Understanding Dementia: A helpful guide for health professionals

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The mind encompasses so much of who we are within it, housing our feelings, thoughts, judgment, languages, and memories. It keeps these cognitive functions intact as long as our neurons are firing properly and remain connected. But what happens if those connections between them begin to malfunction and nerve cells die off? Those changes in the brain lead to what’s known as dementia. It’s important to note that dementia is a general term for disorders that fall under its umbrella, such as Alzheimer’s disease, Vascular dementia, Lewy body dementia, and Frontotemporal dementia.

Memory loss, confusion, difficulty managing daily tasks, and getting lost are examples of symptoms that patients living with dementia may face. Dementia can cause mild issues with daily living or lead to a person becoming completely dependent on others to take care of their needs.

Although it tends to affect people who are over 65 years old, it’s important to remember that dementia is not a normal part of aging and needs to be addressed by a healthcare professional. There are currently more than 55 million people with dementia worldwide, with about 10 million new cases each year. At this point, there’s still no cure for dementia, but it’s imperative for healthcare professionals to understand the symptoms and treatment options that are available. The research on dementia prevention is ongoing, but encouraging patients to adopt a healthy lifestyle, learn about the risk factors, and address different ways to reduce them is truly a critical step in the right direction.

Some actionable steps to reduce dementia risk factors:

Keep systolic blood pressure of 130 or below from age 40 and beyond
Protect ears from loud noises to reduce hearing loss
Encourage patients to use hearing aids if necessary
Prevent head injury
Reduce alcohol consumption
Reduce obesity
Encourage good sleep hygiene
Avoid smoking
Receive both primary and secondary education

Types of Dementia

Now that we have a general overview of dementia let’s start discussing the different types of dementia, beginning with the most common one, Alzheimer’s Disease.

Alzheimer’s disease affects three key cognitive areas: memory, language, and learning. The decline seen within these areas is gradual and often over the course of several years. There are important changes that occur in the brain leading to this disease, such as amyloid plaques, which are a collection of misfolded proteins in between nerve cells that disrupt normal function, as well as neurofibrillary tangles, which are accumulations of the tau protein within neurons that impairs the communication between them. When neurons lose connection to one another and eventually die, this leads to brain atrophy.

Now, let’s delve into signs and symptoms.

Memory loss is one of the first presenting symptoms in patients with Alzheimer’s disease. Other signs and symptoms present depending on the severity of the disease. Check them out below.

Symptoms of Mild Alzheimer’s disease

Impaired judgment
Memory loss
Difficulty keeping track of dates
Issues handling finances
Wandering and getting lost in familiar areas
Forgetting newly learned information
Increased aggression and/or anxiety
Issues with problem-solving
Changes in mood and/or personality

Symptoms of Moderate Alzheimer’s disease

Reduced attention span
Increased memory loss and confusion
Difficulty recognizing family and friends occasionally
Loss of ability to learn new things
Difficulty with daily tasks such as getting dressed
Sleep pattern changes
Changes in mood
Hallucinations or delusions
Withdrawal from social activities

Symptoms of Severe Alzheimer’s disease

Loss of ability to communicate
No awareness of recent events or experiences
Problems swallowing
Increased sleeping
Loss of bladder and bowel control
Loss of interest in eating
Weight loss

As you can imagine, the progression of Alzheimer’s disease is troubling for both the patient and their loved ones. As patients progress through different dementia stages, they’ll need increased supervision and assistance with critical parts of daily life.

Next, let’s discuss how Alzheimer’s gets diagnosed. A doctor will begin by evaluating a patient by gathering a thorough medical history, conducting a neurological and physical exam, and interviewing someone close to the patient, such as a family member or friend. Our loved ones are often the first to notice the early symptoms of Alzheimer’s disease and can often attest to changes in personality, behavior, and overall health.

Another part of the evaluation will include blood, urine, or cerebrospinal fluid testing to rule out other possible causes of a patient’s symptoms. Then, there needs to be an assessment of a patient’s memory and cognitive function. There are quite a few screening tools that can be used, such as the Mini-Mental Status Exam (MMSE), Mini-Cog, Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB), and the Blessed Orientation-Memory-Concentration (BOMC). Each tool has a different scoring system and aims to measure distinct cognitive areas such as attention, recall, orientation, and language. If the results are indicative of cognitive impairment, the doctor will refer the patient to a neuropsychologist for further evaluation. Brain scans such as CT, MRI, or PET scans may also be helpful in evaluating patients with suspected Alzheimer’s disease to look for any brain abnormalities.

