View source for Dementia

{{Short description|Long-term brain disorders causing impaired memory, thinking and behavior}}
{{about|the cognitive disorder}}
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{{redirect-multi|2|Senile|Demented}}
{{Use mdy dates|date=May 2024}}
{{Infobox medical condition (new)
| name          = Dementia
| synonyms      = Senility,<ref name="medline2021">{{cite web |title=Dementia |url=https://medlineplus.gov/dementia.html |website=medlineplus.gov |access-date=January 20, 2022}}</ref> senile dementia
|image         = File:An old man diagnosed as suffering from senile dementia. Colo Wellcome L0026689.jpg
|caption       = [[Lithograph]] of a man diagnosed with dementia in the 1800s
|field         = [[Neurology]], [[psychiatry]]
|symptoms      = Decreased ability to think and remember, emotional problems, problems with [[language]], decreased [[motivation]], general decline in cognitive abilities<ref name="WHO2022"/>
|complications = Malnutrition, [[aspiration pneumonia]], inability to perform self-care tasks, personal safety challenges, [[akinetic mutism]]<ref>{{cite web |title=Dementia |url=https://www.mayoclinic.org/diseases-conditions/dementia/symptoms-causes/syc-20352013 |website=mayoclinic.org |publisher=Mayo Clinic |access-date=June 5, 2022}}</ref>
|onset         = Varies, usually gradual<ref name="WHO2022"/>
|duration      = Varies, usually long term<ref name="WHO2022"/>
|causes        = [[Alzheimer's disease]], [[vascular dementia]], [[Lewy body disease]], [[frontotemporal dementia]], and others<ref name="WHO2022"/>
|risks         = Lack of education and socialization, family history
|diagnosis     = [[Cognitive testing]] ([[mini–mental state examination]])<ref name=Creavin/>
|differential  = [[Delirium]], [[hypothyroidism]]<ref name="NICE2">{{cite web |title=Differential diagnosis dementia |url=https://cks.nice.org.uk/topics/dementia/diagnosis/differential-diagnosis/ |website=NICE |access-date=January 20, 2022}}</ref><ref>{{cite book| vauthors = Hales RE |title=The American Psychiatric Publishing Textbook of Psychiatry|date=2008|publisher=American Psychiatric Pub|isbn=978-1-58562-257-3|page=311|url=https://books.google.com/books?id=2RzFWRIAsPAC&pg=PA311|url-status=live|archive-url=https://web.archive.org/web/20170908004600/https://books.google.com/books?id=2RzFWRIAsPAC&pg=PA311|archive-date=September 8, 2017}}</ref>
|prevention    = Early education, prevent high blood pressure, prevent [[obesity]], no smoking, social engagement<ref name="Lancet2020"/>
|treatment     = Varies, some types can be reversed, but [[supportive care]] is given to people suffering from irreversible forms of dementia.<ref name="WHO2022"/>
|medication    = Varies depending on the type, most medications have a small benefit<ref name=Comm2012/>
|prognosis     = Varies, life expectancy usually shortened
|frequency     = 55 million (2021)<ref name="WHO2022"/>
|deaths        = 2.4&nbsp;million (2016)<ref name=GBD2019>{{cite journal | vauthors = Nichols E, Szoeke CE, Vollset SE, Abbasi N, Abd-Allah F, Abdela J, etal | collaboration = GBD 2016 Dementia Collaborators | title = Global, regional, and national burden of Alzheimer's disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016 | journal = The Lancet. Neurology | volume = 18 | issue = 1 | pages = 88–106 | date = January 2019 | pmid = 30497964 | pmc = 6291454 | doi = 10.1016/S1474-4422(18)30403-4 }}</ref>
|alt           =
}}
'''Dementia''' is a [[syndrome]] associated with many [[neurodegenerative disease]]s, characterized by a general decline in cognitive abilities that affects a person's ability to perform [[activities of daily living|everyday activities]]. This typically involves problems with [[memory]], [[thinking]], [[behavior]], and [[motor control]].<ref>{{Cite web |title=Dementia |url=https://www.who.int/news-room/fact-sheets/detail/dementia |access-date=April 4, 2024 |website=who.int |language=en}}</ref> Aside from [[memory impairment]] and a [[thought disorder|disruption in thought patterns]], the most common symptoms of dementia include emotional problems, difficulties with [[language]], and decreased [[motivation]].<ref name="WHO2022">{{cite web |title=Dementia |url=https://www.who.int/news-room/fact-sheets/detail/dementia |website=who.int |access-date=September 26, 2022 |language=en}}</ref> The symptoms may be described as occurring in a [[continuum (measurement)|continuum]] over several stages.<ref name="Bathini" />{{efn|[[Prodromal]] subtypes of delirium-onset [[dementia with Lewy bodies]] have been proposed as of 2020.<ref name=McKeithFerman2020>{{cite journal |vauthors=McKeith IG, Ferman TJ, Thomas AJ, et al.|title=Research criteria for the diagnosis of prodromal dementia with Lewy bodies |journal=Neurology |volume=94 |issue=17 |pages=743–755 |date=April 2020 |pmid=32241955 |pmc=7274845 |doi=10.1212/WNL.0000000000009323|type= Review}}</ref>}} Dementia ultimately has a significant effect on the individual, their [[caregiver]]s, and their social relationships in general.<ref name="WHO2022"/> A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater [[cognitive]] decline than might be caused by the normal [[aging]] process.<ref name="Memory Loss">{{cite book | vauthors = Budson A, Solomon P |title=Memory loss : a practical guide for clinicians|year=2011|publisher=Elsevier Saunders|location=[Edinburgh?]|isbn=978-1-4160-3597-8|url=https://books.google.com/books?id=48HAK0HOF6cC&pg=PR10}}</ref>
Several diseases and injuries to the brain, such as a [[stroke]], can give rise to dementia. However, the most common cause is [[Alzheimer's disease]], a neurodegenerative disorder.<ref name="WHO2022"/> The [[DSM-5|''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5)]], has re-described dementia as a [[DSM-5#Neurocognitive disorders|mild or major neurocognitive disorder]] with varying degrees of severity and many [[Etiology|causative]] subtypes. The [[International Classification of Diseases]] ([[ICD-11]]) also classifies dementia as a neurocognitive disorder (NCD) with many forms or subclasses.<ref name="ICD11A">{{cite web |title=ICD-11 for Mortality and Morbidity Statistics |url=https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f546689346 |website=icd.who.int |access-date=January 20, 2022}}</ref> Dementia is listed as an acquired brain syndrome, marked by a decline in cognitive function, and is contrasted with [[neurodevelopmental disorder]]s.<ref name="DementiaUK">{{Cite web|title=What is mixed dementia|url=https://www.dementiauk.org/understanding-dementia/types-and-symptoms/mixed-dementia/|access-date=December 13, 2020|website=[[Dementia UK]]|archive-date=November 1, 2020|archive-url=https://web.archive.org/web/20201101110234/https://www.dementiauk.org/understanding-dementia/types-and-symptoms/mixed-dementia/|url-status=dead}}</ref> It is also described as a spectrum of disorders with causative subtypes of dementia based on a known disorder, such as [[Parkinson's disease]] for [[Parkinson's disease dementia]], [[Huntington's disease]] for Huntington's disease dementia, [[vascular disease]] for [[vascular dementia]], [[HIV infection]] causing [[HIV dementia]], [[frontotemporal lobar degeneration]] for [[frontotemporal dementia]], [[Lewy body disease]] for [[dementia with Lewy bodies]], and [[prion disease]]s.<ref name="Wilson1">{{cite journal |vauthors=Wilson H, Pagano G, Politis M |title=Dementia spectrum disorders: lessons learnt from decades with PET research |journal=J Neural Transm (Vienna) |volume=126 |issue=3 |pages=233–251 |date=March 2019 |pmid=30762136 |pmc=6449308 |doi=10.1007/s00702-019-01975-4 |url=}}</ref> Subtypes of neurodegenerative dementias may also be based on the underlying pathology of misfolded proteins, such as [[synucleinopathies]] and [[tauopathies]].<ref name="Wilson1"/> The coexistence of more than one type of dementia is known as [[mixed dementia]].<ref name="DementiaUK"/>
Many neurocognitive disorders may be caused by another medical condition or disorder, including brain tumours and [[subdural hematoma]], [[endocrine disorder]]s such as [[hypothyroidism]] and [[hypoglycemia]], [[nutritional deficiencies]] including [[thiamine]] and [[niacin]], infections, immune disorders, liver or kidney failure, [[metabolic disorder]]s such as [[Kufs disease]], some [[leukodystrophies]], and [[neurological disorder]]s such as [[epilepsy]] and [[multiple sclerosis]]. Some of the neurocognitive deficits may sometimes show improvement with treatment of the causative medical condition.<ref name="DSM5a">{{cite book | author = American Psychiatric Association |url=https://archive.org/details/diagnosticstatis0005unse/page/641|title=Diagnostic and statistical manual of mental disorders : DSM-5|date=2013|publisher=American Psychiatric Association|isbn=978-0-89042-554-1|edition=5th|location=Washington, DC|pages=[https://archive.org/details/diagnosticstatis0005unse/page/591 591–603]}}</ref>
Diagnosis of dementia is usually based on [[Medical history|history of the illness]] and [[cognitive testing]] with [[Neuroimaging|imaging]]. [[Blood test]]s may be taken to rule out other possible causes that may be reversible, such as hypothyroidism (an underactive thyroid), and to determine the dementia subtype. One commonly used cognitive test is the [[mini–mental state examination]]. Although the greatest risk factor for developing dementia is aging, dementia is not a normal part of the aging process; many people aged 90 and above show no signs of dementia.<ref name="NIHa2022">{{cite web |title=The Dementias: Hope Through Research {{!}} National Institute of Neurological Disorders and Stroke |url=https://www.ninds.nih.gov/health-information/patient-caregiver-education/hope-through-research/dementias-hope-through-research?search-term=Vascular%20dementia |website=ninds.nih.gov |access-date=December 9, 2022}}</ref> Several risk factors for dementia, such as smoking and [[obesity]], are preventable by lifestyle changes. [[Screening (medicine)|Screening]] the general older population for the disorder is not seen to affect the outcome.<ref name="Lin"/>
Dementia is currently the seventh leading cause of death worldwide and has 10&nbsp;million new cases reported every year (approximately one every three seconds).<ref name="WHO2022"/> There is no known [[cure]] for dementia. [[Acetylcholinesterase inhibitor]]s such as [[donepezil]] are often used and may be beneficial in mild to moderate disorder, but the overall benefit may be minor. There are many measures that can improve the quality of life of a person with dementia and their caregivers. [[Cognitive behavioral therapy|Cognitive and behavioral interventions]] may be appropriate for treating the associated symptoms of depression.<ref name="Cochrane2015">{{cite journal | vauthors = Orgeta V, Leung P, Del-Pino-Casado R, Qazi A, Orrell M, Spector AE, Methley AM | title = Psychological treatments for depression and anxiety in dementia and mild cognitive impairment | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 4 | page = CD009125 | date = April 2022 | pmid = 35466396 | pmc = 9035877 | doi = 10.1002/14651858.CD009125.pub3 }}</ref>
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== Signs and symptoms ==
The [[signs and symptoms]] of dementia are termed as the [[neuropsychiatric symptoms]]—also known as the ''behavioral'' and ''psychological'' symptoms—of dementia.<ref name="Radue">{{cite book | vauthors = Radue R, Walaszek A, Asthana S | chapter = Chapter 24 – Neuropsychiatric symptoms in dementia | volume = 167 | pages = 437–454 | date = 2019 | pmid = 31753148 | doi = 10.1016/B978-0-12-804766-8.00024-8 | isbn = 978-0-12-804766-8 | title = Handbook of Clinical Neurology | s2cid = 208230186 }}</ref><ref name="Kales">{{cite journal | vauthors = Kales HC, Gitlin LN, Lyketsos CG | title = Assessment and management of behavioral and psychological symptoms of dementia | journal = BMJ | volume = 350 | issue = | page = h369 | date = March 2015 | pmid = 25731881 | pmc = 4707529 | doi = 10.1136/bmj.h369 }}</ref> The behavioral symptoms can include [[agitation (dementia)|agitation]], restlessness, inappropriate behavior, sexual disinhibition, and verbal or physical aggression.<ref name="Sahin" /> These symptoms may result from impairments in [[cognitive inhibition]].<ref name="APAorg">{{cite web |title=Inhibition in Cognition |url=https://www.apa.org/pubs/books/4318042 |website=apa.org |access-date=February 7, 2021}}</ref> The psychological symptoms can include depression, [[hallucination]]s (most often visual),<ref name="medline">{{cite web |title=Hallucinations: MedlinePlus Medical Encyclopedia |url=https://medlineplus.gov/ency/article/003258.htm |website=medlineplus.gov |access-date=December 9, 2022 |language=en}}</ref> delusions, apathy, and anxiety.<ref name="Sahin">{{cite journal | vauthors = Şahin Cankurtaran E | title = Management of Behavioral and Psychological Symptoms of Dementia | journal = Noro Psikiyatri Arsivi | volume = 51 | issue = 4 | pages = 303–312 | date = December 2014 | pmid = 28360647 | pmc = 5353163 | doi = 10.5152/npa.2014.7405 | doi-broken-date = December 2, 2024 }}</ref><ref>{{Cite journal | vauthors = Shub D, Kunik ME |title=Psychiatric Comorbidity in Persons With Dementia: Assessment and Treatment Strategies |journal=Psychiatric Times |volume=26 |issue=4 |date=April 16, 2009 |url=http://www.psychiatrictimes.com/alzheimer-dementia/article/10168/1403050 |url-status=live |archive-url=https://web.archive.org/web/20090427144308/http://www.psychiatrictimes.com/alzheimer-dementia/article/10168/1403050 |archive-date=April 27, 2009 }}</ref> The most commonly affected areas of brain function include [[memory]], [[language]], [[attention]], [[problem solving]], and [[visuospatial function]] affecting perception and orientation. The symptoms progress at a continuous rate over several stages, and they vary across the dementia subtypes.<ref>{{cite web|title=Dementia – Signs and Symptoms|publisher= American Speech Language D Association|url=http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935289&section=Signs_and_Symptoms}}</ref><ref name="Bathini" /> Most types of dementia are slowly progressive with some deterioration of the brain well established before signs of the disorder become apparent. There are often [[comorbidity|other conditions]] present, such as [[high blood pressure]] or [[diabetes]], and there can sometimes be as many as four of these comorbidities.<ref name="GOVUK">{{cite web |title=Dementia: comorbidities in patients – data briefing |url=https://www.gov.uk/government/publications/dementia-comorbidities-in-patients/dementia-comorbidities-in-patients-data-briefing |website=GOV.UK |access-date=November 22, 2020 |language=en}}</ref>
Signs of dementia include getting lost in a familiar neighborhood, using unusual words to refer to familiar objects, forgetting the name of a close family member or friend, forgetting old memories, and being unable to complete tasks independently.<ref>{{Cite web |date=December 19, 2019 |title=What Is Dementia? {{!}} CDC |url=https://www.cdc.gov/aging/dementia/index.html |access-date=October 3, 2022 |website=cdc.gov |language=en-us}}</ref> People with developing dementia often fall behind on bill payments; specifically mortgage and credit cards, and a crashing [[credit score]] can be an early indicator of the disease.<ref>{{cite journal |last1=Gresenz |first1=Carole Roan |last2=Mitchell |first2=Jean M. |last3=Rodriguez |first3=Belicia |last4=Turner |first4=R. Scott |last5=van der Klaauw |first5=Wilbert |date=May 2024 |title=The Financial Consequences of Undiagnosed Memory Disorders |url=https://www.newyorkfed.org/medialibrary/media/research/staff_reports/sr1106.pdf |journal=Federal Reserve Bank of New York Staff Reports |series=Staff Reports (Federal Reserve Bank of New York) |issue=1106 |doi=10.59576/sr.1106 |access-date=July 27, 2024}}</ref><ref>{{cite web |url=https://www.nytimes.com/2024/05/31/business/economy/alzheimers-disease-personal-finance.html |title=Alzheimer's Takes a Financial Toll Long Before Diagnosis, Study Finds |last=Casselman |first=Ben |date=May 31, 2024 |website=[[The New York Times]] |access-date=July 27, 2024 |quote=Credit scores among people who later develop dementia begin falling sharply long before their disease is formally identified. A year before diagnosis, these people were 17.2 percent more likely to be delinquent on their mortgage payments than before the onset of the disease, and 34.3 percent more likely to be delinquent on their credit card bills. | archive-url=http://web.archive.org/web/20240630171647/https://www.nytimes.com/2024/05/31/business/economy/alzheimers-disease-personal-finance.html | archive-date=June 30, 2024 }}</ref>
People with dementia are more likely to have problems with incontinence than those of a comparable age without dementia; they are three times more likely to have [[urinary incontinence]] and four times more likely to have [[fecal incontinence]].<ref>{{Cite journal |date=June 21, 2022 |title=Continence, dementia, and care that preserves dignity |url= https://evidence.nihr.ac.uk/themedreview/continence-dementia-and-care-that-preserves-dignity/ |journal=NIHR Evidence |doi=10.3310/nihrevidence_51255|s2cid=251785991 }}</ref><ref>{{cite journal | vauthors = Grant RL, Drennan VM, Rait G, Petersen I, Iliffe S | title = First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using The Health Improvement Network primary care database | journal = PLOS Medicine | volume = 10 | issue = 8 | page = e1001505 | date = August 2013 | pmid = 24015113 | pmc = 3754889 | doi = 10.1371/journal.pmed.1001505 | veditors = Prince MJ | doi-access = free }}</ref>
== Stages ==
The course of dementia is often described in four stages – pre-dementia, early, middle, and late, that show a pattern of progressive cognitive and functional impairment. More detailed descriptions can be arrived at by the use of numeric scales. These scales include the Global Deterioration Scale for Assessment of Primary Degenerative Dementia (GDS or Reisberg Scale), the Functional Assessment Staging Test (FAST), and the [[Clinical Dementia Rating]] (CDR).<ref name="Sheehan"/> Using the GDS, which more accurately identifies each stage of the disease progression, a more detailed course is described in seven stages – two of which are broken down further into five and six degrees. Stage 7(f) is the final stage.<ref name="DCC">{{cite web |title=Seven Stages of Dementia {{!}} Symptoms, Progression & Durations |url=https://www.dementiacarecentral.com/aboutdementia/facts/stages/ |access-date=December 19, 2020}}</ref><ref name="ALZ">{{cite web |title=Clinical Stages of Alzheimer's |url=https://www.alzinfo.org/understand-alzheimers/clinical-stages-of-alzheimers/ |website=Fisher Center for Alzheimer's Research Foundation |access-date=December 19, 2020 |date=January 29, 2014}}</ref>
===Pre-dementia===
Pre-dementia includes pre-clinical and [[prodromal]] stages. The latter stage includes [[mild cognitive impairment]] (MCI), delirium-onset, and psychiatric-onset presentations.<ref>{{Cite web |author=Scharre DW |title=Preclinical, Prodromal, and Dementia Stages of Alzheimer's Disease |url=https://practicalneurology.com/articles/2019-june/preclinical-prodromal-and-dementia-stages-ofalzheimers-disease |date=June 2019 |access-date=June 28, 2022 |website=Practical Neurology |language=en}}</ref>
====Pre-clinical====
Sensory dysfunction is claimed for the pre-clinical stage, which may precede the first clinical signs of dementia by up to ten years.<ref name="Bathini"/> Most notably the [[sense of smell]] is lost,<ref name="Bathini">{{cite journal | vauthors = Bathini P, Brai E, Auber LA | title = Olfactory dysfunction in the pathophysiological continuum of dementia | journal = Ageing Research Reviews | volume = 55 | page = 100956 | date = November 2019 | pmid = 31479764 | doi = 10.1016/j.arr.2019.100956 | url = http://doc.rero.ch/record/327719/files/alb_odp.pdf | s2cid = 201742825 }}</ref><ref name="Bhatia-Dey">{{cite journal |vauthors=Bhatia-Dey N, Heinbockel T |title=The Olfactory System as Marker of Neurodegeneration in Aging, Neurological and Neuropsychiatric Disorders |journal=Int J Environ Res Public Health |volume=18 |issue=13 |date=June 2021 |page=6976 |pmid=34209997 |doi=10.3390/ijerph18136976 |pmc=8297221 |url=|doi-access=free }}</ref> associated with depression and a loss of appetite leading to poor nutrition.<ref name=Boesveldt>{{cite journal |vauthors=Boesveldt S, Parma V |title=The importance of the olfactory system in human well-being, through nutrition and social behavior |journal=Cell Tissue Res |volume=383 |issue=1 |pages=559–567 |date=January 2021 |pmid=33433688 |pmc=7802608 |doi=10.1007/s00441-020-03367-7 |url=}}</ref> It is suggested that [[Anosmia|this dysfunction]] may come about because the [[olfactory epithelium]] is exposed to the environment, and the lack of [[blood–brain barrier]] protection allows toxic elements to enter and cause damage to the [[chemosensory]] networks.<ref name="Bathini"/>
====Prodromal====
Pre-dementia states considered as prodromal are [[mild cognitive impairment]] (MCI) and ''mild behavioral impairment'' (MBI).<ref name=Sherman>{{cite journal |vauthors=Sherman C, Liu CS, Herrmann N, Lanctôt KL |title=Prevalence, neurobiology, and treatments for apathy in prodromal dementia |journal=Int Psychogeriatr |volume=30 |issue=2 |pages=177–184 |date=February 2018 |pmid=28416030 |doi=10.1017/S1041610217000527 |s2cid=46788701 |url=}}</ref><ref name="Breton">{{cite journal | vauthors = Breton A, Casey D, Arnaoutoglou NA | title = Cognitive tests for the detection of mild cognitive impairment (MCI), the prodromal stage of dementia: Meta-analysis of diagnostic accuracy studies | journal = International Journal of Geriatric Psychiatry | volume = 34 | issue = 2 | pages = 233–242 | date = February 2019 | pmid = 30370616 | doi = 10.1002/gps.5016 | s2cid = 53097138 }}</ref><ref name="Bateman">{{cite journal |vauthors=Bateman DR, Gill S, Hu S, Foster ED, Ruthirakuhan MT, Sellek AF, Mortby ME, Matušková V, Ng KP, Tarawneh RM, Freund-Levi Y, Kumar S, Gauthier S, Rosenberg PB, Ferreira de Oliveira F, Devanand DP, Ballard C, Ismail Z |title=Agitation and impulsivity in mid and late life as possible risk markers for incident dementia |journal= Alzheimer's & Dementia: Translational Research & Clinical Interventions|volume=6 |issue=1 |page=e12016 |date=2020 |pmid=32995467 |pmc=7507499 |doi=10.1002/trc2.12016 |url=}}</ref> Signs and symptoms at the prodromal stage may be subtle, and the early signs often become apparent only in hindsight.<ref name="ADCS">{{cite journal |vauthors=Atri A |title=The Alzheimer's Disease Clinical Spectrum: Diagnosis and Management |journal=Med Clin North Am |volume=103 |issue=2 |pages=263–293 |date=March 2019 |pmid=30704681 |doi=10.1016/j.mcna.2018.10.009 |url=|doi-access=free }}</ref> Of those diagnosed with MCI, 70% later progress to dementia.<ref name="Memory Loss" /> In mild cognitive impairment, changes in the person's brain have been happening for a long time, but the symptoms are just beginning to appear. These problems, however, are not severe enough to affect daily function. If and when they do, the diagnosis becomes dementia. The person may have some memory problems and trouble finding words, but they can solve everyday problems and competently handle their life affairs.<ref name="hugo">{{cite journal | vauthors = Hugo J, Ganguli M | title = Dementia and cognitive impairment: epidemiology, diagnosis, and treatment | journal = Clinics in Geriatric Medicine | volume = 30 | issue = 3 | pages = 421–442 | date = August 2014 | pmid = 25037289 | pmc = 4104432 | doi = 10.1016/j.cger.2014.04.001 }}</ref> During this stage, it is ideal to ensure that advance care planning has occurred to protect the person's wishes. Advance directives exist that are specific to sufferers of dementia;<ref>{{Cite web |title=Advance Directive for Dementia |url=https://dementia-directive.org/ |access-date=January 12, 2023 |website=dementia-directive.org |language=en-US}}</ref> these can be particularly helpful in addressing the decisions related to feeding which come with the progression of the illness. Mild cognitive impairment has been relisted in both [[DSM-5]] and [[ICD-11]] as "mild neurocognitive disorders", i.e. milder forms of the major neurocognitive disorder (dementia) subtypes.<ref name="DSM5">{{cite book | author = American Psychiatric Association |url=https://archive.org/details/diagnosticstatis0005unse/page/591|title=Diagnostic and statistical manual of mental disorders : DSM-5|date=2013|publisher=American Psychiatric Association|isbn=978-0-89042-554-1|edition=5th|location=Washington, DC|pages=[https://archive.org/details/diagnosticstatis0005unse/page/591 591–603]}}</ref>
