Improve Memory

Related Terms

  • Acetylcholine, agnosia, alcoholism, ALS, amyloid beta precursor protein, amyotrophic lateral sclerosis, aphasia, APOE, apolipoprotein E, APP, apraxia, bradycardia, cholinesterase inhibitor, chronic obstructive pulmonary disease, cognition, cognitive, computerized tomography, concussion, COPD, Creutzfeldt-Jakob disease, CT, delirium, dementia, eurotoxicity, hemorrhage, homocysteine, Huntington's disease, hydrocephalus, hypercalcemia, hypercholesterolemia, hypertension, hypoglycemia, hypothyroidism, hypoxia, inflammation, Lewey body dementia, magnetic resonance imaging, MRI, multi-infarct disease, neuritic, neurons, neurosyphilis dementia, neurotransmitters, normal pressure hydrocephalus, non-steroidal anti-inflammatory drug, NSAID, PET, Pick's disease, pneumonia, positron emission tomography, pseudodementia, pulmonary embolism, statin, subdural hematoma, vascular dementia.

Background

  • Dementia refers to a loss of cognitive function (an intellectual process resulting in an understanding, perception, or awareness of one's thoughts and ideas). Dementia can be caused by changes in the brain such as those associated with disease or trauma. The changes may occur gradually or quickly.
  • Cognition is the act or process of thinking, perceiving, and learning. Cognitive functions that may be affected by dementia include decision making, judgment, memory, spatial orientation, thinking, reasoning, and verbal communication. Dementia may also result in behavioral and personality changes, depending on the area(s) of the brain affected.
  • Dementia is actually a word for a group of symptoms caused by disorders that affect the brain. It is not a specific disease. Individuals with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose the ability to solve problems or control emotions and their personalities may change. These individuals may become agitated or hallucinate.
  • Dementia usually results from a widespread destruction of, or interference with, brain cells. Consequently, there is a loss of mental functions previously controlled by those cells.
  • Many different diseases can cause dementia, including Alzheimer's disease, Huntington's disease (an inherited movement disorder), and stroke (neurological damage due to a lack of oxygen to the brain). Drugs are available to treat some of these diseases. While these drugs cannot cure dementia or repair brain damage, they may improve symptoms or slow down the disease.
  • Dementia can be progressive, such as with Alzheimer's disease, or occur for a short period of time, perhaps as the result of a head injury.
  • Progressive dementia is most common among the elderly. These individuals are usually termed "senile." However, dementia should not be considered a part of the normal aging process. Most individuals who reach their elderly years do not develop dementia.
  • Some dementia is reversible and can be cured partially or completely with a doctor's treatment. The degree of reversibility often depends on how quickly the underlying cause is treated. Irreversible dementia is caused by an incurable condition (such as in Alzheimer's disease and Huntington's disease). Individuals with irreversible dementia are eventually unable to care for themselves and may require constant care.
  • Some types of dementia, such as Alzheimer's disease and Huntington's disease, have been linked to genetics. However, most cases of dementia are thought to involve multiple factors besides heredity, such as age, gender, and lifestyle choices.
  • An estimated two million people in the United States suffer from severe dementia and another one to five million people experience mild to moderate dementia. Approximately five to eight percent of individuals over the age of 65 have some form of dementia; the number doubles every five years over age 65.

