ICD-10 defines dementia as “a syndrome due to disease of the brain, usually of a chronic or progressive nature, [characterized by signs of] disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. Consciousness is not clouded. The impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behavior, or motivation. This syndrome occurs in Alzheimer’s disease, in cerebrovascular disease, and in other conditions primarily or secondarily affecting the brain.” (ICD, 2007)
These deficits represent a decline from a previous level of functioning, so dementia does not refer to low intellectual functioning or mental retardation that are developmental and static conditions. This decline is often noted by the individual affected, a family member or other caretaker, or the clinician, and should be demonstrated on standardized neuropsychological testing, and if that is not possible, another measurable clinical assessment. These cognitive deficits interfere with independent functioning in daily activities, and cannot occur exclusively in the context of a delirium, or be better explained by another mental disorder (Sadock, et al., 2017).
Dementia Signs (Sadock, et al., 2017)
The typical characteristic feature of dementia is cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Patients must demonstrate impairment in one or more cognitive domains.
There is inability to learn new information or to recall previously learned information. It manifests as forgetting recent events and conversations, repetitive questions, repetitive retelling of stories, forgetting the date, forgetting appointments, misplacing objects, losing valuables, and forgetting that food is cooking on the stove. Patients are unable to learn new information or new skills. They may become overwhelmed, disoriented, or confused in a new environment. As the illness progresses, long-term memory gets affected and patients will no longer recall their personal past history and will forget previously highly learned material.
It manifests as word-finding difficulties resulting in reduced fluency of speech, word substitutions, or mispronunciation. They can have difficulty remembering names of distant relatives and friends or people they see
infrequently, but later they may forget names of close family and friends. They often have difficulty maintaining conversations, and soon they stop initiating conversation. Eventually, speech becomes incomprehensible and unintelligible.
Impairment of Perception and Motor Activities
They are unable to recognize familiar objects, familiar faces or in later stages, one’s own reflection in the mirror. It also manifests as a lack of insight into one’s own impairment and unrealistic assessment of one’s abilities. There may be difficulties in navigating in familiar environments. They will have difficulty using familiar tools or machines (i.e., microwave oven, washing machine, lawnmower, drill) or trouble performing previously acquired skills (i.e., knitting, woodworking). In later stages, there may be impairment in ability to perform activities of daily living, such as dressing, bathing, or feeding.
Impairment in Executive Functioning
This refers to disturbances in planning, organizing, sequencing, and abstracting as reflected in difficulty performing complex tasks or problem-solving, such as trouble preparing a meal, managing medications, or managing finances. Judgment is often impaired and bad decisions are made.
Impairment of Social Skills
They will have difficulty recognizing social cues or emotions in others, apathy, disinhibition, and changes in levels of extraversion or introversion. There may be a change in personality. Eventually, they may start making sexually or politically inappropriate comments and showing disinhibited and intrusive behaviors that lack awareness for another’s personal space.
Major depression is common early in the course of dementia, in about 10 percent of cases. Depressive symptoms are even more common. These symptoms, emotional lability, and irritability may be related to psychological reactions to the awareness of losing one’s memory and anticipation of increasing functional impairment. Suicidal ideation and behavior may also occur.
Anxiety is fairly common throughout the course of dementia and occurs in about 60 percent of patients. It usually manifests as fear of being alone, and patients will search for their caregivers so as not to be alone.
Some may have disinhibition and impulsivity, such as making inappropriate jokes, being overly familiar with strangers, disregarding social norms, inappropriate sexual remarks or behaviors, impulsive buying, or succumbing to salespeople or exploitative schemes. Alternatively, there may be amotivation and withdrawal.
Psychotic symptoms in dementia generally occur in the middle stages of illness and often co-occur with behavioral disturbance. A common early psychotic symptom is paranoia and the belief that belongings have been stolen. In later stages, patients may have hallucinations, most commonly visual hallucinations. They may see deceased relatives. People often believe they are still working or engaging in previous activities. Psychotic symptoms can sometimes lead to agitation, aggression, and behavioral disturbance as patients act out on their hallucinations, paranoia, or delusional thinking.
With advancing dementia, altered sleep-wake cycles, like going to bed late, and sleeping late in the morning. They may also take frequent naps.
Agitation and Aggression
Agitation and aggression become more prominent as the disease progresses. These behaviors are not always aggressive or directed toward a target. They could be continually pacing back and forth, or there can be purposeless hyperactivity such as continuously rummaging through drawers. Agitation and aggression can come in both physical and verbal forms, with some individuals hitting or striking out, while others may swear, make threats, or have persistent disruptive, but non-threatening vocalizations.
Other Behavioral Disturbances
As cognitive impairment progresses, some individuals become at risk of wandering. Disinhibited social behavior may also be seen, with individuals making inappropriate comments or gestures in public places.
Stages of Dementia (WHO, 2019) (Sadock, et al., 2017)
Onset is gradual. Common symptoms during this stage include:
- Losing track of the time
- Becoming lost in familiar places
- Depressed mood, emotional lability, and irritability
As dementia progresses to the middle stage, the signs and symptoms include:
- Forgetting recent events and conversations, repetitive questions, repetitive retelling of stories, forgetting the date, forgetting appointments, misplacing objects, losing valuables, and forgetting that food is cooking on the stove. Difficulty remembering names of distant relatives and friends or people they see infrequently.