[[Kynurenine]] is a metabolite of [[tryptophan]] that regulates microbiome signaling, immune cell response, and neuronal excitation. A disruption in the [[kynurenine pathway]] may be associated with the neuropsychiatric symptoms and cognitive prognosis in mild dementia.<ref name=Cervenka>{{cite journal |vauthors=Cervenka I, Agudelo LZ, Ruas JL |title=Kynurenines: Tryptophan's metabolites in exercise, inflammation, and mental health |journal=Science |volume=357 |issue=6349 |page= eaaf9794|date=July 2017 |pmid=28751584 |doi=10.1126/science.aaf9794 |url=|doi-access=free }}</ref><ref name=Solvang>{{cite journal |vauthors=Solvang SH, Nordrehaug JE, Aarsland D, et al |title=Kynurenines, Neuropsychiatric Symptoms, and Cognitive Prognosis in Patients with Mild Dementia |journal=Int J Tryptophan Res |volume=12 |issue= |page=1178646919877883 |date=2019 |pmid=31632053 |pmc=6769202 |doi=10.1177/1178646919877883 |url=}}</ref>
=== Early ===
In the early stage of dementia, symptoms become noticeable to other people. In addition, the symptoms begin to interfere with daily activities, and will register a score on a [[mini–mental state examination]] (MMSE). MMSE scores are set at 24 to 30 for a normal cognitive rating and lower scores reflect severity of symptoms. The symptoms are dependent on the type of dementia. More complicated chores and tasks around the house or at work become more difficult. The person can usually still take care of themselves but may forget things like taking pills or doing laundry and may need prompting or reminders.<ref>{{Cite book|title=Dementia care at a glance| vauthors = Jenkins C, Ginesi L, Keenan B |isbn=978-1-118-85998-8|location=Chichester, West Sussex | publisher = John Wiley & Sons |oclc=905089525|year = 2016}}</ref>
The symptoms of early dementia usually include memory difficulty, but can also include some [[anomic aphasia|word-finding problems]], and problems with [[executive functions]] of planning and organization.<ref>{{cite journal |author5-link=Martin Rossor | vauthors = Rohrer JD, Knight WD, Warren JE, Fox NC, Rossor MN, Warren JD | title = Word-finding difficulty: a clinical analysis of the progressive aphasias | journal = Brain | volume = 131 | issue = Pt 1 | pages = 8–38 | date = January 2008 | pmid = 17947337 | pmc = 2373641 | doi = 10.1093/brain/awm251 }}</ref> Managing finances may prove difficult. Other signs might be getting lost in new places, repeating things, and personality changes.<ref>{{cite journal | vauthors = Islam M, Mazumder M, Schwabe-Warf D, Stephan Y, Sutin AR, Terracciano A | title = Personality Changes With Dementia From the Informant Perspective: New Data and Meta-Analysis | journal = Journal of the American Medical Directors Association | volume = 20 | issue = 2 | pages = 131–137 | date = February 2019 | pmid = 30630729 | pmc = 6432780 | doi = 10.1016/j.jamda.2018.11.004 }}</ref>
In some types of dementia, such as [[dementia with Lewy bodies]] and [[frontotemporal dementia]], personality changes and difficulty with organization and planning may be the first signs.<ref>{{cite web | title = Diagnosing Lewy Body Dementia | publisher = National Institute on Aging | url = https://www.nia.nih.gov/health/diagnosing-lewy-body-dementia | access-date = May 10, 2020}}</ref>
=== Middle ===
As dementia progresses, initial symptoms generally worsen. The rate of decline is different for each person. MMSE scores between 6 and 17 signal moderate dementia. For example, people with moderate Alzheimer's dementia lose almost all new information. People with dementia may be severely impaired in solving problems, and their social judgment is often impaired. They cannot usually function outside their own home, and generally should not be left alone. They may be able to do simple chores around the house but not much else, and begin to require assistance for personal care and hygiene beyond simple reminders.<ref name="Memory Loss" /> A [[anosognosia|lack of insight]] into having the condition will become evident.<ref name="Wilson">{{cite journal |vauthors=Wilson RS, Sytsma J, Barnes LL, Boyle PA |title=Anosognosia in Dementia |journal=Current Neurology and Neuroscience Reports |volume=16 |issue=9 |page=77 |date=September 2016 |pmid=27438597 |doi=10.1007/s11910-016-0684-z|s2cid=3331009 }}</ref><ref name="CNN">{{cite journal |vauthors=Sunderaraman P, Cosentino S |title=Integrating the Constructs of Anosognosia and Metacognition: a Review of Recent Findings in Dementia |journal=Current Neurology and Neuroscience Reports |volume=17 |issue=3 |page=27 |date=March 2017 |pmid=28283961 |doi=10.1007/s11910-017-0734-1|pmc=5650061 }}</ref>
=== Late ===
People with late-stage dementia typically turn increasingly inward and need assistance with most or all of their personal care. People with dementia in the late stages usually need 24-hour supervision to ensure their personal safety, and meeting of basic needs. If left unsupervised, they may [[Wandering (dementia)|wander]] or fall; may not recognize common dangers such as a hot stove; or may not realize that they need to use the bathroom and become [[Urinary incontinence|incontinent]].<ref name=hugo/> They may not want to get out of bed, or may need assistance doing so. Commonly, the person no longer recognizes familiar faces. They may have significant changes in sleeping habits or have trouble sleeping at all.<ref name="Memory Loss" />
Changes in eating frequently occur. Cognitive awareness is needed for eating and swallowing and progressive cognitive decline results in eating and [[swallowing difficulties]]. This can cause food to be refused, or choked on, and help with feeding will often be required.<ref name="Payne">{{cite journal | vauthors = Payne M, Morley JE | title = Editorial: Dysphagia, Dementia and Frailty | journal = The Journal of Nutrition, Health & Aging | volume = 22 | issue = 5 | pages = 562–565 | date = May 1, 2018 | pmid = 29717753 | doi = 10.1007/s12603-018-1033-5 | s2cid = 13753522 | doi-access = free }}</ref> For ease of feeding, food may be liquidized into a thick purée. They may also struggle to walk, particularly among those with [[Alzheimer's disease]].<ref name="Sala Della et al. 2004">{{cite journal | vauthors = Della Sala S, Spinnler H, Venneri A | title = Walking difficulties in patients with Alzheimer's disease might originate from gait apraxia | journal = Journal of Neurology, Neurosurgery, and Psychiatry | volume = 75 | issue = 2 | pages = 196–201 | date = February 2004 | pmid = 14742586 | pmc = 1738895 | url = https://jnnp.bmj.com/content/jnnp/75/2/196.full.pdf | url-status = live | archive-url = https://ghostarchive.org/archive/20221009/https://jnnp.bmj.com/content/jnnp/75/2/196.full.pdf | archive-date = October 9, 2022 }}</ref><ref>{{cite journal | vauthors = Mc Ardle R, Galna B, Donaghy P, Thomas A, Rochester L | title = Do Alzheimer's and Lewy body disease have discrete pathological signatures of gait? | journal = Alzheimer's & Dementia | volume = 15 | issue = 10 | pages = 1367–1377 | date = October 2019 | pmid = 31548122 | doi = 10.1016/j.jalz.2019.06.4953 | doi-access = free }}</ref><ref>{{cite web |title=Mental, physical and speech abilities in later stages of dementia |url=https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/how-dementia-progresses/mental-and-physical-activities |website=Alzheimer's Society |date=June 29, 2022 |access-date=July 30, 2022}}</ref> In some cases, [[terminal lucidity]], a form of [[paradoxical lucidity]], occurs immediately before death; in this phenomenon, there is an unexpected recovery of mental clarity.<ref>{{cite journal | vauthors = Mashour GA, Frank L, Batthyany A, Kolanowski AM, Nahm M, Schulman-Green D, Greyson B, Pakhomov S, Karlawish J, Shah RC | display-authors = 6 | title = Paradoxical lucidity: A potential paradigm shift for the neurobiology and treatment of severe dementias | journal = Alzheimer's & Dementia | volume = 15 | issue = 8 | pages = 1107–1114 | date = August 2019 | pmid = 31229433 | doi = 10.1016/j.jalz.2019.04.002 | doi-access = free | hdl = 2027.42/153062 | hdl-access = free }}</ref>
==Causes==
Many causes of dementia are [[neurodegenerative]], and [[protein misfolding]] is a cardinal feature of these.<ref name=Chung>{{cite journal |vauthors=Chung CG, Lee H, Lee SB |title=Mechanisms of protein toxicity in neurodegenerative diseases |journal=Cell Mol Life Sci |volume=75 |issue=17 |pages=3159–3180 |date=September 2018 |pmid=29947927 |pmc=6063327 |doi=10.1007/s00018-018-2854-4 |url=}}</ref> Other common causes include vascular dementia, dementia with Lewy bodies, frontotemporal dementia, and mixed dementia (commonly Alzheimer's disease and vascular dementia).<ref name="WHO2022"/>{{efn| Kosaka (2017) writes: "Dementia with Lewy bodies (DLB) is now well known to be the second most frequent dementia following Alzheimer disease (AD). Of all types of dementia, AD is known to account for about 50%, DLB about 20% and vascular dementia (VD) about 15%. Thus, AD, DLB, and VD are now considered to be the three major dementias."<ref>{{cite book|veditors= Kosaka K |editor-link= Kenji Kosaka (psychiatrist)|date=2017 |title= Dementia with Lewy bodies: clinical and biological aspects|edition= 1st |publisher= Springer: Japan |doi= 10.1007/978-4-431-55948-1 |isbn= 978-4-431-55948-1|s2cid= 45950966}}</ref><!-- Page v --> The NINDS (2020) says that Lewy body dementia "is one of the most common causes of dementia, after Alzheimer's disease and vascular disease."<ref name= NINDS2020Book>{{cite web|title=Lewy body dementia: Hope through research |url= https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Lewy-Body-Dementia-Hope-Through-Research |website= National Institute of Neurological Disorders and Stroke |publisher = US National Institutes of Health |access-date= March 18, 2020 |date= January 10, 2020}}</ref> Hershey (2019) says, "DLB is the third most common of all the neurodegenerative diseases behind both Alzheimer's disease and Parkinson's disease".<ref>{{cite journal |vauthors=Hershey LA, Coleman-Jackson R |title=Pharmacological management of dementia with Lewy dodies |journal=Drugs Aging |volume=36 |issue=4 |pages=309–319 |date=April 2019 |pmid=30680679 |pmc=6435621 |doi=10.1007/s40266-018-00636-7 |type= Review}}</ref><!-- Page 309 -->}}<ref name="JAMA"/> Less common causes include [[normal pressure hydrocephalus]], [[Parkinson's disease dementia]], [[syphilis]], [[HIV dementia|HIV]], and [[Creutzfeldt–Jakob disease]].<ref>{{cite book | vauthors = Gauthier S | title = Clinical diagnosis and management of Alzheimer's disease | date = 2006 | publisher = Informa Healthcare | location = Abingdon, Oxon | isbn = 978-0-203-93171-4 | pages = 53–54 | edition = 3rd | url = https://books.google.com/books?id=a221hX4WuwUC&pg=PA54|url-status=live|archive-url=https://web.archive.org/web/20160503111047/https://books.google.com/books?id=a221hX4WuwUC&pg=PA54|archive-date=May 3, 2016}}</ref>
=== Alzheimer's disease ===
{{Main|Alzheimer's disease}}
[[File:Alzheimers brain.jpg|thumb|Brain [[atrophy]] in severe Alzheimer's]]
Alzheimer's disease accounts for 60–70% of cases of dementia worldwide. The most common symptoms of Alzheimer's disease are [[short-term memory loss]] and [[Anomic aphasia|word-finding difficulties]]. Trouble with [[visuospatial function]]ing (getting lost often), reasoning, judgment and [[insight]] fail. Insight refers to whether or not the person realizes they have memory problems.
The part of the brain most affected by Alzheimer's is the [[hippocampus]]. Other parts that show [[atrophy]] (shrinking) include the [[Temporal lobe|temporal]] and [[parietal lobe]]s. Although this pattern of brain shrinkage suggests Alzheimer's, it is variable and a brain scan is insufficient for a diagnosis.
Little is known about the events that occur during and that actually cause Alzheimer's disease. This is due to the fact that, historically, brain tissue from patients with the disease could only be studied after the person's death. Brain scans can now help diagnose and distinguish between different kinds of dementia and show severity. These include magnetic resonance imaging (MRI), computerized tomography (CT), and positron emission tomography (PET).  However, it is known that one of the first aspects of Alzheimer's disease is overproduction of [[amyloid]]. Extracellular senile plaques (SPs), consisting of beta-amyloid (Aβ) peptides, and intracellular [[neurofibrillary tangle]]s (NFTs) that are formed by hyperphosphorylated tau proteins, are two well-established pathological hallmarks of AD.<ref>{{cite journal | vauthors = Abyadeh M, Gupta V, Chitranshi N, Gupta V, Wu Y, Saks D, Wander Wall R, Fitzhenry MJ, Basavarajappa D, You Y, Salekdeh GH, Haynes PA, Graham SL, Mirzaei M | display-authors = 6 | title = Mitochondrial dysfunction in Alzheimer's disease – a proteomics perspective | journal = Expert Review of Proteomics | volume = 18 | issue = 4 | pages = 295–304 | date = April 2021 | pmid = 33874826 | doi = 10.1080/14789450.2021.1918550 | s2cid = 233310698 }}</ref> Amyloid causes [[inflammation]] around the [[Amyloid plaques|senile plaques of the brain]], and too much buildup of this inflammation leads to changes in the brain that cannot be controlled, leading to the symptoms of Alzheimer's.<ref>{{cite journal | vauthors = Wenk GL | title = Neuropathologic changes in Alzheimer's disease | journal = The Journal of Clinical Psychiatry | volume = 64 | issue = Suppl 9 | pages = 7–10 | date = 2003 | pmid = 12934968 | url = http://www.psychiatrist.com/jcp/article/pages/2003/v64s09/v64s0902.aspx }}</ref>
Several articles have been published on a possible relationship (as an either primary cause or exacerbation of Alzheimer's disease) between general [[anesthesia]] and Alzheimer's in specifically [[the elderly]].<ref>{{cite journal | vauthors = Papon MA, Whittington RA, El-Khoury NB, Planel E | title = Alzheimer's disease and anesthesia | journal = Frontiers in Neuroscience | volume = 4 | page = 272 | date = 2011 | pmid = 21344011 | pmc = 3034231 | doi = 10.3389/fnins.2010.00272 | doi-access = free }}</ref>
=== Vascular ===
{{Main|Vascular dementia}}
Vascular dementia accounts for at least 20% of dementia cases, making it the second most common type.<ref name=pmid24267647>{{cite journal | vauthors = Iadecola C | title = The pathobiology of vascular dementia | journal = Neuron | volume = 80 | issue = 4 | pages = 844–866 | date = November 2013 | pmid = 24267647 | pmc = 3842016 | doi = 10.1016/j.neuron.2013.10.008 }}</ref> It is caused by disease or injury affecting the [[cerebral circulation|blood supply to the brain]], typically involving a series of [[mini-stroke]]s. The symptoms of this dementia depend on where in the brain the strokes occurred and whether the blood vessels affected were large or small.<ref name="Memory Loss"/> Repeated injury can cause progressive dementia over time, while a single injury located in an area critical for cognition such as the hippocampus, or thalamus, can lead to sudden cognitive decline.<ref name=pmid24267647 /> Elements of vascular dementia may be present in all other forms of dementia.<ref name=Baskys>{{cite journal |vauthors=Baskys A, Cheng JX |title=Pharmacological prevention and treatment of vascular dementia: approaches and perspectives |journal=Exp Gerontol |volume=47 |issue=11 |pages=887–891 |date=November 2012 |pmid=22796225 |doi=10.1016/j.exger.2012.07.002 |s2cid=1153876 |url=}}</ref>
[[Neuroimaging|Brain scans]] may show evidence of multiple strokes of different sizes in various locations. People with vascular dementia tend to have risk factors for [[vascular disease|disease of the blood vessels]], such as [[tobacco use]], [[high blood pressure]], [[atrial fibrillation]], [[Hypercholesterolemia|high cholesterol]], [[diabetes]], or other signs of vascular disease such as a previous heart attack or [[angina]].<ref>{{Cite web|title=Vascular dementia – Symptoms and causes|url=https://www.mayoclinic.org/diseases-conditions/vascular-dementia/symptoms-causes/syc-20378793|access-date=July 8, 2021|website=Mayo Clinic|language=en}}</ref>
=== Lewy bodies ===
{{Main|Dementia with Lewy bodies}}
The prodromal symptoms of dementia with Lewy bodies (DLB) include [[mild cognitive impairment]], and [[delirium]] onset.<ref name="McKeith">{{cite journal |vauthors=McKeith IG, Ferman TJ, Thomas AJ, et al |title=Research criteria for the diagnosis of prodromal dementia with Lewy bodies |journal=Neurology |volume=94 |issue=17 |pages=743–755 |date=April 2020 |pmid=32241955 |pmc=7274845 |doi=10.1212/WNL.0000000000009323 |url=}}</ref>
The symptoms of DLB are more frequent, more severe, and earlier presenting than in the other dementia subtypes.<ref name="Jurek">{{cite journal |vauthors=Jurek L, Herrmann M, Bonze M et al.|title=Behavioral and psychological symptoms in Lewy body disease: a review |journal= Gériatrie et Psychologie Neuropsychiatrie du Vieillissement|volume=16 |issue=1 |pages=87–95 |date=March 1, 2018 |pmid=29569570 |doi=10.1684/pnv.2018.0723 }}</ref>
Dementia with Lewy bodies has the primary symptoms of fluctuating cognition, alertness or attention; [[REM sleep behavior disorder]] (RBD); one or more of the main features of [[parkinsonism]], not due to medication or stroke; and repeated visual hallucinations.<ref name= McKeithConsensus2017>{{cite journal |vauthors=McKeith IG, Boeve BF, Dickson DW, et al |title=Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium |journal=Neurology |volume=89 |issue=1 |pages=88–100 |date=July 2017 |pmid=28592453 |pmc=5496518 |doi=10.1212/WNL.0000000000004058 |type=Review}}</ref> The visual hallucinations in DLB are generally vivid hallucinations of people or animals and they often occur when someone is about to fall asleep or wake up. Other prominent symptoms include problems with planning (executive function) and difficulty with visual-spatial function,<ref name="Memory Loss" /> and disruption in [[autonomic nervous system|autonomic bodily functions]].<ref name= Taylor2020>{{cite journal |vauthors=Taylor JP, McKeith IG, Burn DJ et al |title=New evidence on the management of Lewy body dementia |journal=Lancet Neurol |volume=19 |issue=2 |pages=157–169 |date=February 2020 |pmid=31519472 |doi=10.1016/S1474-4422(19)30153-X |pmc=7017451 |type= Review }} Courtesty link available [https://ore.exeter.ac.uk/repository/bitstream/handle/10871/36535/Management%20Lewy%20body%20dementia_versionsubmittedtoTLNwithappendix.pdf?sequence=10&isAllowed=y here.]</ref> Abnormal sleep behaviors may begin before cognitive decline is observed and are a core feature of DLB.<ref name= McKeithConsensus2017/> RBD is diagnosed either by sleep study recording or, when sleep studies cannot be performed, by medical history and validated questionnaires.<ref name= McKeithConsensus2017/>
=== Parkinson's disease ===
[[Parkinson's disease]] is associated with [[Lewy body dementia]] that often progresses to [[Parkinson's disease dementia]] following a period of dementia-free Parkinson's disease.<ref name=Gomperts>{{cite journal |vauthors=Gomperts SN |title=Lewy Body Dementias: Dementia With Lewy Bodies and Parkinson Disease Dementia |journal=Continuum (Minneap Minn) |volume=22 |issue=2 Dementia |pages=435–463 |date=April 2016 |pmid=27042903 |pmc=5390937 |doi=10.1212/CON.0000000000000309|type=Review}}</ref>
=== Frontotemporal ===
{{Main|Frontotemporal dementia}}
Two types of FTD feature [[aphasia]] (language problems) as the main symptom. One type is called semantic variant primary progressive aphasia (SV-PPA). The main feature of this is the loss of the meaning of words. It may begin with difficulty naming things. The person eventually may lose the meaning of objects as well. For example, a drawing of a bird, dog, and an airplane in someone with FTD may all appear almost the same.<ref name="Memory Loss" /> In a classic test for this, a patient is shown a picture of a pyramid and below it a picture of both a palm tree and a pine tree. The person is asked to say which one goes best with the pyramid. In SV-PPA the person cannot answer that question. The other type is called non-fluent agrammatic variant primary progressive aphasia (NFA-PPA). This is mainly a problem with producing speech. They have trouble finding the right words, but mostly they have a difficulty coordinating the muscles they need to speak. Eventually, someone with NFA-PPA only uses one-syllable words or may become totally mute.
A frontotemporal dementia associated with [[amyotrophic lateral sclerosis]] (ALS) known as (FTD-ALS) includes the symptoms of FTD (behavior, language and movement problems) co-occurring with [[amyotrophic lateral sclerosis]] (loss of motor neurons). Two FTD-related disorders are [[progressive supranuclear palsy]] (also classed as a Parkinson-plus syndrome),<ref name=PS>{{Cite web|title=Progressive Supranuclear Palsy Fact Sheet {{!}} National Institute of Neurological Disorders and Stroke|url=https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/progressive-supranuclear-palsy-fact-sheet#:~:text=Progressive%20supranuclear%20palsy%20(PSP)%20is,nerve%20cells%20in%20the%20brain.|access-date=January 20, 2021|website=ninds.nih.gov}}</ref><ref name=Acta2>{{cite journal |vauthors=Lopez G, Bayulkem K, Hallett M |title=Progressive supranuclear palsy (PSP): Richardson syndrome and other PSP variants |journal=Acta Neurol Scand |volume=134 |issue=4 |pages=242–249 |date=October 2016 |pmid=27070344 |pmc=7292631 |doi=10.1111/ane.12546 |url=}}</ref> and [[corticobasal degeneration]].<ref name="Memory Loss" /> These disorders are tau-associated.
