In the emergency department, we care more about acute disease. Anything with the word chronic makes us roll our eyes (mine included!). Dementia is part of those chronic degenerative issues. It is always interesting though to know more, and using the right terms in always in our advantages. Also, we all have older adults in our family!
Here is a very brief review of what dementia is, and more specifically what is the difference between normal aging, mild cognitive impairment and dementia. Keep reading, I assure you it is simple and useful!
It is true, there is some cognitive decline normally associated with aging. As you get old (yes we all will), the cerebral processing is slower. There can be some subjective memory complaints and a mild increase in “tip of the tongue” phenomenon. The most important feature is that there is no objective finding on clinical testing (like say with a MOCA).
Mild cognitive impairment (MCI) is defined by an abnormal result on an objective testing without any functional impact. When a “diagnosis” is made, it is important to closely follow these patient because 10-15% each year will progress in dementia.
Dementia is defined by objective cognitive impairment revealing deficits in at least 2 domains (memory, judgment, language, visuo-spatial, personality change, executive function) with a functional impact.
What is exactly a functional impact? Functional status relates to the ability of doing basics activity of daily living (eating, ambulating, dressing, toileting, grooming, bathing) and instrumental activities of daily living (shopping, housekeeping, communication, banking, meal preparation, scheduling, driving, transportation use). Instrumental activities are the first one to disappear with dementia, then basic activities.
How do you grade dementia (mild, moderate, severe)? The answer does not reside in the result number of the MOCA. It depends on the degree of functional impairment.
There are many types of dementia; the two most prevalent are Alzheimer disease and vascular dementia. Here are a few highlights for each main dementia types.
- Alzheimer disease: the main complaint is progressive memory lost (predominance of short term), then others domains get affected.
- Vascular dementia: could be abrupt after a stroke (progression in step pattern), the most predominant feature is executive function impairment.
- Frontal dementia: behaviour and executive function impairment will appears first.
- Temporal dementia: language and aphasia are predominant features.
- Lewy Body dementia: Fluctuation of cognition, visual hallucinations and Parkinsonism. The memory is not very affected.
- Parkinson disease dementia: the cognitive impairment will appear at least one year after the onset of the movement disorder.
- Progressive supra-nuclear paralysis (PSP): voluntary downward gaze impairment with parkinsonism, frequent falls and cognitive impairment.
No specific diagnostic test exists yet. A number of lab work and imaging could be done to rule out other rare organic reversible causes of dementia. The best diagnostic test is a precise longitudinal history of complaints and symptoms from the patient himself and his family/collaterals.
There is no cure. It is a slow and frustrating degenerative disease. Medications (anti-cholinesterase and NMDA-R) have a lot of adverse effect/contraindications and few positive results. It does not mean that there is noting else we can do.
- Encouraging having hobbies and participation in life duties (feeling useful)
- Decrease the cardiovascular risk factors (better hypertension control, diabetes, coronary artery disease, smoking cessation, etc.)
I will add, social support, social support, and… social support.
In order to end positively this post, there is a decrease incidence of dementia recently due mostly by better vascular risk factors control according to a Canadian study. You may realized though is that the prevalence is still increasing as the population aged.
Research is ongoing and lots of resources are available through the Alzheimer society for patients, caregiver, and family. If you want to make a difference…!