Dementia: Symptoms, stages, and types

Dementia is a collective term used to describe various symptoms of cognitive decline, such as forgetfulness. It is a symptom of several underlying diseases and brain disorders.

Dementia is not a single disease in itself, but a general term to describe symptoms of impairment in memory, communication, and thinking.

While the likelihood of having dementia increases with age, it is not a normal part of aging.

An analysis of the most recent census estimates that 4.7 million people aged 65 years or older in the United States were living with Alzheimer's disease in 2010. The Alzheimer's Association estimates that:

    just over a tenth of people aged 65 years or more have Alzheimer's disease
    this proportion rises to about a third of people aged 85 and older
    Alzheimer's accounts for 60-80 percent of all cases of dementia

This article discusses the potential causes of dementia, the various types, and any available treatments.
Fast facts on dementia

    there are an estimated 47.5 million dementia sufferers worldwide
    one new case of dementia is diagnosed every 4 seconds
    dementia mostly affects older people but is not a normal part of aging

Dementia symptoms
A person with dementia may show any of the symptoms listed below, mostly due to memory loss.

Some symptoms they may notice themselves, others may only be noticed by caregivers or healthcare workers.

The signs used to compile this list are published by the American Academy of Family Physicians (AAFP) in the journal American Family Physician.

Possible symptoms of dementia:

    Recent memory loss - a sign of this might be asking the same question repeatedly.
    Difficulty completing familiar tasks - for example, making a drink or cooking a meal.
    Problems communicating - difficulty with language; forgetting simple words or using the wrong ones.
    Disorientation - getting lost on a previously familiar street, for example.
    Problems with abstract thinking - for instance, dealing with money.
    Misplacing things - forgetting the location of everyday items such as keys, or wallets, for example.
    Mood changes - sudden and unexplained changes in outlook or disposition.
    Personality changes - perhaps becoming irritable, suspicious or fearful.
    Loss of initiative - showing less interest in starting something or going somewhere.

As the patient ages, late-stage dementia symptoms tend to worsen.
Dementia stages

Sometimes, dementia is roughly split into four stages:

Mild cognitive impairment: characterized by general forgetfulness. This affects many people as they age but it only progresses to dementia for some.

Mild dementia: people with mild dementia will experience cognitive impairments that occasionally impact their daily life. Symptoms include memory loss, confusion, personality changes, getting lost, and difficulty in planning and carrying out tasks.

Moderate dementia: daily life becomes more challenging, and the individual may need more help. Symptoms are similar to mild dementia but increased. Individuals may need help getting dressed and combing their hair. They may also show significant changes in personality; for instance, becoming suspicious or agitated for no reason. There are also likely to be sleep disturbances.

Severe dementia: at this stage, symptoms have worsened considerably. There may be a loss of ability to communicate, and the individual might need full-time care. Simple tasks, such as sitting and holding one's head up become impossible. Bladder control may be lost.
Dementia types

There are several types of dementia, including:

Alzheimer's disease is characterized by "plaques" between the dying cells in the brain and "tangles" within the cells (both are due to protein abnormalities). The brain tissue in a person with Alzheimer's has progressively fewer nerve cells and connections, and the total brain size shrinks.
Dementia with Lewy bodies is a neurodegenerative condition linked to abnormal structures in the brain. The brain changes involve a protein called alpha-synuclein.
Mixed dementia refers to a diagnosis of two or three types occurring together. For instance, a person may show both Alzheimer's disease and vascular dementia at the same time.
Parkinson's disease is also marked by the presence of Lewy bodies. Although Parkinson's is often considered a disorder of movement, it can also lead to dementia symptoms.
Huntington's disease is characterized by specific types of uncontrolled movements but also includes dementia.

Other disorders leading to symptoms of dementia include:

Frontotemporal dementia also known as Pick's disease.
Normal pressure hydrocephalus when excess cerebrospinal fluid accumulates in the brain.
Posterior cortical atrophy resembles changes seen in Alzheimer's disease but in a different part of the brain.
Down syndrome increases the likelihood of young-onset Alzheimer's.

Early signs of dementia can include:

    Changes in short-term memory.
    Changes in mood.
    Trouble finding the right words.
    Apathy.
    Confusion.
    Being repetitive.
    Finds it hard to follow a storyline.
    Trouble completing everyday tasks.
    Poor sense of direction.
    Difficulty adapting to changes.

Dementia causes

Dementias can be caused by brain cell death, and neurodegenerative disease - progressive brain cell death that happens over time - is associated with most dementias.

However it is not known if the dementia causes the brain cell death, or the brain cell death causes the dementia.