=== Huntington's disease ===
{{Main|Huntington's disease}}
Huntington's disease is a [[neurodegenerative disease]] caused by mutations in a single gene ''HTT'', that encodes for [[huntingtin]] protein. Symptoms include cognitive impairment and this usually declines further into dementia.<ref name=Frank2014>{{cite journal | vauthors = Frank S | title = Treatment of Huntington's disease | journal = Neurotherapeutics | volume = 11 | issue = 1 | pages = 153–160 | date = January 2014 | pmid = 24366610 | pmc = 3899480 | doi = 10.1007/s13311-013-0244-z}}</ref>
The first main symptoms of Huntington's disease often include:
* difficulty concentrating
* memory lapses
* depression - this can include low mood, lack of interest in things, or just abnormal feelings of hopelessness
* stumbling and clumsiness that is out of the ordinary
* mood swings, such as irritability or aggressive behavior to insignificant things<ref>{{Cite web |date=February 16, 2018 |title=Huntington's disease – Symptoms |url=https://www.nhs.uk/conditions/huntingtons-disease/symptoms/ |access-date=June 28, 2022 |website=nhs.uk |language=en}}</ref>
=== HIV ===
{{Main|HIV-associated neurocognitive disorder}}
HIV-associated dementia results as a late stage from [[HIV infection]], and mostly affects younger people.<ref name="MSD2019"/> The essential features of HIV-associated dementia are disabling cognitive impairment accompanied by motor dysfunction, speech problems and behavioral change.<ref name="MSD2019">{{cite web |title=HIV-Associated Dementia – Neurologic Disorders |url=https://www.msdmanuals.com/professional/neurologic-disorders/delirium-and-dementia/hiv-associated-dementia |website=MSD Manual Professional Edition |language=en}}</ref> Cognitive impairment is characterised by mental slowness, trouble with [[memory]] and poor [[Attentional control|concentration]]. Motor symptoms include a loss of fine motor control leading to clumsiness, poor balance and tremors. Behavioral changes may include [[apathy]], [[lethargy]] and diminished emotional responses and spontaneity. [[histopathology|Histopathologically]], it is identified by the infiltration of [[monocyte]]s and [[macrophage]]s into the [[central nervous system]] (CNS), [[gliosis]], pallor of [[myelin sheath]]s, abnormalities of [[dendritic cell|dendritic]] processes and [[neuron]]al loss.<ref name=Gray>{{cite journal | vauthors = Gray F, Adle-Biassette H, Chretien F, Lorin de la Grandmaison G, Force G, Keohane C | title = Neuropathology and neurodegeneration in human immunodeficiency virus infection. Pathogenesis of HIV-induced lesions of the brain, correlations with HIV-associated disorders and modifications according to treatments | journal = Clinical Neuropathology | volume = 20 | issue = 4 | pages = 146–155 | year = 2001 | pmid = 11495003 }}</ref>
=== Creutzfeldt–Jakob disease ===
{{Main|Creutzfeldt–Jakob disease}}
Creutzfeldt–Jakob disease is a rapidly progressive [[prion disease]] that typically causes dementia that worsens over weeks to months. [[Prion]]s are disease-causing pathogens created from abnormal proteins.<ref>{{cite journal | vauthors = Collinge J | title = Molecular neurology of prion disease | journal = Journal of Neurology, Neurosurgery, and Psychiatry | volume = 76 | issue = 7 | pages = 906–919 | date = July 2005 | pmid = 15965195 | pmc = 1739714 | doi = 10.1136/jnnp.2004.048660 }}</ref>
=== Alcoholism ===
{{Main|Alcohol-related dementia}}
Alcohol-related dementia, also called alcohol-related brain damage, occurs as a result of excessive use of [[alcohol (drug)|alcohol]] particularly as a substance abuse disorder. Different factors can be involved in this development including [[thiamine deficiency]] and age vulnerability.<ref name=Ridley>{{cite journal |vauthors=Ridley NJ, Draper B, Withall A |title=Alcohol-related dementia: an update of the evidence |journal=Alzheimers Res Ther |volume=5 |issue=1 |page=3 |date=2013 |pmid=23347747 |pmc=3580328 |doi=10.1186/alzrt157 |doi-access=free }}</ref><ref name=Nunes>{{cite book |vauthors=Nunes PT, Kipp BT, Reitz NL, Savage LM |title=Late Aging Associated Changes in Alcohol Sensitivity, Neurobehavioral Function, and Neuroinflammation |chapter=Aging with alcohol-related brain damage: Critical brain circuits associated with cognitive dysfunction |series=International Review of Neurobiology |volume=148 |pages=101–168 |date=2019 |pmid=31733663 |pmc=7372724 |doi=10.1016/bs.irn.2019.09.002 |isbn=978-0-12-817530-9 }}</ref> A degree of brain damage is seen in more than 70% of those with [[alcohol use disorder]]. Brain regions affected are similar to those that are affected by aging, and also by Alzheimer's disease. Regions showing loss of volume include the frontal, temporal, and parietal lobes, as well as the cerebellum, thalamus, and hippocampus.<ref name=Nunes/> This loss can be more notable, with greater cognitive impairments seen in those aged 65 years and older.<ref name=Nunes/>
=== Mixed dementia ===
More than one type of dementia, known as mixed dementia, may exist together in about 10% of dementia cases.<ref name="WHO2022"/> The most common type of mixed dementia is Alzheimer's disease and vascular dementia.<ref>{{Cite web|title=What is mixed dementia?|url=https://www.alzheimers.org.uk/blog/what-is-mixed-dementia|access-date=December 13, 2020|website=Alzheimer's Society|language=en}}</ref> This particular type of mixed dementia's main onsets are a mixture of old age, high blood pressure, and damage to blood vessels in the brain.<ref name="DementiaUK"/>
Diagnosis of mixed dementia can be difficult, as often only one type will predominate. This makes the treatment of people with mixed dementia uncommon, with many people missing out on potentially helpful treatments. Mixed dementia can mean that symptoms onset earlier, and worsen more quickly since more parts of the brain will be affected.<ref name="DementiaUK"/>
=== Other ===
Chronic [[inflammatory condition]]s that may affect the brain and cognition include [[Behçet's disease]], [[multiple sclerosis]], [[sarcoidosis]], [[Sjögren's syndrome]], [[lupus]], [[celiac disease]], and [[non-celiac gluten sensitivity]].<ref name=Schofield2005>{{cite journal | vauthors = Schofield P | title = Dementia associated with toxic causes and autoimmune disease | journal = International Psychogeriatrics | volume = 17 | issue = Suppl 1 | pages = S129–S147 | year = 2005 | pmid = 16240488 | doi = 10.1017/s1041610205001997 | hdl = 1959.13/24647 | s2cid = 11864913 | type = Review | hdl-access = free }}</ref><ref name=RosenbloomSmith2009>{{cite journal | vauthors = Rosenbloom MH, Smith S, Akdal G, Geschwind MD | title = Immunologically mediated dementias | journal = Current Neurology and Neuroscience Reports | volume = 9 | issue = 5 | pages = 359–367 | date = September 2009 | pmid = 19664365 | pmc = 2832614 | doi = 10.1007/s11910-009-0053-2 | type = Review }}</ref> These types of dementias can rapidly progress, but usually have a good response to early treatment. This consists of [[immunomodulators]] or [[steroid]] administration, or in certain cases, the elimination of the causative agent.<ref name=RosenbloomSmith2009 /> A 2019 review found no association between celiac disease and dementia overall but a potential association with vascular dementia.<ref name=ZisHadjivassiliou2019 /> A 2018 review found a link between celiac disease or non-celiac gluten sensitivity and cognitive impairment and that celiac disease may be associated with Alzheimer's disease, vascular dementia, and [[frontotemporal dementia]].<ref name=MakhloufMesselmani2018>{{cite journal| vauthors=Makhlouf S, Messelmani M, Zaouali J, Mrissa R| title=Cognitive impairment in celiac disease and non-celiac gluten sensitivity: review of literature on the main cognitive impairments, the imaging and the effect of gluten free diet. | journal=Acta Neurol Belg | year= 2018 | volume= 118 | issue= 1 | pages= 21–27 | pmid=29247390 | doi=10.1007/s13760-017-0870-z | s2cid=3943047 | type=Review }}</ref> A [[gluten-free diet|strict gluten-free diet]] started early may protect against dementia associated with [[gluten-related disorders]].<ref name=ZisHadjivassiliou2019 /><ref name=MakhloufMesselmani2018 />
Cases of easily reversible dementia include [[hypothyroidism]], [[vitamin B12 deficiency|vitamin B<sub>12</sub> deficiency]], [[Lyme disease]], and [[neurosyphilis]]. For Lyme disease and neurosyphilis, testing should be done if risk factors are present. Because risk factors are often difficult to determine, testing for neurosyphilis and Lyme disease, as well as other mentioned factors, may be undertaken as a matter of course where dementia is suspected.<ref name="Memory Loss" />{{rp|31–32}}
Many other medical and neurological conditions include dementia only late in the illness. For example, a proportion of patients with [[Parkinson's disease]] develop dementia, though widely varying figures are quoted for this proportion.<ref name=AarslandKurz2010>{{cite journal | vauthors = Aarsland D, Kurz MW | title = The epidemiology of dementia associated with Parkinson disease | journal = Journal of the Neurological Sciences | volume = 289 | issue = 1–2 | pages = 18–22 | date = February 2010 | pmid = 19733364 | doi = 10.1016/j.jns.2009.08.034 | type = Review | s2cid = 24541533 }}</ref> When dementia occurs in Parkinson's disease, the underlying cause may be [[dementia with Lewy bodies]] or [[Alzheimer's disease]], or both.<ref name=pmid17101891>{{cite journal | vauthors = Galvin JE, Pollack J, Morris JC | title = Clinical phenotype of Parkinson disease dementia | journal = Neurology | volume = 67 | issue = 9 | pages = 1605–1611 | date = November 2006 | pmid = 17101891 | doi = 10.1212/01.wnl.0000242630.52203.8f | s2cid = 25023606 }}</ref> Cognitive impairment also occurs in the Parkinson-plus syndromes of [[progressive supranuclear palsy]] and [[corticobasal degeneration]] (and the same underlying pathology may cause the clinical syndromes of [[frontotemporal lobar degeneration]]). Although the acute [[porphyria]]s may cause episodes of confusion and psychiatric disturbance, dementia is a rare feature of these rare diseases. [[Limbic-predominant age-related TDP-43 encephalopathy]] (LATE) is a type of dementia that primarily affects people in their 80s or 90s and in which [[TDP-43]] protein deposits in the [[limbic]] portion of the brain.<ref>{{cite journal | vauthors = Abbasi J | title = Debate Sparks Over LATE, a Recently Recognized Dementia | journal = JAMA | volume = 322 | issue = 10 | pages = 914–916 | date = September 2019 | pmid = 31433447 | doi = 10.1001/jama.2019.12232 | s2cid = 201118832 }}</ref>
[[Hereditary disorder]]s that can also cause dementia include: some [[metabolic disorder]]s such as [[lysosomal storage disorder]]s, [[Leukodystrophies#Types|leukodystrophies]], and [[spinocerebellar ataxia]]s.
Persistent loneliness may significantly increase the risk of dementia according to a 2024 new study published in ''Nature Mental Health.''<ref>{{Cite web |last=Mundell |first=Ernie |date=2024-10-10 |title=Loneliness Raises Odds for Dementia by 31% |url=https://www.healthday.com/health-news/mental-health/loneliness-raises-odds-for-dementia-by-31 |access-date=2024-10-12 |website=www.healthday.com |language=en}}</ref>  Researchers found that loneliness was associated with a 31% higher likelihood of developing any form of dementia, and it also raised the risk of cognitive impairment by 15%.<ref>{{Cite journal |last1=Luchetti |first1=Martina |last2=Aschwanden |first2=Damaris |last3=Sesker |first3=Amanda A. |last4=Zhu |first4=Xianghe |last5=O'Súilleabháin |first5=Páraic S. |last6=Stephan |first6=Yannick |last7=Terracciano |first7=Antonio |last8=Sutin |first8=Angelina R. |date=2024 |title=A meta-analysis of loneliness and risk of dementia using longitudinal data from >600,000 individuals |url=https://www.nature.com/articles/s44220-024-00328-9 |journal=Nature Mental Health |volume=2 |issue=11 |language= |pages= 1350–1361|doi=10.1038/s44220-024-00328-9 |issn=}}</ref>
== Diagnosis ==
Symptoms are similar across dementia types and it is difficult to diagnose by symptoms alone. Diagnosis may be aided by [[brain scanning]] techniques. In many cases, the diagnosis requires a [[brain biopsy]] to become final, but this is rarely recommended (though it can be performed at [[autopsy]]). In those who are getting older, general screening for [[cognitive impairment]] using cognitive testing or early diagnosis of dementia has not been shown to improve outcomes.<ref name="Lin">{{cite journal | vauthors = Lin JS, O'Connor E, Rossom RC, Perdue LA, Eckstrom E | title = Screening for cognitive impairment in older adults: A systematic review for the U.S. Preventive Services Task Force | journal = Annals of Internal Medicine | volume = 159 | issue = 9 | pages = 601–612 | date = November 2013 | pmid = 24145578 | doi = 10.7326/0003-4819-159-9-201311050-00730 | doi-access = free }}</ref><ref name="Martin">{{cite journal |vauthors=Martin S, Kelly S, Khan A, Cullum S, Dening T, Rait G, Fox C, Katona C, Cosco T, Brayne C, Lafortune L |title=Attitudes and preferences towards screening for dementia: a systematic review of the literature |journal=BMC Geriatr |volume=15 |issue= |page=66 |date=June 2015 |pmid=26076729 |pmc=4469007 |doi=10.1186/s12877-015-0064-6 |url= |doi-access=free }}</ref> However, screening exams are useful in 65+ persons with memory complaints.<ref name="Memory Loss" />
Normally, symptoms must be present for at least six months to support a diagnosis.<ref name=Def>{{cite web |title=Dementia definition |url=http://www.mdguidelines.com/dementia/definition |work=MDGuidelines |publisher=Reed Group |access-date=June 4, 2009 |url-status=live |archive-url=https://web.archive.org/web/20090629080241/http://www.mdguidelines.com/dementia/definition |archive-date=June 29, 2009}}</ref> Cognitive dysfunction of shorter duration is called ''[[delirium]]''. Delirium can be easily confused with dementia due to similar symptoms. Delirium is characterized by a sudden onset, fluctuating course, a short duration (often lasting from hours to weeks), and is primarily related to a somatic (or medical) disturbance. In comparison, dementia has typically a long, slow onset (except in the cases of a stroke or trauma), slow decline of mental functioning, as well as a longer trajectory (from months to years).<ref>{{cite journal | vauthors = Caplan JP, Rabinowitz T | title = An approach to the patient with cognitive impairment: delirium and dementia | journal = The Medical Clinics of North America | volume = 94 | issue = 6 | pages = 1103–1116, ix | date = November 2010 | pmid = 20951272 | doi = 10.1016/j.mcna.2010.08.004 }}</ref>
Some [[mental illnesses]], including depression and [[psychosis]], may produce symptoms that must be [[Differential diagnosis|differentiated]] from both delirium and dementia.<ref name=Glea>{{cite journal | vauthors = Gleason OC | title = Delirium | journal = American Family Physician | volume = 67 | issue = 5 | pages = 1027–1034 | date = March 2003 | pmid = 12643363 | url = http://www.aafp.org/afp/20030301/1027.html | url-status = live | archive-url = https://web.archive.org/web/20070929110228/http://www.aafp.org/afp/20030301/1027.html | archive-date = September 29, 2007 }}</ref> These are differently diagnosed as [[pseudodementia]]s, and any dementia evaluation needs to include a depression screening such as the Neuropsychiatric Inventory or the [[Geriatric Depression Scale]].<ref name=Lai>{{cite journal | vauthors = Lai CK | title = The merits and problems of Neuropsychiatric Inventory as an assessment tool in people with dementia and other neurological disorders | journal = Clinical Interventions in Aging | volume = 9 | issue = | pages = 1051–1061 | date = 2014 | pmid = 25031530 | pmc = 4099101 | doi = 10.2147/CIA.S63504 | doi-access = free }}</ref><ref name="Memory Loss" /> Physicians used to think that people with memory complaints had depression and not dementia (because they thought that those with dementia are generally unaware of their memory problems). However, researchers have realized that many older people with memory complaints in fact have mild cognitive impairment the earliest stage of dementia. Depression should always remain high on the list of possibilities, however, for an elderly person with memory trouble. Changes in thinking, hearing and vision are associated with normal ageing and can cause problems when diagnosing dementia due to the similarities.<ref name="Worrall, L. 2003 pp. 297-298">{{cite book | vauthors = Worrall L, Hickson LM | year = 2003 | chapter = Implications for theory, practice, and policy | pages = 297–298 | veditors = Worrall LE, Hickson LM | title = Communication disability in aging: from prevention to intervention | location = Clifton Park, NY | publisher = Delmar Learning | isbn = 978-0-7693-0015-3 }}</ref> Given the challenging nature of predicting the onset of dementia and making a dementia diagnosis clinical decision making aids underpinned by machine learning and artificial intelligence have the potential to enhance clinical practice.<ref>{{cite journal | vauthors = James C, Ranson JM, Everson R, Llewellyn DJ | title = Performance of Machine Learning Algorithms for Predicting Progression to Dementia in Memory Clinic Patients | journal = JAMA Network Open | volume = 4 | issue = 12 | page = e2136553 | date = December 2021 | pmid = 34913981 | pmc = 8678688 | doi = 10.1001/jamanetworkopen.2021.36553 }}</ref>
=== Cognitive testing ===
{{See also|Cognitive inhibition|Executive dysfunction#Testing and measurement}}
{| align="right" border="2"| class="wikitable" style="text-align:center; margin-left:15px"
|+Sensitivity and specificity of common tests for dementia
|-
! Test
! [[Sensitivity and specificity|Sensitivity]]
! [[Sensitivity and specificity|Specificity]]
! Reference
|-
| ''MMSE''
| 71–92%
| 56–96%
|<ref name=pmid12779304>{{cite journal | vauthors = Boustani M, Peterson B, Hanson L, Harris R, Lohr KN | title = Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force | journal = Annals of Internal Medicine | volume = 138 | issue = 11 | pages = 927–937 | date = June 2003 | pmid = 12779304 | doi = 10.7326/0003-4819-138-11-200306030-00015 | s2cid = 20779164 }}</ref>
|-
| ''3MS''
| 83–93%
| 85–90%
|<ref name=pmid17178826>{{cite journal | vauthors = Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA | title = A review of screening tests for cognitive impairment | journal = Journal of Neurology, Neurosurgery, and Psychiatry | volume = 78 | issue = 8 | pages = 790–799 | date = August 2007 | pmid = 17178826 | pmc = 2117747 | doi = 10.1136/jnnp.2006.095414 }}</ref>
|-
| ''AMTS''
| 73–100%
| 71–100%
|<ref name=pmid17178826/>
|}
Various brief [[cognitive test]]s (5–15 minutes) have reasonable reliability to screen for dementia, but may be affected by factors such as age, education and ethnicity.<ref>{{cite journal | vauthors = Ranson JM, Kuźma E, Hamilton W, Muniz-Terrera G, Langa KM, Llewellyn DJ | title = Predictors of dementia misclassification when using brief cognitive assessments | journal = Neurology. Clinical Practice | volume = 9 | issue = 2 | pages = 109–117 | date = April 2019 | pmid = 31041124 | pmc = 6461420 | doi = 10.1212/CPJ.0000000000000566 }}</ref> Age and education have a significant influence on the diagnosis of dementia. For example, Individuals with lower education are more likely to be diagnosed with dementia than their educated counterparts.<ref>Contador, I. et al. (2017) "Impact of literacy and years of education on the diagnosis of dementia:A population-based study,” Journal of Clinical and Experimental Neuropsychology, 39(2), pp. 112–119. Available at: https://doi.org/10.1080/13803395.2016.1204992.</ref> While many tests have been studied,<ref name=pmid17163083>{{cite journal | vauthors = Sager MA, Hermann BP, La Rue A, Woodard JL | title = Screening for dementia in community-based memory clinics | journal = WMJ | volume = 105 | issue = 7 | pages = 25–29 | date = October 2006 | pmid = 17163083 | url = http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/issues/wmj_v105n7/sager.pdf | url-status = dead | archive-url = https://web.archive.org/web/20100626094646/http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/issues/wmj_v105n7/sager.pdf | archive-date = June 26, 2010 }}</ref><ref name=pmid17287448>{{cite journal | vauthors = Fleisher AS, Sowell BB, Taylor C, Gamst AC, Petersen RC, Thal LJ | title = Clinical predictors of progression to Alzheimer disease in amnestic mild cognitive impairment | journal = Neurology | volume = 68 | issue = 19 | pages = 1588–1595 | date = May 2007 | pmid = 17287448 | doi = 10.1212/01.wnl.0000258542.58725.4c | s2cid = 9129604 }}</ref><ref name=pmid12614094>{{cite journal | vauthors = Karlawish JH, Clark CM | title = Diagnostic evaluation of elderly patients with mild memory problems | journal = Annals of Internal Medicine | volume = 138 | issue = 5 | pages = 411–419 | date = March 2003 | pmid = 12614094 | doi = 10.7326/0003-4819-138-5-200303040-00011 | s2cid = 43798118 }}</ref> presently the [[mini mental state examination]] (MMSE) is the best studied and most commonly used. The MMSE is a useful tool for helping to diagnose dementia if the results are interpreted along with an assessment of a person's personality, their ability to perform activities of daily living, and their behaviour.<ref name=Creavin>{{cite journal | vauthors = Creavin ST, Wisniewski S, Noel-Storr AH, Trevelyan CM, Hampton T, Rayment D, Thom VM, Nash KJ, Elhamoui H, Milligan R, Patel AS, Tsivos DV, Wing T, Phillips E, Kellman SM, Shackleton HL, Singleton GF, Neale BE, Watton ME, Cullum S | display-authors = 6 | title = Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 1 | page = CD011145 | date = January 2016 | pmid = 26760674 | pmc = 8812342 | doi = 10.1002/14651858.CD011145.pub2 | hdl-access = free | hdl = 1983/00876aeb-2061-43f5-b7e1-938c666030ab }}</ref> Other cognitive tests include the [[abbreviated mental test score]] (AMTS), the, "modified mini–mental state examination" (3MS),<ref name=pmid3611032>{{cite journal | vauthors = Teng EL, Chui HC | title = The Modified Mini-Mental State (3MS) examination | journal = The Journal of Clinical Psychiatry | volume = 48 | issue = 8 | pages = 314–318 | date = August 1987 | pmid = 3611032 }}</ref> the [[Cognitive Abilities Screening Instrument]] (CASI),<ref name= pmid8054493>{{cite journal | vauthors = Teng EL, Hasegawa K, Homma A, Imai Y, Larson E, Graves A, Sugimoto K, Yamaguchi T, Sasaki H, Chiu D | display-authors = 6 | title = The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia | journal = International Psychogeriatrics | volume = 6 | issue = 1 | pages = 45–58; discussion 62 | year = 1994 | pmid = 8054493 | doi = 10.1017/S1041610294001602 | s2cid = 25322040 }}</ref> the [[Trail-making test]],<ref>{{cite journal | vauthors = Tombaugh TN | title = Trail Making Test A and B: normative data stratified by age and education | journal = Archives of Clinical Neuropsychology | volume = 19 | issue = 2 | pages = 203–214 | date = March 2004 | pmid = 15010086 | doi = 10.1016/S0887-6177(03)00039-8 | doi-access = free }}</ref> and the [[Executive dysfunction#Clock drawing test|clock drawing test]].<ref name="Sheehan">{{cite journal | vauthors = Sheehan B | title = Assessment scales in dementia | journal = Therapeutic Advances in Neurological Disorders | volume = 5 | issue = 6 | pages = 349–358 | date = November 2012 | pmid = 23139705 | pmc = 3487532 | doi = 10.1177/1756285612455733 }}</ref> The MoCA ([[Montreal Cognitive Assessment]]) is a reliable screening test and is available online for free in 35 different languages.<ref name="Memory Loss" /> The MoCA has also been shown somewhat better at detecting mild cognitive impairment than the MMSE.<ref>{{cite journal | vauthors = Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H | display-authors = 6 | title = The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment | journal = Journal of the American Geriatrics Society | volume = 53 | issue = 4 | pages = 695–699 | date = April 2005 | pmid = 15817019 | doi = 10.1111/j.1532-5415.2005.53221.x | s2cid = 9014589 }}<!--|access-date=April 24, 2014 --></ref><ref name="Breton"/> People with [[hearing loss]], which commonly occurs alongside dementia, score worse in the MoCA test, which could lead to a false diagnosis of dementia. Researchers have developed an adapted version of the MoCA test, which is accurate and reliable and avoids the need for people to listen and respond to questions.<ref>{{cite journal | vauthors = Dawes P, Reeves D, Yeung WK, Holland F, Charalambous AP, Côté M, David R, Helmer C, Laforce R, Martins RN, Politis A, Pye A, Russell G, Sheikh S, Sirois MJ, Sohrabi HR, Thodi C, Gallant K, Nasreddine Z, Leroi I | display-authors = 6 | title = Development and validation of the Montreal cognitive assessment for people with hearing impairment (MoCA-H) | journal = Journal of the American Geriatrics Society | volume = 71 | issue = 5 | pages = 1485–1494 | date = May 2023 | pmid = 36722180 | doi = 10.1111/jgs.18241 | s2cid = 256457783 | doi-access = free }}</ref><ref>{{Cite journal |date=February 8, 2023 |title=How to identify dementia in people with hearing loss |url=https://evidence.nihr.ac.uk/alert/how-to-identify-dementia-in-people-with-hearing-loss/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_59137 |s2cid=260465275 }}</ref> The AD-8 – a screening questionnaire used to assess changes in function related to cognitive decline – is potentially useful, but is not diagnostic, is variable, and has risk of bias.<ref>{{cite journal | vauthors = Hendry K, Green C, McShane R, Noel-Storr AH, Stott DJ, Anwer S, Sutton AJ, Burton JK, Quinn TJ | display-authors = 6 | title = AD-8 for detection of dementia across a variety of healthcare settings | journal = The Cochrane Database of Systematic Reviews | volume = 3 | issue = 3 | page = CD011121 | date = March 2019 | pmid = 30828783 | pmc = 6398085 | doi = 10.1002/14651858.CD011121.pub2 }}</ref> An [[integrated cognitive assessment]] (''CognICA'') is a five-minute test that is highly sensitive to the early stages of dementia, and uses an application deliverable to an [[iPad]].<ref name="Bee">{{cite news | vauthors = Bee P |title=The five-minute test that can tell if you're on the road to dementia |url=https://www.thetimes.co.uk/article/dementia-test-integrated-cognitive-awareness-cognica-x2tqx0jhd |access-date=January 1, 2022 |language=en}}</ref><ref name="FDA"/> Previously in use in the UK, in 2021 CognICA was given [[Food and Drug Administration|FDA approval]] for its commercial use as a [[medical device]].<ref name="FDA">{{cite web |title=FDA Clears 5-Minute Test for Early Dementia |url=https://www.medscape.com/viewarticle/961277 |website=Medscape |access-date=January 1, 2022 |language=en}}</ref>
Another approach to screening for dementia is to ask an informant (relative or other supporter) to fill out a questionnaire about the person's everyday cognitive functioning. Informant questionnaires provide complementary information to brief cognitive tests. Probably the best known questionnaire of this sort is the ''[[Informant Questionnaire on Cognitive Decline in the Elderly]] (IQCODE)''.<ref>{{cite journal | vauthors = Jorm AF | title = The Informant Questionnaire on cognitive decline in the elderly (IQCODE): a review | journal = International Psychogeriatrics | volume = 16 | issue = 3 | pages = 275–293 | date = September 2004 | pmid = 15559753 | doi = 10.1017/S1041610204000390 | s2cid = 145256616 }}</ref> Evidence is insufficient to determine how accurate the IQCODE is for diagnosing or predicting dementia.<ref>{{cite journal | vauthors = Burton JK, Stott DJ, McShane R, Noel-Storr AH, Swann-Price RS, Quinn TJ | title = Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early detection of dementia across a variety of healthcare settings | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 7 | page = CD011333 | date = July 2021 | pmid = 34275145 | pmc = 8406787 | doi = 10.1002/14651858.CD011333.pub3 }}</ref> The Alzheimer's Disease Caregiver Questionnaire is another tool. It is about 90% accurate for Alzheimer's when by a caregiver.<ref name="Memory Loss" /> The ''[[General Practitioner Assessment Of Cognition]]'' combines both a patient assessment and an informant interview. It was specifically designed for use in the primary care setting.
