DEMENTIA

a syndrome characterised by diverse behavioural, cognitive and emotional impairments. The Royal College of Physicians of London, defined dementia as an acquired global impairment of higher cortical functions including memory, capacity to solve problems, learned percepto-motor skills, social skills, language and communication, and control of emotion, in the absence of clouding of consciousness.

INCIDENCE AND PREVALENCE

It is estimated that there are 24.3 million people with dementia worldwide, with 4.6 million new cases each year. The number of people affected is expected to double every 20 years. The forecasted rate of increase is estimated to be more than 300% in India, China and their South Asian and Western Pacific neighbours. About 6.1% of the population 65 years of age and older, suffer from dementia (about 0.5% of the worldwide population). Fifty nine percent of PWD are females.

SUBTYPES
Alzheimers disease
the most common type of the primary degenerative dementia (60-80%) of cases. Characterised by progressive deterioration of short term memory and other higher cortical functions. Motor skills are generally preserved until late in the disease. Supportive features include altered behaviour and inability to carry out activities of daily living (ADL). predominantly affects the older age group (> 65 years), but early onset can occur. A clinical diagnosis of AD can be made accurately in 90% of cases, Diagnosis can only be confirmed on brain biopsy by the presence of neuritic plaques (NPs), which are the accumulated deposits of amyloid B40 and amyloid B42, and neurofibrillary tangles (NFTs), the hyperphosphorylated tau proteins. severity of the cognitive decline is more closely related to the NFTs burden. still unknown what triggers the changes in the neurons.

SUBTYPES
Vascular Dementia
a heterogeneous disease with diverse vascular pathologies, such as strategic infarcts, multiple cortical infarcts, and subcortical ischaemic lesions. Major cardiovascular risk factors are independent risk factors for the development of atherosclerosis and vascular dementia. These risk factors also predispose to acute stroke, which is a well established factor for the development of VaD.

SUBTYPES
Lewy Body Diseases
Parkinson disease dementia (PDD)
Lewy bodies is found primarily in the subcortical regions of the brain, the midbrain, substantia nigra and locus ceruleus. usually a 10 to 15 year lag time between the Parkinson diagnosis and the onset of dementia

Dementia with LB
Lewy bodies in the subcortical and cortical (frontotemporal) regions of the brain. Amyloid plaques can also be found in DLB. The cardinal features of dementia with Lewy bodies are: dementia, delirium (fluctuating cognition), early and vivid visual hallucinations and Parkinsonism. Any two of the supportive features of repeated falls, syncope, transient disturbances of consciousness, neuroleptic sensitivity, systematised delusions and/or hallucinations in other modalities, further strengthens the diagnosis.

SUBTYPES
Frontotemporal Dementia
a frequent cause of dementia in younger individuals with disease onset <65 years (mean age of onset is 52.8 to 56 years) characterized by behavioural changes and a dysexecutive syndrome. 20% of all cases of dementia About 38% to 40% of Frontotemporal Lobar Degeneration has a genetic component, of which 80% have an autsomal dominant pattern of inheritance. Frontotemporal Lobar Degeneration is caused by the progressive dysfunction of the frontal and/or temporal lobes, with unilateral or bilateral involvement.

SUBTYPES
Mixed Dementia
In autopsy
coexisting vascular pathology occurs in 24% to 28% of AD cases. Pathological Parkinson disease is present in 20% of patients with AD 50% of patients with DLB have AD pathology.

DIFFERENTIAL DIAGNOSIS

CLOCK DRAWING TEST

INVESTIGATIONS

PHARMACOLOGICAL INTERVENTIONS
Cognitive enhancers
Eg. Donepezil, galantamine, rivastigmine Mechanism:
augmenting the levels of acetylcholine in the brain to compensate for the losses of cholinergic function. continuous stimulation of NMDA receptors by glutamate which triggers a cascade of biochemical events that damage and kill surrounding neurones.

Recommended for mild to moderate dementia. Only Donepezil apporoved for severe dementia.