Related Subjects:
|Dementias
|Abbreviated Mental Test Score (AMTS)
|Alzheimer disease
|Dementia with Lewy bodies
|Frontotemporal dementia
|Corticobasal degeneration
|Creutzfeldt Jakob disease
|Vascular Dementia
|Primary progressive aphasia
|Anti Dementia Drugs
|AIDS Dementia Complex
|Normal Pressure Hydrocephalus
|Acetylcholinesterase inhibitors
|Mental Capacity Act 2005
|Behavioural and Psychological Symptoms of Dementia
People with dementia are particularly vulnerable to abuse and neglect.
All health and social care staff should receive training and follow the local multi-agency policy on adult protection.
đź“– About Dementia
- Dementia is a progressive neurodegenerative syndrome with decline in cognition affecting daily function.
- Domains: memory, language, attention, visuospatial skills, executive function.
- Distinguish from delirium (acute, fluctuating, often reversible) and depression (“pseudodementia”).
🔬 Etiology & Pathophysiology
- Alzheimer’s Disease (AD): Amyloid-β plaques, tau tangles, APOE-e4 link.
- Vascular Dementia (VaD): Ischaemic injury, risks = HTN, diabetes, cholesterol.
- Lewy Body Dementia (LBD): α-synuclein deposits, hallucinations + parkinsonism.
- Frontotemporal Dementia (FTD): Tau/TDP-43, early behaviour/language change.
- Mixed Dementia: Overlap of AD + VaD.
- Other causes: Alcohol, infections, metabolic, prion disease.
🧩 Key Clinical Findings
- Early: short-term memory loss → later global impairment.
- Mood/personality change, language impairment, visuospatial loss.
- BPSD (Behavioural & Psychological Symptoms): agitation, depression, psychosis, sleep disturbance.
- Loss of ADLs (e.g. finances, driving, personal care).
- Collateral history from family/carers is essential for diagnosis.
đź“Š Comparison of Dementia Subtypes
| Subtype |
Pathology |
Key Features |
Notes |
| Alzheimer’s |
Aβ plaques + tau tangles |
Memory loss, disorientation |
Most common (50–70%) |
| Vascular |
Cerebrovascular infarcts |
Stepwise decline, focal signs |
Control risk factors |
| Lewy Body |
α-synuclein deposits |
Fluctuating cognition, hallucinations, Parkinsonism |
⚠️ Neuroleptic sensitivity |
| Frontotemporal |
Tau / TDP-43 |
Personality, behaviour, language change |
Younger onset (50s–60s) |
đź©ş Clinical Assessment
- History: Onset, tempo, functional impact, risk factors, family history.
- Collateral history: From relatives/carers to assess changes over time.
- Cognitive Testing: MMSE, MoCA, ACE-III. MoCA more sensitive for MCI and executive dysfunction.
- ADLs/IADLs: Ask about ability with cooking, finances, medication, driving.
- Exam: Neurological signs (parkinsonism, focal deficits), cardiovascular exam (AF, bruits).
- Screen for delirium: 4AT tool if acute confusion suspected.
🧪 Investigations
- Bloods: FBC, U&E, LFTs, TFTs, B12, folate, calcium, glucose, syphilis/HIV if at risk.
- Neuroimaging:
- CT brain: to exclude structural lesions and look for atrophy/vascular changes.
- MRI brain: more sensitive; hippocampal atrophy in AD, white matter disease in VaD, frontal/temporal atrophy in FTD.
- Specialist Imaging: PET (FDG-PET hypometabolism; amyloid/tau PET in research).
- CSF Biomarkers: Low Aβ42 and raised tau support AD (not routine NHS yet).
- EEG: May show generalised slowing in advanced disease; triphasic waves in CJD.
- Neuropsychological testing: Detailed cognitive profiling when diagnosis uncertain.
đźź© NICE Key Points (2023):
- Offer cholinesterase inhibitors for mild–moderate Alzheimer’s.
- Memantine for moderate–severe Alzheimer’s or intolerance to cholinesterase inhibitors.
- Cholinesterase inhibitors for Lewy body dementia.
- No specific drug for vascular dementia – manage vascular risk factors.
- Avoid antipsychotics unless severe risk of harm – use lowest dose, shortest duration.
đź’Š Management Strategies
- Non-pharmacological: Cognitive stimulation therapy, reminiscence therapy, occupational therapy, physical activity, social engagement, environmental modification (good lighting, calendars, clear signage).
- Pharmacological:
- Cholinesterase inhibitors: donepezil, rivastigmine, galantamine (AD, LBD, Parkinson’s dementia).
- Memantine: for moderate–severe AD, or if cholinesterase inhibitors not tolerated.
- SSRIs: for depression/anxiety in dementia, especially FTD.
- Antipsychotics: only for severe distress/aggression; avoid in LBD/PD dementia due to sensitivity.
- Vascular Dementia: Aggressive risk factor management (BP, diabetes, lipids, smoking cessation, antiplatelets if vascular disease).
- Caregiver support: Carer education, respite care, referral to social services, Alzheimer’s Society resources.
⚠️ Complications & Prognosis
- Falls, aspiration pneumonia, malnutrition, urinary incontinence, behavioural disturbance.
- Progression varies: AD median survival 7–10 years; FTD and LBD often more rapid.
- Early palliative approach: focus on comfort, advance care planning, family support.
⚖️ Ethical Considerations
- Formal capacity assessments for decision-making.
- Best interest decisions under Mental Capacity Act if capacity lost.
- Advance care planning: DNACPR, lasting power of attorney, advance statements.
- Safeguarding and protection from abuse/neglect.
đź” Latest Research
- Monoclonal antibodies targeting amyloid (e.g., lecanemab, donanemab).
- Tau-targeted immunotherapies (early-phase trials).
- Digital therapeutics: cognitive apps, wearable monitoring.
- Blood-based biomarkers (plasma tau, neurofilament light chain) under investigation.
- Stem cell therapies remain experimental.
đź“š Glossary
- ADLs: Basic self-care (bathing, eating).
- IADLs: Complex tasks (finances, meds).
- BPSD: Behavioural & psychological symptoms of dementia.