The ABC's Of Tickle Me Elbow and The Razorblade Eyelash Twins

From Wikipedia, the free encyclopedia See also: Fermentation in food processing § Brewing and winemaking Main articles: Beer and Brewing Philistine pottery beer jug Beer is one of the oldest human-produced drinks. The written history of ancient Egypt and Mesopotamia records the use of beer, and the drink has spread throughout the world; a 3,900-year-old Sumerian poem honouring Ninkasi, the patron goddess of brewing, contains the oldest surviving beer-recipe, describing the production of beer from barley bread, and in China, residue on pottery dating from around 5,000 years ago shows that beer was brewed using barley and other grains.[1] Some say the invention of bread and beer led to the development of technology and static civilization.[2][3][4] Beer may have been known in Neolithic Europe as far back as 5,000 years ago,[5] and was mainly brewed on a domestic scale.[6][better source needed] Beer produced before the Industrial Revolution continued to be made and sold on a domestic scale, although by the 7th century CE beer was also being produced and sold by European monasteries. During the Industrial Revolution, the production of beer moved from artisanal manufacture to industrial manufacture, and domestic manufacture ceased to be significant by the end of the 19th century.[7][page needed] The development of hydrometers and thermometers changed brewing by allowing the brewer more control of the process, and giving greater knowledge of the brewing product. Today, the brewing industry is a global business, consisting of several dominant[citation needed] multinational companies and many thousands of smaller producers ranging from brewpubs to regional breweries.[8][failed verification] More than 133 billion liters (35 billion gallons) of beer are sold per year – producing total global revenues of $294.5 billion (£147.7 billion) in 2006.[9] The global beer market is projected to grow by $148.43 billion between 2024 and 2028, according to a report by Technavio.[10] Early beers See also: Ancient Egyptian cuisine Rock mortars in Raqefet Cave, used to make beer during the Stone Age. A replica of ancient Egyptian beer, brewed from emmer wheat by the Courage brewery in 1996 As almost any cereal containing certain sugars can undergo spontaneous fermentation due to wild yeasts in the air, it is possible that beer-like drinks were independently developed throughout the world soon after a tribe or culture had domesticated cereal. Chemical tests of ancient pottery jars reveal that beer was produced about 3,500 BCE in what is today Iran, and was one of the first-known biological engineering tasks where the biological process of fermentation is used; the earliest chemically confirmed barley beer to date was discovered at Godin Tepe in the central Zagros Mountains of Iran, where fragments of a jug, from between 5,400 and 5,000 years ago was found to be coated with beerstone, a by-product of the brewing process.[11] Archaeological findings also show that Chinese villagers were brewing fermented alcoholic drinks as far back as 7000 BCE on small and individual scale, with the production process and methods similar to that of ancient Egypt and ancient Mesopotamia.[12] The process by which the production of beer was discovered is a matter of debate. Author Thomas Sinclair says in his book, "Beer, Bread, and the Seeds of Change: Agriculture's Imprint on World History" that the discovery of beer may have been an accidental find. The precursor to beer was soaking grains in water and making a porridge or gruel, as grain was chewy and hard to digest alone. Ancient peoples would heat the gruel and leave it throughout the days until it was gone. A benefit to heating the gruel would be to sanitize the water and the temperature required to denature grain proteins would also denature disease microbes. Leaving the gruel to sit would change it. Fermentation would occur and they noticed the change in taste and effect. Yeasts would settle on the mixture and rapidly consume the oxygen in the mixture. The low oxygen would then cause the yeast to digest sugars by anaerobic respiration, which causes the release of ethanol (alcohol) and carbon dioxide as by-products and, hence, beer was born.[13] The earliest archaeological evidence of fermentation consists of 13,000-year-old residues of a beer with the consistency of gruel, used by the semi-nomadic Natufians for ritual feasting, at the Raqefet Cave in the Carmel Mountains near Haifa in Israel.[14][15] The first written records of brewing come from Mesopotamia (ancient Iraq).[16] These include early evidence of beer in the 3,900-year-old Sumerian poem honoring Ninkasi, the patron goddess of brewing, which contains the oldest surviving beer recipe, describing the production of beer from barley via bread.[17] "Ninkasi, you are the one who pours out the filtered beer of the collector vat... It is [like] the onrush of Tigris and Euphrates."[18] Approximately 5,000 years ago, workers in the city of Uruk were paid by their employers in beer.[19] Beer is also mentioned in the Epic of Gilgamesh, in which the 'wild man' Enkidu is given beer to drink. "... he ate until he was full, drank seven pitchers of beer, his heart grew light, his face glowed and he sang out with joy."[16] In February 2019, archaeologists from Mola Headland Infrastructure and experts from Highways England found evidence of first Iron Age beer dated back over 2,000 years during road works in Cambridgeshire.[20][21][22][23] In February 2021, archaeologists found a 5,000-old beer factory in Abydos, Egypt, dating back to the reign of King Narmer, Early Dynastic Period.[24] Confirmed written evidence of ancient beer production in Armenia can be obtained from Xenophon in his work Anabasis (5th century BCE) when he was in one of the ancient Armenian villages in which he wrote: There were stores within of wheat and barley and vegetables, and wine made from barley in great big bowls; the grains of barley malt lay floating in the beverage up to the lip of the vessel, and reeds lay in them, some longer, some shorter, without joints; when you were thirsty you must take one of these into your mouth, and suck. The beverage without admixture of water was very strong, and of a delicious flavour to certain palates, but the taste must be acquired.[25][26] Beer became vital to all the grain-growing civilizations of Eurasian and North African antiquity, including Egypt – so much so that in 1868 James Death put forward a theory in The Beer of the Bible that the manna from heaven that God gave the Israelites was a bread-based, porridge-like beer called wusa.[27] These beers were often thick, more of a gruel than a drink, and drinking straws were used by the Sumerians to avoid the bitter solids left over from fermentation. Though beer was drunk in Ancient Rome, it was replaced in popularity by wine.[28] Tacitus wrote disparagingly of the beer brewed by the Germanic peoples of his day. Thracians were also known to consume beer made from rye, even since the 5th century BCE, as the ancient Greek logographer Hellanicus of Lesbos says. Their name for beer was brutos, or brytos. The Romans called their brew cerevisia, from the Celtic word for it. Beer was apparently enjoyed by some Roman legionaries. For instance, among the Vindolanda tablets (from Vindolanda in Roman Britain, dated c. 97–103 CE), the cavalry decurion Masculus wrote a letter to prefect Flavius Cerialis inquiring about the exact instructions for his men for the following day. This included a polite request for beer to be sent to the garrison (which had entirely consumed its previous stock of beer).[29] Ancient Nubians had used beer as an antibiotic medicine.[30] Alulu beer receipt recording a purchase of "best" beer from a brewer, c. 2050 BCE, from the Sumerian city of Umma in ancient Iraq.[31] A funerary model of a bakery and brewery, from the Eleventh dynasty of Egypt, c. 2009–1998 BCE In ancient Mesopotamia, clay tablets indicate that the majority of brewers were probably women, and that brewing was a fairly well respected occupation during the time, being the only profession in Mesopotamia which derived social sanction and divine protection from female deities/goddesses, specifically: Ninkasi, who covered the production of beer, Siris, who was used in a metonymic way to refer to beer, and Siduri, who covered the enjoyment of beer.[32][33] Mesopotamian brewing appears to have incorporated the usage of a twice-baked barley bread called bappir, which was exclusively used for brewing beer.[34] It was discovered early that reusing the same container for fermenting the mash would produce more reliable results; brewers on the move carried their tubs with them.[35] The Ebla tablets, discovered in 1974 in Ebla, Syria, show that beer was produced in the city in 2500 BCE.[36] Early traces of beer and the brewing process have been found in ancient Babylonia as well. At the time, brewers were women as well, but also priestesses. Some types of beers were used especially in religious ceremonies. In 2100 BCE, the Babylonian king Hammurabi included regulations governing tavern keepers in his law code for the kingdom.[37] In Ancient India, the Vedas and Ramayana mention a beer-like drink called sura consumed during the Vedic Period (c. 1500 – c. 500 BCE).[38] It was the favourite of the god Indra.[39][40] Kautilya has also mentioned two intoxicating beverages made from rice called Medaka and Prasanna.[40] Beer was part of the daily diet of Egyptian pharaohs over 5,000 years ago. Then, it was made from baked barley bread, and was also used in religious practices.[41] During the building of the Great Pyramids in Giza, Egypt, each worker got a daily ration of four to five liters of beer, which served as both nutrition and refreshment that was crucial to the pyramids' construction.[42] The Greek writer Sophocles (450 BCE) discussed the concept of moderation when it came to consuming beer in Greek culture, and believed that the best diet for Greeks consisted of bread, meats, various types of vegetables, and beer[citation needed] or "ζῦθος" (zythos) as they called it.[43] The ancient Greeks also made barleywine (Greek: "κρίθινος οἶνος" – krithinos oinos, "barley wine"[44][45]) mentioned by Greek historian Polybius in his work The Histories, where he states that Phaeacians kept barleywine in silver and golden kraters.[46] During the £1.5bn upgrade of the A14 in Cambridgeshire, evidence was found that beer was brewed in Britain more than 2,000 years ago. Steve Sherlock, the Highways England archaeology lead for the A14 project said, "It’s a well-known fact that ancient populations used the beer-making process to purify water and create a safe source of hydration, but this is potentially the earliest physical evidence of that process taking place in the UK." Roger Protz, the former editor of the Campaign for Real Ale's Good Beer Guide, said, "When the Romans invaded Britain they found the local tribes brewing a type of beer called curmi."[47] In Europe during the Middle Ages, a brewers' guild might adopt a patron saint of brewing. Arnulf of Metz (c. 582–640) and Arnulf of Oudenburg (c. 1040–1087) were recognized by some French and Flemish brewers.[48] Belgian brewers, too, venerated Arnulf of Oudenburg (aka Arnold of Soissons),[49] who is also recognized as the patron saint of hop-pickers. Christian monks built breweries, to provide food, drink, and shelter to travelers and pilgrims.[41] Charlemagne, Frankish king and ruler of the Holy Roman Empire during the 8th century, considered beer to be an important part of living, and is often thought to have trained some brewers himself.[37] Medieval Europe Beer was one of the most common drinks during the Middle Ages. It was consumed daily by all social classes in the northern and eastern parts of Europe where grape cultivation was difficult or impossible,[citation needed] and brewing it was considered a common household task, orchestrated by women.[50] Though wine of varying qualities was the most common drink in the south, beer was still popular among the lower classes. The idea that beer was consumed more commonly than water during medieval times is considered by some historians to be a myth.[51] Water was cheaper than beer, and towns/villages were built close to sources of fresh water such as rivers, springs, and wells to facilitate easy access to the resource.[52] Though probably one of the most popular drinks in Europe, beer was frequently disdained as being unhealthy, possibly because ancient Greek and more contemporary Arab physicians had little or no experience with the drink. In 1256, the Aldobrandino of Siena described the nature of beer in the following way: But from whichever it is made, whether from oats, barley or wheat, it harms the head and the stomach, it causes bad breath and ruins the teeth, it fills the stomach with bad fumes, and as a result anyone who drinks it along with wine becomes drunk quickly; but it does have the property of facilitating urination and makes one's flesh white and smooth.[53] The use of hops in beer was written of in 822 by the Carolingian Abbot Adalard of Corbie.[54] Flavoring beer with hops was known at least since the 9th century, but was only gradually adopted because of difficulties in establishing the right proportions of ingredients. Before that, gruit, a mix of various herbs, had been used, but did not have the same preserving properties as hops. Beer flavored without hops was often spoiled soon after preparation and could not be exported. The only other alternative was to increase the alcohol content, which was rather expensive. Hopped beer was perfected in the medieval towns of Bohemia by the 13th century. German towns pioneered a new scale of operation with standardized barrel sizes that allowed for large-scale export. Previously beer had been brewed at home, but the production was now successfully replaced by medium-sized operations of about eight to ten people. This type of production spread to Holland in the 14th century and later to Flanders and Brabant, and reached England by the late 15th century.[55] English ale and beer brewing were carried out separately, no brewer being allowed to produce both. The Brewers Company of London stated "no hops, herbs, or other like thing be put into any ale or liquore wherof ale shall be made – but only liquor (water), malt, and yeast." This comment is sometimes misquoted as a prohibition on hopped beer.