Risk Factors

  • Age: The greatest risk factor for dementia is advanced age. Dementia is considered a late-life disease because it tends to develop mostly in elderly people. About five to eight percent of all people over the age of 65 have some form of dementia; this number doubles every five years above that age. It is estimated that as many as half of people in their 80s suffer from dementia. Research has determined that a decline in cerebral glucose metabolism commonly found in advanced aging may be a risk factor in the development of dementia.
  • Heredity: The risk of developing dementia, such as dementia associated with Alzheimer's disease or Huntington's disease, appears to be slightly higher if a first-degree relative (a parent, sister, or brother) has the disease.
  • Trauma: Trauma to the brain can result in damage to brain cells, leading to dementia. Brain trauma can result from accidents (such as motor vehicle wrecks and falls), assaults (such as gunshot wounds or beatings), or from sports activities (such as boxing) without protective gear. Dementia caused as a result of trauma can be permanent or temporary, depending on the extent of damage and the ability of the individual's body to recover.
  • Infections: Infections of brain structures, such as meningitis (inflammation of the protective membranes in the brain) and encephalitis (inflammation of the brain), are primary causes of dementia. Other infections, such as human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) and syphilis (a bacterial sexually transmitted disease), can affect the brain in later stages. In all cases, inflammation in the brain damages cells. Damage to memory due to infection can be permanent or temporary, depending upon the extent of the damage and the ability of the individual's body to recover.
  • Normal pressure hydrocephalus: The brain floats in a clear fluid called cerebrospinal fluid. This fluid also fills internal spaces in the brain called ventricles. If too much fluid collects outside of the brain, it causes a condition known as hydrocephalus. This condition raises the fluid pressure inside the skull and compresses brain tissue from outside. It may cause severe damage and death. If fluid builds up in the ventricles (four communicating cavities filled with cerebrospinal fluid in the brain), the fluid pressure remains normal. This condition is known as normal pressure hydrocephalus, but it causes brain tissue to be compressed from within. The compression on the brain from the fluid build up causes a decrease in the delivery of oxygen to brain tissues, thus causing damage that can lead to permanent or temporary dementia.
  • Simple hydrocephalus: Simple hydrocephalus may cause typical dementia symptoms or lead to coma. The difference in simple hydrocephalus and normal pressure hydrocephalus is that individuals have trouble walking and become incontinent (unable to control urination) at the same time they start to lose mental functions, such as memory, in simple hydrocephalus. If normal pressure hydrocephalus is diagnosed early, the internal fluid pressure may be lowered by the placement of a shunt. A shunt is a medical device that helps drain excess cerebrospinal fluid from the ventricles, decreasing pressure. This can stop the dementia, gait (pattern of walking) problems, and the incontinence from becoming severe.
  • Brain tumors: Tumors can contribute to signs and symptoms of dementia in a number of ways. A tumor can press on structures that control hormone secretion in the brain, such as the hypothalamus or pituitary gland. Tumors can also press directly on brain cells, damaging them and causing cell death. Treating the tumor, with chemotherapy, radiation, or surgery, may reverse the symptoms in some cases.
  • Toxic exposure: Individuals exposed to toxic chemicals, such as those who pave roads or paint cars, especially without adequate protective equipment and ventilation, may develop dementia from the damage these substances can cause to brain cells. Some toxic exposures may be treatable and avoiding further exposure can prevent further damage.
  • Metabolic disorders: Diseases of the liver, pancreas, or kidneys can lead to dementia by disrupting the balances of substances in the blood, including minerals, vitamins, and sugars. Often, these changes occur rapidly and affect the individual's level of alertness and consciousness. This is called delirium. Although the individual with delirium, like the one with dementia, cannot think well or remember, treatment of the underlying disease may fully reverse the condition. If the underlying disease persists, however, brain cells may die and the individual may develop dementia.
  • Hormone disorders: Disorders of hormone-secreting and hormone-regulating organs, such as the thyroid gland, the parathyroid glands, the pituitary gland, or the adrenal glands, can lead to hormone imbalances. These imbalances may lead to dementia if not corrected with hormonal supplementation in the form of drugs and supplements.
  • Hypoxia: Hypoxia is a lack of oxygen in the body. Individuals who do not have enough oxygen in their blood may develop dementia because the blood brings oxygen to the brain cells. Brains cells need oxygen to survive. The most common causes of hypoxia are lung diseases, such as emphysema or pneumonia. These limit oxygen intake or transfer of oxygen from the airways of the lungs to the blood. Cigarette smoking is a frequent cause of emphysema. Smoking can increase hypoxic brain damage by damaging the lungs and also by increasing the levels of carbon monoxide in the blood. Heart disease leading to congestive heart failure may also lower the amount of oxygen in the blood. Sudden, severe hypoxia may also cause brain damage and symptoms of dementia. Sudden hypoxia may occur if an individual is comatose or has to be resuscitated. Vascular dementia, or dementia as a result of a lack of blood flow to the brain, can be caused by anemia. Anemia is the decreased capacity of red blood cells to carry oxygen to the body's tissues. This results in cell death, such as in the brain, causing temporary or permanent dementia.
  • Drugs: Some prescription and non-prescription drugs can cause temporary problems with memory and concentration as side effects, mainly in the elderly. Misuse or abuse of medications chronically (long-term), whether intentional or accidental, may lead to dementia. Illegal drugs, such as cocaine and heroin, may also lead to signs and symptoms of dementia.
  • Nutritional deficiencies: Deficiencies of certain nutrients, especially the B vitamins, may lead to dementia if not corrected. Homocysteine levels in the body are increased with vitamin deficiencies including folic acid, vitamin B1 (thiamin), and vitamin B12 (cyanocobalamin). Homocysteine is an amino acid, which helps build proteins in the body. An elevated homocysteine level is thought to be a risk factor for developing dementia along with increasing the risk of developing heart disease. Iron deficiency may lead to anemia, which can lead to brain cell death and eventually dementia.
  • Chronic alcoholism: Dementia in individuals with chronic (long-term) alcoholism is believed to be a result of other complications such as liver disease and nutritional deficiencies.