But, as well as progressive brain cell death, like that seen in Alzheimer's disease, dementia can be caused by a head injury, a stroke, or a brain tumor, among other causes.

Vascular dementia (also called multi-infarct dementia) - resulting from brain cell death caused by conditions such as cerebrovascular disease, for example, stroke. This prevents normal blood flow, depriving brain cells of oxygen.

Injury - post-traumatic dementia is directly related to brain cell death caused by injury.

Some types of traumatic brain injury - particularly if repetitive, such as those received by sports players - have been linked to certain dementias appearing later in life. Evidence is weak, however, that a single brain injury raises the likelihood of having a degenerative dementia such as Alzheimer's disease.

Dementia can also be caused by:

    Prion diseases - for instance, CJD (Creutzfeldt-Jakob disease).
    HIV infection - how the virus damages brain cells is not certain, but it is known to occur.
    Reversible factors - some dementias can be treated by reversing the effects of underlying causes, including medication interactions, depression, vitamin deficiencies, and thyroid abnormalities.

Diagnosing dementia

The first step in testing memory performance and cognitive health involves standard questions and tasks.

Research has shown that dementia cannot be reliably diagnosed without using the standard tests below, completing them fully, and recording all the answers; however, diagnosis also takes account of other factors.

Cognitive dementia tests

Today's cognitive dementia tests are widely used and have been verified as a reliable way of indicating dementia. They have changed little since being established in the early 1970s. The abbreviated mental test score has ten questions, which include:

    What is your age?
    What is the time, to the nearest hour?
    What is the year?
    What is your date of birth?

Each correct answer gets one point; scoring six points or fewer suggests cognitive impairment.

The General Practitioner Assessment of Cognition (GPCOG) test includes an added element for recording the observations of relatives and caregivers.

Designed for doctors, this sort of test may be the first formal assessment of a person's mental ability.

The second part of the test probes someone close to the patient and includes six questions to find out whether the patient has:

    become less able to remember recent events or conversations
    begun struggling to find the right words or using inappropriate ones
    found difficulty managing money or medications
    needed more help with transport (without the reason being, for example, injury)

If the test does suggest memory loss, standard investigations are then recommended, including routine blood tests and a CT brain scan.

Clinical tests will identify, or rule out, treatable causes of memory loss and help to narrow down potential causes, such as Alzheimer's disease.

The mini-mental state examination (MMSE) is a cognitive test which measures:

    orientation to time and place
    word recall
    language abilities
    attention and calculation
    visuospatial skills

The MMSE is used to help diagnose dementia caused by Alzheimer's disease and also to rate its severity and whether drug treatment is needed.

Dementia treatments
Brain cell death cannot be reversed, so there is no known cure for degenerative dementia.

Management of disorders such as Alzheimer's disease is instead focused on providing care and treating symptoms rather than their underlying cause.

If dementia symptoms are due to a reversible, non-degenerative cause, however, treatment may be possible to prevent or halt further brain tissue damage.

Examples include injury, medication effects, and vitamin deficiency.

Symptoms of Alzheimer's disease can be reduced by some medications. There are four drugs, called cholinesterase inhibitors, approved for use in the U.S.:

    donepezil (brand name Aricept)
    galantamine (Reminyl)
    rivastigmine (Exelon)
    tacrine (Cognex)

A different kind of drug, memantine (Namenda), an NMDA receptor antagonist, may also be used, alone or in combination with a cholinesterase inhibitor.

Cholinesterase inhibitors can also help with the behavioral elements of Parkinson's disease.

Other quality-of-life care

"Brain training" may help improve cognitive functioning and help deal with forgetfulness in the early stages of Alzheimer's. This might involve the use of mnemonics and other memory aids such as computerized recall devices.
Prevention of dementia

Certain risk factors are known to be associated with dementia. However, age is the biggest predictor. Other risk factors include:

    Smoking and alcohol use.
    Atherosclerosis (cardiovascular disease causing the arteries to narrow).
    High levels of "bad" cholesterol (low-density lipoprotein).
    Above-average blood levels of homocysteine (a type of amino acid).
    Diabetes.
    Mild cognitive impairment can sometimes, but not always, lead to dementia.


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Walking patterns could identify dementia types:

Researchers have found that walking may be a key clinical tool in helping doctors accurately identify the specific type of dementia a patient has.
Published in the Alzheimer's & Dementia: The Journal of the Alzheimer's Association, the research have shown that people with Alzheimer's disease or Lewy body dementia have unique walking patterns that signal subtle differences between the two conditions.
The study also shows that people with Lewy body dementia change their walking steps more - varying step time and length - and are asymmetric when they move, in comparison to those with Alzheimer's disease.
"The results from this study are exciting as they suggest that walking could be a useful tool to add to the diagnostic toolbox for dementia," said study's lead author .

