels and brain waves

Metabolic disorders and poisoning are unmasked with the help of blood tests. A lumbar puncture is used to examine cerebrospinal fluid (nerve fluid), which can detect chronic inflammation of the brain. Special proteins can also be found in the cerebrospinal fluid, as they are only found in Alzheimer's or Creutzfeld-Jakob's disease.

A Doppler or Duplex sonography makes deposits of fat and calcium (arteriosclerosis) in the vessels supplying the brain visible. The probability of vascular dementia can also be deduced from the examination results.

An EEG (electro-encephalogram) rarely leads to the cause, but does clarify the extent of mental decline.

In very rare exceptions, a biopsy of the brain (tissue removal) becomes necessary. If this is necessary, it is important that this examination is only carried out by experienced specialists in an appropriate setting.

Slow down the disease

For the most part, dementia cannot be cured today, but the deterioration in the brain can be halted, such as in Alzheimer's disease and vascular dementia. If the reduction in mental performance is due to another disease (e.g. brain tumour, severe depression, metabolic disorders in the brain), dementia can often be successfully treated by treating the underlying disease.

Exercising the brain

Dementia therapy is particularly important for the person with dementia to be able to cope with everyday challenges for as long as possible. For this purpose, there are special homes (e.g. day clinics) that focus on brain training. The aim here is to learn a basic framework for the daily routine so that dementia patients can cope better. Those affected are accompanied through the day by psychologists, social workers and other specialists and receive assistance.

A particular advantage of such homes is the ability to involve relatives in the treatment.

Mental performance can be maintained or at least its deterioration slowed down by using physiotherapy, manual and artistic training with the help of an occupational therapist.

Medication

Medicines can now do a lot, but should still only be one element of a treatment plan, i.e. combined with brain training. Various drugs are available for the different causes of dementia.

The top priority is to slow down the disease or even bring it to a temporary halt. The drugs have different modes of action. A trial is certainly worthwhile, even if no major changes follow. Because dementias progress continuously, even stopping the disease is a success.

Acetylcholinesterase inhibitors

In the early to middle stages of Alzheimer's disease, vascular dementia and Lewy body dementia, so-called acetylcholinesterase inhibitors are the first choice. These improve the exchange of signals between nerve cells in the brain. This is achieved by blocking acetylcholinesterase (an enzyme), which allows it to break down less acetylcholine, leaving more of the neurotransmitter available. Disease progression can be delayed by an average of one year as a result.

NMDA antagonists

If the disease is already moderate to severe, NMDA antagonists are recommended. They can be combined with acetylcholinesterase inhibitors and prevent overstimulation of nerves by glutamate (also a neurotransmitter). Excess glutamate damages nerve cells and causes them to die. The use of these drugs is not effective for vascular and Lewy body dementia.

Other drugs

There are also some drugs that are said to have a positive effect on brain performance. These include extracts of the ginkgo tree. These extracts are said to promote blood circulation and contribute to a better supply of oxygen and glucose (sugar) to the brain.

Calcium antagonists are supposed to help normalize the disturbed calcium metabolism of the affected nerve cells and thus improve the transmission of information.

However, specialist societies do not recommend these agents because their efficacy has not been scientifically proven to date.

If necessary, it is also useful to use drugs against restlessness and sleep disorders, movement disorders (similar to Parkinson's) and depression in order to alleviate accompanying symptoms. However, their use must be closely monitored to avoid side effects or interactions.

Check-ups

Any drug treatment of dementia requires regular monitoring by the treating specialist or therapist. The latter can better follow the course of the disease, assist relatives and adapt the treatment strategy to changing conditions.

Tips for relatives

Ensure that the affected person has a balanced mixed diet with sufficient amounts of vitamins and fish oil as well as plenty of fluids (water, unsweetened tea).

Support the person with dementia with a clearly structured daily routine and easily visible calendars and clocks.

Although dementia patients are mainly cared for by the family, other services should also be used to avoid excessive demands. These are, for example, day care at social stations and day care centres.

There are self-help groups and also groups for relatives. There you can learn from the experience of others and share your own. Your doctor can help you with brochures and other information material.

In many cases of dementia, a cure is impossible. A combination therapy of medication and brain training makes it possible to halt or slow down the disease and significantly improves the quality of life of those affected.

Dementias that are based on another disease are very well curable. An example of this is severe hypothyroidism. From the time when the thyroid gland is functioning sufficiently normally again, mental performance improves increasingly. This can be achieved, for example, by administering thyroid hormones in tablet form.

If the cause is a degradation process in the area of the brain (such as in Alzheimer's disease), the death of the affected person occurs on average after 10 years from diagnosis. Since dementias only occur in old age, life expectancy is only slightly shortened, if at all.

Vascular or alcohol-related dementia can be well prevented by a healthy lifestyle (regular exercise, balanced diet).

However, other forms such as Alzheimer's disease cannot yet be prevented. At present, however, specialists are intensively researching a drug that enables the immune system to react to the proteins that cause Alzheimer's disease. This should make immunisation possible. Unfortunately, this is such a complex process that functional drugs are likely to be years away.

Coincidentally, it was discovered that some cholesterol-lowering drugs also have anti-inflammatory effects. Whether cholesterol synthesis inhibitors (CSE inhibitors for short) can also prevent dementia is currently being investigated. They could be used in dementias caused by chronic infections.