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The rate of progression depends upon the underlying cause.
The duration of history helps establish the cause of dementia: Alzheimer‘s disease is slowly progressive over years, whereas encephalitis may be rapid over weeks. Dementia due to cerebrovascular disease appears to occur ’stroke by stroke‘
- Acetylcholinesterase inhibitors ( Donepezil , Rivastigmine, Galantamine have been shown to enhance cognitive performance in early disease. Memantine is approved for moderate disease. However they do not cure!
Treat concurrent depression, anxiety and sleep disorders
Neuroleptic use may be required for behavioral disturbance
Mangement of AD requires careful advice and counseling of the patient and family and shared care involving the family, caregivers, GPs, hospital specialist, and community psychiatric services
Caused by abnormal microscopic deposits of protein, called Lewy bodies, which destroy nerve cells
Lewy bodies cause symptoms typical of Parkinson disease, such as tremor and muscle rigidity, as well as dementia similar to that of Alzheimer disease
Progressive cognitive decline, combined with three additional defining features: (1) pronounced “fluctuations” in alertness and attention; (2) recurrent visual hallucinations, and (3) parkinsonian motor symptoms, such as rigidity and the loss of spontaneous movement
DLB usually occurs sporadically, in people with no known family history of the disease. However, rare familial cases have occasionally been reported
2:1 male:female ratio
Lewy body dementia is not reversible and has no known cure
It is presumed that at some preceding period, impedence to normal SCF flow causes raised intraventricular pressure and ventricular dilatation. Compensatory mechanisms permit a reduction in CSF pressure yet the ventricular dilatation persists and causes symptoms.
Diagnosis is based on clinical picture plus CT scan/MRI evidence of ventricular enlargement.
NPH must be differentiated from pts whose ventricular enlargement is merely the result of shrinkage of the surrounding brain, e.g. AD. These pts do not respond to CSF shunting, whereas a proportion of NPH pts (but not all) show a definitive improvement with ventriculo-peritoneal shunting.
Reduction of intellectual function is common after severe head injury
Chronic subdural haematoma can also present as progressive dementia, especially in the elderly
Punch-drunk encephalopathy (dementia pugilistica) is the cumulative result of repeated cerebral trauma It occurs in both amateur and professional boxers and it manifests by dysarthria, ataxia and expy signs associated with ’subcortical‘ dementia. There is no treatment for this progressive syndrome
American Psychiatric Association (APA) has established 2 criteria for the diagnosis of dementia:
erosion of recent and remote memory
Impairment of one or more of the following functions
Language Misuse of words or inability to remember and use words correctly (i.e., aphasia) Motor activity Unable to perform motor activities even though physical ability remains intact (i.e., apraxia) Recognition Unable to recognize objects, even though sensory function is intact (i.e., agnosia) Executive function Unable to plan, organize, think abstractly
The American College of Physicians and the American Academy of Family Physicians have published a clinical practice guideline on pharmacologic therapies for dementia based on a review of 59 randomized trials of 5 FDA-approved drugs (donepezil, galantamine, rivastigmine, tacrine, and memantine) in more than 16,000 patients
The guideline recommends the following:
Base decisions about starting a cholinesterase inhibitor on individualized assessments.
Base the choice of pharmacologic agent on tolerability, adverse effects, ease of use, and cost
Further research on effectiveness of the medications alone and in combination for clinical outcomes is required
Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians ; Ann Intern Med. 2008;148:370-378