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Tuesday, 29 October 2013

Dementia - Symptoms and Complications

I. Dementia
About 5-8% of all people over the age of 65 have some form of dementia, and this number doubles every five years above that age. Dementia is the loss of mental ability that is severe enough to interfere with people's every life and Alzheimer's disease is the most common type of dementia in aging people. American typical diet contains high amount of saturated and trans fat, artificial ingredients with less fruits and vegetable which can lead to dementia and other kind of diseases

II. Symptoms and Complications of Dementia
Dementia is a neuropsychiatric disorder as a result of cognitive impairment and behavioral disturbances. The behavioral and psychological symptoms of dementia (BPSD) are common, contributing to caregiver burden and premature institutionalization. The true symptoms of dementia are a progressive loss of memory and other mental abilities of that can cause impairment of a person's ability to perform usual tasks in everyday life.
A. Symptoms
A.1. Symptoms of Alzheimer's disease 
Alzheimer's disease is a brain disorder named for German physician Alois Alzheimer. Alzheimer's destroys brain cells, causing problems with memory, thinking and behavior severe enough to affect language communication, memory, lifelong hobbies or social life. Alzheimer's gets worse over time, and it is fatal. Over 1 million people in US alone are currently afflicted by Alzheimer's disease because of degeneration of hippocampus and cerebral cortex of the brain where memory, language and cognition are located. With this mental disorder, brain cells gradually die and generate fewer and fewer chemical signals day by day resulting in diminished of functions. Overtime memory thinking as well as behavior deteriorates. Today, there is no know cure. 
In a study conducted by Hospital de Cruces, Plaza de Cruces s/n, Barakaldo of a total of 1014 patients (463 with higher and 551 with lower BPSD scores) were included (mean age 77 ± 7 years, 65% women). Almost all patients (90%) had BPSD at inclusion, 17% of which reported psychotic outbreaks. The most prevalent symptoms were lack of concentration (56%), tremors (56%), depression (44%), lack of cooperation (36%), and delusions (32%). Patients with higher BPSD scores showed a significantly higher prevalence of psychotic symptoms (delusions, hallucinations, and delirium) and tremors, while emotional symptoms (tearfulness and apathy) predominated in patients with lower BPSD scores. MMSE and ADAS-Noncog scores were negatively associated (p = 0.0284), suggesting a correlation between cognitive impairment and BPSD. Lack of concentration and appetite change significantly correlated with MMSE (p = 0.0472 and p = 0.0346, respectively). Rivastigmine and donepezil were the first choice therapies in mild to moderate dementia. ADAS-Noncog was generally considered better or similar to other scales (82%), and 68% of the investigators were willing to use it in the future.
Other symptoms include
1. Increasing forgetfulness
2. Communication difficulty
3. Depression
4. Anxiety
5. Mood and personal change
6. Difficulty making decision
7. Repeat question
8. Memory loss
9. Poor judgment
10. Etc.

A.2. Symptoms of Diminished quality of acetylcholine
If the nerves located in front of the brain perish, causing diminished quality of acetylcholine resulting in language difficulty, memory loss, concentration problem and reduced moblile skills because of lacking reaction in muscular activity and refection.
Symptoms of deficiency of acetylcholine include(2)
1. Difficulty remembering names and faces after meeting people
2. Difficulty remembering peoples birthdays and numbers
3. Difficulty remembering lists, directions or instructions
4. Forgetting common facts
5. Trouble understanding spoken or written language
6. Forget where I put things (e.g. keys)
7. Slowed and/or confused thinking
8. Difficulty finding the right words before speaking
9. Disorientation
10. Prefer to do things alone than in groups / social withdrawal
11. Rarely feel passionate
12. Feel despair and lack joy
13. Lost some of my creativity / lack imagination
14 Dry mouth
15. Etc.

A.3. Dementia due to long-term alcohol abuse
Dementia is common in patients with alcoholism. Although the symptoms of alcohol dementia are essentially the same as the symptoms present in other types of dementia, but there are few qualitative differences between alcohol dementia and other types of dementia. According to the article, "What's alcohol-related dementia?" The author(s) wrote" Alcohol dementia presents as a more global deterioration in intellectual function with memory not being specifically affected. Sufferers can present in their early thirties although the more common age for presentation is in the fifth, sixth and seventh decades. This condition is not, as suggested, a true dementia, in that recovery is possible. This seems to be more common in women and the recovery rates are better than for Korsakoff's Psychosis, provided correct support and alcohol abstinence is ensured. Most presentations are somewhere along the spectrum between Korsakoff's Psychosis and a global dementia. Others can present with damage to the frontal lobes to their brain which causes disinhibition, loss of planning, and executive functions and a blithe disregard for the consequences of their behaviour. Alcohol misuse can cause a general alcohol dementia that damages cells throughout the brain. Other types of alcohol-related dementia such as Korsakoff's Syndrome cause the destruction of certain areas of the brain, where changes in memory are the main symptom"(3)
Other symptoms include
1. Memory impairment
2. Language disturbance
3. Impaired ability to carry out motor activities despite intact motor function
d. Failure to recognize or identify objects despite intact sensory function
4.  Planning, organizing, sequencing, abstracting
5. Etc.

