| "Dementia" means an acquired, persisting decrease in | | | | cancerous, but because space inside the skull is |
| mental functioning. Dementia is not a disease or a | | | | limited, they cause trouble by crowding the brain. |
| final diagnosis; instead, it refers to a category of | | | | Subdural hematomas and epidural hematomas are |
| symptoms that can be the result of a diverse group | | | | two other space-occupying abnormalities that crowd |
| of conditions and diseases. | | | | the brain. These are masses of clotted blood usually |
| Everyone with eyes and a brain of their own knows | | | | caused by traumatic blows to the head. The injuries |
| that dementia is a very common and serious | | | | producing the bleeding are not always remembered |
| problem, robbing some people of their memories, | | | | or, if remembered, might have been dismissed as |
| ability to function independently and even their | | | | trivial at the time they occurred. These, too, can be |
| personalities. As a community-based neurologist, I see | | | | totally removed by a neurosurgeon. |
| all too many cases of dementia, but the part that | | | | Normal pressure hydrocephalus is another cause of |
| worries me the most is when patients, family | | | | dementia responding to neurosurgery, but in this |
| members and even medical personnel assume that | | | | condition the surgeon doesn't remove a mass-lesion. |
| nothing can be done and don't even bother to | | | | Instead, the surgeon places a tube inside one of the |
| evaluate for underlying causes. | | | | brain's swollen fluid-chambers known as ventricles, |
| Although it is certainly true that modern medicine | | | | allowing the excessive fluid-accumulation to drain |
| lacks effective treatments for many causes of | | | | away through the tube and into another body-space |
| dementia, it's also true that still others can be cured | | | | where it causes no harm. Normal pressure |
| or favorably modified. It would be a shame to | | | | hydrocephalus can be identified not only by its |
| assume that a case was untreatable and thereby | | | | dementia and enlarged ventricles, but by the |
| miss something that could have been cured or better | | | | concurrent presence of a prominent walking |
| managed. | | | | impairment as well as urinary incontinence. |
| So how do dementia specialists or other doctors | | | | Non-surgical treatments can be helpful for other |
| investigate cases of dementia? The medical | | | | causes of dementia. Two conditions involving a |
| detective-work begins with a thorough history and | | | | deficiency or shortage of a biochemical are |
| physical examination. | | | | hypothyroidism and vitamin B12 deficiency. Finding |
| Clues might come from the history of the patient's | | | | one of these is a blessing in disguise because they |
| other medical problems, the medication list, use of | | | | are easily fixed. In hypothyroidism, the thyroid gland |
| alcohol or other drugs, or from other physical | | | | in the neck secretes too little thyroid hormone. This is |
| problems that developed concurrently with the | | | | managed by making up for the shortfall in pill form. In |
| dementia. Apart from the general physical exam, the | | | | vitamin B12 deficiency, the problem is that this |
| doctor also explores the patient's ability to pay | | | | essential vitamin is not properly absorbed into the |
| attention, remember, calculate, draw pictures, reason, | | | | bloodstream via the gastrointestinal tract, so the |
| comprehend words and express himself or herself. | | | | deficiency is treated by periodic injections of vitamin |
| Further neurological examination assesses other | | | | B12. |
| aspects of brain function like vision, hearing, strength, | | | | As people get older and acquire more medical |
| coordination, sensation, walking and reflexes. | | | | problems, their list of medications often grows longer. |
| After compiling the results of the history and | | | | One or more of the medications they take might |
| examination, the physician can usually judge the | | | | interfere with mental functioning. Common offenders |
| relative likelihoods of different underlying causes for | | | | are medications for urinary incontinence, anxiety or |
| the dementia, but follows up these clinical judgments | | | | insomnia. If a problem-medication is eliminated or |
| with additional medical tests to nail down the most | | | | replaced with another drug, the patient's mental |
| likely cause. The irreducible minimum of additional | | | | prowess can improve. |
| testing includes a brain scan--either a CT or an | | | | Depression is a common cause of dementia in which |
| MRI--plus a panel of blood tests. | | | | the mood disorder itself interferes with |
| The brain scan might detect a brain tumor, previously | | | | concentration, memory and other mental |
| unsuspected strokes, clotted blood compressing the | | | | performance. In many cases the mental impairments |
| brain or hydrocephalus (water on the brain) all of | | | | are more prominent than the mood disturbance, |
| which can cause dementia and which can also be | | | | causing it to be overlooked. Depression is treated |
| treated. The blood tests look for salt-and-water | | | | with medication, psychotherapy, or both. |
| imbalances, abnormal blood-sugar levels, kidney | | | | Chronic infections with the Lyme and syphilis bacteria |
| impairment, liver impairment, excessive calcium levels, | | | | can be resolved with appropriate antibiotics. |
| thyroid disease, and deficiencies of vitamin B12 and | | | | Occasionally a fungal infection is to blame, and can |
| folic acid. Each of these problems, if found, would | | | | also be treated with specific medication. Treatments |
| warrant specific treatment. | | | | for HIV are less good, but this disease still needs to |
| Other tests can be applied depending on the | | | | be identified in order to obtain the best possible |
| physician's judgment of their usefulness in individual | | | | outcome. |
| cases. These might include an electroencephalogram | | | | Chronic alcohol abuse can damage the brain and |
| (brain-wave test), lumbar puncture (spinal tap) or a | | | | cause dementia. In most cases the previously caused |
| PET (positron emission tomographic) scan, which is a | | | | damage cannot be undone, but further damage can |
| newer technique that shows the relative activity of | | | | be prevented through treatment of the alcoholism. |
| brain cells in different parts of the brain. Additional | | | | Wernicke's encephalopathy is an alcohol-associated |
| blood-tests can screen for infections with human | | | | cause of confusion for which injections of thiamine |
| immunodeficiency virus (HIV) or the bacteria | | | | (vitamin B1) are urgently needed. |
| associated with Lyme disease or syphilis. | | | | Strokes can also produce dementia. Strokes are |
| After all is said and done, what turns up? | | | | caused by disrupted circulation which damages parts |
| Unfortunately, about half the dementia cases | | | | of the brain. In most cases, the patient and family |
| evaluated in this way lead to a diagnosis of | | | | were aware of strokes when they occurred, but in |
| Alzheimer's disease or similar degenerative brain | | | | other cases one or more strokes might have gone |
| disease for which there is no cure. Although | | | | undetected at the time they occurred. Prior strokes |
| treatments exist for these degenerative dementias, | | | | cannot be undone, but recognition of the presence |
| their benefits are modest. | | | | of strokes can lead to preventive measures to |
| It's the other half of the cases which reveal an | | | | decrease the likelihood of future strokes. |
| interesting grab-bag of different underlying causes | | | | Apart from the conditions and diseases already |
| and, for that matter, treatments. | | | | mentioned, the list of potential causes of dementia is |
| Neurosurgery can be indicated for dementias caused | | | | longer still. In brief, not every cause of dementia can |
| by brain tumors, especially meningiomas which are | | | | be cured or significantly improved, but without a |
| slow-growing tumors that respond poorly to | | | | thoughtful, thorough, medical evaluation the ones that |
| chemotherapy or radiation therapy, but can be totally | | | | can be treated could easily go undetected. |
| removed in surgical operations. Meningiomas are not | | | | |