Vascular Dementia

Now, on to Vascular dementia. As the name suggests, blood vessels are involved in causing this type of dementia, but how exactly? Conditions that damage blood vessels and interfere with oxygen delivery to the brain lead to abnormalities, with a particular focus on the white matter of the brain, which are often detected with MRI scans in patients with vascular dementia. These abnormalities interfere with the brain’s ability to transfer signals amongst different regions, eventually leading to cognitive decline. Strokes and small vessel disease lead to changes in the brain that increase the risk of developing vascular dementia. Other risk factors that are associated with vascular dementia include:

It’s important to note that there is an overlap among the dementia symptoms within the types of dementia, such as confusion, getting lost in familiar areas, sleep pattern changes, hallucinations, delusions, impaired judgment, and withdrawal from social activities. Therefore, these symptoms will also present in vascular dementia.

In terms of diagnosis, there are several ways to evaluate a patient. The first step is obtaining a detailed medical history and a physical exam. Inquiring about high blood pressure or prior strokes gives healthcare professionals more insight into what may be causing the cognitive decline. Next, assessing the cognitive areas using applicable screening tools is also necessary. Finally, an MRI or CT scan will allow the provider to determine any changes to the brain.

Lewy Body Dementia

Lewy Body Dementia, also referred to as dementia with Lewy bodies and caused by irregular deposition of the alpha-synuclein protein, has a gradual onset. This type of dementia leads to issues with movement, thought, behavior, and mood. The accumulation of Lewy bodies within the brain also affects the production of neurotransmitters such as acetylcholine and dopamine, which impair their normal functions within the brain.

Diagnosing it can be challenging, and clinicians may unknowingly misdiagnose Lewy body dementia as Parkinson’s or Alzheimer’s disease due to the symptom overlap with these disorders. Lewy body dementia symptoms include:

Visual hallucinations
Fluctuations in concentration and alertness throughout the day
Difficulty swallowing
Shuffling walk
Stiff muscles
Tremors
Rapid Eye Movement (REM) sleep behavior disorder
Restless leg syndrome
Insomnia
Depression
Paranoia
Delusions
Dizziness
Fainting

Due to shared symptoms among these diseases, there are quite a few ways to evaluate a patient for Lewy body dementia in order to distinguish it from other conditions. As always, it begins with a thorough medical history and physical exam. Patients should have at least two of the following symptoms:

Frequent visual hallucinations
REM sleep behavior disorder
Fluctuating alertness and ability to think clearly
Symptoms resembling Parkinson’s disease (tremors, shuffling walk, rigid muscles)

Other essential evaluations include a neurological exam, cognitive function assessment, blood/urine tests, brain scans, and a polysomnogram to evaluate sleep. Polysomnograms are useful in diagnosis because Lewy body dementia is commonly associated with various sleep disorders.

Aside from the behavioral changes, memory loss, and overall cognitive decline of dementia, these conditions also lead to communication challenges. As dementia progresses, patients can begin to have difficulty speaking, incorrectly using words, or repeating certain ones, which often leads to patients feeling frustrated, embarrassed, and socially withdrawn. Communication is vital between patients and their caregivers; when words fail, body language and facial expressions can help foster communication.

Frontotemporal Dementia

Frontotemporal dementia (FTD) is a group of disorders that are caused by the degeneration of the frontal and temporal lobes of the brain primarily in patients between the ages of 45-64, and can be attributed to the abnormal collection of Tau and TDP-43 proteins and loss of neurons. There are two types of Frontotemporal dementia, including behavioral frontotemporal dementia (bvFTD) and primary progressive aphasia (PPA). The most common type is the behavioral variant, and as the name suggests, the symptoms primarily involve changes in behavior, as well as personality and judgment.

Symptoms include:

Lack of empathy or sympathy
Lack of interest or concern
Saying inappropriate things or acting impulsively
Overeating
Exploring objects orally
Difficulty with attention, problem-solving, and planning

Issues with language and/or movement may also develop in patients with this variant as the disease progresses.

Primary progressive aphasia (PPA) causes challenges with speech and comprehension. There are three types of primary progressive aphasia, each impacting language differently. In semantic PPA, patients can’t understand the meaning of certain words and exhibit difficulty recognizing well-known objects and people. Logopenic PPA causes patients to have a hard time finding the right words while speaking; however, their comprehension remains intact. Lastly, agrammatic PPA causes issues with grammar; patients may not use connecting words such as “to”, “from”, they may also use incorrect verb tenses, or mix up the order of words in a sentence. Memory tends to stay intact in most patients with primary progressive aphasia.

When it comes to diagnosing Frontotemporal dementia, there are a few tests to do after a thorough clinical history and physical exam, including blood tests to rule out other conditions, a sleep study to rule out obstructive sleep apnea as symptoms may overlap, neuropsychological testing to evaluate memory and reasoning, and MRI and PET scans to look for atrophy or degeneration in the brain. Though these tests are helpful, a definitive diagnosis cannot be made until after a patient has passed away and an autopsy is performed.

Psychosis in Dementia

As we’ve learned about the symptoms associated with the various types of dementias, you may have noticed that delusions and hallucinations have been mentioned a few times. While these symptoms are most commonly associated with psychosis, they can also occur in the context of dementia.

