Mohammed T. Abou-Saleh

294 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYSYMPTOMS/SIGNS SUGGESTIVEOF DEMENTIA SYNDROMEi.e.(1) Neuropsychological signs4As (amnesia, aproxia, agnosia, aphasia)(2) Neuropsychiatric features (behavioural andpsychological symptoms, BPSD)(3) Problems in activities of daily livingAcquired vs. Congenital Learning disabilityGlobalvs.FocalAmnestic syndromeFocal aphasiaFocal apraxiaClearconsciousnessvs.CloudedconsciousnessDeliriumDepressionabsentvs.DepressionpresentPseudodementiaTreat depressionNot causedby drugsvs.DruginducedAltermedicationNot due tonormal ageingvs.Normal ageingReassureNon-reversiblevs.PotentiallyreversibleAppropriatetreatmentAlzheimer's diseaseVascular dementiaLewy body dementiaDementia of frontal lobeFigure 54.1Diagnostic algorithm for dementiafamily history of affective disorder. Patients tend to answerquestions with ‘‘don’t know’’ responses, there is a variability intheir ability to perform tasks of similar difficulty, theycommunicate a sense of distress and complain of their cognitivedeficits 11 . Structural brain changes have been described in thiscondition 12 . Pseudodementia is currently a term in disreputeand the alternative (dementia syndrome of depression) isconsidered to be more accurate. The diagnosis of pseudodementiais made on clinical grounds and should always beconsidered in a demented patient. Validation of the diagnosis isby successful treatment and return to normal of the cognitivedeficit 13,14 . Some clinicians would argue that a trial ofantidepressants should be given in all cases of dementia.VASCULAR DEMENTIAThere are two main types of vascular dementia, one involvingsubcortical structures affecting small arteries, leading tothe clinical picture of subcortical dementia (see below forcardinal features), and one involving medium-sized arteries(anterior, middle and posterior cerebral arteries), leading to acortical dementia. The clinical features of vascular corticaldementia have been defined in the Hachinski score 15 . Physicalexamination will generally reveal neurological signs, such asdisturbances of gait rigidity, spasticity and reflex abnormalities,and CT often reveals cerebral infarction. Diagnostic criteria havebeen described 16,17 .