Senile dementia - Alzheimer's type (SDAT); SDAT Last reviewed: September 26, 2011.
Dementia is a loss of brain function that occurs with certain diseases. Alzheimer's disease (AD), is one form of dementia that gradually gets worse over time. It affects memory, thinking, and behavior.
Causes, incidence, and risk factors
You are more likely to get Alzheimer's disease (AD) if you:
Are older. However, developing AD is not a part of normal aging.
Have a close blood relative, such as a brother, sister, or parent with AD.
Have certain genes linked to AD, such as APOE epsilon4 allele
The following may also increase your risk, although this is not well proven:
Being female
Having high blood pressure for a long time
History of head trauma
There are two types of AD:
Early onset AD: Symptoms appear before age 60. This type is much less common than late onset. However, it tends to get worse quickly. Early onset disease can run in families. Several genes have been identified.
Late onset AD: This is the most common type. It occurs in people age 60 and older. It may run in some families, but the role of genes is less clear.
The cause of AD is not clear. Your genes and environmental factors seem to play a role. Aluminum, lead, and mercury in the brain is no longer believed to be a cause of AD.
Symptoms
Dementia symptoms include difficulty with many areas of mental function, including:
Emotional behavior or personality
Language
Memory
Perception
Thinking and judgement (cognitive skills)
Dementia usually first appears as forgetfulness.
Mild cognitive impairment is the stage between normal forgetfulness due to aging, and the development of AD. People with MCI have mild problems with thinking and memory that do not interfere with everyday activities. They are often aware of the forgetfulness. Not everyone with MCI develops AD.
Symptoms of MCI include:
Difficulty performing more than one task at a time
Difficulty solving problems
Forgetting recent events or conversations
Taking longer to perform more difficult activities
The early symptoms of AD can include:
Difficulty performing tasks that take some thought, but used to come easily, such as balancing a checkbook, playing complex games (such as bridge), and learning new information or routines
Getting lost on familiar routes
Language problems, such as trouble finding the name of familiar objects
Losing interest in things previously enjoyed, flat mood
Misplacing items
Personality changes and loss of social skills
As the AD becomes worse, symptoms are more obvious and interfere with your ability to take care of yourself. Symptoms can include:
Change in sleep patterns, often waking up at night
Delusions, depression, agitation
Difficulty doing basic tasks, such as preparing meals, choosing proper clothing, and driving
Difficulty reading or writing
Forgetting details about current events
Forgetting events in your own life history, losing awareness of who you are
Hallucinations, arguments, striking out, and violent behavior
Poor judgment and loss of ability to recognize danger
Using the wrong word, mispronouncing words, speaking in confusing sentences
Withdrawing from social contact
People with severe AD can no longer:
Understand language
Recognize family members
Perform basic activities of daily living, such as eating, dressing, and bathing
Other symptoms that may occur with AD:
Incontinence
Swallowing problems
Signs and tests
A skilled health care provider can often diagnose AD disease with the following steps:
Complete physical exam, including neurological exam
Asking questions about your medical history and symptoms
A mental status examination
A diagnosis of AD is made when certain symptoms are present, and by making sure other causes of dementia are not present.
Tests may be done to rule out other possible causes of dementia, including:
Anemia
Brain tumor
Chronic infection
Intoxication from medication
Severe depression
Stroke
Thyroid disease
Vitamin deficiency
Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain may be done to look for other causes of dementia, such as a brain tumor or stroke.
In the early stages of dementia, brain image scans may be normal. In later stages, an MRI may show a decrease in the size of different areas of the brain.
While the scans do not confirm the diagnosis of AD, they do exclude other causes of dementia (such as stroke and tumor).
However, the only way to know for certain that someone has AD is to examine a sample of their brain tissue after death. The following changes are more common in the brain tissue of people with AD:
"Neurofibrillary tangles" (twisted fragments of protein within nerve cells that clog up the cell)
"Neuritic plaques" (abnormal clusters of dead and dying nerve cells, other brain cells, and protein)
"Senile plaques" (areas where products of dying nerve cells have accumulated around protein).
Treatment
There is no cure for AD. The goals of treatment are:
Slow the progression of the disease (although this is difficult to do)
Manage symptoms, such as behavior problems, confusion, and sleep problems
Change your home environment so you can better perform daily activities
Support family members and other caregivers
DRUG TREATMENT
Medicines are used to help slow down the rate at which symptoms become worse. The benefit from these drugs is usually small. You and your family may not notice much of a change.