Causes

  • More than 50 conditions are associated with dementia, including degenerative neurological disorders (such as Parkinson's disease and Alzheimer's disease), vascular disorders (such as deep vein thrombosis), inherited disorders (such as Huntington's disease), and infectious diseases (such as human immunodeficiency virus or HIV).
  • AIDS dementia complex (ADC): AIDS dementia complex (ADC), also known as HIV dementia, HIV encephalopathy, and HIV-associated dementia, is a common brain disorder associated with HIV infection and AIDS. Researchers believe that HIV itself causes ADC, but it is not clear exactly how the virus damages the brain cells. It has been suggested that the HIV proteins may damage nerve cells directly or indirectly.
  • Many researchers suspect that HIV damages the neurons indirectly. According to some scientists, HIV either infects or activates cells called macrophages and microglia. These cells then produce toxins that can stimulate a series of reactions, which instruct nerve cells (called neurons) to kill themselves. The infected macrophages and microglia also appear to produce proteins called chemokines and cytokines that mediate and regulate immunity, inflammation, and the development of blood cells. These chemokines and cytokines can also affect neurons, as well as astrocytes. The affected astrocytes, which normally protect and nurture neurons, may cause damage to neurons.
  • Alcoholism: Alcoholism can lead to vitamin B1 (thiamin) deficiency, seizures, and head injuries that produce dementia. Chronic drug abuse, with drugs such as cocaine and heroin, also can cause symptoms of dementia.
  • Alzheimer's disease: Alzheimer's disease (AD) causes 50-70% of all cases of dementia. AD is the progressive deterioration of areas in the brain essential for learning and memory. Several factors, including age, gender, and lifestyle choices have been associated with AD.
  • In addition, people with family histories of AD appear to have an increased risk of developing the disease. However, the genetic risk factors associated with the condition remain largely unexplained. Researchers have identified a few genetic mutations that greatly increase the risk in some families. A clear inherited pattern of AD exists in less than 10% of cases.
  • Early-onset familial Alzheimer's disease has been associated with three predisposition genes: PS1 on chromosome 14, PS2 on chromosome 1, and APP on chromosome 21. These genes affect the production of the amyloid precursor protein and the production of toxic beta-amyloid, creating plaques associated with Alzheimer's disease. Mutations in PS1 account for 30-50% of patients younger than 60 with a strong family history. More than 70 different mutations in the PS1 gene have been reported. All three genes are inherited as autosomal dominant genes. This means that carriers of the genes have a 50% chance of passing their genes to their children.
  • Up to 20% of pre-senile AD cases are due to the presence of susceptibility genes. Susceptibility genes cause the disease to occur earlier in life than it would without the gene. It is important to note that the mechanism by which this earlier onset occurs is not well understood.
  • One of the most well-understood genetic risk factors for Alzheimer's disease is the apolipoprotein E (APOE) gene. Mutations in this gene increase the chances of developing late-onset AD. The APOE gene is found in three different forms: APOE 2, APOE 3, and APOE 4. APOE 4 has been associated with an increased risk for developing AD. Unlike the predisposition genes, not all patients with the susceptibility gene APOE 4 will develop AD. Carrying an APOE 4 gene does not predict that a patient will definitely develop AD. Patients with two copies of the APOE 4 gene have a significantly increased risk of developing the condition, and patients with only one copy have a three-fold increased risk compared to the general population. Researchers expect to discover more susceptibility and risk reducing genes.
  • In addition, nearly all people with Down syndrome who live into their 40s develop AD. Down syndrome is a condition in which extra genetic material causes delays in the way a child develops and often leads to intellectual disabilities.
  • Amyotrophic lateral sclerosis: Amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease, is a progressive neuromuscular disease that weakens and eventually destroys motor neurons. Neurons are components of the nervous system that connect the brain with the skeletal muscles. Most experts believe that ALS does not affect an individual's mental processes. In most people, neither cognitive processes (such as thinking, learning, memory, and speech) nor behavior is affected. Occasionally, however, a person with ALS does experience dementia. Dementia in ALS is thought to be due to destruction of cells in the frontal lobe of the brain. Dementia is rare in ALS. It occurs in all ethnic groups and in both men and women. People aged 55-65 years are most likely to be affected.
