neurologic disorders
Dementia
Symptoms and Signs of Dementia
(See also Behavioral and Psychologic Symptoms of Dementia .) Dementia impairs cognition globally. Onset is gradual, although family members may suddenly notice deficits (eg, when function becomes impaired). Often, loss of short-term memory is the first sign. At first, early symptoms may be indistinguishable from those of age-associated memory impairment or mild cognitive impairment, but then progression becomes apparent. Although symptoms of dementia exist in a continuum, they can be divided into Early Intermediate Late Personality changes and behavioral disturbances may develop early or late. Motor and other focal neurologic deficits occur at different stages, depending on the type of dementia; they occur early in vascular dementia and late in Alzheimer disease. Incidence of seizures is somewhat increased during all stages. Psychosis—hallucinations, delusions, or paranoia—occurs in about 10% of patients with dementia, although a higher percentage may experience these symptoms temporarily. Many disorders, particularly during exacerbations, can worsen the symptoms of dementia. These disorders include Evaluation of the Patient With a Liver Disorder , Drinking Alcohol Use Disorder and Rehabilitation , even in moderate amounts, may also worsen the symptoms of dementia and contribute to its progression (eg, by reducing brain volume), and most experts recommend that patients with dementia stop drinking alcohol. Recent memory is impaired; learning and retaining new information become difficult. Language problems (especially with word finding), mood swings, and personality changes develop. Patients may have progressive difficulty with independent activities of daily living (eg, balancing their checkbook, finding their way around, remembering where they put things). Abstract thinking, insight, or judgment may be impaired. Patients may respond to loss of independence and memory with irritability, hostility, and agitation. Functional ability may be further limited by the following: Agnosia : Impaired ability to identify objects despite intact sensory function Apraxia : Impaired ability to do previously learned motor activities despite intact motor function Aphasia : Impaired ability to comprehend or use language Although early dementia may not compromise sociability, family members may report strange behavior accompanied by emotional lability. Patients become unable to learn and recall new information. Memory of remote events is reduced but not totally lost. Patients may require help with basic activities of daily living (eg, bathing, eating, dressing, toileting). Personality changes may progress. Patients may become irritable, anxious, self-centered, inflexible, or angry more easily. They may become more passive, with a flat affect; they may develop depression, become indecisive, lose spontaneity, or generally withdraw from social situations. Personality traits or habits may become more exaggerated (eg, concern with money becomes obsession with it). Behavioral and Psychologic Symptoms of Dementia may develop: Patients may wander or become suddenly and inappropriately agitated, hostile, uncooperative, or physically aggressive. By this stage, patients have lost all sense of time and place because they cannot effectively use normal environmental and social cues. Patients often get lost; they may be unable to find their own bedroom or bathroom. They remain ambulatory but are at risk of falls or accidents secondary to confusion. Altered sensation or perception may culminate in psychosis with hallucinations and paranoid and persecutory delusions. Sleep patterns are often disorganized. Patients cannot walk, feed themselves, or do any other activities of daily living; they may become incontinent. Recent and remote memory is completely lost. Patients may be unable to swallow. They are at risk of undernutrition, pneumonia (especially due to aspiration), and pressure ulcers. Because they depend completely on others for care, placement in a long-term care facility often becomes necessary. Eventually, patients become mute. Because such patients cannot relate any symptoms to a physician and because older patients often have no febrile or leukocytic response to infection, a physician must rely on experience and acumen whenever a patient appears ill. End-stage dementia results in coma and death, usually due to infection. 