"It is a key development as a more accurate diagnosis means that we know that people are getting the right treatment, care and management for the dementia they have," she added.
For the study, researchers analysed the walk of 110 people, including 29 older adults whose cognition was intact, 36 with Alzheimer's disease and 45 with Lewy body dementia.
Participants moved along a walkway - a mat with thousands of sensors inside - which captured their footsteps as they walked across it at their normal speed and this revealed their walking patterns.
People with Lewy body dementia had a unique walking pattern in that they changed how long it took to take a step or the length of their steps more frequently than someone with Alzheimer's disease, whose walking patterns rarely changed.
When a person has Lewy body dementia, their steps are more irregular and this is associated with increased falls risk.
Their walking is more asymmetric in step time and stride length, meaning their left and right footsteps look different to each other.
The study found that analysing both step length variability and step time asymmetry could accurately identify 60 per cent of all dementia subtypes - which has never been shown before.

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How does dementia progress over time?

Dementia is a generic term that can refer to a variety of illnesses or disease states. The range of symptoms involves impaired thinking, memory, and communication.

To have a diagnosis of dementia, the decline in function must impact a person's ability to perform everyday activities.

Researchers looking at data from 2000 to 2012 found that around 8.8 percent of people aged 65 years and older in the United States had a form of dementia.

In this article, we look at several types of dementia and how they change as the condition progresses.

Stages
Symptoms of dementia tend to get worse over time.

The rate of progression varies between people. Genetics, age, and overall health, as well as the underlying cause of the dementia might play a role in how fast the disease progresses.

Dementia has distinct stages that shape treatment and impact on health in different ways. It should be noted that scientists have devised different systems of staging for a variety of dementia types, including dementia that occurs with Alzheimer's disease.

No staging system is perfect, and the stages often overlap. Symptoms may appear at certain stages, then resolve, while other health effects progressively get worse.
Early symptoms

Dementia often, but not always, starts with a mild decline in the ability to think. For example, a person may forget a recent conversation or the name of a familiar object.

Keep in mind that everyone has moments in which something gets stuck on the tip of their tongue.

Dementia goes beyond this. Moments such as these happen with increased frequency, though they may not initially reduce the quality of life or a person's ability to function on a day-to-day basis.

Early symptoms may also include a decreased ability to perform certain tasks, such as paying bills or following a recipe. People close to an individual with dementia may also notice subtle changes in personality.

At this stage, a person with dementia may start to realize that something is not right but may choose to hide their symptoms.

Some types of dementia may affect language, while others affect memory or movement. It is easiest to distinguish the types in their early stages.
Moderate dementia symptoms

As dementia progresses, symptoms become harder to hide. More noticeable symptoms may develop. Help with self-care or everyday activities may be necessary.

Personality changes may become more noticeable. The person may experience paranoia, confusion, or fear, and memory loss may increase.

People with moderate dementia commonly forget their address or other personal information, including their phone number.

Sleep patterns and moods may also change.
Late-stage or severe dementia symptoms

Gradually, dementia can progress and become severe. At this stage, it often significantly impairs a person's memory. A person with severe dementia may not recognize family members.

Symptoms of late-stage dementia may include an inability to communicate, walk, and control bowel and bladder function.

Severe dementia can also cause muscle rigidity and abnormal reflexes. A person will usually need full-time personal care for eating, bathing, and dressing.

People with severe dementia are vulnerable to infections, including pneumonia, and they be unable to move in bed. In this case, bedsores are a risk.

Knowing the stages of dementia can help a person plan, but everyone with dementia has a unique experience. It is important to make the necessary lifestyle adaptations while remaining flexible about meeting needs as they evolve.
Treatment options over time
Currently, no cure is available for dementia. However, treatments can help reduce symptoms and manage behavioral changes.

The right treatment may change over time. A doctor may prescribe different classifications of medication as the disease progresses.

Medications can reduce symptoms by adjusting chemicals that carry messages to the brain cells.

These drugs are called cholinesterase inhibitors. Doctors often prescribe them for people with mild to moderate symptoms. Cholinesterase inhibitors treat symptoms associated with confusion, communication, and memory.

In people with moderate to severe dementia, treatment may also include memantine. Memantine is a drug that may help improve language, thinking, and memory functions.

Memantine works by regulating glutamate, a chemical in the brain that supports memory and learning. Memantine may delay the progression of dementia symptoms temporarily in some people.

