The Correlation Between StrokeAndDementia To Men In Age Above 40 In West Java, 2009

Author :Audra Firthi Dea Noorafiatty030 . 08 . 046

FACULTY OF MEDICINE TRISAKTI UNIVERSITYJAKARTA2009PREFACEAssalamualaikum Wr. WbFirst of all, I want to give my highest gratitude to The Almighty God, Allah SWT, who gives me so much bless, so I can finish this paper promptly and properly. In this opportunity, I would also like to thank to my parent who have given spiritual and material support. In addition, I would like to acknowledge with sincere gratitude to Mrs. Tanty as my teacher who has given me guidance to finish this paper.This paper, titled The Correlation between stroke and dementia, is made to complete the English assignment for subject English 2 in the Faculty of Medicine Trisakti University. I choose this topic because stroke can highly cause dementia. In recent years, studies found that the mortality because of stroke is increase.With this paper I hope I can share information about stroke and dementia. I know my paper is still far from perfect, but i hope that my paper can be of assistance to the community and society. Thank you.

Wassalamualaikum Wr. WbJakarta, July 2009

Audra firthi dea noorafiatty

CONTENTS

PREFACE .iCONTENTS ii

CHAPTER IINTRODUCTION1.1. Background1.2. Problems1.3. Limitation of Problems1.4. Objective1.5. Method of Writing1.6. Frame of Writing

CHAPTER IISTROKE2.1. Definition of stroke2.2. Etiology of stroke2.3. Epidemiology of stroke2.4. Pathogenesis of stroke2.5. Symptoms and Sign of stroke2.6. Diagnosis of stroke2.7. Therapy of stroke2.8. Treatment of stroke2.9. Complication of stroke2.10. Prevention of stroke2.11. Prognosis of strokeCHAPTER IIIDEMENTIA3.1. Definition of dementia3.2. Etiology of dementia3.3. Epidemiology of dementia3.4. Pathogenesis of dementia3.5. Symptoms and Sign of dementia3.6. Diagnosis of dementia3.7. Therapy of dementia3.8. Treatment of dementia3.9. Complication of dementia 3.10. Prevention of dementia3.11. Prognosis of dementiaCHAPTER IV THE CORRELATION BETWEEN STROKE AND DEMENTIA TO MEN IN AGE ABOVE 40 IN WEST JAVA, 2009

CHAPTER VCONCLUSION

BIBLIOGRAPHY

CHAPTER IINTRODUCTIONI.1 BackgroundStroke is becoming a global epidemic disease which leads to dementia. Stroke ranked as the second leading cause of death after ischemic heart disease. Data on causes of death from the 1990s have shown that cerebrovascular diseases (stroke) remain a leading cause of death. In 2001 it was estimated that cerebrovascular diseases (stroke) accounted for 5.5 million deaths world wide, equivalent to 9.6 % of all deaths. Two-thirds of these deaths occurred in people living in developing countries and 40% of the subjects were aged less than 70 years. Additionally, cerebrovascular disease is the leading cause of disability in adults and each year millions of stroke survivors has to adapt to a life with restrictions in activities of daily living as a consequence of cerebrovascular disease.Stroke is a nonspecific term encompassing a heterogeneous group of pathophysiologic causes, including thrombosis, embolism, and hemorrhage.Strokes currently are broadly classified as eitherhemorrhagic or ischemic. Acute ischemic stroke refers to stroke caused by thrombosis or embolism and accounts for 85% of all strokes.1.2 ProblemsThe Incidence of stroke is now days increased than years before. World Health Organization reported their data, the probability of a first stroke or first transitory ischemic attack is around 1.6 per 1,000 and 0.42 per 1,000. Stroke patients are at highest risk of death in the first weeks after the event, and between 20% to 50% die within the first month depending on type, severity, age, comorbidity and effectiveness of treatment of complications.People who have had a stroke have a 9 times greater risk of dementia than people who have not had a stroke. About 1 in 4 people who have a stroke develop signs of dementia within 1 year.Vascular dementia is most common in older people, who are more likely than younger people to have vascular diseases. It is more common in men than in women..

1.3 Limitation of Problems What is dementia? Why does dementia happen? What are the causes of dementia? What is stroke? How does stroke work? Why does stroke happen?

1.4 Objectives To give information about dementia. To explain about the etiology of dementia. To explain about the causes of dementia. To give information about stroke. To explain about how stroke works. To explain about why stroke happens.

1.5 Methods of WritingThis topic is approached through a selective literature review. This study used the database assembled by the Indonesian Heart Health Surveys Research Group between 1986 and 1992 a stratified representative sample comprising Indonesian men residents aged 40 to 50.

1.6 Frame of Writing

CHAPTER IINTRODUCTION1.1. Background1.2. Problems1.3. Limitation of Problems1.4. Objective1.5. Method of Writing1.6. Frame of Writing

CHAPTER IISTROKE2.1. Definition of stroke2.2. Etiology of stroke2.3. Epidemiology of stroke2.4. Pathogenesis of stroke2.5. Symptoms and Sign of stroke2.6. Diagnosis of stroke2.7. Therapy of stroke2.8. Treatment of stroke2.9. Complication of stroke2.10. Prevention of stroke2.11. Prognosis of strokeCHAPTER IIIDEMENTIA3.1. Definition of dementia3.2. Etiology of dementia3.3. Epidemiology of dementia3.4. Pathogenesis of dementia3.5. Symptoms and Sign of dementia3.6. Diagnosis of dementia3.7. Therapy of dementia3.8. Treatment of dementia3.9. Complication of dementia 3.10. Prevention of dementia3.11. Prognosis of dementia

CHAPTER IV THE CORRELATION BETWEEN STROKE AND DEMENTIA TO MEN IN AGE ABOVE 40 IN WEST JAVA, 2009

CHAPTER VCONCLUSION

BIBLIOGRAPHY

CHAPTER IISTROKE

2.1. DEFINITIONStroke is characterized by the sudden loss of blood circulation to an area of the brain due to a lack of oxygen, when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain, resulting in a corresponding loss of neurologic function. Also previously called cerebrovascular accident (CVA)or stroke syndrome or it is sometimes called a "brain attack". The WHO (1980) defines stroke as rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin.

