Types of dementia

All dementias involve cognitive decline that impacts daily living. However, it's important
to pinpoint the specific type of dementia in order to optimize treatment. More than 50
conditions involve dementia, but the most common types of dementia are Alzheimer's
disease and vascular dementia.

Alzheimer's disease
Alzheimer's disease is the most common form of dementia, accounting for up to twothirds of all diagnosed cases. If your dementia symptoms are the result of Alzheimer's
disease, medications can delay the onset of more debilitating symptoms. Early diagnosis
can prolong independence and is the first step towards treatment, management, and
living life fully.

Vascular dementia
Vascular dementia results from a series of small strokes or changes in the brain's blood
supply. Sudden onset of symptoms may be a sign of this dementia. Vascular dementia
severely impacts memory and cognitive functioning. However, there are ways to prevent
and reduce its severity.

Mixed dementia
Mixed dementia is a condition in which Alzheimer's disease and vascular dementia occur
simultaneously. The combination of the two types of dementia most commonly occurs in
people of an advanced age, often indicated by cardiovascular disease and dementia
symptoms that get worse slowly over time.

Less common forms of dementia

Pick's Disease Pick's disease affects personality, orientation and behavior. It

may be more common in women and occurs at an early age.

Creutzfeldt-Jakob Disease The disease progresses rapidly along with

mental deterioration and involuntary movements.

Huntington's Disease Huntington's is an inherited, degenerative disease.

The disease causes involuntary movement and usually begins during mid-life.

Parkinson's Dementia Parkinson's is a progressive disorder of the central

nervous system. In later stages of Parkinson's disease, some patients develop
dementia.

Lewy Body Dementia This disease causes symptoms similar to Alzheimer's

disease. Individuals with Lewy Body dementia experience hallucinations and
can become fearful.

Common signs and symptoms of dementia include:

Memory loss

Impaired judgment

Difficulties with abstract thinking

Faulty reasoning

Inappropriate behavior

Loss of communication skills

Disorientation to time and place

Gait, motor, and balance problems

Neglect of personal care and safety

Hallucinations, paranoia, agitation

Dementia can be caused by:

Medical conditions that progressively attack brain cells and

connections, most commonly seen in Alzheimer's disease, Parkinson's
disease, or Huntington's disease.

Medical conditions such as strokes that disrupt oxygen flow and rob
the brain of vital nutrients. Additional strokes may be prevented by reducing
high blood pressure, treating heart disease, and quitting smoking.

Poor nutrition, dehydration, and certain substances, including drugs

and alcohol. Treating conditions such as insulin resistance, metabolic
disorders, and vitamin deficiencies may reduce or eliminate symptoms of
dementia.

Single trauma or repeated injuries to the brain. Depending on the location

of the brain injury, cognitive skills and memory may be impaired.

Infection or illness that affects the central nervous system, including

Creutzfeldt-Jakob disease and HIV. Some conditions are treatable, including
liver or kidney disease, depression-induced pseudo dementia, and operable
brain tumors.

NREM SLEEP

What Is Non-REM Sleep?

The period of NREM sleep is made up of stages 1-4. Each stage can last from 5 to 15
minutes. A completed cycle of sleep consists of a progression from stages 1-4 before REM
sleep is attained, then the cycle starts over again.

Stage 1: Polysomnography (sleep readings) shows a reduction in activity between

wakefulness and stage 1 sleep. The eyes are closed during Stage 1 sleep. One can be
awakened without difficulty, however, if aroused from this stage of sleep, a person may feel

as if he or she has not slept. Stage 1 may last for five to 10 minutes. Many may notice the
feeling of falling during this stage of sleep, which may cause a sudden muscle contraction
(called hypnic myoclonia).
Stage 2: This is a period of light sleep during which polysomnographic readings

show intermittent peaks and valleys, or positive and negative waves. These waves indicate
spontaneous periods of muscle tone mixed with periods of muscle relaxation. The heart rate
slows and the body temperature decreases. At this point, the body prepares to enter deep
sleep.
Stages 3 and 4: These are deep sleep stages, with stage 4 being more intense than
Stage 3. These stages are known as slow-wave, or delta, sleep. If aroused from sleep during
these stages, a person may feel disoriented for a few minutes.
During the deep stages of NREM sleep, the body repairs and regenerates tissues, builds
bone and muscle, and appears to strengthen the immune system. As you get older, you
sleep more lightly and get less deep sleep. Aging is also associated with shorter time spans
of sleep, although studies show the amount of sleep needed doesn't appear to diminish with
age.

REM SLEEP

Physiology of REM sleep

During REM, certain neurons in the brain stem, called REM sleep-on cells, become especially active these cells are most likely what trigger this phase in the sleep cycle.
Once triggered and in a state of REM, the body stops releasing neurotransmitters - called monoamines that are responsible for stimulating the motor neurons; this means that the muscles stop moving,
essentially entering a state of temporary paralysis.
8

Some people don't experience the paralysis, their muscles continue to move, even while they are in REM
sleep. They may act out their dreams in violent or dramatic ways, this is a condition called REM behavior
disorder (RBD).