  • Creutzfeldt-Jakob disease: Creutzfeldt-Jakob disease (CJD) is a transmissible, rapidly progressing, neurodegenerative disorder called a spongiform degeneration and is related to "mad cow disease." The initial symptom of CJD is usually a vague personality change, followed within weeks or months by rapidly progressing dementia. The dementia is often accompanied by other central nervous system problems, such as visual disturbances and involuntary jerks of the limbs termed myoclonus.
  • Huntington's disease: Huntington's disease (HD) is an inherited condition caused by a single abnormal gene. Each child of an HD parent has a 50% chance of inheriting the HD gene. Because signs and symptoms typically appear in middle age, some parents may not know they carry the gene until they have already had children and possibly passed on the trait. If a child does not inherit the HD gene, he or she will not develop the disease and cannot pass it to subsequent generations. In most cases, a person who inherits the HD gene will eventually develop the disease.
  • Infection: Disease caused by viral, bacterial, or fungal infection can lead to impaired cognitive function. In some cases, appropriate treatment of the underlying condition can reverse symptoms. Infections that may cause dementia-like symptoms include meningitis (inflammation of the membranes that cover the brain and spinal cord) and encephalitis (inflammation of the brain). Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are viral infections that may lead to AIDS dementia complex during late stages of the disease. Antiretroviral therapy has been reported to reduce the incidence of AIDS dementia.
  • Lewy body dementia: Lewy body dementia is similar to AD, but may progress more rapidly. Abnormal brain cells called cortical Lewy bodies occur throughout the brain and produce symptoms such as a decline in cognitive function and memory loss.
  • Medications: Prescription and non-prescription drugs that may cause dementia include: anticholinergics, such as hyoscyamine (Levsin®) or tolterodine (Detrol®); barbiturates, such as secobarbital (Seconal®); benzodiazepines, such as alprazolam (Xanax®) and diazepam (Valium®); cough suppressants, such as dextromethorphan; digitalis (Lanoxin®); monoamine oxidase inhibitors, such as phenelzine (Nardil®); and tricyclic antidepressants (TCAs), such as amitriptylline (Elavil®), doxepin (Sinequan®), and imipramine (Tofranil®). These medications are more likely to cause signs of dementia in the elderly than in younger, healthier individuals.
  • Metabolic disorders: Metabolic disorders, such as hypothyroidism (low level of thyroid hormone or thyroid stimulating hormone), hypoglycemia (low blood sugar level), hypercalcemia (high blood calcium level), and liver disease, can affect cognitive function. Treating the underlying condition can restore function.
  • Multi-infarct disease: Multi-infarct disease is the second most common cause of irreversible dementia. In this condition, multiple strokes lead to a progressive decline in cognition. Strokes are neurological damage in the brain due to a lack of oxygen. Multiple infarct dementia is more common in men over 50 years old. A person with this condition may also experience motor weakness, urinary incontinence, and ataxia (irregular muscle coordination) and may develop hypertension, diabetes, or vascular disease.
  • Neurosyphilis dementia: Neurosyphilis dementia may result from late-stage syphilis. This disease also may cause heart problems, tremors, ataxia (loss of muscle coordination), paralysis, and blindness. Damage may be irreversible.
  • Parkinson's disease: Several factors, including age, gender, exposure to pesticides and herbicides, reduced estrogen levels, and medications, are thought to play a role in Parkinson's disease. In addition, having one or more close relatives with Parkinson's disease increases the chances that the person will also develop the disease. However, the risk of developing Parkinson's disease is still less than five percent if a relative has the condition.
  • Pick's disease: Pick's disease is also similar to AD. In most patients, the frontal and temporal lobes of the brain atrophy (partial or complete wasting). This illness usually affects people between the ages of 40-60 years.
  • Progressive supranuclear palsy: Progressive supranuclear palsy produces clinical features similar to Parkinson's disease and often causes severe cognitive difficulties.
  • Structural abnormalities: Structural abnormalities that can produce dementia include brain tumors located in areas involved with cognitive function, chronic subdural hematoma (blood clot in the brain) resulting from head injury (common in the elderly and alcoholics), hydrocephalus, and normal pressure hydrocephalus. Surgical treatment may relieve symptoms.