A.4. Multi-infarct dementia
Also known asvascular dementia , is the second most common form of dementia after Alzheimer's disease in older adults. It is caused by different mechanisms all resulting in vascular lesions in the brain. Major depression, depressed mood/anhedonia, and subjective and neurovegetative symptoms of depression that were unaccompanied by depressed mood/anhedonia in patients with clinically-diagnosed Alzheimer's disease (AD) and multi-infarct dementia (MID), as separate entities in AD and MID(4).
Symptoms include(5)
1. Confusion
2. Memory problems
3. Wandering Getting lost
4. Bladder incontinence
5. Bowel incontinence
6. Emotional problems
7. Laughing inappropriately
8. Crying inappropriately
9. Difficulty following instructions
10. Etc.

A.5. Dementia associated with Parkinson's disease
Parkinson disease (PD) is a disabling, progressive condition. It is a cognitive deficits due to the interruption of frontal-subcortical loops that facilitate cognition and that parallel the motor loop. Contrary to common perception, many Non-motor symptoms (NMS) of PD occur early in PD and some may even predate the diagnosis of PD that is based on motor signs. These include olfactory deficit, sleep problems such as rapid eye movement behaviour disorder, constipation and the more recently described male erectile dysfunction.(6). Other symptoms include(7)
1. Slow movement
2. Tremors
3. Rigidity
4. Poor balance
5. Constipation 
6. Difficulty swallowing 
7. Choking, coughing, or drooling 
8. Excessive salivation 
9. Excessive sweating 
10. Loss of bowel and/or bladder control
11. Etc.

A.6. Creutzfeldt-Jakob disease (CJD)
People who have eaten contaminated beef many years may be infected without even knowing it. Creutzfeldt-Jakob disease is a quickly progressing and fatal disease that consists of dementia, muscle twitching and spasm. CJD is characterized by rapidly progressive dementia. Initially, individuals experience problems with muscular coordination; personality changes, including impaired memory, judgment, and thinking; and impaired vision. People with the disease also may experience insomnia, depression, or unusual sensations.(8). Other symptoms include
1. Confusion
2. Depression
3. Lack of coordination
4. Strange physical sensations
5. Etc.

A.7. Subdural hematoma
It is the accumulation of blood beneath the outer covering of the brain that result from the rupture of blood vessel. Subdural hemorrhages may cause an increase in tracranial pressure, which can cause compression of and damage to delicate brain tissue. Acute subdural hematoma has a high mortality rate.
Other symptoms include(9)
1. A history of recent head injury
2. Loss of consciousness
3. Irritability
4. Seizures
5. Pain and Numbness
6. Headache
7. Dizziness
8. Disorientation
9. Weakness
10. Weakness or lethargy
11. Nausea or vomiting
12. Loss of appetite
13. Personality changes
14. Confused speech
15. Difficulty with balance or walking
16. Altered breathing patterns
17. Hearing loss or hearing ringing (tinnitus)
18. Blurred Vision
19. Deviated gaze, or abnormal movement of the eyes
20. Etc.

B. Complications
In the study conducted by Ichinomiya City Hospital, Ichinomiya, Japan, Dr. Ukai K,  and Mizuno Y. showed that Physical complications that occurred in our ward in the 12 months from April 2007 to March 2008 were recorded. Our ward has 50 beds and, over the 12 months, the average occupation rate was approximately 90%. We subdivided physical complications into two categories: (i) serious emergencies occurring in the ward with a possible high risk of mortality within a few days (e.g. pneumonia and upper airway obstruction); and (ii) life-threatening complications arising in the ward that required diagnosis and treatment by specialists from other medical departments (e.g. bone fracture and cancer)(10).
1. Pneumonia
In the study of Beth Israel Deaconess Medical Center, Boston, Massachusetts, Dr. Givens JL showed that Pneumonia is common among patients with advanced dementia, especially toward the end of life. Whether antimicrobial treatment improves survival or comfort is not well understood. The objective of this study was to examine the effect of antimicrobial treatment for suspected pneumonia on survival and comfort in patients with advanced dementia.(11)

2. Obstructive Sleep Apnea Syndrome (OSAS) 
The prevalence of OSAS increases with aging, occurring in up to 25% of older adults and up to 48% in patients with Alzheimer's disease. OSAS causes hypoxia, fragmented sleep, daytime sleepiness, cognitive dysfunction, functional decline, and brain damage resulting from reduced cerebral blood flow, ischemic brain lesions, microvascular reactivity, white matter lesions, and grey matter loss(12)

3. Bone fracture
In the study to investigate the relationship between bone mass and dementia in elderly hip fracture patients from areas with different aluminium concentrations in water supplies to determine  whether a high concentration of aluminium in the drinking water and the negative calcium balance of age-related osteoporosis together predispose to senile dementia.(13)

4. Urinary incontinence
Urinary incontinence may require insertion of a urinary catheter, which is known to increase the risk of UTIs. Urinary incontinence is a common problem in dementia. Almost invariably, the person with dementia will develop incontinence as the disease progresses. However, the primary reasons for incontinence are often not because of any significant pathology in the urinary system. Rather, it is due to factors outside the urinary system.(14)

5. Venous thromboembolism
In the study to assess  37988 patients of whom 1316 (3.5%) had dementia, Venous thromboembolism (VTE) patients with dementia had a high incidence of fatal pulmonary embolism (PE) and fatal bleeding. In those initially presenting with PE, the risk of dying of PE far outweighed that of fatal bleeding. In patients presenting with DVT alone, the risk of fatal PE was lower than that of fatal bleeding.(15)

6. Etc.

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