| "Dementia" means an acquired, persisting | | | | hematomas and epidural hematomas are two |
| decrease in mental functioning. Dementia is not a | | | | other space-occupying abnormalities that crowd |
| disease or a final diagnosis; instead, it refers to a | | | | the brain. These are masses of clotted blood |
| category of symptoms that can be the result of | | | | usually caused by traumatic blows to the head. |
| a diverse group of conditions and | | | | The injuries producing the bleeding are not always |
| diseases.Everyone with eyes and a brain of their | | | | remembered or, if remembered, might have been |
| own knows that dementia is a very common and | | | | dismissed as trivial at the time they occurred. |
| serious problem, robbing some people of their | | | | These, too, can be totally removed by a |
| memories, ability to function independently and | | | | neurosurgeon.Normal pressure hydrocephalus is |
| even their personalities. As a community-based | | | | another cause of dementia responding to |
| neurologist, I see all too many cases of dementia, | | | | neurosurgery, but in this condition the surgeon |
| but the part that worries me the most is when | | | | doesn't remove a mass-lesion. Instead, the |
| patients, family members and even medical | | | | surgeon places a tube inside one of the brain's |
| personnel assume that nothing can be done and | | | | swollen fluid-chambers known as ventricles, |
| don't even bother to evaluate for underlying | | | | allowing the excessive fluid-accumulation to drain |
| causes.Although it is certainly true that modern | | | | away through the tube and into another |
| medicine lacks effective treatments for many | | | | body-space where it causes no harm. Normal |
| causes of dementia, it's also true that still others | | | | pressure hydrocephalus can be identified not only |
| can be cured or favorably modified. It would be a | | | | by its dementia and enlarged ventricles, but by |
| shame to assume that a case was untreatable | | | | the concurrent presence of a prominent walking |
| and thereby miss something that could have been | | | | impairment as well as urinary |
| cured or better managed.So how do dementia | | | | incontinence.Non-surgical treatments can be helpful |
| specialists or other doctors investigate cases of | | | | for other causes of dementia. Two conditions |
| dementia? The medical detective-work begins | | | | involving a deficiency or shortage of a biochemical |
| with a thorough history and physical | | | | are hypothyroidism and vitamin B12 deficiency. |
| examination.Clues might come from the history of | | | | Finding one of these is a blessing in disguise |
| the patient's other medical problems, the | | | | because they are easily fixed. In hypothyroidism, |
| medication list, use of alcohol or other drugs, or | | | | the thyroid gland in the neck secretes too little |
| from other physical problems that developed | | | | thyroid hormone. This is managed by making up |
| concurrently with the dementia. Apart from the | | | | for the shortfall in pill form. In vitamin B12 |
| general physical exam, the doctor also explores | | | | deficiency, the problem is that this essential |
| the patient's ability to pay attention, remember, | | | | vitamin is not properly absorbed into the |
| calculate, draw pictures, reason, comprehend | | | | bloodstream via the gastrointestinal tract, so the |
| words and express himself or herself. Further | | | | deficiency is treated by periodic injections of |
| neurological examination assesses other aspects | | | | vitamin B12.As people get older and acquire more |
| of brain function like vision, hearing, strength, | | | | medical problems, their list of medications often |
| coordination, sensation, walking and reflexes.After | | | | grows longer. One or more of the medications |
| compiling the results of the history and | | | | they take might interfere with mental functioning. |
| examination, the physician can usually judge the | | | | Common offenders are medications for urinary |
| relative likelihoods of different underlying causes | | | | incontinence, anxiety or insomnia. If a |
| for the dementia, but follows up these clinical | | | | problem-medication is eliminated or replaced with |
| judgments with additional medical tests to nail | | | | another drug, the patient's mental prowess can |
| down the most likely cause. The irreducible | | | | improve.Depression is a common cause of |
| minimum of additional testing includes a brain | | | | dementia in which the mood disorder itself |
| scan--either a CT or an MRI--plus a panel of blood | | | | interferes with concentration, memory and other |
| tests.The brain scan might detect a brain tumor, | | | | mental performance. In many cases the mental |
| previously unsuspected strokes, clotted blood | | | | impairments are more prominent than the mood |
| compressing the brain or hydrocephalus (water on | | | | disturbance, causing it to be overlooked. |
| the brain) all of which can cause dementia and | | | | Depression is treated with medication, |
| which can also be treated. The blood tests look | | | | psychotherapy, or both.Chronic infections with the |
| for salt-and-water imbalances, abnormal | | | | Lyme and syphilis bacteria can be resolved with |
| blood-sugar levels, kidney impairment, liver | | | | appropriate antibiotics. Occasionally a fungal |
| impairment, excessive calcium levels, thyroid | | | | infection is to blame, and can also be treated with |
| disease, and deficiencies of vitamin B12 and folic | | | | specific medication. Treatments for HIV are less |
| acid. Each of these problems, if found, would | | | | good, but this disease still needs to be identified in |
| warrant specific treatment.Other tests can be | | | | order to obtain the best possible outcome.Chronic |
| applied depending on the physician's judgment of | | | | alcohol abuse can damage the brain and cause |
| their usefulness in individual cases. These might | | | | dementia. In most cases the previously caused |
| include an electroencephalogram (brain-wave test), | | | | damage cannot be undone, but further damage |
| lumbar puncture (spinal tap) or a PET (positron | | | | can be prevented through treatment of the |
| emission tomographic) scan, which is a newer | | | | alcoholism. Wernicke's encephalopathy is an |
| technique that shows the relative activity of brain | | | | alcohol-associated cause of confusion for which |
| cells in different parts of the brain. Additional | | | | injections of thiamine (vitamin B1) are urgently |
| blood-tests can screen for infections with human | | | | needed.Strokes can also produce dementia. |
| immunodeficiency virus (HIV) or the bacteria | | | | Strokes are caused by disrupted circulation which |
| associated with Lyme disease or syphilis.After all | | | | damages parts of the brain. In most cases, the |
| is said and done, what turns up? Unfortunately, | | | | patient and family were aware of strokes when |
| about half the dementia cases evaluated in this | | | | they occurred, but in other cases one or more |
| way lead to a diagnosis of Alzheimer's disease or | | | | strokes might have gone undetected at the time |
| similar degenerative brain disease for which there | | | | they occurred. Prior strokes cannot be undone, |
| is no cure. Although treatments exist for these | | | | but recognition of the presence of strokes can |
| degenerative dementias, their benefits are | | | | lead to preventive measures to decrease the |
| modest.It's the other half of the cases which | | | | likelihood of future strokes.Apart from the |
| reveal an interesting grab-bag of different | | | | conditions and diseases already mentioned, the list |
| underlying causes and, for that matter, | | | | of potential causes of dementia is longer still. In |
| treatments.Neurosurgery can be indicated for | | | | brief, not every cause of dementia can be cured |
| dementias caused by brain tumors, especially | | | | or significantly improved, but without a thoughtful, |
| meningiomas which are slow-growing tumors that | | | | thorough, medical evaluation the ones that can be |
| respond poorly to chemotherapy or radiation | | | | treated could easily go undetected.(C) 2005 by |
| therapy, but can be totally removed in surgical | | | | Gary CordingleyGary Cordingley, MD, PhD, is a |
| operations. Meningiomas are not cancerous, but | | | | clinical neurologist, teacher and researcher who |
| because space inside the skull is limited, they | | | | works in Athens, Ohio. |
| cause trouble by crowding the brain. Subdural | | | | |