Signs and Symptoms

  • Symptoms develop when the underlying condition, such as Alzheimer's disease or alcoholism, affects areas of the brain involved with learning, memory, decision-making, and language.
  • Memory impairment is often the first symptom to be noticed. An individual with dementia may be unable to remember ordinary information, such as their birth date, phone number, and address, and may be unable to recognize friends and family members.
  • There is a progressive decline in cognitive function, including decision making, judgment, orientation in time and space, problem solving, and verbal communication.
  • Behavioral changes may be found in eating, dressing, and toileting. Dementia patients may be unable to dress without help and become incontinent or lose the ability to control urine flow. Normal interests, such as hobbies and social groups, are abandoned. Routine activities, such as driving, grocery shopping, and housecleaning, are unable to be performed. Individuals with dementia also have changes in personality, such as inappropriate responses and lack of emotional control.
  • Trauma may cause prolonged or permanent changes in cognition, memory, emotions, or behavior.

Diagnosis

  • A diagnosis of dementia requires a medical history, physical examination (including neurological examination), and appropriate laboratory tests.
  • Medical history: Taking a thorough medical history involves gathering information about the onset, duration, and progression of symptoms. Also, any possible risk factors for dementia, such as a family history of the disorder or other neurological diseases, past medical history (conditions or diseases), and drug use (prescription, recreational, and non-prescription), will be evaluated.
  • The American Psychiatric Association has established two generally accepted criteria for the diagnosis of dementia: (1) a decline in recent and past memory and (2) impairment of one or more of the following functions: language (aphasia or the misuse of words or inability to remember and use words correctly); motor activity (apraxia or unable to perform motor activities even though physical ability remains intact); recognition (agnosia or unable to recognize objects, even though sensory function is intact); and executive function (unable to plan, organize, and think abstractly). Symptoms often develop gradually and show a progressive deterioration in function.
  • Delirium: The doctor must distinguish between delirium and dementia. Delirium is a transient (occurring over a short period of time), acute mental disturbance that manifests as disorganized thinking and a decreased ability to pay attention to the external world. Delirium is often caused by infectious disease, brain tumor(s), poisoning, drug or alcohol intoxication or withdrawal, seizures, head trauma, and metabolic disorders. It is important to treat underlying conditions promptly, as they may be life-threatening or progressive if left untreated. Symptoms of delirium include disorientation related to person, place, and time, memory impairment, rambling (irrelevant, incoherent speech), and a reduced level of consciousness.
  • Pseudodementia: Pseudodementia, a type of severe depression that occurs mainly in elderly people, causes many older individuals to fear that their memory and other mental abilities are diminishing as they age, even if this is not the case. A doctor will determine if the individual is suffering from this condition. The cognitive changes that resemble dementia include slow motor movements and thinking and short-term memory loss. Individuals who are depressed may be apathetic and answer questions without attempting to provide the correct response. They may exhibit poor eye contact and little spontaneous movement.
  • Blood tests: Blood tests to determine basic health will be used. A complete blood count (CBC) will determine thyroid problems, liver health, blood sugar levels, electrolyte (such as sodium and potassium) balances, vitamin deficiencies, and immune health. Blood tests can also determine if sexually transmitted diseases exist, such as human immunodeficiency virus (HIV) or syphilis.
  • Neuropsychological testing: Sometimes doctors undertake a more extensive assessment of memory, problem-solving abilities, attention spans, counting skills, and language. This is especially helpful in trying to detect dementias at an early stage. Doctors use formal psychological tests to determine if an individual's mental abilities are as expected for his or her age and education. The patterns of any mental deficits observed during neuropsychological testing can help doctors sort out possible causes of dementia.
  • A Mental status evaluation screens memory, problem-solving abilities, attention spans, counting skills, and language skills. Questions such as "what day is it today?" or "who is the president of the United States?" may be asked. Recall tests are another example. Doctors may list familiar objects and then ask a person to repeat them immediately and again five minutes later. The Clock Drawing Test, the Mini-Mental State Examination (MMSE), and the Functional Assessment Staging (FAST) are commonly used mental status evaluation tools for determining if Alzheimer's disease or dementia are present.
  • Brain scans: Doctors may want to take a picture of the brain using a brain scan. Several types of brain scans are available, including computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, and positron emission tomography (PET) scan. Doctors can pinpoint visible abnormalities in the brain using these imaging techniques.
  • Electroencephalography: Electroencephalography (EEG) traces brain wave activity. Some central nervous system disorders cause distinct changes in brain wave activity. Alzheimer's disease generally reveals "slow" waves. An EEG can help distinguish a severely depressed or delirious individual whose brain waves are normal from an individual with a degenerative neurological disease.
  • Genetic testing: Huntington's disease is diagnosed by analyzing DNA in the blood sample to determine if the gene exists for that condition. Huntington's disease is due to a single gene on chromosome 4. If someone has Huntington's disease he/she has a 50% chance of passing that gene to his/her children, causing the development of the disease.
  • Similarly, an analysis of DNA in the blood sample may reveal the ApoE4 gene, which is found in about one-third of Alzheimer's disease patients. However, until preventative treatment is available, testing an asymptomatic patient for APOE is not recommended. Clinical testing is also available for the PS1 gene, which accounts for many cases of the disease.

Complications

  • Complications depend on the underlying cause of the dementia. Complications include loss of ability to function or care for self, verbal and physical abusiveness to loved ones, loss of ability to interact, increased infections anywhere in the body, reduced life span, abuse by an overstressed caregiver, side effects of medications used to treat the disorder, and depression (common in patients with Alzheimer's disease).
  • Infections: In severe and advanced dementia, individuals may lose all ability to care for themselves. This can make them more prone to additional health problems such as pneumonia, which is a bacterial infection of the lungs and respiratory system. The individual may have difficulty swallowing food and liquids, which may cause them to aspirate (inhale) some of what they eat and drink into their airways and lungs, which may lead to pneumonia.
  • Urinary incontinence may require the placement of a urinary catheter, which increases the risk of urinary tract infections. Untreated urinary tract infections can lead to more serious, life-threatening infections.
  • Falls and their complications: Individuals with dementia may become disoriented, increasing their risk of falls. Falls can lead to bone fractures that require hospitalization, medications, and surgery, increasing symptoms of dementia such as confusion and agitation. In addition, falls are a common cause of serious head injuries, such as brain hemorrhage (bleeding in the brain). Prolonged immobilization after surgery and hospitalization may also increase the risk of a pulmonary embolism (blood clot in the lungs), which can be life-threatening.