Dementia patients often experience visual hallucinations and tend to have the delusion that their caregiver is trying to harm them. This type of delusion can be due to an inability to recognize their caregivers from memory impairment or difficulties with vision and is often very challenging for both patients and caregivers.

These symptoms cause paranoia, anxiety, agitation, and fear for patients. While caregivers may find dealing with dementia-related psychosis frustrating and challenging, they may find it helpful and stress-reducing to attend support groups and fully understand that the patient’s actions aren’t intentional but due to the evolution of their symptoms.

The Benefits of Early Dementia Diagnosis

Unfortunately, dementia is irreversible, but getting an early diagnosis is beneficial to both patients and their families. It can help patients and their loved ones know what to expect as the disease progresses and give patients the opportunity to make informed decisions about their care before their cognitive abilities decline significantly. Early diagnosis also gives families more time to make long-term care decisions, like whether they’ll receive residential or at-home care, and establish a financial plan.

Healthcare Team Collaboration and Caregiver Support

Managing the different aspects of dementia and a patient’s co-existing conditions may improve patient outcomes, provide more support for families, and support a well-rounded healthcare plan. A collaborative healthcare team should include a primary care physician, psychiatrist, neurologist, clinical psychologist, social worker, neuropsychologist, nurse, and home health aide(s).

It’s important to take into account that caregivers carry a lot of the weight of a loved one living with dementia. Watching someone they once knew so well gradually lose essential aspects of their memory and personality and change their overall behavior is very difficult. There are support resources for caregivers, and they include options like support groups, helplines, and educational classes.

Treatment and Management

Dementia is treated with medication and non-pharmacological options like acetylcholine and glutamate, which are both neurotransmitters involved with memory and judgment. Certain dementia medications, known as cholinesterase inhibitors and glutamate modulators, aim to prevent the breakdown or modulate these neurotransmitters to treat the symptoms associated with cognitive issues and decline.

For sleep-related issues associated with dementia (especially insomnia), a medication targeting the sleep-wake cycle is helpful. Antipsychotics mitigate agitation in dementia patients but shouldn’t be used with patients with dementia-related psychosis due to an increased risk of death. Anti-anxiety medications and antidepressants are also added to the treatment regimen when needed to deal with depressive or anxiety symptoms.

Non-pharmacological approaches are also helpful in ensuring that both the patient and caregiver feel safe and supported. The behavioral changes that dementia patients experience are distressing, but there are a few approaches that may be helpful:

Curate a calm and clutter-free environment
Provide breaks for the patient between lots of stimulation
Consider palliative care to focus on maximizing patient comfort
Avoid confrontation (e.g., don’t correct their view of reality)
Speech therapy for patients with language and communication difficulty
Alternate communication tools such as a communication notebook with pictures of loved ones, activities, and common objects for patients to point to when they have difficulty speaking or finding the correct word

Ethical Considerations

Every patient deserves both informed consent and for their autonomy to be respected. Dementia, however, poses a tough challenge for physicians, as dementia patients are often cognitively impaired, which can affect their decision-making capacity. There are tests to assess cognitive function and decision-making capacity, but interviewing the patient remains critical for determining their status and ability to consent. Fortunately, patients with mild or mild to moderate cognitive impairment often still possess the capacity to give their consent for medical treatment.

In the end, there’s a delicate balance between respecting a dementia patient’s autonomy while also prioritizing their safety. Since capacity may fluctuate depending on the severity of the disease, it may be useful for patients to communicate their medical decisions through a healthcare proxy or an advance directive.

Future Directions in Dementia Research

There are promising advancements in treatment options, interventions, and even new areas of study of dementia. For Alzheimer’s disease, there are new drugs on the horizon that slow cognitive decline, known as anti-amyloid drugs, which target the harmful amyloid plaques that build up in the brain and remove them. For patients involved with the clinical trials for this drug, slowing the progression of the disease has improved their quality of life. Though this treatment is promising, the side effects are under investigation, and insurance approval for using them is limited.

There’s also new research investigating the use of a blood test to assess the levels of beta-amyloid protein and tau protein, which is helpful when investigating cognitive impairment in patients since it may lead to earlier diagnosis of the disease, or offer a way to rule it out, leading providers to search for other underlying causes of cognitive impairment.

An exciting area of study involves research on posterior cortical atrophy. Patients with it present difficulty differentiating between moving and stationary objects, accurately judging distances, and problems writing. What’s interesting about posterior cortical atrophy is that 94% of patients with it also had Alzheimer’s disease, demonstrating that it’s essential for providers to learn more about this disease and accurately diagnose it since it can lead to an earlier diagnosis of Alzheimer’s disease.

It’s crucial to raise awareness about dementia, its types, symptoms, and diagnostic approaches. While there’s no cure, early diagnosis and intervention can improve patient outcomes and quality of life. Additionally, ongoing research offers hope for better treatments and diagnostic methods in the future. By prioritizing dementia education, promoting healthy lifestyle choices, and supporting patients and caregivers, we can work towards better managing and understanding this complex condition.