What is dementia?
Dementia is a degenerative disease of the brain that is associated with deficits in cognitive, emotional and social skills and leads to impaired social and occupational functions. Above all, the short-term memory, also the mind, language and motor skills, also affected the personality structure in some forms. Decisive is the loss of acquired thinking skills as opposed to innate intellectual deficit. Today various causes of dementia have been resolved; some forms can be treated to some extent, that is, the symptoms can be delayed at the initial stage of dementia. The most common form of dementia is Alzheimer's disease. Alzheimer's disease usually occurs on only beyond the age of 60. It is among the geriatric psychiatry disorders - rarer forms of dementia can also occur in younger patients.
Forms of dementia
There are many forms of dementia, their common and best known is Alzheimer's disease. The main dementias, which are differ in cause, course and age of onset:
-Alzheimer's disease
-Vascular dementia
-Lewy Body Dementia
-Creutzfeldt-Jakob disease
-Korsakoff's syndrome
-Parkinson dementia
Definition of dementia
The diagnostic criteria for dementia include combinations of deficits in cognitive, emotional and social skills that lead to an impairment of social and occupational functions. As a symptom applies the memory disorder. At the beginning of the disease are disorders of short-term memory and the memory, disappear in their further course already impressed contents of long term memory, so that the persons concerned are losing acquired during their life skills.
Definition of dementia according to ICD 10
Dementia (ICD-10 code F00-F03) is a syndrome as a result usually of a chronic or progressive disease of the brain is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, speech and judgment in meaning the ability for decision. Consciousness is not clouded. For the diagnosis of dementia, the symptoms must have passed at least six months after ICD. The senses (sense organs, perception) function in the manner customary for the person frame. Usually accompany changes in emotional control, emotional state, social behavior, or motivation, the cognitive impairments; occasionally these syndromes occur even sooner. They are found in Alzheimer's disease, vascular disease of the brain and other condition images, affecting primary or secondary brain and neurons.
Definition of dementia in the DSM-IV
The cognitive deficits cause significant impairment in social and occupational functions and provide a significant deterioration from a previous level of performance. They do not occur in the context of a rapid onset of consciousness or delirium. To memory impairment at least one of the following disorders still must be added:
-Aphasia: language disorder
-Apraxia: impaired ability to carry out motor activities
-Agnosia: inability to identify or recognize objects
-Dysexekutives syndrome: disorder of executive functions, ie planning, organizing, maintaining a sequence
Risk Factors and Prevention dementia
Main risk factor for dementia is advanced age. The predominance of the female sex among the stakeholders is probably primarily due to the higher a few years life expectancy of women. Depression is considered a risk factor for developing dementia. They occur mainly in the early stages of dementia to dementia frequently and can also precede. Conversely, if inadequate clarification often old people mistakenly assigned the diagnosis of dementia with mental illness, which may show that the Mini-mental state examination again greatly improved.
Other risk factors are beyond cardiovascular factors, such as hypertension, high homocysteine levels, renal insufficiency, obesity and diabetes mellitus. A role is played by defects of the vascular system, the impaired insulin metabolism and signaling and a defect in the glucose transport mechanism in the brain.
The current medical treatment options can influence the course of dementia positive only in a very modest extent. Therefore, the prevention of dementia is of particular importance, whose cornerstone is to limit the risk factors. Here today regarded as the most promising strategies primarily the control of cardiovascular risk factors, physical activity (sports), social commitment, control of body weight (diet) and the early treatment of depression. Since tobacco smoking is a possible risk factor for dementia, the setting of cigarette smoking also contributes to dementia prevention. A recent study confirmed that especially sports and a healthy lifestyle (and therefore the prevention of cardiac risk factors) can prevent dementia. A healthy lifestyle in addition to regular physical activity are also nicotine abstinence, daily consumption of fruits and vegetables and excessive alcohol consumption. A normal body weight does not prevent the decrease of cognitive functions according to this study.
A study published in 2012, long-term study indicates a link between dental health and the risk factors for dementia. Accordingly, the risk of developing dementia, around the 1.85-fold higher when 13 or more teeth are missing and the gaps are not supplied with fixed restorations. Research subject were 4425 Japanese residents who were about 65 years old and have been accompanied over 4 years. 220 of them suffering from dementia.