Treatment

  • In some cases, the appropriate treatment for the underlying condition can resolve dementia completely or partially. The type of treatment depends on the condition. For example, antibiotics are used to treat infection and surgery is performed to remove a blood clot or tumor.
  • Cholinesterase inhibitors: The U.S. Food and Drug Administration (FDA) has approved two classes of drugs to treat cognitive symptoms of dementia including Alzheimer's disease. The first to be approved were cholinesterase inhibitors, which increase the amount of the brain chemical acetylcholine. The three most commonly prescribed cholinesterase inhibitors include donepezil (Aricept®), rivastigmine (Exelon®), and galantamine (Razadyne®). Tacrine (Cognex®), the first cholinesterase inhibitor, was approved in 1993 but is rarely prescribed today because of associated side effects, including possible liver damage. About half of the people who take cholinesterase inhibitors experience a modest improvement in cognitive symptoms. Side effects include diarrhea, vertigo (dizziness), drowsiness, fatigue (extreme tiredness), nausea, and vomiting. Individuals with liver disease, peptic ulcer disease, chronic obstructive pulmonary disease (COPD), and bradycardia (slow heartrate) should not take these drugs.
  • Memantine: Memantine (Namenda®) is a drug approved by the FDA for treatment of moderate to severe Alzheimer's disease. Memantine is classified as an uncompetitive low-to-moderate affinity N-methyl-D-aspartate (NMDA) receptor antagonist, the first Alzheimer's drug of this type approved in the United States. It appears to work by regulating the activity of glutamate, one of the brain's specialized messenger chemicals involved in information processing, storage, and retrieval. Glutamate plays an essential role in learning and memory by triggering NMDA receptors to allow a controlled amount of calcium to flow into a nerve cell, creating the chemical environment required for information storage. Excess glutamate, on the other hand, over stimulates NMDA receptors to allow too much calcium into nerve cells, leading to disruption and death of cells. Memantine may protect cells against excess glutamate by partially blocking NMDA receptors. Side effects include headache, constipation, confusion, and dizziness.
  • Other medications: Medications may be needed to treat the neurobehavioral symptoms associated with dementia. These symptoms interfere with normal daily activities and sleeping. Depression that occurs during the early stages are commonly treated with antidepressant medication, such as selective serotonin reuptake inhibitors (SSRIs) including fluoxetine (Prozac®) and sertraline (Zoloft®), and the tricyclic antidepressants (TCAs), including amitriptylline (Elavil®). Side effects include drowsiness, fatigue, and sedation. TCAs may increase mental confusion. Agitation may be treated with antipsychotic medications, such as haloperidol (Haldol®), risperidone (Risperdal®), olanzapine [Zyprexa®), and quetiapine (Seroquel®). Antipsychotics are not FDA-approved to treat symptoms of dementia and may increase the risk for death in elderly dementia patients. Side effects include sedation, confusion, and tardive dyskinesia (a movement disorder characterized by lip smacking, facial grimacing, and unsteady gait).
  • Long-term care: An individual with dementia may need monitoring and assistance at home or in an institution. Options include in-home care, boarding homes, adult day care, and convalescent or long-term care facilities (nursing homes).
  • Visiting nurses or aides, volunteer services, homemakers, adult protective services, and other community resources may help a family care for a patient with dementia. In some communities, support groups may be available. Family counseling can help family members cope with home care.
  • In any care setting, there should be familiar objects and people. Lights can be left on at night to reduce disorientation. The activity schedule should be simple. Behavior modification may help some people to control unacceptable or dangerous behavior. This consists of rewarding appropriate behaviors and ignoring inappropriate ones (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may also help reduce disorientation.
  • Advance directives, power of attorney, and other legal actions may make it easier to decide about the care of the person with dementia. Legal advice should be sought early in the course of the disorder, before the person with dementia is unable to make such decisions.
  • Prognosis: The outcome of dementia varies. Dementia usually gets worse and often results in a decreased quality of life and decreased life span. Patients may survive eight to 10 years with Alzheimer's disease. Some have been known to live 25 years with the disease. Death usually occurs due to secondary infections (including pneumonia), heart disease, or malnutrition.

Integrative Therapies

Strong scientific evidence: A

  • Ginkgo: Ginkgo biloba has been used medicinally for thousands of years. The scientific literature overall does suggest that ginkgo may benefit people with dementia (multi-infarct and Alzheimer's type), and may be as helpful as acetylcholinesterase inhibitor drugs such as donepezil (Aricept®). Well-designed research comparing ginkgo to prescription drug therapies is needed.
  • Avoid if allergic or hypersensitive to members of the Ginkgoaceae family. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.

Good scientific evidence: B

  • Aromatherapy: Aromatherapy is the use of essential oils from plants for healing purposes. There is suggestive preliminary evidence that aromatherapy using essential oil of lemon balm (Melissa officinalis) may effectively reduce severe agitation in dementia when applied to the face and arms twice daily. Other research reports that steam inhalation of lavender aromatherapy may have similar effects. However, there is a conflicting study that reports no benefits of aromatherapy using lemon balm, Lavender officinalis, sweet orange (Citrus aurantium), or tea tree oil (Malaleuca alternifolia). Overall, the evidence does suggest potential benefits. It is not clear if this is because of anxiety-reducing qualities of these therapies. Additional study is necessary. There is also preliminary research suggesting that aromatherapy used with massage may help to calm people with dementias who are agitated. However, it is not clear if this approach is any better than massage used alone.
  • Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine (medicine practiced in India) and is widely used in India for enhancing memory, pain relief, and treating epilepsy. Although bacopa is traditionally used in Ayurvedic medicine to enhance cognition, high-quality clinical trials are lacking. Two methodologically weak studies found some evidence that bacopa improves cognition. However, more high-quality and independent research is needed before bacopa can be recommended for enhancing brain function in adults or children.
  • Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.
  • Ginkgo: Multiple clinical trials have evaluated ginkgo for a syndrome called cerebral insufficiency. This condition, more commonly diagnosed in Europe than the United States, may include poor concentration, confusion, absent-mindedness, decreased physical performance, fatigue, headache, dizziness, depression, and anxiety. It is believed that cerebral insufficiency is caused by decreased blood flow to the brain due to clogged blood vessels. Some studies report benefits of ginkgo in patients with these symptoms, but most have been poorly designed without reliable results. Better studies are needed before a conclusion can be made.
  • Avoid if allergic or hypersensitive to members of the Ginkgoaceae family. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.
  • Music therapy: Music is used to influence physical, emotional, cognitive and social well-being and improve quality of life for healthy people as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In people with Alzheimer's dementia and other mental disorders in older adults, music therapy has been found to reduce aggressive or agitated behavior, improve mood, and improve cooperation with daily tasks such as bathing. Music therapy may also be beneficial for dementia-associated neuropsychiatric symptoms, such as depression and aggressive behavior. Music therapy may help maintain mental performance in elderly adults undergoing surgical procedures, reduce postoperative confusion and delirium, and increase energy levels.
  • Music therapy is generally known to be safe.

