This document provides an overview of dementia, including its definition, terminology, epidemiology, causes, stages, clinical features, classification, diagnosis, and investigations. Some key points include: - Dementia is characterized by impairment of intellectual functions, memory, and personality. It interferes with daily life. - Alzheimer's disease is the most common cause, accounting for around 70% of cases. Vascular dementia is the second most common. - Symptoms vary depending on the area of brain affected but generally include cognitive decline and neurological or psychiatric features. - Diagnosis involves ruling out other causes through examinations, imaging, and lab tests. Unfortunately, dementia is usually progressive and currently incurable.

1. M. MUHAMMAD SULAIMAN
MBChB IV
HABIB MEDICAL SCHOOL-IUIU
BUTABIKA NATIONAL REFERRAL MENTAL HOSPITAL
KAMPALA-UGANDA
EAST AFRICA

2.  Definition
 Terminologies
 Epidemiology
 Causes
 Stages
 scaling
 Clinical features
 Classification
 Diagnosis
 Investigations

3.  The word "dementia" is related to demens a Latin word for
"mad," or "insane.”
 is a chronic organic mental disorder, characterized by the
following main clinical features:
1. Impairment of intellectual functions
2. Impairment of memory (predominantly of recent
memory, especially in early stages)
3. Deterioration of personality with lack of personal
care.

4.  It can also simply be defined as a chronic
acquired syndrome characterized by
progressive, usually irreversible, global
cognitive deficits sufficient to interfere with the
day to day life of the person affected.
 It is often known as Major Neurocognitive
Disorder (The DSM-5’s New Term for
Dementia)

5.  Impairment of all these functions occurs
globally, causing interference with day-to-day
activities and interpersonal relationships.
 There is impairment of judgment and impulse
control, and also impairment of abstract
thinking.
 There is however usually no impairment of
consciousness (unlike in delirium).
 The course of dementia is usually progressive

6.  Dysphasia: Impairment in producing or
understanding speech (expressive dysphasia
and receptive dysphasia respectively) related
to cortical abnormality. In contrast with
dysarthria where the abnormality is in the
organs of speech production.

7.  Agnosia: Inability to interpret sensations and
hence to recognize things, typically as a result
of brain damage. Could be visual, auditory,
and tactile.
 Apraxia: Inability to perform a movement or
task when asked despite having the desire and
physical capability to carry it out.

8.  Information on dementia prevalence in Africa
is very limited.
 The overall prevalence of dementia in adults
older than 50 years in Africa was estimated to
be about 2.4%, which translates to 2.76 million
people living with a disease in 2010. About 2.10
millions of them live in Sub–Saharan Africa.

9.  Prevalence was the highest among females
aged 80 and over (19.7%) and there was little
variation between regions.
 Alzheimer’s disease was the most prevalent
cause of dementia (57.1%) followed by vascular
dementia (26.9%).
 The main risk factors were increasing age,
female sex and cardiovascular disease.

10.  A Ugandan study found that 13.2 % of all
elderly patients of >60 years admitted on non-
psychiatric wards had dementia followed by
depression as the two most common
psychiatric diseases of the elderly.
 https://www.researchgate.net/publication/300756721_A_Case_of_Alzhei
mer's_Dementia_in_Uganda

11.  Parenchymatous brain
disease
Alzheimer’s disease, Pick’s
disease, Parkinson’s
disease, Huntington’s
chorea, Lewy body
dementia, Steel
Richardson syndrome
(Progressive Supranuclear
Palsy)
 Vascular dementia
Multi-infarct dementia,
subcortical vascular
dementia
( Binswanger’s disease)
 Toxic dementias
Bromide intoxication,
drugs, heavy metals,
alcohol,
carbon monoxide,
analgesics,
anticonvulsants,
benzodiazepines,
psychotropic drugs
 Metabolic dementias
Chronic hepatic or uremic
encephalopathy, dialysis
dementia, Wilson’s disease

12.  Endocrine causes
Thyroid, parathyroid,
pituitary, adrenal
dysfunction
 Deficiency dementias
Pernicious anaemia, Pellagra,
folic acid deficiency,
thiamine deficiency.
 Hydrocephalic dementia
Normal pressure
hydrocephalus
 Dementias due to infections
Creutzfeldt-Jacob disease,
neurosyphilis, chronic
meningitis, viral
encephalitis, AIDS dementia,
sub acute sclerosing
panencephalitis (SSPE)
 Neoplastic dementias
Neoplasms and other
intracranial space-occupying
lesions
 Traumatic dementias
Chronic subdural
hematoma, head injury

13.  D= Drugs, Delirium
 E = Emotions (such as depression) and
Endocrine Disorders
 M= Metabolic Disturbances
 E = Eye and Ear Impairments
 N= Nutritional Disorders e.g. Vit. B12
deficiency, nicotinic acid
 T = Tumors, Toxicity, Trauma to Head
 I = Infectious Disorders e.g. AIDS
complex and neurosyphilis
 A = Alcohol, Arteriosclerosis

14.  The early stage - loss of recent memory, inability to learn and
retain new information, language problems (especially word
finding), mood swings, and personality changes. progressive
difficulty performing activities of daily living
 The intermediate stage - unable to learn and recall new
information, require assistance with bathing, eating, dressing,
or toileting. Wandering, agitation, hostility, uncooperativeness,
or physical aggressiveness. disorientation in place and time,
often hallucinations, delusions, mood disturbances.
 The severe stage - unable to walk or to perform any activity of
daily living and usually are totally incontinent. Recent and
remote memory is completely lost. Patients may be unable to
swallow and eat and are at risk of malnutrition, pneumonia
(especially from aspiration), and pressure sores. Often aphasia,
bulimia, apathy, sexual disinhibition, cry.

