Dementia

Topic Overview

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Alzheimer’s disease is the most common cause of dementia. This topic focuses on other conditions that cause dementia. For more information on Alzheimer’s, see the topic Alzheimer's Disease.

What is dementia?

We all forget things as we get older. Many older people have a slight loss of memory that does not affect their daily lives. But memory loss that gets worse may mean that you have dementia.

Dementia is a loss of mental skills that affects your daily life. It can cause problems with your memory and how well you can think and plan. Usually dementia gets worse over time. How long this takes is different for each person. Some people stay the same for years. Others lose skills quickly.

Your chances of having dementia rise as you get older. But this does not mean that everyone will get it. People rarely have dementia before age 60. But, after age 85, up to half of all adults have it.

If you or a loved one has memory loss that is getting worse, see your doctor. It may be nothing to worry about. If it is dementia, treatment may help.

What causes dementia?

Dementia is caused by damage to or changes in the brain. Things that can cause dementia include:

In a few cases, dementia is caused by a problem that can be treated. Examples include having an underactive thyroid gland (hypothyroidism), not getting enough vitamin B12, and fluid buildup in the brain (normal-pressure hydrocephalus). In these cases, treating the problem may cure the dementia.

In some people, depression can cause memory loss that seems like dementia. Depression can be treated.

As you age, medicines may affect you more. Taking some medicines together may cause symptoms that look like dementia. Be sure your doctor knows about all of the medicines you take. This means all prescription medicines and all over-the-counter medicines, herbs, vitamins, and supplements.

What are the symptoms?

Usually the first symptom is memory loss. Often the person who has a memory problem does not notice it, but family and friends do. As dementia gets worse:

  • You may have more trouble doing things that take planning, like making a list and going shopping.
  • You may have trouble using or understanding words.
  • You may get lost in places you know well.

Over time, people with dementia may begin to act very different. They may become scared and strike out at others, or they may become clingy and childlike. They may stop brushing their teeth or bathing.

Later, they cannot take care of themselves. They may not know where they are. They may not know their loved ones when they see them.

How is dementia diagnosed?

There is no single test for dementia. To diagnose it, your doctor will:

  • Do a physical exam.
  • Ask questions about recent and past illnesses and life events. The doctor will want to talk to a close family member to check details.
  • Ask you to do some simple things that test your memory and other mental skills. Your doctor may ask you to tell what day and year it is, repeat a series of words, or draw a clock face.

The doctor may do tests to look for a cause that can be treated. For example, you might have blood tests to check your thyroid or to look for an infection. You might also have a test that shows a picture of your brain, like an MRI and a CT scan. These tests can help your doctor find a tumor or brain injury. They can also show if there has been shrinking in parts of the brain. This can be a sign of dementia.

How is it treated?

There are medicines you can take for dementia. They cannot cure it, but they can slow it down for a while and make it easier to live with.

As dementia gets worse, a person may get depressed or angry and upset. Treatment, such as medicines and counseling, may help. So can getting out more and having an active social life.

If a stroke caused the dementia, there are things you can do to reduce the chance of another stroke. Stay at a healthy weight, exercise, and keep your blood pressure and cholesterol at normal levels. If you have diabetes, keep your blood sugar in your target range.

Keeping both your mind and your body active is a good idea for anyone. So is not smoking.

How can I help my loved one with dementia?

There are many things you can do to help your loved one be safe at home. For example, get rid of throw rugs, and put handrails in bathrooms to help prevent falls. Post reminder notes around the house. Put a list of important phone numbers by the telephone. You also can help your loved one stay active. Play cards or board games, and take walks.

Work with your loved one to make decisions about the future before dementia gets worse. It is important to write a living will and a durable power of attorney. A living will states the types of medical care your loved one wants. A durable power of attorney lets your loved one pick someone to be the health care agent. This person makes care decisions after your loved one cannot.

Watching a loved one slip away can be sad and scary. Caring for someone with dementia can leave you feeling drained. Be sure to take care of yourself and to give yourself breaks. Ask family members to share the load, or get other help.

Your loved one will need more and more care as dementia gets worse. In time, he or she may need help to eat, get dressed, or use the bathroom. You may be able to give this care at home, or you may want to think about using a nursing home. A nursing home can give this kind of care 24 hours a day. The time may come when a nursing home is the best choice.

You are not alone. Many people have loved ones with dementia. Ask your doctor about local support groups, or search the Internet for online support groups, such as the Alzheimer's Association. Help is available.

Frequently Asked Questions

Learning about dementia:

Being diagnosed:

Getting treatment:

Ongoing concerns:

Living with dementia:

End-of-life issues:

Health Tools Health Tools help you make wise health decisions or take action to improve your health.

Health Tools help you make wise health decisions or take action to improve your health.


Decision Points focus on key medical care decisions that are important to many health problems. Decision Points focus on key medical care decisions that are important to many health problems.
  Alzheimer's or other dementia: Should I move my relative into long-term care?

Cause

Dementia is caused by damage to or changes in the brain. A variety of conditions can cause dementia, including:

After Alzheimer's disease, dementia caused by strokes (vascular dementia) is the most common type of dementia. Many people have mixed types of dementia. Mental function lost to vascular dementia cannot be restored, but future damage may be prevented by reducing the risk for stroke.