2.2. ETIOLOGYStroke occurs every forty to forty five seconds and is the leading cause of death in world. If it is the leading cause of death then what is stroke? Stroke is when blood flow to the brain is disrupted. The disruption is caused by the blood clot or plaque that causes blockage in one of the very crucial blood vessels. The blockage to the crucial blood vessels is called the ischemic stroke. On the other hand if the blood vessel bursts and the blood spill in to the tissues surrounding it then it is called hemorrhagic stroke

2.3. EPIDEMIOLOGYStroke is the third leading cause of death in the United States after heart disease and cancer, with and incidence of approximately 550,000 cases per year, and is also a leading cause of disability in adults [NSA, 1996]. In 1995, an estimated 2,312,180 deaths occurred in the U.S. [Rosenberg HM, et al. Births and deaths: United States, 1995. Monthly Vital Statistics Report. 1996;45(3), Suppl 2]. Of these, 158,061 deaths were caused by cerebrovascular disease (stroke), representing a death rate of 60.2 per 100,000 total estimated U.S. population. The comparable figures for heart disease and cancer were 738,781 (281.2) and 537,969 (204.7). In 1994, nearly 1 in 15 Americans died as a result of stroke. [American Heart Association. 1997 Heart and Stroke Statistical Update].

2.4. PATHOGENESISThe pathogenic process leading from the development of the cerebrovascular or extracranial atherosclerosis of the occurrence of acute ischemic stroke and consequent cell damage is complex, and many of the intermediary damage is complex, and many of the intermediary steps are not completely understood.Ischemic stroke may arise from the atherosclerotic large cerebral arteries or atherosclerotic small cerebral arteries. Ischemic stroke may also be cardioembolic in origin. Most investigations of atherogenesis have focused on the coronary arteries but, with some possible exceptions, similar processes occur in the cerebral circulation. In the brain, the process is better characterized in the larger arteries than in small arteries supplying deep cerebral white matter. Some evidence suggests that the underlying pathogenetic process in small arteries may differ from that described in larger arteries. Atherogenesis is a decades-long process in which the lumen of a blood vessel becomes narrowed by cellular and extracellular substances to the point of obstruction In the third decade of life, some atheromatous lesions evolve into complicated fibrous plaques, consisting of a central acellular area of lipid covered by a cap of smooth muscle cells and collagen. Caps tend to form slowly at first, but with deposition of platelets and fibrin on the surface (which appears to be the result of endothelial injury) the caps thicken quickly, possibly as a result of thrombosis-dependent fibrotic organization.The progression of early atherosclerotic lesions to clinically relevant advanced atherosclerotic lesions occurs with increased frequency in persons with risk factors for atherosclerotic disease (eg, heypercholesterolemia, hypertension, cigarette smoking).

2.5. SYMPTOMS AND SIGNSThe symptoms of stroke is different, depends on the area of the brain affected In some cases, a person may not even be aware that he or she has had a stroke. Symptoms usually develop suddenly and without warning. They may be episodic (occurring and then stopping) or they may slowly get worse over time.Symptoms may include: Change in alertness (consciousness) Coma Lethargy Sleepiness Stupor Unconsciousness Withdrawn Difficulty speaking or understanding others Difficulty swallowing Weakness (most common symptoms) Paralysis of one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm Bells palsy or face paralysis Difficulty writing or reading Headache Occurs when lying flat Wakes you up from sleep Gets worse when you change positions or when you bend, strain, or cough Starts suddenly Loss of coordination Loss of balance Movement changes, usually on only one side of the body Difficulty moving any body part Loss of fine motor skills Nausea or vomiting Seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. Sensation changes, usually on only one side of the body Decreased sensation Numbness or tingling Suddent confusion Vision changes Decreased vision Loss of all or part of vision

