138. CCA Study Notes: Alzheimer’s, Vascular, Lewy Body, Frontotemporal and Mixed Dementia

The Big Picture

Dementia affects how the brain works. It can change a person’s memory, thinking, behaviour, and ability to manage everyday activities.

There are different types of dementia. Some mainly affect memory at first. Others may cause changes in behaviour, movement, or attention. The symptoms and speed of change are not the same for everyone.

Understanding these differences helps you recognize important signs and remember that every person with dementia has their own needs, preferences, and life story.

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Course Notes: Key Ideas You Need to Know

Primary and Secondary Dementias

Irreversible dementias can be divided into two groups based on what causes them.

Type	Meaning
Primary dementia	Dementia that does not result from another disease.
Secondary dementia	Dementia that results from a physical disease, injury, or the ingestion of damaging substances.

Irreversible means the condition cannot be reversed.

Another important term is cognitive function. This refers to brain abilities such as remembering, thinking, reasoning ⓘ, understanding, making judgements, and behaving.

A neurocognitive disorder involves a significant decline in abilities such as attention, memory, learning, language, deliberate movement, everyday functioning, and social functioning.

The different types of dementia do not necessarily affect all these abilities in the same way.

Alzheimer’s Disease and Related Dementias (ADRD)

Alzheimer’s disease and related dementias (ADRD) are progressive conditions that damage nerve cells in the brain. Over time, thinking and memory become seriously impaired ⓘ.

Key facts:

• ADRD is the most common form of dementia.
• It accounts for over 64% of dementias among Canadians.
• It is a primary disorder of the brain, meaning it is not caused by another illness.
• Depending on its extent, ADRD may be categorized as a minor or major neurocognitive disorder.
• ADRD gets progressively worse, although the rate of decline varies.

A diagnosis of dementia does not automatically mean the person has ADRD. Other types can produce different symptoms and follow different patterns.

What Happens in the Brain?

Dr. Alois Alzheimer first identified Alzheimer’s disease in 1906. He described two important changes in the brain.

1. Plaques: Deposits that become toxic to brain cells when they accumulate to excessive levels.
2. Tangles: Abnormal structures that interfere with important cell processes and eventually cause living cells to die.

The brain contains neurons, which are nerve cells that communicate with one another.

In ADRD, these nerve cells become progressively less able to send messages to other nerve cells.

The loss of connectivity, or communication between brain cells, happens long before the cells die. This loss of communication is responsible for Alzheimer’s symptoms.

As more brain cells die, the brain physically shrinks. This affects how the brain functions.

Age, Causes, and Progression

ADRD usually develops after age 65 and is often diagnosed after age 80. It can also affect people in their 40s and 50s.

The exact cause is unknown, but having a family history of ADRD is a known risk factor.

Number to remember:

• The disease may progress over 3 to 20 years.
• On average, people live with ADRD for 8 to 12 years.

The speed of decline differs from one person to another. Stages can help describe the general pattern of the disease and guide care decisions.

There is currently no cure for ADRD. Some medications can slow its progression.

Ten Warning Signs of ADRD

The Alzheimer Society of Canada identifies ten important warning signs.

1. Memory loss affecting daily life: Frequently forgetting information or having difficulty remembering something new.
2. Difficulty with familiar tasks: Struggling with activities the person previously knew how to do, such as cooking or dressing.
3. Language difficulties: Forgetting words or replacing them with words that do not fit the conversation.
4. Disorientation in time and space: Losing track of the day or becoming lost somewhere familiar.
5. Impaired judgement: Failing to recognize a health problem that needs attention or choosing unsuitable clothing for the weather.
6. Problems with abstract thinking: Having trouble understanding numbers or how they are used, such as on a calculator.
7. Misplacing objects: Putting familiar belongings in unusual places where they do not belong.
8. Changes in mood and behaviour: Becoming unusually irritable or quick-tempered.
9. Personality changes: Acting differently than usual, including becoming suspicious or feeling threatened.
10. Loss of initiative: Showing less interest in friends, family, or favourite activities.

Important: A person showing these warning signs should be examined by a physician.

Disorientation means confusion or difficulty remembering people, time, or places. It can result from changes in the brain, disease processes, or substance-related factors.

Knowing the Person Behind the Dementia

People living with dementia have personal values, preferences, interests, and life experiences.