Before using these medicines, ask the doctor or nurse:
What are the potential side effects? Is the medicine worth the risk?
When is the best time, if any, to use these medicines?
Medicines for AD include:
Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne, formerly called Reminyl). Side effects include stomach upset, diarrhea, vomiting, muscle cramps, and fatigue.
Memantine (Namenda). Possible side effects include agitation or anxiety.
Other medicines may be needed to control aggressive, agitated, or dangerous behaviors. Examples include haloperidol, risperidone, and quetiapine. These are usually given in very low doses due to the risk of side effects including an increased risk of death.
It may be necessary to stop any medications that make confusion worse. Such medicines may include painkillers, cimetidine, central nervous system depressants, antihistamines, sleeping pills, and others. Never change or stop taking any medicines without first talking to your doctor.
SUPPLEMENTS
Some people believe certain vitamins and herbs may help prevent or slowdown AD.
There is no strong evidence that Folate (vitamin B6), vitamin B12, and vitamin E prevent AD or slows the disease once it occurs.
High-quality studies have not shown that ginkgo biloba lowers the chance of developing dementia. DO NOT use ginkgo if you take blood-thinning medications like warfarin (Coumadin) or a class of antidepressants called monoamine oxidase inhibitors (MAOIs).
If you are considering any drugs or supplements, you should talk to your doctor first. Remember that herbs and supplements available over the counter are NOT regulated by the FDA.
Support Groups
For additional information and resources for people with Alzheimer's disease and their caregivers, see Alzheimer's disease support groups.
Expectations (prognosis)
How quickly AD gets worse is different for each person. If AD develops quickly, it is more likely to worsen quickly.
Patients with AD often die earlier than normal, although a patient may live anywhere from 3 - 20 years after diagnosis.
The final phase of the disease may last from a few months to several years. During that time, the patient becomes totally disabled. Death usually occurs from an infection or organ failure.
Complications
Abuse by an over-stressed caregiver
Bedsores
Loss of muscle function that makes you unable to move your joints
Infection, such as urinary tract infection and pneumonia
Other complications related to immobility
Falls and broken bones
Harmful or violent behavior toward self or others
Loss of ability to function or care for self
Loss of ability to interact
Malnutrition and dehydration
Calling your health care provider
Call your health care provider if someone close to you has symptoms of dementia.
Call your health care provider if a person with AD has sudden change in mental status. A rapid change may be a sign of another illness.
Talk to your health care provider if you are caring for a person with AD and you can no longer care for the person in your home.
Prevention
Although there is no proven way to prevent AD, there are some practices that may be worth incorporating into your daily routine, particularly if you have a family history of dementia. Talk to your doctor about any of these approaches, especially those that involve taking a medication or supplement.
Consume a low-fat diet.
Eat cold-water fish (like tuna, salmon, and mackerel) rich in omega-3 fatty acids, at least 2 to 3 times per week.
Reduce your intake of linoleic acid found in margarine, butter, and dairy products.
Increase antioxidants like carotenoids, vitamin E, and vitamin C by eating plenty of darkly colored fruits and vegetables.
Maintain a normal blood pressure.
Stay mentally and socially active throughout your life.
Consider taking nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), sulindac (Clinoril), or indomethacin (Indocin). Statin drugs, a class of medications normally used for high cholesterol, may help lower your risk of AD. Talk to your doctor about the pros and cons of using these medications for prevention.
In addition, early testing of a vaccine against AD is underway.
References
Aisen PS, Schneider LS, Sano M, Diaz-Arrastia R, van Dyck CH, et al. High-dose B vitamin supplementation and cognitive decline in Alzheimer's disease: a randomized controlled trial. JAMA. 2008;300:1774-1783. [PubMed] DeKosky ST, Kaufer DI, Hamilton RL, Wolk DA, Lopez OL. The dementias. In: Bradley WG, Daroff RB, Fenichel GM, Jankovic J, eds. Bradley: Neurology in Clinical Practice. 5th ed. Philadelphia, Pa: Butterworth-Heinemann Elsevier; 2008:chap 70. DeKosky ST, Williamson JD, Fitzpatrick AL, Kronmal RA, Ives DG, Saxton JA, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008;300:2253-2262. [PubMed] Knopman DS. Alzheimer’s disease and other dementias. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 409. Mayeux R. Early Alzheimer's disease. N Engl J Med. 2010 Jun 10;362(4):2194-2201. Peterson RC. Clinical practice. Mild cognitive impairment. N Engl J Med 2011 Jun 9;364(23):2227-2234. Qaseem A, et al., American College of Physicians/American Academy of Family Physicians Panel on Dementia. Current pharmacologic treatment of dementia: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2008 Mar 4;148(5):370-8. [PubMed] Querfurth HW, LaFerla FM. Alzheimer's disease. N Engl J Med. 2010 Jan 28;362(4):329-44. Review Date: 9/26/2011.
