Written by Dr. Sanjana V.B Bhms,dbrm,cdn

Founder & medical director of siahmsr wellness.in

All rights reserved with siahmsr digital healthcare[siahmsr wellness]

Reviewed by SIAHMSR medical team.

Dementia – A neurocognitive disorder

  Dementia refers to a neurocognitive disorder characterized by progressive cognitive decline that interferes with the ability to function independently. Dementia is a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities. Dementia is categorized as a Neurocognitive Disorder (NCD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

 Alzheimer’s disease is the most common type of dementia. Currently more than 55 million people suffer from dementia globally. Among them, over 60% of the people belong to low-and middle-income countries. There is an annual spike of nearly 10 million new cases.

    Dementia mostly affects old people; however dementia is not simply forgetting something due to age related changes. It is more complicated than the occasional forgetfulness in old people.  The risk of dementia increases with ageing, particularly after age 65. The symptoms of dementia appears gradually and it is progressive and persistent. In dementia there is destruction or degeneration to nerve cells of brain, ultimately leading to deterioration in cognitive function (i.e. the ability to process thought) and it is more complex than the age related changes in cognition while consciousness is not affected in dementia.

   The impairment in cognitive function is commonly followed, and occasionally preceded, by changes in mood, emotional control, behavior, or motivation. Synaptic failure, inflammation and change in cerebral metabolism  resulting from damage to cerebral cortex neuronal system lead to cognitive impairment in dementia. Learning  and memory, language, complex attention, executive function, perceptual-motor and social cognition are affected in dementia.

This neurocognitive disorder is classified as mild or major, depending on the severity of symptoms manifested in individuals. Dementia runs in families and genes play a crucial role mostly. But every case of dementia is not familial.  A  positive family history may not be present in all types of dementia. Older African Americans are twice more likely to have dementia than whites. Hispanics 1.5 times more likely to have dementia than whites. Smoking also enhances the risk for dementia.

What is mild cognitive deficits MCI? How it is related to dementia?

People having mild cognitive deficits but who do not meet the criteria for dementia are considered to have mild cognitive impairment (MCI). People having MCI may be presenting with problems with memory, language, thinking or judgement that are greater than the expected cognitive changes associated with normal aging.  MCI can be assessed objectively with cognitive tests, the impairments are considered to be insufficient to interfere with an individual’s daily life and independence. In the early stages of Alzheimer’s disease (AD), the affected individuals may present with MCI. And having MCI also enhances the risk for Alzheimer’s disease and other dementias in future.

Types of dementia

The common types of dementia are Alzheimer’s disease [AD], vascular dementia, Lewy body dementia and frontotemporal dementia

   Alzheimer’s disease is the most common cause of dementia, accounting for 60 to 80 percent of cases. The risk increases by 10 to 30 percent with presence of Alzheimer’s disease in the family. The  accumulation of beta-amyloid plaques and neurofibrillary tangles, first in the brain areas of the entorhinal cortex and the hippocampus and resulting neuronal injury and death cause dementia in AD. The cholinergic neurotransmission decreases due to neuronal death leading to loss of memory and cognition. The neurotransmitter choline acetyltransferase (involved in the synthesis of acetylcholine) activity is reduced in AD .Later beta amyloid  plaque deposition spreads to other parts of the brain, neurons progressively die in affected regions, and thereby worsening the symptoms of AD. Genetics also plays a crucial role in the development of AD.

 In AD short-term memory loss is most commonly the first sign. Gradual deficits in cognitive function occur progressively over time as the disease advances. AD usually presents with problems in memory and visuospatial abilities (e.g., becoming lost in a familiar environment). Personality changes and behavioral problems may develop as the disease progresses.

   Vascular dementia is the second common type of dementia. About 10 percent of dementia cases are happening after strokes or other issues with blood flow to the brain. This is known as vascular dementia. This type of dementia is also known as multi-infarct dementia, as it results  from neuronal deprivation of oxygen caused by conditions of reduced blood flow to the brain. Diabetes, high blood pressure and high cholesterol are risk factors for vascular dementia. Memory may not be affected in vascular dementia, but a sudden change in executive function (e.g., thinking, reasoning) appear after a stroke

  Lewy body dementia[LBD] is another type of dementia associated with memory loss, balance problems, stiffness or trembling. This type of dementia is caused by abnormal deposits of alpha-synuclein protein (Lewy bodies) inside neurons. It accounts for 5% to 15% of all dementias. LBD is characterized by fluctuating cognitive impairment with variations in attention and alertness, recurrent complex visual hallucinations and spontaneous parkinsonism. Lethargy, daytime somnolence, sustained periods of staring into space are common in LBD.  Periods of improved memory, episodes of disorganized speech and periods of decreased attention along with neurological symptoms such as rigidity, bradykinesia and rapid eye movement (REM) sleep disorders are common in early LBD. It may progress to Parkinson’s disease later.