2.6. DIAGNOSISWe can diagnose stroke by : Anamnesis (trying to get information from the patient about medical history, life style,family history, etc) Physical examination (includes a careful head and neck examination for signs of trauma, infection, and meningeal irritation, detecting extracranial causes of stroke symptoms, distinguishing stroke from stroke mimics, determining and documenting for future comparison the degree of deficit, and localizing the lesion). Special test, like: Neurogical examinationThis test is performed by a physician in order to uncover deficiencies in brain function which might confirm the suspicion that a person is actually having a stroke. Each part of the neurological exam tests a different area of the brain, including: Awareness and consciousness Speech, language, and memory function Vision and eye movements Sensation and movement in the face arms and legs Reflexes Walking and sense of balance CT-scan This technique is usually the first test done when a patient comes to a hospital emergency room with stroke symptoms. It is a good tests for this purpose not only because it easily detect bleeding inside the brain, but also because it can be performed quickly.The test uses low-dose X-rays to show an image of the brain and it can determine whether a stroke is caused by a blockage or a bleed, and the size and location of the stroke. The test is painless. This test can detect hemorrhagic or ischemic stroke. MRI This is one of the most helpful tests in the diagnosis of stroke because it can detect strokes within minutes of their onset. Its images of the brain are also superior in quality by comparison with CT images. Because of this, MRI is the test of preference in the diagnosis of stroke. A special type of MRI called magnetic resonance angiography, or MRA, lets doctors precisely visualize narrowing or blockage of blood vessels in the brain. Transcranial Doppler This test uses sound waves to measure blood flow through the major blood vessels in the brain. Narrow areas inside of a blood vessel demonstrate faster blood flow than normal areas. This information can be used by doctors to follow the progress of occluded blood vessels.Another important use for the TCD is the assessment of blood flow through blood vessels in the area of a hemorrhagic stroke, as these blood vessels have a propensity to undergo vasospasm a dangerous contraction of the wall of a blood vessel which can block blood flow. Lumbar PunctureAlso known as a spinal tap this test is sometimes performed in the emergency room when there is a strong suspicion for a hemorrhagic stroke in someone whose CT scan does not show clear blood. The test involves the introduction of a needle into an area within the lower part of the spinal column where it is safe to collect cerebrospinal fluid (CSF). When there is bleeding in the brain, blood can be seen in the CSF. Cerebral AngiographyThis test use to visualize blood vessels in the neck and brain. During this test a special dye which can be seen using X-rays is injected into the carotid arteries, which bring blood to the brain. In a person who has a partial or a total obstruction in one of these blood vessels, or in any other blood vessel inside the brain, little or no dye can be seen flowing through it. Cerebral angiography can also help doctors diagnose the following common conditions known to be associated with aneurysms and arterio-venous malformations. ElectrocardiogramThis test, also known as an EKG or ECG, helps doctors identify problems with the electrical conduction of the heart. Normally, the heart beats in a regular, rhythmic pattern which promotes smooth blood flow towards the brain and other organs. Transthoracic echocardiogram (TTE)This test, also known as an echo uses sound waves to look for blood clots or other sources of emboli inside the heart. It also is used to look for abnormalities in heart function which can lead to blood clot formation inside the heart chambers. TTEs are also used to investigate if blood clots from the legs can travel through the heart and reach the brain. Leg UltrasoundDoctors usually perform this test on stroke patients diagnosed with a patent foramen ovale. The test uses sound waves to look for blood clots in the deep veins of the legs, which are also known as deep venous thromboses or DVTs. DVTs can cause strokes by making a long journey which ends up in the brain. Blood TestsFor the most part, blood tests help doctors look for diseases known to increase the risk of stroke, including high cholesterol, diabetes, blood clotting disorder

2.7. THERAPYThere is four categories of medicines that can treat stroke, the medicines are :1. AnticoagulationCurrently, only one medicine is approved to treat new strokes. It is the clot-busting medication called tissue plasminogen activator (t-PA). This medicine works with the body's own chemicals and helps dissolve the blockage in the blood vessel in the brain that may be causing the stroke. It is the same drug that is often used to treat heart attacks. Not all people with stroke can receive the clot-busting drug t-PA. For t-PA to work, it must be given within 3 hours of the onset of symptoms. The earlier the drug is given within those 3 hours, the better it works. The clot-busting medication is not used for anyone having a hemorrhagic stroke.2. Reperfusion agents (thrombolytics)Thrombolytics restore cerebral blood flow among some patients with acute ischemic stroke and may lead toimprovement or resolution of neurologic deficits. Unfortunately, thrombolytics can also cause symptomatic intracranial hemorrhage, defined as radiographic evidence of hemorrhage combined with escalation of NIHSS by 4 or more points.3. Anti-Platelet Agents AspirinBlocks prostaglandin synthetase action, which, in turn, inhibits prostaglandin synthesis and prevents formation of platelet-aggregating thromboxane A2. Also acts on hypothalamic heat-regulating center to reduce fever Ticlopidine (ticlid)Second-line antiplatelet therapy for patients who cannot tolerate aspirin or in whom aspirin not effective.4. Neuroprotective agentsDespite very promising results in several animal studies as of yet no single neuroprotective agent in ischemic stroke is supported by randomized placebo-controlled human studies. Nevertheless, substantial research is underway evaluating their use for this indication. Since the ischemic cascade is a dynamic process, the efficacy of interventions to protect the ischemic penumbra also may prove to be time dependent.

2.8. TREATMENTThere are two treatments for treating stroke Self-care at homeStroke is a medical emergency and seconds count. Brain cells begin to die within 4 minutes of the beginning of a stroke. Call for emergency medical transport to a hospital's emergency department. Current treatments for acute stroke must be given by a doctor and within a short time of the onset of symptoms. If you think you are having a stroke or someone with you is having a stroke,go to hospital immediately. Do not wait to see if symptoms go away. Do not take aspirin, this will be given later if needed. Do not drive yourself or wait for a ride to the hospital.

Medical treatmentThe initial treatment for stroke is supportive. Usually will be given fluids through an IV because if you're having a stroke, you may often be dehydrated. Oxygen may be given to be sure that your brain is getting the maximal amount. Unlike people with chest pain, people having a stroke are not given an aspirin immediately. You are requested not to eat or drink until your ability to swallow is assessed. Blood pressure control: It is important not to lower the blood pressure too much so that the brain will get enough blood. Many different medications can be used to lower the blood pressure including pills, nitroglycerin paste, or IV injections. If the blood pressure is very high, you would be placed on a continuous IV flow of medication. If you have acute stroke, you will be admitted to the hospital for monitoring and further testing to figure out the cause of the stroke and ways to prevent a future stroke. Once you have had a stroke, you are at greater risk than others of having an additional stroke.