Clinical neuropsychologists provide diagnostic consultation following administration of a full battery of cognitive testing, often lasting several hours, to determine functional patterns of decline associated with varying types of dementia. Tests of memory, executive function, processing speed, attention and language skills are relevant, as well as tests of emotional and psychological adjustment. These tests assist with ruling out other etiologies and determining relative cognitive decline over time or from estimates of prior cognitive abilities.<ref>{{cite journal | vauthors = Jacova C, Kertesz A, Blair M, Fisk JD, Feldman HH | title = Neuropsychological testing and assessment for dementia | journal = Alzheimer's & Dementia | volume = 3 | issue = 4 | pages = 299–317 | date = October 2007 | pmid = 19595951 | doi = 10.1016/j.jalz.2007.07.011 | s2cid = 40462470 }}</ref>
=== Laboratory tests ===
Routine [[blood test]]s are usually performed to rule out treatable causes. These include tests for [[vitamin B12|vitamin B<sub>12</sub>]], [[folic acid]], [[thyroid-stimulating hormone]] (TSH), [[C-reactive protein]], [[full blood count]], [[electrolyte]]s, [[calcium in biology|calcium]], [[renal function]], and [[liver enzyme]]s. Abnormalities may suggest [[vitamin deficiency]], infection, or other problems that commonly cause confusion or disorientation in the elderly.<ref>{{cite journal | vauthors = Boise L, Camicioli R, Morgan DL, Rose JH, Congleton L | title = Diagnosing dementia: perspectives of primary care physicians | journal = The Gerontologist | volume = 39 | issue = 4 | pages = 457–464 | date = August 1999 | pmid = 10495584 | doi = 10.1093/geront/39.4.457 | doi-access = free }}</ref>
=== Imaging ===
A [[CT scan]] or [[MRI scan]] is commonly performed to possibly find either [[normal pressure hydrocephalus]], a potentially reversible cause of dementia, or connected tumor. The scans can also yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. These tests do not pick up diffuse metabolic changes associated with dementia in a person who shows no gross neurological problems (such as paralysis or weakness) on a neurological exam.<ref>{{cite journal | vauthors = Espino DV, Jules-Bradley AC, Johnston CL, Mouton CP | title = Diagnostic approach to the confused elderly patient | journal = American Family Physician | volume = 57 | issue = 6 | pages = 1358–1366 | date = March 1998 | pmid = 9531917 | url = https://www.aafp.org/afp/1998/0315/p1358.html }}</ref>
The [[functional neuroimaging]] modalities of [[SPECT]] and [[Positron emission tomography|PET]] are more useful in assessing long-standing cognitive dysfunction, since they have shown similar ability to diagnose dementia as a clinical exam and cognitive testing.<ref>{{cite journal | vauthors = Bonte FJ, Harris TS, Hynan LS, Bigio EH, White CL | title = Tc-99m HMPAO SPECT in the differential diagnosis of the dementias with histopathologic confirmation | journal = Clinical Nuclear Medicine | volume = 31 | issue = 7 | pages = 376–378 | date = July 2006 | pmid = 16785801 | doi = 10.1097/01.rlu.0000222736.81365.63 | s2cid = 39518497 }}</ref> The ability of SPECT to differentiate vascular dementia from Alzheimer's disease, appears superior to differentiation by clinical exam.<ref>{{cite journal | vauthors = Dougall NJ, Bruggink S, Ebmeier KP | title = Systematic review of the diagnostic accuracy of 99mTc-HMPAO-SPECT in dementia | journal = The American Journal of Geriatric Psychiatry | volume = 12 | issue = 6 | pages = 554–570 | year = 2004 | pmid = 15545324 | doi = 10.1176/appi.ajgp.12.6.554 | s2cid = 12375536 | url = http://pdfs.semanticscholar.org/a7d5/ff2ea1aa86a8bb85050dc0e1058b745bd05f.pdf | archive-url = https://web.archive.org/web/20200713032045/http://pdfs.semanticscholar.org/a7d5/ff2ea1aa86a8bb85050dc0e1058b745bd05f.pdf | url-status = dead | archive-date = July 13, 2020 }}</ref>
The value of [[Pittsburgh compound B|PiB]]-PET imaging using [[Pittsburgh compound B]] (PiB) as a [[radiotracer]] has been established in predictive diagnosis, particularly Alzheimer's disease.<ref name=Angelopoulou>{{cite journal |vauthors=Angelopoulou E, Paudel YN, Shaikh MF, Piperi C |title=Flotillin: A Promising Biomarker for Alzheimer's Disease |journal=J Pers Med |volume=10 |issue=2 |date=March 2020 |page=20 |pmid=32225073 |pmc=7354424 |doi=10.3390/jpm10020020 |url=|doi-access=free }}</ref>
==Prevention==
{{Main|Prevention of dementia}}
===Risk factors{{anchor|Causes}}===
{{See also|Neuroplastic effects of pollution}}
Risk factors for dementia include [[high blood pressure]], high levels of [[LDL cholesterol]], [[vision loss]], [[hearing loss]], [[tobacco smoking|smoking]], [[obesity]], [[Depression (mood)|depression]], [[Physical inactivity|inactivity]], [[diabetes]], lower levels of education and low social contact. Over-indulgence in alcohol, lack of sleep, [[anemia]], traumatic brain injury, and air pollution can also increase the chance of developing dementia.<ref name="Lancet2020">{{cite journal |vauthors=Livingston G, Huntley J, Sommerlad A, et al |date=August 2020 |title=Dementia prevention, intervention, and care: 2020 report of the Lancet Commission |journal=Lancet |volume=396 |issue=10248 |pages=413–446 |doi=10.1016/S0140-6736(20)30367-6 |pmc=7392084 |pmid=32738937}}</ref><ref>{{cite journal |vauthors=Zhang YR, Xu W, Zhang W, et al |date=October 2022 |title=Modifiable risk factors for incident dementia and cognitive impairment: An umbrella review of evidence |journal=J Affect Disord |volume=314 |issue= |pages=160–167 |doi=10.1016/j.jad.2022.07.008 |pmid=35863541}}</ref><ref>{{Cite journal |last1=Livingston |first1=Gill |last2=Huntley |first2=Jonathan |last3=Liu |first3=Kathy Y |last4=Costafreda |first4=Sergi G |last5=Selbæk |first5=Geir |last6=Alladi |first6=Suvarna |last7=Ames |first7=David |last8=Banerjee |first8=Sube |last9=Burns |first9=Alistair |last10=Brayne |first10=Carol |last11=Fox |first11=Nick C |last12=Ferri |first12=Cleusa P |last13=Gitlin |first13=Laura N |last14=Howard |first14=Robert |last15=Kales |first15=Helen C |date=August 2024 |title=Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission |url=https://linkinghub.elsevier.com/retrieve/pii/S0140673624012960 |journal=The Lancet |language=en |volume=404 |issue=10452 |pages=572–628 |doi=10.1016/S0140-6736(24)01296-0}}</ref><ref>{{Cite web |last1=Larson |first1=Eric B. |last2=Gitlin |first2=Laura |date=2024-08-12 |title=Dementia risk factors identified in new global report are all preventable – addressing them could reduce dementia rates by 45% |url=https://theconversation.com/dementia-risk-factors-identified-in-new-global-report-are-all-preventable-addressing-them-could-reduce-dementia-rates-by-45-236290 |access-date=2024-10-17 |website=The Conversation |language=en-US}}</ref> Many of these risk factors, including the lower level of education, smoking, physical inactivity and diabetes, are modifiable.<ref name="pmid28960500">{{cite journal | vauthors = Huntley J, Corbett A, Wesnes K, Brooker H, Stenton R, Hampshire A, Ballard C | title = Online assessment of risk factors for dementia and cognitive function in healthy adults | journal = International Journal of Geriatric Psychiatry | volume = 33 | issue = 2 | pages = e286–e293 | date = February 2018 | pmid = 28960500 | doi = 10.1002/gps.4790 | s2cid = 33822160 | url = https://discovery.ucl.ac.uk/id/eprint/10073477/}}</ref> Several of the group are known as ''vascular risk factors'' that may be possible to be reduced or eliminated.<ref name="IRNDP">{{cite web |title=vascular risk factors and brain health |url=https://coghealth.net.au/wp-content/uploads/2018/12/English-Vascular-Risk-Factors.pdf |archive-url=https://ghostarchive.org/archive/20221009/https://coghealth.net.au/wp-content/uploads/2018/12/English-Vascular-Risk-Factors.pdf |archive-date=October 9, 2022 |url-status=live |access-date=January 1, 2021}}</ref> Managing these risk factors can reduce the risk of dementia in individuals in their late midlife or older age. A reduction in a number of these risk factors can give a positive outcome.<ref>{{cite journal | vauthors = Ding J, Davis-Plourde KL, Sedaghat S, Tully PJ, Wang W, Phillips C, Pase MP, Himali JJ, Gwen Windham B, Griswold M, Gottesman R, Mosley TH, White L, Guðnason V, Debette S, Beiser AS, Seshadri S, Ikram MA, Meirelles O, Tzourio C, Launer LJ | display-authors = 6 | title = Antihypertensive medications and risk for incident dementia and Alzheimer's disease: a meta-analysis of individual participant data from prospective cohort studies | journal = The Lancet. Neurology | volume = 19 | issue = 1 | pages = 61–70 | date = January 2020 | pmid = 31706889 | pmc = 7391421 | doi = 10.1016/S1474-4422(19)30393-X }}</ref> The decreased risk achieved by adopting a healthy lifestyle is seen even in those with a high genetic risk.<ref>{{cite journal | vauthors = Lourida I, Hannon E, Littlejohns TJ, Langa KM, Hyppönen E, Kuzma E, Llewellyn DJ | title = Association of Lifestyle and Genetic Risk With Incidence of Dementia | journal = JAMA | volume = 322 | issue = 5 | pages = 430–437 | date = July 2019 | pmid = 31302669 | pmc = 6628594 | doi = 10.1001/jama.2019.9879 }}</ref>
In addition to the above risk factors, other psychological features, including certain personality traits (high [[neuroticism]], and low [[conscientiousness]]), low [[purpose in life]], and high [[loneliness]], are risk factors for Alzheimer's disease and related dementias.<ref>{{cite journal | vauthors = Aschwanden D, Strickhouser JE, Luchetti M, Stephan Y, Sutin AR, Terracciano A | title = Is personality associated with dementia risk? A meta-analytic investigation | journal = Ageing Research Reviews | volume = 67 | page = 101269 | date = May 2021 | pmid = 33561581 | pmc = 8005464 | doi = 10.1016/j.arr.2021.101269 }}</ref><ref>{{cite journal | vauthors = Sutin AR, Aschwanden D, Luchetti M, Stephan Y, Terracciano A | title = Sense of Purpose in Life Is Associated with Lower Risk of Incident Dementia: A Meta-Analysis | journal = Journal of Alzheimer's Disease | volume = 83 | issue = 1 | pages = 249–258 | year = 2021 | pmid = 34275900 | pmc = 8887819 | doi = 10.3233/JAD-210364 }}</ref><ref>{{cite journal | vauthors = Luchetti M, Terracciano A, Aschwanden D, Lee JH, Stephan Y, Sutin AR | title = Loneliness is associated with risk of cognitive impairment in the Survey of Health, Ageing and Retirement in Europe | journal = International Journal of Geriatric Psychiatry | volume = 35 | issue = 7 | pages = 794–801 | date = July 2020 | pmid = 32250480 | pmc = 7755119 | doi = 10.1002/gps.5304 }}</ref> For example, based on the [[English Longitudinal Study of Ageing]] (ELSA), research found that loneliness in older people can increase the risk of dementia by one-third. Not having a partner (being single, divorced, or widowed) can double the risk of dementia. However, having two or three closer relationships might reduce the risk by three-fifths.<ref>{{Cite journal |date=May 27, 2020 |title=Loneliness, but not social isolation, predicts development of dementia in older people |url=https://evidence.nihr.ac.uk/alert/loneliness-but-not-social-isolation-predicts-development-of-dementia-in-older-people/ |journal=NIHR Evidence |type=Plain English summary |language=en |doi=10.3310/alert_40330|s2cid=241649845 }}</ref><ref>{{cite journal | vauthors = Rafnsson SB, Orrell M, d'Orsi E, Hogervorst E, Steptoe A | title = Loneliness, Social Integration, and Incident Dementia Over 6 Years: Prospective Findings From the English Longitudinal Study of Ageing | journal = The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences | volume = 75 | issue = 1 | pages = 114–124 | date = January 2020 | pmid = 28658937 | pmc = 6909434 | doi = 10.1093/geronb/gbx087 | veditors = Carr D }}</ref>
The two most modifiable risk factors for dementia are [[physical inactivity]] and lack of cognitive stimulation.<ref name="Cheng">{{cite journal | vauthors = Cheng ST | title = Cognitive Reserve and the Prevention of Dementia: the Role of Physical and Cognitive Activities | journal = Current Psychiatry Reports | volume = 18 | issue = 9 | page = 85 | date = September 2016 | pmid = 27481112 | pmc = 4969323 | doi = 10.1007/s11920-016-0721-2 }}</ref> Physical activity, in particular [[aerobic exercise]], is associated with a reduction in age-related brain tissue loss, and neurotoxic factors thereby preserving brain volume and neuronal integrity. Cognitive activity strengthens [[neural plasticity]] and together they help to support [[cognitive reserve]]. The neglect of these risk factors diminishes this reserve.<ref name="Cheng"/>
Sensory impairments of vision and hearing are modifiable risk factors for dementia.<ref name=Dawes>{{cite journal |vauthors=Dawes P |title=Hearing interventions to prevent dementia |journal=HNO |volume=67 |issue=3 |pages=165–171 |date=March 2019 |pmid=30767054 |pmc=6399173 |doi=10.1007/s00106-019-0617-7 |url=}}</ref> These impairments may precede the cognitive symptoms of Alzheimer's disease for example, by many years.<ref name="Panza">{{cite journal | vauthors = Panza F, Lozupone M, Sardone R, Battista P, Piccininni M, Dibello V, La Montagna M, Stallone R, Venezia P, Liguori A, Giannelli G, Bellomo A, Greco A, Daniele A, Seripa D, Quaranta N, Logroscino G | display-authors = 6 | title = Sensorial frailty: age-related hearing loss and the risk of cognitive impairment and dementia in later life | journal = Therapeutic Advances in Chronic Disease | volume = 10 | page = 2040622318811000 | date = 2019 | pmid = 31452865 | pmc = 6700845 | doi = 10.1177/2040622318811000 | doi-access = free }}</ref> Hearing loss may lead to [[social isolation]] which negatively affects cognition.<ref name=Tho2017>{{cite journal | vauthors = Thomson RS, Auduong P, Miller AT, Gurgel RK | title = Hearing loss as a risk factor for dementia: A systematic review | journal = Laryngoscope Investigative Otolaryngology | volume = 2 | issue = 2 | pages = 69–79 | date = April 2017 | pmid = 28894825 | pmc = 5527366 | doi = 10.1002/lio2.65 }}</ref> Social isolation is also identified as a modifiable risk factor.<ref name="Panza"/> Age-related hearing loss in midlife is linked to cognitive impairment in late life, and is seen as a risk factor for the development of Alzheimer's disease and dementia. Such hearing loss may be caused by a [[central auditory processing disorder]] that makes the understanding of speech against background noise difficult. Age-related hearing loss is characterised by slowed central processing of auditory information.<ref name="Panza"/><ref name="Hubbard">{{cite journal | vauthors = Hubbard HI, Mamo SK, Hopper T | title = Dementia and Hearing Loss: Interrelationships and Treatment Considerations | journal = Seminars in Speech and Language | volume = 39 | issue = 3 | pages = 197–210 | date = July 2018 | pmid = 29933487 | doi = 10.1055/s-0038-1660779 | s2cid = 49383232 }}</ref> Worldwide, mid-life hearing loss may account for around 9% of dementia cases.<ref name="Ford">{{cite journal | vauthors = Ford AH, Hankey GJ, Yeap BB, Golledge J, Flicker L, Almeida OP | title = Hearing loss and the risk of dementia in later life | journal = Maturitas | volume = 112 | pages = 1–11 | date = June 2018 | pmid = 29704910 | doi = 10.1016/j.maturitas.2018.03.004 | s2cid = 13998812 }}</ref>
[[Frailty syndrome|Frailty]] may increase the risk of cognitive decline, and dementia, and the inverse also holds of cognitive impairment increasing the risk of frailty. Prevention of frailty may help to prevent cognitive decline.<ref name="Panza"/>
There are no medications that can prevent cognitive decline and dementia.<ref name="Pharmacologic Interventions to Prev">{{cite journal | vauthors = Fink HA, Jutkowitz E, McCarten JR, Hemmy LS, Butler M, Davila H, Ratner E, Calvert C, Barclay TR, Brasure M, Nelson VA, Kane RL | display-authors = 6 | title = Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review | journal = Annals of Internal Medicine | volume = 168 | issue = 1 | pages = 39–51 | date = January 2018 | pmid = 29255847 | doi = 10.7326/M17-1529 | s2cid = 24193907 }}</ref> However blood pressure lowering medications might decrease the risk of dementia or cognitive problems by around 0.5%.<ref>{{cite journal | vauthors = Hughes D, Judge C, Murphy R, Loughlin E, Costello M, Whiteley W, Bosch J, O'Donnell MJ, Canavan M | display-authors = 6 | title = Association of Blood Pressure Lowering With Incident Dementia or Cognitive Impairment: A Systematic Review and Meta-analysis | journal = JAMA | volume = 323 | issue = 19 | pages = 1934–1944 | date = May 2020 | pmid = 32427305 | pmc = 7237983 | doi = 10.1001/jama.2020.4249 }}</ref>
Economic disadvantage has been shown to have a strong link to higher dementia prevalence,<ref>{{cite journal | vauthors = Arapakis K, Brunner E, French E, McCauley J | title = Dementia and disadvantage in the USA and England: population-based comparative study | journal = BMJ Open | volume = 11 | issue = 10 | page = e045186 | date = October 2021 | pmid = 34615672 | pmc = 8496387 | doi = 10.1136/bmjopen-2020-045186 }}</ref> which cannot yet be fully explained by other risk factors.
===Dental health===
Limited evidence links poor oral health to cognitive decline. However, failure to perform tooth brushing and gingival inflammation can be used as dementia risk predictors.<ref>{{cite journal | vauthors = Daly B, Thompsell A, Sharpling J, Rooney YM, Hillman L, Wanyonyi KL, White S, Gallagher JE | title = Evidence summary: the relationship between oral health and dementia | journal = British Dental Journal | volume = 223 | issue = 11 | pages = 846–853 | date = January 2018 | pmid = 29192686 | doi = 10.1038/sj.bdj.2017.992 | s2cid = 19633523 | url = https://researchportal.port.ac.uk/portal/files/8739213/Evidence_summary_the_relationship_between_oral_health_and_dementia_post_print.pdf }}</ref>
====Oral bacteria====
The link between Alzheimer's and [[gum disease]] is [[oral bacteria]].<ref name="Miklossy">{{cite journal | vauthors = Miklossy J | title = Historic evidence to support a causal relationship between spirochetal infections and Alzheimer's disease | journal = Frontiers in Aging Neuroscience | volume = 7 | page = 46 | date = 2015 | pmid = 25932012 | pmc = 4399390 | doi = 10.3389/fnagi.2015.00046 | doi-access = free }}</ref> In the oral cavity, bacterial species include ''[[P. gingivalis]]'', ''[[F. nucleatum]]'', ''[[Prevotella intermedia|P. intermedia]]'', and ''[[T. forsythia]]''. Six oral treponema [[spirochete]]s have been examined in the brains of Alzheimer's patients.<ref name = "Olsen_2015" /> Spirochetes are neurotropic in nature, meaning they act to destroy nerve tissue and create inflammation. Inflammatory pathogens are an indicator of Alzheimer's disease and bacteria related to gum disease have been found in the brains of patients with Alzheimer's disease.<ref name="Olsen_2015" /> The bacteria invade nerve tissue in the brain, increasing the permeability of the [[blood–brain barrier]] and promoting the onset of Alzheimer's. Individuals with a plethora of tooth plaque risk cognitive decline.<ref name="BDJ_2017">{{cite journal | vauthors = | title = Can poor oral health lead to dementia? | journal = British Dental Journal | volume = 223 | issue = 11 | page = 840 | date = December 2017 | pmid = 29243693 | doi = 10.1038/sj.bdj.2017.1064 | s2cid = 25898592 }}</ref> Poor oral hygiene can have an adverse effect on speech and nutrition, causing general and cognitive health decline.
