Dementia is a syndrome of cognitive deficits caused due to certain underlying disease conditions.

It characterised by weak memory, decreased ability to think, calculate, judge, reason, deterioration of language, difficulty in orientation of time and location, lack of initiative, emotional and behavioural problems.

CAUSES OF DEMENTIA

Dementia in most patients is secondary to one or more underlying conditions that affects Central Nervous System like certain –

• Hereditary or Acquired Genetic Disorders
• Autoimmune Conditions
• Metabolic Disorders
• Vascular Diseases
• Prions Disorders
• Infectious Diseases
• Injuries
• Surgeries
• Alcoholism
• Drug addictions
• Medications
• etc.

Below mentioned are the most common diseases that shows symptoms of dementia.

• Alzheimer’s Disease(60-80% of all cases)
• Vascular Dementia(20% of all cases)
• Fronto-Temporal Lobar Degeneration
• Dementia with Lewy Body
• Hutington’s Disease
• Parkinson’s Disease

Of all the causes of dementia, Alzheimer’s Disease is present in almost 60-80% of all the cases as the underlying cause of dementia, making it the most common cause of dementia. In many patients Alzheimer’s Disease co-exists with some other condition as underlying cause of dementia.

Depending upon the underlying cause and its stage of progression it may be either

• Non-Progressive or Slow-progressive or Fast-progressive
• Reversible or Irreversible

Presence of number of symptoms, its appearance, sequence and intensity depends upon the underlying causative disease condition.

More or less the overall picture of dementia remains the same in various diseases only weightage to different parameter like (recall, Orientation of Time and Place, Attention and Calculation, Registration, Recall, Repetition, Language, Complex Commands) of cognitive deterioration differs a bit in different diseases and different stages. This helps in rough clinical assessment of underlying condition.

SIGNS AND SYMPTOMS

It is characterised by symptoms borne out of cognitive deficits

• Forgetfulness especially recent events causing patient to misplace things and ask repeated questions, repeats phrases, difficulty in recalling names of objects or persons.
• Decreased ability to think, making patient seem irrational in judging, reasoning concluding, taking decisions, initiatives
• Lack of attention and difficulty in calculations makes it difficult for patient to maintain his finances.
• Reduced vocubulary, causing deterioration in language.
• Difficulty in orientation of time, directionality and location causing patient of getting lost frequently.
• Difficulty in recognising and identifying objects due to lack of visuo-spatial articulation.
• Tremors, difficulty in balancing.
• Difficulty in eating especially swallowing needs liquid or thickened liquid diet.
• Difficulty in daily routine, house keeping and self care.

All this above neurocognitive disorders results in emotional problems and low spirits and other neuro-psychiatric symptoms as mentioned below

Common Neuspychiatric symptoms of dementia are termed as “Behavioural and Psychological Symptoms of Dementia -BPSD” listed below

• Anxiety
• Depression
• Agitation
• Aggression
• Restlessness
• Impulsive
• Elated
• Sleep disorders
• Delusions
• Hallucinations
• Disturbed Appetite
• Lack of attention
• Difficulty in problem solving

Initially symptoms are very difficult to notice and only close relative can judge or evaluate the signs and symptoms.

Over time these symptoms starts becoming more noticable as the patients condition starts deteriorating as the disease progresses.

The progression of disease is divided into four stages, where in, above mentioned symptoms gradually worsen in each progressive stage viz.

1)Mild Cognitive Impairment (MCI)

• Scores 27-30 on MMSE scale of cognition.
• No one can notice easily untill patient is evaluated.
• Impairement is not so severe so as to interfere persons Activities of Daily Living (ADL).
• At this stage patient is not termed as dementia patient its more of a prodromal phase
• Not all but most of these patient deteriorate in cognitive deficits and progress in to Early Stage Dementia

2)Early Stage Dementia

• Scores 20-25 on MMSE scale of cognition.
• Only close relatives and caretaker can notice the signs and symptoms.
• Difficulty in complex activity and comands.
• Signs and symptoms depends much upon the underlying disease, that which symptom will be more pronounced. Eg. In dementia of Alzheimer’s Disease the memory related symptoms will be more pronounced in first stage while in dementia with lewy bodies and frontotemporal difficulty in organisation and planning will be more pronounced.

3)Mid Stage Dementia (or Moderate)

• Score on MMSE scale 6-17.
• Now the symptoms are noticable to everyone.
• Gets confused in unfamiliar place.
• Can do only simple work much difficulty in Instrumental Activities of Daily Living(IADLS).
• Needs frequent reminders for everything
• At these stage they have started becoming dependent and cant be left alone.

4)Late Stage Dementia (or Severe)

• Sore on MMSE scale below 6.
• Cannot do even Basic Activities of Daily Living(basicADLS)
• Requires full-time assistance and become completely dependent cannot be left alone.
• Patient cant easily recognise even close relative.
• Tremors and loss of balance, may fall and injure themself.
• Difficulty in identifying and handling objects in this case they might accidentally injury themself by misshandling objects.
• Difficulty in eating espescially in swallowing, liquid or thickened liquid diet is prefered.
• Cannot retain urine or stools and requires assistance in toilet hyegine.
• Issues with appetite, sleep and behaviour.

DIAGNOSIS

COGNITION TESTS

There are many patient based/caretaker based/ combination of patient cum caretaker based questionaire tests designed to evaluate cognitive skills of patient.

These tests helps us to evaluate different parameters of cognitive skills like

• Memory Recall
• Orientation of Time
• Orientation of Place
• Attention
• Calculation
• Registration
• Repetition
• Language
• Complex Commands
• Etc

Based on the score weightage of different parameters and the total score we can not only assess the grading and stage of the condition but also it gives rough differentiation on probable underlying disease that has caused dementia. Accordingly we can determine if any further investigations are required to diagnose the underlying disease.

Every tests has its own pros and cons and specificity and sensitivity. So more than one of the following test may be called in if required.

Patient Specific Tests

• MMSE – Mini Mental State Examination
• 3MS – Modified Mini Mental State Examinations
• AMTS – Abreviated Mental Test Score
• CASI – Cognitive Abilities Assessment Instrument
• MoCA – Montreal Cognitive Assessment
• Trail Making Tests

Questionaires for Caretakers Relatives and other informants

• IQCODE – Informant Questionnaire on Cognitive Decline in the Elderly

Combination of Patient specific and informant specific questionaires test

• General Practitioner Assessment of Cognition

LABORATORY INVESTIGATIONS

• Blood tests to rule out any other anomalies like and vitamin deficiencies, hormonal imbalances, electrlyte imbalances, infections that may potentially show similar symptoms.
• MRI, CT, PIB-PET, DTBZ-PET, helps diagnose some of the disease that are know to cause dementia.
• Brain Biopsy to confirm the doubted underlying disease condition.
• CSF analysis.

HOMEOPATHIC MEDICINES FOR DEMENTIA

• LACHESIS
• HYOCYAMUS NIGER
• GELSEMIUM SEMPERVIRENS
• ANACARDIUM ORIENTALE
• BACOPA MONNEIRI
• OPIUM
• CANABIS INDICA
• BELLADONNA
• BAPTISIA TINCTORIA
• TERRENTULA HISPANICA