2.9. COMPLICATIONIf you have stroke, you're more likely to develop a number of potentially serious health problems. The complication is depending on how long the brain suffers a lack of blood flow, a stroke can sometimes cause temporary or permanent disabilities. Stroke complications differ depending what part of the brain was affected and may include: Paralysis or loss of muscle movement. Sometimes, a lack of blood flow to the brain can cause a person to become paralyzed on one side of the body, or lose control of certain muscles, such as those on one side of the face. With physical therapy, you may see improvement in muscle movement or paralysis. Difficulty talking or swallowing. A stroke may cause a person to have less control over the way the muscles in the mouth move, making it difficult to talk, swallow or eat. A person may also have difficulty speaking because a stroke has caused aphasia, a condition in which a person has difficulty expressing thoughts through language. Therapy with a speech and language pathologist may improve this disability. Memory loss or troubles with understanding. It's common that people who suffer strokes have some memory loss. Others may develop difficulty understanding concepts. This complication may improve with rehabilitation therapies. Pain. Some people who have a stroke may have pain, numbness, or other strange sensations in parts of their body affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may have an uncomfortable tingling sensation in that arm. You may also be sensitive to temperature changes, especially extreme cold. This is called central stroke pain or central pain syndrome (CPS). This complication may improve with time, but because the pain is caused by a problem in the brain instead of a physical injury, there are few medications to treat CPS.People who have a stroke may also become withdrawn and less social. They may lose the ability to care for themselves and may need a caretaker to help them with their grooming needs and daily chores after a stroke.

2.10. PREVENTIONKnowing your risk factors and adopting a healthy lifestyle are the best steps you can take to prevent a stroke. In general, a healthy lifestyle means that you: Control high blood pressure (hypertension). One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control. If you've had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke. Exercising, managing stress, maintaining a healthy weight, and limiting sodium and alcohol intake are all ways to keep high blood pressure in check. In addition to recommendations for lifestyle changes, your doctor may prescribe medications to treat high blood pressure, such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers. Lower your cholesterol and saturated fat intake. Eating less cholesterol and fat, especially saturated fat, may reduce the plaques in your arteries. If you can't control your cholesterol through dietary changes alone, your doctor may prescribe a cholesterol-lowering medication. Don't smoke. Quitting smoking reduces your risk of stroke. Several years after quitting, a former smoker's risk of stroke is the same as that of a nonsmoker. Control diabetes. You can manage diabetes with diet, exercise, weight control and medication. Strict control of your blood sugar may reduce damage to your brain if you do have a stroke. Maintain a healthy weight. Being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol levels. Exercise regularly. Aerobic exercise reduces your risk of stroke in many ways. Exercise can lower your blood pressure, increase your level of high-density lipoprotein (HDL) cholesterol, and improve the overall health of your blood vessels and heart. It also helps you lose weight, control diabetes and reduce stress. Gradually work up to 30 minutes of activity such as walking, jogging, swimming or bicycling on most, if not all, days of the week. Manage stress. Stress can cause a temporary spike in your blood pressure a risk factor for brain hemorrhage or long-lasting hypertension. It can also increase your blood's tendency to clot, which may elevate your risk of ischemic stroke. Simplifying your life, exercising and using relaxation techniques are all approaches that you can learn to reduce stress. Drink alcohol in moderation, if at all. Alcohol can be both a risk factor and a preventive measure for stroke. Binge drinking and heavy alcohol consumption increase your risk of high blood pressure and of ischemic and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol can increase your HDL cholesterol and decrease your blood's clotting tendency. Both factors can contribute to a reduced risk of ischemic stroke. Don't use illicit drugs. Many street drugs, such as cocaine and crack cocaine, are established risk factors for a TIA or a stroke. Follow a healthy dietIn addition, eat healthy foods. A brain-healthy diet should include: Five or more daily servings of fruits and vegetables, which contain nutrients such as potassium, folate and antioxidants that may protect you against stroke. Foods rich in soluble fiber, such as oatmeal and beans. Foods rich in calcium, a mineral found to reduce stroke risk. Soy products, such as tempeh, miso, tofu and soy milk, which can reduce your low-density lipoprotein (LDL) cholesterol and raise your HDL cholesterol level. Foods rich in omega-3 fatty acids, including cold-water fish, such as salmon, mackerel and tuna. Preventive medicationsIf you've had an ischemic stroke, your doctor may recommend medications to help reduce your risk of having a TIA or stroke.

2.11. PROGNOSISThe prognosis of stroke is unpredictable. About 20% of patients die in hospital. Others have complications of stroke. Although stroke is a disease of the brain, it can affect the entire body. Some of the disabilities that can result from stroke include paralysis, cognitive deficits, speech problems, emotional difficulties, daily living problems, and pain

CHAPTER IIIDEMENTIA

1.1. DEFINITIONDementia is not a specific disease. It is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain,especially brain function. People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They also lose their ability to solve problems and maintain emotional control, and they may experience personality changes and behavioral problems such as agitation, delusions, and hallucinations. While memory loss is a common symptom of dementia, memory loss by itself does not mean that a person has dementia. Doctors diagnose dementia only if two or more brain functions - such as memory, language skills, perception, or cognitive skills including reasoning and judgment - are significantly impaired without loss of consciousness. There are many disorders that can cause dementia. Some, such as AD (Alzheimer disease), lead to a progressive loss of mental functions. But other types of dementia can be halted or reversed with appropriate treatment. With AD and many other types of dementia, disease processes cause many nerve cells to stop functioning, lose connections with other neurons, and die. In contrast, normal aging does not result in the loss of large numbers of neurons in the brain.

