Die „Demenz“ und das „dementielle Syndrom“
Die Demenz bzw. das „dementielle Syndrom“ oder „Demenz-Syndrom“ ist die häufigste organischbedingte psychische Störung und bezieht sich heute nicht mehr alleine auf die Störung der Kognitionund des Gedächtnis, wenngleich Gedächtnisstörungen ein notweniges und oft das wegweisende Kardinalsymptom jeder Demenz bleibt. Die Diagnose bezeichnet dabei ein gleichermassen charakteristisches wie vielgestaltiges, erworbenes Muster von Defiziten, die sich in einem meist schleichenden Prozess bei den betroffenen Personen einstellen und deren Lebens- und Alltagskompetenzen zunehmend einschränken. Am Ende dieses Prozesses steht oft der Tod, oft lange vorher aber bereits ein erhebliches Angewiesensein auf soziale und finanzielle Unterstützung. Nach der aktuellen Definition ist nicht jeder dementielle Prozess unumkehrbar, für die meisten Demenzen, vorweg die Alzheimer-Demenz, trifft dies aber zu!
Die Symptomatik der Demenzen ist sehr vielgestaltig und je nach Demenztyp verschieden. Obligates (d.h. notwendiges) Symptom aller Demenzen, allerdings nicht immer schon zu Beginn sichtbar, ist die Gedächtnisstörung.
Ohne Merkfähigkeitsstörung bzw. Störung des Gedächtnis keine Demenz! Aber es gilt umgekehrt: nicht jede Gedächtnisstörung ist Ausdruck eines dementiellen Prozesses!
Die Alzheimer-Demenz als die häufigste Demenz wird auf den folgenden Seiten besonders berücksichtigt. Sie ist zusammenfassend durch folgende Eigenschaften gekennzeichnet: Zu Beginn der Erkrankung stehen häufig unspezifische Symptome im Vordergrund, die dann meist nicht als Vorboten der Demenz erkannt werden können:
- Stimmungslabilität
- Rückzugstendenzen
- Antriebslosigkeit
Dann treten meist die „pathognomonischen“ (d.h. für die Krankheit charakteristischen) Störungen des Gedächtnisses auf, wobei das Kurzzeitgedächtnis weit vor dem Langzeitgedächtnis betroffen ist.Im weiteren Verlauf können dann sämtliche höheren Hirnleistungen und Persönlichkeitseigenschaften betroffen werden. Es finden sich dann unterschiedlich ausgeprägt Störungen des Denkens, Sprechens, Rechnens, Lesens, der räumlichen Orientierung, der praktischen Fertigkeiten, der Kritikfähigkeit, der Beziehungsfähigkeit etc..Später sind dann auch die Aktivitäten des täglichen Lebens betroffen, wie die Ernährung, die Körperhygiene, die Kontinenz etc.. Ab wann eine erworbene, hirnorganisch bedingte Einschränkung der intellektuellen Leistungsfähigkeit und des Gedächtnis als „Demenz“ bezeichnet werden kann, darüber herrscht auch in den modernen Klassifikationsmanualen ICD-10 und DSM-IV eine unterschiedliche Auffassung. Klar wird, dass die Grenzziehung willkürlich ist. Dies bezieht sich v.a. auch auf die Grenzziehung zwischen Demenz und dem „normalen“ Abbau der Leistungsfähigkeit im Alter. Es gibt Demenzformen, z.B. der M. Pick, bei denen zwar Gedächtnisstörungen obligatorisch vorhanden sind, aber weitaus nicht im Vordergrund stehen. Stattdessen können Persönlichkeitsänderungen („Wesensänderungen“) oder Antriebsstörungen die auffälligsten Merkmale sein.Sehr wichtig, und deshalb an dieser Stelle bereits explizit erwähnt, ist die Abgrenzung der „Demenz“ von anderen, nicht-organischen Ursachen. Die „Depression“ ist hier an erster Stelle zu nennen und wichtigste Differentialdiagnose zur Demenz. Auch depressive Menschen sind im Rahmen der psychischen Beeinträchtigung