The Correlation Between Stroke

And
Dementia To Men In Age Above 40
In West Java, 2009

Author :
Audra Firthi Dea Noorafiatty
030 . 08 . 046

FACULTY OF MEDICINE TRISAKTI UNIVERSITY

JAKARTA
2009
PREFACE
Assalamualaikum Wr. Wb
First 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. Wb
Jakarta, July 2009

Audra firthi dea noorafiatty

CONTENTS

PREFACE
CONTENTS

................................................................................................................................i
............................................................................................................................. ii

CHAPTER I

INTRODUCTION
1.1. Background
1.2. Problems
1.3. Limitation of Problems
1.4. Objective
1.5. Method of Writing
1.6. Frame of Writing

CHAPTER II

STROKE
2.1. Definition of stroke
2.2. Etiology of stroke
2.3. Epidemiology of stroke
2.4. Pathogenesis of stroke
2.5. Symptoms and Sign of stroke
2.6. Diagnosis of stroke
2.7. Therapy of stroke
2.8. Treatment of stroke
2.9. Complication of stroke
2.10. Prevention of stroke

2.11. Prognosis of stroke

CHAPTER III

DEMENTIA
3.1. Definition of dementia
3.2. Etiology of dementia
3.3. Epidemiology of dementia
3.4. Pathogenesis of dementia
3.5. Symptoms and Sign of dementia
3.6. Diagnosis of dementia
3.7. Therapy of dementia
3.8. Treatment of dementia
3.9. Complication of dementia
3.10. Prevention of dementia
3.11. Prognosis of dementia

CHAPTER IV

THE CORRELATION BETWEEN STROKE AND DEMENTIA TO MEN

IN AGE ABOVE 40 IN WEST JAVA, 2009

CHAPTER V

BIBLIOGRAPHY

CONCLUSION

CHAPTER I
INTRODUCTION
I.1 Background
Stroke 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 either hemorrhagic or ischemic. Acute ischemic stroke refers to
stroke caused by thrombosis or embolism and accounts for 85% of all strokes.
1.2 Problems
The 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 Writing

This 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 I

INTRODUCTION
1.1. Background
1.2. Problems
1.3. Limitation of Problems
1.4. Objective

1.5. Method of Writing

1.6. Frame of Writing

CHAPTER II

STROKE
2.1. Definition of stroke
2.2. Etiology of stroke
2.3. Epidemiology of stroke
2.4. Pathogenesis of stroke
2.5. Symptoms and Sign of stroke
2.6. Diagnosis of stroke
2.7. Therapy of stroke
2.8. Treatment of stroke
2.9. Complication of stroke
2.10. Prevention of stroke
2.11. Prognosis of stroke

CHAPTER III

DEMENTIA
3.1. Definition of dementia
3.2. Etiology of dementia
3.3. Epidemiology of dementia

3.4. Pathogenesis of dementia

3.5. Symptoms and Sign of dementia
3.6. Diagnosis of dementia
3.7. Therapy of dementia
3.8. Treatment of dementia
3.9. Complication of dementia
3.10. Prevention of dementia
3.11. Prognosis of dementia

CHAPTER IV

THE CORRELATION BETWEEN STROKE AND DEMENTIA TO MEN

IN AGE ABOVE 40 IN WEST JAVA, 2009

CHAPTER V

CONCLUSION

BIBLIOGRAPHY

CHAPTER II
STROKE

2.1. DEFINITION
Stroke 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. ETIOLOGY
Stroke 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. EPIDEMIOLOGY
Stroke 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. PATHOGENESIS
The 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 decadeslong 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 SIGNS

The 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. DIAGNOSIS
We 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 examination
This 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 Puncture
Also 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 Angiography
This 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.
Electrocardiogram
This 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 Ultrasound
Doctors 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 Tests
For 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. THERAPY
There is four categories of medicines that can treat stroke, the medicines are :
1. Anticoagulation
Currently, 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 to improvement 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
Aspirin
Blocks 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 agents
Despite very promising results in several animal studies as of yet no single
neuroprotective agent in ischemic stroke is supported by randomized placebocontrolled 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. TREATMENT
There are two treatments for treating stroke
Self-care at home
Stroke 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 treatment
The 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. COMPLICATION
If 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.

PREVENTION
Knowing 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 cholesterollowering 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 diet
In 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 lowdensity 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 medications
If you've had an ischemic stroke, your doctor may recommend medications to help
reduce your risk of having a TIA or stroke.

2.11.PROGNOSIS
The 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 III
DEMENTIA

1.1.

DEFINITION
Dementia 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. ETIOLOGY
Dementia 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.

EPIDEMIOLOGY
Dementia 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.

PATHOGENESIS
Certain 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 SIGN

Symptoms 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 history
Medical 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 examination
A 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,

1.7.

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

THERAPY
Except

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 tolerable
1.8.

TREATMENT
Although an 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 Home
Many 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 Treatment
Treatment 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 stages with 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 drugs such

as methylphenidate (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 complications

Some 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.

COMPLICATION
The 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.

PREVENTION
The 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
injury

The 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.

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

Stroke-Related Dementia Overview

Stroke (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 has a number of causes, for example a vessel (artery) supplying
blood to the brain can become blocked by a fatty 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 or loss 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 Causes
Vascular 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 Symptoms

Cognitive 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 Tests

Many 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 testing
Neuropsychological 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 tests
These 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 studies
Brain 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 tests

Other 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 stroke
Stroke-Related Dementia Treatment
Treatments 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
dipyridamole with 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 therapy
Symptoms 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 Prevention

In 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 Outlook
At 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 V
CONCLUSION

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 has a number of causes, for example a vessel (artery) supplying blood to
the brain can become blocked by a fatty 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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