1.2. ETIOLOGYDementia may result from primary diseases of the brain or other conditions The most common types of dementia are Alzheimer's disease, vascular dementia, Lewy body dementia, frontotemporal dementias, and HIV-associated dementia. Dementia also occurs in patients with Parkinson's disease, Huntington's disease, progressive supranuclear palsy, Creutzfeldt-Jakob disease, Gerstmann-Strussler-Scheinker syndrome, other prion disorders, and neurosyphilis. Patients can have > 1 type (mixed dementia).Some structural brain disorders (eg, normal-pressure hydrocephalus, subdural hematoma), metabolic disorders (eg, hypothyroidism, vitamin B12 deficiency), and toxins (eg, lead) cause a slow deterioration of cognition that may resolve with treatment. This impairment is sometimes called reversible dementia, but some experts restrict the term dementia to irreversible cognitive deterioration.Depression may mimic dementia (and was formerly called pseudodementia), the 2 disorders often coexist. However, depression may be the first manifestation of dementia.Changes in cognition, including memory, occur with aging, but they are not dementia. The elderly have a relative deficiency in recall, particularly in speed of recall, compared with recall during their youth. However, this change does not affect daily function. Mild cognitive impairment is more severe than age-associated memory impairment; memory is impaired compared with that of age-matched controls, but other cognitive domains and daily function are not affected. Up to 50% of patients with mild cognitive impairment develop dementia within 3 year.Any disorder may exacerbate cognitive deficits in patients with dementia. Delirium often occurs in patients with dementia. Drugs, particularly benzodiazepines and anticholinergics (eg, some tricyclic antidepressants, antihistamines, antipsychotics, benztropine), may temporarily cause or worsen symptoms of dementia, as may alcohol, even in moderate amounts. New or progressive renal or liver failure may reduce drug clearance and cause drug toxicity after years of taking a stable drug dose (eg, of propranolol).

1.3. EPIDEMIOLOGYDementia affects 1725 million people worldwide, with an estimated four million in the US and an estimated 800,000 people in the UK. It affects predominantly elderly people, and as population growth increases in this age range, the numbers affected by dementia are expected to rise significantly. The prevalence of dementia in people over the age of 65 is 5% and in people over 80, it is 20%. It has been estimated that 26% of women and 21% of men over the age of 85 have some form of dementia, of whom approximately 50% have Alzheimers disease (AD).

1.4. PATHOGENESISCertain aspects of the clinical syndrome of dementia, cerebral atrophy, predominantly sensory neuropathy, and vacuolar myelopathy in AIDS resemble those seen in vitamin B12 deficiency. Pathologically, there are similarities not only in the changes in the spinal cord, but also in the brain and peripheral nerves. Macrophage activation with secretion of cytokines and other biologically reactive substances within the nervous system is sustained in the late stages of HIV infection by the general effects of immune depletion, including loss of T cells (with concomitant reduction of macrophage regulatory molecules) and recurrent opportunistic infections, and may be further augmented by the local presence of the virus itself (or its surface glycoprotein gp120). A similar mechanism may underlie the pathogenesis of dementia, cerebral atrophy, and peripheral neuropathy. Local factors or differential susceptibility between the central and peripheral nervous system may determine whether myelinotoxic or neurotoxic processes predominate; the prominence of myelin involvement in the spinal cord, and axonal involvement peripherally may reflect both ends of this range, with the brain manifesting a more equal balance of both processes.

1.5. SYMPTOMS AND SIGNSymptoms of dementia very considerably by the individual and the underlying cause of the dementia. Most people affected by dementia have some (but not all) of these symptoms. The symptoms may be very obvious, or they may be very subtle and go unrecognized for some time. The first sign of dementia is usually loss of short-term memory. Other symptoms and signs are as follows: Early dementia Word (finding difficulty) May be able to compensate by using synonyms or defining the word Forgetting names, appointments, or whether or not the person has done something, losing things Difficulty performing familiar tasks (Driving, cooking a meal, household chores, managing personal finances) Personality changes (for example, sociable person becomes withdrawn or a quiet person is coarse and silly) Uncharacteristic behavior Mood swings, often with brief periods of anger or rage Poor judgment Behavior disorders - Paranoia and suspiciousness Decline in level of functioning but able to follow established routines at home Confusion, disorientation in unfamiliar surroundings - May wander, trying to return to familiar surroundings

Intermediate dementia Worsening of symptoms seen in early dementia, with less ability to compensate Unable to carry out activities of daily living without help Disrupted sleep (often napping in the daytime, up at night) Unable to learn new information Increasing disorientation and confusion even in familiar surroundings Greater risk of falls and accidents due to poor judgment and confusion Behavior disorders, paranoid delusions, aggressiveness, agitation, inappropriate sexual behavior Hallucinations Confabulation (believing the person has done or experienced things that never happened) Inattention, poor concentration, loss of interest in the outside world Abnormal moods (anxiety, depression)

Severe dementia Worsening of symptoms seen in early and intermediate dementia Complete dependence on others for activities of daily living May be unable to walk or move from place to place unassisted Impairment of other movements such as swallowing, increases risk of malnutrition, choking, and aspiration (inhaling foods and beverages, saliva, or mucus into lungs) Complete loss of short and long-term memory, may be unable to recognize even close relatives and friends

1.6. DIAGNOSIS Medical historyMedical history involves gathering information about the onset, duration, and progression of symptoms and any possible risk factors for dementia, such as a family history of the disorder or other neurological disease, history of stroke, and alcohol or other drug (prescription or over-the-counter) use Physical examinationA physical examination can help rule out treatable causes of dementia and identify signs of stroke or other disorders that can contribute to dementia. It can also identify signs of other illnesses, such as heart disease or kidney failure, that can overlap with dementia Neurological examination Brain scan (CT scan, MRI, electroencephalograph or EEG) Laboratory test Urinalysis Toxicology screen Complete blood count Cerebrospinal fluid analysis