Reviewed by: Luc Jasmin, MD, PhD, Department of Neurosurgery at Cedars-Sinai Medical Center, Los Angeles, and Department of Anatomy at UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
Bipolar disorder is a condition in which people go back and forth between periods of a very good or irritable mood and depression. The "mood swings" between mania and depression can be very quick.
Causes, incidence, and risk factors
Bipolar disorder affects men and women equally. It usually starts between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.
Types of bipolar disorder:
People with bipolar disorder type I have had at least one manic episode and periods of major depression. In the past, bipolar disorder type I was called manic depression.
People with bipolar disorder type II have never had full mania. Instead they experience periods of high energy levels and impulsiveness that are not as extreme as mania (called hypomania). These periods alternate with episodes of depression.
A mild form of bipolar disorder called cyclothymia involves less severe mood swings. People with this form alternate between hypomania and mild depression. People with bipolar disorder type II or cyclothymia may be wrongly diagnosed as having depression.
In most people with bipolar disorder, there is no clear cause for the manic or depressive episodes. The following may trigger a manic episode in people with bipolar disorder:
Life changes such as childbirth
Medications such as antidepressants or steroids
Periods of sleeplessness
Recreational drug use
Symptoms
The manic phase may last from days to months. It can include the following symptoms:
Very high self-esteem (false beliefs about self or abilities)
Very involved in activities
Very upset (agitated or irritated)
These symptoms of mania occur with bipolar disorder I. In people with bipolar disorder II, the symptoms of mania are similar but less intense.
The depressed phase of both types of bipolar disorder includes the following symptoms:
Daily low mood or sadness
Difficulty concentrating, remembering, or making decisions
Eating problems
Loss of appetite and weight loss
Overeating and weight gain
Fatigue or lack of energy
Feeling worthless, hopeless, or guilty
Loss of pleasure in activities once enjoyed
Loss of self-esteem
Thoughts of death and suicide
Trouble getting to sleep or sleeping too much
Pulling away from friends or activities that were once enjoyed
There is a high risk of suicide with bipolar disorder. Patients may abuse alcohol or other substances, which can make the symptoms and suicide risk worse.
Sometimes the two phases overlap. Manic and depressive symptoms may occur together or quickly one after the other in what is called a mixed state.
Signs and tests
Many factors are involved in diagnosing bipolar disorder. The health care provider may do some or all of the following:
Ask about your family medical history, such as whether anyone has or had bipolar disorder
Ask about your recent mood swings and for how long you've had them
Perform a thorough examination to look for illnesses that may be causing the symptoms
Run laboratory tests to check for thyroid problems or drug levels
Talk to your family members about your behavior
Take a medical history, including any medical problems you have and any medications you take
Watch your behavior and mood
Note: Drug use may cause some symptoms. However, it does not rule out bipolar affective disorder. Drug abuse may be a symptom of bipolar disorder.
Treatment
Periods of depression or mania return in most patients, even with treatment. The main goals of treatment are to:
Avoid moving from one phase to another
Avoid the need for a hospital stay
Help the patient function as well as possible between episodes
Prevent self-injury and suicide
Make the episodes less frequent and severe
The health care provider will first try to find out what may have triggered the mood episode. The provider may also look for any medical or emotional problems that might affect treatment.
The following drugs, called mood stabilizers, are usually used first:
Other drugs used to treat bipolar disorder include:
Antipsychotic drugs and anti-anxiety drugs (benzodiazepines) for mood problems
Antidepressant medications can be added to treat depression. People with bipolar disorder are more likely to have manic or hypomanic episodes if they are put on antidepressants. Because of this, antidepressants are only used in people who also take a mood stabilizer.
Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar disorder if it does not respond to medication. ECT uses an electrical current to cause a brief seizure while the patient is under anesthesia. ECT is the most effective treatment for depression that is not relieved with medications.
Transcranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain. It is most often used after ECT.
Patients who are in the middle of manic or depressive episodes may need to stay in a hospital until their mood is stable and their behavior is under control.
Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the possible risks and benefits of treatment for their children.