15.  Rather than simply using “mild stage”,
“middle stage”, and “late stage” dementia as
descriptors, there are scales that exist that are
slightly more comprehensive in description…
 These include:
- Global Deterioration Scale / Reisberg Scale.
- Functional Assessment Staging Test (FAST).
- Clinical Dementia Rating (CDR)

16. • Memory impairment: starts with short-term and
progresses to long-term.
• History of personality change, forgetfulness,
social withdrawal, lability of affect,
disinhibition, diminished self-care, apathy,
fatigue, deteriorating executive functioning.
• Hallucinations and delusions often paranoid
(20–40%) and poorly systematized.
• Anxiety and/or depression in 50%.

17.  Neurological features (e.g. seizures, focal
deficits, primitive reflexes, pseudobulbar palsy,
long-tract signs).
• Catastrophic reaction.
• Pathological emotion—spontaneous lability.
• Sundowner syndrome—as evening approaches
confusion increases and falls become common.
 Apraxias and Agnosias.

18.  Dementias may be classified in terms of
primary site of pathology. Since site of
pathology in the brain correlates with
neuropsychiatric symptomatology, this is a
useful system of classification.
 Can also be classified according to aetiology
e.g. Alzheimer’s Dementia, ….

19. 1. Fronto-temporal e.g.
Pick’s disease (causes frontotemporal lobar
degeneration with build-up of tau proteins in
neurons, accumulating into silver-staining,
spherical aggregations known as "Pick bodies)
characterised by prominent personality change
which may manifest as a frontal lobe syndrome.
 A common cause of early-onset dementia, it is
often undiagnosed. Language impairments tend to
involve reduction in content (semantic anomia).
 CT shows fronto-temporal atrophy and SPECT
shows fronto-temporal metabolism.

20.  Posterior–parietal e.g. Alzheimer’s disease.
Characterized by early memory loss and focal
cognitive deficits. Personality changes are later
manifestations. Language impairments involve
problems with word-finding (lexical anomia).
 CT shows thinning (<12 mm) of the cortex of
the medial temporal lobe.

21. 2. Subcortical dementias;
Parkinson’s disease, Huntington’s disease, Wilson’s
disease, Binswanger encephalopathy, Progressive
Supranuclear Palsy (PSNP) HIV-associated
dementia, NPH.
Clinical features: gross psychomotor slowing; depressed
mood; movement disorders; mild amnesia; and
personality changes.
3. Cortical–subcortical dementias e.g. Lewy body
dementia. Clinical features: cortical and subcortical
symptoms.
4. Multifocal dementias e.g. CJD .
Clinical features: rapid onset and course; involves
cerebellum and subcortical structures.

22.  Alzheimer’s Dementia
 This is the commonest cause of dementia, seen
in about 70% of all cases of dementia in USA
 More commonly seen in women.
 There is some evidence to suggestive of that a
genetic basis.
 The diagnosis is by exclusion of all other causes
of dementia, no distinct diagnostic clinical
features or laboratory investigations.

23.  Its most common symptoms are short-term
memory loss and word-finding difficulties.
Also trouble with visual-spatial areas (for
example they may begin to get lost often),
reasoning, judgment, and insight.
 Common early symptoms of Alzheimer's
include repetition, getting lost, difficulties
keeping track of bills, problems with cooking
especially new or complicated meals, forgetting
to take medication, and word-finding
problems.
 The part of the brain most affected by
Alzheimer's is the hippocampus.

24.  Other parts of the brain that will show
shrinking (atrophy) include the temporal and
parietal lobes. Although this pattern suggests
Alzheimer's, the brain shrinkage in Alzheimer's
disease is very variable, and a scan of the brain
cannot actually make the diagnosis.

26.  Amnesia
 Aphasia
 Apraxia
 Agnosia
 Associated symptoms: Psychiatric
symptoms ( depression, hallucination)
and behavior symptoms (aggression,
wandering, sexual disinhibition and sleep
disturbances.

27.  Age
 Genetic (down syndrome, chromosome 14,19
and homozygous for the E4 alleles)
 Head injury
 Aluminum exposure

28.  Not considered a treatable disorder.
 However, Cholinesterase Inhibitors such as
Rivastigmine (1.5 - 6 mg twice a day),
Donepezil (5-10 mg/day), and Galantamine (4
mg -12 mg twice a day) have been used in the
recent past for treatment of moderate dementia
with Alzheimer’s disease

29.  Considered to be the second most common
cause of the degenerative dementias,
accounting for about 4% of all dementias.
 Has the primary symptoms of visual
hallucinations and "Parkinsonism (includes
tremor, rigid muscles, and a face without
emotion.
 The visual hallucinations in DLB are generally
very vivid hallucinations of people and/or
animals and they often occur when someone is
about to fall asleep or just waking up.

