 Dementia is an acquired global impairment of intellect, memory and personality, but without impairment of consciousness.  It is usually but not always progressive  Although dementia is global or generalized disorder, it often begins with focal cognitive or behavioral disturbances  Most common causes: Alzheimer’s disease(50- 60%), vascular dementia (20-25%), and dementia with Lewy bodies (15-20%)

 Both DSM-IV and ICD-10 definitions require impairment in two or more cognitive domains (memory, language, abstract thinking and judgment, praxis, visuoperceptual skills, personality, and social conduct) sufficient to interfere with social or occupational functioning.  Deficits may initially be too mild or circumscribed to fulfill this definition.  The fluctuation in alertness which characterize delirium is usually absent, except in dementia with Lewy bodies.

1. Primary neurodegenerative disorders: Alzheimer’s, Lewy bodies, Pick’s, Parkinson’s, Prion diseses, Huntington’s disease. 2. Vascular: vascular dementia, multiple strokes, focal thalamic and basal ganglia strokes, subdural hematoma 3. Inflammatory and autoimmune: SLE, Bahcet’s, MS, neurosarcoidosis 4. Traumatic : head injury 5. Infections and related conditions: HIV, neurosyphilis 6. Metabolic and endocrine : uremia, dialysis, hypothyroidism, hypoglycemia, hypopituitarism, Cushing’s disease

7. Neoplastic 8. Post-radiation 9. Post- anoxic 10. Vitamin and other nutritional deficiencies : B12, folate 11. Toxic: alcohol, heavy metals, organic solvents 12. Other causes: normal pressure hydrocephalus

 The presenting complaint is usually of poor memory  Other features include disturbances of behavior, language, personality, mood,or perception  Dementia is often exposed by a change in social circumstances or an intercurrent illness; indeed,patients with dementia are specially susceptible for superimposed delirium.

 Forgetfulness is usually early and prominent  Impaired attention and concentration are common and non-specific features  Difficulty in new learning is usually the most conspicuous feature.  Memory loss is more evident for recent than for more remote material  Loss is more in episodic memory (day-day events) while there is relative preservation of procedural memory  Loss of flexibility and adaptability for new situations with the appearance of rigid and stereotyped routines

 As dementia progress patients became unable to care for themselves and they neglect social conventions.  Disorientation for time and later for place and person is common  Behavior become aimless  Thinking slows and become impoverished in content and perseverative  False ideas often with persecutory kind appear and in later stages the thinking becomes grossly fragmented and incoherent  Eventually patient may become mute  Behavioral, affective, and psychotic features accompany the cognitive deficits during dementia.  Mortality is increased with death often following bronchopneumonia and a terminal coma

subcorticalcortical memorymoderateSevere, early languagenormalDysphasias, early personalityApathetic, inertindifferent moodFlat, depressednormal coordinationimpairednormal Cognitive and motor speedslowednormal Abnormal movementsCommon, choreiform or tremor rare

 In all patients: full blood count, ESR, urea and electrolytes, liver function tests, calcium and phosphate, thyroid function tests, syphilis serology, urinalysis, B12 and folate.  Worth considering: HIV status, chest radiograph, EEG, CT & MRI of brain, ECG, neuropsychological assessment

 A-Drug therapy for cognitive deficits: 1. Cholinesterase inhibitors: can decrease the cognitive defects in 60%of patients like tacrine( risk of liver damage is high) which lead to incompliance,and donepezil( aricept) which has less severe side effects. 2. Vitamin E :which can decrease the rate of functional decline. 3. Selegiline:MAO B inhibitor which delays cognitive deterioration. Its major defect is orthostatic hypotension.No need for dietary restriction.

 B – Drug therapy for psychosis and agitation : antipsychotic drugs like risperidone and clozapine. Also benzodiazepines like lorazepam for sleep disorders.  Anticonvulsant agents, antiandrogens( medroxyprogesterone) for disinhibited sexual behavior.  C -antidepressants

 Epilepsy is the tendency to recurrent seizures  A seizure is consisting of a paroxysmal electrical discharge in the brain and its clinical sequelae.  The tendency to recurrent seizures in epilepsy should be distinguished from isolated seizures due to : drugs, hypoglycemia, and intercurrent illness.

 Psychiatric co-morbidity is common in people with epilepsy, with overall rates increased at least two folds.  Many different types of psychiatric disorders are associated with epilepsy,including cognitive,affective,emotional and behavioral disturbances.  These can occur before, during,after,and in between seizures.  The relationship between epilepsy and psychiatric disorders can be reflected in : a shared etiology (temporal lobe pathology can cause both epilepsy and psychosis), the effects of stigma, and the side effects of antiepileptic drugs that might cause psychiatric problems.

 Called prodromal states  Mood disturbances  Increasing tension, irritability  Anxiety and depression  Usually occur several hours or even days before a seizure,and usually increasing in severity as the seizure approaches.

 In complex partial seizures there might be affective disturbances, hallucinations, anxiety,automatism  Absence seizures : altered awareness and automatism

 Impaired consciousness  Delirium  Psychosis

 Not related to the occurrence of fits  Cognitive problems  Psychosis  Sexual problems  Depression  Suicide and deliberate self harm  Personality change

 There are two main groups of patients who have suffered head injury: 1. The relatively small group with persistent serious cognitive and behavioral sequele 2. A larger group with emotional symptoms and personality change

 Occur after recovery from coma  Delirium  Delusional misidentification  Agitation and disinhibition  Inappropriate sexual behavior

 Post-concussional syndrome: a group of symptoms include anxiety, depression and irritability, accompanied by headache, dizziness, fatigue, poor concentration, and insomnia. It might be psychologically based and usually resolve spontaneously.  Lasting cognitive impairment: deficits in memory and executive functions ( planning, problem solving, organizing, etc…)  Personality change: irritability, apathy, loss of spontaneity and drive, disinhibition, and decreased control of aggressive impulses.  Emotional disorder: depression, anxiety, and emotional lability.  Psychosis: may be transient or chronic  Boxing and head injury: 10-20% of professional boxers develop what is called punch drunk syndrome or dementia pugilistica.