[56] However, hopped beer was opposed by some: Ale is made of malte and water; and they the which do put any other thynge to ale than is rehersed, except yest, barme, or goddesgood [three words for yeast], doth sophysticat there ale. Ale for an Englysshe man is a naturall drinke. Ale muste haue these properties, it muste be fresshe and cleare, it muste not be ropy, nor smoky, nor it must haue no wefte nor tayle. Ale shulde not be dronke vnder .v. dayes olde …. Barly malte maketh better ale than Oten malte or any other corne doth … Beere is made of malte, of hoppes, and water; it is a naturall drynke for a doche [Dutch] man, and nowe of late dayes it is moche vsed in Englande to the detryment of many Englysshe men … for the drynke is a colde drynke. Yet it doth make a man fatte, and doth inflate the bely, as it doth appere by the doche mennes faces and belyes.[57] Early modern Europe A 16th-century brewery In Europe, beer brewing largely remained a home activity in medieval times. By the 14th and 15th centuries, beermaking was gradually changing from a family-oriented activity to an artisan one, with taverns and monasteries brewing their own beer for mass consumption. In the late Middle Ages, the brewing industry in northern Europe changed from a small-scale domestic industry to a large-scale export industry. The key innovation was the introduction of hops, which began in northern Germany in the 13th century. Hops sharply improved both the brewing process and the quality of beer. Other innovations from German lands involved larger kettle sizes and more frequent brewing. Consumption went up, while brewing became more concentrated because it was a capital-intensive industry. Thus in Hamburg per capita consumption increased from an average of 300 liters per year in the 15th century to about 700 in the 17th century.[58] The use of hops spread to the Netherlands and then to England. In 15th century England, an unhopped beer would have been known as an ale, while the use of hops would make it a beer. Hopped beer was imported to England from the Netherlands as early as 1400 in Winchester, and hops were being planted on the island by 1428. The popularity of hops was at first mixed—the Brewers Company of London went so far as to state "no hops, herbs, or other like thing be put into any ale or liquore wherof ale shall be made—but only liquor (water), malt, and yeast."[This quote needs a citation] However, by the 16th century, ale had come to refer to any strong beer, and all ales and beers were hopped, giving rise to the verse noted by the antiquary John Aubrey: Greeke, Heresie, Turkey-cocks and Beer Came into England all in a year. the year, according to Aubrey, being the fifteenth of Henry VIII (1524).[59] In 1516, William IV, Duke of Bavaria, adopted the Reinheitsgebot (purity law), perhaps the oldest food regulation still in use through the 20th century (the Reinheitsgebot passed formally from German law in 1987). The Gebot ordered that the ingredients of beer be restricted to water, barley, and hops; yeast was added to the list after Louis Pasteur's discovery in 1857. The Bavarian law was applied throughout Germany as part of the 1871 German unification as the German Empire under Otto von Bismarck, and has since been updated to reflect modern trends in beer brewing. To this day, the Gebot is considered a mark of purity in beers, although this is controversial. Most beers until relatively recent times were top-fermented. Bottom-fermented beers were discovered by accident in the 16th century after beer was stored in cool caverns for long periods; they have since largely outpaced top-fermented beers in terms of volume. For further discussion of bottom-fermented beers, see Pilsner and Lager. Asia China Documented evidence and recently excavated tombs indicate that the Chinese brewed alcoholic drinks from both malted grain and grain converted by mold from prehistoric times, but that the malt conversion process was largely considered inefficient in comparison with the use of molds specially cultivated on rice carrier (the resulting molded rice being called 酒麴 (Jiǔ qū) in Chinese and Koji in Japanese) to convert cooked rice into fermentable sugars, both in the amount of resulting fermentable sugars and the residual by products (the Chinese use the dregs left after fermenting the rice, called 酒糟 (Jiǔzāo), as a cooking ingredient in many dishes, frequently as an ingredient to sauces where Western dishes would use wine), because the rice undergoes starch conversion after being hulled and cooked, rather than whole and in husks like barley malt. Furthermore, the hop plant being unknown in East Asia, malt-based alcoholic drinks did not preserve well over time, and the use of malt in the production of alcoholic drinks gradually fell out of favor in China until disappearing from Chinese history by the end of the Tang dynasty. The use of rice became dominant, such that wines from fruits of any type were historically all but unknown except as imports in China. The production of alcoholic drink from cooked rice converted by microbes continues to this day, and some classify the different varieties of Chinese 米酒 (Mǐjiǔ) and Japanese sake as beer since they are made from converted starch rather than fruit sugars. However, this is a debatable point, and such drinks are generally referred to as "rice wine" or "sake" which is really the generic Chinese and Japanese word for all alcoholic drinks. The earliest evidence of beer-making in China is from around 5,000 years ago at the Mijiaya site.[60] Other Some Pacific island cultures ferment starch that has been converted to fermentable sugars by human saliva, similar to the chicha of South America. This practice is also used by many other tribes around the world, who either chew the grain and then spit it into the fermentation vessel or spit into a fermentation vessel containing cooked grain, which is then sealed up for the fermentation. Enzymes in the spittle convert the starch into fermentable sugars, which are fermented by wild yeast. Whether or not the resulting product can be called beer is sometimes disputed, since: As with Asian rice-based liquors, it does not involve malting. This method is often used with starches derived from sources other than grain, such as yams, taro, or other such root vegetables. Some Taiwanese tribes have taken the process a step further by distilling the resulting alcoholic drink, resulting in a clear liquor. However, as none of the Taiwanese tribes are known to have developed systems of writing, there is no way to document how far back this practice goes, or if the technique was brought from mainland China by Han Chinese immigrants. Judging by the fact that this technique is usually found in tribes using millet (a grain native to northern China) as the ingredient, the latter seems much more likely.[citation needed] Asia's first brewery was incorporated in 1855 (although it was established earlier) by Edward Dyer at Kasauli in the Himalayan Mountains in India under the name Dyer Breweries. The company still exists and is known as Mohan Meakin, today comprising a large group of companies across many industries. The Industrial Revolution The Caledonian Brewery, founded in 1869, Edinburgh, Scotland Following significant improvements in the efficiency of the steam engine in 1765, industrialization of beer became a reality. Further innovations in the brewing process came about with the introduction of the thermometer in 1760 and hydrometer in 1770, which allowed brewers to increase efficiency and attenuation. Prior to the late 18th century, malt was primarily dried over fires made from wood, charcoal, or straw, and after 1600, from coke. In general, none of these early malts would have been well shielded from the smoke involved in the kilning process, and consequently, early beers would have had a smoky component to their flavors; evidence indicates that maltsters and brewers constantly tried to minimize the smokiness of the finished beer. Writers of the period describe the distinctive taste derived from wood-smoked malts, and the almost universal revulsion it engendered. The smoked beers and ales of the West Country were famous for being undrinkable – locals and the desperate excepted. This is from "Directions for Brewing Malt Liquors" (1700): In most parts of the West, their malt is so stenched with the Smoak of the Wood, with which 'tis dryed, that no Stranger can endure it, though the inhabitants, who are familiarized to it, can swallow it as the Hollanders do their thick Black Beer Brewed with Buck Wheat. An even earlier reference to such malt was recorded by William Harrison, in his "Description of England", 1577: In some places it [malt] is dried at leisure with wood alone, or straw alone, in other with wood and straw together, but, of all, the straw-dried is the most excellent. For the wood-dried malt, when it is brewed, beside that the drink is higher of colour, it doth hurt and annoy the head of him that is not used thereto, because of the smoke. Such also as use both indifferently do bark, cleave, and dry their wood in an oven, thereby to remove all moisture that should procure the fume ... "London and Country Brewer" (1736) specified the varieties of "brown malt" popular in the city: Brown Malts are dryed with Straw, Wood and Fern, etc. The straw-dryed is the best, but the wood sort has a most unnatural Taste, that few can bear with, but the necessitous, and those that are accustomed to its strong smoaky tang; yet it is much used in some of the Western Parts of England, and many thousand Quarters of this malt has been formerly used in London for brewing the Butt-keeoing-beers with, and that because it sold for two shillings per Quarter cheaper than Straw-dryed Malt, nor was this Quality of the Wood-dryed Malt much regarded by some of its Brewers, for that its ill Taste is lost in nine or twelve Months, by the Age of the Beer, and the strength of the great Quantity of Hops that were used in its preservation. A hydrometer measures beer's specific gravity The hydrometer transformed how beer was brewed. Before its introduction beers were brewed from a single malt: brown beers from brown malt, amber beers from amber malt, pale beers from pale malt. Using the hydrometer, brewers could calculate the yield from different malts. They observed that pale malt, though more expensive, yielded far more fermentable material than cheaper malts. For example, brown malt (used for Porter) gave 54 pounds of extract per quarter, whilst pale malt gave 80 pounds. Once this was known, brewers switched to using mostly pale malt for all beers supplemented with a small quantity of highly coloured malt to achieve the correct colour for darker beers. The invention of the drum roaster in 1817 by Daniel Wheeler allowed for the creation of very dark, roasted malts, contributing to the flavour of porters and stouts. Its development was prompted by a British law of 1816 forbidding the use of any ingredients other than malt and hops. Porter brewers, employing a predominantly pale malt grist, urgently needed a legal colourant. Wheeler's patent malt was the solution. Yeast ring used by Swedish homebrewers in the 19th century to preserve the yeast between brewing sessions. Louis Pasteur's 1857 discovery of yeast's role in fermentation led to brewers developing methods to prevent the souring of beer by undesirable microorganisms. In 1912, brown bottles began to be used by Joseph Schlitz Brewing Company of Milwaukee, Wisconsin in the United States. This innovation has since been accepted worldwide and prevents harmful rays from destroying the quality and stability of beer.[61] Modern beer Bottling beer in a modern facility, 1945, Australia Traditional fermenting building (center) and modern fermenting building (left) in Pilsner Urquell Brewery (Czech Republic) Many European nations have unbroken brewing traditions dating back to the earliest historical records. Beer is an especially important drink in countries such as Belgium, Germany, Austria, Ireland, the UK (England, Wales, Scotland and Northern Ireland), France, the Scandinavian countries, Poland, the Czech Republic, Spain and others having strong and unique brewing traditions with their own history, characteristic brewing methods, and styles of beer. Unlike in many parts of the world, there is a significant market in Europe (the UK in particular) for beer containing live yeast. These unfiltered, unpasteurised brews are more challenging to handle than the commonly sold "dead" beers; "live" beer quality can suffer with poor care, but many people prefer its taste. While beer is usually matured for relatively short times (a few weeks to a few months) compared to wine, some of the stronger so-called real ales have been found to develop character and flavour over the course of as much as several decades. World beer consumption per capita In some parts of the world, breweries that had begun as a family business by Germans or other European émigrés grew into large companies, often passing into hands with more concern for profits than traditions of quality, resulting in a degradation of the product. In 1953, New Zealander Morton Coutts developed the technique of continuous fermentation. Coutts patented his process, which involves beer flowing through sealed tanks, fermenting under pressure, and never coming into contact with the atmosphere, even when bottled. His process was introduced in the US and UK, but is now used for commercial beer production only in New Zealand.[62] In some sectors brewers are reluctant to embrace new technology for fear of losing the traditional characteristics of their beer. For example, Marston's Brewery in Burton on Trent still uses open wooden Burton Union sets for fermentation in order to maintain the quality and flavour of its beers, while Belgium's lambic brewers go so far as to expose their brews to outside air in order to pick up the natural wild yeasts which ferment the wort. Traditional brewing techniques protect the beer from oxidation by maintaining a carbon dioxide blanket over the wort as it ferments into beer. Modern breweries now brew many types of beer, ranging from ancient styles such as the spontaneously fermented lambics of Belgium; the lagers, dark beers, wheat beers and more of Germany; the UK's stouts, milds, pale ales, bitters, golden ale and new modern American creations such as chili beer, cream ale, and double India pale ales. Today, the brewing industry is a huge global business, consisting of several multinational companies, and many thousands of smaller producers ranging from brewpubs to regional breweries. Advances in refrigeration, international and transcontinental shipping, marketing and commerce have resulted in an international marketplace, where the consumer has literally hundreds of choices between various styles of local, regional, national and foreign beers. United States Prior to Prohibition, there were thousands of breweries in the United States, mostly brewing heavier beers than modern US beer drinkers are used to. Beginning in 1920, most of these breweries went out of business, although some converted to soft drinks and other businesses. Bootlegged beer was often watered down to increase profits, beginning a trend, still on-going today, of the American markets heavily advertising the weaker beers and keeping them popular. Consolidation of breweries and the application of industrial quality control standards have led to the mass-production and the mass-marketing of huge quantities of light lagers. Advertising became supreme, and bigger companies fared better in that market. The decades after World War II saw a huge consolidation of the American brewing industry: brewing companies would buy their rivals solely for their customers and distribution systems, shutting down their brewing operations.