Doctors Revision

Neurological System

Dementia

A chronic, usually progressive decline in multiple cognitive domains (including memory, thinking, judgment, language) severe enough to interfere with daily functioning and independence. Not a normal part of aging.

Also known as: Major Neurocognitive Disorder

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Referral and warning signs

When to refer

Refer to specialist (Geriatrician, Neurologist, Psychiatrist - H/RR) for: Confirmation of diagnosis and determination of dementia type. Investigation of potentially reversible causes. Initiation and management of dementia-specific medications (Donepezil, Memantine). Management of complex or severe behavioral symptoms. Assistance with advance care planning and accessing support services.

Red flags

  • Rapid onset or progression of cognitive decline (weeks/months - suspect delirium or other acute cause)
  • Early onset dementia (<65 years)
  • Prominent early behavioral or language changes (suggests frontotemporal dementia)
  • Early prominent parkinsonism or visual hallucinations (suggests Dementia with Lewy Bodies)
  • Focal neurological signs (suggests stroke, tumor)
  • Gait disturbance early in course (suggests Vascular Dementia, NPH)
  • Presence of systemic illness or signs of infection

Signs and symptoms

  • Progressive impairment of short-term memory (difficulty learning new information).
  • Impairment of long-term memory (may be less affected initially).
  • Impaired judgment and poor abstract thinking.
  • Language disturbances (aphasia): Difficulty finding words, understanding, reading, writing.
  • Difficulties with complex tasks (apraxia): Inability to perform previously learned motor tasks despite intact motor function (e.g., dressing, cooking).
  • Difficulties with recognition (agnosia): Failure to recognize objects or people despite intact sensory function.
  • Executive dysfunction: Problems with planning, organizing, sequencing, problem-solving.
  • Personality changes: Apathy, withdrawal, irritability, agitation, aggression, disinhibition.
  • Mood changes: Depression, anxiety.
  • Psychotic symptoms (later stages): Delusions, hallucinations.
  • Behavioral changes: Wandering, restlessness, sleep disturbances.
  • Difficulties with Activities of Daily Living (ADLs): Initially instrumental ADLs (managing finances, medications, transportation), later basic ADLs (bathing, dressing, feeding, toileting).
  • Incontinence (urinary, fecal) in later stages.

Risk factors

  • Age (strongest risk factor).
  • Genetics/Family history (e.g., Alzheimer's disease, Huntington's).
  • Vascular risk factors (for Vascular Dementia): Hypertension, diabetes, smoking, high cholesterol, stroke history, heart disease.
  • Brain infections (Syphilis, HIV/AIDS, Meningitis history, prion disease).
  • Metabolic/Endocrine disorders (Hypothyroidism, severe Vitamin B12/B1 deficiency).
  • Repeated head trauma.
  • Chronic alcohol abuse.
  • Exposure to toxins (e.g., carbon monoxide).
  • Normal Pressure Hydrocephalus.
  • Chronic subdural hematoma.
  • Brain tumors (rarely).

Diagnosis

Clinical assessment

Diagnosis based on history from patient and reliable informant (family/carer) detailing cognitive decline interfering with function. Requires comprehensive clinical assessment including: Detailed history of symptom onset and progression. Assessment of cognitive domains (memory, language, executive function, visuospatial skills). Functional assessment (ADLs). Neurological examination. Mental state examination (mood, psychosis). Review of medications.

Investigations

  • Cognitive Screening Tests: Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Clock Drawing Test (useful bedside tools).
  • Laboratory tests (to rule out reversible causes): CBC, Electrolytes, Renal function, Liver function, Thyroid function tests (TSH), Vitamin B12 level, RPR/VDRL (for syphilis), HIV test.
  • Neuroimaging (CT or MRI Brain): To identify structural causes (stroke, tumor, hydrocephalus, hematoma) and patterns of atrophy suggestive of specific dementia types (e.g., Alzheimer's, frontotemporal). Usually H/RR level.
  • Lumbar puncture (rarely): If infection (e.g., chronic meningitis, neurosyphilis) or Normal Pressure Hydrocephalus suspected.
  • EEG (rarely): If seizures or Creutzfeldt-Jakob disease suspected.

