DEMENTIA ACROSS AGES

“I told my three-year old daughter as we stood outside the car in her school parking lot, the rain pouring down on us as she sobbed breathlessly in my arms. She didn’t want to go in the car. She just wanted me to stand there, holding her. And I didn’t want to rush her, or tell her to stop crying. I’ll hold you for as long as it takes.”

At this moment the mother thought about how it’s all her fault that her child is going through all this, how she could have given more time to her, loved her a little more and then began to cry herself seamlessly sitting in a group therapy session about DEMENTIA ACROSS AGES and then the person sitting next to her began his story at the age of 61…. I remember thinking that unless you’re dealing with a disease yourself, or are extremely close to someone dealing with one, you just don’t get it. It was all a but just a fog of knowledge I had on Dementia and all its underlines.

So,

What Is Dementia?

Dementia is the umbrella term for a number of neurological conditions, of which the major symptom is the decline in brain function due to physical changes in the brain.

According to World Health Organisation, dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing. It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement.

Dementia results from a variety of diseases and injuries that primarily or secondarily affect the brain, such as Alzheimer’s disease or stroke.

It is one of the major causes of disability and dependency among older people worldwide. It can be overwhelming, not only for the people who have it, but also for their carers and families.

There is often a lack of awareness and understanding of dementia, resulting in stigmatization and barriers to diagnosis and care.

Types Of Dementia Across Ages?

There are approximately 100 types of dementia, the most common being Alzheimer’s disease (estimated to make up 62 per cent of cases in the UK), vascular dementia (17%), dementia with Lewy bodies (4%), frontotemporal dementia (2%) and Parkinson’s disease (2%).

Less common causes are Huntington’s disease, alcohol-related dementia, prion diseases and dementia resulting from syphilis. It has been estimated that ten per cent of cases are of mixed origin, for example incorporating aspects of both Alzheimer’s disease and vascular dementia.

These figures are not, however, universally accepted: there is significant dispute, for example, over the prevalence of Lewy body dementia, and post-mortem studies of donated brains suggest that many more people may, in fact, have had ‘mixed’ dementia than is recognised in clinical practice.

Alzheimer’s disease

During the course of Alzheimer’s disease, excessive and abnormally folded proteins accumulating in the brain result in the formation of protein ‘plaques’ around neurones and ‘tangles’ inside neurones, leading to the death of these brain cells, particularly in the region responsible for memory.

The levels of neurotransmitters (chemical ‘messengers’) are also affected, disrupting communication within the brain. A combination of factors including age, genetic inheritance, environmental factors, diet and overall general health contribute to the onset and progression of the disease.

Vascular dementia

A stroke or a series of small strokes may cause damage to the network of blood vessels (the vascular system) that transport blood within the brain. The resulting disruptions in the supply of oxygen (which is transported in the blood) can lead to the death of brain cells, resulting in the symptoms of this type of dementia.

Dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD)

Lewy bodies are spherical protein deposits that build up in brain cells, interfere with the chemical ‘messengers’ in the brain, and disrupt the brain’s normal functioning. The precise mechanisms by which the Lewy bodies cause damage in the brain are not yet well understood.

Lewy bodies are also found in the brains of people with Parkinson’s disease, and a significant number of people with Parkinson’s disease will also go on to develop dementia.

Rarer causes of dementia

There are many other rarer causes of dementia, including progressive supranuclear palsy, Huntington’s disease, prion diseases such as Creutzfeldt-Jakob disease (CJD), and dementia associated with alcohol, HIV, multiple sclerosis and syphilis. A link has been suggested between head injury and later development of dementia, although this remains controversial.

Inherited dementia

The most common forms of dementia are ‘sporadic’: that is, they occur in no particular pattern and are likely to be a result of interaction between environmental factors and the genetic make-up of the individual. A small proportion of dementia however, have a strong genetic component.

DEMENTIA IN CHILDHOOD

When you hear the word dementia, you probably associate it with elderly people. As we age, our cognitive abilities gradually decrease, making us forget things or feel confused.

Although this is expected with old age, if the symptoms appear worse than what’s considered normal, all the arrows point towards dementia. But isn’t this only for the elderly?

The risk of children acquiring this terrible disease is very real. Some children may appear to be completely healthy but their mind may not be functioning normally. There are various health conditions and disorders that can give rise to dementia in children.

Different types of genetic illnesses, head injuries, and infections can adversely affect the brain of your child. Below are some of the causes:

Heavy metal poisoning

Chronic heavy metal exposure, such as lead, can cause symptoms of dementia in children. These toxic metals are present everywhere including in the food we eat and the air we breathe. The adverse effects of heavy metal poisoning are more prevalent in children and can lead to problems well into the adulthood.

Hypothyroidism

Hypothyroidism in children is caused by an underactive thyroid gland that is unable to meet the thyroxine hormone requirement of the body. There are two types of hypothyroidism that include congenital and acquired. Congenital hypothyroidism is present during infancy whereas acquired hypothyroidism develops later on in childhood.

Encephalitis

Encephalitis is the inflammation of the brain caused by a viral infection. Children less than a year old are at a higher risk of developing this infection. Also, this infection is more common in areas with a large population of ticks and mosquitos.