1.7. THERAPYExcept for the cholinesterase inhibitors, the US Food and Drug Administration(FDA) has not approved any drug specifically for dementia. The drugs listed here are some of the most frequently prescribed from each class. Cholinesterase inhibitors: Tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), galantamine/galanthamine (Reminyl) Antidepressants/anxiolytics: Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) Antipsychotics: Haloperidol (Haldol), risperidone (Risperdal), quetiapine (Seroquel), olanzapine (zyprexa), ziprasidone (Geodon) Anticonvulsants: Valproic acid (Depakote), carbamazepine (Tegretol) gabapentin (Neurontin), lamotrigine (Lamictal)All drugs cause side effects. In prescribing a drug, doctors weigh whether the benefits of the drug outweigh the side effects. Seniors are especially likely to experience drug side effects. People with dementia who are taking any of these drugs must be checked often to make sure that the side effects are tolerable1.8. TREATMENTAlthoughan individual with dementia should always be under medical care, family members handle much of the day-to-day care. Medical care should focus on optimizing the individual's health and quality of life while helping family members cope with the many challenges of caring for a loved one with dementia. Medical care depends on the underlying condition, but it most often consists of medications and nondrug treatments such as behavioral therapy. Self-Care at HomeMany individuals with dementia in the early and intermediate stages are able to live independently, they must have checks by a local relative or friend and those who have difficulty with activities of daily living require at least part-time help from a family caregiver or home health aide. Visiting nurses can make sure that these individuals take their medications as directed. Individuals with dementia should remain physically, mentally, and socially active. Daily physical exercise helps the body and mind function and maintains a healthy weight. Exercise can be as simple as a daily walk. The individual should engage in as much mental activity as he or she can handle, mental activity is believed to slow the progress of some types of dementia (puzzles, games, reading, and safe hobbies and crafts are good choices). Social interaction is stimulating and enjoyable for most people with dementia, most senior centers or community centers have scheduled activities, such as parties and clubs, that are suitable for those with dementia. A balanced diet that includes low-fat protein foods and plenty of fruits and vegetables helps maintain a healthy weight and prevent malnutrition and constipation. An individual with dementia should not smoke, both for health and safety reasons. Medical TreatmentTreatment of dementia focuses on correcting all reversible factors and slowing irreversible factors. This can improve function significantly, even in people who have irreversible conditions such as Alzheimer disease. Some of the important treatment strategies in dementia are described here. Slowing progression of dementia Dementia due to some conditions, such as Alzheimer disease, can sometimes be slowed in the early-to-intermediate stageswith medication. Many different types of medications have been or are being tried in dementia. The medications that have worked the best so far are the cholinesterase inhibitors.Cholinesterase is an enzyme that breaks down a chemical in the brain called acetylcholine. Acetylcholine acts as an important messaging system in the brain. Cholinesterase inhibitors, by stopping the breakdown of this neurotransmitter, increase the amount of acetylcholine in the brain of a person with dementia and improve brain function. These drugs not only improve or stabilize mental functions, they may also have positive effects on behavior and activities of daily living. They are not a cure, and in many people the effect is fairly modest. In others, these drugs do not have much of a noticeable effect. Moreover, the effects are temporary, since these drugs do not change the underlying medical condition.

Treating depression Because depression is so common in people with dementia, treatment of depression can at least partially relieve symptoms. Depression is usually treated with any of a group of drugs known as antidepressants. The most important of these are the drugs known as selective serotonin re-uptake inhibitors (SSRIs). Stimulant drugssuch asmethylphenidate (used to treat attention deficit disorders in children) may be used to treat depression in people with dementia. Some of the medications that treat depression also help with anxiety. Treating specific symptoms and complicationsSome symptoms and complications of dementia can be relieved by medical treatment, even if no treatment exists for the underlying cause of the dementia. Behavioral disorders may improve with individualized therapy aimed at identifying and changing specific problem behaviors. Mood swings and emotional outbursts may be treated with mood-stabilizing drugs. Agitation and psychosis (hallucinations and delusions) may be treated with antipsychotic medication or, in some cases, anticonvulsants. Seizures usually require anticonvulsant medication. Sleeplessness can be treated by changing certain habits and, in some cases, by taking medication. Infections require treatment with antibiotics. Dehydration and malnutrition may be treated with rehydration and supplements or with behavioral therapies. Aspiration, pressure sores, and injuries can be prevented with appropriate care.

1.9. COMPLICATIONThe list of complications that have been mentioned in various sources for Dementia includes: Memory problems Personality problems (see Personality change) Behavioral problems Abuse by an overstressed caregiver Increased infections anywhere in the body Loss of ability to function or care for self Loss of ability to interact Reduced life span Side effects of medications used to treat the disorder

1.10. PREVENTIONThe following may help prevent certain types of dementia: Maintaining a healthy lifestyle that includes a balanced diet, regular exercise, moderate use of alcohol, and no smoking or substance abuse Taking precautions to prevent infections (such as practicing safe sex) Using protective equipment such as a seat belt or motorcycle helmet to prevent head injuryThe following may allow early treatment and at least partial reversal of dementia: Being alert for symptoms and signs that suggest dementia Early recognition of underlying medical conditions, such as HIV infection Most causes of dementia are not preventable. You can reduce the risk of vascular dementia, which is caused by a series of small strokes, by quitting smoking and controlling high blood pressure and diabetes. Eating a low-fat diet and exercising regularly may also reduce the risk of vascular dementia

1.11. PROGNOSISThe prognosis of Dementia usually refers to the likely outcome of Dementia. The prognosis of Dementia may include the duration of Dementia, chances of complications of Dementia, probable outcomes, prospects for recovery, recovery period for Dementia, survival rates, death rates, and other outcome possibilities in the overall prognosis of Dementia. Naturally, such forecast issues are by their nature unpredictable.The outlook for most types of dementia is poor. Irreversible or untreated dementia usually continues to worsen over time. The condition usually progresses over years until the person's death.