Knowing these details helps community support workers and long-term care staff build relationships and provide more personalized care.

The Alzheimer Society of Canada developed a resource called I’m Living with Dementia. It helps people share information about themselves with health care providers.

This includes:

• Their personal needs
• Things they like and dislike
• Their interests
• Information about who they are as individuals

A person’s dementia does not replace their identity or personal history.

Vascular Dementia

Vascular dementia, also called multi-infarct dementia, is one of the most common types of dementia. Among older people, it is second only to Alzheimer’s disease.

Vascular dementia develops when the brain does not receive enough blood over time.

This usually happens because of a stroke or several strokes.

How Reduced Blood Flow Damages the Brain

Blood carries oxygen and nutrients to brain cells.

When the brain’s blood supply becomes blocked or reduced because of diseased blood vessels, these cells may become damaged.

If the blood supply is interrupted for more than a few seconds, brain cells can die.

Damage may affect the cortex, a part of the brain involved in learning, memory, and language.

Some strokes are so small that the person may not notice symptoms. These are described as silent strokes or transient ischemic attacks (TIAs).

Over time, repeated damage can lead to increasing problems with memory, thinking, and orientation.

There is also a connection between heart health and brain health. Certain heart conditions, including dysrhythmia, or problems with the heart’s rhythm, can cause strokes.

How Vascular Dementia Progresses

Vascular dementia does not always develop at the same speed.

Its onset ⓘ depends partly on the person’s health and the severity of the stroke or strokes.

• Smaller events over time may lead to a gradual decline in memory.
• A larger stroke can cause major symptoms immediately.
• Some people develop changes slowly, while others experience sudden changes.

A major pattern of vascular dementia is stepwise progression.

This means the person’s abilities may decline, remain stable for a period, and then decline again.

This differs from a pattern of steady decline.

Signs and Symptoms of Vascular Dementia

Vascular dementia can affect thinking, emotions, personality, and daily activities.

Common mental and emotional symptoms include:

• Slower thinking
• Memory difficulties and general forgetfulness
• Mood changes, including depression or irritability
• Hallucinations and delusions
• Disorientation, which may become worse at night
• Personality changes and reduced social skills

As vascular dementia progresses, a person may have increasing difficulty with activities such as eating, dressing, or shopping.

Symptoms differ between individuals. Physical and behavioural changes may appear suddenly or develop gradually.

Treatment and Management

There is currently no known cure for vascular dementia.

Certain lifestyle changes and practical strategies may help:

• Prevent strokes
• Compensate ⓘ for losses in thinking and memory
• Slow the development of the disease

The condition and its progression vary from person to person.

Dementia with Lewy Bodies (DLB)

Dementia with Lewy bodies (DLB) is one of the most common forms of progressive dementia.

It involves worsening cognitive function together with three important defining features.

Three Main Features of DLB

1. Severe fluctuations in alertness and attention
   
   The person’s level of awareness or ability to pay attention can change greatly.
   
   Examples include sleep disturbances, frequent drowsiness, low energy, long periods of staring, and disorganized speech.
2. Recurrent visual hallucinations
   
   Visual hallucinations occur repeatedly.
3. Parkinson’s disease-like movement symptoms
   
   These include rigidity and loss of spontaneous movement.

People with DLB may also experience depression.

What Causes DLB Symptoms?

DLB involves the buildup of Lewy bodies, which are accumulated pieces of protein inside the nuclei of nerve cells.

These deposits occur in areas of the brain involved in certain parts of:

• Memory
• Movement control

The deposits are associated with the symptoms of DLB.

Why DLB Can Be Difficult to Diagnose

DLB shares symptoms with both Parkinson’s disease and Alzheimer’s disease.

These similarities can make it difficult for a physician to identify the exact diagnosis.

Lewy bodies may also be present in the brains of people with Parkinson’s disease or ADRD.

This suggests that DLB may be related to those conditions or may occur alongside one of them.

Most cases of DLB occur sporadically, meaning there is no known family history. Rare cases involving families have also been reported.

Frontotemporal Dementia (FTD)

Frontotemporal dementia (FTD) is a type of dementia that often causes noticeable changes in behaviour, personality, and thinking.

FTD accounts for about 5% of all dementias.

It generally begins between ages 40 and 60. Women are slightly more affected than men.

