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Minor problems with memory and understanding, such as forgetting a name or taking more time to figure out directions, are a normal part of aging for everyone. However, some older adults develop extreme problems with remembering, understanding, or thinking. For example, they can "get lost" walking to the bathroom, become confused by simple tasks, forget the names of loved ones, and have difficulty speaking logically. These problems can be very difficult for people to cope with, and they also strongly affect family, friends, and other caregivers.

The most common mental disorders in late life are dementia and delirium. These two conditions share several characteristics that sometimes make it difficult to tell them apart. In addition, dementia and delirium also commonly occur at the same time. (See also Delirium.)

Dementia is a progressive loss of intellectual ability that becomes severe enough to interfere with social functioning and activities of daily life. This loss generally develops over a long period of time (eg, months to years) and affects many areas of mental functioning. Memory loss is generally prominent, and it is usually accompanied by other difficulties in intellectual or mental capacity. Difficulties in planning meals, managing finances, taking medications, using a telephone, and driving without getting lost are fairly common in the early stages. Behavior and mood changes are common, including personality changes, irritability, anxiety, or depression. These types of changes may be the first signs that alert others of a problem.

Dementia generally begins after age 60. It affects approximately one in five people by the age of 85. It is important to emphasize that dementia is more than just the normal slowdown in processing new information that we experience with age. Dementia is progressive and disabling; it is not a normal part of aging.

Dementia has a major impact on society. The total costs approach $100 billion annually, including costs of medical care, long-term care, home care, and lost productivity for caregivers. Eventually, almost 75% of people with dementia need to be admitted to a long-term care facility and to remain there for a long time. Medicare, Medicaid, and private insurance pay much of the direct cost, but families caring for people with dementia must bear the greatest burden of expense. In addition, the financial costs of dementia are only one part of the total burden. The emotional toll is immense for both people with dementia and their families. Nearly half of primary caregivers for people with dementia experience psychological distress, particularly depression.

• Types of Dementia
  • Alzheimer's disease
  • Vascular dementia
  • Dementia caused by infection
  • Reversible causes of dementia
• Diagnosis
• Management
  • Drug treatment
  • Vitamin and herbal remedies
  • Regular medical checkups
• Caregiver and Family Assistance

Types of Dementia
The most common types of dementia are Alzheimer's disease and vascular dementia. The latter is generally due to blockage of blood vessels in the brain caused by small strokes. Perhaps 10%-20% of dementias are due to a combination of Alzheimer's disease and multiple small strokes. Another form of dementia that may be relatively common is associated with things called "Lewy bodies" in the brain cells. A small percentage of dementias are due to alcoholism, head injuries, brain tumors, and various diseases (Huntington's disease, Parkinson's disease, and Pick's disease). Dementia can also be caused by infection and is a major feature of advanced AIDS.

Alzheimer's disease
Approximately four million Americans have Alzheimer's disease. Alzheimer's disease accounts for nearly two thirds of dementia in older adults. The two greatest risk factors are age and family history. Alzheimer's disease affects approximately 6%-8% of people aged 65 and older, and about 30% or more of people aged 85 and older. Among those with first-degree relatives (ie, parents, siblings) who have Alzheimer's, nearly half contract the disease by age 90. Other possible risk factors include a previous head injury and a low level of formal education. In addition, Alzheimer's is more common in women than in men.

In Alzheimer's disease, memory loss is usually subtle and progressive, and reminders do not help much. Language difficulties are also consistently seen. Early in the course of the disease, affected people may have difficulty finding the right word. This can later progress to more severe difficulties in understanding languages and speaking. People with Alzheimer's disease can usually still repeat words, but develop more and more trouble naming things independently or understanding what they mean.

People with Alzheimer's disease may have difficulty recognizing or finding objects, or drawing simple designs. Caregivers often report that the person gets lost, even in their own neighborhood. The abilities to organize, plan, and think abstractly are frequently lost, which usually interferes with being able to make appropriate judgments at work or in social situations.

Behavioral and psychiatric symptoms are also common in Alzheimer's disease. These include wandering, aggressive behaviors, visual hallucinations, and delusions. The delusions often involve being unreasonably suspicious of other people, including caregivers, or being concerned that others are stealing personal possessions. These behaviors are extremely troubling to caregivers and often result in family distress, leading to a decision to place the older adult in a nursing home.