[63] Despite the record increases in production between 1870 and 1895, the number of firms fell by 46%. Average brewery output rose significantly, driven partly by a rapid increase in output by the largest breweries. As late as 1877, only four breweries topped 100,000 barrels annually. By 1895, the largest sixteen firms had greatly increased their productive capacity and were all brewing over 250,000 barrels annually;[64] and imports have become more abundant since the mid-1980s. The number of breweries has been claimed as being either over 1,500 in 2007 or over 1,400 in 2010, depending on the source. As of June 2013, The Brewers Association reports the total number of currently operating US breweries to be 2,538, with only 55 of those being non-craft breweries.[65][66][67][68] Mythology Gambrinus – king of beer The Finnish epic Kalevala, collected in written form in the 19th century but based on oral traditions many centuries old, devotes more lines to the origin of beer and brewing than it does to the origin of mankind. The mythical Flemish king Gambrinus (from Jan Primus (John I)), is sometimes credited with the invention of beer. According to Czech legend, deity Radegast, god of hospitality, invented beer. Ninkasi was the patron goddess of brewing in ancient Sumer. In Egyptian mythology, the immense blood-lust of the fierce lioness goddess Sekhmet was only sated after she was tricked into consuming an extremely large amount of red-coloured beer (believing it to be blood): she became so drunk that she gave up slaughter altogether and became docile. In Norse mythology the sea god Ægir, his wife Rán, and their nine daughters, brewed ale (or mead) for the gods. In the Lokasenna, it is told that Ægir would host a party where all the gods would drink the beer he brewed for them. He made this in a giant kettle that Thor had brought. The cups in Ægir's hall were always full, magically refilling themselves when emptied. Ægir had two servants in his hall to assist him; Eldir [Fire-Kindler] and Fimafeng [Handy]. In Nart sagas, Satanaya (Ubykh [satanaja], Adyghe [setenej], Ossetian [ʃatana]), the mother of the Narts, a fertility figure and matriarch, invented beer. Recent Irish Mythology attributes the invention of beer to fabled Irishman Charlie Mops Etymology The word beer comes from old Germanic languages, and is with variations used in continental Germanic languages, bier in German and Dutch, but not in Nordic languages. The word was imported into the British Isles by tribes such as the Saxons. It is disputed where the word originally comes from. Many other languages have borrowed the Dutch/German word, such as French bière, Italian birra, Romanian "bere" and Turkish bira. The Nordic languages have öl/øl, related to the English word ale. Spanish, Portuguese and Catalan have words that evolved from Latin cervisia, originally of Celtic origin. Slavic languages use pivo with small variations, based on a pre-Slavic word meaning "drink" and derived from the verb meaning "to drink". Chuvash "pora" its r-Turkic counterpart, which may ultimately be the source of the Germanic beer-word.[69] From Wikipedia, the free encyclopedia "Senile" and "Demented" redirect here. For other uses, see Senile (disambiguation) and Demented (disambiguation). Dementia 1896 lithograph of a man diagnosed with "senile dementia", a now outdated term Specialty Neurology, psychiatry Symptoms Decreased ability to think and remember, emotional problems, problems with language, decreased motivation, general decline in cognitive abilities[1] Complications Malnutrition, aspiration pneumonia, inability to perform self-care tasks, personal safety challenges, akinetic mutism[2] Usual onset Varies, usually gradual[1] Duration Varies, usually long term[1] Causes Alzheimer's disease, vascular dementia, Lewy body disease, frontotemporal dementia, and others[1] Risk factors Several across the life course (e.g. less education, hearing loss, vision loss, physical inactivity, obesity, high cholesterol, hypertension, diabetes, smoking, excessive alcohol consumption, social isolation, air pollution, traumatic brain injury, depression)[3] Diagnostic method Clinical assessment, cognitive testing (mini–mental state examination)[4] and imaging. Differential diagnosis Delirium, depression, hypothyroidism[5][6] Prevention Addressing risk factors throughout the life course, e.g. preventing, reducing or treating hearing and vision loss, depression, head injury and vascular risk factors (e.g. cholesterol, diabetes), decreasing smoking, and maintaining physical activity and cognitive stimulation[3] Treatment Varies but supportive care is given[1] Medication Varies depending on the type and stage, most medications have a small benefit[7] Prognosis Varies, dementia is a life limiting condition and life expectancy is usually shortened Frequency 57 million (2021)[1] Deaths 1.62 million dementia-related deaths (2019) estimated to increase to 4.91 million by 2050[8] Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities.[9] This typically involves problems with memory, thinking, behavior, and motor control.[10] Aside from memory impairment and a disruption in thought patterns, the most common symptoms of dementia include emotional problems, difficulties with language, and decreased motivation.[1] The symptoms may be described as occurring in a continuum over several stages.[11][a] Dementia is a life-limiting condition, having a significant effect on the individual, their caregivers, and their social relationships in general.[1] A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than might be caused by the normal aging process.[13] Several diseases and injuries to the brain, such as a stroke, can give rise to dementia. However, the most common cause is Alzheimer's disease, a neurodegenerative disorder.[1] Dementia is a neurocognitive disorder with varying degrees of severity (mild to major) and many forms or subtypes.[14] Dementia is an acquired brain syndrome, marked by a decline in cognitive function, and is contrasted with neurodevelopmental disorders.[15] It has also been described as a spectrum of disorders with subtypes of dementia based which known disorder caused its development, such as Parkinson's disease for Parkinson's disease dementia, Huntington's disease for Huntington's disease dementia, vascular disease for vascular dementia, HIV infection causing HIV dementia, frontotemporal lobar degeneration for frontotemporal dementia, Lewy body disease for dementia with Lewy bodies, and prion diseases.[16] Subtypes of neurodegenerative dementias may also be based on the underlying pathology of misfolded proteins, such as synucleinopathies and tauopathies.[16] The coexistence of more than one type of dementia is known as mixed dementia.[15] Many neurocognitive disorders may be caused by another medical condition or disorder, including brain tumours and subdural hematoma, endocrine disorders such as hypothyroidism and hypoglycemia, nutritional deficiencies including thiamine and niacin, infections, immune disorders, liver or kidney failure, metabolic disorders such as Kufs disease, some leukodystrophies, and neurological disorders such as epilepsy and multiple sclerosis. Some of the neurocognitive deficits may sometimes show improvement with treatment of the causative medical condition.[17] Diagnosis of dementia is usually based on history of the illness and cognitive testing with imaging. Blood tests may be taken to rule out other possible causes that may be reversible, such as hypothyroidism (an underactive thyroid), and imaging can be used to help determine the dementia subtype and exclude other causes. [18] Although the greatest risk factor for developing dementia is aging, dementia is not a normal part of the aging process; many people aged 90 and above show no signs of dementia.[18] Risk factors, diagnosis and caregiving practices are influenced by cultural and socio-environmental factors.[19] Several risk factors for dementia, such as smoking and obesity, are preventable by lifestyle changes. Screening the general older population for the disorder is not seen to affect the outcome.[20] Dementia is currently the seventh leading cause of death worldwide and has 10 million new cases reported every year (approximately one every three seconds).[1] There is no known cure for dementia.[21] Acetylcholinesterase inhibitors such as donepezil are often used in some dementia subtypes and may be beneficial in mild to moderate stages, but the overall benefit may be minor. There are many measures that can improve the quality of life of a person with dementia and their caregivers. Cognitive and behavioral interventions may be appropriate for treating the associated symptoms of depression.[22] Signs and symptoms The signs and symptoms of dementia may vary depending on the underlying subtype. However, there are some common features that may be grouped into three areas: cognitive, neuropsychiatric (also known as behavioural and psychological), and physical.[3] The cognitive symptoms of dementia relate to the area of the brain affected. Typically this includes memory plus one other cognitive region.[23] The most commonly affected areas of brain function include memory, language, attention, problem solving, and visuospatial function affecting perception and orientation. Signs of dementia include getting lost in a familiar neighborhood, using unusual words to refer to familiar objects, forgetting the name of a close family member or friend, forgetting old memories, and being unable to complete tasks independently.[24] People with developing dementia can often fall behind on bill payments; specifically mortgage and credit cards, and a crashing credit score can be an early indicator of the disease.[25][26] The symptoms progress at a continuous rate over several stages, and they vary across the dementia subtypes.[27][11] Most types of dementia are slowly progressive with some deterioration of the brain well established before signs of the disorder become apparent. The behavioral symptoms can include agitation, restlessness, inappropriate behavior, sexual disinhibition, and verbal or physical aggression.[28] Psychological symptoms can include depression, hallucinations (most often visual),[29] delusions, apathy, and anxiety.[28][30] Behavioural symptoms in dementia are thought to be often due to unmet needs or untreated physical symptoms.[31][32] Many of these symptoms may be improved by non-pharmacological measures such as appropriate exercise and empowering carers.[33] Underlying physical causes of distress may also need to be targeted.[3] Dementias may also produce a number of physical manifestations. These may include changes in gait, falls, repetitive movements, parkinsonism, or seizures.[23] People with dementia are more likely to have problems with incontinence than those of a comparable age without dementia; they are three times more likely to have urinary incontinence and four times more likely to have fecal incontinence.[34][35] Dementia can also affect the person’s eating and drinking, often causing swallowing issues and weight loss that worsen as the illness progresses to later stages.[36] Pain can also affect people with dementia, potentially as many as 79.6% of people with dementia in nursing homes may experience pain. However pain can be difficult to assess as people with dementia may be unable to communicate this verbally and instead it may manifest as behavioural symptoms.[37] People with dementia may often have other health conditions present, such as high blood pressure or diabetes, and there can sometimes be as many as four of these comorbidities.[38] There is also increased prevalence of sarcopenia (muscle loss) and frailty among people with dementia.[39] Stages The course of dementia is often described in four stages (pre-dementia, early, middle, and late) that show a pattern of progressive cognitive and functional impairment. More detailed descriptions can be arrived at by the use of numeric scales. These scales include: The GDS/FAST Staging System[40] Global Deterioration Scale (GDS or Reisberg Scale)[41] Functional Assessment Staging Tool (FAST)[42] Brief Cognitive Rating Scale (BCRS)[43][44] Clinical Dementia Rating (CDR)[45][46] Using the GDS, which more accurately identifies each stage of the disease progression, a more detailed course is described in seven stages – two of which are broken down further into five and six degrees. Stage 7(f) is the final stage.[47][48] Pre-dementia Pre-dementia includes pre-clinical and prodromal stages. The latter stage includes mild cognitive impairment (MCI), delirium-onset, and psychiatric-onset presentations.[49] Pre-clinical Sensory dysfunction is claimed for the pre-clinical stage, which may precede the first clinical signs of dementia by up to ten years.[11] Most notably the sense of smell is lost,[11][50] associated with depression and a loss of appetite leading to poor nutrition.[51] It is suggested that this dysfunction may come about because the olfactory epithelium is exposed to the environment, and the lack of blood–brain barrier protection allows toxic elements to enter and cause damage to the chemosensory networks.[11] Prodromal Pre-dementia states considered as prodromal are mild cognitive impairment (MCI) and mild behavioral impairment (MBI).[52][53][54] Signs and symptoms at the prodromal stage may be subtle, and the early signs often become apparent only in hindsight.[55] Of those diagnosed with MCI, 70% later progress to dementia.