Dementia Defined
The term dementia has represented many different meanings
and connotations over time. The word itself comes from Latin,
literally meaning to be “without a mind.” It is an ancient term
that appears as both a disease state in Roman medical texts and
a form of political sarcásm in the philosophical works of Cicero.
In the past wvo centuries, the term dementia has most often
been used to refer to brain disease characterized by intellectual
impairment. 'Ihe terms presenile dementia and senile dementia
were frequently used to refer to disease stares that developed
before or after 65 years of age, respectively, and eventually the
term scnílity became synonymous with dementia. In earlier
diagnostic schemes, dementia had also been referred to as an
organic mental syndrome and an organic brain syndrome.
Regardless of the diagnostic term, dementia historically was
viewed as a fonn of permanent brain damage.
DIAGNOSTIC CRITERIA AND ASSOCIATED
FEATURES
According to the current diagnostic classificutiolx in the
Diagnastir and Statí.stical Manual of Mental Disorclers, Fourth
Edition Text Revision dementia refers to the
development of multiple cognitive or intellectual deficits that
involve memory impairment of new or previously learned
information and one or more of the following dismrhances:
1. Aphasia, or language disturbance;
2. Apraxia, ur impairment in carrying out skilled motor
activities despite intact motor function;
3. Agnosia, or deficits in recognizing familiar persons or
objects despite intact sensory function;
4. Executive dysfunction, or impairments in planning, initi-
ating, organizing, and abstract reasoning.
These deficits result in significant impairment in both
social and occupational functioning, and they represent zx
decline, often with an insidious onset and progressive course,
from a previous level of functioning. Associated features of
dementia that are not formally listed as para of the diagnostic
criteria include personality changes, behavioral disruptions
(e.g., agitation, disinhibition), apathy, depression, psychosis,
anxiety, sleep disturbances, sexual dysfunction, neurologic
symptoms (e.g., motor and gait disturbances, seizures), and
delirium. Collectively, these symptoms result in a disorder
devastating for both the affected individuals and their loved
ones and caregivers. Therefore, the fact that the immediate
caregivers of individuals with dementia have higher than
expected rates of medical and psychiatrie illness, especially
depression, and increased mortality is not surprising.
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Mr. Krone, a retired tailor, had immigrated to the United States
from Poland at the age of 10 years and had spent most of his
early life working in the garment industry in New York City.
He later worked as a furríer, running his own business for
mona than 20 yeaxs Hc: was married for mon: than 60 years and
had two grown daughters. Mr. Krone retired at the age of 70,
and he and his wife moved to a retirement community in
Fìorida. His wife passed away when he was 85, and, thereafter,
Mr, Krone insisted on living by himself, despite his daughters’
concern that his memory and physical strength had declined,
Shortly after his 90th birthday, Mr. Krone fell and broke his
hip. After the hip surgery, he was admitted to a long-term
Care facility for 2 months of rehabilitation, which eventu-
ally resulted in 2 permanent placement. Staff reported that
Mr. Krone had significant cognitive impairment and symptoms
of depression. He frequently spoke abuut his deceased wife,
stating that he wished lo join her. Six months aller admission,
Mr, Krone developed pneumonia, leading lo his hospitaliza-
tion. On his return to the facility, the staff noted that he was
delirious, paranoid, and agitated. The delirium resolved after
approximately 2 weeks, but Mr, Krone's dementia appealed to
be much worse. He continued to be quite depressed and even
overtly suicidal, with episodes of paranoia and agitation.
These symptoms improved slowly after Mr. Krone was placed
in zu unit for residents with behavioral problems and was
treated with psychotropic medicatioils.
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Many delrails of this case-a slow, insidious course; comorbid
medical problems that lead to further decline; and associ-
ated problems, including depression, psychosis, agitation,
and delirium are typical for dementia, especially Alzheimer
disease. As this case illustrates, longterm care placement is a
frequent result.
EPIDEMIOLOGY
In the United States, approximately 4 million individuals
have severe dementia, While another 1 to 5 million have mild
to moderate dementia. The overall prevalence of dementia
increases from between 5% and 7% at age 65 to 15% to 20%
at age 75 and 25% to 50% after the age of 85. Some have pre-
dicted that, barring any major advance in prevention or cure,
the number of older Americans who are most vulnerable to
developing dementia (those 85 years of age and older) will
nearly double in the next 30 years, causing a treníendnus
surge in the number of dementia cases. The estimated annual
cost of treating dementia in the United States ranges from $40
billion to $100 billion, averaging nearly $200,000 per patient.
Gnly heart disease and cancer incur greater economic costs.
CLASSIFICATION
Many different ways exist for classifying dementia subtypes,
including classification by etiology, anatomic location, course,
and prognosis. DSM-IV-TR lists the following major of
dementia, Without regard to a specific method of classification:
1.Dementia of the Alzheimer type;
2.Vascular dementia;
3.Dementia due to one of the following: human immuno-
deficiency virus disease, head trauma, Parkinson disease,
Huntington disease, Pick disease, or Creutzfeldt-Jakob
disease;
4. Dementia due to a general medical condition (specify the
condition);
5. Substance-induced persisting dementia;
6. Dementia due to multiple etiologies;
7. Dementia, not otherwise specified.
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KEY POINT
Of this list, Alzheimer disease is the most common, accounting for
50% to 70% of all dementias, while vascular dementia accounts
for slightly more than 20%. Much overlap is encountered here
because approximately 30% of patients with Alzheimer disease
also have
vascular dementia.
vascular dementia.
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Demenltia due to Lewy body disease is not listed in DSM-IV-TR,
but il may account for nearly 20% of all dementias. All
other types of dementia represent less than 10% of total cases,
although considerable overlap is seen with Alzheimer disease
and the other major types. Although the
describes the majority of dementias, it also obscures the great
diversity of subtypes. This chapter reviews several approaches
to classification and then presents a complete list of dementia
subtypes (grouped by etiology) in Table 1.1.
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TABLE 1.1,. Subtypes of Dementia, Grouped by Etiology
Etiology Subtype
Primary cortical Alzheimer disease
degeneration Dementia with Lewy bodies (diffuse,
mixed, cerebral)
Frontotemporai dementia or Pick disease
Primary progressive aphasia
Agyrophilic grain disease
Primary subcortical Dementia with Lewy bodies (transitional
degeneration and brainstem)
Parkinson disease
Corticobasal degeneration
Progressive supranuctear palsy
Multiple system atrophy
Cerebrovascuiar Vascular dementia
disease largevessel and smallvessel strokes
Multiple lacunar infarcts
Binswanger disease
Cerebral autosomal dominant-arteriopathy
with subcortical infarcts and
leukoencephalopathy (CADASIL)
Cerebral amyloid angiopathy
(Continued)