Dementia is a term used to describe various symptoms of cognitive decline such as forgetfulness, but

is not a clinical diagnosis itself until an underlying disease or disorder has been identified.
Dementia is a collective term used to describe the problems that people with various underlying brain disorders
or damage can have with their memory, language and thinking. Alzheimer's disease is the best known and
most common disorder under the umbrella of dementia.
Below you will find out what dementia is and discover some of its causes. This page also outlines which signs
and symptoms signal dementia and the tests and diagnosis that patients may undergo to confirm a
dementia disorder. There is also a section overviewingtreatment and prevention strategies.
What is dementia?
Dementia is not a single disease in itself, but a general term to describe symptoms such as impairments to
memory, communication and thinking.
1

While the likelihood of having dementia increases with age, it is not a normal part of aging. Before we had
today's understanding of specific disorders, "going senile" used to be a common phrase for dementia
("senility"), which misunderstood it as a standard part of getting old.
1,2

Light cognitive impairments, by contrast, such as poorer short-term memory, can happen as a normal part of
aging (we slowly start to lose brain cells as we age beyond our 20s
3
). This is known as age-related cognitive
decline, not dementia, because it does not cause the person or the people around them any
problems.
1
Dementia describes two or more types of symptom that are severe enough to affect daily
activities.
Symptoms that are classed as "mild cognitive impairment" - which, unlike cognitive decline, are not a normal
part of aging - do not qualify as dementia either, since these symptoms are not severe enough.
1
For some
people though, this milder disease leads to dementia later on.
4

A number of brain disorders with more severe symptoms are classified as dementias, with Alzheimer's disease
being the best known and most common.
An analysis of the most recent census estimates that 4.7 million people aged 65 years or older in the US were
living with Alzheimer's disease in 2010.
5
The Alzheimer's Association has used this analysis to number-crunch
the extent of the disorder in its 2013 report. It 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.
The non-profit organization says Alzheimer's accounts for between 60% and 80% of all cases of dementia, with
vascular dementia caused by stroke being the second most common type.
What causes dementia?
All dementias are caused by brain cell death,
1
and neurodegenerative disease - progressive brain cell
death that happens over a course of time - is behind most dementias.
4,6


Nerve cells (neurons) in the brain - loss or damage can cause dementia. Alzheimer's disease is the
leading cause.
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 braintumor, among other causes.
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Some of the causes are simpler to understand in terms of how they affect the brain and lead to dementia:
1

Vascular dementia - this results from brain cell death caused by conditions such ascerebrovascular
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 received by sports players - have been
linked to certain dementias appearing later in life. Evidence is weak, however, that a single brain injury will
raise the likelihood of having a degenerative dementia such as Alzheimer's disease.
7

Dementia can also be caused by:
1,2,8

Prion diseases - from certain types of protein, as in CJD (Creutzfeldt-Jakob disease) and GSS (Gerstmann-
Straussler-Scheinker syndrome).
HIV infection - when the problem is simply termed HIV-associated dementia. How the virus damages brain
cells is not certain.
Reversible factors - some dementias can be treated by reversing the effects of underlying causes, including
medication interactions, depression, vitamin deficiencies (for example, thiamine/B1, leading to Wernicke-
Korsakoff syndrome, which is most often caused by alcohol misuse), and thyroid abnormalities.
Alzheimer's dementia is caused by progressive brain cell death. Estimates range between 60% and 80% for
the proportion of all cases of dementia being accounted for by Alzheimer's disease.
2
In the US, about 5.3 million
people are thought to have the disorder among the estimated 6.8 million individuals who have some form of
dementia.
4

Alzheimer's is thought to be caused by "plaques" between the dying cells in the brain and "tangles" within the
cells (both are protein abnormalities: a build-up of "beta-amyloid" in plaques and the disintegration of "tau"
protein in tangles).
These inclusions in the brain are always present with the disorder but whether they are themselves the cause,
or if there is some other underlying process, is not known - and there is some overlap with other disorders that
show similar changes in brain cells.
1,9

The brain tissue in a person with Alzheimer's has progressively fewer nerve cells and connections, and the
total brain size shrinks.
1,9

