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   Reversible dementias   
   Manjari Tripathi and Deepti Vibha   
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   Abstract   
   In recent years, more attention has been given to the early diagnostic   
   evaluation of patients with dementia which is essential to identify patients   
   with cognitive symptoms who may have treatable conditions. Guidelines suggest   
   that all patients presenting    
   with dementia or cognitive symptoms should be evaluated with a range of   
   laboratory tests, and with structural brain imaging with computed tomography   
   (CT) or magnetic resonance imaging (MRI). While many of the disorders reported   
   as ‘reversible dementiasâ   
   €™ are conditions that may well be associated with cognitive or behavioral   
   symptoms, these symptoms are not always sufficiently severe to fulfill the   
   clinical criteria for dementia. Thus, while the etiology of a condition may be   
   treatable it should not    
   be assumed that the associated dementia is fully reversible. Potentially   
   reversible dementias should be identified and treatment considered, even if   
   the symptoms are not sufficiently severe to meet the clinical criteria for   
   dementia, and even if partial    
   or full reversal of the cognitive symptoms cannot be guaranteed. In the   
   literature, the most frequently observed potentially reversible conditions   
   identified in patients with cognitive impairment or dementia are depression,   
   adverse effects of drugs, drug    
   or alcohol abuse, space-occupying lesions, normal pressure hydrocephalus, and   
   metabolic conditions land endocrinal conditions like hypothyroidism and   
   nutritional conditions like vitamin B-12 deficiency. Depression is by far the   
   most common of the    
   potentially reversible conditions. The review, hence addresses the common   
   causes of reversible dementia and the studies published so far.   
      
   Keywords: Dementia, reversible, treatable   
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   INTRODUCTION   
   As clinicians have approached dementia with therapeutic nihilism, there has   
   been limited interest in extensive differential diagnosis beyond the exclusion   
   of the traditional reversible dementias. Nevertheless, all dementias are   
   treatable through nursing,    
   social work, and palliative medical interventions. Early recognition of a   
   progressive degenerative dementia gives patients the opportunity to express or   
   clarify end-of-life plans while judgment and personality are largely intact,   
   and enables the family    
   to plan for the financial aspects of caring for the affected person.[1] It is   
   estimated that 24.3 million people worldwide have dementia, with 4.6 million   
   new cases of dementia every year (one new case every 7 s). The number of   
   people affected will    
   double every 20 years to reach 81.1 million by 2040.[2] Dementia is a clinical   
   diagnosis whose evaluation involves assessment of the presenting problem;   
   history about the patient that is provided by an informant (someone who knows   
   the patient, usually a    
   family member); complete physical and neurologic examination; evaluation of   
   cognitive, behavioral, and functional status; and laboratory and imaging   
   studies.   
      
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   REVERSIBLE DEMENTIA: IS IT DEMENTIA?   
   For a clinical diagnosis of dementia, deficits in memory and in at least one   
   other cognitive domain must be documented, the deficits should interfere with   
   occupational or social functioning, and there must be evidence of a systemic   
   or brain disorder that    
   may be the primary cause of the cognitive deficits (American Psychiatric   
   Association, 1993). The American Academy of Neurology practice parameter   
   recommends structural neuroimaging, which may include CT or MRI, and screening   
   for depression, vitamin B12    
   deficiency, and hypothyroidism. Based on these criteria the screening for   
   syphilis without risk factors is not justified. Neuroimaging screening   
   evaluations are recommended to detect conditions such as subdural hematomas,   
   cerebral infarcts, cerebral    
   tumors, and normal pressure hydrocephalus [Table 1].   
      
   Table 1   
   Table 1   
   DSM IV criteria for dementia[3]   
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   HOW COMMON?   
   The reported frequency of dementia due to potentially reversible causes varies   
   from 0 to 23%.[4–6] Commonest among these causes are alcohol and medication   
   related dementia, depression induced cognitive impairment, surgical brain   
   lesions such as normal    
   pressure hydrocephalus [NPH], tumors and chronic subdural hematomas, metabolic   
   disorders such as hypothyroidism, hypoparathyroidism, vitamin B12 deficiency   
   and central nervous system (CNS) infections such as neurosyphilis and HIV   
   [Table 2].[7]   
      
   Table 2   
   Table 2   
   Prevalence of potentially reversible conditions in patients with cognitive   
   impairment or dementia   
   The Indian study by Srikanth found reversible causes, especially   
   neuroinfections and vitamin B12 deficiency to account for 18% of all   
   dementias.[8]   
      
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   WHAT ARE THE REVERSIBLE CAUSES?   
   There are several clearly reversible causes of dementia that are remembered by   
   the mnemonic DEMENTIA:   
      
   Drugs (any drug with anticholinergic activity), emotional- depression,   
   metabolic (hypothyroid), eyes and ears declining, normal pressure   
   hydrocephalus tumor or other space-occupying lesion, infection (syphilis,   
   AIDS), anemia (vitamin B12 or folate    
   deficiency).   
      
   The major syndromes with progressive dementia include Alzheimer disease (AD),   
   vascular dementia (VaD), dementia with lewy bodies (DLB) and frontotemporal   
   dementia (FTD) [Table 3].   
      
   Table 3   
   Table 3   
   Causes of potentially reversible cognitive impairment or dementia   
   Neuroinfections and inflammations   
      
   AIDS-dementia complex, HIV encephalopathy, or HIV-associated dementia is a   
   neurologic complication of acquired immunodeficiency syndrome, eventually   
   occurring in one fourth of patients who have AIDS. It typically occurs in the   
   later stages of HIV    
   infection and has diminished since the introduction of highly active   
   antiretroviral therapy.[9] Cryptococcus and JC virus infections typically   
   present with meningitis or progressive focal neurologic deficits,   
   respectively; however, they also can present    
   with rapid progression of dementia.   
      
      
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