Some causes of dementia can be reversed with treatment, but most cannot. Common causes of dementia that cannot be reversed are:

  • Parkinson's disease , which is a movement disorder. Dementia is common in people with this condition.
  • Dementia with Lewy bodies , which causes protein deposits (Lewy bodies) in brain cells. It can cause short-term memory loss like some other brain diseases, but it can also cause the person to fall often and to see things that aren't there (hallucinations).
  • Frontotemporal dementia , a group of diseases that includes Pick's disease. These diseases can cause changes in personality, behavior, or language.
  • Severe head injury that caused a loss of consciousness.

Less common causes of dementia that cannot be reversed include:

  • Huntington's disease , which is a rare, inherited illness.
  • Leukoencephalopathies, which are diseases that affect the deeper, white-matter brain tissue.
  • Vascular dementia that may occur in people with long-term high blood pressure or severe hardening of the arteries (atherosclerosis).
  • Creutzfeldt-Jakob disease, a rare and fatal condition that destroys brain tissue.
  • Brain injuries from accidents or boxing.
  • Some cases of multiple sclerosis (MS) or amyotrophic lateral sclerosis (ALS).
  • Multiple-system atrophy (a group of degenerative brain diseases affecting speech, movement, and autonomic functions).
  • Infections such as mad cow disease and late-stage syphilis. Antibiotics can effectively treat syphilis at any stage, but they cannot reverse the brain damage already done.

Doctors can treat some causes of dementia and restore mental function. These include:

Some disorders that cause dementia can run in families. Doctors often suspect an inherited cause if someone younger than 50 has symptoms of dementia. For more information, see the topic Alzheimer's Disease.

It is important to know that memory loss can be caused by conditions other than dementia, such as depression, and that those conditions can be treated. Also, occasional trouble with memory (such as briefly forgetting someone's name) can be a normal part of aging. But if you are worried about memory loss or if a loved one has memory loss that is getting worse, see your doctor.

Symptoms

Symptoms of dementia vary depending on the cause and the area of the brain that is affected. Memory loss is usually the earliest and most noticeable symptom. Other key symptoms of dementia include:

  • Having difficulty recalling recent events.
  • Not recognizing familiar people and places.
  • Having trouble finding the right words to express thoughts or name objects.
  • Having difficulty performing calculations.
  • Having problems planning and carrying out tasks, such as balancing a checkbook, following a recipe, or writing a letter.
  • Having trouble exercising judgment, such as knowing what to do in an emergency.
  • Having difficulty controlling moods or behaviors. Depression is common, and agitation or aggression may occur.
  • Not keeping up personal care such as grooming or bathing.

Some types of dementia cause key symptoms:

  • People who have dementia with Lewy bodies often have highly detailed visual hallucinations. They may fall frequently.
  • The first symptoms of frontotemporal dementia may be personality changes or unusual behavior. People with this condition may not express any caring for others, or they may say rude things, expose themselves, or make sexually explicit comments.

Symptoms of dementia that come on suddenly suggest vascular dementia or possibly delirium—short-term confusion caused by a new or worsening illness.

What Happens

How quickly dementia progresses depends on what is causing it and the area of the brain that is affected. Some types of dementia progress slowly over several years. Other types may progress more rapidly. If vascular dementia is caused by a series of small strokes, the loss of mental skills may be gradual. If it is caused by a single stroke in a large blood vessel, loss of function may occur suddenly.

The course of dementia varies greatly from one person to another. Early diagnosis and treatment with medicines used for Alzheimer's (cholinesterase inhibitors such as donepezil [Aricept]) may help preserve mental functioning for a while in people with vascular dementia, dementia with Lewy bodies, or Parkinson's disease.1 Even without these medicines, some people remain stable for months or years, while others decline rapidly.

Many people with dementia are not aware of their mental decline. They may deny their condition and blame others for the problems they experience. Those who are aware may mourn their loss of abilities and become hopeless and depressed.

Depending on the type of dementia, the person's behavior may eventually become out of control. The person may become angry, agitated, and combative or clingy and childlike. He or she may wander and become lost. These problems can make it difficult for family members or others to continue providing care at home.

Even with the best care, people with dementia tend to have a shorter life span than the average person their age. Death usually results from lung or kidney infections caused by being bedridden.

What to think about

Many older people have a slight loss of mental skills (usually recent memory) that doesn't affect their daily functioning. This is called mild cognitive impairment by some. People who have mild impairment may be in the early stage of dementia, or they may stay at their present level of ability for a long time.

What Increases Your Risk

Aging is the main risk factor for all types of dementia. Some diseases that cause dementia (such as early-onset Alzheimer's disease and some frontotemporal dementias) may run in families.