Fronto-temporal dementia [ FTD ] is a peculiar type of dementia linked with changes in personality and behavior because of changes in specific brain areas. FTD is a general term used to describe disorders, such as Pick’s disease, that affect the frontal and temporal lobes of the brain. People with this dementia behave inappropriately, making offensive comments without reason and start neglecting responsibilities at home or work. Their language skills like speaking or understanding also affected. Personality changes and behavioural disturbances are key features of FTD and occur early in young people.

   In some people more than one type of dementia may coexist, particularly in people aged 80 and older. Dementia due to Alzheimer’s disease and stroke may occur in the same person. This is called mixed dementia. Other reversible causes of dementia include side effect of medication, increased pressure in the brain, vitamin deficiency, and thyroid hormone imbalance etc.

  Dementia is currently the seventh leading cause of death and one of the major causes of disability and dependency among older people globally. Women experience higher disability-adjusted life years and death from dementia.

Factors which enhance the risk for development of dementia include:

·       Old age (more common in those 65 or older)

·       high blood pressure (hypertension)

·       high blood sugar (diabetes)

·        Overweight  or obesity

·       Smoking

·       drinking too much alcohol

·        Physical  inactivity

·       Social isolation

·       Depression

 The clinical presentation of dementia

 In dementia there may be a decline in cognitive abilities that impacts a person's ability to perform everyday activities. The clinical presentation of dementia varies greatly from person to person. The cognitive deficits  may present as memory loss, communication and language impairments, agnosia (inability to recognize objects), apraxia (difficulty to perform previously learned tasks) and impaired executive function (reasoning, judgement and planning). People with dementia may experience various types of problems in:

·       Memory

·       Attention

·       Communication

·       Reasoning, judgment, and problem solving

·       Visual perception beyond typical age-related changes in vision

Signs that may indicate dementia include:

·       Getting lost in a familiar neighborhood

·       Using unusual words to refer to familiar objects

·       Forgetting the name of a close family member or friend

·       Forgetting old memories

·       losing or misplacing things

·       getting lost when walking or driving

·       being confused, even in familiar places

·       losing track of time

·       difficulties solving problems or making decisions

·       Inability to do things independently.

     Changes in mood and behavior also follow or precede the main symptoms of dementia and these include:

·       anxious, sad, or angry  mood about memory loss

·       personality changes

·       inappropriate behavior

·       withdrawal from work

·       indifferent to social activities

·       not interested in other people’s emotions

Prognosis

  Usually most of the symptoms of dementia worsen over time, while a few symptoms diminish for a particular period or only occur in the later stages of dementia. As the disease progresses, the ability to do things independently decreases.

 Dementia has physical, psychological, social and economic impacts. The people affected with dementia fail to recognize family members or friends.

There can be loss of control over their bladder and bowls.

They may have trouble eating and drinking .

Aggressive behavior may happen in dementia and it will be troublesome to care givers and the patient too.

Behavioural and psychological symptoms of dementia are considered as complications of dementia. They include agitation, apathy, aggression, psychosis, hallucinations and delusions. Unfortunately, many behavioural and psychological symptoms, such as wandering, hoarding, inappropriate behaviours (e.g., sexual disinhibition, eating inappropriate objects), repetitive behaviour and restlessness, do not respond well to medications.

Diagnosis

  The diagnosis of dementia requires observation of a change from a person's usual mental functioning and a greater cognitive decline than what is caused by normal aging.  In clinical practice, the diagnosis of dementia and its subtype is made based on a detailed patient history, physical examination, cognitive assessment and laboratory testing. Neuroimaging studies such as magnetic resonance imaging or computed tomography scans, may help to establish the diagnosis. As cognitive impairment has multifactorial causations, a detailed history is vital.

 A medication review should be part of the evaluation as various clinical conditions and drug intake may contribute to cognitive impairment, including adverse drug effects, depression, thyroid disease, vitamin B12 deficiency, hypercalcemia, sleep apnea, atrial fibrillation, subdural hematoma and delirium. It is important to differentiate all these based on case history, clinical examinations, lab and imaging studies.