[13] In mild cognitive impairment, changes in the person's brain have been happening for a long time, but the symptoms are just beginning to appear. These problems, however, are not severe enough to affect daily function. If and when they do, the diagnosis becomes dementia. The person may have some memory problems and trouble finding words, but they can solve everyday problems and competently handle their life affairs.[56] During this stage, it is ideal to ensure that advance care planning has occurred to protect the person's wishes. Advance directives exist that are specific to people living with dementia.[57] These can be particularly helpful in addressing the decisions related to feeding which come with the progression of the illness. Mild cognitive impairment has been relisted in both DSM-5 and ICD-11 as "mild neurocognitive disorders", i.e. milder forms of the major neurocognitive disorder (dementia) subtypes.[58] Kynurenine is a metabolite of tryptophan that regulates microbiome signaling, immune cell response, and neuronal excitation. A disruption in the kynurenine pathway may be associated with the neuropsychiatric symptoms and cognitive prognosis in mild dementia.[59][60] Early In the early stage of dementia, symptoms become noticeable to other people. In addition, the symptoms begin to interfere with daily activities, and will register a score on a mini–mental state examination (MMSE). MMSE scores are set at 24 to 30 for a normal cognitive rating and lower scores reflect severity of symptoms. The symptoms are dependent on the type of dementia. More complicated chores and tasks around the house or at work become more difficult. The person can usually still take care of themselves but may forget things like taking pills or doing laundry and may need prompting or reminders.[61] The symptoms of early dementia usually include memory difficulty, but can also include some word-finding problems, and problems with executive functions of planning and organization.[62] Managing finances may prove difficult. Other signs might be getting lost in new places, repeating things, and personality changes.[63] In some types of dementia, such as dementia with Lewy bodies and frontotemporal dementia, personality changes and difficulty with organization and planning may be the first signs.[64] Middle As dementia progresses, initial symptoms generally worsen. The rate of decline is different for each person. MMSE scores between 6 and 17 signal moderate dementia. For example, people with moderate Alzheimer's dementia lose almost all new information. People with dementia may be severely impaired in solving problems, and their social judgment is often impaired. They cannot usually function outside their own home, and generally should not be left alone. They may be able to do simple chores around the house but not much else, and begin to require assistance for personal care and hygiene beyond simple reminders.[13] A lack of insight into having the condition will become evident.[65][66] Late People with late-stage dementia typically turn increasingly inward and need assistance with most or all of their personal care. People with dementia in the late stages usually need 24-hour supervision to ensure their personal safety, and meeting of basic needs. If left unsupervised, they may wander or fall; may not recognize common dangers such as a hot stove; or may not realize that they need to use the bathroom and become incontinent.[56] They may not want to get out of bed, or may need assistance doing so. Commonly, the person no longer recognizes familiar faces. They may have significant changes in sleeping habits or have trouble sleeping at all.[13] Changes in eating frequently occur. Cognitive awareness is needed for eating and swallowing and progressive cognitive decline results in eating and swallowing difficulties. This can cause food to be refused, or choked on, and help with feeding will often be required.[67] For ease of feeding, food may be liquidized into a thick purée. They may also struggle to walk, particularly among those with Alzheimer's disease.[68][69][70] In some cases, terminal lucidity, a form of paradoxical lucidity, occurs immediately before death; in this phenomenon, there is an unexpected recovery of mental clarity.[71] Causes Many causes of dementia are neurodegenerative, and protein misfolding is a cardinal feature of these.[72] Other common causes include vascular dementia, dementia with Lewy bodies, frontotemporal dementia, and mixed dementia (commonly Alzheimer's disease and vascular dementia).[1][b][23] Less common causes include normal pressure hydrocephalus, Parkinson's disease dementia, syphilis, HIV, and Creutzfeldt–Jakob disease.[76] Alzheimer's disease Main article: Alzheimer's disease Brain atrophy in severe Alzheimer's Alzheimer's disease accounts for 60–70% of cases of dementia worldwide. The most common symptoms of Alzheimer's disease are short-term memory loss and word-finding difficulties. Trouble with visuospatial functioning (getting lost often), reasoning, judgment and insight fail. Insight refers to whether or not the person realizes they have memory problems. The part of the brain most affected by Alzheimer's is the hippocampus. Other parts that show atrophy (shrinking) include the temporal and parietal lobes. Although this pattern of brain shrinkage suggests Alzheimer's, it is variable and a brain scan is insufficient for a diagnosis. Little is known about the events that occur during and that actually cause Alzheimer's disease. This is due to the fact that, historically, brain tissue from people with the disease could only be studied after the person's death. Brain scans can now help diagnose and distinguish between different kinds of dementia and show severity. These include magnetic resonance imaging (MRI), computerized tomography (CT), and positron emission tomography (PET). However, it is known that one of the first aspects of Alzheimer's disease is overproduction of amyloid. Extracellular senile plaques (SPs), consisting of beta-amyloid (Aβ) peptides, and intracellular neurofibrillary tangles (NFTs) that are formed by hyperphosphorylated tau proteins, are two well-established pathological hallmarks of AD.[77] Amyloid causes inflammation around the senile plaques of the brain, and too much buildup of this inflammation leads to changes in the brain that cannot be controlled, leading to the symptoms of Alzheimer's.[78] Several articles have been published on a possible relationship (as an either primary cause or exacerbation of Alzheimer's disease) between general anesthesia and Alzheimer's in specifically the elderly.[79] Vascular Main article: Vascular dementia Vascular dementia accounts for at least 20% of dementia cases, making it the second most common type.[80] It is caused by disease or injury affecting the blood supply to the brain, typically involving a series of mini-strokes. The symptoms of this dementia depend on where in the brain the strokes occurred and whether the blood vessels affected were large or small.[13] Repeated injury can cause progressive dementia over time, while a single injury located in an area critical for cognition such as the hippocampus, or thalamus, can lead to sudden cognitive decline.[80] Elements of vascular dementia may be present in all other forms of dementia.[81] Brain scans may show evidence of multiple strokes of different sizes in various locations. People with vascular dementia tend to have risk factors for disease of the blood vessels, such as tobacco use, high blood pressure, atrial fibrillation, high cholesterol, diabetes, or other signs of vascular disease such as a previous heart attack or angina.[82] Lewy bodies Main article: Dementia with Lewy bodies The prodromal symptoms of dementia with Lewy bodies (DLB) include mild cognitive impairment, and delirium onset.[83] The symptoms of DLB are more frequent, more severe, and earlier presenting than in the other dementia subtypes.[84] Dementia with Lewy bodies has the primary symptoms of fluctuating cognition, alertness or attention; REM sleep behavior disorder (RBD); one or more of the main features of parkinsonism, not due to medication or stroke; and repeated visual hallucinations.[85] The visual hallucinations in DLB are generally vivid hallucinations of people or animals and they often occur when someone is about to fall asleep or wake up. Other prominent symptoms include problems with planning (executive function) and difficulty with visual-spatial function,[13] and disruption in autonomic bodily functions.[86] Abnormal sleep behaviors may begin before cognitive decline is observed and are a core feature of DLB.[85] RBD is diagnosed either by sleep study recording or, when sleep studies cannot be performed, by medical history and validated questionnaires.[85] Parkinson's disease Parkinson's disease is associated with Lewy body dementia that often progresses to Parkinson's disease dementia following a period of dementia-free Parkinson's disease.[87] Frontotemporal Main article: Frontotemporal dementia Frontotemporal dementias (FTDs) are characterized by drastic personality changes and language difficulties. In all FTDs, the person has a relatively early social withdrawal and early lack of insight. Memory problems are not a main feature.[13][88] There are six main types of FTD. The first has major symptoms in personality and behavior. This is called behavioral variant FTD (bv-FTD) and is the most common. The hallmark feature of bv-FTD is impulsive behavior, and this can be detected in pre-dementia states.[54] In bv-FTD, the person shows a change in personal hygiene, becomes rigid in their thinking, and rarely acknowledges problems; they are socially withdrawn, and often have a drastic increase in appetite. They may become socially inappropriate. For example, they may make inappropriate sexual comments, or may begin using pornography openly. One of the most common signs is apathy, or not caring about anything. Apathy, however, is a common symptom in many dementias.[13] Two types of FTD feature aphasia (language problems) as the main symptom. One type is called semantic variant primary progressive aphasia (SV-PPA). The main feature of this is the loss of the meaning of words. It may begin with difficulty naming things. The person eventually may lose the meaning of objects as well. For example, a drawing of a bird, dog, and an airplane in someone with FTD may all appear almost the same.[13] In a classic test for this, a person is shown a picture of a pyramid and below it a picture of both a palm tree and a pine tree. The person is asked to say which one goes best with the pyramid. In SV-PPA the person cannot answer that question. The other type is called non-fluent agrammatic variant primary progressive aphasia (NFA-PPA). This is mainly a problem with producing speech. They have trouble finding the right words, but mostly they have a difficulty coordinating the muscles they need to speak. Eventually, someone with NFA-PPA only uses one-syllable words or may become totally mute. A frontotemporal dementia associated with amyotrophic lateral sclerosis (ALS) known as (FTD-ALS) includes the symptoms of FTD (behavior, language and movement problems) co-occurring with amyotrophic lateral sclerosis (loss of motor neurons). Two FTD-related disorders are progressive supranuclear palsy (also classed as a Parkinson-plus syndrome),[89][90] and corticobasal degeneration.[13] These disorders are tau-associated. Huntington's disease Main article: Huntington's disease Huntington's disease is a neurodegenerative disease caused by mutations in a single gene HTT, that encodes for huntingtin protein. Symptoms include cognitive impairment and this usually declines further into dementia.[91] The first main symptoms of Huntington's disease often include: difficulty concentrating memory lapses depression - this can include low mood, lack of interest in things, or just abnormal feelings of hopelessness stumbling and clumsiness that is out of the ordinary mood swings, such as irritability or aggressive behavior to insignificant things[92] HIV Main article: HIV-associated neurocognitive disorder HIV-associated dementia results as a late stage from HIV infection, and mostly affects younger people.[93] The essential features of HIV-associated dementia are disabling cognitive impairment accompanied by motor dysfunction, speech problems and behavioral change.[93] Cognitive impairment is characterised by mental slowness, trouble with memory and poor concentration. Motor symptoms include a loss of fine motor control leading to clumsiness, poor balance and tremors. Behavioral changes may include apathy, lethargy and diminished emotional responses and spontaneity. Histopathologically, it is identified by the infiltration of monocytes and macrophages into the central nervous system (CNS), gliosis, pallor of myelin sheaths, abnormalities of dendritic processes and neuronal loss.[94] Creutzfeldt–Jakob disease Main article: Creutzfeldt–Jakob disease Creutzfeldt–Jakob disease is a rapidly progressive prion disease that typically causes dementia that worsens over weeks to months. Prions are disease-causing pathogens created from abnormal proteins.[95] Alcoholism Main article: Alcohol-related dementia Alcohol-related dementia, also called alcohol-related brain damage, occurs as a result of excessive use of alcohol particularly as a substance abuse disorder. Different factors can be involved in this development including thiamine deficiency and age vulnerability.[96][97] A degree of brain damage is seen in more than 70% of those with alcohol use disorder. Brain regions affected are similar to those that are affected by aging, and also by Alzheimer's disease. Regions showing loss of volume include the frontal, temporal, and parietal lobes, as well as the cerebellum, thalamus, and hippocampus.[97] This loss can be more notable, with greater cognitive impairments seen in those aged 65 years and older.[97] Mixed dementia More than one type of dementia, known as mixed dementia, may exist together in about 10% of dementia cases.[1] The most common type of mixed dementia is Alzheimer's disease and vascular dementia.[98] This particular type of mixed dementia's main onsets are a mixture of old age, high blood pressure, and damage to blood vessels in the brain.[15] Diagnosis of mixed dementia can be difficult, as often only one type will predominate. This makes the treatment of people with mixed dementia uncommon, with many people missing out on potentially helpful treatments. Mixed dementia can mean that symptoms onset earlier, and worsen more quickly since more parts of the brain will be affected.[15] Other Chronic inflammatory conditions that may affect the brain and cognition include Behçet's disease, multiple sclerosis, sarcoidosis, Sjögren's syndrome, lupus, celiac disease, and non-celiac gluten sensitivity.