Dementia is an acquired, generalized, and usually progressive impairment of cognitive function. Dementia differs from other disorders of cognitive function, such as coma (see Chapter 3, Coma) or confusional states (see Chapter 4, Confusional States), in that the level of consciousness (wakefulness or arousal) is preserved in dementia. Although the prevalence of dementia increases with advancing age (Figure 5-1), dementia is not an invariable consequence of aging and results instead from diseases involving the cerebral cortex, its subcortical connections, or both. Normal aging may be associated with minor alterations in neurologic function (Table 5-1) and with neuroanatomic changes, such as enlargement of cerebral ventricles and cortical sulci seen on computed tomography (CT) or magnetic resonance imaging (MRI) scans (Figure 5-2). However, these are not indicative of dementia. The term mild cognitive impairment (MCI) is sometimes used to describe deficits that are more severe than are customarily seen with normal aging but are insufficiently pronounced to warrant a diagnosis of dementia. Nevertheless, patients with MCI have an increased risk (approximately 10% per year) of developing dementia.
Table 5-1.Neurologic Changes in Normal Aging. |Favorite Table|Download (.pdf) Table 5-1. Neurologic Changes in Normal Aging.
|Slowed information processing |
|Impaired learning and recall of new information |
|Reduced spontaneous word finding and verbal fluency |
|Increased reaction time |
|Small, sluggishly reactive pupils |
|Impaired upgaze |
|Impaired convergence |
|Atrophy of intrinsic hand and foot muscles |
|Increased muscle tone |
|Flexion (stooped) posture |
|Small-stepped or broad-based gait |
|Reduced visual acuity |
|Reduced auditory acuity |
|Reduced gustatory acuity |
|Reduced olfactory acuity |
|Reduced vibration sense |
|Primitive reflexes |
|Absent abdominal reflexes |
|Absent ankle reflexes |
Relationship between advancing age and incidence and prevalence of dementia. (Used with permission from Halter JB, Ouslander JG, Tinetti ME. Hazzard’s Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill; 2009.)
CT scan in cerebrocortical atrophy, showing ventricular dilation (A) and prominent cortical sulci (B).
In contrast to dementia, which affects multiple spheres of cognitive function, more limited disorders of cognition may also occur. These include deficits in language function (aphasia) or motor (apraxia) or sensory integration, which are considered in Chapter 1, Neurologic History & Examination. Memory disturbance (amnestic disorder or amnesia), another example of a circumscribed cognitive defect, is discussed in this chapter. Memory may also be impaired in normal aging and in dementia, but in the former impairment is mild, and in the latter it is accompanied by defects in, for example, reasoning, judgment, behavior, or language. Some causes of dementia, notably Alzheimer disease, produce early and disproportionate impairment of memory and, at least in the early stages of disease, ...