Batten disease

Batten disease is a form of neuronal ceroid lipofuscinoses disorder that affects children. Batten disease is an inherited disorder caused by a defective gene that results in the accumulation of lipofuscin in the brain. The symptoms usually appear between the age of 5 and 10 years with the onset of vision problems.

Niemann-Pick disease

Niemann-Pick is a rare inherited neurodegenerative disorder that leads to progressive dementia amongst children. The disease causes excess storage of cholesterol and glycosphingolipids in the brain.

Lafora body disease

Lafora body disease is a neurodegenerative disorder that is inherited in an autosomal recessive manner. The disease is characterized by the onset of epileptic seizures that worsen over time. Children suffering from Lafora disease experience cognitive decline and, ultimately, dementia.

The symptoms

Memory loss- One of the most common symptoms of dementia in children is memory loss. We all forget things from time to time. However, if your child is forgetting things more frequently or asking the same questions repeatedly, it could be an indication of dementia.
Problems with language- Children with dementia may have trouble putting together words and difficulty with expressive and receptive language skills in general. You may notice abnormalities in both verbal and non-verbal communication.
Loss of intellectual skills- Children suffering from dementia can display a lack of problem-solving ability. Since the symptoms of dementia are generally progressive in nature, the impairment of the intellectual function gradually worsens over time. This can lead to an inability to learn new things.
Personality changes- Most children with dementia undergo behavioural changes over the course of the disease, these changes including:
Mood swings and lack of emotional control
Displaying anxiety, anger, and uneasiness
Confusion about people and places
Screaming and crying often
Lack of personal hygiene
Clumsiness

DEMENTIA IN YOUNG AND MIDDLE ADULTHOOD

Dementia is a major public health concern that is a growing burden owing to an ageing society. However, the high prevalence of dementia in the elderly can overshadow the importance of its occurrence in younger patients.

Young-onset dementia can present a substantial diagnostic challenge but can also provide important biological insights that might also be applicable to the more common presentation in older patients.

For example, the high prevalence of inherited dementia in younger age-groups has led to the identification of causative genes and subsequent molecular pathology of direct relevance to the more common sporadic disease seen in older patients.

Causes of Young Onset of Dementia

Brain cells make a large number of proteins, such as amyloid or tau, by assembling them from raw materials (amino acids). These proteins are broken down again and the raw materials recycled for other proteins. If too much protein is made or not enough is broken down then protein can collect in the cell.

This may block other functions of the cell or be toxic to the cell, eventually causing the brain cell to die. It is thought that many dementia are caused by abnormal collection of protein in this way.

Although protein build-up follows general patterns in different regions of the brain in particular dementia, these patterns vary considerably. Brain pathology may develop in more than one brain region at a time as the illness progresses causing symptoms to Proteins and Dementia change.

Types of Dementia that takes place during Young Onset of Dementia

Alzheimer’s disease

Alzheimer’s is the most common type of dementia in younger people and may affect around a third of younger people with dementia. However, this is a much smaller proportion than in older people with the condition, up to two thirds of whom have Alzheimer’s disease.

Another difference is that younger people are much more likely to have an ‘atypical’ form of Alzheimer’s disease than older people. Atypical Alzheimer’s disease is when the first symptoms are not memory loss, which is the most common symptom of late onset Alzheimer’s disease.

Instead, the first symptoms are usually problems with vision, speech or planning, decision-making and behaviour.

Vascular dementia

Vascular dementia occurs when there are problems in the blood supply to the brain. It is closely linked to diabetes and to cardiovascular diseases such as stroke and heart disease. It is probably the second most common type of dementia in younger people around 15% of dementia in this age group may be vascular dementia. Symptoms of vascular dementia vary. Early memory loss is less common than in Alzheimer’s disease, whereas problems with thinking things through and slower speed of thought are more common. When vascular dementia follows a stroke, physical symptoms (such as limb weakness) are common.

Dementia with Lewy bodies

This type of dementia is caused by the build-up of tiny protein deposits (Lewy bodies) in the brain. About 5% of younger people with dementia may have dementia with Lewy bodies.

Lewy bodies also cause Parkinson’s disease and about one third of people with Parkinson’s eventually develop dementia. Symptoms of dementia with Lewy bodies include varying levels of alertness, and people can also develop hallucinations and the features of Parkinson’s disease (such as slower movement, stiffness, trembling of the limbs).

Multiple sclerosis

Cognitive impairment may be the presenting feature of multiple sclerosis and it is common late in the course; most cases have predominantly frontal executive dysfunction, resulting from front subcortical disconnection with extensive cerebral white matter disease.

Intellectual deterioration generally progresses slowly, however cognitive impairment is more severe in chronic progressive than in relapsing-remitting disease.

Wilson’s disease

Wilson’s disease is a treatable cause of YOD. Accumulated tissue copper causes progressive toxicity to the nervous system, liver, blood, and other organs.

Abnormalities in behaviour and personality, depression, and cognitive deterioration are common.