You have a greater chance of developing vascular dementia if you:

Other factors that may increase your risk of dementia include:

  • Having ongoing low blood pressure if you are older than 75. Researchers think this risk may be the result of the brain not getting enough blood. More studies are needed to determine the best blood pressure for older adults, one that lowers their risk for heart disease but provides enough blood flow to keep the brain healthy.2
  • Having a high level of homocysteine. Homocysteine is an amino acid normally found in small amounts in the blood. High levels of homocysteine are thought to cause plaque to build up in the blood vessels. Over time, this can lead to serious problems such as stroke, heart attack, and pulmonary embolism. It may also lead to mental declines. Homocysteine levels are generally stable until age 40 but then begin to increase naturally, especially after age 70.3
  • Using hormone therapy after the age of 65. Hormone replacement therapy (HRT)—a combination of estrogen and progesterone—was once believed to provide protection from dementia or cognitive impairment. However, the Women's Health Initiative found that HRT actually increased the risk for Alzheimer's disease and other dementias in women age 65 and older who took it for more than 4 years.4 Estrogen alone (estrogen replacement therapy) had similar effects.5 Whether either of these therapies might help reduce the risk of later dementia when used around the age of menopause is not known.6

When To Call a Doctor

Call 911 or other emergency services immediately if signs of a stroke or transient ischemic attack (TIA) develop suddenly. These may include:

  • Numbness, weakness, or inability to move the face, arm, or leg, especially on one side of the body.
  • Vision problems in one or both eyes, such as dimness, blurring, double vision, loss of vision, or a sensation that a shade is being pulled down over your eyes.
  • Confusion; trouble speaking or understanding.
  • Trouble walking; dizziness; loss of balance or coordination.
  • Severe headache with no known cause.

Call a doctor immediately if a person suddenly becomes confused, emotionally upset, or doesn't seem to know who or where he or she is. These are signs of delirium, which can be caused by a reaction to medications or a new or worsening medical condition.

Call a doctor if you or a person you are close to has new and troubling memory loss that is more than an occasional bout of forgetfulness. This may be an early sign of dementia.

Watchful Waiting

Occasional forgetfulness or memory loss can be a normal part of aging. But any new or increasing memory loss or problems with daily living should be reported to a doctor. Learn the warning signs of dementia, and talk to a doctor if you or a family member shows any of these signs. They include increased trouble finding the right words when speaking, getting lost going to familiar places, and acting more irritable or suspicious than usual.

Who To See

The following health professionals can evaluate symptoms of memory loss or confusion:

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Doctors diagnose the cause of dementia by asking questions about the person's medical history and doing a physical exam, a mental status exam, and lab and imaging tests.

Tests can help the doctor learn whether dementia is caused by a treatable condition. Even for those dementias that cannot be reversed, knowing the type of dementia a person has can help the doctor prescribe medicines or other treatments that may improve mood and behavior and help the family.

Medical history

During a medical history and physical exam, the doctor will ask the affected person and a close relative or partner about recent illnesses or other life events that could cause memory loss or other symptoms such as behavioral problems. The doctor may ask the person to bring in all medicines he or she takes. This can help the doctor determine whether the problem might be caused by the person being overmedicated or having a drug interaction.

Although a person may have more than one illness causing dementia, symptoms sometimes can distinguish one form from another. For example, early in the course of frontotemporal dementia people may display a lack of social awareness and develop obsessions with eating, neither of which occurs early in other dementias.

Mental status exam

A doctor or other health professional will conduct a mental status exam. This test usually involves such activities as having the person tell what day and year it is, repeat a series of words, draw a clock face, and count back from 100 by 7s.

Other tests have been developed to diagnose dementia. Doctors can use one such test, Addenbrooke's Cognitive Examination, to distinguish Alzheimer's disease from frontotemporal dementia. Orientation, attention, and memory are worse in Alzheimer's, while language skills and ability to name objects are worse in frontotemporal dementia.

Lab tests

Numerous medical conditions can cause mental impairment. During a physical exam, the doctor will look for signs of other medical conditions and have lab tests done to find any treatable condition. Routine tests include:

Other lab tests that may be done include:

Imaging tests

Brain imaging tests such as CT scans and magnetic resonance imaging (MRI) may also be done to make sure another problem is not causing the symptoms. These tests may rule out brain tumors, strokes, normal-pressure hydrocephalus, or other conditions that could cause dementia symptoms.

MRI can show shrinkage in parts of the brain that occurs in some types of dementia. MRI and CT scan also can show evidence of strokes from vascular dementia.

Two other forms of imaging—single photon emission CT (SPECT) and PET scan—are not used routinely to diagnose dementia. But they may be useful if the symptoms are confusing or odd. These tests can help identify several forms of dementia, including vascular dementia and frontotemporal dementia.

In some cases, electrical activity in the brain may be measured using an electroencephalogram (EEG). Doctors seldom use this test to diagnose dementia, but they may use it to distinguish dementia from delirium and to look for unusual brain activity found in Creutzfeldt-Jakob disease, a rare cause of dementia.

In rare cases, a brain biopsy may be done if a treatable cause of dementia is suspected.

After death, an autopsy may be done to find out for sure what caused dementia. This information may be helpful to family members concerned about genetic causes. For more information, see the topic Alzheimer's Disease.

Treatment Overview

Some cases of dementia are caused by medical conditions that can be treated, fully or partly restoring mental function. When dementia cannot be reversed, the goal of treatment is to make life as easy as possible for the person and the caregivers.

Initial treatment

If the cause of dementia can be reversed, the doctor will prescribe treatment. For example, the person might:

  • Take vitamins for a deficiency of vitamin B12.
  • Take thyroid hormones for hypothyroidism.
  • Have surgery to remove a brain tumor or to reduce pressure on the brain.
  • Stop or change medicines that are causing memory loss or confusion.
  • Take medicines to treat an infection, such as encephalitis, that is causing changes in mental state.
  • Take medicine to treat depression.
  • Get treatment for reversible conditions caused by AIDS.