Functions of REM sleep

Memory Consolidation
One theory states that REM sleep is important for the consolidation, or stabilization of spacial and
procedural memory.
9

Mitchison and Crick, in their hypothesis of sleep and neural networks, proposed that REM sleep can help
eliminate abnormal modes of interaction in the neural networks of the cerebral cortex.
10

Stimulation of Central Nervous System (CNS) Development

Another theory states that this sleep stage is vital for the development of the human brain in infants. It
proposes that REM sleep is responsible for the neural stimulation necessary to develop mature neural
connections.
11

Supporting evidence for this is seen in how the number of hours spent in REM sleep reduces as one ages,
and how sleep deprivation in early life can be a cause of behavioral problems, sleep disruption and
decreased brain mass. This theory suggests that REM sleep might not have any essential role in mature
human brains.

Creativity and REM sleep

REM sleep facilitates the way creativity combines certain associative elements into new combinations that
are necessary or helpful for problem solving. This has been attributed to the cholinergic and noradrenergic
neuromodulation that occurs while someone is in a REM state.
In fact, one study concluded that REM sleep, might foster the formation of associative networks.

Acute confusional state

Acute Confusional States
Acute confusional states (acute cerebral failure or acute
brain failure) is an acquired mental disorder characterized by
deficits in attention and coherence of thoughts and actions
often associated with an altered level of arousal, global cognitive
dysfunction, perceptual disturbances, sleep-wake cycle
disruption, affective disturbance, and emotional liability. 37
Acute confusional states result from dysfunction secondary
to such causes as drug intoxication, metabolic disorders, or
nervous system disease. A common cause of an acute confusional
state is withdrawal from alcohol, barbiturate, or other
sedative drug ingestion. Acute confusional states of toxic origin
may have either sudden or gradual onset, depending on
the amount of exposure to the toxin. These states often occur
with febrile illnesses, with systemic diseases such as heart failure,
after head injury or anesthesia, postnatally, or with certain
focal cerebral lesions.38
PATHOPHYSIOLOGY Acute confusional states arise
from disruption of a widely distributed neural network
involving the reticular activating system of the upper brainstem
and its projections to the thalamus, basal ganglion,
and specific association areas of the cortex and limbic areas.
Delirium
(hyperkinetic confusional states) is associated with
right middle temporal gyrus or left temporo-occipital junction
disruption.37 These areas receive extensive input from the
limbic areas and modulate motivational and affective aspects
of attention. Hypokinetic confusional states are more likely associated
with right-sided frontal-basal ganglion disruption.37
These areas modulate motor exploratory aspects of attention.
Most metabolic disturbances that produce a confusional
state interfere with neuronal metabolism or synaptic transmission.
Many drugs and toxins also interfere with neurotransmission
function at the synapse. Cholinergic pathways

critical for attention and arousal are often disrupted.

CLINICAL MANIFESTATIONS The predominant

features of an acute confusional state are impaired or lost detection.
Because of dysfunction of the anterior cingulate gyrus
(see Figures 16-10 and 14-7), the ability to focus, sustain, or
shift attentional focus is seriously impaired or completely lost.
The person is highly distractible and unable to concentrate
on incoming sensory information or on any particular mental
or motor task. Besides impaired attention, the person loses
coherence of thought and actions. The person may persist in
thoughts or actions that are no longer appropriate (perseveration)
and be unable to monitor the environment for events
of importance (impaired vigilance). The person demonstrates
irrelevant or inappropriate responses.
The onset of an acute confusional state usually is abrupt
rather than insidious. The first clinical manifestations are difficulty
in concentration, restlessness, irritability, tremulousness,
insomnia, and poor appetite. Later there are top-down
processing problems, including misperception, illusion, hallucination,
and delirium. Obsessions, compulsive behavior,
and rituals may be evident.
In hypokinetic acute confusional states, the individual exhibits
decreases in mental function. Alertness is decreased, as
are attention span, accurate perception, and interpretation of
the environment. Forgetfulness is prominent. Reactions to
the environment are slowed and indecisive. The individual
dozes frequently.
Delirium, an acute hyperkinetic confusional state, typically
develops over 2 to 3 days. Early clinical manifestations include
difficulty in concentrating, restlessness, irritability, insomnia,
tremulousness, and poor appetite. Some persons experience
seizures. Unpleasant, even terrifying, dreams may occur.
In a fully developed delirium state, the individual is
completely
inattentive and perceptions are grossly altered.
Misperception and misinterpretation are predominant. Hallucinations
may be present. The person appears distressed
and often very perplexed. Conversation is incoherent. Frank
tremor is evident, and a great deal of restless movement is
common. Violent behavior may be present. The individual
cannot sleep, is flushed, and has dilated pupils, a rapid pulse
(tachycardia), temperature elevation, and perfuse sweating
(diaphoresis). Delirium typically abates suddenly or gradually
in 2 to 3 days, although occasional delirium states persist for
several weeks.

EVALUATION AND TREATMENT An acute confusional

state is an acute medical problem. The initial goal is to
establish that the individual is confused, and the cause must
be distinguished as organic or functional (Table 16-17). Next
the goal is to determine whether the confusion is delirium,
an acute hypokinetic confusional state, or an underlying
dementia. The precise cause of an acute confusional state is
established
through the complete history and physical examination.
Laboratory tests include an electrocardiogram and
blood, urine, CSF, and radiologic studies.
Once the cause is established, treatment is directed at controlling

the primary disorder. In an acute confusional state,