Dementia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D.

Overview

Dementia is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal aging, it should be disoriented from delirium which involves an acute onset, and usually is reversible. Dementia may affect several cognitive areas, such as memory, attention, language, and problem-solving. In advanced stages of the condition, affected persons may be disoriented in time, place, and/or in person. The diagnosis of dementia is primarily clinical and ruling-out other conditions by imaging and laboratory tests. It is important to always screen for depression, especially in older people, since this may be the underlying problem.

Life Threatening Causes

There are no identified life-threatening causes in dementia that may lead to death within 24 hours since all conditions are chronic.

Common Causes

• Alzheimer's Disease
• Parkinson's Disease
• Binswanger's Disease
• Dementia with Lewy bodies
• Thiamine deficiency
• Vascular dementia
• Marijuana abuse
• AIDS
• Neurosyphilis
• Normal pressure hydrocephalus
• Vitamin B12 deficiency
• Vitamin B6 deficiency

Diagnosis

Shown below is an algorithm summarizing the diagnosis of amnesia according to the the American Academy of Neurology guidelines:

Progressive decline in cognitive function with chronic onset

Severe disimpairment in social functioning? Decline from previous levels of functioning and performance Symptoms are not explained by major psychiatric disorder

No

Normal aging

Dementia

Measure vitamin B12, and folate, and TSH

Abnormal?

Yes

Vitamin deficiency, hypothyroidism

Positive for SIGE CAPS questionary?

Yes

Depression

Take history and perform physical examination

Initial short term memory loss

Vascular risk factors, imaging evidence of cerebrovascular involvement

Young age, behavioral symptoms or language impairment

Bradikinesia or features of parkinsonism, fluctuating cognition, [[visual hallucinations]]

Dementia occuring 1 year after onset of Parkinson disease

Alzheimer disease

Vascular dementia

Frontotemporal dementia

Dementia with Lewy bodies

Parkinson's disease

Treatment

Treat the underlying cause:

• To view the treatment of Alzheimer disease click here.
• To view the treatment of vascular dementia click here.
• To view the treatment of frontotemporal dementia click here.
• To view the treatment of dementia with Lewy bodies click here.
• To view the treatment of Parkinson's disease click here.

General management of dementia for maintaining brain health according to the American Neurological Asociation is as follows:

Recommendations for maintaining brain health in elderly patients with and without AD
Consider following a Mediterranean-style diet, with fish, vegetables, legumes, fruit, cereals, unsaturated fatty acids (e.g., olive oil), and a limited amount of meat or dairy products. Consider taking supplements containing omega-3 (particularly docosahexaenoic acid), B-complex vitamins (including B12, B6, folic acid), and vitamin E. Keep alcohol intake to a low-to-moderate level (e.g., one glass of wine per day with dinner). Engage in regular physical activity. Maintain leisure and social activities – keep socially engaged. Continue or take up activities that help to stimulate the brain, e.g., Tai Chi, dancing, puzzles. Become educated about dementia and seek support from others with dementia, e.g., the Alzheimer's Association, Keep Memory Alive, and other community groups. Include music in daily life – listening to music, playing an instrument, singing. Maintain regular sleep patterns. Manage stress – stop doing things if they are becoming too stressful (e.g., volunteer work, answering the telephone), keep to a regular daily schedule, and include relaxing activities (e.g., playing with pets, massage, and aromatherapy).
Do not modify

Do's

• Perform laboratory testing to exclude potentially reversible causes of amnesia. Initial tests should include a CBC, urine toxicology, thyroid function, folate, and vitamin B12 level.
• When pereforming cognitive assesment, use tests such as MMSE, Mini-cog, MoCA, SIB-8, and AD8.
• When determining level of independence and level of disability, use test such as ADCS–ADL.
• When determining the level of behavioral symptoms, use the NPI-Q test.
• Identify primary caregiver and assess his health, as well as adequacy of family and other support systems.
• Perform a non-contrasted CT scan to diagnose vascular disease, normal pressure hydrocephalus, tumors, and abscess.
• Perform a minimental status test on physical examination and pay especial attention in concentration domain. Minimental testing has the potential distinguish mild cognitive impairment from dementia.
• Always have in mind depression as a possible cause of memory impairmant. Depression is common cause of amnesia; a SIGE CAPS evaluation may disclose an underlying mood disorder.

Don'ts

• If alcoholism and thiamine deficiency is suspected, do not administer glucose before thiamine. Administration of glucose before thiamine may lead to Wernicke encephalopathy.