Neurological manifestations include tremor, dystonia, chorea, ataxia, dysarthria, a characteristic grimacing facial expression, and the pathognomonic corneal Kayser-Fleischer ring.

DEMENTIA IN LATE ADULTHOOD AND OLD AGE.

Dementia is not a normal part of ageing, but predominantly affects older people, with global prevalence rates over the age of 60 years ranging between 5% and 7%, 3 increasing exponentially with age with an estimated 20% of people over 85 years showing evidence of the condition.

Early onset AD presenting under the age of 65 years may be associated with genetic mutations on chromosomes, but account for less than 0.1% of all patients seen.

Apolipoprotein E4 (Apo E4) is consistently documented to increase the risk of late onset AD, but up to 20 new susceptibility genes are currently under review. First degree relatives of those with late onset AD have approximately twice the expected lifetime risk of disease.

Causes of Dementia

Alzheimer Disease (AD)

AD is the most common cause of dementia, a neuro-degenerative condition that is insidious and progressive. Impaired new learning and recall (amnestic loss not improved with prompting) displayed as a pervasive forgetfulness is an early feature. Communication changes are noted, with shrinking vocabulary and expressive or word finding difficulties.

Dementia with Lewy Bodies

DLB is a common form of dementia in late life. It is associated with higher rates of morbidity, mortality, carer stress and a poorer quality of life than AD.

Pathologically, DLB is characterised by the presence of Lewy related pathology – abnormal aggregates of the synaptic protein alpha-synuclein which form inclusion bodies (Lewy bodies) or Lewy neurites Neuropsychological characteristics include early visuospatial problems, executive dysfunction with prominent attentional impairment and less impaired episodic memory than in AD.

Relationship to Parkinson Disease

The development of dementia in Parkinson’s disease (PD) is well-recognised, the risk increasing with age. ‘Lewy body dementia’ is a term that describes both DLB and Parkinson disease dementia (PDD), recognising that they share common clinical and pathological features and may represent 2 points along a possibly continuous spectrum of Lewy body diseases.

Vascular Cognitive Impairment/Dementia

The term VCI was coined to encompass a spectrum of disease that includes subtypes described on the basis of clinical and radiological findings, ranging from mild cognitive impairment, to VaD and mixed neurodegenerative dementia.

NOW THE BIG QUESTION IS WHAT IS THE DIAGNOSIS AND TREATMENT FOR IT!

Diagnosis of Dementia

Diagnosing dementia and its type can be challenging. People have dementia when they have cognitive impairment and lose their ability to perform daily functions, such as taking their medication, paying bills and driving safely.

To diagnose the cause of the dementia, the doctor must recognize the pattern of the loss of skills and function and determine what a person is still able to do.

More recently, biomarkers have become available to make a more accurate diagnosis of Alzheimer’s disease No single test can diagnose dementia, so doctors are likely to run a number of tests that can help pinpoint the problem.

Cognitive and neuropsychological tests
Neurological evaluation
Brain scans
CT or MRI- These scans can check for evidence of stroke or bleeding or tumour or hydrocephalus.
PET scans- These can show patterns of brain activity and whether the amyloid protein, a hallmark of Alzheimer’s disease, has been deposited in the brain.
Psychiatric evaluation- A mental health professional can determine whether depression or another mental health condition is contributing to your symptoms.

Treatment for Dementia Across Ages

There is no cure or medication to slow progression of AD, but symptomatic benefit is available with acetyl cholinesterase inhibitors (AChEI) (donepezil, rivastigmine and galantamine) and memantine, which is a N-methyl-Daspartate partial antagonist. AChEI have shown modest symptomatic improvement in cognitive function, global outcome and activities of daily living.

Around 40–50% of people with AD respond symptomatically, although clinical markers to indicate those most likely to respond are not established.

In the absence of more effective therapies, these medications remain an important option in the management of AD. Side-effects include nausea, vomiting, diarrhoea, dizziness, weight loss and bradycardia.

Evidence suggests positive benefits for nonPET Scan cognitive symptoms, especially apathy, depression and anxiety and improved function and decreased rate of decline compared with placebo.

CONCLUSION

As Dementia progress, the person’s reliance on other people increases. When a person can no longer fully care for themselves, there’s a tendency to treat them more like a patient than a person.

No one deserves to live a life like that of one suffering this burden on his/her life after all, these individuals are not children, and in fact, they have an array of life experiences that define who they are. Their experiences go well beyond what those caring for them may even imagine.

A person with dementia is an individual, unique and valuable human being. As dementia progresses, people can feel vulnerable and need support and more importantly.

Support and love so be there for them do you duty as human help each other out and make life of the once facing these adversities little better with your light of kindness as one day everyone has to die.

Books Referred:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA: American Psychiatric Association; 2013
Sadock Benjamin James, Kaplan Harlod I, Study Guide and Self-examination Review for Kaplan and Sadock’s “Synopsis of Psychiatry, Lippincott Williams and Wilkins, 2005
Steele, Cynthia, 2010, Dementia Care, McGraw-Hil Medical
V. Olga, B. Emery, 2003, Dementia: Presentations, Different Diagnosis and Nosology, Johns Hopkins University Press

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