Unclear or conflicting scientific evidence: C

  • Acupressure, shiatsu: Acupressure may decrease verbal and physical agitated behavior in dementia patients. Further study is needed before a conclusion can be made.
  • With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious long-term complications have not been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
  • Acupuncture: Acupuncture has been reported to help improve memory and cognitive performance in the elderly. However, there is currently insufficient available evidence for the use of acupuncture in cognitive disorders and communication disorders. There is also insufficient evidence to recommend the use of acupuncture in the treatment of vascular dementia. More research is necessary.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Arginine: There is not enough information available to make a strong recommendation about the use of the amino acid arginine in senile dementia.
  • Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.
  • Art therapy: Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. The aesthetic aspect of the creation of art is thought to lift one's mood, boost self-awareness, and improve self-esteem. Art therapy also allows the opportunity to exercise the eyes and hands, improve eye-hand coordination, and stimulate neurological pathways from the brain to the hands. Art therapy may be an effective means of improving quality of life in the elderly. Art therapy has been used in only a few studies with Alzheimer's disease (AD) patients, with some suggestion of benefit in alleviating negative emotions and minimizing problematic behaviors. However, further studies are needed for definitive conclusions. There is evidence that the non-directed use of visual art (pictures) as a means of encouraging communication among elderly nursing home residents may increase well-being. It may also reduce blood pressure and improve medical health status with regard to reported dizziness, fatigue, pain, and use of laxatives.
  • Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
  • Ayurveda: The herb Brahmi (Bacopa monnieri) is used in many Ayurvedic preparations for a variety of ailments. There is evidence from well-designed studies that it may improve memory and cognitive function in adults. Another study suggests that the herbal preparation Maharishi Amrit Kalash (MAK) -4 may enhance attention capacity or alertness, and thus reverse some of the detrimental cognitive effects of aging. Further research is needed to confirm these results.
  • Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long period of time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs may interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before use. Use guggul cautiously with peptic ulcer disease. Patients should avoid sour food, alcohol, and heavy exercise with use of this herb. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia chebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.
  • Bacopa: Bacopa monnieri leaf extract is called brahmi in Ayurvedic medicine and is widely used in India for enhancing memory, pain relief, and treating epilepsy. However, additional study is needed before a firm conclusion can be drawn.
  • Bacopa may interact with medications such as calcium channel blockers (used for arrhythmias and high blood pressure), thyroid medications, phenytoin (Dilantin®), and drugs metabolized by the liver. Use cautiously with drugs or herbs that are metabolized by cytochrome P450 enzymes, thyroid drugs, calcium blocking drugs, and sedatives. Avoid if allergic/hypersensitive to Bacopa monnieri, its constituents, or any member of the Srcophulariaceae (figwort) family. Avoid if pregnant or breastfeeding.
  • Beta-carotene: Antioxidants such as beta-carotene may be helpful for increasing cognitive performance and memory. Long-term, but not short-term, beta-carotene supplementation appears to benefit cognition.
  • Avoid if sensitive to beta-carotene, vitamin A, or any other ingredients in beta-carotene products.
  • Black tea: Several preliminary studies have examined the effects of caffeine, tea, or coffee use on short and long-term memory enhancement. It remains unclear if tea is beneficial for this use. Limited, low-quality research also reports that the use of black tea may improve mental performance/alertness and cognition.
  • Black tea contains caffeine, which is a stimulant. Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.
  • Boron: Preliminary human studies report better performance on tasks of eye-hand coordination, attention, perception, short-term memory, and long-term memory with the use of boron. Although boron has not been studied in AD, it may be beneficial in improving cognitive function.
  • Avoid if allergic or sensitive to boron, boric acid, borax, citrate, aspartate, or glycinate. Avoid with a history of diabetes, seizure disorder, kidney disease, liver disease, depression, anxiety, high blood pressure, skin rash, anemia, asthma, or chronic obstructive pulmonary disease (COPD). Avoid with hormone-sensitive conditions like breast cancer or prostate cancer. Avoid if pregnant or breastfeeding.
  • Bupleurum: In early study, an herbal combination formula containing bupleurum has been used as a treatment for minimal brain damage in children. Additional research is needed as results are inconclusive.
  • Avoid if allergic or hypersensitive to bupleurum, members of the Apiaceae or Umbelliferae (carrot) families, snakeroot, cow parsnip, or poison hemlock. Use cautiously if operating motor vehicles or hazardous machinery. Use cautiously with low blood pressure, diabetes, or edema. Use cautiously with a history of bleeding, hemostatic disorders, or drug-related hemostatic disorders. Use cautiously if taking blood thinners. Avoid if pregnant or breastfeeding.
  • Chromium: Early research suggests that chromium picolinate may help improve cognitive function in the elderly. Further study is needed in this area.
  • Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke, and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.