====Oral viruses====
[[Herpes simplex virus]] (HSV) has been found in more than 70% of those aged over 50. HSV persists in the peripheral nervous system and can be triggered by stress, illness or fatigue.<ref name = "Olsen_2015">{{cite journal | vauthors = Olsen I, Singhrao SK | title = Can oral infection be a risk factor for Alzheimer's disease? | journal = Journal of Oral Microbiology | volume = 7 | page = 29143 | date = September 17, 2015 | pmid = 26385886 | pmc = 4575419 | doi = 10.3402/jom.v7.29143 }}</ref> High proportions of viral-associated proteins in [[amyloid plaques]] or [[neurofibrillary tangle]]s (NFTs) confirm the involvement of HSV-1 in Alzheimer's disease pathology. NFTs are known as the primary marker of Alzheimer's disease. HSV-1 produces the main components of NFTs.<ref>{{cite journal | vauthors = Carter CJ | title = Alzheimer's disease plaques and tangles: cemeteries of a pyrrhic victory of the immune defence network against herpes simplex infection at the expense of complement and inflammation-mediated neuronal destruction | journal = Neurochemistry International | volume = 58 | issue = 3 | pages = 301–320 | date = February 2011 | pmid = 21167244 | doi = 10.1016/j.neuint.2010.12.003 | s2cid = 715832 }}</ref>
===Diet===
Diet is seen to be a modifiable risk factor for the development of dementia. Thiamine deficiency is identified to increase the risk of Alzheimer's disease in adults.<ref>Gibson, GE, Hirsch, JA, Fonzetti, P, et al. (2016) Vitamin B1 (thiamine) and dementia. Ann N Y Acad Sci 1367, 21–30</ref> The role of thiamine in brain physiology is unique and essential for the normal cognitive function of older people.<ref>Butterworth, RF (2003) Thiamin deficiency and brain disorders. Nutr Res Rev 16, 277–284.</ref> Many dietary choices of the elderly population, including the higher intake of gluten-free products, compromise the intake of thiamine as these products are not fortified with thiamine.<ref>Hoffman, R. (2016). Thiamine deficiency in the Western diet and dementia risk. British Journal Of Nutrition, 116(1), 188–189.</ref>
The [[Mediterranean diet|Mediterranean]] and [[DASH diet|DASH]] diets are both associated with less cognitive decline. A different approach has been to incorporate elements of both of these diets into one known as the [[MIND diet]].<ref name=Acta1>{{cite journal |vauthors=Dominguez LJ, Barbagallo M |title=Nutritional prevention of cognitive decline and dementia |journal=  Acta Bio Medica: Atenei Parmensis|volume=89 |issue=2 |pages=276–290 |date=June 2018 |pmid=29957766 |pmc=6179018 |doi=10.23750/abm.v89i2.7401 |url=}}
</ref> These diets are generally low in saturated fats while providing a good source of carbohydrates, mainly those that help stabilize blood sugar and insulin levels.<ref>{{Cite web| vauthors = Goodman B |title=Diet Affects Markers of Alzheimer's Disease|url=https://www.webmd.com/alzheimers/news/20110613/diet-affects-markers-of-alzheimers-disease|access-date=December 13, 2020|website=WebMD|language=en}}</ref> Raised [[blood sugar level]]s over a long time, can damage nerves and cause memory problems if they are not managed.<ref>{{Cite web|date=January 15, 2019|title=Memory loss can be caused by a number of factors, from short term causes such as low blood sugar or medication side effects to long term health issues such as dementia.|url=https://www.diabetes.co.uk/diabetes-complications/diabetes-and-memory-loss.html|access-date=December 13, 2020|website=Diabetes|language=en-GB}}</ref> Nutritional factors associated with the proposed diets for reducing dementia risk include [[unsaturated fatty acid]]s, [[vitamin E]], [[vitamin C]], [[flavonoid]]s, [[vitamin B]], and [[vitamin D]].<ref name = "Cao_2016">{{cite journal | vauthors = Cao L, Tan L, Wang HF, Jiang T, Zhu XC, Lu H, Tan MS, Yu JT | display-authors = 6 | title = Dietary Patterns and Risk of Dementia: a Systematic Review and Meta-Analysis of Cohort Studies | journal = Molecular Neurobiology | volume = 53 | issue = 9 | pages = 6144–6154 | date = November 2016 | pmid = 26553347 | doi = 10.1007/s12035-015-9516-4 | s2cid = 8188716 | oclc = 6947867710 }}</ref><ref>{{cite journal | vauthors = Canevelli M, Lucchini F, Quarata F, Bruno G, Cesari M | title = Nutrition and Dementia: Evidence for Preventive Approaches? | journal = Nutrients | volume = 8 | issue = 3 | page = 144 | date = March 2016 | pmid = 26959055 | pmc = 4808873 | doi = 10.3390/nu8030144 | publisher = [[MDPI]] | oclc = 8147564576 | doi-access = free }}</ref> A study conducted at the University of Exeter in the United Kingdom seems to have confirmed these findings with fruits, vegetables, whole grains, and healthy fats creating an optimum diet that can help reduce the risk of dementia by roughly 25%.<ref name="Shannon">{{cite journal |vauthors=Shannon OM, Ranson JM, Gregory S, Macpherson H, Milte C, Lentjes M, Mulligan A, McEvoy C, Griffiths A, Matu J, Hill TR, Adamson A, Siervo M, Minihane AM, Muniz-Tererra G, Ritchie C, Mathers JC, Llewellyn DJ, Stevenson E |title=Mediterranean diet adherence is associated with lower dementia risk, independent of genetic predisposition: findings from the UK Biobank prospective cohort study |journal=BMC Med |volume=21 |issue=1 |page=81 |date=March 2023 |pmid=36915130 |doi=10.1186/s12916-023-02772-3 |pmc=10012551 |s2cid=257499227 |url= |doi-access=free }}</ref>
The MIND diet may be more protective but further studies are needed. The Mediterranean diet seems to be more protective against Alzheimer's than DASH but there are no consistent findings against dementia in general. The role of [[olive oil]] needs further study as it may be one of the most important components in reducing the risk of cognitive decline and dementia.<ref name=Acta1/><ref name=Omar>{{cite journal |vauthors=Omar SH |title=Mediterranean and MIND Diets Containing Olive Biophenols Reduces the Prevalence of Alzheimer's Disease |journal=Int J Mol Sci |volume=20 |issue=11 |date=June 2019 |page=2797 |pmid=31181669 |pmc=6600544 |doi=10.3390/ijms20112797 |url=|doi-access=free }}</ref>
In those with [[celiac disease]] or [[non-celiac gluten sensitivity]], a strict [[gluten-free diet]] may relieve the symptoms given a mild cognitive impairment.<ref name="ZisHadjivassiliou2019" /><ref name="MakhloufMesselmani2018" /> Once dementia is advanced no evidence suggests that a gluten-free diet is useful.<ref name="ZisHadjivassiliou2019">{{cite journal| vauthors=Zis P, Hadjivassiliou M| title=Treatment of Neurological Manifestations of Gluten Sensitivity and Coeliac Disease. | journal=Curr Treat Options Neurol | date=February 26, 2019 | volume= 21 | issue= 3 | page= 10 | pmid=30806821 | doi=10.1007/s11940-019-0552-7 | type=Review | doi-access=free }}</ref>
[[Omega-3 fatty acid]] supplements do not appear to benefit or harm people with mild to moderate symptoms.<ref>{{cite journal | vauthors = Burckhardt M, Herke M, Wustmann T, Watzke S, Langer G, Fink A | title = Omega-3 fatty acids for the treatment of dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | page = CD009002 | date = April 2016 | issue = 4 | pmid = 27063583 | doi = 10.1002/14651858.CD009002.pub3 | pmc = 7117565 }}</ref> However, there is good evidence that omega-3 incorporation into the diet is of benefit in treating depression, a common symptom,<ref name="Firth">{{cite journal |vauthors=Firth J, Teasdale SB, Allott K, Siskind D, Marx W, Cotter J, Veronese N, Schuch F, Smith L, Solmi M, Carvalho AF, Vancampfort D, Berk M, Stubbs B, Sarris J |title=The efficacy and safety of nutrient supplements in the treatment of mental disorders: a meta-review of meta-analyses of randomized controlled trials |journal=World Psychiatry |volume=18 |issue=3 |pages=308–324 |date=October 2019 |pmid=31496103 |pmc=6732706 |doi=10.1002/wps.20672 |url=}}</ref> and potentially modifiable risk factor for dementia.<ref name="Lancet2020"/>
==Management==
{{Main|Caring for people with dementia}}
There are limited options for treating dementia, with most approaches focused on managing or reducing individual symptoms. There are no treatment options available to delay the onset of dementia.<ref>{{cite journal | vauthors = Hafdi M, Hoevenaar-Blom MP, Richard E | title = Multi-domain interventions for the prevention of dementia and cognitive decline | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 11 | page = CD013572 | date = November 2021 | pmid = 34748207 | pmc = 8574768 | doi = 10.1002/14651858.CD013572.pub2 | s2cid = 243846602 }}</ref> [[Acetylcholinesterase inhibitor]]s are often used early in the disorder course; however, benefit is generally small.<ref name="Comm2012">{{cite journal | author = Commission de la transparence | title = Drugs for Alzheimer's disease: best avoided. No therapeutic advantage | journal = Prescrire International | volume = 21 | issue = 128 | page = 150 | date = June 2012 | pmid = 22822592 | trans-title = Drugs for Alzheimer's disease: best avoided. No therapeutic advantage }}</ref><ref>{{cite journal | vauthors = Schneider LS, Mangialasche F, Andreasen N, Feldman H, Giacobini E, Jones R, Mantua V, Mecocci P, Pani L, Winblad B, Kivipelto M | display-authors = 6 | title = Clinical trials and late-stage drug development for Alzheimer's disease: an appraisal from 1984 to 2014 | journal = Journal of Internal Medicine | volume = 275 | issue = 3 | pages = 251–283 | date = March 2014 | pmid = 24605808 | pmc = 3956752 | doi = 10.1111/joim.12191 }}</ref> More than half of people with dementia may experience psychological or behavioral symptoms including agitation, sleep problems, aggression, and/or psychosis. Treatment for these symptoms is aimed at reducing the person's distress and keeping the person safe. Treatments other than medication appear to be better for agitation and aggression.<ref>{{cite journal | vauthors = Watt JA, Goodarzi Z, Veroniki AA, Nincic V, Khan PA, Ghassemi M, Thompson Y, Tricco AC, Straus SE | display-authors = 6 | title = Comparative Efficacy of Interventions for Aggressive and Agitated Behaviors in Dementia: A Systematic Review and Network Meta-analysis | journal = Annals of Internal Medicine | volume = 171 | issue = 9 | pages = 633–642 | date = November 2019 | pmid = 31610547 | doi = 10.7326/M19-0993 | s2cid = 204699972 }}</ref> Cognitive and behavioral interventions may be appropriate. Some evidence suggests that education and support for the person with dementia, as well as caregivers and family members, improves outcomes.<ref>{{cite journal | vauthors = Vandepitte S, Van Den Noortgate N, Putman K, Verhaeghe S, Verdonck C, Annemans L | title = Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review | journal = International Journal of Geriatric Psychiatry | volume = 31 | issue = 12 | pages = 1277–1288 | date = December 2016 | pmid = 27245986 | doi = 10.1002/gps.4504 | s2cid = 3464912 }}</ref> Palliative care interventions may lead to improvements in comfort in dying, but the evidence is low.<ref name="Walsh_2021">{{cite journal |vauthors=Walsh SC, Murphy E, Devane D, Sampson EL, Connolly S, Carney P, O'Shea E |date=September 2021 |title=Palliative care interventions in advanced dementia |journal=The Cochrane Database of Systematic Reviews |volume=2021 |issue=9 |page=CD011513 |doi=10.1002/14651858.CD011513.pub3 |pmc=8478014 |pmid=34582034}}</ref> Exercise programs are beneficial with respect to activities of daily living, and potentially improve dementia.<ref name="Forb2015">{{cite journal | vauthors = Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S | title = Exercise programs for people with dementia | journal = The Cochrane Database of Systematic Reviews | volume = 132 | issue = 4 | page = CD006489 | date = April 2015 | pmid = 25874613 | doi = 10.1002/14651858.CD006489.pub4 | pmc = 9426996 | type = Submitted manuscript }}</ref>
The effect of therapies can be evaluated for example by assessing agitation using the Cohen-Mansfield Agitation Inventory (CMAI); by assessing mood and engagement with the Menorah Park Engagement Scale (MPES);<ref name="pmid23515663">{{cite journal |vauthors=Camp CJ |title=Origins of Montessori Programming for Dementia |journal=Non-pharmacological Therapies in Dementia |volume=1 |issue=2 |pages=163–174 |date=2010 |pmid=23515663 |pmc=3600589 }}</ref> and the Observed Emotion Rating Scale (OERS)<ref name="pmid27489560">{{cite journal |vauthors=Cheong CY, Tan JA, Foong YL, Koh HM, Chen DZ, Tan JJ, Ng CJ, Yap P |title=Creative Music Therapy in an Acute Care Setting for Older Patients with Delirium and Dementia |journal=Dementia and Geriatric Cognitive Disorders Extra |volume=6 |issue=2 |pages=268–275 |date=2016 |pmid=27489560 |pmc=4959431 |doi=10.1159/000445883 }}</ref> or by assessing indicators for depression using the Cornell Scale for Depression in Dementia (CSDD)<ref name="pmid25256214">{{cite journal |vauthors=Jeon YH, Li Z, Low LF, Chenoweth L, O'Connor D, Beattie E, Liu Z, Brodaty H |title=The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes |journal=The American Journal of Geriatric Psychiatry |volume=23 |issue=8 |pages=784–793 |date=August 2015 |pmid=25256214 |doi=10.1016/j.jagp.2014.08.013}}</ref> or a simplified version thereof.<ref name="pmid27538349">{{cite journal |vauthors=Jeon YH, Liu Z, Li Z, et al. |title=Development and Validation of a Short Version of the Cornell Scale for Depression in Dementia for Screening Residents in Nursing Homes |journal=The American Journal of Geriatric Psychiatry |volume=24 |issue=11 |pages=1007–1016 |date=November 2016 |pmid=27538349 |doi=10.1016/j.jagp.2016.05.012|hdl=1959.4/unsworks_39417 |url=https://unsworks.unsw.edu.au/bitstreams/de316361-79bd-4823-a0dc-a4659509cc2d/download |hdl-access=free }}</ref>
Often overlooked in treating and managing dementia is the role of the caregiver and what is known about how they can support multiple interventions. Findings from a 2021 systematic review of the literature found caregivers of people with dementia in nursing homes do not have sufficient tools or clinical guidance for behavioral and psychological symptoms of dementia (BPSD) along with medication use.<ref>{{cite journal | vauthors = Harper AE, Rouch S, Leland NE, Turner RL, Mansbach WE, Day CE, Terhorst L | title = A Systematic Review of Tools Assessing the Perspective of Caregivers of Residents With Dementia | journal = Journal of Applied Gerontology | volume = 41 | issue = 4 | pages = 1196–1208 | date = April 2022 | pmid = 34229505 | doi = 10.1177/07334648211028692 | s2cid = 235758241 }}</ref> Simple measures like talking to people about their interests can improve the quality of life for [[care home]] residents living with dementia. A programme showed that such simple measures reduced residents' agitation and depression. They also needed fewer GP visits and hospital admissions, which also meant that the programme was cost-saving.<ref>{{Cite journal |date=November 26, 2020 |title=The WHELD programme for people with dementia helps care home staff deliver person-centred care |url=https://evidence.nihr.ac.uk/alert/wheld-dementia-care-homes-person-centred-care/ |journal=NIHR Evidence |type=Plain English summary |language=en |doi=10.3310/alert_42713|s2cid=240719455 }}</ref><ref>{{cite journal | vauthors = Ballard C, Orrell M, Moniz-Cook E, Woods R, Whitaker R, Corbett A, Aarsland D, Murray J, Lawrence V, Testad I, Knapp M, Romeo R, Zala D, Stafford J, Hoare Z, Garrod L, Sun Y, McLaughlin E, Woodward-Carlton B, Williams G, Fossey J | display-authors = 6 | title = Improving mental health and reducing antipsychotic use in people with dementia in care homes: the WHELD research programme including two RCTs | journal = Programme Grants for Applied Research | volume = 8 | issue = 6 | pages = 1–98 | date = July 2020 | pmid = 32721145 | doi = 10.3310/pgfar08060 | s2cid = 225489651 | doi-access = free }}</ref>
===Psychological and psychosocial therapies===
{{main|Psychological therapies for dementia}}
Psychological therapies for dementia include some limited evidence for [[reminiscence therapy]] (namely, some positive effects in the areas of quality of life, cognition, communication and mood – the first three particularly in care home settings),<ref name="Reminiscence therapy for dementia">{{cite journal | vauthors = Woods B, O'Philbin L, Farrell EM, Spector AE, Orrell M | title = Reminiscence therapy for dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | page = CD001120 | date = March 2018 | issue = 3 | pmid = 29493789 | pmc = 6494367 | doi = 10.1002/14651858.CD001120.pub3 }}</ref> some benefit for [[cognitive reframing]] for caretakers,<ref>{{cite journal | vauthors = Vernooij-Dassen M, Draskovic I, McCleery J, Downs M | title = Cognitive reframing for carers of people with dementia | journal = The Cochrane Database of Systematic Reviews | issue = 11 | page = CD005318 | date = November 2011 | pmid = 22071821 | doi = 10.1002/14651858.CD005318.pub2 | hdl = 2066/97731 | arxiv = 0706.4406 | s2cid = 205178315 }}</ref> unclear evidence for [[validation therapy]]<ref>{{cite journal | vauthors = Neal M, Barton Wright P | title = Validation therapy for dementia | journal = The Cochrane Database of Systematic Reviews | issue = 3 | page = CD001394 | year = 2003 | pmid = 12917907 | doi = 10.1002/14651858.CD001394 }}</ref> and tentative evidence for [[mental exercise]]s, such as cognitive stimulation programs for people with mild to moderate dementia.<ref>{{cite journal | vauthors = Woods B, Aguirre E, Spector AE, Orrell M | title = Cognitive stimulation to improve cognitive functioning in people with dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2 | issue = 2 | page = CD005562 | date = February 2012 | pmid = 22336813 | doi = 10.1002/14651858.CD005562.pub2 | s2cid = 7086782 }}</ref> Offering personally tailored activities may help reduce challenging behavior and may improve quality of life.<ref name="Möhler_2020">{{cite journal | vauthors = Möhler R, Renom A, Renom H, Meyer G | title = Personally tailored activities for improving psychosocial outcomes for people with dementia in community settings | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | page = CD010515 | date = August 2020 | issue = 8 | pmid = 32786083 | doi = 10.1002/14651858.CD010515.pub2 | pmc = 8094398 }}</ref> It is not clear if personally tailored activities have an impact on [[Affect (psychology)|affect]] or improve for the quality of life for the caregiver.<ref name="Möhler_2020" />
[[Adult daycare]] centers as well as special care units in nursing homes often provide specialized care for dementia patients. Daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers. In addition, [[home care]] can provide one-to-one support and care in the home allowing for more individualized attention that is needed as the disorder progresses. Psychiatric nurses can make a distinctive contribution to people's mental health.<ref>{{cite book | vauthors = Barker P | title = Psychiatric and mental health nursing: the craft of caring |publisher=Arnold |location=London |year=2003 |isbn=978-0-340-81026-2 |oclc=53373798}}</ref>
Since dementia impairs normal communication due to changes in receptive and expressive language, as well as the ability to plan and problem solve, agitated behavior is often a form of communication for the person with dementia. Actively searching for a potential cause, such as pain, physical illness, or overstimulation can be helpful in reducing agitation.<ref name="Weitzel 2011">{{cite journal | vauthors = Weitzel T, Robinson S, Barnes MR, et al. | title = The special needs of the hospitalized patient with dementia | journal = Medsurg Nursing | volume = 20 | issue = 1 | pages = 13–18; quiz 19 | year = 2011 | pmid = 21446290 }}</ref> Additionally, using an "ABC analysis of behavior" can be a useful tool for understanding behavior in people with dementia. It involves looking at the antecedents (A), behavior (B), and consequences (C) associated with an event to help define the problem and prevent further incidents that may arise if the person's needs are misunderstood.<ref>{{cite journal | vauthors = Cunningham C | title = Understanding challenging behaviour in patients with dementia | journal = Nursing Standard | volume = 20 | issue = 47 | pages = 42–45 | year = 2006 | pmid = 16913375 | doi = 10.7748/ns2006.08.20.47.42.c4477 }}</ref> The strongest evidence for non-pharmacological therapies for the management of changed behaviors in dementia is for using such approaches.<ref name=Dyer2017>{{cite journal | vauthors = Dyer SM, Harrison SL, Laver K, Whitehead C, Crotty M | title = An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia | journal = International Psychogeriatrics | volume = 30 | issue = 3 | pages = 295–309 | date = March 2018 | pmid = 29143695 | doi = 10.1017/S1041610217002344 | doi-access = free }}</ref> Low quality evidence suggests that regular (at least five sessions of) [[music therapy]] may help institutionalized residents. It may reduce depressive symptoms and improve overall behaviors. It may also supply a beneficial effect on emotional well-being and quality of life, as well as reduce anxiety.<ref>{{cite journal | vauthors = van der Steen JT, Smaling HJ, van der Wouden JC, Bruinsma MS, Scholten RJ, Vink AC | title = Music-based therapeutic interventions for people with dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | page = CD003477 | date = July 2018 | issue = 7 | pmid = 30033623 | pmc = 6513122 | doi = 10.1002/14651858.CD003477.pub4 | hdl = 1874/350441 }}</ref> In 2003, The [[Alzheimer's Society]] established 'Singing for the Brain' (SftB) a project based on pilot studies which suggested that the activity encouraged participation and facilitated the learning of new songs. The sessions combine aspects of reminiscence therapy and music.<ref>{{cite journal | vauthors = Osman SE, Tischler V, Schneider J | title = 'Singing for the Brain': A qualitative study exploring the health and well-being benefits of singing for people with dementia and their carers | journal = Dementia | volume = 15 | issue = 6 | pages = 1326–1339 | date = November 2016 | pmid = 25425445 | pmc = 5089222 | doi = 10.1177/1471301214556291 }}</ref> Musical and interpersonal connectedness can underscore the value of the person and improve quality of life.<ref name="pmid27044417">{{cite journal | vauthors = Johnston B, Narayanasamy M | title = Exploring psychosocial interventions for people with dementia that enhance personhood and relate to legacy- an integrative review | journal = BMC Geriatrics | volume = 16 | page = 77 | date = April 2016 | pmid = 27044417 | pmc = 4820853 | doi = 10.1186/s12877-016-0250-1 | doi-access = free }}</ref>
Some London hospitals found that using color, designs, pictures and lights helped people with dementia adjust to being at the hospital. These adjustments to the layout of the dementia wings at these hospitals helped patients by preventing confusion.<ref>{{Cite news|url=https://www.economist.com/britain/2018/09/15/british-hospitals-are-having-a-dementia-friendly-makeover|title=British hospitals are having a dementia-friendly makeover|newspaper=The Economist|access-date=September 19, 2018}}</ref>
[[Life story work]] as part of [[Reminiscence therapy#Dementia|reminiscence therapy]], and video biographies have been found to address the needs of clients and their caregivers in various ways, offering the client the opportunity to leave a legacy and enhance their personhood and also benefitting youth who participate in such work. Such interventions can be more beneficial when undertaken at a relatively early stage of dementia. They may also be problematic in those who have difficulties in processing past experiences<ref name="pmid27044417"/>
[[Animal-assisted therapy]] has been found to be helpful. Drawbacks may be that pets are not always welcomed in a communal space in the care setting. An animal may pose a risk to residents, or may be perceived to be dangerous. Certain animals may also be regarded as "unclean" or "dangerous" by some cultural groups.<ref name="pmid27044417"/>
Occupational therapy also addresses psychological and psychosocial needs of patients with dementia through improving daily occupational performance and caregivers' competence.<ref name="ajot.aota.org">{{cite journal | vauthors = Raj SE, Mackintosh S, Fryer C, Stanley M | title = Home-Based Occupational Therapy for Adults With Dementia and Their Informal Caregivers: A Systematic Review | journal = The American Journal of Occupational Therapy | volume = 75 | issue = 1 | pages = 7501205060p1–7501205060p27 | date = January 1, 2021 | pmid = 33399054 | doi = 10.5014/ajot.2020.040782 | s2cid = 230618534 }}</ref> When compensatory intervention strategies are added to their daily routine, the level of performance is enhanced and reduces the burden commonly placed on their caregivers.<ref name="ajot.aota.org"/> Occupational therapists can also work with other disciplines to create a client centered intervention.<ref name="Frankenstein_2020">{{Cite journal| vauthors = Frankenstein LL, Jahn G |date=April 20, 2020|title=Behavioral and Occupational Therapy for Dementia Patients and Caregivers|url=https://econtent.hogrefe.com/doi/10.1024/1662-9647/a000225|journal=GeroPsych|volume=33|issue=2|pages=85–100|doi=10.1024/1662-9647/a000225|s2cid=219081899|issn=1662-9647}}</ref> To manage cognitive disability, and coping with behavioral and psychological symptoms of dementia, combined occupational and behavioral therapies can support patients with dementia even further.<ref name="Frankenstein_2020" />
==== Cognitive training and rehabilitation ====
There is no strong evidence to suggest that [[cognitive training]] is beneficial for people with Parkinson's disease, dementia, or mild cognitive impairment.<ref>{{cite journal |display-authors=3| vauthors = Orgeta V, McDonald KR, Poliakoff E, Hindle JV, Clare L, Leroi I | title = Cognitive training interventions for dementia and mild cognitive impairment in Parkinson's disease | journal = Cochrane Database of Systematic Reviews | volume = 2020 | issue = 2 | page = CD011961 | date = February 2020 | pmid = 32101639 | pmc = 7043362 | doi = 10.1002/14651858.cd011961.pub2 }}</ref>  However, a 2023 review found that [[cognitive rehabilitation]] may be effective in helping individuals with mild to moderate dementia to manage their daily activities.<ref>{{Cite journal |display-authors=3|last1=Kudlicka |first1=Aleksandra |last2=Martyr |first2=Anthony |last3=Bahar-Fuchs |first3=Alex |last4=Sabates |first4=Julieta |last5=Woods |first5=Bob |last6=Clare |first6=Linda |date=June 29, 2023 |editor-last=Cochrane Dementia and Cognitive Improvement Group |title=Cognitive rehabilitation for people with mild to moderate dementia |journal=Cochrane Database of Systematic Reviews |language=en |volume=2023 |issue=6 |page=CD013388 |doi=10.1002/14651858.CD013388.pub2 |pmc=10310315 |pmid=37389428}}</ref>
==== Personally tailored activities ====
Offering personally tailored activity sessions to people with dementia in long-term care homes may slightly reduce challenging behavior.<ref>{{cite journal | vauthors = Möhler R, Calo S, Renom A, Renom H, Meyer G | title = Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care | journal = The Cochrane Database of Systematic Reviews | volume = 2023 | issue = 3 | page = CD009812 | date = March 2023 | pmid = 36930048 | pmc = 10010156 | doi = 10.1002/14651858.CD009812.pub3 }}</ref>
===Medications===
No medications have been shown to prevent or cure dementia.<ref>{{cite journal | vauthors = Rafii MS, Aisen PS | title = Recent developments in Alzheimer's disease therapeutics | journal = BMC Medicine | volume = 7 | page = 7 | date = February 2009 | pmid = 19228370 | pmc = 2649159 | doi = 10.1186/1741-7015-7-7 | doi-access = free }}</ref> Medications may be used to treat the behavioral and cognitive symptoms, but have no effect on the underlying disease process.<ref name="Memory Loss" /><ref name=Lleo2006>{{cite journal | vauthors = Lleó A, Greenberg SM, Growdon JH | title = Current pharmacotherapy for Alzheimer's disease | journal = Annual Review of Medicine | volume = 57 | issue = 1 | pages = 513–533 | year = 2006 | pmid = 16409164 | doi = 10.1146/annurev.med.57.121304.131442 }}</ref>