[99][100] These types of dementias can rapidly progress, but usually have a good response to early treatment. This consists of immunomodulators or steroid administration, or in certain cases, the elimination of the causative agent.[100] Celiac disease does not seem to raise the risk of dementia in general but it may increase the risk of vascular dementia.[101] Both celiac disease or non-celiac gluten sensitivity might raise the risk of cognitive impairment which can be one of the early signs of subsequent dementia.[102] A strict gluten-free diet started early may protect against dementia associated with gluten-related disorders.[101][102] Cases of easily reversible dementia include hypothyroidism, vitamin B12 deficiency, Lyme disease, and neurosyphilis. For Lyme disease and neurosyphilis, testing should be done if risk factors are present. Because risk factors are often difficult to determine, testing for neurosyphilis and Lyme disease, as well as other mentioned factors, may be undertaken as a matter of course where dementia is suspected.[13]: 31–32  Many other medical and neurological conditions include dementia only late in the illness. For example, a proportion of people with Parkinson's disease develop dementia, though widely varying figures are quoted for this proportion.[103] When dementia occurs in Parkinson's disease, the underlying cause may be dementia with Lewy bodies or Alzheimer's disease, or both.[104] Cognitive impairment also occurs in the Parkinson-plus syndromes of progressive supranuclear palsy and corticobasal degeneration (and the same underlying pathology may cause the clinical syndromes of frontotemporal lobar degeneration). Although the acute porphyrias may cause episodes of confusion and psychiatric disturbance, dementia is a rare feature of these rare diseases. Limbic-predominant age-related TDP-43 encephalopathy (LATE) is a type of dementia that primarily affects people in their 80s or 90s and in which TDP-43 protein deposits in the limbic portion of the brain.[105] Hereditary disorders that can also cause dementia include: some metabolic disorders such as lysosomal storage disorders, leukodystrophies, and spinocerebellar ataxias. Persistent loneliness may significantly increase the risk of dementia.[106][107] Loneliness is associated with a 31% higher likelihood of developing any form of dementia, and can also raise the risk of cognitive impairment by 15%.[107] Diagnosis Symptoms are similar across dementia types and it is difficult to diagnose by symptoms alone. Diagnosis may be aided by brain scanning techniques. In many cases, the diagnosis requires a brain biopsy to become final, but this is rarely recommended (though it can be performed at autopsy). In those who are getting older, general screening for cognitive impairment using cognitive testing or early diagnosis of dementia has not been shown to improve outcomes.[20][108] However, screening exams are useful in 65+ persons with memory complaints.[13] Normally, symptoms must be present for at least six months to support a diagnosis.[109] Cognitive dysfunction of shorter duration is called delirium. Delirium can be easily confused with dementia due to similar symptoms. Delirium is characterized by a sudden onset, fluctuating course, a short duration (often lasting from hours to weeks), and is primarily related to a somatic (or medical) disturbance. In comparison, dementia has typically a long, slow onset (except in the cases of a stroke or trauma), slow decline of mental functioning, as well as a longer trajectory (from months to years).[110] Some mental illnesses, including depression and psychosis, may produce symptoms that must be differentiated from both delirium and dementia.[111] These are differently diagnosed as pseudodementias, and any dementia evaluation needs to include a depression screening such as the Neuropsychiatric Inventory or the Geriatric Depression Scale.[112][13] Physicians used to think that people with memory complaints had depression and not dementia (because they thought that those with dementia are generally unaware of their memory problems). However, researchers have realized that many older people with memory complaints in fact have mild cognitive impairment the earliest stage of dementia. Depression should always remain high on the list of possibilities, however, for an elderly person with memory trouble. Changes in thinking, hearing and vision are associated with normal ageing and can cause problems when diagnosing dementia due to the similarities.[113] Given the challenging nature of predicting the onset of dementia and making a dementia diagnosis clinical decision making aids underpinned by machine learning and artificial intelligence have the potential to enhance clinical practice.[114] Cognitive testing See also: Cognitive inhibition and Executive dysfunction § Testing and measurement Sensitivity and specificity of common tests for dementia Test Sensitivity Specificity Reference MMSE 71–92% 56–96% [115] 3MS 83–93% 85–90% [116] AMTS 73–100% 71–100% [116] Various brief cognitive tests (5–15 minutes) have reasonable reliability to screen for dementia, but may be affected by factors such as age, education and ethnicity.[117] Age and education have a significant influence on the diagnosis of dementia. For example, Individuals with lower education are more likely to be diagnosed with dementia than their educated counterparts.[118] While many tests have been studied,[119][120][121] presently the mini mental state examination (MMSE) is the best studied and most commonly used. The MMSE is a useful tool for helping to diagnose dementia if the results are interpreted along with an assessment of a person's personality, their ability to perform activities of daily living, and their behaviour.[4] Other cognitive tests include the abbreviated mental test score (AMTS), the, "modified mini–mental state examination" (3MS),[122] the Cognitive Abilities Screening Instrument (CASI),[123] the Trail-making test,[124] and the clock drawing test.[46] The MoCA (Montreal Cognitive Assessment) is a reliable screening test and is available online for free in 35 different languages.[13] The MoCA has also been shown somewhat better at detecting mild cognitive impairment than the MMSE.[125][53] People with hearing loss, which commonly occurs alongside dementia, score worse in the MoCA test, which could lead to a false diagnosis of dementia. Researchers have developed an adapted version of the MoCA test, which is accurate and reliable and avoids the need for people to listen and respond to questions.[126][127] The AD-8 – a screening questionnaire used to assess changes in function related to cognitive decline – is potentially useful, but is not diagnostic, is variable, and has risk of bias.[128] An integrated cognitive assessment (CognICA) is a five-minute test that is highly sensitive to the early stages of dementia, and uses an application deliverable to an iPad.[129][130] Previously in use in the UK, in 2021 CognICA was given FDA approval for its commercial use as a medical device.[130] Another approach to screening for dementia is to ask an informant (relative or other supporter) to fill out a questionnaire about the person's everyday cognitive functioning. Informant questionnaires provide complementary information to brief cognitive tests. Probably the best known questionnaire of this sort is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).[131] Evidence is insufficient to determine how accurate the IQCODE is for diagnosing or predicting dementia.[132] The Alzheimer's Disease Caregiver Questionnaire is another tool. It is about 90% accurate for Alzheimer's when by a caregiver.[13] The General Practitioner Assessment Of Cognition combines both a patient assessment and an informant interview. It was specifically designed for use in the primary care setting. Clinical neuropsychologists provide diagnostic consultation following administration of a full battery of cognitive testing, often lasting several hours, to determine functional patterns of decline associated with varying types of dementia. Tests of memory, executive function, processing speed, attention and language skills are relevant, as well as tests of emotional and psychological adjustment. These tests assist with ruling out other etiologies and determining relative cognitive decline over time or from estimates of prior cognitive abilities.[133] Laboratory tests Routine blood tests are usually performed to rule out treatable causes. These include tests for vitamin B12, folic acid, thyroid-stimulating hormone (TSH), C-reactive protein, full blood count, electrolytes, calcium, renal function, and liver enzymes. Abnormalities may suggest vitamin deficiency, infection, or other problems that commonly cause confusion or disorientation in the elderly.[134] Imaging A CT scan or MRI scan is commonly performed to possibly find either normal pressure hydrocephalus, a potentially reversible cause of dementia, or connected tumor. The scans can also yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. These tests do not pick up diffuse metabolic changes associated with dementia in a person who shows no gross neurological problems (such as paralysis or weakness) on a neurological exam.[135] The functional neuroimaging modalities of SPECT and PET are more useful in assessing long-standing cognitive dysfunction, since they have shown similar ability to diagnose dementia as a clinical exam and cognitive testing.[136] The ability of SPECT to differentiate vascular dementia from Alzheimer's disease, appears superior to differentiation by clinical exam.[137] The value of PiB-PET imaging using Pittsburgh compound B (PiB) as a radiotracer has been established in predictive diagnosis, particularly Alzheimer's disease.[138] Prevention Main article: Prevention of dementia Risk factors See also: Neuroplastic effects of pollution Risk factors for dementia include high blood pressure, high levels of LDL cholesterol, vision loss, hearing loss, smoking, obesity, depression, inactivity, diabetes, lower levels of education and low social contact. Over-indulgence in alcohol, lack of sleep, anemia, traumatic brain injury, and air pollution can also increase the chance of developing dementia.[139][140][141][142] Many of these risk factors, including the lower level of education, smoking, physical inactivity and diabetes, are modifiable.[143] Several of the group are known as vascular risk factors that may be possible to be reduced or eliminated.[144] Managing these risk factors can reduce the risk of dementia in individuals in their late midlife or older age. A reduction in a number of these risk factors can give a positive outcome.[145] The decreased risk achieved by adopting a healthy lifestyle is seen even in those with a high genetic risk.[146] In addition to the above risk factors, other psychological features, including certain personality traits (high neuroticism, and low conscientiousness), low purpose in life, and high loneliness, are risk factors for Alzheimer's disease and related dementias.[147][148][149] For example, based on the English Longitudinal Study of Ageing (ELSA), research found that loneliness in older people can increase the risk of dementia by one-third. Not having a partner (being single, divorced, or widowed) can double the risk of dementia. However, having two or three closer relationships might reduce the risk by three-fifths.[150][151] The two most modifiable risk factors for dementia are physical inactivity and lack of cognitive stimulation.[152] Physical activity, in particular aerobic exercise, is associated with a reduction in age-related brain tissue loss, and neurotoxic factors thereby preserving brain volume and neuronal integrity. Cognitive activity strengthens neural plasticity and together they help to support cognitive reserve. The neglect of these risk factors diminishes this reserve.[152] Sensory impairments of vision and hearing are modifiable risk factors for dementia.[153][154][155] These impairments may precede the cognitive symptoms of Alzheimer's disease for example, by many years.[156] Hearing loss may lead to social isolation which negatively affects cognition.[157] Social isolation is also identified as a modifiable risk factor.[156] Age-related hearing loss in midlife is linked to cognitive impairment in late life, and is seen as a risk factor for the development of Alzheimer's disease and dementia. Such hearing loss may be caused by a central auditory processing disorder that makes the understanding of speech against background noise difficult. Age-related hearing loss is characterised by slowed central processing of auditory information.[156][158] Worldwide, mid-life hearing loss may account for around 9% of dementia cases.[159] Frailty may increase the risk of cognitive decline, and dementia, and the inverse also holds of cognitive impairment increasing the risk of frailty. Prevention of frailty may help to prevent cognitive decline.[156] There are no medications that can prevent cognitive decline and dementia.[160] However blood pressure lowering medications might decrease the risk of dementia or cognitive problems by around 0.5%.[161] Economic disadvantage has been shown to have a strong link to higher dementia prevalence,[162] which cannot yet be fully explained by other risk factors. Dental health Limited evidence links poor oral health to cognitive decline. However, failure to perform tooth brushing and gingival inflammation can be used as dementia risk predictors.[163] Oral bacteria There is some evidence that oral bacteria in people with gum disease may be a link to declines in cognitive health.[164] The proposed mechanism is still being studied, but research has linked specific types of bacteria in the mouth to those found in some people's brain who have Alzheimer's disease. There is also some evidence that people with a high level of tooth plaque are also at a greater risk of cognitive decline.[165] Poor oral hygiene can have an adverse effect on speech and nutrition, causing general and cognitive health decline.[citation needed] Oral viruses Herpes simplex virus (HSV) has been found in more than 70% of those aged over 50. HSV persists in the peripheral nervous system and can be triggered by stress, illness or fatigue.[166] High proportions of viral-associated proteins in amyloid plaques or neurofibrillary tangles (NFTs) confirm the involvement of HSV-1 in Alzheimer's disease pathology. NFTs are known as the primary marker of Alzheimer's disease. HSV-1 produces the main components of NFTs.