Treatment options may also include medications that reduce behavioral and psychological changes, such as anxiety and sleep problems.

In later stages, doctors may recommend particular drugs to treat specific symptoms, such as fear, restlessness, and hallucinations.

As dementia progresses, treatment may also focus on improving the quality of life. For example, occupational therapy can help teach people with dementia how to use adaptive equipment or improve fine motor skills.
Types of dementia
Dementia has a variety of causes, and different types of dementia cause different changes in the brain. Each type also progresses in a different way.
Common types of dementia include Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and mixed dementia.
Alzheimer's disease
The most common cause of dementia is Alzheimer's disease. According to the Alzheimer's Association, the disease is responsible for between 60 and 80 percent of dementia cases.

The causes of Alzheimer's are not entirely clear, but healthcare professionals find clumps of a protein called beta-amyloid in the brains of people with this disease.
Alzheimer's often develops gradually and may be the slowest of all types to progress.
Vascular dementia

Vascular dementia can occur when blood circulation to the brain decreases as a result of a stroke or another problem, damaging blood vessels in the brain.

This type causes difficulties in planning and making decisions, slow or sluggish thought, and problems concentrating, with brief episodes of confusion.

There are two subtypes of vascular dementia, and they progress in different ways.
Subcortical dementia progresses at a pace similar to Alzheimer's, while stroke-related dementia develops more suddenly. Symptoms are consistent, then grow rapidly more severe, before becoming stable again.
Dementia with Lewy bodies
Lewy bodies are deposits of protein that develop throughout the brain, including in the cerebral cortex, which oversees language and thinking. They damage and kill nerves in the brain over time.
In the early stages of dementia with Lewy bodies, alertness and attentiveness may vary wildly from day to day or even throughout the same day.

People with this type of dementia may hallucinate, and they often feel persecuted as a result.
The symptoms may start to resemble Alzheimer's as this type of dementia progresses, with episodes of memory loss, shouting, and confrontational behavior. These symptoms can be especially challenging for caregivers.

Mixed dementia
Mixed dementia involves more than one cause. There may be damage to blood vessels and harmful deposits of protein in the brain, for example.
The overlap in types and stages can make it more difficult to predict how symptoms present and develop.
Dementia has a complicated, multifaceted set of symptoms, and caregivers should focus on providing a reactive support network.

Diagnosis and outcome
No single test can determine whether a person has dementia.

Tests will evaluate:
    thinking ability
    neurological function
    reasoning
    language
    memory
    movement and balance
    visual perception
A medical history and blood tests can help rule out other possible causes of dementia symptoms.

Imaging studies, such as a CT or PET scan, can identify specific protein deposits in the brain or a disrupted blood supply.

Dementia scales can help determine if dementia is present and how far it has progressed. The Global Deterioration Scale can be useful in determining the severity of overall dementia.

Doctors use a range of scales to assess dementia stages. The tests measure the severity of symptoms and the ability to carry out daily functions.

A common test is the mini-mental state examination, which people sometimes shorten to MMSE. It gives information about a variety of areas of cognition, such as orientation, registration, recall, language, and praxis.

Stages range from 1 to 7, in which stage 7 is the most severe. A doctor will conduct a combination of tests to make an assessment.

The outlook for people with dementia varies. Age at diagnosis and response to treatment are two factors that affect how the condition progresses.
Living with dementia in the later stages

A person with dementia may wish to have input in decisions about care before they become unable to communicate their wishes.

This advanced care planning provides the opportunity for a person with dementia to state what they want and do not want, such as living in a nursing home or receiving care at home.

Living with late-stage dementia can often be challenging for individuals and their caregivers. As symptoms progress, more care becomes necessary.

Strategies that may help include techniques to trigger memory, such as visual clues, music, and notes.

Assistive technology devices are also available, such as communications aids, automatic shutoff devices, and computerized recall devices.

Caregivers should create an environment that is calm and safe. It is crucial to identify and correct safety concerns, for example by removing tripping hazards and otherwise making sure that rooms are easy to navigate.

Caregivers should also ensure that the individual follows their medication regimen and receives enough nutrition.
Late-stage dementia can also be a difficult time for caregivers. It is important to have a strong support system and allow time to recharge.

Q: What is the most severe form of dementia?
A: Regardless of the type of dementia, they can all be quite severe and disrupt the lives of those involved.
Dementia involves not only the person with the diagnosis but also those close to the person, such as their spouse or children. A diagnosis of dementia is often life-changing for the family unit.
From a practical perspective, I would say the most severe form of dementia is one in which the individual has limited-to-no resources and a minimal or nonexistent support system.

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