See the Medical News Today Alzheimer's disease page for more detailed information about this specific type
of dementia.
Dementia with Lewy bodies is also caused by neurodegeneration linked to abnormal structures in the brain.
Here, the brain changes involve a protein called alpha-synuclein.
10

Mixed dementia refers to a diagnosis of two or three types occurring together. A person may show both
Alzheimer's disease and vascular dementia at the same time. Or the combination could be Lewy bodies and
Alzheimer's. There can also be a combination of all three types.
10

Parkinson's disease is also marked by the presence of Lewy bodies. While the part of the brain affected
means there are classic movement symptoms, people with Parkinson's can also go on to develop dementia
symptoms as the degenerative changes in the brain gradually spread.
10

Huntington's disease is similar to Parkinson's in the respect of being classically marked by uncontrolled
movements yet having dementia as a component. It results in mood changes, too. Huntington's is an inherited
condition caused by a single faulty gene. This can produce the disease at any age - as young at 2 years of age
and as old as 80, but typically between the ages of 30 and 50 years.
10

Other disorders leading to symptoms of dementia include:
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Frontotemporal dementia (also known as Pick's disease)
Normal pressure hydrocephalus (when excess cerebrospinal fluid accumulates in the brain)
Posterior cortical atrophy (caused by the same tissue abnormalities seen in Alzheimer's disease, but in a
different part of the brain), and
Down syndrome (people born with this are more likely to develop young-onset Alzheimer's).
Signs and symptoms

Memory loss in dementia can be serious enough for the person to forget where they are, even on their
home street.
The symptoms of dementia experienced by patients, or noticed by people close to them, are exactly the same
signs that healthcare professionals look for. Therefore, detailed information on these is given in the next section
about tests and diagnosis.
A person with dementia may show any of the following problems, mostly due to memory loss - some of which
they may notice (or become frustrated with) themselves, while others may only be picked up by carers or
healthcare workers as a cause for concern. The signs used to compile this list are published by the American
Academy of Family Physicians (AAFP) in the journal American Family Physician:
6

Recent memory loss - a sign of this might be asking the same question repeatedly, forgetting about already
asking it.
Difficulty completing familiar tasks - for example, making a drink or cooking a meal, but forgetting and
leaving it.
Problems communicating - difficulty with language by forgetting simple words or using the wrong ones.
Disorientation - with time and place, getting lost on a previously familiar street close to home, for example,
and forgetting how they got there or would get home again.
Poor judgment - the AAFP says: "Even a well person might get distracted and forget to watch a child for a
little while. People with dementia, however, might forget all about the child and just leave the house for the
day."
Problems with abstract thinking - for example, dealing with money.
Misplacing things - including putting them in the wrong places and forgetting about doing this.
Mood changes - unlike those we all have, swinging quickly through a set of moods.
Personality changes - becoming irritable, suspicious or fearful, for example.
Loss of initiative - showing less interest in starting something or going somewhere.
The Alzheimer's Association has put together Know the 10 signs - a PDF document listing real-life examples
of how this type of dementia can affect people.

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Tests and diagnosis
The first step in testing concerns about memory performance and cognitive health involves standard questions
and tasks. Asking for knowledge of facts that should be known to any adult will give healthcare professionals
an indication of whether there is dementia or not and help to guide a decision on further investigation. Simple
word knowledge tests and drawing tasks are included alongside memory questions.
It is important that healthcare professionals carry out standardized testing of cognition, as opposed to gaining
informal impressions of a person's mental abilities. Research has shown that dementia cannot be reliably
differentiated without using the standard tests below, completing them fully and recording all the answers
before forming a diagnostic indication that also takes account of other factors.
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Equally important is that people with concerns about their own or someone else's possible dementia get the
problem checked by a doctor, both because of the confusing nature of the symptoms and because there are
various causes that could need checking and treating.
Cognitive tests
Today's cognitive tests are in widespread use and have been verified as a reliable way of indicating
dementia.
11
They have changed little since being established in the early 1970s. The simple questions that are
used come from a set first developed in 1972 by Professor Henry Hodkinson, working at the time in a London
hospital as a UK specialist in geriatric medicine.
12