[167] A Swedish cohort study from 2024 suggests that persons infected with HSV have twice the risk of developing dementia compared to non-infected participants. [168] Diet Diet is seen to be a modifiable risk factor for the development of dementia. Thiamine deficiency is identified to increase the risk of Alzheimer's disease in adults.[169] The role of thiamine in brain physiology is unique and essential for the normal cognitive function of older people.[170] Many dietary choices of the elderly population, including the higher intake of gluten-free products, compromise the intake of thiamine as these products are not fortified with thiamine.[171] The Mediterranean and DASH diets are both associated with less cognitive decline. A different approach has been to incorporate elements of both of these diets into one known as the MIND diet.[172] These diets are generally low in saturated fats while providing a good source of carbohydrates, mainly those that help stabilize blood sugar and insulin levels.[173] Raised blood sugar levels over a long time, can damage nerves and cause memory problems if they are not managed.[174] Nutritional factors associated with the proposed diets for reducing dementia risk include unsaturated fatty acids, vitamin E, vitamin C, flavonoids, vitamin B, and vitamin D.[175][176] A study conducted at the University of Exeter in the United Kingdom seems to have confirmed these findings with fruits, vegetables, whole grains, and healthy fats creating an optimum diet that can help reduce the risk of dementia by roughly 25%.[177] The MIND diet may be more protective but further studies are needed. The Mediterranean diet seems to be more protective against Alzheimer's than DASH but there are no consistent findings against dementia in general. The role of olive oil needs further study as it may be one of the most important components in reducing the risk of cognitive decline and dementia.[172][178] In those with celiac disease or non-celiac gluten sensitivity, a strict gluten-free diet may relieve the symptoms given a mild cognitive impairment.[101][102] Once dementia is advanced no evidence suggests that a gluten-free diet is useful.[101] Omega-3 fatty acid supplements do not appear to benefit or harm people with mild to moderate symptoms.[179] However, there is good evidence that omega-3 incorporation into the diet is of benefit in treating depression, a common symptom,[180] and potentially modifiable risk factor for dementia.[139] Management Main article: Caring for people with dementia There are limited options for treating dementia, with most approaches focused on managing or reducing individual symptoms. There are no treatment options available to delay the onset of dementia.[181] Acetylcholinesterase inhibitors are often used early in the disorder course; however, benefit is generally small.[7][182] More than half of people with dementia may experience psychological or behavioral symptoms including agitation, sleep problems, aggression, and/or psychosis. Treatment for these symptoms is aimed at reducing the person's distress and keeping the person safe. Treatments other than medication appear to be better for agitation and aggression.[183] Cognitive and behavioral interventions may be appropriate. Some evidence suggests that education and support for the person with dementia, as well as caregivers and family members, improves outcomes.[184] Exercise programs are beneficial with respect to activities of daily living.[185] As with all brain disorders, some people with dementia could potentially be a danger to themselves or others. Such behavioral symptoms might result in the person being involuntarily admitted to a mental health ward for assessment, care and treatment. However, this is a last resort, and potential alternatives could be considered by family or friends of people with dementia.[186][187] Palliative care interventions may lead to improvements in comfort in dying, but it is not yet clear from the evidence how it can be best used to support people dying with advanced dementia and their families.[188] The effect of therapies can be evaluated for example by assessing agitation using the Cohen-Mansfield Agitation Inventory (CMAI); by assessing mood and engagement with the Menorah Park Engagement Scale (MPES);[189] and the Observed Emotion Rating Scale (OERS)[190] or by assessing indicators for depression using the Cornell Scale for Depression in Dementia (CSDD)[191] or a simplified version thereof.[192] Often overlooked in treating and managing dementia is the role of the caregiver and what is known about how they can support multiple interventions. Caregivers of people with dementia in nursing homes do not have sufficient tools or clinical guidance for behavioral and psychological symptoms of dementia (BPSD) along with medication use.[193] Simple measures like talking to people about their interests can improve the quality of life for care home residents living with dementia. A programme showed that such simple measures reduced residents' agitation and depression. They also needed fewer GP visits and hospital admissions, which also meant that the programme was cost-saving.[194][195] Psychological and psychosocial therapies Main article: Psychological therapies for dementia Psychological therapies for dementia include some limited evidence for reminiscence therapy (namely, some positive effects in the areas of quality of life, cognition, communication and mood – the first three particularly in care home settings),[196] some benefit for cognitive reframing for caretakers,[197] unclear evidence for validation therapy[198] and tentative evidence for mental exercises, such as cognitive stimulation programs for people with mild to moderate dementia.[199] Offering personally tailored activities may help reduce challenging behavior and may improve quality of life.[200] It is not clear if personally tailored activities have an impact on affect or improve for the quality of life for the caregiver.[200] Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers. In addition, home care can provide one-to-one support and care in the home allowing for more individualized attention that is needed as the disorder progresses. Psychiatric nurses can make a distinctive contribution to people's mental health.[201] Since dementia impairs normal communication due to changes in receptive and expressive language, as well as the ability to plan and problem solve, agitated behavior is often a form of communication for the person with dementia. Actively searching for a potential cause, such as pain, physical illness, or overstimulation can be helpful in reducing agitation.[202] Additionally, using an "ABC analysis of behavior" can be a useful tool for understanding behavior in people with dementia. It involves looking at the antecedents (A), behavior (B), and consequences (C) associated with an event to help define the problem and prevent further incidents that may arise if the person's needs are misunderstood.[203] The strongest evidence for non-pharmacological therapies for the management of changed behaviors in dementia is for using such approaches.[204] Low quality evidence suggests that regular (at least five sessions of) music therapy may help institutionalized residents. It may reduce depressive symptoms and improve overall behaviors. It may also supply a beneficial effect on emotional well-being and quality of life, as well as reduce anxiety.[205][needs update] In 2003, The Alzheimer's Society established 'Singing for the Brain' (SftB) a project based on pilot studies which suggested that the activity encouraged participation and facilitated the learning of new songs. The sessions combine aspects of reminiscence therapy and music.[206] Musical and interpersonal connectedness can underscore the value of the person and improve quality of life.[207] Some London hospitals found that using color, designs, pictures and lights helped people with dementia adjust to being at the hospital. These adjustments to the layout of the dementia wings at these hospitals helped patients by preventing confusion.[208] Life story work as part of reminiscence therapy, and video biographies have been found to address the needs of clients and their caregivers in various ways, offering the client the opportunity to leave a legacy and enhance their personhood and also benefitting youth who participate in such work. Such interventions can be more beneficial when undertaken at a relatively early stage of dementia. They may also be problematic in those who have difficulties in processing past experiences[207] Animal-assisted therapy has been found to be helpful. Drawbacks may be that pets are not always welcomed in a communal space in the care setting. An animal may pose a risk to residents, or may be perceived to be dangerous. Certain animals may also be regarded as "unclean" or "dangerous" by some cultural groups.[207] Occupational therapy also addresses psychological and psychosocial needs of patients with dementia through improving daily occupational performance and caregivers' competence.[209] When compensatory intervention strategies are added to their daily routine, the level of performance is enhanced and reduces the burden commonly placed on their caregivers.[209] Occupational therapists can also work with other disciplines to create a client centered intervention.[210] To manage cognitive disability, and coping with behavioral and psychological symptoms of dementia, combined occupational and behavioral therapies can support patients with dementia even further.[210] Cognitive training and rehabilitation There is no strong evidence to suggest that cognitive training is beneficial for people with Parkinson's disease, dementia, or mild cognitive impairment.[211] However, a 2023 review found that cognitive rehabilitation may be effective in helping individuals with mild to moderate dementia to manage their daily activities.[212] Personally tailored activities Offering personally tailored activity sessions to people with dementia in long-term care homes may slightly reduce challenging behavior.[213] Medications No medications have been shown to prevent or cure dementia.[214] Medications may be used to treat the behavioral and cognitive symptoms, but have no effect on the underlying disease process.[13][215] Donepezil Acetylcholinesterase inhibitors, such as donepezil, may be useful for Alzheimer's disease,[216] Parkinson's disease dementia, DLB, or vascular dementia.[215] The quality of the evidence is poor[217] and the benefit is small.[7] No difference has been shown between the agents in this family.[218] In a minority of people side effects include a slow heart rate and fainting.[219] Rivastigmine is recommended for treating symptoms in Parkinson's disease dementia.[23] Medications that have anticholinergic effects increase all-cause mortality in people with dementia, although the effect of these medications on cognitive function remains uncertain, according to a systematic review published in 2021.[220] Before prescribing antipsychotic medication in the elderly, an assessment for an underlying cause of the behavior is needed.[221] Severe and life-threatening reactions occur in almost half of people with DLB,[86][222] and can be fatal after a single dose.[223] People with Lewy body dementias who take neuroleptics are at risk for neuroleptic malignant syndrome, a life-threatening illness.[224] Extreme caution is required in the use of antipsychotic medication in people with DLB because of their sensitivity to these agents.[85] Antipsychotic drugs are used to treat dementia only if non-drug therapies have not worked, and the person's actions threaten themselves or others.[225][226][227][228] Aggressive behavior changes are sometimes the result of other solvable problems, that could make treatment with antipsychotics unnecessary.[225] Because people with dementia can be aggressive, resistant to their treatment, and otherwise disruptive, sometimes antipsychotic drugs are considered as a therapy in response.[225] These drugs have risky adverse effects, including increasing the person's chance of stroke and death.[225] Given these adverse events and small benefit antipsychotics are avoided whenever possible.[204] Generally, stopping antipsychotics for people with dementia does not cause problems, even in those who have been on them a long time.[229] N-methyl-D-aspartate (NMDA) receptor blockers such as memantine may be of benefit but the evidence is less conclusive than for AChEIs.[216] Due to their differing mechanisms of action memantine and acetylcholinesterase inhibitors can be used in combination however the benefit is slight.[230][231] An extract of Ginkgo biloba known as EGb 761 has been widely used for treating mild to moderate dementia and other neuropsychiatric disorders.[232] Its use is approved throughout Europe.[233] The World Federation of Biological Psychiatry guidelines lists EGb 761 with the same weight of evidence (level B) given to acetylcholinesterase inhibitors, and memantine. EGb 761 is the only one that showed improvement of symptoms in both AD and vascular dementia. EGb 761 is seen as being able to play an important role either on its own or as an add-on particularly when other therapies prove ineffective.[232] EGb 761 is seen to be neuroprotective; it is a free radical scavenger, improves mitochondrial function, and modulates serotonin and dopamine levels. Many studies of its use in mild to moderate dementia have shown it to significantly improve cognitive function, activities of daily living, neuropsychiatric symptoms, and quality of life.[232][234] However, its use has not been shown to prevent the progression of dementia.[232] While depression is frequently associated with dementia, the use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) do not appear to affect outcomes.[235][236] However, the SSRIs sertraline and citalopram have been demonstrated to reduce symptoms of agitation, compared to placebo.[237] No solid evidence indicates that folate or vitamin B12 improves outcomes in those with cognitive problems.[238] Statins have no benefit in dementia.[239] Medications for other health conditions may need to be managed differently for a person who has a dementia diagnosis. It is unclear whether blood pressure medication and dementia are linked. People may experience an increase in cardiovascular-related events if these medications are withdrawn.[240] The Medication Appropriateness Tool for Comorbid Health Conditions in Dementia (MATCH-D) criteria can help identify ways that a diagnosis of dementia changes medication management for other health conditions.[241] These criteria were developed because people with dementia live with an average of five other chronic diseases, which are often managed with medications. The systematic review that informed the criteria were published subsequently in 2018 and updated in 2022.