- Becoming lost in familiar surroundings, including at home.
- At risk of wandering.
- Having increasing difficulty with communication: word-finding difficulties resulting in reduced fluency of speech, word substitutions, or mispronunciation.
- Delusions, such as paranoia and the belief that belongings have been stolen.
- Needing help with personal care
- They could be continually pacing back and forth, or there can be purposeless hyperactivity such as continuously rummaging through drawers.
In the late stage of dementia, there is near-total dependence and inactivity. Memory disturbances are serious and the signs include:
- Becoming unaware of the time and place.
- No longer recall their personal past history and will forget previously highly learned material.
- Forget the names of close family and friends.
- Speech becomes incomprehensible and unintelligible.
- Impairment in ability to perform activities of daily living, such as dressing, bathing, or feeding, thus necessitating assistance.
- Having difficulty walking.
- Altered sleep-wake cycles, like going to bed late, and sleeping late in the morning. They may also take frequent naps.
- In later stages, patients may have hallucinations, most commonly visual hallucinations. They may see deceased relatives.
- Disinhibited social behavior may also be seen, with individuals making inappropriate comments or gestures in public places.
- Agitation and aggression can come in both physical and verbal forms, with some individuals hitting or striking out, while others may swear, make threats, or have persistent disruptive, but non-threatening vocalizations.
ICD-10 Code Dementia (ICD, 2007)
Dementia in Alzheimer’s disease
Alzheimer’s disease is a primary degenerative cerebral disease of unknown cause. The disorder is usually insidious in onset and develops slowly but steadily over a period of several years.
Dementia in Alzheimer’s disease with early-onset
Dementia in Alzheimer’s disease with onset before the age of 65, with a relatively rapid deteriorating course and with marked multiple disorders of the higher cortical functions.
Dementia in Alzheimer’s disease with late-onset
Dementia in Alzheimer’s disease with onset after the age of 65, usually in the late 70s or thereafter, with a slow progression, and with memory impairment as the principal feature.
Dementia in Alzheimer’s disease, atypical or mixed type
Atypical dementia, Alzheimer’s type
Dementia in Alzheimer’s disease, unspecified
Vascular dementia is the result of localized dead brain tissue due to loss of local blood supply (infarcts) to the brain due to vascular disease. The infarcts are usually small but cumulative in their effect. Onset is usually in later life.
Vascular dementia of acute onset
Usually develops rapidly after a succession of strokes. In rare cases, a single large infarction may be the cause.
Gradual in onset, following a number of transient ischemic (diminished blood supply) episodes which produce an accumulation of infarcts in the brain.
Subcortical vascular dementia
Includes cases with a history of high bl;ood pressure and foci of ischemic destruction in the brain. The cerebral cortex is usually preserved and this contrasts with the clinical picture which may closely resemble that of dementia in Alzheimer’s disease.
Mixed cortical and subcortical vascular dementia
Other vascular dementia
Vascular dementia, unspecified
Dementia in other diseases classified elsewhere
Cases of dementia due, or presumed to be due, to causes other than Alzheimer’s disease or cerebrovascular disease. Onset may be at any time in life, though rarely in old age.
Dementia in Pick’s disease
A progressive dementia, commencing in middle age, characterized by early, slowly progressing changes of character and social deterioration, followed by impairment of intellect, memory, and language functions, with apathy, euphoria and, occasionally, extrapyramidal phenomena.
Dementia in Creutzfeldt-Jakob disease
A progressive dementia with extensive neurological signs, due to specific neuropathological changes that are presumed to be caused by a transmissible agent. Onset is usually in middle or later life but may be at any adult age. The course is subacute, leading to death within one to two years.
Dementia in Huntington’s disease
A dementia occurring as part of a widespread degeneration of the brain. The disorder is transmitted by a single autosomal dominant gene. Symptoms typically emerge in the third and fourth decade. Progression is slow, leading to death usually within 10 to 15 years.
Dementia in Parkinson’s disease
A dementia developing in the course of established Parkinson’s disease. No particular distinguishing clinical features have yet been demonstrated.
Dementia in human immunodeficiency virus (HIV) disease
Dementia developing in the course of HIV disease, in the absence of a concurrent illness or condition other than HIV infection that could explain the clinical features.
Dementia in other specified diseases classified elsewhere
Organic amnesic syndrome, not induced by alcohol and other psychoactive substances
A syndrome of prominent impairment of recent and remote memory while immediate recall is preserved, with reduced ability to learn new material and disorientation in time. Confabulation may be a marked feature, but perception and other cognitive functions, including the intellect, are usually intact. The prognosis depends on the course of the underlying lesion.
ICD, 2007. Chapter V: Mental and behavioral disorders (F00-F99). [Online]
Available at: https://apps.who.int/classifications/apps/icd/icd10online2007/index.htm?gf00.htm+
[Accessed 28 Sep 2019].
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.
WHO, 2019. Dementia. [Online]
Available at: https://www.who.int/news-room/fact-sheets/detail/dementia
[Accessed 28 Sep 2019].