CHAPTER IVTHE CORRELATION BETWEEN STROKE AND DEMENTIA TO MEN IN AGE ABOVE 40 IN WEST JAVA, 2009

Stroke-Related Dementia OverviewStroke (brain attack) is a disease of the blood vessels in and around the brain. It occurs when part of the brain does not receive enough blood to function normally and the cells die (infarction), or when a blood vessel ruptures (hemorrhagic stroke). Infarction is more common than hemorrhage and hasa number of causes, for example a vessel (artery) supplying blood to the brain can become blocked by afatty deposit (plaque), which can form clots and send pieces into vessels further in the brain, or these arteries become thickened or hardened, narrowing the space where the blood flows (atherosclerosis). In addition, clots can arise in the heart and travel to the brain. Permanent damage to brain cells can result.The symptoms of stroke vary, depending on which part of the brain is affected. Common symptoms of stroke are sudden paralysis orloss of sensation in part of the body (especially on one side),partial loss of vision or double vision, or loss of balance. Loss of bladder and bowel control can also occur. Other symptoms include decline in cognitive mental functions such as memory, speech and language, thinking, organization, reasoning, or judgment. Changes in behavior and personality may occur. If these symptoms are severe enough to interfere with everyday activities, they are called dementia.Cognitive decline related to stroke is usually called vascular dementia or vascular cognitive impairment to distinguish it from other types of dementia. In the United States, it is the second most common form of dementia after Alzheimer disease. Vascular dementia is preventable, but only if the underlying vascular disease is recognized and treated early.People who have had a stroke have a 9 times greater risk of dementia than people who have not had a stroke. About 1 in 4 people who have a stroke develop signs of dementia within 1 year. Vascular dementia is most common in older people, who are more likely than younger people to have vascular diseases. It is more common in men than in women.Stroke-Related Dementia CausesVascular dementia is not a single disease but a group of conditions relating to different vascular problems. What all the conditions have in common is that a critical part of the brain does not receive enough oxygen. The vascular damage underlying stroke-related dementia occurs in several different patterns. Multi-infarct dementia occurs after a series of strokes in different parts of the brain. Single-infarct dementia occurs when one large vascular lesion causes a severe infarction, or there is a single infarction in a strategic area of the brain. Dementia due to lacunar lesions occurs when only the smaller arteries are affected, causing multiple small infarctions. Binswanger disease also a disease of small arteries, but the damage primarily occurs in the white matter area of the brain. Dementia due to hemorrhagic (bleeding) stroke occurs when a blood vessel bursts causing bleeding in the brain.The major cause of the vascular lesions underlying stroke-related dementia is untreated high blood pressure (hypertension). Diabetes, atherosclerosis (hardening of the arteries), heart disease, high cholesterol, peripheral vascular disease, and smoking are other risk factors. Other causes include uncommon vascular diseases.Vascular dementia may occur with Alzheimer disease. ApoE4 is a protein whose main role is to help transport cholesterol in the blood. A high level of this protein in the blood poses a significant risk factor for Alzheimer dementia and has been linked to vascular dementia.

Stroke-Related Dementia SymptomsCognitive symptoms may appear abruptly, over weeks or months in a stepwise manner, or even gradually over years. The appearance of symptoms varies by the type of stroke and the part of the brain affected. Cognitive decline usually occurs within 3 months of a recognized stroke and may indicate vascular dementia. The following are common symptoms of vascular dementia: Memory loss, especially problems remembering recent events Inattention, poor concentration, difficulty following instructions Difficulty planning and organizing tasks Confusion Wandering, getting lost in familiar surroundings Poor judgment Difficulties with calculations, reasoning, or problem solving Psychosis - Agitation, aggression, hallucinations, delusions, loss of contact with reality, inability to relate appropriately to surroundings and other people Mood and behavior changes Depression Laughing or crying inappropriately

Exams and TestsMany different conditions can cause dementia symptoms. Your health care provider has the difficult task of finding the cause of your symptoms. This is very important, because some causes of dementia are reversible with treatment while others are not. The process of narrowing down the possibilities to reach your diagnosis is complicated. Your health care provider will gather information from several different sources. At any time in the process, he or she may consult an expert in dementia (geriatrician, neurologist,psychiatrist).The first step in the evaluation is the medical interview. You will be asked questions about your symptoms and when they appeared, about medical problems now and in the past, about medications you have taken now and in the past, about family medical problems, and about your habits and lifestyle. A physical examination will look for physical disabilities and signs of underlying conditions, such as high blood pressure, heart and blood vessel disease, and previous strokes. It will also include a mental status examination. This involves following simple directions and answering questions that check orientation, attention, language, and memory. Neuropsychological testing may be done to identify the extent of dementia. Neuropsychological testingNeuropsychological testing is a detailed cognitive assessment that helps to pinpoint and document a person's cognitive problems and strengths. Results vary with the site and severity of vascular disease in the brain. This testing can help find subtle or early cognitive deficits and give a more accurate diagnosis of the problems, thus assisting in treatment planning. The testing involves answering questions and performing tasks that have been carefully prepared for this purpose. It is carried out by a psychologist or other specially trained professional. It assesses the individual's appearance, mood, anxiety level, and experience of delusions or hallucinations. It assesses cognitive abilities such as memory for words and visual patterns, attention, orientation to time and place, use of language, and ability to carry out various tasks and follow instructions. Reasoning, abstract thinking, and problem solving are also tested.

