Dementia

Disease Description (Causes and Symptoms)

• Definition: A clinical syndrome (dementia) in which multiple cognitive domains, such as memory, language, and judgment, are acquiredly impaired, interfering with the performance of daily activities.
• Major causes and pathophysiology
  • Alzheimer’s disease: Neurodegenerative changes (amyloid plaques, tau pathology, etc.) gradually cause neuronal loss, leading to progressive brain atrophy. Accounts for approximately 50–60% of all dementia cases.
  • Vascular dementia: Occurs when neuronal damage results from impaired cerebral blood flow (multiple microinfarcts, large-vessel cerebral infarction, cerebral hemorrhage, etc.). Accounts for approximately 20–30% of cases.
  • Other causes: Reversible causes may include normal-pressure hydrocephalus, brain tumors, nutritional deficiencies (e.g., vitamin B12), infections, and medication-related or metabolic abnormalities.
• Major symptoms
  • Memory impairment (difficulty remembering new information), persistent cognitive decline distinguishable from ordinary forgetfulness
  • Language impairment (anomic aphasia), decline in judgment and calculation ability
  • Visuospatial impairment (getting lost), personality and emotional changes (depression, apathy, etc.)
  • Confusion, disorientation, sleep disturbances, behavioral symptoms (wandering, hallucinations, aggression, etc.)

Treatment Methods

• Etiological treatment
  • Correct reversible causes (vitamin deficiencies, hypothyroidism, etc.)
  • Symptoms of normal-pressure hydrocephalus may improve with cerebrospinal fluid drainage (e.g., shunt placement)
  • Surgery may be considered when surgical correction of conditions such as brain tumors or hemorrhage is possible
  • Vascular dementia: Actively control vascular risk factors such as hypertension, diabetes, hyperlipidemia, and smoking
• Pharmacological treatment (aimed at alleviating symptoms and delaying progression)
  • Cholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine — used to preserve cognitive function in mild to moderate Alzheimer’s disease and other conditions
  • NMDA receptor antagonist: Memantine — used in moderate to severe Alzheimer’s disease
  • Antidepressants and antipsychotics may be used for cognitive and behavioral symptoms (depression, anxiety, sleep problems, aggression, etc.), but considering their side effects and risks (e.g., atypical antipsychotics increase the risk of death in patients with dementia), use at the lowest dose for the shortest duration is recommended
• Nonpharmacological treatment and rehabilitation
  • Cognitive stimulation therapy, occupational therapy, functional activity training, regular exercise (such as walking), and maintaining social activities
  • Education for patients and families, creating a caregiving and safe environment, and nutritional management
• Precautions and self-management
  • Anticholinergic medications, some antipsychotics, and benzodiazepines may worsen cognitive function and should be used with caution
  • Manage the risks of falls and aspiration (modify the environment; supervision during meals is necessary)
  • Prevention of infections (pneumonia and urinary tract infections): oral hygiene and appropriate mobility and repositioning management
  • Review polypharmacy and reduce unnecessary medications as recommended
• Treatment goal: Suppress progression, maintain quality of life, and prevent complications rather than achieve a cure

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare
  • A list of currently used medications (including prescription drugs, over-the-counter medications, herbal medicines, and nutritional supplements)
  • Medical and family history (especially dementia, cerebrovascular disease, and genetic disorders)
  • Copies of previous test results (blood tests, brain imaging such as MRI/CT, neuropsychological test results, etc.)
  • Notes summarizing when symptoms appeared and how they progressed (when they began, their severity, and in what situations they worsen or improve)
  • Examples of changes in the ability to perform daily activities (managing money, finding one’s way, eating, etc.)
  • A caregiver or family member who observes the symptoms is recommended to accompany the patient
• Example questions for the doctor during an outpatient visit to help with diagnosis (for patients and caregivers)
  • "When and how did the symptoms begin, and how have they progressed?"
  • "What difficulties have recently occurred in daily activities (cooking, taking medications, going out, etc.)?"
  • "Have there been changes in sleep, eating, or mood? Are there behavioral symptoms (wandering, hallucinations, etc.)?"

Examples of General Questions to Ask the Doctor

• Is this symptom really dementia, and what is the difference from ordinary forgetfulness?
• What additional tests should be performed, and what is the purpose of each test (blood tests, MRI, neuropsychological testing, etc.)?
• What pharmacological treatment is recommended, and what are its expected effects and major side effects?
• What should be done regarding lifestyle habits or prevention?
• What follow-up testing interval and caregiving plan (rehabilitation and caregiving) do you recommend?

Examples of Disease-Specific Questions

• Based on this patient’s clinical presentation and test results, which is more likely: Alzheimer’s disease or vascular dementia? What additional tests are needed to confirm the diagnosis?
• Could the medications the patient is currently taking (or their medical history) worsen cognitive function? Are there any medications that should be adjusted?