Most people with Alzheimer's disease have severe disability within 8-12 years. Generally, these people have little insight into their own disabilities as the disease progresses. The severity of the dementia is strongly related to life expectancy, ie, those with severe dementia live the shortest. Wandering, falling, urinary incontinence (ie, wetting oneself), and behavioral problems (eg, paranoia, agitation, or hallucinations) are also associated with a poor outlook.

Vascular dementia
Vascular dementia accounts for 15%-25% of dementias. Mental functioning is generally damaged by multiple small strokes that decrease blood supply to various parts of the brain. Sometimes, mental difficulty begins suddenly, followed by sudden loss of function. Risk factors for vascular dementia include high blood pressure, high blood fat, diabetes, smoking, and old age. Vascular dementia is also more common in men than in women. A person may have several neurologic difficulties, including loss of the use of one-half of the body, loss of vision or hearing, speaking difficulties, difficulty organizing things, difficulty naming objects, etc (see Rehabilitation).

Dementia caused by infection
Infections can also cause dementia, but this is much less common than Alzheimer's disease or vascular dementia. A very rare infectious disease called Creutzfeldt-Jakob disease is thought to be caused by an infectious protein called a prion. In this disease, the first symptoms are subtle changes in behavior including fatigue, difficulty concentrating, and depression. Eventually, several mental and intellectual difficulties develop. Muscle jerks and incoordination are common and may rapidly lead to a condition in which the person cannot move. The final stages are characterized by seizures. A variant of Creutzfeldt-Jakob disease might be caused by the prion responsible for so-called "mad cow disease."

In many people who have AIDS, the human immunodeficiency virus (HIV) may infect the brain directly and cause a slowly progressive dementia. Most affected people are forgetful. They have a hard time paying attention to anything, and their thought processes slow down. They may appear withdrawn, listless, or depressed, and psychiatric symptoms may be present. In some AIDS patients, dementia can develop secondary to infection of the brain by other organisms.

Reversible causes of dementia
A few cases of dementia (5%-10%) are caused by something that is at least partially reversible. One of the most common of these causes is chronic alcoholism (ie, excessive drinking for more than 10 years). This type of dementia affects primarily memory and non-verbal skills. In addition to alcohol, other toxic substances may cause dementia after relatively high levels of exposure over a long time (eg, past occupational exposures). Examples include metals such as arsenic, lead, thallium, manganese, and mercury.

In some cases, dementia can be caused by an overactive or underactive thyroid gland. Vitamin B12 deficiency can also be associated with dementia. Treatment to return the thyroid hormone or B12 to normal levels may dramatically improve this dementia.

Forgetfulness, slowness to respond, poor attention, and confusion are also common among older adults who have clinical depression. This is not truly dementia, although it has sometimes been called "pseudodementia." Clues to depression usually include sleep disturbances, problems with appetite, and a lowered sex drive (see Depression). Diagnosis and treatment of the depression should reverse the symptoms. However, it is important to recognize that depression and dementia may exist together-some people who initially respond to antidepressant medication may later develop symptoms of dementia that is irreversible.

Diagnosis
Dementia can be difficult to diagnose in the early stages. However, if it is identified early, it will give you and your loved ones time to prepare. For example, it will allow you to participate in treatment decisions and future planning (living wills, etc) while you are able. So, if you are having problems with memory or other thought processes, you should see a doctor, preferably one specializing in medicine for older adults. You may also be referred to a neurologist or psychiatrists for more in-depth evaluation of your memory.

The diagnosis of dementia is generally based on a discussion at the healthcare provider's office. You will be asked questions about your general mental and physical health, medications you are taking, and specific questions designed to test memory, language, ability to retain new information, etc. Someone else who knows you well (eg, a close friend or relative) should go with you and report any changes that they have noticed. Your healthcare provider will use this initial discussion to establish a baseline for your current level of mental function. The discussion should be in your native language.

You should also have a complete physical examination, including appropriate laboratory tests (eg, blood, urine, etc) to check for underlying problems and reversible causes of dementia. Your healthcare provider may also recommend a CAT scan or MRI to help with the diagnosis of dementia and to identify underlying causes that may be reversible (eg, a brain tumor). In certain circumstances, an EEG or spinal tap might also be recommended.

