Physical changes

A general physical decline is almost invariable with accompanying wasting. The commonest cause of death is bronchopneumonia. Urinary and faecal incontinence can have a multiplicity of causes. Neurological signs are common and include primitive reflexes (snout and grasp), alterations of tone, tremor, myoclonus and epileptic fits.

Natural History

Presentation may be delayed, either by an insightful patient or a worried relative. The earliest manifestations of the disease are subtle - the individual may forget a familiar name and hurriedly cover up the omission; lists may be written to compensate for a more general amnesia. Topographical dyspraxia (and getting lost) and nominal dysphasia may become apparent. Affective symptoms are relatively common in this early stage.

After some time the progression is such that all areas of intellect and personality are affected and the symptoms discussed above will be apparent. In the later stages the physical symptoms dominate and the patient may become increasingly bed bound and all needs must be met by carers - whether relatives or nurses.

The usual duration is from 3 to 8 years. Onset can be from the age of 40. Arbitrarily onset before 65 is known as pre-senile and onset after 65 as senile. It remains an unanswered question as to whether early onset cases form a different type of the disease. It does however appear that early onset is associated with a more aggressive variant.

Management

Management of dementia requires a multi-disciplinary approach addressing the problems not only as they pertain to the patient but also to their family. Relatives ‘lose’ their loved ones who remain alive and in need of increasingly intimate care. This has been termed a ‘living bereavement’. Attention will be paid to minimising ‘problem’ behaviour (by the use of modification in the environment and medication) and to maximising available function. The vast majority of patients with dementia will be cared for outside of institutional care. In latter years the private sector (for good or bad) has taken over much of the care of those who are unable to remain at home.

DIFFUSE LEWY BODY DEMENTIA (DLBD)

The relationship between DLBD and AD is currently hotly disputed. The neuropathological features of both are frequently found together. The clinical features show an admixture of symptoms of classical AD and parkinsonism. It is increasingly realised that many patients - previously thought of as suffering from ‘atypical AD’ have DLBD at post mortem. A fluctuating mental state (suggestive of delirium) and hallucinations combined with an underlying dementia andr parkinsonism is highly suggestive of DLBD. These patients are said to be highly sensitive to the adverse effects of neuroleptic medication.