After treatment for reversible conditions, the person will continue to see his or her doctor to make sure the symptoms do not return.

For people with vascular dementia, doctors may prescribe medicines to lower high blood pressure and medicines for high cholesterol (statins). These drugs cannot reverse existing dementia, but they may prevent future strokes and heart disease that can lead to further brain damage.

If the cause of dementia cannot be treated, the doctor will work with the person and caregivers to develop a plan to make life easier and more comfortable. Care plans may include tips to help the person be independent and manage daily life as long as possible. Education of the family and other caregivers is critical to successfully caring for a person with dementia. If you are or will be a caregiver, start learning what you can expect and what you can do to manage problems as they arise. For more information, see the Home Treatment section of this topic.

While medicines cannot cure dementia, they may help improve mental function, mood, or behavior. Medicines that your doctor may prescribe include:

  • Cholinesterase inhibitors such as donepezil (Aricept), galantamine (Reminyl), or rivastigmine (Exelon), to improve or maintain mental function. These drugs were developed to treat Alzheimer's disease, but they may be tried in other dementias. Studies indicate that they hold promise for the treatment of people with vascular dementia. Both donepezil and galantamine have been shown to improve mental function with few side effects.7 Rivastigmine may help people with dementia with Lewy bodies and Parkinson's disease, but side effects such as nausea, vomiting, and weight loss are common.8 Exelon patches cause fewer side effects. At present, medicines can slow but not stop the progress of dementia.
  • Memantine (Namenda). This type of medicine can slow the late stages of Alzheimer's disease. It may also benefit those with mild to moderate vascular dementia.8 More studies are under way.
  • Antidepressants to treat depression. They must be used carefully because they can cause delirium in people with dementia. Antidepressants that have the fewest side effects in people with dementia are SSRIs, such as fluoxetine (Prozac, for example) and citalopram (Celexa).9
  • Medicines to ease anxiety, agitation, aggression, and hallucinations. Some of these medicines, called antipsychotic drugs, are not approved by the FDA for the treatment of dementia. Studies of people with psychosis due to dementia who were treated with these medicines, including Zyprexa and Risperdal, found an increased risk of death.10, 11 Discuss this risk with your doctor before using these medicines.

People who are recently diagnosed and their families should begin to make plans for the future. If possible, make decisions while the person is able to participate in the decision making. These are difficult but important conversations. Questions include:

  • What kind of care does the person need right now?
  • Who will take care of the person in the future?
  • What can the family expect as the disease progresses?
  • What kind of planning needs to be done?

As soon as possible after dementia is diagnosed, family members should discuss what financial and legal planning will be needed. Along with a will, the person should write a living will and assign a durable power of attorney for health care. These documents will ensure that the person's wishes for medical care, especially life-sustaining treatment, are recorded. For more information, see Writing an Advance Directive.

Ongoing treatment

The goal of ongoing treatment for dementia is to keep the person safely at home for as long as possible and to provide support and guidance to the caregivers.

Health professionals will work with the person and his or her family or other caregivers to improve mental function as much as possible. Adjustments to the home can make the person's life easier and safer. You can install handrails in showers and remove rugs to improve safety. Calendars and lists can aid memory; you can place sticky notes or signs with pictures on them around the house to help the person remember where objects are stored and to guide the person to the bathroom or kitchen. For more information, see the Home Treatment section of this topic.

The person may also take medicines such as:

  • Cholinesterase inhibitors such as donepezil (Aricept), galantamine (Reminyl), or rivastigmine (Exelon). These drugs were developed to treat Alzheimer's disease, but they may be tried in other dementias to improve or maintain mental function. Studies indicate that this class of drugs holds promise for the treatment of people with vascular dementia. Both donepezil and galantamine have been shown to improve mental function with few side effects.7 Rivastigmine may help people with dementia with Lewy bodies, but side effects such as nausea, vomiting, and weight loss are common.8 At present, cholinesterase inhibitors can slow but not stop the progress of dementia. It is not clear how long these medicines will work. They may only stop the progress of dementia for a short time.
  • Memantine (Namenda). This new type of medicine can slow the late stages of Alzheimer's disease. It may also benefit those with mild to moderate vascular dementia.8 More studies are under way.
  • Antidepressants to treat depression. They must be used carefully because they can cause delirium in people with dementia. Antidepressants that have the fewest side effects in people with dementia are SSRIs, such as fluoxetine (Prozac, for example) and citalopram (Celexa).9
  • Medicines to ease anxiety, agitation, aggression, and hallucinations, which can become worse as dementia progresses. Some of these medicines, called antipsychotic drugs, are not approved by the FDA for the treatment of dementia. Studies of people with psychosis due to dementia who were treated with these medicines, including Zyprexa and Risperdal, found an increased risk of death.10, 11 Discuss this risk with your doctor before using these medicines.

Routine follow-up visits to a health professional (every 3 to 6 months) are necessary to monitor medications and the person's level of functioning.

If the person's condition is getting worse, decisions need to be made while he or she is able to participate in the decision making. Issues include preparing documents such as a living will and a durable power of attorney. These documents ensure that the person's wishes for medical care, especially life-sustaining treatment, are in writing. For more information, see Writing an Advance Directive.