Management
Specific, reversible causes of dementia, such as low levels of thyroid hormone or vitamin B12, can be treated directly. However, there is no specific cure or drug treatment for most cases of dementia (eg, Alzheimer's disease or vascular dementia). Instead, the primary goal is to maintain quality of life and ability to function for as long as possible. In general, management plans involve techniques to stimulate memory and thinking, along with making certain changes in lifestyle and environment. The objective is to provide support to make up for lost skills. Medications are primarily used to treat underlying problems (eg, depression), or as a last resort to control dangerous behaviors. Other management strategies include the following:

• Treat underlying medical problems.
• Correct visual or hearing losses (ie, replace poorly fitting hearing aids, eyeglasses, etc).
• Identify and remove medications that can lead to problems.
• Identify and remove medications that can lead to problems.
• Provide regular daily activities and structure.
• Monitor for new medical problems.
• Maintain sleeping and eating patterns.
• Maintain sleeping and eating patterns.
• Ensure adequate respite for caregivers.
• Educate caregivers about practical aspects of dementia care and about behavioral disturbances.
• Educate caregivers on communication skills, avoiding confrontational behavior, supporting activities of daily living, and on activities for dementia care.
• Simplify bathing and dressing with the use of adaptive clothing and assistive devices if needed (see Rehabilitation [Assistive Devices]).
• Identify and seek help from experienced professionals and community resources (as needed).
• Seek information and assistance from local Alzheimer's association.

Caregivers must consider the best methods for managing the person's mood and behavior. Characteristically, Alzheimer's victims may suffer from depression, anxiety, hallucinations, or aggressive behavior. They can wander and get lost, and become very agitated at night. Caregivers must identify which, if any, of these problems is severe enough to need specific management. A management plan for each problem should be developed, while realizing that other problems may not improve. Considering the following questions may be helpful:

• How much agitation or arousal is being shown?
• How aware is the person of their surroundings and the consequences of his or her actions?
• Does he or she have the capacity to control these behaviors?
• Are there appropriate outlets for self-expression?

Management techniques
Techniques to improve memory and reduce confusion include conspicuous displays of clocks, calendars, and to-do lists. Newspapers, radio, and television also benefit some people. Speaking in simple sentences and reminding people repeatedly about conversation content may improve communication. Reminiscence therapy may also be helpful. This involves stimulating recall of pleasant experiences from the past. However, it is important to remember that most of these techniques are helpful primarily in the early stages (ie, those with mild to moderate illness). Attempts to force recall in more advanced disease can lead to frustration and agitation, for both the affected individual and his or her caregivers.

Caregivers concerned with management of people suffering from dementia should keep in mind that people do better with a "moderate" amount of ongoing sensory and social stimulation. Too little stimulation may cause withdrawal, while over-stimulation can increase confusion or agitation. If possible, visual and hearing difficulties should be corrected.

Regular daily routines in familiar surroundings are helpful in dealing with people who have dementia. This type of environment is reassuring and maximizes existing mental capabilities. Stimulants in the evening (eg, caffeinated beverages) are not recommended, because they can cause sleep problems. Medications should be reviewed carefully in case any are contributing to mental problems. Additional helpful strategies include simplifying the environment, removing clutter, and providing better lighting.

Behavioral Management of Insomnia

• Establish a stable routine for going to bed and waking up.
• Make the environment comfortable for sleeping (attention to noise, light, temperature, etc).
• Increase activity and light exercise during the day.
• Reduce or eliminate caffeine, nicotine, and alcohol.
• Reduce evening fluid consumption to minimize wetting the bed.
• Give laxatives early in the day if the person has difficulty eliminating.
• Control nighttime pain.
• Limit daytime naps to 20-30 minutes.
• Use relaxation, stress management, and breathing techniques to encourage sleep.

Caregivers should learn about behavior patterns that can be expected and make changes in the environment that might be helpful. For example, taking the knobs off the stove can prevent cooking accidents or locking doors can prevent wandering and getting lost. In addition, caregivers should look out for and, if possible, correct any factors that might worsen a behavior problem or create a new one. These include stress in the household or medical problems in addition to dementia.

Under no circumstances should a person with dementia be allowed to drive. Although preserving a person's independence is desirable, it should not be at the expense of safety for the affected person or anyone else.