Prof Hodkinson's research identified the most effective 10 questions in a previous list of 26 to screen older
people in confused states. The questionnaire - which is one of the dementia tools most commonly used by
family and hospital doctors
11
- is known as the abbreviated mental test score (AMTS).
The abbreviated mental test score has 10 questions:
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1. What is your age?
2. What is the time, to the nearest hour?
3. Repeat an address at the end of the test that I will give you now (e.g. "42 West Street")
4. What is the year?
5. What is the name of the hospital or town we are in?
6. Can you recognize two people (e.g. the doctor, nurse, home help, etc.)?
7. What is your date of birth?
8. In what year did World War 1 begin? (Other widely known dates in the past can be used.)
9. Name the president/prime minister/monarch.
10. Count backwards from 20 down to 1.
Each correct answer attracts one point; scoring seven or more indicates normal functioning while getting six
points or fewer suggests cognitive impairment.
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People with dementia might forget where in this circle to write the hours of a clock face. One test for this
also asks the patient to draw in hands at ten past eleven.
The GPCOG test is briefer than the AMTS in terms of the questions asked of the patient, but if these raise
concern there is an added element for recording the observations of relatives and carers.
Designed for GPs, this sort of test may be the first formal assessment of a person's mental ability that is done
before fuller tests are considered.
13

The doctor records the answers to questions and tasks given at the GPCOG test website.
This online diagnostic tool returns a score after the first, patient-based set of questions, then prompts whether
"more information is required" from relatives in a second step. At the end of the two-part test, a statement is
given on whether "cognitive impairment is indicated". The test was developed at Australia's University of New
South Wales.
One task for the patient part of the GPCOG test is to write the hours of a clock face around a blank circle on a
piece of paper - with accurate relative spacing - and then draw the hour and minute hands to show ten past
eleven.
The second part of the test, which probes someone "close to the person" being evaluated - the informant
interview - has six questions around the following areas of cognition, finding 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. "Further and special investigations" may also be needed.

Cognitive checklists measure dementia symptoms and other tests also help to narrow down, for example,
Alzheimer's disease.
The clinical tests (see below) will identify, or rule out, treatable causes for the memory loss and help to narrow
down whether there is a degenerative cause such as Alzheimer's disease.
The mini mental state examination (MMSE) is a fuller cognitive test. The shorter tests above are reliable
alternatives to the MMSE, and considered more effective in some settings.
13,14

Primary care doctors have less time but are in a good position to do the initial screening with shorter tests,
while specialists will be referred to for further evaluation with, for example, the MMSE alongside other testing to
confirm whether there is dementia and diagnose the particular type.
4

In some settings, it is standard for all patients to skip straight to the MMSE as the first screen for dementia. For
example, all older people in a geriatric healthcare setting may be tested on admission.
The mini mental state examination measures:
4,15

Orientation to time and place
Word recall
Language abilities
Attention and calculation
Visuospatial skills.
Abilities to name objects, follow verbal and written commands, write a sentence spontaneously and copy a
complex shape are tested.
1

The maximum possible score is 30 points and dementia is suggested at scores of up to between 24 and 27,
with normal being anything over this.
Doctors should consider adjustments for age and education because performance in the test can be influenced
by demographic, non-dementia factors.
14,16
The following should be taken into account:
14

Educational level, skills, prior level of functioning and attainment
Language and culture
Any sensory impairments (for example, hearing loss)
Psychiatric illness or physical/neurological problems.
The mini mental state examination is used to help diagnose dementia caused by Alzheimer's disease and also
to rate its severity and when drug treatment is needed. Mild-to-moderate Alzheimer's disease is classified by an
MMSE score below 26, moderate disease is below 20 but above 10, and severe Alzheimer's produces a score
of less than 10.
14,16

Other tests
The cognitive tests above are central to diagnosing whether dementia is present and for tracking progression
and severity after a particular disorder is confirmed.
At the earliest stages of diagnosis, before a disorder such as Alzheimer's can be narrowed down, other tests
are done, often to rule out treatable causes or pinpoint a dementia with an obvious cause. The other reason for
more tests is that different diseases can overlap.
Doctors will "take a history" (ask the patient questions), carry out a physical examination to uncover any signs
of, for example, a stroke, heart condition or kidney disease and check neurological function, by testing balance,
senses and reflexes.
1

