Page 318 - Medicine and Surgery

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314 Chapter 7: Nervous system

Urgent neurosurgical assistance is required in the case Spatial memory and orientation (e.g. wandering, get-
of a depressed skull fracture, or expanding intracranial ting lost).
haemorrhage, particularly extradural haematomas or Personality and behaviour, loss of social skills, some-
acute subdural haematomas. times with aggression or sexual disinhibition.
Apathy and/or depression are common, there may be
Prognosis disturbances of sleep, confusion of day & night, with
Recovery may take weeks to months. Prolonged coma nocturnalrestlessnessandwandering.Auditoryorvisual
can still be followed by good recovery. 10 per 100,000 hallucinations and delusions are particularly common
people die annually and the prevalence of survivors in dementia with Lewy bodies. Other neurological signs
with a persisting disability or impairment is 100 such as hemiparesis, seizures tend to occur very late in
per 100,000. dementia.
Generally, in the early stages, the patient is aware
of a loss of their memory and may become very frus-
Dementia trated and anxious. It may at first be attributed to ‘old
age’. They lose the ability to function in daily life grad-
Definition
ually, and in later stages they become more apathetic,
Asyndromeofacquiredcognitiveimpairment,withpro-
with little spontaneous effort and therefore require full
gressive global loss of cognitive function in the context
personal care such as feeding, washing, dressing and
of normal arousal.
toiletting.
Acollateral history from a relative or close carer who
Incidence
has known the patient for a long time is essential. The
1% of those aged 65–74 years, 10% of those over 75 and
carer is often the one most emotionally affected by the
25% of those over 85 years.
changes wrought by dementia.
Aetiology
There are numerous causes of dementia, including Investigations
Alzheimer’s disease (most common >60%).
These are to exclude any treatable causes of chronic con-
multi-infarct dementia caused by multiple small in-
fusion.
farctions, decline may be step-wise (∼20%). Bloods: FBC, U&Es, calcium, LFTs, Vit B 12 ,thyroid
dementia with Lewy bodies (5%).
function tests, blood glucose, syphilis serology.
fronto-temporal dementias (∼10%) such as cortical
Chest X-ray.
atrophy. CT or MRI brain to look for cortical atrophy and ex-
alcohol.
cludehydrocephalus,subduralhaematomaoraspace-
hydrocephalus, subdural haematoma, previous head
occupying lesion such as a cerebral metastasis. There
injuries (punch-drunk syndrome). may be specific changes of specific dementias.
infections such as syphilis, HIV or prion diseases

(Creutzfeld Jacob disease). Management
The specific management strategies are covered under
Clinical features specific causes but general treatment includes the fol-
See also under specific causes of dementia. Patients may lowing:
have impairment of the following cognitive functions: Multidisciplinary assessment.
Learning and retaining new information, e.g. remem- Family support responding to the changing needs of

bering recent events. carers.
Impaired reasoning, judgement. Home care/day care/respite care/residential care/

Ability to carry out complex tasks, e.g. managing hospital care.

household finances. Behaviouralproblemsmayrespondtophenothiazines
Language skills, e.g. word finding. or atypical neuroleptics.