[242] Palliative care Given the progressive and terminal nature of dementia, palliative care can be helpful to people with dementia and caregivers. Palliative care is the active total care of people with an incurable condition like dementia and their families by a multi-professional team.[243] It aims to improve quality of life and is provided through person-centered and integrated care.[244] A palliative care approach can support people affected by dementia at any stage of the condition. It can help people with dementia and their caregivers to understand what to expect, deal with loss of physical and mental abilities, support the person's wishes and goals including surrogate decision making, and discuss wishes for or against CPR and life support.[245][246] Because there is uncertainty around how and when people with dementia decline,[247] and because most people prefer to allow the person with dementia to make their own decisions, palliative care involvement before the late stages of dementia is recommended.[248][249][250] For example, in England, it is estimated that 40% of people at any stage of dementia would benefit from palliative care.[251] This proportion of people is expected to increase dramatically by 2040.[252] In the early stages of dementia, palliative care can involve advocacy around establishing goals of care in the future, reassurance of continued support, planning for future scenarios of care and establishing long-term relationships with care providers.[253] In later stages, a palliative approach to dementia care may have specific benefit to goals of care and end-of-life conversations, symptom management, prescribing practices and emergency department visits.[254] However, more research is needed to know how palliative care can be best used to support people dying with advanced dementia and their families.[255] Towards the end of life, people with dementia frequently present to the emergency department with unmet palliative care needs.[256] Community palliative care is associated with the reduced likelihood of attending the emergency department among people with dementia nearing the end of life.[257] Palliative care for people with dementia living at home may help improve end-of-life care outcomes such as neuropsychiatric symptoms.[258] People with advanced dementia may not readily receive specialist palliative care input.[259] Reasons for this are varied but may include lack of agreement of when to refer people with dementia,[260] and a lack of coordination across care settings, communication challenges, limited training opportunities for healthcare staff and because dementia is not considered to be a life-limiting condition.[259] In fact, people with dementia and their carers and members of the public often don't know that dementia is not a normal part of aging and that it is a terminal condition.[261][262] Further research is needed to determine the appropriate palliative care interventions and how they can be implemented to help people with dementia.[188][258] Person-centered care Person-centered care is an approach that places the individual at the heart of care, taking into account their unique needs, preferences, experiences, and values. It is built on getting to know the person with the condition through a personal relationship.[263] This is especially important for people living with dementia, as the approach aims to maintain the dignity of people with dementia and sense of identity throughout the course of their illness.[264] Person-centered care interventions could not only reduce agitation, neuropsychiatric symptoms, and depression but also help improve the quality of life for people with dementia.[265] Moreover, the potential benefits of a person-centered care approach for dementia care workers have been reported, indicating its effectiveness in reducing stress, burnout, and job dissatisfaction.[263][266] Person centered assessment Person-centered outcome measures (PCOMs) are standardized, validated questionnaires that measure people’s opinions of their own health and well-being. They emphasize person-centered care by focusing on the symptoms and concerns that are most important to people and their families.[267][268] PCOMs comprise patient-reported outcome measures (PROMs) and proxy-reported outcome measures for those unable to self-report.[269] Used in routine care PCOMs support systematic assessment and monitoring of an individual’s health and wellbeing, enable shared decision-making, enable changes in care provision (such as improved communication or referral to other services), improve outcomes (such as improved symptom management) and enable evaluation of care provision. The use of PCOMs have the potential to serve as a scalable and sustainable way to support integrated palliative care for older people including those living with dementia.[267] PCOMs can be single-domain or multi-domain tools, focussing on individual symptoms or multiple symptoms, depending on the scope of assessment.[270] Single-domain PCOMs focus on one specific area of care. For example, the Pain Assessment in Advanced Dementia (PAINAD) scale is used to assess pain in individuals living with advanced dementia.[271] Multi-domain PCOMs could assess multiple domains, including the symptom burden, function, psychological or spiritual problems, treatment satisfaction, health-related quality of life. The Integrated Palliative Care Outcome Scale for Dementia (IPOS-Dem) is an example of a comprehensive palliative dementia PCOM, used to measure symptoms and concerns for people with dementia.[272] Sleep disturbances Over 40% of people with dementia report sleep problems. Approaches to treating these sleep problems include medications and non-pharmacological approaches.[273] The use of medications to alleviate sleep disturbances that people with dementia often experience has not been well researched, even for medications that are commonly prescribed.[274] In 2012 the American Geriatrics Society recommended that benzodiazepines such as diazepam, and non-benzodiazepine hypnotics, be avoided for people with dementia due to the risks of increased cognitive impairment and falls.[275] Benzodiazepines are also known to promote delirium.[276] Additionally, little evidence supports the effectiveness of benzodiazepines in this population.[274][277] No clear evidence shows that melatonin or ramelteon improves sleep for people with dementia due to Alzheimer's,[274] but it is used to treat REM sleep behavior disorder in dementia with Lewy bodies.[86] Limited evidence suggests that a low dose of trazodone may improve sleep, however more research is needed.[274] Non-pharmacological approaches have been suggested for treating sleep problems for those with dementia, however, there is no strong evidence or firm conclusions on the effectiveness of different types of interventions, especially for those who are living in an institutionalized setting such as a nursing home or long-term care home.[273] Pain See also: Assessment in nonverbal patients and Pain Assessment in Advanced Dementia As people age, they experience more health problems, and most health problems associated with aging carry a substantial burden of pain; therefore, between 25% and 50% of older adults experience persistent pain. Seniors with dementia experience the same prevalence of conditions likely to cause pain as seniors without dementia.[278] Pain is often overlooked in older adults and, when screened for, is often poorly assessed, especially among those with dementia, since they become incapable of informing others of their pain.[278][279] Beyond the issue of humane care, unrelieved pain has functional implications. Persistent pain can lead to decreased ambulation, depressed mood, sleep disturbances, impaired appetite, and exacerbation of cognitive impairment[279] and pain-related interference with activity is a factor contributing to falls in the elderly.[278][280] Although persistent pain in people with dementia is difficult to communicate, diagnose, and treat, failure to address persistent pain has profound functional, psychosocial and quality of life implications for this vulnerable population. Health professionals often lack the skills and usually lack the time needed to recognize, accurately assess and adequately monitor pain in people with dementia.[278][281] Family members and friends can make a valuable contribution to the care of a person with dementia by learning to recognize and assess their pain. Educational resources and observational assessment tools are available.[278][282][283] Eating difficulties Persons with dementia may have difficulty eating. Whenever it is available as an option, the recommended response to eating problems is having a caretaker assist them.[225] For people who do not have dementia, a secondary option when they cannot swallow effectively would be to consider gastrostomy feeding tube placement as a way to give nutrition. However, for people with dementia, assistance with oral feeding is at least as good as tube feeding in bringing comfort and maintaining functional status while lowering risk of aspiration pneumonia and death[225][284] It can be tried if the reasons for the person’s problems with eating, drinking or swallowing are treatable and it’s expected that they will be able to start eating and drinking normally afterwards.[285] Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers. Tube feedings may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration.[286][287] Benefits in those with advanced dementia has not been shown.[288] The risks of using tube feeding include agitation, rejection by the person (pulling out the tube, or otherwise physical or chemical immobilization to prevent them from doing this), or developing pressure ulcers.[225] The procedure is directly related to a 1% fatality rate[289] with a 3% major complication rate.[290] The percentage of people at end of life with dementia using feeding tubes in the US has dropped from 12% in 2000 to 6% as of 2014.[291][292] The immediate and long-term effects of modifying the thickness of fluids for swallowing difficulties in people with dementia are not well known.[293] While thickening fluids may have an immediate positive effect on swallowing and improving oral intake, the long-term impact on the health of the person with dementia should also be considered.[293] Exercise Further information: Neurobiological effects of physical exercise Exercise programs may improve the ability of people with dementia to perform daily activities, but the best type of exercise is still unclear.[294] Getting more exercise can slow the development of cognitive problems such as dementia, proving to reduce the risk of Alzheimer's disease by about 50%. A balance of strength exercise, to help muscles pump blood to the brain, and balance exercises are recommended for aging people. A suggested amount of about 2+1⁄2 hours per week can reduce risks of cognitive decay as well as other health risks like falling.[295] Assistive technology and digital health There is a lack of high-quality scientific evidence to determine whether assistive technology effectively supports people with dementia to manage memory issues.[296] Some of the specific things that are used today that helps with dementia today are: clocks, communication aids, electrical appliances the use monitoring, GPS location/ tracking devices, home care robots, in-home cameras, and medication management are just to name a few.[297] As the technology advances, virtual reality is also being explored as a powerful technology to elicit memories and to improve wellbeing.[298] Technology has the potential to be a valuable intervention for alleviating loneliness and promoting social connections.[299] It could facilitate activities of daily living, and provide ways to connect people that are geographically distant.[300] Other types of developed technologies to aid services include telehealth or telemedicine services, utilising digital communication for delivery of health-related services and information through phone calls, mobile apps, and video conferencing.[301] Telemedicine has given results for cognitive assessment and diagnosis that are similar to in-person visits, and it has also helped improve outcomes after rehabilitation. Telemedicine is often well received by people affected by dementia who can rely on the support of staff and family to navigate the technology. While it has potential to widen access to services, those with sensory impairment may be excluded.[301] Digital health interventions can play a role in supporting family caregivers of people with dementia, by offering a source of support from connective platforms, with 24/7 accessibility, as well as opportunity for remote monitoring. However, challenges such as the digital divide, privacy concerns and the need for greater personalisation for individual users are recognised issues.[301] Remotely delivered information for caregivers Remotely delivered interventions including support, training and information may reduce the burden for the informal caregiver and improve their depressive symptoms.[302] There is no certain evidence that they improve health-related quality of life.[302] In several localities in Japan, digital surveillance may be made available to family members, if a person with dementia is prone to wandering and going missing.[303] Alternative medicine Scientific evidence of the therapeutic values of aromatherapy and massage is unclear and limited. There is no convincing evidence about their effectiveness but no general conclusions can be drawn about the benefits or harms of these alternative treatments.[304][305] It is not clear if cannabinoids have any harmful or beneficial effects on dementia.[306] Epidemiology Deaths per million persons in 2012 due to dementia 0–4 5–8 9–10 11–13 14–17 18–24 25–45 46–114 115–375 376–1266 Disability-adjusted life year for Alzheimer and other dementias per 100,000 inhabitants in 2004 <100 100–120 120–140 140–160 160–180 180–200 200–220 220–240 240–260 260–280 280–300 >300 The number of cases of dementia worldwide in 2021 was estimated at 55 million, with close to 10 million new cases each year.[1] According to a report by the World Health Organization, "In 2021, Alzheimer’s disease and other forms of dementia ranked as the seventh leading cause of death, killing 1.8 million lives."[307] By 2050, the number of people living with dementia around the world is estimated to be over 150 million.[308] Globally, the fastest increase in serious health-related suffering by 2060 is expected to occur among people with dementia.