Diagnostics
Important information for differential diagnosis and to select the imaging examination process provides the medical history, especially with the details of the caregivers are taken into account. The victims themselves often do not fall on his memory problems and / or you can temporarily at appointments in high shape (known phenomenon for doctor visits). On the other hand, it is also possible that he overestimated his memory impairment in the context of a depressive mood. Technical studies such as magnetic resonance imaging or computed tomography of the head or electroencephalography are also used to differentiate between other brain diseases meaningful.
In order not to overlook any treatable cause, should be at least the following blood tests: blood count, vitamin B12 levels, blood sugar, liver function tests, kidney function, electrolytes, thyroid hormones, CRP. Helpful to corroborate a first suspicion and also to check the progression of dementia in addition to the medical history initially simple psychometric test methods such as the MMSE, the clock test or DemTect. Such simple and quick tests can then also be used for follow-up studies, for example, to check the response to drugs or therapeutic procedures.
As in previous years, the diagnostic capabilities have improved massively, today a diagnosis of Alzheimer's disease at the stage of mild cognitive impairment (MCI) is possible. Among the diagnostic procedures for such a diagnosis before the onset of dementia include the presentation of the atrophy of the medial temporal lobe on MRI, the measurement of τ- and β-amyloid in the CSF, the representation of cortical metabolic deficits in positron emission tomography (PET) with [18F] - fluoro-2-deoxy-D-glucose (FDG) as well as the opportunity to make amyloid in the brain with PET ligands visible in vivo. In addition, there is increasing evidence that the subjective indication of a patient, to be forgetful, a reliable parameter to predict the development of dementia very early stage. This raises the hope, too early can prevent dementia, such as with a reduced calorie diet or something more physical activity. German scientists have also developed a clinical score, in the doctor's office the occurrence of Alzheimer's disease can be estimated at around 80-percent prediction accuracy with without technical aids in elderly people without dementia.
The available at selected centers with PET FDG is also an established method for the differential diagnosis of dementia. This can be already in early stages places in the brain demonstrate reduced glucose metabolism and as a dementia of the Alzheimer type or frontotemporal dementia (Pick's disease) demonstrate. Dementia by depression show a different pattern of activity in PET.
For the diagnosis of dementia associated with extrapyramidal motor disorders, the J123 scintigraphy with beta-CIT or DAT scan, the J123-IBZM scintigraphy and PET with L-dopa is used. Thus, a Parkinson's disease, multiple system atrophy, progressive supranuclear palsy and essential tremor are deferred.
Differential diagnosis of dementia
Some psychological and neurological disorders can be confused with dementia, such as the following.:
-Depression
-Age-related cognitive decline, also "age forgetfulness"
-Mild cognitive disorder
-Denial and avoidance behavior
-Deprivationserscheinungen or hospitalism with regression, such as in nursing homes.
-Delirium
-Psychosis and mania (eg schizophrenia, mania and psychotic depression)
-One mutism
-Simple aphasia
-Lack of fluid (dehydration)
What are the symptoms of dementia?
In advance of dementia are often observed mental disorders that often little from those of depression can be distinguished, such as loss of interest and initiative, irritability, feeling of being overwhelmed, loss of affective vibration ability, depression.
Cognitive symptoms
Dementias of all symptom is memory disturbance, in particular short-term memory. The forgetfulness is initially something normal. Often the outer facade of the person is well preserved, at least in the early stages, so that the memory impairment can be very good about playing in superficial contact. This works particularly well the people who all their lives had many social contacts - the mandatory tone replaced at times the content of the message (communication).
Later, longer lose past memory contents. If the dementia progresses, other disorders of brain function occur added, such as word-finding problems, arithmetic problems, disorders of spatial perception and severe fatigue, so that the parties involved are often lost, especially when in the them for decades familiar surroundings take place structural changes.
In the advanced stage of the victims eventually realize once again not their immediate families. You are totally apathetic, bedridden and incontinent.
The dementia limits the life expectancy. But the dementia itself is not a cause of death, but the beneficiaries of the dementias.