The psychiatric complications of dementia include paranoid or accusatory beliefs, delusions, and hallucinations. If these symptoms are mild, they do not need to be treated. However, if they are more pronounced, they can lead to aggressive behavior that ranges from cursing and spitting to direct physical attacks. Maintaining composure, distracting the individual, and making changes in the environment can all help in dealing with aggressive behavior. For example, soothing music can sometimes help to relieve stress and agitation. Taking the time to slowly and gently complete a potentially disruptive task (eg, bathing) may also help reduce this sort of behavior.

Wandering affects up to one-half of people with severe dementia. Agitation, depression, hallucinations, boredom, the need for more frequent bathroom visits, or pain can cause a demented person to wander. If these problems can be corrected the wandering may lessen. Regular exercise is also often helpful. An armband or identification bracelet that cannot be removed is a good way to help others promptly identify and return a lost wanderer. Drug treatments and physical restraints do not cure wandering and usually increase agitation and irritability. However, in very rare circumstances they may be necessary for safety reasons.

Confusion or agitation that occurs in the early evening or night is called "sundowning." The best way to manage this is to keep the environment soothing, eg, a quiet room with low lighting and soft music or television. Talking quietly to the agitated person can be helpful.

Drug treatment
In some cases, drug treatment may be needed to reduce difficult behavior, or to treat underlying medical or psychiatric problems. However, people who have dementia may not be able to report whether they are having any side effects. In these cases, caregivers should learn about and watch for possible side effects (see also Drug Treatment). Doctors and pharmacists are excellent sources of this information.

Occasionally, sedative medications may be needed for sundowning. Unfortunately, these drugs can also potentially increase confusion. Medication may also be needed to control agitated, aggressive, or hostile behavior, especially if there is the potential for injury.

Currently, there is no treatment that consistently improves memory in people with Alzheimer's disease. However, several drugs are available that can help stabilize the decline in mild to moderate dementia by working to increase the amount of a specific chemical in the brain called acetylcholine. Other medications may slow down the progression of advanced Alzheimer's disease via other mechanisms. Your healthcare provider can discuss possible medications and their potential side effects with you.

Vitamin and herbal remedies
Several over-the-counter supplements claim to improve mental function in older adults. These include Ginkgo biloba extract, vitamin E, and selegiline (see Complementary and Alternative Medicine). However, the effectiveness of these products has not been proved, and research findings are inconsistent.

Regular medical checkups
Regular monitoring and health checkups should be scheduled every 3 to 6 months for people with dementia. During such visits, your healthcare provider can evaluate and treat other illnesses, including sleep and behavior problems. Current medications and their effects can also be reviewed.

Caregiver and Family Assistance
Caring for people who have dementia is difficult and requires considerable perseverance. Most people can be good caregivers if they have the proper guidance and support. However, caregivers who are inexperienced, domineering, or who have medical or psychiatric problems themselves may cause behavioral disturbances. Caregivers are also under a tremendous amount of stress, which makes them vulnerable to depression and to drug or alcohol abuse. These consequences appear to be more closely related to characteristics of the caregivers (eg, morale, health, and coping skills) than to the severity of mental or functional problems in the older person for whom they are caring. It is important for caregivers to know about the person's illness and its likely course, the type of therapy that may be needed, and any difficulties in function and behavior that may develop. This helps caregivers not to place unrealistic demands on the person with dementia.

Education and assistance improve the quality of care and help reduce caregiver stress and burnout. The Alzheimer's Association (see Related Websites) has chapters throughout the United States and is a useful source of information and support groups. Families and other caregivers should learn about services in their community that might provide assistance, including opportunities to give the caregivers some "time off." Caregiver distress is often reduced by participating in a support group, which may relieve feelings of anger, frustration, and guilt. Respite care is another community resource that offers caregivers relief.

Clearly, all decisions regarding management of a person who has dementia can become very difficult, especially if placement in a nursing home is being considered. Discussion about placement options for long-term care should begin earlier rather than later, so that the individual and family members have time to make arrangements and begin to adjust emotionally. Power of attorney, guardianship, and end-of-life issues, such as advanced directives and life-sustaining measures, should also be discussed (see Ethical and Legal Issues). The family may also want to consider information about arrangements for an autopsy. An examination of the brain after death may be important to help understand the cause of the dementia and to provide useful information for other family members.