Depending on what the doctor thinks could need further investigation, other diagnostics include laboratory tests
of blood and urine samples, brain scans (possibly including CT, MRI, and EEG), genetic testing in the case of
suspected inherited disorders such as Huntington's, and sometimes psychiatric assessment if, for example,
depression may be involved.
1

Medical News Today's page on Alzheimer's answers this: Is there a biological test for Alzheimer's disease?
Recent developments in tests and diagnosis from MNT news
Four biomarkers of dementia have been suggested by other work, published inNeurology in August 2012.
Research into blood plasma levels of different "analytes" identified four that were altered in people with
Alzheimer's and milder forms of dementia (apoE, B-type natriuretic peptide, C-reactive protein and pancreatic
polypeptide).
Physical abilities of the "oldest old". In people aged 90 years or more, performance in measures such as
grip strength, standing balance, a 4-meter walk and "chair stands" was linked to dementia risk in a University of
California, Irvine, study reported in theArchives of Neurology in January 2013. The researchers ask whether
this and further research could uncover a cause-and-effect relationship to physical abilities and help with the
early identification of risk factors and with the prevention of dementia.
Treatment and prevention
Brain cell death cannot be reversed so there is no known treatment to cure a degenerative cause of dementia
symptoms or fully halt its progress. Management of disorders such as Alzheimer's disease is instead focused
on providing care and treating symptoms rather than their underlying cause.
1,3

If dementia symptoms are due to a reversible, non-degenerative cause, however, treatment may be possible,
to prevent or halt further brain tissue damage.
1,3
Examples include injury, medication effects, vitamin deficiency.
Symptoms of Alzheimer's disease can be reduced by drugs to help improve an individual's quality of life - there
are four drugs in a class called cholinesterase inhibitor approved for this in the US:
1

Donepezil (brand name Aricept)
Alantamine (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.
1

A cholinesterase inhibitor such as donepezil can also help with the behavioral elements ofParkinson's
disease.
1

Other quality-of-life care

A therapeutic robot companion shown with its researcher, Professor Cook.
"Brain training" can help in the early stages of Alzheimer's to improve cognitive functioning and help deal with
forgetfulness. This might involve the use of mnemonics and other memory aids such as computerized recall
devices.
1

Of course, care from healthcare professionals, and relatives to some extent, can help people with the later
stages of dementia.
There have been some tech developments in this area, too - an innovation to provide a therapeutic robot
companion has been shown to help sufferers be less anxious, aggressive and lonely. See our news story -
Robo-pets help dementia patients - about the PARO baby seal reported in the May 2013 issue of
the Journal of Gerontological Nursing. The picture shows the baby seal with Northumbria University's Professor
Glenda Cook, one of the report's authors.
Recent developments in dementia treatment from MNT news
A new target for drugs against brain cell death has been discovered by researchers publishing their findings
in the journal Science Translational Medicine in October 2013.
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A major pathway leading to brain cell death in mice was blocked by an orally administered drug compound,
successfully preventing neurodegeneration in the animals.
Numerous scientists have hailed the study's findings as a breakthrough for neurodegenerative diseases such
as Alzheimer's disease.
Professor Roger Morris, acting head of King's College London's department of chemistry told the UK
newspaper The Independent: "This finding, I suspect, will be judged by history as a turning point in the
search for medicines to control and prevent Alzheimer's disease."
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Key to scientists' comments, however, is the fact that there is no guarantee the drug success in mice will
translate into safe, effective treatment for people - and even if it does, it is likely to take a decade or more of
further research.
Prevention
Certain risk factors are known to be associated with dementia and many of them are modifiable - something we
can act on and so possibly contribute to avoiding dementia. But age is the biggest predictor of dementia, and
there is nothing we can do to reverse this, of course.
Other risk factors include:
1

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, which is also a risk factor for cardiovascular disease and stroke, which may lead to vascular
dementia
Mild cognitive impairment, which can sometimes, but not always, lead to dementia.
There is a lot of research into risk factors associated with Alzheimer's disease so there may be lifestyle
measures we can take to potentially reduce our risk and enjoy a healthier life more generally. Medical News
Today has a page compiling ideas from researchers on how to prevent Alzheimer's disease and dementia -
including information about heart health, diet, exercise and keeping an active brain.
Written by Markus MacGill