Motor symptoms
Also motor disorders usually include the image of advanced dementia, if it is not a dementia that begins with motor disorders such as Parkinson's disease. Patients are increasingly stiff all over. Her gait is small steps, shuffling and legs. They fall risk, also because there is a disorder of postural reflexes.
Behavioral disorders
The behavioral disturbances in dementia are called BPSD (Behavioural and Psychological Symptoms of Dementia). Including counting the apathy (76.0%), Aberrant motor behavior (ie aimless wandering, 64.5%), eating disorders (eating Unessbarem, 63.7%), irritability / lability (63.0%), agitation / aggression (62.8%), insomnia (53.8%), depression / dysphoria (54.3%), anxiety (50.2%), delusions (49.5%), disinhibition (29.5%), hallucinations (27.8%), and euphoria (16.6%). The brackets refer to the prevalence of 12 BPSD in Alzheimer's patients.
Psychotic symptoms can occur with all forms of dementia. Relatively typical they are for Lewy body dementia, dementia in Parkinson's disease form. It is all about visual hallucinations. Typically see the first affected, especially in the twilight of the dawn persons not present, with which they sometimes even lead discussions. Patients can usually dissociate hallucinations at this stage of their (pseudo-); that is, they know that the persons with whom they speak, are not present. Later they see animals or mythical creatures, pattern on the walls, Staubfussel. Finally, they see grotesque, most threatening things, like kidnappings. This scenic hallucinations are very anxious usually dyed. Patients are often aggressive when they install the best intentions in approaching relatives and nurses in her delusional system. Here the transitions to delirium are fluent.
People with dementia lose their initiative. They neglect their previous hobbies, their personal care and cleaning up her apartment. Finally, they are no longer able to feed themselves adequately. You have no drive to eat, hunger and lose eventually forget to chew and swallow the food. They become emaciated and are prone to internal diseases such as pneumonia. Shifts in the day-night rhythm can cause considerable problems nursing.
Therapy
Pharmacotherapy
For several years against dementia drugs are available (anti-dementia drugs). Firstly, it is centrally active Cholinergica (cholinesterase inhibitors) such as donepezil, galantamine, rivastigmine, or, on the other hand memantine. This preparation came in 2009 and in 2010 the Institute for Quality and Efficiency in Health Care, however, to the conclusion that there was no evidence for a benefit of memantine therapy in Alzheimer's disease. This clinical experience shows that very well benefit some patients of the drugs on the one hand, others do not. Cure the dementia is not currently, but reside in many cases in their course by 1 to 2 years, if it is detected and treated early.
Later shows that treatment with the drugs known brings no improvement. For some time, there is also a treatment with a medicated plaster available. Through constant drug levels, fewer side effects, so that a higher dosage is possible. At the same time care by nurses is facilitated because the application of the patch is often easier than the administration of tablets or solutions. The aim is to improve the cognitive abilities and the everyday skills of affected patients.
As controversial apply in their effect garlic and Piracetam. Is controversial and the efficacy of Ginkgo biloba. The Institute for Quality and Efficiency in Health Care (IQWiG) in 2008 came to the conclusion that patients with Alzheimer's disease from therapy with the standardized extract EGb 761 then benefit when it is taken regularly in a daily dosage of 240 milligrams. A US study (GEM study, "Ginkgo Evaluation of Memory") and its sub-analysis showed, however, that the extract compared to placebo during the mean observation period of six years neither prevent the occurrence of Alzheimer's disease nor the decrease in mental could counteract services. However, the authors themselves pointed out some methodological weaknesses of their study.
The "Cochrane Collaboration" came in 2008 nevertheless concluded that ginkgo biloba extracts had no reliable effect against dementia. All sedative drugs that are given for example in sleep or shifts in the day-night rhythm, impair cognitive performance. The same is true for antipsychotic drug with anticholinergic side effects that are sometimes unavoidable in hallucinations. Drug treatment of vascular dementia corresponds both to the treatment of chronic vascular disease (atherosclerosis), on the other hand have also in dementia dementia treatment proven to be effective, both Azetylcholinesterasehemmer and memantine.