Second edition

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Section 5.2, this may or may not be a syndrome sui genereis –
it might just as well be thought of as a prodrome to a
dementia.
Delirium is distinguished from dementia by the presence
of prominent confusion; here, however, one must
keep in mind that some diseases may be characterized by
both dementia and intermittent delirium. In multi-infarct
dementia, for example, each fresh stroke may be heralded
by an episode of delirium that, once having cleared spontaneously,
leaves the patient not confused but more
demented. Furthermore, some diseases, albeit characterized
primarily by dementia, may also cause intermittent, brief,
episodes of confusion, as may occur in diffuse Lewy body
disease.
Mental retardation is distinguished primarily by its
course: in mental retardation, the intellectual development
of patients proceeds only to a certain point, at which it
‘stalls’, leaving patients on an intellectual ‘plateau’ beyond
which they do not progress. Importantly, there is no decrement
in intellectual ability but merely a plateauing. In contrast,
there is in dementia a definite decrement from a
previously acquired level of intellectual ability. Importantly,
as noted above, some disorders may cause both mental
retardation and a dementia: for example, in the setting of
mental retardation secondary to Down’s syndrome, a
dementia eventually develops in most patients who survive
past the age of 40.
Amnesia is distinguished from dementia by the restricted
nature of the cognitive deficit: in amnestic disorders, one
finds only a deficit in memory, whereas in dementia, in
addition to a defective memory, one also finds other cognitive
deficits, for example in abstracting or calculating abilities.
It must be borne in mind, however, that some
dementing conditions, such as Alzheimer’s disorder, may
present with a pure amnesia that persists for a prolonged
period before being joined by other cognitive deficits.
Treatment
Treatment, if possible, is directed at the underlying condition,
as discussed in the respective chapters. What follows
here are general measures, applicable in most cases.
Patients’ liberty should be circumscribed proportionate
to their reduced abilities; thus, financial affairs should usually
be managed by others and guardianship may be
required. Driving privileges are often retained by patients
with great tenacity, but these too must eventually be withdrawn.
Visiting nurses, ‘meals on wheels’ and adult daycare
centers should each be considered, as they help patients
maintain functional abilities and enable them to stay at
home longer. Cognitively stimulating activities should also
be encouraged (Olazaran et al. 2004) and patients should be
encouraged to do crossword puzzles, play card games, etc.,
as these all help to preserve cognitive abilities.
If patients have to move, for example to a retirement/
nursing home, efforts should be made to make the patient
5.2 Mild cognitive impairment 173
feel ‘at home’, for example by bringing in familiar photographs
and, where possible, furniture, and by subscribing
to the patient’s home-town paper. If patients are admitted
to hospital, the same measures should be undertaken; furthermore,
the room should have a large calendar and clock
and, whenever possible, a window with a view.
The need for prosthetic devices (e.g., glasses, hearing aids,
dentures, and ‘quad canes’) should be assessed, and medical
regimens should be kept as simple as possible. Although
many patients eventually require a wheelchair, ambulation
should be encouraged and maintained for as long as possible.
Rigorous internal medical follow-up is essential, and it
must be kept in mind that, in patients with dementia, even
trivial intercurrent illnesses, such as an uncomplicated
urinary tract infection, may cause dramatic cognitive
decrements.
In addition to implementing treatment, where possible,
of the underlying cause of the dementia, consideration
may also be given to symptomatic treatment of various
clinical features such as agitation, delusions or hallucinations,
depression, and insomnia.
Agitation in dementia, as discussed in detail in Section
6.4, may respond to either risperidone or olanzapine, in low
doses, for example 0.25–1 mg of risperidone or 2.5–7.5 mg
of olanzapine; the same medications may also be effective in
the treatment of delusions or hallucinations. It must be
borne in mind, however, that, although safer than the firstgeneration
antipsychotics (e.g., haloperidol) (Wang et al.
2005), these second-generation agents still carry with them
an increased risk of death or stroke, especially in those
patients who are 80 years or older, or those treated concurrently
with benzodiazepines (Kryzhanovskaya et al. 2006),
and, consequently, they must be used cautiously and continued
only if the benefits are substantial.
Depression may be treated with an antidepressant, and
consideration may be given to either citalopram or escitalopram,
as these tend to be the best tolerated of the available
agents.
Insomnia may be treated with melatonin or ramelteon;
if these are ineffective, consideration may be given to
agents such as zolpidem, with careful monitoring for any
daytime sedation.
5.2 MILD COGNITIVE IMPAIRMENT
Mild cognitive impairment (MCI) (Gautier et al. 2006;
Portet et al. 2006; Winblad et al. 2004) is a recently
described syndrome seen in elderly patients, characterized,
as the name suggests, by an impairment in cognitive ability
that, although clearly representing a departure from the
patient’s premorbid baseline, is not severe enough to cause
significant impairment in day-to-day activities; among
those patients of 65 years or older, the prevalence of such
impairment ranges anywhere from 3 to 19 percent.
As noted below, neuropathologic studies indicate that
most of these patients suffer from an early stage of one or