Dementia Overview and Types

RPD (Rapidly Progressive Dementia) can stem from tumors, infections (like HIV), metabolic issues, autoimmune diseases, psychiatric factors, toxins, vascular events, neurodegenerative disorders (like Alzheimer's), Creutzfeldt-Jakob disease, or anti-NMDA receptor encephalitis.

Gathering information on the onset, type, and progression of symptoms, precipitating events (if any), risk factors, medications, or concurrent illnesses is crucial in diagnosing Rapidly Progressive Dementia.

Objective testing, including physical, neurological exams, and brief cognitive tests (like MMSE), is essential after a suspected cognitive disorder is raised.

A brief cognitive test used to differentiate dementia from depression. It assesses orientation, memory, language, and visuospatial skills.

AD is often characterized by a gradual onset and progressive memory decline.

FTD or a language variant of AD usually presents with progressive aphasia (language problems) or prominent apathy (lack of interest/energy).

Vascular or mixed dementia often has abrupt onset, usually without new medications or secondary infections.

A critical diagnostic tool involves data from family and others, covering symptom timing, type, precipitating events, risk factors, new medications, and onset of systemic diseases.

Neuropsychiatric symptoms (NPSs) are behavioral and psychological changes that occur in people with dementia.

Common NPSs include agitation, depression, apathy, delusions, hallucinations, sleep problems, irritability, mood swings, anxiety, vocal disruptions, aggression, sundowning, wandering, pacing, hoarding, and inappropriate sexual behavior.

NPSs significantly affect both patients and caregivers, leading to greater impairment in daily activities, faster cognitive decline, lower quality of life, earlier institutionalization, and increased caregiver depression.

NPSs can arise from neurobiological factors within the brain, unmet needs of the patient (like thirst or discomfort), caregiver factors, environmental triggers, or a combination of these.

Instead of 'challenging behaviors,' the term 'responsive behaviors' is preferred because it acknowledges that these behaviors reflect attempts to communicate distress or unmet needs.

Sundowning is a pattern of increased agitation, confusion, and restlessness in the late afternoon or evening.

NPSs can affect the safety and care of patients with MCI or dementia.

NPSs are becoming increasingly significant in dementia care because they can worsen the disease progression and lead to negative outcomes for both patients and caregivers.

Using medications to manage behavioral and psychological symptoms in people with dementia

Before prescribing, inform the patient and caregiver about the medication's benefits and risks, get consent, and adjust doses carefully for older adults.

Older adults with dementia are more vulnerable to side effects from medications, including sedation, cognitive decline, and drug interactions.

Low-dose psychostimulants can be used for apathy in dementia patients partially responsive to SSRIs, but they have risks like increased heart rate and agitation.

Antidepressants may be used if depression is suspected as a cause for NPSs, but they have limited effectiveness for dementia alone. Closely monitor for side effects.

Agitation is a common NPS and often requires targeted medication when other treatments fail.

High doses of SSRIs can worsen apathy and reduce emotional response.

Avoid psychostimulants in patients with severe cardiovascular disease due to potential risks like increased heart rate and agitation.

Anticonvulsant mood stabilizers like carbamazepine and valproic acid are not routinely used to treat NPSs in dementia patients unless they have a pre-existing diagnosis of bipolar disorder.

Cholinesterase inhibitors can worsen agitation in individuals with Frontotemporal Dementia (FTD).

Antipsychotics are used to treat psychosis and aggression in dementia patients, but they come with significant side effects.

Longer-term use of typical antipsychotics, as well as some atypical antipsychotics, can lead to the development of tardive dyskinesia, especially in older female dementia patients.

Cholinesterase inhibitors are medications that improve cognitive function in individuals with Alzheimer's disease, Dementia with Lewy Bodies, and other dementias by slightly boosting neurotransmitter levels.

Antipsychotics can cause sedation, postural hypotension, increased risk of falls, fractures, cerebrovascular events, mortality, extrapyramidal symptoms (EPS), and metabolic adverse effects like weight gain and dyslipidemia.

Haloperidol is the antipsychotic most likely to cause extrapyramidal symptoms (EPS) and should only be used for treating agitation or psychosis in delirium.

When choosing an antipsychotic, consider the patient's age, gender, specific symptoms, and history of other medical conditions, as some medications may pose greater risks to certain individuals.

Levodopa is a medication used to treat Parkinson's disease (PD) by converting to dopamine in the brain, helping improve motor symptoms.

Dopamine agonists are medications that mimic dopamine's effects, used in PD to improve motor symptoms and can be used before levodopa to delay dyskinesia.

Using dopamine agonists before levodopa in younger patients can delay the onset of dyskinesia, involuntary movements caused by long-term levodopa use.

Elderly PD patients often start levodopa treatment immediately because dopamine agonists can have more side effects and might not delay dyskinesia in this age group.

PD medication dosages need to be adjusted over time due to the progressive nature of the disease and the development of motor complications.

Non-dopaminergic medications like beta-blockers or anticholinergics may be useful for tremor in early PD to postpone the use of dopamine-related medications.

COMT and MAO-B inhibitors are medications that block the breakdown of dopamine, prolonging its effects and helping manage 'wearing off' symptoms.

A lacunar stroke is a type of stroke caused by a blockage in small arteries in the brain, often due to degenerative lesions or micro-atherothrombosis.

An embolism is a blockage in a blood vessel caused by a traveling clot (emboli), reducing blood flow and potentially causing a stroke.

PD patients often experience motor fluctuations, switching between 'on' time with controlled symptoms and 'off' time with symptom recurrence.

A cardiac embolism occurs when a blood clot forms in the heart and travels to the brain, causing a stroke. This can happen due to conditions like atrial fibrillation, ischemic heart disease, or valvular heart disease.

A hemorrhagic stroke happens when a blood vessel in the brain ruptures, causing bleeding inside or around the brain.

Intracerebral hemorrhage is bleeding within the brain tissue itself, often caused by weakened blood vessels due to factors like high blood pressure, aging, or aneurysms.

Subarachnoid hemorrhage is bleeding in the space surrounding the brain, often caused by a ruptured aneurysm at the base of the brain.

Hemorrhagic transformation is when an ischemic stroke (blockage) turns into a hemorrhagic stroke (bleeding). This can occur spontaneously or due to clot breakdown after treatment.

There are two main types of stroke: ischemic, caused by a blockage, and hemorrhagic, caused by bleeding.