[[File:Donepezil skeletal.svg|thumb|upright=1.15|Donepezil]]
[[Acetylcholinesterase inhibitor]]s, such as [[donepezil]], may be useful for Alzheimer's disease,<ref name="Bond_2012">{{cite journal | vauthors = Bond M, Rogers G, Peters J, Anderson R, Hoyle M, Miners A, Moxham T, Davis S, Thokala P, Wailoo A, Jeffreys M, Hyde C | display-authors = 6 | title = The effectiveness and cost-effectiveness of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease (review of Technology Appraisal No. 111): a systematic review and economic model | journal = Health Technology Assessment | volume = 16 | issue = 21 | pages = 1–470 | date = 2012 | pmid = 22541366 | pmc = 4780923 | doi = 10.3310/hta16210 }}</ref> Parkinson's disease dementia, DLB, or vascular dementia.<ref name=Lleo2006/> The quality of the evidence is poor<ref>{{cite journal | vauthors = Rodda J, Morgan S, Walker Z | title = Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer's disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine | journal = International Psychogeriatrics | volume = 21 | issue = 5 | pages = 813–824 | date = October 2009 | pmid = 19538824 | doi = 10.1017/S1041610209990354 | doi-broken-date = November 1, 2024 | s2cid = 206299435 }}</ref> and the benefit is small.<ref name=Comm2012/> No difference has been shown between the agents in this family.<ref name="Bir2006">{{cite journal | vauthors = Birks J | title = Cholinesterase inhibitors for Alzheimer's disease | journal = The Cochrane Database of Systematic Reviews | issue = 1 | page = CD005593 | date = January 2006 | volume = 2016 | pmid = 16437532 | doi = 10.1002/14651858.CD005593 | pmc = 9006343 | veditors = Birks JS }}</ref> In a minority of people side effects include a [[slow heart rate]] and [[fainting]].<ref>{{cite journal | vauthors = Gill SS, Anderson GM, Fischer HD, Bell CM, Li P, Normand SL, Rochon PA | title = Syncope and its consequences in patients with dementia receiving cholinesterase inhibitors: a population-based cohort study | journal = Archives of Internal Medicine | volume = 169 | issue = 9 | pages = 867–873 | date = May 2009 | pmid = 19433698 | doi = 10.1001/archinternmed.2009.43 | doi-access = free }}</ref> [[Rivastigmine]] is recommended for treating symptoms in Parkinson's disease dementia.<ref name="JAMA">{{cite journal | vauthors = Arvanitakis Z, Shah RC, Bennett DA | title = Diagnosis and Management of Dementia: Review | journal = JAMA | volume = 322 | issue = 16 | pages = 1589–1599 | date = October 2019 | pmid = 31638686 | pmc = 7462122 | doi = 10.1001/jama.2019.4782 }}</ref>
Medications that have [[anticholinergic]] effects increase all-cause mortality in people with dementia, although the effect of these medications on cognitive function remains uncertain, according to a systematic review published in 2021.<ref>{{cite journal | vauthors = Wang K, Alan J, Page AT, Dimopoulos E, Etherton-Beer C | title = Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review | journal = Maturitas | volume = 151 | pages = 1–14 | date = September 2021 | pmid = 34446273 | doi = 10.1016/j.maturitas.2021.06.004 | publisher = Elsevier BV }}</ref>
Before prescribing antipsychotic medication in the elderly, an assessment for an underlying cause of the behavior is needed.<ref>{{Citation |author1 = AMDA – The Society for Post-Acute and Long-Term Care Medicine |author1-link = AMDA – The Society for Post-Acute and Long-Term Care Medicine |date = February 2014 |title = Ten Things Physicians and Patients Should Question |publisher = AMDA – The Society for Post-Acute and Long-Term Care Medicine |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/amda/ |access-date = April 20, 2015 |url-status = live |archive-url = https://web.archive.org/web/20150412185806/http://www.choosingwisely.org/doctor-patient-lists/amda/ |archive-date = April 12, 2015 }}</ref> Severe and life-threatening reactions occur in almost half of people with DLB,<ref name= Taylor2020/><ref name= Walker2015>{{cite journal |vauthors=Walker Z, Possin KL, Boeve BF, Aarsland D |title=Lewy body dementias |journal=Lancet |volume=386 |issue=10004 |pages=1683–1697 |date=October 2015 |pmid=26595642 |pmc=5792067 |doi=10.1016/S0140-6736(15)00462-6 |type=Review}}</ref> and can be fatal after a single dose.<ref name= Boot2105>{{cite journal |vauthors=Boot BP |title=Comprehensive treatment of dementia with Lewy bodies |journal=Alzheimers Res Ther |volume=7 |issue=1 |page=45 |date=2015 |pmid=26029267 |pmc=4448151 |doi=10.1186/s13195-015-0128-z |type=Review |doi-access=free }}</ref> People with Lewy body dementias who take neuroleptics are at risk for neuroleptic malignant syndrome, a life-threatening illness.<ref name= Gomperts2016>{{cite journal |vauthors=Gomperts SN |title=Lewy body dementias: Dementia with Lewy bodies and Parkinson disease dementia |journal=Continuum (Minneap Minn) |volume=22 |issue=2 Dementia |pages=435–463 |date=April 2016 |pmid=27042903 |pmc=5390937 |doi=10.1212/CON.0000000000000309 |type=Review}}</ref> Extreme caution is required in the use of antipsychotic medication in people with DLB because of their sensitivity to these agents.<ref name= McKeithConsensus2017/> Antipsychotic drugs are used to treat dementia only if non-drug therapies have not worked, and the person's actions threaten themselves or others.<ref name="AGSantipsychotic">{{Cite journal |author1 = American Geriatrics Society |author1-link = American Geriatrics Society |title = Five Things Physicians and Patients Should Question |journal = Choosing Wisely: An Initiative of the ABIM Foundation |url = http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/ |access-date = August 1, 2013 |url-status = live |archive-url = https://web.archive.org/web/20130901100140/http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/ |archive-date = September 1, 2013 }}</ref><ref>{{Citation |author1 = American Psychiatric Association |author1-link = American Psychiatric Association |date = September 2013 |title = Five Things Physicians and Patients Should Question |publisher = [[American Psychiatric Association]] |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/ |access-date = December 30, 2013 |url-status = live |archive-url = https://web.archive.org/web/20131203174206/http://www.choosingwisely.org/doctor-patient-lists/american-psychiatric-association/ |archive-date = December 3, 2013 }}</ref><ref name=NICEUK>{{cite web |title=Dementia: assessment, management and support for people living with dementia and their carers {{!}} Guidance and guidelines {{!}} NICE |url=https://www.nice.org.uk/guidance/ng97/chapter/Recommendations#managing-non-cognitive-symptoms |website=NICE |date=June 20, 2018 |access-date=December 18, 2018}}</ref><ref>{{cite journal | vauthors = Dyer SM, Laver K, Pond CD, Cumming RG, Whitehead C, Crotty M | title = Clinical practice guidelines and principles of care for people with dementia in Australia | journal = Australian Family Physician | volume = 45 | issue = 12 | pages = 884–889 | date = December 2016 | pmid = 27903038 | url = https://search.informit.com.au/documentSummary;dn=577322425689666;res=IELHEA }}</ref> Aggressive behavior changes are sometimes the result of other solvable problems, that could make treatment with antipsychotics unnecessary.<ref name="AGSantipsychotic"/> Because people with dementia can be aggressive, resistant to their treatment, and otherwise disruptive, sometimes antipsychotic drugs are considered as a therapy in response.<ref name="AGSantipsychotic"/> These drugs have risky adverse effects, including increasing the person's chance of stroke and death.<ref name="AGSantipsychotic"/> Given these adverse events and small benefit antipsychotics are avoided whenever possible.<ref name=Dyer2017/> Generally, stopping antipsychotics for people with dementia does not cause problems, even in those who have been on them a long time.<ref>{{cite journal | vauthors = Declercq T, Petrovic M, Azermai M, Vander Stichele R, De Sutter AI, van Driel ML, Christiaens T | title = Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia | journal = The Cochrane Database of Systematic Reviews | volume = 3 | issue = 3 | page = CD007726 | date = March 2013 | pmid = 23543555 | doi = 10.1002/14651858.CD007726.pub2 | hdl = 1854/LU-3109108 | url = https://espace.library.uq.edu.au/view/UQ:296637/UQ296637_OA.pdf | hdl-access = free }}</ref>
[[NMDA receptor|N-methyl-D-aspartate (NMDA) receptor]] blockers such as [[memantine]] may be of benefit but the evidence is less conclusive than for AChEIs.<ref name="Bond_2012" /> Due to their differing mechanisms of action memantine and acetylcholinesterase inhibitors can be used in combination however the benefit is slight.<ref name=Rain>{{cite journal | vauthors = Raina P, Santaguida P, Ismaila A, Patterson C, Cowan D, Levine M, Booker L, Oremus M | display-authors = 6 | title = Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline | journal = Annals of Internal Medicine | volume = 148 | issue = 5 | pages = 379–397 | date = March 2008 | pmid = 18316756 | doi = 10.7326/0003-4819-148-5-200803040-00009 | doi-access = free }}</ref><ref name=Atri>{{cite journal | vauthors = Atri A, Shaughnessy LW, Locascio JJ, Growdon JH | title = Long-term course and effectiveness of combination therapy in Alzheimer disease | journal = Alzheimer Disease and Associated Disorders | volume = 22 | issue = 3 | pages = 209–221 | year = 2008 | pmid = 18580597 | pmc = 2718545 | doi = 10.1097/WAD.0b013e31816653bc }}</ref>
An extract of ''[[Ginkgo biloba]]'' known as ''EGb 761'' has been widely used for treating mild to moderate dementia and other neuropsychiatric disorders.<ref name=Kandia>{{cite journal | vauthors = Kandiah N, Ong PA, Yuda T, Ng LL, Mamun K, Merchant RA, Chen C, Dominguez J, Marasigan S, Ampil E, Nguyen VT, Yusoff S, Chan YF, Yong FM, Krairit O, Suthisisang C, Senanarong V, Ji Y, Thukral R, Ihl R | display-authors = 6 | title = Treatment of dementia and mild cognitive impairment with or without cerebrovascular disease: Expert consensus on the use of Ginkgo biloba extract, EGb 761<sup>®</sup> | journal = CNS Neuroscience & Therapeutics | volume = 25 | issue = 2 | pages = 288–298 | date = February 2019 | pmid = 30648358 | pmc = 6488894 | doi = 10.1111/cns.13095 }}</ref> Its use is approved throughout Europe.<ref name=McKeage>{{cite journal | vauthors = McKeage K, Lyseng-Williamson KA | title = ''Ginkgo biloba'' extract EGb 761<sup>®</sup> in the symptomatic treatment of mild-to-moderate dementia: a profile of its use | journal = Drugs & Therapy Perspectives | volume = 34 | issue = 8 | pages = 358–366 | date = 2018 | pmid = 30546253 | pmc = 6267544 | doi = 10.1007/s40267-018-0537-8 }}</ref> The World Federation of Biological Psychiatry guidelines lists EGb 761 with the same weight of evidence (level B) given to acetylcholinesterase inhibitors, and memantine. EGb 761 is the only one that showed improvement of symptoms in both AD and vascular dementia. EGb 761 is seen as being able to play an important role either on its own or as an add-on particularly when other therapies prove ineffective.<ref name=Kandia/> EGb 761 is seen to be neuroprotective; it is a free radical scavenger, improves mitochondrial function, and modulates [[serotonin]] and dopamine levels. Many studies of its use in mild to moderate dementia have shown it to significantly improve cognitive function, activities of daily living, neuropsychiatric symptoms, and quality of life.<ref name=Kandia/><ref name=Wang>{{cite journal | vauthors = Wang M, Peng H, Peng Z, Huang K, Li T, Li L, Wu X, Shi H | display-authors = 6 | title = Efficacy and safety of ginkgo preparation in patients with vascular dementia: A protocol for systematic review and meta-analysis | journal = Medicine | volume = 99 | issue = 37 | page = e22209 | date = September 2020 | pmid = 32925798 | pmc = 7489658 | doi = 10.1097/MD.0000000000022209 }}</ref> However, its use has not been shown to prevent the progression of dementia.<ref name=Kandia/>
While depression is frequently associated with dementia, the use of [[antidepressant]]s such as [[selective serotonin reuptake inhibitors]] (SSRIs) do not appear to affect outcomes.<ref>{{cite journal | vauthors = Jones HE, Joshi A, Shenkin S, Mead GE | title = The effect of treatment with selective serotonin reuptake inhibitors in comparison to placebo in the progression of dementia: a systematic review and meta-analysis | journal = Age and Ageing | volume = 45 | issue = 4 | pages = 448–456 | date = July 2016 | pmid = 27055878 | doi = 10.1093/ageing/afw053 | doi-access = free | hdl = 20.500.11820/56792c91-31f0-44cb-8ac0-7f50fad8d91e | hdl-access = free }}</ref><ref>{{cite journal | vauthors = Dudas R, Malouf R, McCleery J, Dening T | title = Antidepressants for treating depression in dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | page = CD003944 | date = August 2018 | issue = 8 | pmid = 30168578 | pmc = 6513376 | doi = 10.1002/14651858.CD003944.pub2 | collaboration = Cochrane Dementia and Cognitive Improvement Group }}</ref> However, the SSRIs [[sertraline]] and [[citalopram]] have been demonstrated to reduce symptoms of agitation, compared to placebo.<ref>{{cite journal | vauthors = Seitz DP, Adunuri N, Gill SS, Gruneir A, Herrmann N, Rochon P | title = Antidepressants for agitation and psychosis in dementia | journal = The Cochrane Database of Systematic Reviews | issue = 2 | page = CD008191 | date = February 2011 | pmid = 21328305 | doi = 10.1002/14651858.CD008191.pub2 }}</ref>
No solid evidence indicates that [[folate]] or [[vitamin B12|vitamin B<sub>12</sub>]] improves outcomes in those with cognitive problems.<ref>{{cite journal | vauthors = Malouf R, Grimley Evans J | title = Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people | journal = The Cochrane Database of Systematic Reviews | issue = 4 | page = CD004514 | date = October 2008 | pmid = 18843658 | doi = 10.1002/14651858.CD004514.pub2 | author-link2 = John Grimley Evans }}</ref> [[Statins]] have no benefit in dementia.<ref>{{cite journal | vauthors = McGuinness B, Craig D, Bullock R, Malouf R, Passmore P | title = Statins for the treatment of dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 7 | page = CD007514 | date = July 2014 | pmid = 25004278 | doi = 10.1002/14651858.CD007514.pub3 | pmc = 11112650 | url = https://pure.qub.ac.uk/portal/files/47030701/Statins%20for%20the%20treatment%20of%20dementia%20(Review)%20-%20Cochrane%20Database%20Syst%20Rev%202010%20-%20Craig%20D,%20Passmore%20AP..pdf | access-date = September 3, 2019 | url-status = dead | archive-url = https://web.archive.org/web/20190903072943/https://pure.qub.ac.uk/portal/files/47030701/Statins%2520for%2520the%2520treatment%2520of%2520dementia%2520(Review)%2520-%2520Cochrane%2520Database%2520Syst%2520Rev%25202010%2520-%2520Craig%2520D,%2520Passmore%2520AP..pdf | archive-date = September 3, 2019 }}</ref> Medications for other health conditions may need to be managed differently for a person who has a dementia diagnosis. It is unclear whether blood pressure medication and dementia are linked.<!--<ref name=Sus2016/> --> People may experience an increase in cardiovascular-related events if these medications are withdrawn.<ref name="Sus2016">{{cite journal | vauthors = Jongstra S, Harrison JK, Quinn TJ, Richard E | title = Antihypertensive withdrawal for the prevention of cognitive decline | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | page = CD011971 | date = November 2016 | issue = 11 | pmid = 27802359 | pmc = 6465000 | doi = 10.1002/14651858.CD011971.pub2 }}</ref>
The [[MATCH-D|Medication Appropriateness Tool for Comorbid Health Conditions in Dementia]] (MATCH-D) criteria can help identify ways that a diagnosis of dementia changes medication management for other health conditions.<ref>{{cite journal | vauthors = Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C | title = Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel | journal = Internal Medicine Journal | volume = 46 | issue = 10 | pages = 1189–1197 | date = October 2016 | pmid = 27527376 | pmc = 5129475 | doi = 10.1111/imj.13215 }}</ref> These criteria were developed because people with dementia live with an average of five other chronic diseases, which are often managed with medications. The systematic review that informed the criteria were published subsequently in 2018 and [[doi:10.1002/jppr.1802|updated]] in 2022.<ref>{{Cite journal| vauthors = Wang K, Alan J, Page A, Percival M, Etherton-Beer C |date=2018|title=Medication use to manage comorbidities for people with dementia: a systematic review|journal=Journal of Pharmacy Practice and Research|language=en|volume=48|issue=4|pages=356–367|doi=10.1002/jppr.1403|issn=2055-2335|doi-access=free}}</ref>
=== Sleep disturbances ===
Over 40% of people with dementia report sleep problems. Approaches to treating these sleep problems include medications and non-pharmacological approaches.<ref name="Wilfling_2023">{{cite journal | vauthors = Wilfling D, Calo S, Dichter MN, Meyer G, Möhler R, Köpke S | title = Non-pharmacological interventions for sleep disturbances in people with dementia | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | page = CD011881 | date = January 2023 | pmid = 36594432 | pmc = 9808594 | doi = 10.1002/14651858.CD011881.pub2 }}</ref> The use of medications to alleviate sleep disturbances that people with dementia often experience has not been well researched, even for medications that are commonly prescribed.<ref name="McCleery_2020">{{cite journal | vauthors = McCleery J, Sharpley AL | title = Pharmacotherapies for sleep disturbances in dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 11 | page = CD009178 | date = November 2020 | pmid = 33189083 | pmc = 8094738 | doi = 10.1002/14651858.CD009178.pub4 }}</ref> In 2012 the [[American Geriatrics Society]] recommended that [[benzodiazepines]] such as [[diazepam]], and non-benzodiazepine [[hypnotic]]s, be avoided for people with dementia due to the risks of increased cognitive impairment and falls.<ref name="Beers2012">{{cite journal | vauthors = ((American Geriatrics Society 2012 Beers Criteria Update Expert Panel)) | title = American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults | journal = Journal of the American Geriatrics Society | volume = 60 | issue = 4 | pages = 616–631 | date = April 2012 | pmid = 22376048 | pmc = 3571677 | doi = 10.1111/j.1532-5415.2012.03923.x }}</ref> Benzodiazepines are also known to promote [[delirium]].<ref name="Tisher">{{cite journal | vauthors = Tisher A, Salardini A | title = A Comprehensive Update on Treatment of Dementia | journal = Seminars in Neurology | volume = 39 | issue = 2 | pages = 167–178 | date = April 2019 | pmid = 30925610 | doi = 10.1055/s-0039-1683408 | s2cid = 88474685 }}</ref> Additionally, little evidence supports the effectiveness of benzodiazepines in this population.<ref name="McCleery_2020" /><ref>{{cite journal | vauthors = Lolk A, Gulmann NC | title = [Psychopharmacological treatment of behavioral and psychological symptoms in dementia] | language = da | journal = Ugeskrift for Laeger | volume = 168 | issue = 40 | pages = 3429–3432 | date = October 2006 | pmid = 17032610 }}</ref> No clear evidence shows that [[melatonin (medication)|melatonin]] or [[ramelteon]] improves sleep for people with dementia due to Alzheimer's,<ref name="McCleery_2020" /> but it is used to treat [[REM sleep behavior disorder]] in dementia with Lewy bodies.<ref name="Taylor2020" /> Limited evidence suggests that a low dose of [[trazodone]] may improve sleep, however more research is needed.<ref name="McCleery_2020" />
Non-pharmacological approaches have been suggested for treating sleep problems for those with dementia, however, there is no strong evidence or firm conclusions on the effectiveness of different types of interventions, especially for those who are living in an institutionalized setting such as a nursing home or long-term care home.<ref name="Wilfling_2023" />
===Pain===
<!--This section is linked from [[Pain#In nonverbal patients]]-->
{{See also|Pain#Assessment_in_non-verbal_people|l1=Assessment in nonverbal patients|Pain Assessment in Advanced Dementia}}
As people age, they experience more health problems, and most health problems associated with aging carry a substantial burden of pain; therefore, between 25% and 50% of older adults experience persistent pain. Seniors with dementia experience the same prevalence of conditions likely to cause pain as seniors without dementia.<ref name="Hadjistavropoulos 2007">{{cite journal | vauthors = Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin RH, Helme R, Jackson K, Parmelee PA, Rudy TE, Lynn Beattie B, Chibnall JT, Craig KD, Ferrell B, Ferrell B, Fillingim RB, Gagliese L, Gallagher R, Gibson SJ, Harrison EL, Katz B, Keefe FJ, Lieber SJ, Lussier D, Schmader KE, Tait RC, Weiner DK, Williams J | title = An interdisciplinary expert consensus statement on assessment of pain in older persons | journal = The Clinical Journal of Pain | volume = 23 | issue = 1 Suppl | pages = S1–S43 | date = January 2007 | pmid = 17179836 | doi = 10.1097/AJP.0b013e31802be869 | s2cid = 43777445 }}</ref> Pain is often overlooked in older adults and, when screened for, is often poorly assessed, especially among those with dementia, since they become incapable of informing others of their pain.<ref name="Hadjistavropoulos 2007"/><ref name=Shega>{{cite journal | vauthors = Shega J, Emanuel L, Vargish L, Levine SK, Bursch H, Herr K, Karp JF, Weiner DK | title = Pain in persons with dementia: complex, common, and challenging | journal = The Journal of Pain | volume = 8 | issue = 5 | pages = 373–378 | date = May 2007 | pmid = 17485039 | doi = 10.1016/j.jpain.2007.03.003 | doi-access = free }}</ref> Beyond the issue of humane care, unrelieved pain has functional implications. Persistent pain can lead to decreased ambulation, depressed mood, sleep disturbances, impaired appetite, and exacerbation of cognitive impairment<ref name= Shega/> and pain-related interference with activity is a factor contributing to falls in the elderly.<ref name="Hadjistavropoulos 2007"/><ref name=Blyth>{{cite journal | vauthors = Blyth FM, Cumming R, Mitchell P, Wang JJ | title = Pain and falls in older people | journal = European Journal of Pain | volume = 11 | issue = 5 | pages = 564–571 | date = July 2007 | pmid = 17015026 | doi = 10.1016/j.ejpain.2006.08.001 | s2cid = 27460864 }}</ref>
Although persistent pain in people with dementia is difficult to communicate, diagnose, and treat, failure to address persistent pain has profound functional, [[psychosocial]] and [[quality of life]] implications for this vulnerable population. Health professionals often lack the skills and usually lack the time needed to recognize, accurately assess and adequately monitor pain in people with dementia.<ref name="Hadjistavropoulos 2007"/><ref name=Brown>{{cite journal | vauthors = Brown C |year=2009 |title=Pain, aging and dementia: The crisis is looming, but are we ready? |journal=British Journal of Occupational Therapy |volume=72 |issue=8 |pages=371–375 |doi=10.1177/030802260907200808 |s2cid=73245194 }}</ref> Family members and friends can make a valuable contribution to the care of a person with dementia by learning to recognize and assess their pain. Educational resources and observational assessment tools are available.<ref name= "Hadjistavropoulos 2007"/><ref name=Herr>{{cite journal | vauthors = Herr K, Bjoro K, Decker S | title = Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review | journal = Journal of Pain and Symptom Management | volume = 31 | issue = 2 | pages = 170–192 | date = February 2006 | pmid = 16488350 | doi = 10.1016/j.jpainsymman.2005.07.001 | doi-access = free }}</ref><ref name=Stolee2005>{{cite journal | vauthors = Stolee P, Hillier LM, Esbaugh J, Bol N, McKellar L, Gauthier N | title = Instruments for the assessment of pain in older persons with cognitive impairment | journal = Journal of the American Geriatrics Society | volume = 53 | issue = 2 | pages = 319–326 | date = February 2005 | pmid = 15673359 | doi = 10.1111/j.1532-5415.2005.53121.x | s2cid = 21006144 }}</ref>
===Eating difficulties===
Persons with dementia may have difficulty eating. Whenever it is available as an option, the recommended response to eating problems is having a caretaker [[assisted feeding|assist them]].<ref name="AGSantipsychotic"/> A secondary option for people who cannot swallow effectively is to consider [[Percutaneous endoscopic gastrostomy|gastrostomy]] [[feeding tube]] placement as a way to give nutrition. However, in bringing comfort and maintaining functional status while lowering risk of [[aspiration pneumonia]] and death, assistance with oral feeding is at least as good as tube feeding.<ref name="AGSantipsychotic"/><ref>{{Citation |author1 = AMDA – The Society for Post-Acute and Long-Term Care Medicine |author1-link = AMDA – The Society for Post-Acute and Long-Term Care Medicine |date = February 2014 |title = Five Things Physicians and Patients Should Question |publisher = AMDA – The Society for Post-Acute and Long-Term Care Medicine |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/amda/ |access-date = February 10, 2013 |url-status = live |archive-url = https://web.archive.org/web/20140913011101/http://www.choosingwisely.org/doctor-patient-lists/amda/ |archive-date = September 13, 2014 }}</ref> Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening [[pressure ulcer]]s. Tube feedings may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration.<ref>{{Citation |author1 = AMDA – The Society for Post-Acute and Long-Term Care Medicine |author1-link = AMDA – The Society for Post-Acute and Long-Term Care Medicine |date = February 2014 |title = Five Things Physicians and Patients Should Question |publisher = AMDA – The Society for Post-Acute and Long-Term Care Medicine |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/amda/ |access-date = February 10, 2013 |url-status = live |archive-url = https://web.archive.org/web/20140913011101/http://www.choosingwisely.org/doctor-patient-lists/amda/ |archive-date = September 13, 2014 }}, which cites:
* {{cite journal | vauthors = Teno JM, Gozalo PL, Mitchell SL, Kuo S, Rhodes RL, Bynum JP, Mor V | title = Does feeding tube insertion and its timing improve survival? | journal = Journal of the American Geriatrics Society | volume = 60 | issue = 10 | pages = 1918–1921 | date = October 2012 | pmid = 23002947 | pmc = 3470758 | doi = 10.1111/j.1532-5415.2012.04148.x }}
* {{cite journal | vauthors = Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL | title = Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia | journal = Journal of the American Geriatrics Society | volume = 58 | issue = 3 | pages = 580–584 | date = March 2010 | pmid = 20398123 | pmc = 2872797 | doi = 10.1111/j.1532-5415.2010.02740.x }}
* {{cite journal | vauthors = Gillick MR, Volandes AE | title = The standard of caring: why do we still use feeding tubes in patients with advanced dementia? | journal = Journal of the American Medical Directors Association | volume = 9 | issue = 5 | pages = 364–367 | date = June 2008 | pmid = 18519120 | doi = 10.1016/j.jamda.2008.03.011 }}</ref><ref>{{cite journal | vauthors = Mitchell SL, Kiely DK, Lipsitz LA | title = The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment | journal = Archives of Internal Medicine | volume = 157 | issue = 3 | pages = 327–332 | date = February 1997 | pmid = 9040301 | doi = 10.1001/archinte.1997.00440240091014 }}</ref>