Lab testsThese include blood tests to rule out infections, blood disorders, chemical abnormalities, hormonal disorders, and liver or kidney problems that could cause or mimic dementia symptoms. Lab tests can also pinpoint conditions such as diabetes and certain vascular disorders that could underlie dementia.

Imaging studiesBrain scans are very helpful in detecting stroke. They can also rule out certain other conditions that cause dementia. MRI or CT scan of the brain usually shows signs that indicate stroke or vascular disease, including bleeding. Positron-emission tomography (PET) or single-photon emission computed tomography (SPECT) scan may be helpful in distinguishing vascular dementia from Alzheimer disease. These scans are available only at some large medical centers.

Other testsOther tests may be done to look for conditions that commonly cause stroke and vascular disease. Echocardiography detects certain types of heart disease. Holter monitoring detects heart rhythm disorders. Carotid duplex Doppler ultrasound - Detects blockage of the carotid arteries, the main arteries leading to the brain. Tests may also be done to rule out other causes of dementia, Electroencephalogram (EEG) detects abnormal electrical activity in the brain. Cerebral angiography not used routinely in the evaluation of vascular dementia but sometimes used to detect vascular conditions, including strokeStroke-Related Dementia TreatmentTreatments available now cannot reverse the brain damage caused by a stroke once the injury is more than a few hours old. The goals of treatment are preventing new strokes by enhancing vascular health, slowing the progression of cognitive decline, and treating the symptoms related to it. Treatments include medication, behavioral interventions, and surgery Medical Treatment (drug therapy)Drug therapies in vascular dementia include those that prevent clotting and treat underlying vascular risk factors (for example,high blood pressure and diabetes) to prevent further progression of dementia. Drug therapies may also treat associated symptoms like depression. Antiplatelet agents: These are medications that inhibit blood clotting by altering platelet function and aggregation. Platelet inhibition is a mild form of blood thinning. These agents help prevent recurrent stroke. Ex: Aspirin, ticlopidine (Ticlid [rarely used]), clopidogrel bisulfate (Plavix), and extended-release dipyridamolewith aspirin (Aggrenox) Antihypertensive agents: These drugs reduce blood pressure and thus help prevent strokes. Other agents may be given to treat additional risk factors for stroke (for example, high cholesterol, heart disease, and diabetes). Antidepressant agents: Severe depression is a very common mood disorder in vascular dementia and may contribute to cognitive decline. Treating the depression with medication may not only relieve the depression but also improve mental functioning.If you take medications for other medical conditions, your health care provider may adjust or change these medications. Some drugs can worsen dementia symptoms.

Nondrug therapySymptoms such as social inappropriateness and aggression may improve with various behavior-changing interventions. Some interventions focus on helping the individual adjust or control his or her behavior. Others focus on helping caregivers and other family members change the person's behavior. These approaches sometimes work better when combined with drug treatment.

Stroke-Related Dementia PreventionIn many cases, vascular dementia is preventable. Risk factors for stroke and vascular dementia include high blood pressure, high cholesterol, heart disease, smoking, and diabetes. For many people, risk can be reduced by adopting a healthy lifestyle. People who have had a stroke may be able to reduce their risk of further strokes by drug treatment or surgery in addition to adopting a healthy lifestyle.Stroke-Related Dementia OutlookAt this time, there is no known cure for vascular dementia. While treatment can stop or slow the worsening of symptoms, or even improve them in some cases, the damage done to the brain by a stroke cannot be reversed. As dementia progresses, behavior problems usually become more severe. Troubling behaviors like agitation, aggression, wandering, sleep disorders, and inappropriate sexual behavior may become unmanageable. The physical demands of caregiving, such as bathing, dressing, grooming, feeding, and assisting with using the toilet, may become overwhelming for family members. Under these conditions, the family may decide to place the person in a nursing home or similar facility.Vascular dementia appears to shorten life expectancy. The most common causes of death are complications of dementia and cardiovascular disease.

CHAPTER VCONCLUSION

Stroke is a disease of the blood vessels in and around the brain. It occurs when part of the brain does not receive enough blood to function normally and the cells die (infarction), or when a blood vessel ruptures (hemorrhagic stroke). Infarction is more common than hemorrhage and hasa number of causes, for example a vessel (artery) supplying blood to the brain can become blocked by afatty deposit (plaque), which can form clots and send pieces into vessels further in the brain, or these arteries become thickened or hardened, narrowing the space where the blood flows (atherosclerosis). In addition, clots can arise in the heart and travel to the brain. Stroke can make a permanent damage of brain cells than can cause dementia. Dementia is a disease where the function of brain decrease. . People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They also lose their ability to solve problems and maintain emotional control, and they may experience personality changes and behavioral problems such as agitation, delusions, and hallucinations. While memory loss is a common symptom of dementia, memory loss by itself does not mean that a person has dementia. Doctors diagnose dementia only if two or more brain functions - such as memory, language skills, perception, or cognitive skills including reasoning and judgment - are significantly impaired without loss of consciousness.People who have had a stroke have a 9 times greater risk of dementia than people who have not had a stroke. About 1 in 4 people who have a stroke develop signs of dementia within 1 year. Vascular dementia is most common in older people, who are more likely than younger people to have vascular diseases. It is more common in men than in women.Stroke and dementia can diagnose by anamnesis, physical examination, laboratoty test, and some other neurogical test like CT scan, MRI, EEG, etc. This disease can be treated by some treatment that author has mention before, and the prognosis depends on the treatment.

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