  There are various cognitive screening tools and instruments to assess cognitive impairment. The Mini-Mental State Exam [ MMSE] is the most commonly used cognitive screening tool used globally to assess dementia. It is the most thoroughly studied instrument till date and  MMSE requires 5 to 10 minutes to administer, and it is available in different languages and requires minimal training by a clinical assessor. It provides a global assessment of various cognitive domains: orientation to time and place, registration of words, calculation, attention, concentration, recall of words, language and visual construction.

Treatment

The treatment is decided based on the type of dementia and the underlying causes. In vascular dementia stroke is the cause of dementia. It is addressed with post stroke medications, nutrition, physiotherapy and exercise programs. Alzheimer’s disease is a neurodegenerative disorder with no effective cure till date. 

Nutritional intervention 

 Alzheimer’s disease is a neurodegenerative disorder with genes as its most probable cause. There is no effective cure till date. Recently oxidative stress by free radicals has been implicated with significance. Therefore the role of nutrition and antioxidant rich food is included in the treatment and prevention of Alzheimer’s disease and other neurodegenerative disorders. However ,the research studies show that results are conflicting regarding the role of omega fatty acids and other nutrients in preventing the progress of Alzheimer's disease. Being physically active or taking part in activities and social interactions that stimulate the brain and maintain daily function is important in prevention as well as management of dementia.

Medications

Some medications in modern or conventional medicine can help manage dementia symptoms.

 Cholinesterase inhibitors like donepezil are used to treat Alzheimer disease.

NMDA receptor antagonists like memantine are used for severe Alzheimer disease and vascular dementia.

Medicines to control blood pressure and cholesterol can prevent further damage to the brain due to vascular dementia consequent to stroke.

Selective serotonin reuptake inhibitors (SSRIs) can help with severe symptoms of depression in people living with dementia if lifestyle and social changes found ineffective. In aggressive dementia patients who are at risk of hurting themselves or others, medicines like haloperidol and risperidone can help.

 All the medications are to be recommended by a board certified healthcare provider after careful analysis of each person having dementia. Do not take over the counter medications.

Complementary & alternative system of medicine

Following therapies are available to mitigate the psychological, behavioral and speech related problems.

·       Occupational therapy

·       Speech therapy

·       Mental health counseling.

·       Music or art therapy

·       Homeopathy

Follow the link below.

http://siahmsrwellness.in/dementia-loss-of-memory

 Homeopathy for dementia

Several homeopathic medicines are available for managing the symptoms of various types of dementia such as ALZHEIMER’s disease, vascular dementia after stroke etc.

·       Anacardium – for alzheimer’s disease. Sudden loss of memory.

·       Baryta carbonicum

Emotional instability, anxiety, sudden fits of passion from trifling causes. Great weakness of memory. Aneurysm, history of apoplexy. It is an indicated remedy for vascular dementia as well as Alzheimer’s disease [5].

·       Hyoscyamus niger – is also an important remedy fo Alzheimer’s disease with foolish gestures and talk.

·       Other remedies include :

Conium,acid phosphoricum, picric acid, Stramonium etc.

·       Ginko biloba extract or tincture

It is an important homeopathic medicine as well as a constantly researched herb by scientists.

It is helpful in improving thinking capacity and memory, social behavior and  ability to perform everyday tasks. One study [ a prospective, randomized, double-blind, placebo-controlled, multi-center study ] shows that in dementia of the Alzheimer type and multi-infarct dementia ginko biloba extract is effective [10,11].

References

1.    https://www.cdc.gov/aging/dementia/index.html

2.    https://www.who.int/news-room/fact-sheets/detail/dementia

3.    https://medlineplus.gov/dementia.html

4.    Hildreth KL, Church S. Evaluation and management of the elderly patient presenting with cognitive complaints. Med Clin North Am 2015;99(2):311-35. https://pubmed.ncbi.nlm.nih.gov/25700586/

5.     Ganguli M, Snitz BE, Saxton JA, et al. Outcomes of mild cognitive impairment by definition: a population study. Arch Neurol 2011;68(6):761-7 https://pubmed.ncbi.nlm.nih.gov/21670400/

6.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5384525/

7.    https://alzheimer.ca/en/About-dementia/Dementias/Vascular-Dementia

8.    materia medica by J.H .Clarke.bary.carb

9.    Homeopathic medical repertory Mind dementia [p- 1574]

10.                       Proof of efficacy of the ginkgo biloba special extract EGb 761 in outpatients suffering from mild to moderate primary degenerative dementia of the Alzheimer type or multi-infarct dementia https://pubmed.ncbi.nlm.nih.gov/8741021/

11.                       A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for dementia. North American EGb Study Group PMID: 9343463 DOI: 10.1001/jama.278.16.1327 https://pubmed.ncbi.nlm.nih.gov/9343463/