Benefits in those with advanced dementia has not been shown.<ref>{{cite journal | vauthors = Sampson EL, Candy B, Jones L | title = Enteral tube feeding for older people with advanced dementia | journal = The Cochrane Database of Systematic Reviews | issue = 2 | page = CD007209 | date = April 2009 | volume = 2009 | pmid = 19370678 | doi = 10.1002/14651858.CD007209.pub2 | pmc = 7182132 }}</ref> The risks of using tube feeding include agitation, rejection by the person (pulling out the tube, or otherwise physical or chemical immobilization to prevent them from doing this), or developing pressure ulcers.<ref name="AGSantipsychotic"/> The procedure is directly related to a 1% fatality rate<ref>{{cite journal | vauthors = Lockett MA, Templeton ML, Byrne TK, Norcross ED | title = Percutaneous endoscopic gastrostomy complications in a tertiary-care center | journal = The American Surgeon | volume = 68 | issue = 2 | pages = 117–120 | date = February 2002 | doi = 10.1177/000313480206800202 | pmid = 11842953 | s2cid = 43796062 }}</ref> with a 3% major complication rate.<ref>{{cite journal | vauthors = Finocchiaro C, Galletti R, Rovera G, Ferrari A, Todros L, Vuolo A, Balzola F | title = Percutaneous endoscopic gastrostomy: a long-term follow-up | journal = Nutrition | volume = 13 | issue = 6 | pages = 520–523 | date = June 1997 | pmid = 9263232 | doi = 10.1016/S0899-9007(97)00030-0 }}</ref> The percentage of people at end of life with dementia using feeding tubes in the US has dropped from 12% in 2000 to 6% as of 2014.<ref>{{cite journal | vauthors = Mitchell SL, Mor V, Gozalo PL, Servadio JL, Teno JM | title = Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000–2014 | journal = JAMA | volume = 316 | issue = 7 | pages = 769–770 | date = August 2016 | pmid = 27533163 | pmc = 4991625 | doi = 10.1001/jama.2016.9374 | url = http://jama.jamanetwork.com/data/journals/jama/935644/jld160020.pdf | url-status = live | archive-url = https://web.archive.org/web/20170921235656/http://jama.jamanetwork.com/data/journals/jama/935644/jld160020.pdf | archive-date = September 21, 2017 }}</ref><ref name="NYT20160816">{{Cite news | url = https://www.nytimes.com/2016/08/30/health/tube-feeding-dementia-patients.html | title = The Decline of Tube Feeding for Dementia Patients | date = August 29, 2016 | work = [[The New York Times]] | vauthors = Span P | access-date = August 31, 2016 | url-status = live | archive-url = https://web.archive.org/web/20160903051930/http://www.nytimes.com/2016/08/30/health/tube-feeding-dementia-patients.html | archive-date = September 3, 2016 }}</ref>
The immediate and long-term effects of modifying the thickness of fluids for swallowing difficulties in people with dementia are not well known.<ref name="Flynn_2018">{{cite journal | vauthors = Flynn E, Smith CH, Walsh CD, Walshe M | title = Modifying the consistency of food and fluids for swallowing difficulties in dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 9 | page = CD011077 | date = September 2018 | pmid = 30251253 | pmc = 6513397 | doi = 10.1002/14651858.cd011077.pub2 }}</ref> While thickening fluids may have an immediate positive effect on swallowing and improving oral intake, the long-term impact on the health of the person with dementia should also be considered.<ref name="Flynn_2018" />
=== Exercise ===
{{Further|Neurobiological effects of physical exercise}}
Exercise programs may improve the ability of people with dementia to perform daily activities, but the best type of exercise is still unclear.<ref>{{cite journal | vauthors = Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S | title = Exercise programs for people with dementia | journal = The Cochrane Database of Systematic Reviews | issue = 4 | page = CD006489 | date = April 2015 | volume = 2015 | pmid = 25874613 | doi = 10.1002/14651858.CD006489.pub4 | pmc = 9426996 }}</ref> Getting more exercise can slow the development of cognitive problems such as dementia, proving to reduce the risk of Alzheimer's disease by about 50%. A balance of strength exercise, to help muscles pump blood to the brain, and balance exercises are recommended for aging people. A suggested amount of about {{frac|2|1|2}} hours per week can reduce risks of cognitive decay as well as other health risks like falling.<ref name="Melinda">{{Cite web| vauthors = Smith M, Robinson L, Segal J |title=Preventing Alzheimer's Disease – HelpGuide.org |url=https://www.helpguide.org/articles/alzheimers-dementia-aging/preventing-alzheimers-disease.htm|access-date=December 13, 2020|website=HelpGuide.org|date=November 2, 2018 |language=en-US}}</ref>
=== Assistive technology ===
There is a lack of high-quality evidence to determine whether [[assistive technology]] effectively supports people with dementia to manage memory issues.<ref>{{cite journal | vauthors = Van der Roest HG, Wenborn J, Pastink C, Dröes RM, Orrell M | title = Assistive technology for memory support in dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 6 | page = CD009627 | date = June 2017 | pmid = 28602027 | pmc = 6481376 | doi = 10.1002/14651858.cd009627.pub2 }}</ref> Some of the specific things that are used today that helps with dementia today are: clocks, communication aids, electrical appliances the use monitoring, GPS location/ tracking devices, home care robots, in-home cameras, and medication management are just to name a few.<ref>{{Cite web |title=7 Technological Innovations for Those With Dementia |url=https://www.alzheimers.net/9-22-14-technology-for-dementia |access-date=June 28, 2022 |website=Alzheimers.net |language=en}}</ref> Technology has the potential to be a valuable intervention for alleviating loneliness and promoting social connections, supported by available evidence.<ref>{{cite journal | vauthors = Anderson M, Menon R, Oak K, Allan L | title = The use of technology for social interaction by people with dementia: A scoping review | journal = PLOS Digital Health | volume = 1 | issue = 6 | page = e0000053 | date = June 2022 | pmid = 36812560 | pmc = 9931370 | doi = 10.1371/journal.pdig.0000053 | doi-access = free }}</ref>
===Alternative medicine===
Evidence of the therapeutic values of [[aromatherapy]] and [[massage]] is unclear.<ref>{{cite journal | vauthors = Viggo Hansen N, Jørgensen T, Ørtenblad L | title = Massage and touch for dementia | journal = The Cochrane Database of Systematic Reviews | issue = 4 | page = CD004989 | date = October 2006 | volume = 2006 | pmid = 17054228 | pmc = 6823223 | doi = 10.1002/14651858.CD004989.pub2 }}</ref><ref>{{cite journal | vauthors = Ball EL, Owen-Booth B, Gray A, Shenkin SD, Hewitt J, McCleery J | title = Aromatherapy for dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | page = CD003150 | date = August 2020 | issue = 8 | pmid = 32813272 | pmc = 7437395 | doi = 10.1002/14651858.CD003150.pub3 }}</ref> It is not clear if [[cannabinoid]]s are harmful or effective for people with dementia.<ref>{{cite journal | vauthors = Bosnjak Kuharic D, Markovic D, Brkovic T, Jeric Kegalj M, Rubic Z, Vuica Vukasovic A, Jeroncic A, Puljak L | display-authors = 6 | title = Cannabinoids for the treatment of dementia | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 9 | page = CD012820 | date = September 2021 | pmid = 34532852 | pmc = 8446835 | doi = 10.1002/14651858.CD012820.pub2 }}</ref>
=== Palliative care ===
Given the progressive and terminal nature of dementia, [[palliative care]] can be helpful to patients and their caregivers by helping people with the disorder and their caregivers understand what to expect, deal with loss of physical and mental abilities, support the person's wishes and goals including surrogate decision making, and discuss wishes for or against [[CPR]] and [[life support]].<ref name="pmid15945590">{{cite journal | vauthors = Sampson EL, Ritchie CW, Lai R, Raven PW, Blanchard MR | title = A systematic review of the scientific evidence for the efficacy of a palliative care approach in advanced dementia | journal = International Psychogeriatrics | volume = 17 | issue = 1 | pages = 31–40 | date = March 2005 | pmid = 15945590 | doi = 10.1017/S1041610205001018 | doi-broken-date = November 1, 2024 | url = http://pdfs.semanticscholar.org/6872/9bce1863bcc3eb31cda841fefc2a74e54450.pdf | archive-url = https://web.archive.org/web/20190224204415/http://pdfs.semanticscholar.org/6872/9bce1863bcc3eb31cda841fefc2a74e54450.pdf | url-status = dead | archive-date = February 24, 2019 | s2cid = 7861568 }}</ref><ref name="pmid24997202">{{cite journal | vauthors = Van den Block L | title = The need for integrating palliative care in ageing and dementia policies | journal = European Journal of Public Health | volume = 24 | issue = 5 | pages = 705–706 | date = October 2014 | pmid = 24997202 | doi = 10.1093/eurpub/cku084 | doi-access = free }}</ref> Because the decline can be rapid, and because most people prefer to allow the person with dementia to make their own decisions, palliative care involvement before the late stages of dementia is recommended.<ref>{{cite journal | vauthors = van der Steen JT, Radbruch L, Hertogh CM, de Boer ME, Hughes JC, Larkin P, Francke AL, Jünger S, Gove D, Firth P, Koopmans RT, Volicer L | display-authors = 6 | title = White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care | journal = Palliative Medicine | volume = 28 | issue = 3 | pages = 197–209 | date = March 2014 | pmid = 23828874 | doi = 10.1177/0269216313493685 | author13 = European Association for Palliative Care (EAPC) | doi-access = free | hdl = 2066/137210 | hdl-access = free }}</ref><ref name="pmid18416791">{{cite journal | vauthors = Birch D, Draper J | title = A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia | journal = Journal of Clinical Nursing | volume = 17 | issue = 9 | pages = 1144–1163 | date = May 2008 | pmid = 18416791 | doi = 10.1111/j.1365-2702.2007.02220.x | url = http://oro.open.ac.uk/10829/1/jcnur_2006-0670_r4_FINAL.pdf }}</ref> Further research is required to determine the appropriate palliative care interventions and how well they help people with advanced dementia.<ref name="Walsh_2021" />
[[Person-centered care]] helps maintain the dignity of people with dementia.<ref name="MitchellAgnelli2015">{{cite journal | vauthors = Mitchell G, Agnelli J | title = Person-centred care for people with dementia: Kitwood reconsidered | journal = Nursing Standard | volume = 30 | issue = 7 | pages = 46–50 | date = October 2015 | pmid = 26463810 | doi = 10.7748/ns.30.7.46.s47 }}</ref>
==== Remotely delivered information for caregivers ====
Remotely delivered interventions including support, training and information may reduce the burden for the informal caregiver and improve their depressive symptoms.<ref name="González-Fraile_2021">{{cite journal | vauthors = González-Fraile E, Ballesteros J, Rueda JR, Santos-Zorrozúa B, Solà I, McCleery J | title = Remotely delivered information, training and support for informal caregivers of people with dementia | journal = The Cochrane Database of Systematic Reviews | volume = 1 | page = CD006440 | date = January 2021 | issue = 1 | pmid = 33417236 | pmc = 8094510 | doi = 10.1002/14651858.cd006440.pub3 }}</ref> There is no certain evidence that they improve health-related quality of life.<ref name="González-Fraile_2021" />
In several localities in Japan, [[digital surveillance]] may be made available to family members, if a dementia patient is prone to wandering and going missing.<ref>{{Cite news| vauthors = Dooley B, Ueno H |date=February 2, 2022|title=Where a Thousand Digital Eyes Keep Watch Over the Elderly|language=en-US|work=The New York Times|url=https://www.nytimes.com/2022/02/02/business/japan-elderly-surveillance.html|access-date=February 6, 2022|issn=0362-4331}}</ref>
== Epidemiology ==
[[File:Alzheimer's disease and other dementias world map-Deaths per million persons-WHO2012.svg|thumb|upright=1.3|Deaths per million persons in 2012 due to dementia{{Col-begin}} {{Col-break}}{{legend|#ffff20|0–4}}{{legend|#ffe820|5–8}}{{legend|#ffd820|9–10}}{{legend|#ffc020|11–13}}{{legend|#ffa020|14–17}}{{Col-break}}{{legend|#ff9a20|18–24}}{{legend|#f08015|25–45}}{{legend|#e06815|46–114}}{{legend|#d85010|115–375}}{{legend|#d02010|376–1266}}{{col-end}}]]
[[Image:Alzheimer and other dementias world map - DALY - WHO2004.svg|thumb|upright=1.3|[[Disability-adjusted life year]] for Alzheimer and other dementias per 100,000&nbsp;inhabitants in 2004 {{Col-begin}} {{Col-break}} {{legend|#ffff65|<100}} {{legend|#fff200|100–120}} {{legend|#ffdc00|120–140}} {{legend|#ffc600|140–160}} {{legend|#ffb000|160–180}} {{legend|#ff9a00|180–200}} {{Col-break}} {{legend|#ff8400|200–220}} {{legend|#ff6e00|220–240}} {{legend|#ff5800|240–260}} {{legend|#ff4200|260–280}} {{legend|#ff2c00|280–300}} {{legend|#cb0000|>300}} {{col-end}}]]
The number of cases of dementia worldwide in 2021 was estimated at 55 million, with close to 10&nbsp;million new cases each year.<ref name="WHO2022"/> According to a report by the [[World Health Organization]], "In 2021, Alzheimer’s disease and other forms of dementia ranked as the seventh leading cause of death, killing 1.8 million lives."<ref>{{Cite web |title=The top 10 causes of death |url=https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death |access-date=2024-08-12 |website=www.who.int |language=en}}</ref> By 2050, the number of people living with dementia is estimated to be over 150&nbsp;million globally.<ref>{{cite journal | vauthors = Nichols E, Steinmetz JD, Vollset SE, Fukutaki K, Chalek J, Abd-Allah F, etal | collaboration = GBD 2019 Dementia Forecasting Collaborators | title = Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019 | language = English | journal = The Lancet. Public Health | volume = 7 | issue = 2 | pages = e105–e125 | date = February 2022 | pmid = 34998485 | pmc = 8810394 | doi = 10.1016/S2468-2667(21)00249-8 }}</ref> Around 7% of people over the age of 65 have dementia, with slightly higher rates (up to 10% of those over 65) in places with relatively high life expectancy.<ref name=Gale2018>{{cite journal |vauthors=Gale SA, Acar D, Daffner KR |title=Dementia |journal=Am J Med |volume=131 |issue=10 |pages=1161–1169 |date=October 2018 |pmid=29425707 |doi=10.1016/j.amjmed.2018.01.022 |s2cid=240122313 |url=}}</ref> An estimated 58% of people with dementia are living in low and middle income countries.<ref name="Alzheimer's Disease International_2015">{{Cite web |url=https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf |archive-url=https://ghostarchive.org/archive/20221009/https://www.alz.co.uk/research/WorldAlzheimerReport2015.pdf |archive-date=October 9, 2022 |url-status=live|title=World Alzheimer Report 2015|last=Alzheimer's Disease International|date=Sep 2015|access-date=October 30, 2018}}</ref><ref name="Prince_2012">{{cite journal |vauthors=Prince M, Jackson J |year=2009 |title=World Alzheimer Report 2009 |url=http://www.alz.co.uk/research/world-report |url-status=dead |journal=Alzheimer's Disease International |page=38 |archive-url=https://web.archive.org/web/20120311215443/http://www.alz.co.uk/research/world-report |archive-date=March 11, 2012 |access-date=March 11, 2012}}</ref> The prevalence of dementia differs in different world regions, ranging from 4.7% in Central Europe to 8.7% in North Africa/Middle East; the prevalence in other regions is estimated to be between 5.6 and 7.6%.<ref name="Alzheimer's Disease International_2015" /> The number of people living with dementia is estimated to double every 20 years. In 2016 dementia resulted in about 2.4&nbsp;million deaths,<ref name=GBD2019/> up from 0.8&nbsp;million in 1990.<ref name=GBD2015>{{cite journal | vauthors = Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, etal | collaboration = GBD 2015 Mortality and Causes of Death Collaborators | title = Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1459–1544 | date = October 2016 | pmid = 27733281 | pmc = 5388903 | doi = 10.1016/s0140-6736(16)31012-1 }}</ref> The genetic and environmental risk factors for dementia disorders vary by ethnicity.<ref>{{cite journal | vauthors = Brijnath B, Croy S, Sabates J, Thodis A, Ellis S, de Crespigny F, Moxey A, Day R, Dobson A, Elliott C, Etherington C, Geronimo MA, Hlis D, Lampit A, Low LF, Straiton N, Temple J | display-authors = 6 | title = Including ethnic minorities in dementia research: Recommendations from a scoping review | journal = Alzheimer's & Dementia | volume = 8 | issue = 1 | page = e12222 | date = 2022 | pmid = 35505899 | pmc = 9053375 | doi = 10.1002/trc2.12222 }}</ref><ref>{{cite journal | vauthors = Sabayan B, Wyman-Chick KA, Sedaghat S | title = The Burden of Dementia Spectrum Disorders and Associated Comorbid and Demographic Features | journal = Clinics in Geriatric Medicine | volume = 39 | issue = 1 | pages = 1–14 | date = February 2023 | pmid = 36404023 | doi = 10.1016/j.cger.2022.07.001 | s2cid = 253068389 }}</ref> For instance, Alzheimer's disease among [[Alzheimer's disease in the Hispanic/Latino population|Hispanic/Latino]] and [[Alzheimer's disease in African Americans|African American]] subjects exhibit lower risks associated with gene changes in the [[apolipoprotein E]] gene than do non-Hispanic white subjects.<ref>{{Cite journal |author1=Ariana M. Stickel |author2=Andrew C. McKinnon |author3=Stephanie Matijevik |author4=Matthew D. Grilli |author5=John Ruiz |author6=Lee Ryam |date=February 26, 2021 |title=Apolipoprotein E ε4 Allele-Based Differences in Brain Volumes Are Largely Uniform Across Late Middle Aged and Older Hispanic/Latino- and Non-Hispanic/Latino Whites Without Dementia |journal=Frontiers in Aging Neuroscience |volume=13 |doi=10.3389/fnagi.2021.627322 |doi-access=free |pmid=33716715 |pmc=7952627 }}</ref>
The annual incidence of dementia diagnosis is nearly 10 million worldwide.<ref name="Walsh_2021"/> Almost half of new dementia cases occur in Asia, followed by Europe (25%), the Americas (18%) and Africa (8%). The incidence of dementia increases exponentially with age, doubling with every 6.3-year increase in age.<ref name="Alzheimer's Disease International_2015" /> Dementia affects 5% of the population older than 65 and 20–40% of those older than 85.<ref name="Sadock2008">{{cite book|title=Kaplan & Sadock's concise textbook of clinical psychiatry| vauthors = Sadock BJ, Sadock VA |publisher=Wolters Kluwer/Lippincott Williams & Wilkins |isbn=978-0-7817-8746-8|edition=3rd|location=Philadelphia|page=52 |year=2008|chapter=Delirium, Dementia, and Amnestic and Other Cobnitive Disorders and Mental Disorders Due to a General Medical Condition |chapter-url=https://books.google.com/books?id=ubG51n2NgfwC&pg=PA52}}</ref> Rates are slightly higher in women than men at ages 65 and greater.<ref name="Sadock2008" /> The disease trajectory is varied and the median time from diagnosis to death depends strongly on age at diagnosis, from 6.7 years for people diagnosed aged 60–69 to 1.9 years for people diagnosed at 90 or older.<ref name="Walsh_2021"/>
Dementia impacts not only individuals with dementia, but also their carers and the wider society. Among people aged 60 years and over, dementia is ranked the 9th most burdensome condition according to the 2010 [[Disease burden|Global Burden of Disease]] (GBD) estimates. The global costs of dementia was around US$818&nbsp;billion in 2015, a 35.4% increase from US$604&nbsp;billion in 2010.<ref name="Alzheimer's Disease International_2015" />
A new 2024 study reveals that deaths from dementia in the U.S. have tripled in the past 21 years, rising from around 150,000 in 1999 to over 450,000 in 2020; the likelihood of dying from dementia increased across all demographic groups studied.<ref>{{Cite journal |last1=Ali |first1=Mohsan |last2=Talha |first2=Muhammad |last3=Naseer |first3=Bisal |last4=Jaka |first4=Sanobar |last5=Gunturu |first5=Sasidhar |date=2024-08-13 |title=Divergent Mortality Patterns Associated With Dementia in the United States: 1999–2020 |url=https://www.psychiatrist.com/pcc/divergent-mortality-patterns-associated-with-dementia-united-states-1999-2020/ |journal=The Primary Care Companion for CNS Disorders |language=English |volume=26 |issue=4 |pages=56364 |doi=10.4088/PCC.24m03724 |pmid=39178013 |issn=2155-7780}}</ref>
=== Affected ages ===
{{See also|Early onset dementia}}
About 3% of people between the ages of 65–74 have dementia, 19% between 75 and 84, and nearly half of those over 85 years of age. As more people are living longer, dementia is becoming more common.<ref>{{Cite web |title=What causes young-onset dementia? {{!}} Alzheimer's Society |url=https://www.alzheimers.org.uk/about-dementia/types-dementia/what-causes-young-onset-dementia |access-date=June 28, 2022 |website=alzheimers.org.uk |language=en}}</ref> For people of a specific age, however, it may be becoming less frequent in the developed world, due to a decrease in modifiable risk factors made possible by greater financial and educational resources. It is one of the most common causes of disability among the elderly but can develop before the age of 65 when it is known as early-onset dementia or presenile dementia.<ref name="ADUK">{{cite web |title=What causes young-onset dementia? {{!}} Alzheimer's Society |url=https://www.alzheimers.org.uk/about-dementia/types-dementia/what-causes-young-onset-dementia |website=alzheimers.org.uk |access-date=January 10, 2022 |language=en}}</ref><ref>{{cite journal | vauthors = Vieira RT, Caixeta L, Machado S, Silva AC, Nardi AE, Arias-Carrión O, Carta MG | title = Epidemiology of early-onset dementia: a review of the literature | journal = Clinical Practice and Epidemiology in Mental Health | volume = 9 | pages = 88–95 | date = June 14, 2013 | pmid = 23878613 | pmc = 3715758 | doi = 10.2174/1745017901309010088 }}</ref> Less than 1% of those with Alzheimer's have gene mutations that cause a much earlier development of the disease, around the age of 45, known as [[early-onset Alzheimer's disease]].<ref name="Masters_2015">{{cite journal | vauthors = Masters CL, Bateman R, Blennow K, Rowe CC, Sperling RA, Cummings JL | title = Alzheimer's disease | language = English | journal = Nature Reviews. Disease Primers | volume = 1 | page = 15056 | date = October 2015 | pmid = 27188934 | doi = 10.1038/nrdp.2015.56 | s2cid = 20844163 }}</ref> More than 95% of people with Alzheimer's disease have the sporadic form (late onset, 80–90 years of age).<ref name="Masters_2015"/> Worldwide the cost of dementia in 2015 was put at US$818&nbsp;billion. People with dementia are often physically or chemically restrained to a greater degree than necessary, raising issues of human rights.<ref name="WHO2022"/><ref>{{cite journal | vauthors = Jessop T, Peisah C | title = Human Rights and Empowerment in Aged Care: Restraint, Consent and Dying with Dignity | journal = International Journal of Environmental Research and Public Health | volume = 18 | issue = 15 | page = 7899 | date = July 2021 | pmid = 34360196 | pmc = 8345762 | doi = 10.3390/ijerph18157899 | doi-access = free }}</ref> [[Social stigma]] is commonly perceived by those with the condition, and also by their caregivers.<ref name="Martin"/>
==History==
{{more citations needed section|date=November 2015}}
{{See also|Dementia praecox}}
Until the end of the 19th century, dementia was a much broader clinical concept. It included mental illness and any type of psychosocial incapacity, including reversible conditions.<ref name=Berr>{{cite journal | vauthors = Berrios GE | title = Dementia during the seventeenth and eighteenth centuries: a conceptual history | journal = Psychological Medicine | volume = 17 | issue = 4 | pages = 829–837 | date = November 1987 | pmid = 3324141 | doi = 10.1017/S0033291700000623 | s2cid = 8262492 }}</ref> ''Dementia'' at this time simply referred to anyone who had lost the ability to reason, and was applied equally to psychosis, "organic" diseases like [[syphilis]] that destroy the brain, and to the dementia associated with old age, which was attributed to "[[hardening of the arteries]]".
[[File:A woman diagnosed as suffering from chronic dementia. Colour Wellcome L0026688.jpg|thumb|left|upright=0.7|A 19th-century drawing of a woman diagnosed with dementia]]
Dementia has been referred to in medical texts since [[Ancient history|antiquity]]. One of the earliest known allusions to dementia is attributed to the 7th-century BC [[Ancient Greek philosophy|Greek philosopher]] [[Pythagoras]], who divided the human lifespan into six distinct phases: 0–6 (infancy), 7–21 (adolescence), 22–49 (young adulthood), 50–62 (middle age), 63–79 (old age), and 80–death (advanced age). The last two he described as the "senium", a period of mental and physical decay, and that the final phase was when "the scene of mortal existence closes after a great length of time that very fortunately, few of the human species arrive at, where the mind is reduced to the imbecility of the first epoch of infancy".<ref>{{cite journal | author = Berchtold NC, Cotman CW | year = 1998 | title = Evolution in the conceptu-alization of dementia and Alzheimer's disease: Greco-Roman period to the 1960s | journal = Neurobiol Aging | volume = 19 | issue = 3| pages = 173–189 | doi = 10.1016/s0197-4580(98)00052-9 | pmid = 9661992 | s2cid = 24808582 }}</ref> In 550&nbsp;BC, the Athenian statesman and poet [[Solon]] argued that the terms of a man's will might be invalidated if he exhibited loss of judgement due to advanced age. [[Traditional Chinese medicine|Chinese medical]] texts made allusions to the condition as well, and the characters for "dementia" translate literally to "foolish old person".<ref>{{Cite book|url=https://www.worldcat.org/oclc/19455117|title=Diagnosis and treatment of senile dementia|date=1989|publisher=Springer-Verlag| vauthors = Bergener M, Reisberg B |isbn=0-387-50800-7|location=Berlin|oclc=19455117}}</ref>
Athenian philosophers [[Aristotle]] and [[Plato]] discussed the mental decline that can come with old age and predicted that this affects everyone who becomes old and nothing can be done to stop this decline from taking place. Plato specifically talked about how the elderly should not be in positions that require responsibility because, "There is not much acumen of the mind that once carried them in their youth, those characteristics one would call judgement, imagination, power of reasoning, and memory. They see them gradually blunted by deterioration and can hardly fulfill their function."<ref>{{Cite book | vauthors = Xihua J |title=Diagnosis and Treatment of Senile Dementia: Research Methods and Perspective |year=1989 |isbn=93-80615-34-5 |page=38 |publisher=Madhav Books (P) Limited, a unit of Serials Publications |language=English}}</ref>
For comparison, the Roman statesman [[Cicero]] held a view much more in line with modern-day medical wisdom that loss of mental function was not inevitable in the elderly and "affected only those old men who were weak-willed". He spoke of how those who remained mentally active and eager to learn new things could stave off dementia. However, Cicero's views on aging, although progressive, were largely ignored in a world that would be dominated for centuries by Aristotle's medical writings. Physicians during the Roman Empire, such as [[Galen]] and [[Celsus]], simply repeated the beliefs of Aristotle while adding few new contributions to medical knowledge.
[[Byzantine Empire|Byzantine]] physicians sometimes wrote of dementia. It is recorded that at least seven emperors whose lifespans exceeded 70 years displayed signs of cognitive decline. In [[Constantinople]], special hospitals housed those diagnosed with dementia or insanity, but these did not apply to the emperors, who were above the law and whose health conditions could not be publicly acknowledged.