oft „wie dement“ oder „pseudo-dement“, d.h. sie können sich während der akuten Erkrankung manchmal kaum etwas merken und sind zu höheren intellektuellen Leistungen nicht fähig. Selbst Testuntersuchungen können oft nicht sicher klären, ob ein „dementielles Syndrom“ tatsächlich ein dementielles Syndrom ist oder Ausdruck einer schweren Depression. Erschwerend kommt hier hinzu, dass auch echte „dementielle“ Prozesse oft von Depressionen begleitet werden! Häufig kann also erst die Verlaufsbeobachtung und probatorische Therapieversuche mit einem Antidepressivum Klarheit bringen! Einen ersten Hinweis gibt oft die klinische Beobachtung: Demenzkranke versuchen i.d. Regel, den fortschreitenden Leistungsabbau vor Anderen geheimzuhalten und zu verleugnen. Depressive Menschen nehmen den (vorübergehenden) Leistungsverlust sich selber sehr übel und klagen viel darüber!Eine andere wichtige Abgrenzung der Demenz gegen nicht-organische Störungen der Kognition ist die gegen die sogenannte „psychogene Amnesie“ oder den „psychogenen Dämmerzustand“, die früheren Konzepten zur Hysterie nahestehen und, wie der Name schon sagt, „psychogen“ sind. Aus den genannten Gründen ist die Diagnostik und Differentialdiagnostik der Demenzformen untereinander und zu anderen Störungsbildern, die mit kognitiven Störungen einhergehen, sehr umfangreich und umfasst neben der allgemeinen psychiatrisch-neurologischen und internistischen Untersuchung laborchemische, testpsychologische und bildgebende Verfahren (Computertomographie, Kernspintomographie).Die Therapierbarkeit der Demenz richtet sich sehr nach der zugrundeliegenden Ursache. So sind zum Beispiel Demenzen aufgrund von Durchblutungsstörungen im Gehirn („vaskuläre Demenz“) z.T. recht gut durch eine optimale medikamentöse Kreislaufeinstellung behandelbar und können oft für längere Zeit in ihrem Fortschreiten gehemmt werden. Wichtig ist daher die jeweilige Klärung der Demenzursache!Die Therapie der Demenz richtet sich, wo immer möglich nach der erkennbaren Ursache. In den meisten Fällen hat sie nur aufschiebende Wirkung und gelingt v.a. in den Frühstadien der Erkrankung. Deshalb ist die Früherkennung und frühzeitige Abklärung sehr wichtig.
Eine frühzeitige, möglichst an den Ursachen ausgerichtete und damit möglichst effiziente Therapie der Demenz ist trotz der häufigen Unheilbarkeit der Störung sehr sinnvoll, weil das Fortschreiten v.a. in den Frühstadien z.T: erheblich verzögert und die Pflegebedürftigkeit der Patienten damit ebenfalls herausgezögert wird.Wichtig ist im Besonderen die umfassende Aufklärung der Angehörigen über das, was sie in den einzelnen Krankheitsstadien erwartet!Die Prognose ist in der überwältigenden Mehrheit der Fälle schlecht, d.h. Demenzen enden nach mehr oder weniger langer Verlaufszeit (in der Regel nach einigen Jahren) mit dem Tod. Nur maximal 10% aller Demenzen lassen sich auf eine potentiell „reversible“ (d.h. umkehrbare) Ursache zurückführen und sind dadurch selber potentiell umkehrbar. Hierzu gehören folgende Ursachen eines dementiellen Syndroms (nach A. Kurz, 2000):
- Depression (23,8%)Chronische Intoxikation (= Vergiftung) (18,5%)Normaldruckhydrozephalus (9,5%) Hypothyreose (6,5%)Bösartige Tumoren (6,5%)Subdurales Hämatom (Bluterguss im Kopf) (6,0%)Alkoholschaden (4,8%) Vitamin-B12-Mangel (3,0%)
- Andere (21,4%)
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