30.  Other prominent symptoms include problems with
attention, organization, problem solving and planning
(executive function) and difficulty with visual-spatial
function.
 Again, imaging studies cannot necessarily make the
diagnosis of DLB, but some signs are particularly common.
A person with DLB will often show occipital hypoperfusion
on SPECT scan or occipital hypometabolism on a PET scan.
 Generally, a diagnosis of DLB is straightforward and unless
it is complicated; a brain scan is not always necessary.
 Antipsychotic medication should be avoided (or used with extreme
caution and in low doses) in patients with Lewy body dementia.

31.  Vascular dementia is a type of dementia that is caused
by disease or injury to blood vessels in the brain, mostly
strokes.
 The exact symptoms of this dementia depend on where
in the brain the strokes have occurred and whether the
vessels are large or small.
 On scans of the brain, a person with vascular dementia
may show evidence of multiple different strokes of
different sizes.
 They also may have risk factors for artery disease such
as tobacco smoking, high blood pressure, atrial
fibrillation, high cholesterol or diabetes.
 He or she might also have other signs of blood vessel
disease such as a previous heart attack or angina.

32.  Multi-infarct Dementia:
-Occurrence of multiple cerebral infarctions can lead to a
progressive disruption of brain function, leading to
dementia.
 - commonest in India, An abrupt onset,
 - Acute exacerbations (due to repeated infarctions),
 - Stepwise clinical deterioration (step-ladder pattern),
 - Fluctuating course,
 - Presence of hypertension (most commonly) or any
other significant cardiovascular disease, and
 - History of previous stroke or transient ischemic
attacks (TIAs).

33. -About 50-70% of patients suffering from AIDS
exhibit a triad of cognitive, behavioral and motor
deficits of subcortical dementia type.
-As the AIDS virus is highly neurotropic and it
crosses the blood-brain barrier early in the course
of the disease
-Cognitive impairment is nearly ubiquitous in AIDS.
-The diagnosis is established by ELISA showing anti-
HIV antibodies, and the Western Blot test (blotting
of antibody specificities to HIV-specific proteins.

34.  One of the most important treatable and
reversible causes of dementia.
 Accounts for less than 1% of dementias.
 Diagnosis is difficult, laboratory tests should be
used for correct diagnosis.
 Prompt treatment can reverse the dementing
process and can lead to complete recovery if
the treatment is star ted within two years of the
onset.

35. Features
 Previous history of
depression
 Depressed mood and
cognition.
 Poor concentration
 No confabulation
 Don’t know or
approximate answer
 No neurological signs
 A presentation of severe
depression in the elderly
where the combination of
psychomotor retardation,
apparent cognitive
deficits, and functional
decline causes diagnostic
confusion with dementia.

36. Laboratory tests
 Full blood count
 Vitamin B12, folic acid
level
 Thyroid-stimulating
hormone (TSH)
 Blood glucose level
 Electrolytes, renal
function, and liver
enzymes.
 Testing for alcohol and
other known dementia-
inducing drugs may be
indicated.
 Comprehensive analysis of
drugs
 Serum cortisol, serum
ammonia, ethanol and
salicylate
 BUN and creatinine
 Serum calcium, phosphorus,
and parathyroid levels
 VDRL and Fluorescent
Treponemal antibody
Absorption (FTA-ABS)
 Lumbar puncture

37.  A CT Scan
 Magnetic Resonance Imaging (MRI Scan)
 Single Photon Emission Computed
Tomography
 Positron Emission Tomography (PET)
 EEG

38.  Family education and support groups
 Restrict/ prevent driving
 Drug therapy for cognitive deficits:
cholinesterase inhibitors/ Vit. E
 Drug therapy for psychosis and agitation:
 Haloperidol, Promazine, Lorazepam
 Drugs to treat depression: Mianserin, SSRI,
Venlafaxine, ECT (Electroconvulsive therapy)
 Sleep disturbances: sleep hygiene and habits,
using drugs sparingly.

39.  Dementia is usually insidious and relentlessly
progressive.
 However, about 20-30% of cases are due to
reversible causes. On average, patients with
Alzheimer disease die within 8 years of onset,
with a range of 2-15 years.
 Younger patients usually have a more
fulminant course. Pick’s disease has a similar
course.
 Subacute encephalopathy may be reversible,
persistent or progressive.

40.  D. Semple, R.Smyth. Oxford handbook of psychiatry, 3rd
Edition. Oxford university press.
 N. Ahuja. Ashort textbook of Psychiatry, seventh edition. Jaypee
Brothers Med publishers (P) Ltd.
 B. J. Sadock, V.A. Sadock, P. Ruiz. Synopsis of Psychiatry,
eleventh edition, Wolters Kluwer.