  • Coenzyme Q10: Coenzyme Q10, or CoQ10, is produced by the human body and is necessary for the basic functioning of cells. Promising preliminary evidence suggests that CoQ10 supplements may slow down, but not cure, dementia in people with Alzheimer's disease. Additional well-designed studies are needed to confirm these results before a firm conclusion can be made.
  • Allergy associated with coenzyme Q10 supplements has not been reported in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin or warfarin), blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.
  • Copper: Copper is a mineral that occurs naturally in many foods including vegetables, legumes, nuts, grains and fruits, as well as shellfish, avocado, and beef (organs such as liver). Conflicting study results report that copper intake may either increase or decrease the risk of developing Alzheimer's disease. Additional research about its effectiveness for Alzheimer's disease prevention is needed.
  • Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6mg/L. Use cautiously with anemia, arthralgias, and myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The United States Recommended Dietary Allowance (RDA) is 1,000μg for pregnant women. The United States Recommended Dietary Allowance (RDA) is 1,300μg for nursing women.
  • Cranberry: Preliminary study results show that cranberry juice may increase overall memory enhancement. Further well-designed clinical trials are needed to confirm these results. It is best not to use sweetened cranberry juice or cranberry juice cocktail due to the high sugar content. The use of 100% cranberry juice products is recommended by healthcare providers.
  • Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.
  • Creatine: Early studies show that creatine may improve memory in certain populations, such as vegetarians and the elderly. Further research is required before recommendations can be made.
  • Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix®)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or with a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.
  • DHEA: Dehydroepiandrosterone (DHEA) is an endogenous hormone (made in the human body) and secreted by the adrenal gland. DHEA serves as precursor to male and female sex hormones (androgens and estrogens). DHEA levels in the body begin to decrease after age 30 and may need to be taken as supplements. Preliminary evidence, from a controlled trial and a case series, gives conflicting results as to whether DHEA offers benefit to individuals with dementia. Well designed clinical trials, with appropriate endpoints are required before recommendations can be made.
  • Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Folate: Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Preliminary evidence indicates that low folate concentrations may be related to Alzheimer's disease. Well-designed clinical trials of folate supplementation are needed before a conclusion can be drawn.
  • Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of the fetus developing a defect. Folate is likely safe if breastfeeding.
  • Ginkgo: There is preliminary research showing small improvements in memory and other brain functions with use of ginkgo in patients with age-associated memory impairment (AAMI), although some studies disagree. Overall, there is currently not enough clear evidence to recommend for or against ginkgo for this condition. It remains unclear if ginkgo is effective for memory enhancement in healthy patients. Further well-designed research is needed as existing study results conflict.
  • Avoid if allergic or hypersensitive to members of the Ginkgoaceae family. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.
  • Ginseng: Early small studies report that Fuyuan mixture, an herbal combination that contains ginseng, may improve symptoms of multi-infarct dementia. The effects of ginseng alone are not clear, and no firm conclusion can be drawn. In addition, the use of ginseng for mental performance has been assessed using standardized measurements of reaction time, concentration, learning, math, and logic. Benefits have been seen both in healthy young people and in older ill patients. Effects have also been reported for the combination use of ginseng with Ginkgo biloba. However, some negative results have also been reported. Therefore, although the sum total of available scientific evidence does suggest some effectiveness of short-term use of ginseng for mental performance, better research is necessary before a strong recommendation can be made.
  • Avoid ginseng with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
  • Gotu kola: Ayurveda regards gotu kola (Centella asiatica) as an important rejuvenating herb for nerve and brain cells, believed to be capable of increasing intelligence, longevity, and memory. Asiaticoside derivatives, including asiatic acid and asiaticoside, were shown to reduce hydrogen peroxide-induced cell death, decrease free radical concentrations, and inhibit beta amyloid cell death in vitro, suggesting a possible role for gotu kola in the treatment and prevention of Alzheimer's disease and beta amyloid toxicity. Limited available clinical study investigated a combination product containing gotu kola on cognitive function in the elderly, but did not find any benefit. Additional study is needed to confirm these findings.
  • Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer, or diabetes. Avoid if pregnant or breastfeeding.
  • Grapeseed: Grape seed oil is a popular (non scented) carrier oil used in aromatherapy. Although grape seed has been compared to lavender oil and thyme oil to reduce agitation in dementia patients, there is not enough scientific evidence to make a conclusion about its effectiveness.
  • Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid with disorders that increase the risk of bleeding or with active bleeding disorders (stomach ulcers, bleeding into the brain, etc.). Avoid if pregnant or b