Taking care of a person with dementia is stressful. If you are a caregiver, seek support from family members or friends. Take care of your own health by getting breaks from caregiving. Counseling, a support group, and adult day care or respite care can help you through stressful times and bouts of burnout.

Treatment if the condition gets worse

As dementia progresses, memory, judgment, and the ability to make and carry out plans (executive function) decline. Depending on the type of dementia, the person's behavior may become out of control; the person may become angry, agitated, or combative. The person may wander and become lost. These problems can make it difficult for family members or others to continue providing care at home. The family may have to consider whether to place the person in a care facility that has a dementia unit.

For more information on making the decision about nursing care, see:

Click here to view a Decision Point. Should I move my relative into long-term care?

Even with the best care, people with dementia tend to have a shorter life span than the average person their age. The progression varies depending on the disease causing dementia and whether the person has other illnesses such as diabetes or heart disease. For more information on decisions you may face as your loved one's condition progresses, see the topic Care at the End of Life.

Prevention

Dementia is difficult to prevent because what causes it often is not known. However, people who have vascular dementia may be able to prevent future declines by lowering their risk of heart disease and stroke. Even if you don't have these known risks, your overall health can benefit from these strategies:

  • Treat or prevent high blood pressure. To do this, you may need to take medicines or you may be able to get results from lifestyle changes such as losing excess weight, exercising, limiting alcohol, cutting back on salt, quitting smoking, and eating a low-fat and low-saturated-fat diet. For more information, see the topic High Blood Pressure (Hypertension).
  • Do not smoke.
  • Stay at a healthy weight. This also reduces your risk of diabetes, another risk factor for dementia.
  • Keep your cholesterol in the normal range. Total cholesterol should be less than 200 mg/dL. For more information, see the topic High Cholesterol.
  • Get plenty of exercise. Try to do at least 2½ hours a week of moderate exercise. One way to do this is to be active 30 minutes a day, at least 5 days a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.12
  • Stay mentally alert by learning new hobbies, reading, or solving crossword puzzles.
  • Stay involved socially. Attend community activities, church, or support groups.

In people who already have had a stroke, treating high blood pressure reduces the risk of another stroke by 20%. Taking aspirin to prevent blood clots lowers the risk of another stroke by 17%.13 For more information on how to reduce your risk for stroke, see the topic Stroke.

Some older people develop symptoms that look like dementia but are the result of taking medicines that don't work well together. You may be able to avoid this problem by making sure your doctor knows about all medicines—both prescription and over-the-counter—and all vitamin, herbal, and dietary supplements you take.

Research

  • One study found that older adults who regularly participated in leisure activities that required mental effort reduced their risk of dementia. Reading, playing board games, playing a musical instrument, and dancing were all found to be helpful, but most likely any hobby that keeps the brain active would be beneficial.14
  • Some evidence suggests that light to moderate alcohol use (1 to 6 drinks a week) may reduce the risk of dementia in older people.15, 16 Since heavier drinking can cause dementia, alcohol use is a widely debated issue.
  • One study found that people age 50 or older who took cholesterol-lowering medicines called statins reduced their risk of developing dementia.17 More recent studies have not found that statins reduce the risk of dementia. But these studies were of people age 65 and older.18, 19 Whether taking statins might help people who start them at a younger age is not known.
  • Hormone replacement therapy (HRT) —a combination of estrogen and progesterone—was once believed to provide protection from dementia or cognitive impairment. But the Women's Health Initiative found that HRT actually increased the risk for Alzheimer's disease and other dementias in women age 65 and older who took it for more than 4 years.4 Estrogen alone (estrogen replacement therapy) had similar effects.5 Whether either of these therapies might help reduce the risk of later dementia when used around the age of menopause is not known.6

Home Treatment

Home treatment for dementia involves teamwork among health professionals and caregivers to create a safe and comfortable environment and to make tasks of daily living as easy as possible.

A diagnosis of dementia can create feelings of anger, fear, and anxiety. A person in the early stage of the illness should seek emotional support from family, friends, and perhaps a counselor experienced in working with people who have dementia. Professional counseling may help the person accept the diagnosis and develop coping strategies.

If the condition is diagnosed early, people with mild dementia can be involved with their doctor and caregivers in planning for the future and organizing the home and daily tasks. Dementia progresses at different rates in different people, so a person may have many months, or even years, of stable functioning. People with dementia may be able to stay mentally and physically active for years.

People with dementia and their caregivers face many challenges, such as:

  • Whether the person should continue driving. Taking away driving privileges may reduce the person's sense of independence and increase dependence. But it is extremely important to prevent the person from driving when it is no longer safe. People in the very early stages of dementia should have their driving performance checked to make sure they can drive safely. Their doctor should reassess their level of functioning every 6 months.
  • What financial and legal planning will be needed. As soon as possible after dementia is diagnosed, the person should write a living will and assign a durable power of attorney for health care. These documents will ensure that the person's wishes for medical care, especially life-sustaining treatment, are recorded. For more information, see the topic Writing an Advance Directive. Family members should also locate all documents necessary to assess the legal and financial affairs of the person. These include prior tax returns, health and life insurance policies, pension information, deeds, mortgages, bank accounts, and investment information.

