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Diagnosing and Treating Older Adults Who Have Dementia

This information is for health and mental health professionals including:

  • psychologists
  • psychiatrists
  • psychotherapists
  • physicians
  • psychiatric nurses
  • clinical social workers

This information is for reference only.  Always consider the needs of individual patients and available resources.

Prevelance
Risk Factors and Symptoms
Diagnosis
Management

Prevelance

Dementia affects between 5 and 7 percent of adults over age 65 and 40 percent of those over age 85.

American Psychological Association, 1998

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Risk Factors and Symptoms


Risk Factors

  • Age
  • Vascular disease
  • Diabetes mellitus
  • Female gender
  • Sedentary lifestyle
  • Low education level
  • Race/Ethnicity
    • Increased risk among African Americans and Latinos, even when controlled for educational level
  • HIV-positive status, especially with co-morbid hepatitis C
  • History of:
    • Cardiovascular accident
    • Alcohol abuse
    • Head trauma

Causes of Dementia

  • Alzheimer’s disease
  • Diffuse Lewy body disease
  • Vascular dementia
  • Alcohol or drug abuse

Common Metabolic and Toxic Causes

  • Vitamin deficiencies:
    • Thiamine (Wernicke-Korsakoff syndrome)
    • Folic acid
    • Vitamin B-12
  • Hypoxia and/or anemia
  • Hyperglycemia or hypoglycemia
  • Medications––especially anti-cholinergic drugs
  • Hyperthyroidism or hypothyroidism
  • Hepatic encephalopathy
  • Chronic renal failure

Common Infectious Causes

  • Neurosyphilis paresis (a syphilitic infection manifested as dementia, seizures, and problems walking and standing)
  • AIDS/HIV-related disorders
  • Meningitis
  • Encephalitis
  • Creutzfeldt-Jakob disease

Other Causes

  • Huntington’s chorea
  • Parkinson’s disease

Possible Protective Factors

  • Mental “exercises”–– crossword puzzles, reading, logic problems, math
  • Physical exercise
  • Diet high in antioxidants and low in animal fats

Symptoms

  • Loss of short-term and long-term memory
  • Loss of abstract thinking and judgment
  • Aphasia or word-finding difficulties
  • Apraxia (inability to carry out motor activities despite intact comprehension and motor function)
  • Agnosia (inability to recognize or identify items despite intact sensory function)
  • Difficulty with construction (inability to copy three-dimensional figures, assemble blocks, or arrange sticks in specific designs)
  • Personality change or alteration and accentuation of premorbid traits
  • “Catastrophic” reactions to misplaced objects
  • Extreme anxiety if left alone or if caregiver is out of sight
  • Loss of the ability to attend to activities of daily living

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Diagnosis


DSM-IV diagnostic criteria

A definitive diagnosis of dementia is based on the following criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):

  1. The development of multiple cognitive deficits manifested by both
    1. Memory impairment (impaired ability to learn new information or to recall previously learned information) and;
    2. One (or more) of the following cognitive disturbances:
      1. Aphasia (language disturbance)
      2. Apraxia (impaired ability to carry out motor activities despite intact motor function)
      3. Agnosia (failure to recognize or identify objects despite intact sensory function)
      4. Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
  2. The cognitive deficits listed above cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
  3. The deficits do not occur exclusively during the course of a delirium
  4. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of one of the conditions listed below:
    • Dementia due to Alzheimer’s disease
    • Dementia due to head trauma
    • Dementia due to cerebrovascular disease
    • Dementia due to Parkinson’s disease
    • Dementia due to Huntington’s disease
    • Dementia due to HIV
    • Dementia due to Pick’s disease
    • Dementia due to Creutzfeldt-Jakob disease
    • Dementia not otherwise specified

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.


Interview guidelines

  • Inquiry regarding risk factors for dementia
  • Interview with patient regarding subjective symptoms of memory loss
  • Interview with caregiver/relatives about instrumental actvities of daily living (IADLs), activities of daily living (ADLs), memory, and other cognitive abilities
  • Brief dementia screen, and if possible referral for neuropsychological testing
  • Lab tests: metabolic profile, complete blood count (CBC), folate, Venereal Disease Research Laboratory (VDRL) test, or rapid plasma reagin (RPR)
  • Possible tests: CT/MRI scan of brain; HIV test

Tests for dementia

Instruments that may be used to screen for dementia include:

Also:

  • The “draw-a-clock task.”Watson, YI, Arfken, CL, and Birge, SJ. Clock completion: An objective screening test for dementia. J Am Geriatrics Society 41:1235-1240, 1993.
  • The Neurobehavioral Cognitive Status Examination (NCSE).Kiernan, RJ, Mueller, J, Langston, JW., et al. The Neurobehavioral Cognitive Status Examination: A brief but quantitative approach to cognitive assessment. Ann Intern Med 1987 Oct; 107(4):481-485.

More comprehensive tests include:

  • The Wechsler Intelligence Scales of intelligence and memory
  • Halstead-Reitan Neuropsychological Test Battery for Adults
  • The Benton tests
    • Visual retention
    • Visual construction
    • Visual form discrimination.

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Management


Medication

Medications for dementia can be grouped into three categories:

  1. Cholinergic neurotransmitter modifying agents such as acetylcholinesterase inhibitors.
  2. Non-cholinergic neurotransmitters/neuropeptide modifying agents.
  3. Other pharmacological agents.

Agency for Healthcare Research and Quality (AHRQ): Evidence Report/Technology Assessment: Number 97; Pharmacological Treatment of Dementia, 2004.


Therapy

  • Behavior modification to help control unacceptable or dangerous behaviors
    • Rewarding appropriate or positive behaviors
    • Ignoring inappropriate behaviors (within the bounds of safety)
  • Reality orientation to reduce disorientation
  • Family counseling to strengthen coping skills
  • Provision of a safe environment
    • Familiar objects and people
    • Lights left on at night to reduce disorientation
  • Control of aggressive or agitated behavior
  • Care of daily needs, may require:
    • Monitoring and assistance in the home
      • In-home care
      • Adult day care
    • Monitoring and assistance in an institutionalized setting
      • Nursing home
    • Visiting nurses or aides, volunteer services, homemakers, or adult protective services

Adapted from:

  • American Psychological Association, Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia (1998). Guidelines for the evaluation of dementia and age-related cognitive decline. Washington, DC: American Psychological Association.
  • Delagarza, VW. Pharmacologic Treatment of Alzheimer's Disease: An Update. Am Fam Physician 2003;68:1365-1372