Diagnostic criteria

Based on diagnostic criteria (e.g., DSM-5 for Major Neurocognitive Disorder): Evidence of significant cognitive decline from previous level in ≥1 cognitive domains, deficits interfere with independence in everyday activities, deficits do not occur exclusively during delirium, deficits not better explained by another mental disorder.

Management

Non-pharmacological management

  • Management of underlying cause if reversible (e.g., treat hypothyroidism, syphilis, B12 deficiency, remove offending drugs).
  • Supportive Care: Maintain safe environment, establish routines, use memory aids (calendars, lists), simplify tasks.
  • Caregiver Education and Support: Crucial for managing behavioral symptoms, coping with disease progression, accessing resources.
  • Cognitive Stimulation/Rehabilitation: Activities to maintain cognitive function.
  • Environmental Modifications: Reduce clutter, improve lighting, ensure safety (prevent falls, wandering).
  • Behavioral Management Strategies: Identify triggers for agitation/aggression, use distraction, redirection, validation therapy.
  • Manage co-occurring conditions: Treat depression, anxiety, sleep disorders, infections, pain.
  • Advance Care Planning.

Pharmacological treatment

  • Cholinesterase Inhibitors (for mild-moderate Alzheimer's disease, Dementia with Lewy Bodies): Donepezil 5mg daily initially, increase to 10mg after 4-6 weeks if tolerated. Rivastigmine, Galantamine are others. May slow cognitive decline temporarily, manage some behavioral symptoms. (H/RR level initiation).
  • NMDA Receptor Antagonist (for moderate-severe Alzheimer's disease): Memantine 5mg daily initially, titrate up to 10mg BD. Can be used alone or with cholinesterase inhibitor. (H/RR level initiation).
  • Management of Behavioral and Psychological Symptoms of Dementia (BPSD): Use non-pharmacological strategies FIRST. If severe agitation, aggression, or psychosis causing distress/risk, consider low-dose antipsychotics cautiously (increased mortality risk, esp. in elderly). Examples: Risperidone 0.25-1mg daily (start low), Haloperidol 0.5-1mg PRN or scheduled (higher EPS risk). Use lowest effective dose for shortest duration. Avoid benzodiazepines if possible (risk of falls, confusion, paradoxical agitation). Trazodone or SSRIs may help with some symptoms (depression, anxiety, insomnia).
  • Treat underlying vascular risk factors aggressively (BP control, statins, antiplatelets) in Vascular Dementia.
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor cognitive function and functional status over time. Monitor for side effects of medications (GI upset, bradycardia with cholinesterase inhibitors; dizziness, headache with memantine; EPS, sedation with antipsychotics). Regularly assess caregiver burden and provide support. Monitor behavioral symptoms and adjust management plan.

Complications

  • Progressive loss of independence
  • Increased risk of falls and injuries
  • Malnutrition and dehydration
  • Infections (UTI, pneumonia)
  • Pressure sores
  • Behavioral disturbances causing caregiver stress
  • Institutionalization
  • Death (often from complications like infection)

Prevention

  • Control vascular risk factors (hypertension, diabetes, cholesterol, smoking cessation).
  • Maintain physically, mentally, and socially active lifestyle.
  • Healthy diet (e.g., Mediterranean diet).
  • Prevent and manage conditions linked to dementia (e.g., depression, hearing loss, alcohol abuse).
  • Head injury prevention.

Patient education

  • Explain the diagnosis, expected progression, and management goals to patient (if appropriate) and caregivers.
  • Emphasize importance of caregiver support and education.
  • Discuss safety issues (driving, wandering, home safety).
  • Explain medication purpose and side effects.
  • Provide information on local support resources if available.
  • Discuss advance directives and future planning.

Uganda-specific notes

Dementia prevalence is expected to rise. Awareness and diagnostic capacity may be limited. Reversible causes like infections (HIV, syphilis, TB), nutritional deficiencies (B12), and hypothyroidism should be actively sought. Access to specialist assessment, neuroimaging, and dementia-specific medications (Donepezil, Memantine) is restricted. Management relies heavily on supportive care and caregiver education. Stigma can be significant.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.1.4

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