Other issues for caregivers

Many people who have dementia are cared for at home by partners or other family members and friends. Taking care of someone with dementia can be physically and emotionally draining, but tips and other help can make it easier.

  • Make sure your home is safe. Keep rooms uncluttered, with clear walkways. Lock up knives, cleaning supplies, and other dangerous substances. Remove throw rugs and consider installing carpet to help prevent slipping. Install handrails, tub mats, and other assistive devices in the bathroom. Provide good lighting, and put night-lights in bedrooms, hallways, and bathrooms.
  • Maintain good nutrition. Offer food more often, including healthy midmorning and midafternoon snacks. If the person has trouble using a spoon or a fork, serve finger foods. Serve one food at a time; choices can be confusing. If the person is losing weight, consider offering a liquid nutrition drink, such as Ensure.
  • Manage sleep problems. Keep the person awake and active during the day. Discourage napping unless doing so causes more problems. Offer warm milk or caffeine-free herbal tea before bedtime. A warm bath close to bedtime may help the person relax.
  • Manage bladder and bowel control problems (incontinence). Encourage the person to use the bathroom on a regular schedule, such as every 2 hours. Mark the bathroom and toilet clearly with signs; use pictures when the person can no longer understand words. Consider using absorbent pads or briefs such as Attends or Depends. If incontinence is a new problem, make sure it is not caused by another condition, such as a urinary tract infection.

Some people with dementia develop behavior problems, such as aggression. These problems can be especially challenging for caregivers. The following strategies may help.

  • Make the most of remaining abilities. It is important to give the person tasks and activities that occupy him or her without pushing too much. Tailor tasks to the person's abilities. For example, if cooking is no longer safe, ask for help in setting the table or making simple dishes such as salad. Reinforce and support the person's efforts to remain independent, even if tasks take more time or aren't done perfectly.
  • Help the person avoid confusion. Label often-used rooms, such as the bathroom, and objects. Keep regular routines for daily activities such as meals, baths, and hobbies. Keep furniture, lamps, pictures, and other objects in the same place.
  • Understand behavior changes. Strange or disruptive behaviors can be one of the most difficult problems for caregivers. The person may do certain things repeatedly or insist on unusual routines or activities. Think about whether the person's unusual behaviors might be motivated by an urge to continue past activities or habits. If so, you may be able to find ways to change the person's environment and set up daily routines that make these behaviors less of a problem.
  • Manage agitation. Keep noise levels low and voices quiet. Develop simple daily routines for bathing, dressing, eating, and other activities. Tell the person in advance about changes in his or her regular schedule (trips, doctor visits), and remind the person often of the upcoming event.
  • Manage wandering. Try to figure out why the person wanders. A person who wanders at a certain time of day may always have taken a walk or gone to work at that time. Lock outside doors, and use alarms and other devices to alert you when the person wanders. Get a medical ID bracelet for the person so that you can be contacted if he or she wanders away.
  • Communicate successfully. Use short, simple, familiar words and sentences. Explain your actions. Be calm and supportive. Use eye contact and use touch to reassure. Don't argue. Offer reassurance and try to distract the person.

Caregivers should remember to seek support from other family and friends. Get counseling, find a support group, and make use of adult day care or other services to help you through stressful times and bouts of burnout. For more information, see the topic Caregiver Tips.

Nursing home placement

Even with the best care, a person with progressive dementia will decline, perhaps to the point where a caregiver is no longer physically, emotionally, or financially able to provide care. The person may develop uncontrollable behavior problems or may have other medical conditions that the caregiver cannot manage.

Several types of assisted-living arrangements are available, although many people with dementia will need full-time care at some point. Making the decision about nursing home placement is often very difficult. Every family needs to consider its own financial situation, emotional capacity, and other issues. For more information, see:

Click here to view a Decision Point. Should I move my relative into long-term care?

Medications

Doctors use medicines to treat dementia in the following ways:

  • To correct an underlying condition causing dementia, such as thyroid replacement for hypothyroidism, vitamins for lack of vitamin B12, or antibiotics for infections
  • To maintain mental functioning for as long as possible when dementia cannot be reversed
  • To prevent worsening of vascular dementia from future small strokes in people with high blood pressure and high cholesterol
  • To manage depression, insomnia, hallucinations, agitation, and aggression

Medication Choices

Doctors may prescribe the following medicines to help maintain mental function:

  • Cholinesterase inhibitors such as donepezil (Aricept), galantamine (Reminyl), and rivastigmine (Exelon). These were developed to treat Alzheimer's disease, but they may be tried in other dementias to maintain mental function. Studies indicate that this class of drugs holds promise for the treatment of people with vascular dementia. Both donepezil and galantamine have been shown to improve mental function with few side effects.7 Rivastigmine was also beneficial for people with dementia with Lewy bodies or Parkinson's disease, but side effects such as nausea, vomiting, and weight loss were common.8 At present, medicines can only slow, not stop, the progress of dementia. It is not clear how long these medicines will work. They may only stop the progress of dementia for a short time.
  • Memantine (Namenda). This is a type of medicine that can slow the late stages of Alzheimer's disease. It may also benefit those with mild to moderate vascular dementia.8 More studies are under way.