How FTD Differs from Alzheimer’s Disease

An important difference involves the symptoms that appear first.

Alzheimer’s Disease	Frontotemporal Dementia
Memory impairment tends to be an early symptom.	Emotional, personality, and social changes tend to appear first.
Changes in memory are an important early feature.	Changes in behaviour and social conduct are especially noticeable early.

FTD affects the frontal lobes of the brain, which helps explain its early changes in emotional and social functioning.

Early Behaviour and Personality Changes

FTD can cause major changes in how a person behaves around others.

These changes may include:

• Loss of inhibition: Showing less restraint in behaviour.
• Apathy: A lack of emotional feeling that appears as indifference.
• Social withdrawal: Pulling away from other people.
• Ritualistic compulsive behaviours: Repeated or ritual-like behaviours.
• Mouthing objects: Putting objects into the mouth.

Mood changes can include euphoria, an exaggerated feeling or expression of well-being that does not match reality.

A person may become unusually outgoing, withdrawn, rude, impatient, or aggressive.

The person may also make inappropriate public remarks or show a decline in social skills.

Changes in sexual behaviour may occur, including a greatly increased interest in sex linked to reduced inhibition. These changes can be distressing and may lead to difficulties involving the police.

Because early FTD often changes behaviour, it may be mistaken for a psychological ⓘ or emotional condition.

In older adults, these changes may also be mistaken for unusual personality traits or social withdrawal.

Language, Thinking, and Memory Changes

FTD can also affect language and the ability to stay focused.

Early changes may include:

• Difficulty finding the right words
• Difficulty naming objects
• Trouble maintaining a train of thought
• Becoming easily distracted
• Difficulty continuing a conversation for long

Language problems may appear in the early stages, although the early difficulties are described as less striking than those seen in ADRD.

As FTD progresses, memory problems become more noticeable.

Apraxia may also become more pronounced.

Apraxia means difficulty performing learned, purposeful movements because the skilled movement system is impaired. This can affect familiar activities such as bathing or brushing teeth.

Pick’s Disease

Pick’s disease is one type of frontotemporal dementia.

It involves abnormal structures in brain cells called Pick’s bodies. These are present in affected areas and elsewhere in the brain.

Behavioural changes may be difficult to notice at first. As behaviour becomes more unusual, dementia may become easier to recognize.

Pick’s disease can cause:

• Major behavioural changes
• Gluttony, or excessive overeating
• Increased alcohol intake
• A compulsion ⓘ to place objects in the mouth

These changes are associated with the brain damage caused by the disease.

Mixed Dementia

Mixed dementia has features of both Alzheimer’s disease and vascular dementia.

It is now thought to be more common than previously believed.

Mixed dementia is important because the combination of two diseases may affect the brain more than either disease alone.

The person may show:

• Symptoms similar to Alzheimer’s disease
• Symptoms similar to vascular dementia
• A combination of symptoms from both conditions

Mixed dementia shows why a person’s symptoms may not fit neatly into only one type of dementia.

Comparing the Five Types of Dementia

Each type has a different set of important features.

Type	Main Feature to Remember
Alzheimer’s disease and related dementias	Progressive brain-cell damage, with memory problems often appearing early.
Vascular dementia	Brain damage from reduced blood flow, often with periods of decline and stability.
Dementia with Lewy bodies	Progressive cognitive decline with changing alertness, visual hallucinations, and movement difficulties.
Frontotemporal dementia	Early changes in behaviour, personality, emotional functioning, and social conduct.
Mixed dementia	Features of both Alzheimer’s disease and vascular dementia.

These patterns help distinguish the conditions, but individual symptoms and progression can vary.

Common Mix-Ups

Wrong Idea	Better Idea
Every person with dementia has Alzheimer’s disease.	Alzheimer’s is the most common form, but several other types exist.
Alzheimer’s and FTD usually have the same earliest symptoms.	Memory problems often appear first in ADRD, while emotional and social changes tend to appear first in FTD.
Vascular dementia always causes a steady decline.	Vascular dementia typically has periods of decline followed by stability.
DLB only affects memory.	DLB also involves major changes in alertness, repeated visual hallucinations, and movement symptoms.
Mixed dementia means only one dementia condition is present.	Mixed dementia combines characteristics of Alzheimer’s disease and vascular dementia.