Clinical features

Onset is usually gradual, unless the dementia is the sequel of a delirious illness. Memory loss is usually the first symptom. This involves recent rather than remote memories, and results in disorientation. Other intellectual functions also deteriorate. In the early stages, the patient may be aware of the memory problems, but, if so, will tend to make light of them or otherwise confabulate so as to minimize the problem in most cases. Most established patients do not complain very much about their memory.

Self-care (appearance) may decline. Affective changes are common, and may consist of lability of mood, sustained depression, or, more rarely, euphoria. Exaggeration of previous personality traits and coarsening of personality accompanied by socially unacceptable behaviour may occur.

Insight may be present in the early stages. Strong emotion, including aggression (sometimes referred to as 'catastrophic reaction'), can understandably occur when patients realize their memory is in severe decline; thus, cognitive testing must always be done sensitively, lest the patients be unduly distressed by realization of their intellectual decline. However, complaints of memory problems volunteered by the patient are seldom a prominent part of the clinical picture.

Insight is usually absent in the later stages. Except in terminal cases, consciousness is unimpaired.

If patients are in their own familiar environment, with friends or family around, they may go undiagnosed, as they may continue to cope with surprising degress of cognitive impairment. But when support disappears - for example, due to illness of a neighbour who regularly checked on them, or when an acute medical problem presents - then the patient may decompensate and the dementia become apparent.

'Sundowning' is often seen, that is, a worsening in confusion in the afternoon and evening; its cause is not clearly known, but may relate to tiredness or to vasospasm. It may be helped by simple nursing measure such as change in rest, exercise, or toileting routines.

'Cortical' and 'subcortical' types of dementia may be distinguished. Cortical dementia includes disturbance of 'higher functions', such as dysphasia, agnosia, and apraxia. In subcortical dementia, these functions are preserved, but the patient is forgetful, slow, and apathetic and may show marked emotional lability with sudden outbursts of laughter or rage.

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