Otherwise, little is recorded about dementia in Western medical texts for nearly 1700 years. One of the few references was the 13th-century friar [[Roger Bacon]], who viewed old age as divine punishment for [[original sin]]. Although he repeated existing Aristotelian beliefs that dementia was inevitable, he did make the progressive assertion that the brain was the center of memory and thought rather than the heart.
Poets, playwrights, and other writers made frequent allusions to the loss of mental function in old age. [[William Shakespeare]] notably mentions it in plays such as ''[[Hamlet]]'' and ''[[King Lear]]''.
During the 19th century, doctors generally came to believe that elderly dementia was the result of [[cerebral atherosclerosis]], although opinions fluctuated between the idea that it was due to blockage of the major arteries supplying the brain or small strokes within the vessels of the [[cerebral cortex]].
In 1907, Bavarian psychiatrist [[Alois Alzheimer]] was the first to identify and describe the characteristics of progressive dementia in the brain of 51-year-old [[Auguste Deter]].<ref name="auto">Zilka, N., & Novak, M. (2006). The tangled story of Alois Alzheimer. ''Bratislavske lekarske listy'', ''107''(9–10), 343–345.</ref> Deter had begun to behave uncharacteristically, including accusing her husband of adultery, neglecting household chores, exhibiting difficulties writing and engaging in conversations, heightened insomnia, and loss of directional sense.<ref name="auto1">{{cite journal | vauthors = Yang HD, Kim DH, Lee SB, Young LD | title = History of Alzheimer's Disease | journal = Dementia and Neurocognitive Disorders | volume = 15 | issue = 4 | pages = 115–121 | date = December 2016 | pmid = 30906352 | pmc = 6428020 | doi = 10.12779/dnd.2016.15.4.115 }}</ref> At one point, Deter was reported to have "dragged a bed sheet outside, wandered around wildly, and cried for hours at midnight."<ref name="auto1"/> Alzheimer began treating Deter when she entered a [[Frankfurt]] mental hospital on November 25, 1901.<ref name="auto1"/> During her ongoing treatment, Deter and her husband struggled to afford the cost of the medical care, and Alzheimer agreed to continue her treatment in exchange for Deter's medical records and donation of her brain upon death.<ref name="auto1"/> Deter died on April 8, 1906, after succumbing to [[sepsis]] and [[pneumonia]].<ref name="auto1"/> Alzheimer conducted the brain biopsy using the [[Bielschowsky stain]] method, which was a new development at the time, and he observed [[senile plaques]], [[neurofibrillary tangle]]s, and atherosclerotic alteration.<ref name="auto"/> At the time, the consensus among medical doctors had been that senile plaques were generally found in older patients, and the occurrence of neurofibrillary tangles was an entirely new observation at the time.<ref name="auto1"/> Alzheimer presented his findings at the 37th psychiatry conference of southwestern Germany in [[Tübingen]] on April 11, 1906; however, the information was poorly received by his peers.<ref name="auto1"/> By 1910, Alois Alzheimer's teacher, [[Emil Kraepelin]], published a book in which he coined the term "Alzheimer's disease" in an attempt to acknowledge the importance of Alzheimer's discovery.<ref name="auto"/><ref name="auto1"/>
By the 1960s, the link between [[neurodegenerative disease]]s and age-related cognitive decline had become more established. By the 1970s, the medical community maintained that vascular dementia was rarer than previously thought and Alzheimer's disease caused the vast majority of old age mental impairments. More recently however, it is believed that dementia is often a mixture of conditions.
In 1976, neurologist [[Robert Katzmann (Neurologist)|Robert Katzmann]] suggested a link between senile dementia and Alzheimer's disease.<ref>{{cite news|url=https://www.nytimes.com/2010/07/17/health/research/17drug.html|title=Drug Trials Test Bold Plan to Slow Alzheimer's| vauthors = Kolata G |date=June 17, 2010|newspaper=The New York Times|access-date=June 17, 2010|url-status=live|archive-url= https://web.archive.org/web/20120409121141/http://www.nytimes.com/2010/07/17/health/research/17drug.html|archive-date=April 9, 2012|author-link=Gina Kolata }}</ref> Katzmann suggested that much of the senile dementia occurring (by definition) after the age of 65, was pathologically identical with Alzheimer's disease occurring in people under age 65 and therefore should not be treated differently.<ref name="Katzman1976">{{cite journal | vauthors = Katzman R | title = Editorial: The prevalence and malignancy of Alzheimer disease. A major killer | journal = Archives of Neurology | volume = 33 | issue = 4 | pages = 217–218 | date = April 1976 | pmid = 1259639 | doi = 10.1001/archneur.1976.00500040001001 }}</ref> Katzmann thus suggested that Alzheimer's disease, if taken to occur over age 65, is actually common, not rare, and was the fourth- or 5th-leading cause of death, even though rarely reported on death certificates in 1976.
A helpful finding was that although the incidence of Alzheimer's disease increased with age (from 5–10% of 75-year-olds to as many as 40–50% of 90-year-olds), no threshold was found by which age all persons developed it. This is shown by documented supercentenarians (people living to 110 or more) who experienced no substantial cognitive impairment. Some evidence suggests that dementia is most likely to develop between ages 80 and 84 and individuals who pass that point without being affected have a lower chance of developing it. Women account for a larger percentage of dementia cases than men, although this can be attributed to their longer overall lifespan and greater odds of attaining an age where the condition is likely to occur.<ref>{{Cite web|title=Prevalence by gender in the UK|url=https://www.dementiastatistics.org/statistics/prevalence-by-gender-in-the-uk/|access-date=October 4, 2021|website=Dementia Statistics Hub|language=en-GB}}</ref>
Much like other diseases associated with aging, dementia was comparatively rare before the 20th century, because few people lived past 80. Conversely, syphilitic dementia was widespread in the developed world until it was largely eradicated by the use of [[penicillin]] after [[World War II]]. With significant increases in life expectancy thereafter, the number of people over 65 started rapidly climbing. While elderly persons constituted an average of 3–5% of the population prior to 1945, by 2010 many countries reached 10–14% and in Germany and Japan, this figure exceeded 20%. Public awareness of Alzheimer's Disease greatly increased in 1994 when former US president [[Ronald Reagan]] announced that he had been diagnosed with the condition.
In the 21st century, [[Frontotemporal dementia|other types of dementia]] were differentiated from Alzheimer's disease and vascular dementias (the most common types). This differentiation is on the basis of pathological examination of brain tissues, by symptomatology, and by different patterns of brain metabolic activity in nuclear medical imaging tests such as [[SPECT]] and [[PET scan]]s of the brain. The various forms have differing prognoses and differing epidemiologic risk factors. The main cause for many diseases, including Alzheimer's disease, remains unclear.<ref>{{Cite web|title=Alzheimer's disease – Symptoms and causes|url=https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/symptoms-causes/syc-20350447|access-date=October 1, 2021|website=Mayo Clinic|language=en}}</ref>
===Terminology===
Dementia in the elderly was once called '''senile dementia''' or '''senility''', and viewed as a normal and somewhat inevitable aspect of [[aging]].<ref name="senility-aa">{{cite web |title=What is dementia? |url=https://www.alz.org/alzheimers-dementia/what-is-dementia |publisher=Alzheimer's Association |access-date=August 6, 2018 |quote=Dementia is often incorrectly referred to as "senility" or "senile dementia," which reflects the formerly widespread but incorrect belief that serious mental decline is a normal part of aging.}}</ref><ref name="senility-mednet">{{cite web | vauthors = Taylor DC |title=Dementia |url=https://www.medicinenet.com/dementia/article.htm |publisher=MedicineNet |access-date=August 6, 2018 |quote=Senile dementia ("senility") is a term that was once used to describe all dementias; this term is no longer used as a diagnosis.}}</ref>
By 1913–20 the term ''[[dementia praecox]]'' was introduced to suggest the development of senile-type dementia at a younger age. Eventually the two terms fused, so that until 1952 physicians used the terms ''dementia praecox'' (precocious dementia) and ''schizophrenia'' interchangeably. Since then, science has determined that dementia and schizophrenia are two different disorders, though they share some similarities.<ref>{{Cite web|title=Healthfully|url=https://healthfully.com/difference-between-dementia-schizophrenia-5688962.html|access-date=December 13, 2020|website=Healthfully|language=en}}</ref> The term ''precocious dementia'' for a mental illness suggested that a type of mental illness like schizophrenia (including [[paranoia]] and decreased cognitive capacity) could be expected to arrive normally in all persons with greater age (see [[paraphrenia]]). After about 1920, the beginning use of ''dementia'' for what is now understood as schizophrenia and senile dementia helped limit the word's meaning to "permanent, irreversible mental deterioration". This began the change to the later use of the term. In recent studies, researchers have seen a connection between those diagnosed with schizophrenia and patients who are diagnosed with dementia, finding a positive correlation between the two diseases.<ref>{{Cite web|title=The Relationship Between Schizophrenia and Dementia|url=https://www.psychologytoday.com/blog/demystifying-psychiatry/201603/the-relationship-between-schizophrenia-and-dementia|access-date=December 13, 2020|website=Psychology Today|language=en-US}}</ref>
The view that dementia must always be the result of a particular disease process led for a time to the proposed diagnosis of "senile dementia of the Alzheimer's type" (SDAT) in persons over the age of 65, with "Alzheimer's disease" diagnosed in persons younger than 65 who had the same pathology. Eventually, however, it was agreed that the age limit was artificial, and that ''Alzheimer's disease'' was the appropriate term for persons with that particular brain pathology, regardless of age.
After 1952, mental illnesses including schizophrenia were removed from the category of ''[[organic brain syndrome]]s'', and thus (by definition) removed from possible causes of "dementing illnesses" (dementias). At the same, however, the traditional cause of senile dementia – "hardening of the arteries" – now returned as a set of dementias of vascular cause (small strokes). These were now termed ''multi-infarct dementias'' or ''[[vascular dementia]]s''.
==Society and culture==
[[File:Care at Home with Dementia, Tigray (8015180561).jpg|thumb|Woman with dementia being cared for at home in [[Ethiopia]]]]The societal cost of dementia is high, especially for caregivers.<ref>{{cite journal | vauthors = Brodaty H, Donkin M | title = Family caregivers of people with dementia | journal = Dialogues in Clinical Neuroscience | volume = 11 | issue = 2 | pages = 217–228 | date = April 29, 2017 | doi = 10.31887/DCNS.2009.11.2/hbrodaty | pmid = 19585957 | pmc = 3181916 }}</ref> According to a UK-based study, almost two out of three carers of people with dementia feel lonely. Most of the carers in the study were family members or friends.<ref>{{Cite journal |date=July 22, 2020 |title=Most people caring for relatives with dementia experience loneliness |url=https://evidence.nihr.ac.uk/alert/most-people-caring-for-relatives-with-dementia-experience-loneliness/ |journal=NIHR Evidence |type=Plain English summary |language=en |doi=10.3310/alert_40575|s2cid=243269845 }}</ref><ref>{{cite journal | vauthors = Victor CR, Rippon I, Quinn C, Nelis SM, Martyr A, Hart N, Lamont R, Clare L | display-authors = 6 | title = The prevalence and predictors of loneliness in caregivers of people with dementia: findings from the IDEAL programme | journal = Aging & Mental Health | volume = 25 | issue = 7 | pages = 1232–1238 | date = July 2021 | pmid = 32306759 | doi = 10.1080/13607863.2020.1753014 | s2cid = 216028843 | doi-access = free | hdl = 10454/17813 | hdl-access = free }}</ref>
{{as of|2015}}, the annual cost per Alzheimer's patient in the United States was around $19,144.36. The total costs for the nation is estimated to be about $167.74&nbsp;billion. By 2030, it is predicted the annual socioeconomic cost will total to about $507&nbsp;billion, and by 2050 that number is expected to reach $1.89&nbsp;trillion. This steady increase will be seen not just within the United States but globally. Global estimates for the costs of dementia were $957.56&nbsp;billion in 2015, but by 2050 the estimated global cost is $9.12&nbsp;trillion.<ref>{{cite journal | vauthors = Jia J, Wei C, Chen S, Li F, Tang Y, Qin W, Zhao L, Jin H, Xu H, Wang F, Zhou A, Zuo X, Wu L, Han Y, Han Y, Huang L, Wang Q, Li D, Chu C, Shi L, Gong M, Du Y, Zhang J, Zhang J, Zhou C, Lv J, Lv Y, Xie H, Ji Y, Li F, Yu E, Luo B, Wang Y, Yang S, Qu Q, Guo Q, Liang F, Zhang J, Tan L, Shen L, Zhang K, Zhang J, Peng D, Tang M, Lv P, Fang B, Chu L, Jia L, Gauthier S | display-authors = 6 | title = The cost of Alzheimer's disease in China and re-estimation of costs worldwide | journal = Alzheimer's & Dementia | volume = 14 | issue = 4 | pages = 483–491 | date = April 2018 | pmid = 29433981 | doi = 10.1016/j.jalz.2017.12.006 | s2cid = 46762069 }}</ref>
Many countries consider the care of people living with dementia a national priority and invest in resources and education to better inform health and social service workers, unpaid caregivers, relatives and members of the wider community. Several countries have authored national plans or strategies.<ref>{{cite news |url=http://www.alz.co.uk/sites/default/files/national-alzheimer-and-dementia-plans.pdf |title=National Alzheimer and Dementia Plans Planned Policies and Activities (PDF) |date=April 2012 |publisher=Alzheimer's Disease International |location=London |url-status=dead |archive-url=https://web.archive.org/web/20120518062839/http://www.alz.co.uk/sites/default/files/national-alzheimer-and-dementia-plans.pdf |archive-date=May 18, 2012 |access-date=December 3, 2012 }}</ref><ref>{{Cite news|url=http://brookdale.jdc.org.il/en/publication/addressing-alzheimers-types-dementiaisraeli-national-strategy-summary-document-interdisciplinary-inter-organizational-group-experts/|title=Addressing Alzheimer's and Other Types of Dementia:Israeli National Strategy Summary Document of the Interdisciplinary, Inter-Organizational Group of Experts » Brookdale|work=Brookdale|access-date=June 4, 2018}}</ref> These plans recognize that people can live reasonably with dementia for years, as long as the right support and timely access to a diagnosis are available. Former British Prime Minister [[David Cameron]] described dementia as a "national crisis", affecting 800,000 people in the United Kingdom.<ref>{{cite news |url=https://www.theguardian.com/society/2012/mar/26/dementia-research-funding-to-double |title=Dementia research funding to more than double to £66m by 2015 | vauthors = Boseley S |work=[[The Guardian]] |date=March 26, 2012 |location=London |issn=0261-3077 |oclc=60623878 |access-date=April 27, 2012 |url-status=live |archive-url=https://web.archive.org/web/20131020053209/http://www.theguardian.com/society/2012/mar/26/dementia-research-funding-to-double |archive-date=October 20, 2013 }}</ref> In fact, dementia has become the leading cause of death for women in England.<ref>{{cite journal | vauthors = O'Dowd A | title = Dementia is now leading cause of death in women in England | journal = BMJ | volume = 358 | page = j3445 | date = July 2017 | pmid = 28710087 | doi = 10.1136/bmj.j3445 | s2cid = 29011449 | id = {{ProQuest|1919058612}} }}</ref>
There, as with all mental disorders, people with dementia could potentially be a danger to themselves or others, they can be detained under the [[Mental Health Act 1983]] for assessment, care and treatment. This is a last resort, and is usually avoided by people with family or friends who can ensure care.
Some hospitals in Britain work to provide enriched and friendlier care. To make the hospital wards calmer and less overwhelming to residents, staff replaced the usual nurses' station with a collection of smaller desks, similar to a reception area. The incorporation of bright lighting helps increase positive mood and allow residents to see more easily.<ref>{{Cite news|url=https://www.economist.com/britain/2018/09/15/british-hospitals-are-having-a-dementia-friendly-makeover|title=British hospitals are having a dementia-friendly makeover|newspaper=The Economist|access-date=September 17, 2018}}</ref>
[[Driving]] with dementia can lead to injury or death. Doctors should advise appropriate testing on when to quit driving.<ref>{{cite web |title=Drivers with dementia a growing problem, MDs warn |date=September 19, 2007 |publisher=CBC News, Canada |url=https://www.cbc.ca/news/science/drivers-with-dementia-a-growing-problem-mds-warn-1.641899?ref=rss |url-status=live |archive-url=https://web.archive.org/web/20071002100058/http://www.cbc.ca/health/story/2007/09/19/drivers-dementia.html?ref=rss |archive-date=October 2, 2007 }}</ref> The United Kingdom [[DVLA]] (Driver & Vehicle Licensing Agency) states that people with dementia who specifically have poor short-term memory, disorientation, or lack of insight or judgment are not allowed to drive, and in these instances the DVLA must be informed so that the driving license can be revoked. They acknowledge that in low-severity cases and those with an early diagnosis, drivers may be permitted to continue driving.
Many support networks are available to people with dementia and their families and caregivers. Charitable organizations aim to raise awareness and campaign for the rights of people living with dementia. Support and guidance are available on assessing testamentary capacity in people with dementia.<ref>{{cite journal | vauthors = Thompson SB | year = 2009 | title = Testamentary capacity and cognitive rehabilitation: implications for head-injured and neurologically impaired individuals | journal = Journal of Cognitive Rehabilitation | volume = 27 | pages = 11–13 }} Also published in: {{cite thesis | vauthors = Thompson S |chapter=Testamentary capacity and cognitive rehabilitation: implications for head-injured and neurologically impaired individuals |pages=372–381 |title=Advancing knowledge into the clinical assessment of dementia |date=September 2010 |chapter-url=https://eprints.bournemouth.ac.uk/16247/ }}</ref>
In 2015, Atlantic Philanthropies announced a $177 million gift aimed at understanding and reducing dementia. The recipient was Global Brain Health Institute, a program co-led by the [[University of California, San Francisco]] and [[Trinity College Dublin]]. This donation is the largest non-capital grant Atlantic has ever made, and the biggest philanthropic donation in Irish history.<ref>{{Cite web |url=http://www.philanthropyroundtable.org/topic/excellence_in_philanthropy/briefly_noted80 |title=Tackling dementia |work=Philanthropy magazine |date=Winter 2016 |url-status=live |archive-url=https://web.archive.org/web/20160211210606/http://www.philanthropyroundtable.org/topic/excellence_in_philanthropy/briefly_noted80 |archive-date=February 11, 2016 }}</ref>
In October 2020, [[the Caretaker (musician)|the Caretaker]]'s last music release, ''[[Everywhere at the End of Time]]'', was popularized by [[TikTok]] users for its depiction of the stages of dementia.<ref>{{Cite web |url=https://www.npr.org/2020/10/22/926607585/tiktok-the-caretaker-challenge-avant-garde |title=What Happens When TikTok Looks To The Avant-Garde For A Challenge? |date=October 22, 2020 |access-date=April 6, 2021 |publisher=[[NPR]] | vauthors = Garvey M |archive-url=https://web.archive.org/web/20201022215520/https://www.npr.org/2020/10/22/926607585/tiktok-the-caretaker-challenge-avant-garde |archive-date=October 22, 2020 |url-status=live}}</ref> Caregivers were in favor of this phenomenon; Leyland Kirby, the creator of the record, echoed this sentiment, explaining it could cause empathy among a younger public.<ref>{{Cite web |url=https://www.nytimes.com/2020/10/23/style/tiktok-caretaker-challenge-dementia.html |title=Why Are TikTok Teens Listening to an Album About Dementia? |date=October 23, 2020 |access-date=April 21, 2021 |website=[[The New York Times]] | vauthors = Ezra M |archive-url=https://web.archive.org/web/20201023171008/https://www.nytimes.com/2020/10/23/style/tiktok-caretaker-challenge-dementia.html |archive-date=October 23, 2020 |url-status=live |url-access=limited}}</ref>
On November 2, 2020, Scottish billionaire Sir [[Tom Hunter]] donated £1&nbsp;million to dementia charities, after watching a former music teacher with dementia, Paul Harvey, playing one of his own compositions on the piano in a viral video. The donation was announced to be split between the Alzheimer's Society and Music for Dementia.<ref>{{cite news|url= https://www.bbc.com/news/uk-54772218 |title= Paul Harvey: Composer with dementia inspires £1m donation |work= BBC News |date= November 2, 2020 |access-date= November 2, 2020 }}</ref>
'''Awareness'''
Celebrities have used their platforms to raise awareness for the different forms of dementia and the need for further support, including former First Lady of California [[Maria Shriver]], [https://mybrain.alz.org/maria-shriver.asp Maria Shriver | My Brain™ | Alzheimer’s Association] Academy Award Winning actor [[Samuel L. Jackson]], Editor-in-Chief of [[Elle (magazine)|ELLE Magazine]] [[Nina García|Nina Garcia]], professional skateboarder [[Tony Hawk]], and others.<ref>{{Cite web |title=Alzheimer's Association Celebrity Champions |url=https://www.alz.org/press/celebrity_champions |access-date=July 19, 2024 |website=Alzheimer's Association}}</ref>
Additional Alzheimer's awareness has been raised through the diagnoses of high-profile persons themselves, including
* Actor [[Bruce Willis]]<ref>{{Cite web |date=2023-02-13 |title=Willis Family Statement {{!}} AFTD |url=https://www.theaftd.org/mnlstatement23/ |access-date=2024-07-19 |language=en-US}}</ref>
* Actor [[Robin Williams]]<ref>{{Cite web |last=Rogers |first=Kristen |date=2022-07-01 |title=What Robin Williams' widow wants you to know about the future of Lewy body dementia |url=https://www.cnn.com/2022/07/01/health/lewy-body-dementia-robin-williams-life-itself-wellness/index.html |access-date=2024-07-19 |website=CNN |language=en}}</ref>
* Activist [[Rosa Parks]]<ref>{{Cite web |url=https://www.nbcnews.com/id/wbna6070417 |title=Doctor: Rosa Parks suffers from dementia |date=September 22, 2004 |website=NBC}}</ref>
* 40th President of the United States, [[Ronald Reagan]]<ref>{{Cite web |title=Reagan's Letter Announcing his Alzheimer's Diagnosis |url=https://www.reaganlibrary.gov/reagans/ronald-reagan/reagans-letter-announcing-his-alzheimers-diagnosis |access-date=2024-07-19 |website=Ronald Reagan |language=en}}</ref>
* Former Mrs. Colorado Springs Joanna Fix [https://gazette.com/life/mrs-colorado-springs-uses-title-young-onset-alzheimers-diagnosis-to-spread-awareness-about-dementia/article_b952f4f6-4e66-11ed-be0d-272532d79150.html Mrs. Colorado Springs uses title, young-onset Alzheimer's diagnosis to spread awareness about dementia]
* TV Host [[Wendy Williams]] [https://apnews.com/article/wendy-williams-dementia-diagnosis-d3cebb8c20f750a623f9d180a50c03e8 Wendy Williams diagnosed with same form of dementia as Bruce Willis]
* Musician [[Tony Bennett]]<ref>{{Cite web |date=2023-07-21 |title=What to know about Tony Bennett's health struggles, from Alzheimer's to addiction |url=https://www.today.com/health/tony-bennett-health-problems-rcna95522 |access-date=2024-07-19 |website=TODAY.com |language=en}}</ref>
* Musician [[Maureen McGovern]]<ref>{{Cite web |title=Maureen McGovern on Living with Alzheimer's Disease: 'You Go One Day at a Time' |url=https://people.com/health/maureen-mcgovern-living-with-alzheimers-disease/ |access-date=2024-07-19 |website=Peoplemag |language=en}}</ref>
* Dancer and [[pin-up model]] [[Rita Hayworth]] [https://www.latimes.com/archives/la-xpm-2006-nov-20-he-myturn20-story.html Rita Hayworth's misdiagnosed struggle]
==Notes==
{{notelist}}
== References ==
{{Reflist}}
== External links ==
{{Medical condition classification and resources
| ICD10 = {{ICD10|F00}}, {{ICD10|F01}}, {{ICD10|F02}}, {{ICD10|F03}}
| ICD10CM = {{ICD10CM|F01}}, {{ICD10CM|F02}}, {{ICD10CM|F03}}
| ICD9 = {{ICD9|290}}-{{ICD9|294}}
| MedlinePlus = 000739
| DiseasesDB = 29283
|eMedicineSubj=article
|eMedicineTopic=793247
| MeshID = D003704
}}
{{Commons category}}
* {{Cite web |title=Result List: PM 32016328: EBSCOhost |url=https://web.s.ebscohost.com/ehost/results?vid=0&sid=27db6ba9-ec43-43de-9285-fb74ccf5fd6d@redis&bquery=PM+32016328&bdata=JkF1dGhUeXBlPWlwLGNvb2tpZSx1cmwsdWlkJmRiPW1uaCZ0eXBlPTEmc2VhcmNoTW9kZT1PciZzaXRlPWVob3N0LWxpdmUmc2NvcGU9c2l0ZQ== |access-date=October 3, 2022 |website=web.s.ebscohost.com |language=en}}
* [https://www.alz.org/ Alzheimer's Association]
* [https://www.nia.nih.gov/health/alzheimers National Institute on Aging – Alzheimer's disease]
{{Diseases of the nervous system}}
{{Mental and behavioural disorders|selected = neurological}}
{{Portal bar|Medicine|Psychiatry|Psychology}}
{{Authority control}}
[[Category:Aging-associated diseases]]
[[Category:Cognitive disorders]]
[[Category:Dementia| ]]
[[Category:Learning disabilities]]
[[Category:Mental disorders due to brain damage]]
[[Category:Wikipedia neurology articles ready to translate]]
[[Category:Wikipedia medicine articles ready to translate]]