SUPPORT PROGRAMS AND THERAPIES
Family treatments that combine support and education about bipolar disorder (psychoeducation) may help families cope and reduce the odds of symptoms returning. Programs that offer outreach and community support services can help people who do not have family and social support.
Important skills include:
Coping with symptoms that are present even while taking medications
Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
Learning to take medications correctly and how to manage side effects
Learning to watch for the return of symptoms, and knowing what to do when they return
Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients find the right support services, and make sure the patient takes medication correctly.
Getting enough sleep is very important in bipolar disorder. A lack of sleep can trigger a manic episode. Therapy may be helpful during the depressive phase. Joining a support group may help bipolar disorder patients and their loved ones.
A patient with bipolar disorder cannot always tell the doctor about the state of the illness. Patients often have trouble recognizing their own manic symptoms.
Changes in mood with bipolar disorder are not predictable. It it is sometimes hard to tell whether a patient is responding to treatment or naturally coming out of a bipolar phase.
Treatments for children and the elderly are not well-studied.
Expectations (prognosis)
Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to make sure that mania and depression are treated as early as possible.
Some people stop taking the medication as soon as they feel better or because the mania feels good. Stopping medication can cause serious problems.
Suicide is a very real risk during both mania and depression. People with bipolar disorder or think or talk about suicide need immediate emergency attention.
Complications
Stopping medication or taking it the wrong way can cause your symptoms to come back, and lead to the following complications:
Alcohol and/or drug abuse
Problems with relationships, work, and finances
Suicidal thoughts and behaviors
This illness is hard to treat. Patients, their friends, and family must know the risks of not treating bipolar disorder.
Calling your health care provider
Call your health provider or an emergency number right way if:
You are having thoughts of death or suicide
You are experiencing severe symptoms of depression or mania
You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms
References
Beynon S, Soares-Weiser K, Woolacott N, Duffy S, Geddes JR. Pharmacological interventions for the prevention of relapse in bipolar disorder: a systematic review of controlled trials. J Psychopharmacol. 2009; 23(5):574-591. [PubMed]
Benazzi F. Bipolar disorder -- focus on bipolar II disorder and mixed depression. Lancet. 2007;369:935-945. [PubMed]
Morriss RK, Faizal MA, Jones AP, Williamson PR, Bolton C, McCarthy JP. Interventions for helping people recognise early signs of recurrence in bipolar disorder. Cochrane Database Syst Rev. 2007;24;(1):CD004854. [PubMed]
Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med. 2007;356:1711-1722. [PubMed]
Review Date: 3/29/2011.
Reviewed by: Fred K. Berger, MD, Addiction and Forensic Psychiatrist, Scripps Memorial Hospital, La Jolla, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
Borderline personality disorder is a condition in which people have long-term patterns of unstable or turbulent emotions, such as feelings about themselves and others.
These inner experiences often cause them to take impulsive actions and have chaotic relationships.
Causes, incidence, and risk factors
The causes of borderline personality disorder (BPD) are unknown. Genetic, family, and social factors are thought to play roles.
Risk factors for BPD include:
Abandonment in childhood or adolescence
Disrupted family life
Poor communication in the family
Sexual abuse
This personality disorder tends to occur more often in women and among hospitalized psychiatric patients.
Symptoms
People with BPD are often uncertain about their identity. As a result, their interests and values may change rapidly.
People with BPD also tend to see things in terms of extremes, such as either all good or all bad. Their views of other people may change quickly. A person who is looked up to one day may be looked down on the next day. These suddenly shifting feelings often lead to intense and unstable relationships.
Other symptoms of BPD include:
Fear of being abandoned
Feelings of emptiness and boredom
Frequent displays of inappropriate anger
Impulsiveness with money, substance abuse, sexual relationships, binge eating, or shoplifting
Intolerance of being alone
Repeated crises and acts of self-injury, such as wrist cutting or overdosing
Signs and tests
Like other personality disorders, BPD is diagnosed based on a psychological evaluation and the history and severity of the symptoms.
Treatment
Many types of individual talk therapy, such as dialectical behavioral therapy (DBT), can successfully treat BPD. In addition, group therapy can help change self-destructive behaviors.
In some cases, medications can help level mood swings and treat depression or other disorders that may occur with this condition.
Expectations (prognosis)
The outlook depends on how severe the condition is and whether the person is willing to accept help. With long-term talk therapy, the person will often gradually improve.
Call your health care provider if you or your child has symptoms of borderline personality disorder. It is especially important to seek help right away if you or your child is having thoughts of suicide.
References
Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA. Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 39.