The doctor may prescribe medicines for high blood pressure and high cholesterol, since these conditions are risk factors for vascular dementia.20 These drugs cannot reverse existing dementia, but they may prevent future strokes and heart disease that can lead to further brain damage. For more information, see the topics High Blood Pressure (Hypertension), High Cholesterol, and Transient Ischemic Attack (TIA).

Medicines that doctors may use to help control mood or behavior problems include:

  • Antidepressants to treat depression, which is common in dementia. They must be used with caution, because they can cause delirium in people with dementia. Antidepressants that have the fewest side effects in people with dementia are the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac, for example) and citalopram (Celexa).9
  • Medicines such as risperidone (Risperdal) or olanzapine (Zyprexa), called antipsychotic drugs. Doctors may use these to treat symptoms such as anxiety, agitation, aggression, sleep problems, firmly held false beliefs (delusions), and hallucinations. Antipsychotic drugs are not approved by the FDA for the treatment of dementia. Studies of people with psychosis due to dementia who were treated with these medicines found an increased risk of death. Discuss this risk with your doctor before taking these medicines.

What To Think About

Rivastigmine (Exelon) can now be given through a skin patch. Skin patches release medicine into the blood at a steady level and may reduce side effects. And it’s easier for caregivers to make sure a person is taking the medicine properly when the person uses a skin patch.

The medicines risperidone (Risperdal) and olanzapine (Zyprexa) have been found to reduce behavior problems and psychosis in people with dementia.8 However, these and similar drugs have some known risks:

  • The U.S. Food and Drug Administration (FDA) issued a public health advisory stating that people with dementia who use antipsychotics may die sooner than those who don't use these drugs. Examples of these antipsychotics include haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal).
  • The makers of Risperdal have issued a warning that older adults taking this medicine may have a slightly higher risk of stroke.

Several new medicines have been studied, including oxiracetam and pentoxifylline. These medicines are experimental and have not yet been rigorously studied for dementias other than Alzheimer's.

Studies have found daily use of SSRIs may increase the risk of bone fracture in adults over age 50. Talk to your doctor about this risk before taking an SSRI.21

FDA advisory about antidepressants. The FDA has issued an advisory to patients, families, and health professionals to closely monitor for signs of suicidal behavior in adults and children taking antidepressants. This is especially important at the beginning of treatment or when doses are changed.

The FDA also advises that people taking antidepressants be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. The FDA has not recommended that people stop using antidepressants but simply to monitor those taking the medications and, if concerns arise, to contact a doctor.

Surgery

In rare cases, surgery may be used to remove a brain tumor or to treat normal-pressure hydrocephalus, both of which can cause dementia. Other causes of dementias cannot be treated with surgery.

Other Treatment

Researchers are investigating many treatments to learn whether they can prevent or delay the development of dementia.

Many people take ginkgo biloba to improve or preserve memory. But studies have not shown that ginkgo biloba helps improve memory or prevent dementia.22 Ginkgo biloba is widely used in Europe to treat age-related dementia, including Alzheimer's disease.

Research is ongoing to look at the usefulness of nonsteroidal anti-inflammatory drugs (NSAIDS), cholesterol-lowering drugs (statins), and other antioxidants.

People with dementia may benefit from a structured group program that encourages them to focus on a variety of topics and to think creatively within their limits. This type of program, sometimes called reality orientation or cognitive stimulation therapy, is offered in some day care and residential settings.23 Occupational therapists focus on a person's ability to perform daily tasks and take part in social activities. Studies have shown occupational therapy can improve the daily functioning of people with dementia.24

Other Places To Get Help

Organizations

National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD  20824
Phone: 1-800-352-9424
(301) 496-5751
TDD: (301) 468-5981
Web Address: www.ninds.nih.gov
 

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health, is the leading U.S. federal government agency supporting research on brain and nervous system disorders. It provides the public with educational materials and information about these disorders.


Alzheimer's Association
225 North Michigan Avenue, Floor 17
Chicago, IL  60601-7633
Phone: 1-800-272-3900
Fax: 1-866-699-1246 toll-free
TDD: 1-866-403-3073 toll-free
E-mail: info@alz.org
Web Address: www.alz.org
 

The Alzheimer's Association is a national organization that provides educational materials, support groups, and community services for people dealing with Alzheimer's disease. It has more than 200 local chapters throughout the United States. The organization publishes a newsletter as well as a wide range of brochures and videos. The Web site includes a lot of useful information for people with Alzheimer's and other dementias, as well as for their caregivers.


American Geriatrics Society: The AGS Foundation for Health and Aging
The Empire State Building
350 Fifth Avenue
Suite 801
New York, NY  10118
Phone: (212) 755-6810
Fax: (212) 832-8646
E-mail: info@americangeriatrics.org
Web Address: www.healthinaging.org
 

The AGS Foundation for Health and Aging was started by the American Geriatrics Society (AGS). The foundation works on behalf of older adults in the areas of wellness and preventive care, self-responsibility and independence, and connections to family and community.

This Web site has stories about healthy aging, information on caring for elders at home, and tips on winter safety, preparing for emergencies, and overcoming the challenges to healthy aging. The site also has links to many other Internet resources on aging.


Family Caregiver Alliance
180 Montgomery Street
Suite 1100
San Francisco, CA  94104
Phone: 1-800-445-8106
(415) 434-3388
E-mail: info@caregiver.org
Web Address: www.caregiver.org
 

This organization supports and assists people who are providing long-term care at home. It also provides education, research, services, and advocacy.


National Institute on Aging
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD  20892
Phone: (301) 496-1752
1-800-222-2225, Information Center
Fax: (301) 496-1072
TDD: 1-800-222-4225 (TTY)
Web Address: www.nih.gov/nia
 

The National Institute on Aging (NIA), one of the centers of the U.S. National Institutes of Health, leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life. The NIA funds research and provides information about health and research advances to the public and interested groups.


References

Citations

  1. Drugs for cognitive loss and dementia (2007). Treatment Guidelines From The Medical Letter, 5(54): 9–14.
  2. Verghese J, et al. (2003). Low blood pressure and the risk of dementia in very old individuals. Neurology, 61(12): 1667–1672.
  3. Garcia A, Zanibbi K (2004). Homocysteine and cognitive function in elderly people. Canadian Medical Association Journal, 171(8): 897–904.
  4. Shumaker SA, et al. (2003). Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. The Women's Health Initiative memory study: A randomized controlled trial. JAMA, 289(20): 2651–2662.
  5. Espeland MA, et al. (2004). Conjugated equine estrogens and global cognitive function in postmenopausal women: Women's Health Initiative Memory Study. JAMA, 291(24): 2959–2968.
  6. North American Menopause Society (2008). Estrogen and progestogen use in postmenopausal women: July 2008 position statement of the North American Menopause Society. Menopause, 15(4): 584–602. Also available online: www.menopause.org/PSHT08.pdf.
  7. Wilkinson D, et al. (2003). Donepezil in vascular dementia. Neurology, 61(4): 479–486.
  8. Warner J, et al. (2006). Dementia, search date February 2006. Online version of Clinical Evidence (15): 1–24.
  9. Bird TD, Miller BL (2008). Dementia. Harrison's Principles of Internal Medicine, 17th ed., pp. 2536–2549. New York: McGraw-Hill.
  10. U.S. Food and Drug Administration (2005). FDA issues public health advisory for antipsychotic drugs used for treatment of behavioral disorders in elderly patients. FDA Talk Paper T05-13. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2005/ANS01350.html.
  11. Wang PS, et al. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22): 2335–2341.
  12. U.S. Department of Health and Human Services (2008). 2008 Physical Activity Guidelines for Americans (ODPHP Publication No. U0036). Washington, DC: U.S. Government Printing Office. Available online: http://www.health.gov/paguidelines/pdf/paguide.pdf.
  13. Roman GC (2002). Vascular dementia revisited: Diagnosis, pathogenesis, treatment, and prevention. Medical Clinics of North America, 86(3): 477–499.
  14. Verghese J, et al. (2003). Leisure activities and the risk of dementia in the elderly. New England Journal of Medicine, 348(25): 2508–2516.
  15. Mukamal KJ, et al. (2003). Prospective study of alcohol consumption and risk of dementia in older adults. JAMA, 289(11): 1405–1413.
  16. Ruitenberg A, et al. (2002). Alcohol consumption and risk of dementia: The Rotterdam study. Lancet, 359(9303): 281–286.
  17. Jick H, et al. (2000). Statins and the risk of dementia. Lancet, 356(9242): 1627–1631.
  18. Zandi PP, et al. (2005). Do statins reduce risk of incident dementia and Alzheimer disease? The Cache County study. Archives of General Psychiatry, 62(2): 217–224.
  19. Li G, et al. (2004). Statin therapy and risk of dementia in the elderly. Neurology, 63(9): 1624–1628.
  20. Tzourio C, et al. (2003). Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Archives of Internal Medicine, 163(9): 1069–1075.
  21. Richards JB, et al. (2007). Effect of selective serotonin reuptake inhibitors on the risk of fracture. Archives of Internal Medicine, 167(2): 188–194.
  22. Birks J, Grimley Evans J (2009). Ginkgo biloba for cognitive impairment and dementia. Cochrane Database of Systematic Reviews (2).
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  24. Graff MJ, et al. (2006). Community-based occupational therapy for patients with dementia and their caregivers: Randomised controlled trial. BMJ, 333(1196). Also available online: http://www.bmj.com/cgi/content/full/333/7580/1196.

Other Works Consulted

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  • Kennedy GJ (2003). Dementia. In CK Cassel et al., eds., Geriatric Medicine, 4th ed., pp. 1079–1093. New York: Springer-Verlag.
  • Kertesz A, Munoz DG (2002). Frontotemporal dementia. Medical Clinics of North America, 86(3): 501–518.
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  • Langa KM, et al. (2004). Mixed dementia: Emerging concepts and therapeutic implications. JAMA, 292(23): 2901–2908.
  • Leverenz JB, McKeith IG (2002). Dementia with Lewy bodies. Medical Clinics of North America, 86(3): 519–535.
  • Santacruz KS, Swagerty D (2001). Early diagnosis of dementia. American Family Physician, 63(4): 703–713.
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  • Weiner MF, Lipton AM, eds. (2003). The Dementias: Diagnosis, Treatment, and Research, 3rd ed. Washington, DC: American Psychiatric Publishing.

Credits

Author Jeannette Curtis
Editor Kathleen M. Ariss, MS
Associate Editor Denele Ivins
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Peter J. Whitehouse, MD - Neurology
Last Updated June 17, 2009

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