[309] Around 7% of people over the age of 65 have dementia, with slightly higher rates (up to 10% of those over 65) in places with relatively high life expectancy.[310] An estimated 58% of people with dementia are living in low and middle income countries.[311][312] The prevalence of dementia differs in different world regions, ranging from 4.7% in Central Europe to 8.7% in North Africa/Middle East; the prevalence in other regions is estimated to be between 5.6 and 7.6%.[311] The number of people living with dementia is estimated to double every 20 years. In 2016 dementia resulted in about 2.4 million deaths,[313] up from 0.8 million in 1990.[314] Estimates show that in 2024 there were 982,000 people living with dementia in the UK and this is expected to rise to 1.4 million people by 2040.[315] The annual incidence of dementia diagnosis is nearly 10 million worldwide.[188] Almost half of new dementia cases occur in Asia, followed by Europe (25%), the Americas (18%) and Africa (8%). The incidence of dementia increases exponentially with age, doubling with every 6.3-year increase in age.[311] Dementia affects 5% of the population older than 65 and 20–40% of those older than 85.[316] Rates are slightly higher in women than men at ages 65 and greater.[316] The disease trajectory is varied and the median time from diagnosis to death depends strongly on age at diagnosis, from 6.7 years for people diagnosed aged 60–69 to 1.9 years for people diagnosed at 90 or older.[188] In 2019, there were 1.62 million dementia-related deaths worldwide. This is expected to increase to 4.91 million by 2050.[8] In 2022 and 2023, dementia was the leading cause of death in England and Wales.[317][318] Deaths from dementia in the U.S. have tripled in the past 21 years, rising from around 150,000 in 1999 to over 450,000 in 2020, and the likelihood of dying from dementia increased across all demographic groups.[319] The genetic and environmental risk factors for dementia disorders vary by ethnicity.[320][321] For instance, Alzheimer's disease among Hispanic/Latino and African American subjects exhibit lower risks associated with gene changes in the apolipoprotein E gene than do non-Hispanic white subjects.[322] In the United States in 2017, over 37% of dementia cases in the United States were associated with cardiometabolic conditions, though the risk varies across regions. The eight key contributors were diabetes, heart failure, atrial fibrillation, coronary artery disease, heart attacks, strokes, hypertension and high cholesterol. Among these, stroke was the most significant factor, doubling the risk of developing dementia (2.2 times higher), followed closely by heart failure (2.1 times) and hypertension (78% increased risk). In contrast, high cholesterol had the weakest correlation, associated with a 27% increased risk. However, there were also geographic disparities, and individuals living in the U.S. South faced a higher likelihood of dementia related to cardiovascular conditions and diabetes.[323][324] Affected ages See also: Early onset dementia About 3% of people between the ages of 65–74 have dementia, 19% between 75 and 84, and nearly half of those over 85 years of age. As more people are living longer, dementia is becoming more common.[325] For people of a specific age, however, it may be becoming less frequent in the developed world, due to a decrease in modifiable risk factors made possible by greater financial and educational resources. It is one of the most common causes of disability among the elderly but can develop before the age of 65 when it is known as early-onset dementia or presenile dementia.[326][327] Less than 1% of those with Alzheimer's have gene mutations that cause a much earlier development of the disease, around the age of 45, known as early-onset Alzheimer's disease.[328] More than 95% of people with Alzheimer's disease have the sporadic form (late onset, 80–90 years of age).[328] People with dementia are often physically or chemically restrained to a greater degree than necessary, raising issues of human rights.[1][329] Social stigma is commonly perceived by those with the condition, and also by their caregivers.[108] Inequities and inequalities A growing body of scientific evidence suggests that inequalities and inequities in dementia exist. Inequalities and inequities are observed in the risk of developing dementia, ability to take part in prevention efforts, access to high-quality dementia care from diagnosis until the end of life, including bereavement support.[330] Post-diagnostic care is often variable and difficult to navigate,[331][332][333] with a disparity in care between dementia and other life-limiting conditions.[334][335][336] Furthermore, substantially less dementia research funding and financial support for the care of people with dementia compared to other life-limiting conditions also exists.[330] Differences in access to high-quality care among dementia subtypes are also noted. People with rare types of dementia compared to those with Alzheimer’s Disease, and those with other physical conditions are less likely to experience high-quality care.[337] Socioeconomic status and deprivation While aging is the largest risk factor for developing dementia, other factors at early (e.g., receiving less education), middle (e.g., physical inactivity) and later stages (e.g., air pollution) are often linked to increased risk.[338] There are significant advantages associated with having a timely dementia diagnosis (i.e., receiving the diagnosis at the milder stages of the condition). However, access to dementia diagnosis can be inequitable. Compared to individuals with high socioeconomic status, those with low socioeconomic status can have more than three-times higher risk of early-onset dementia. Additionally, individuals of low socioeconomic status with unhealthy lifestyles, can have 440% greater risk of developing early-onset dementia compared with individuals of high socioeconomic status with healthy lifestyles.[338] Measures to improve social determinants of health are warranted, as healthy lifestyle promotion alone might not substantially reduce the socioeconomic inequity in early-onset dementia and late-onset dementia risk. People with dementia residing in rural areas often experience challenges in receiving a timely diagnosis and accessing health and social care compared to people living in urban areas.[339] Among older people diagnosed with dementia, those from most deprived areas can be more likely to experience hospitalisations, emergency department visits, potentially inappropriate medication prescriptions, and higher 1-year mortality.[340] People living in the most deprived areas are more likely to experience multiple hospitalisations in the last three months of life and emergency department visits in the last year of life.[341][342] In high-income countries, low socioeconomic position is a risk factor for dying in hospital as well as other indicators of potentially poor-quality end-of-life care.[343] Race and ethnicity Significant differences in dementia incidence and risk exist based on race and ethnicity. The mechanisms responsible for these differences are not yet understood.[344][345] People who are Black in the US are at risk of receiving more futile and invasive treatment towards the end of life.[346] Emerging evidence from other countries also suggest that minority groups from different cultures, ethnicities may experience sub-optimal care from diagnosis to the end-of-life.[347][341][348][349] Gender Globally, women are bearing a disproportionate weight of the dementia impact. Two in three people with dementia are women. Yet, medical data from women are lacking compared to men. Women are more likely to care for another person with dementia (in the workforce and informally). The proportion of women caregivers in low and middle income countries is higher.[350][351] Gender disparities exist towards the end-of-life in palliative caregiving and end-of-life care experiences.[352][353] History This section needs additional citations for verification. Please help improve this article by adding citations to reliable sources in this section. Unsourced material may be challenged and removed. (November 2015) (Learn how and when to remove this message) See also: Dementia praecox Until the end of the 19th century, dementia was a much broader clinical concept. It included mental illness and any type of psychosocial incapacity, including reversible conditions.[354] Dementia at this time simply referred to anyone who had lost the ability to reason, and was applied equally to psychosis, "organic" diseases like syphilis that destroy the brain, and to the dementia associated with old age, which was attributed to "hardening of the arteries". A 19th-century drawing of a woman diagnosed with dementia Dementia has been referred to in medical texts since antiquity. One of the earliest known allusions to dementia is attributed to the 7th-century BC Greek philosopher Pythagoras, who divided the human lifespan into six distinct phases: 0–6 (infancy), 7–21 (adolescence), 22–49 (young adulthood), 50–62 (middle age), 63–79 (old age), and 80–death (advanced age). The last two he described as the "senium", a period of mental and physical decay, and that the final phase was when "the scene of mortal existence closes after a great length of time that very fortunately, few of the human species arrive at, where the mind is reduced to the imbecility of the first epoch of infancy".[355] In 550 BC, the Athenian statesman and poet Solon argued that the terms of a man's will might be invalidated if he exhibited loss of judgement due to advanced age. Chinese medical texts made allusions to the condition as well, and the characters for "dementia" translate literally to "foolish old person".[356] Athenian philosophers Aristotle and Plato discussed the mental decline that can come with old age and predicted that this affects everyone who becomes old and nothing can be done to stop this decline from taking place. Plato specifically talked about how the elderly should not be in positions that require responsibility because, "There is not much acumen of the mind that once carried them in their youth, those characteristics one would call judgement, imagination, power of reasoning, and memory. They see them gradually blunted by deterioration and can hardly fulfill their function."[357] For comparison, the Roman statesman Cicero held a view much more in line with modern-day medical wisdom that loss of mental function was not inevitable in the elderly and "affected only those old men who were weak-willed". He spoke of how those who remained mentally active and eager to learn new things could stave off dementia. However, Cicero's views on aging, although progressive, were largely ignored in a world that would be dominated for centuries by Aristotle's medical writings. Physicians during the Roman Empire, such as Galen and Celsus, simply repeated the beliefs of Aristotle while adding few new contributions to medical knowledge. Byzantine physicians sometimes wrote of dementia. It is recorded that at least seven emperors whose lifespans exceeded 70 years displayed signs of cognitive decline. In Constantinople, special hospitals housed those diagnosed with dementia or insanity, but these did not apply to the emperors, who were above the law and whose health conditions could not be publicly acknowledged. Otherwise, little is recorded about dementia in Western medical texts for nearly 1700 years. One of the few references was the 13th-century friar Roger Bacon, who viewed old age as divine punishment for original sin. Although he repeated existing Aristotelian beliefs that dementia was inevitable, he did make the progressive assertion that the brain was the center of memory and thought rather than the heart. Poets, playwrights, and other writers made frequent allusions to the loss of mental function in old age. William Shakespeare notably mentions it in plays such as Hamlet and King Lear. During the 19th century, doctors generally came to believe that elderly dementia was the result of cerebral atherosclerosis, although opinions fluctuated between the idea that it was due to blockage of the major arteries supplying the brain or small strokes within the vessels of the cerebral cortex. In 1907, Bavarian psychiatrist Alois Alzheimer was the first to identify and describe the characteristics of progressive dementia in the brain of 51-year-old Auguste Deter.[358] Deter had begun to behave uncharacteristically, including accusing her husband of adultery, neglecting household chores, exhibiting difficulties writing and engaging in conversations, heightened insomnia, and loss of directional sense.[359] At one point, Deter was reported to have "dragged a bed sheet outside, wandered around wildly, and cried for hours at midnight."[359] Alzheimer began treating Deter when she entered a Frankfurt mental hospital on November 25, 1901.[359] During her ongoing treatment, Deter and her husband struggled to afford the cost of the medical care, and Alzheimer agreed to continue her treatment in exchange for Deter's medical records and donation of her brain upon death.[359] Deter died on April 8, 1906, after succumbing to sepsis and pneumonia.[359] Alzheimer conducted the brain biopsy using the Bielschowsky stain method, which was a new development at the time, and he observed senile plaques, neurofibrillary tangles, and atherosclerotic alteration.[358] At the time, the consensus among medical doctors had been that senile plaques were generally found in older patients, and the occurrence of neurofibrillary tangles was an entirely new observation at the time.[359] Alzheimer presented his findings at the 37th psychiatry conference of southwestern Germany in Tübingen on April 11, 1906; however, the information was poorly received by his peers.[359] By 1910, Alois Alzheimer's teacher, Emil Kraepelin, published a book in which he coined the term "Alzheimer's disease" in an attempt to acknowledge the importance of Alzheimer's discovery.[358][359] By the 1960s, the link between neurodegenerative diseases and age-related cognitive decline had become more established. By the 1970s, the medical community maintained that vascular dementia was rarer than previously thought and Alzheimer's disease caused the vast majority of old age mental impairments. More recently however, it is believed that dementia is often a mixture of conditions. In 1976, neurologist Robert Katzmann suggested a link between senile dementia and Alzheimer's disease.[360] Katzmann suggested that much of the senile dementia occurring (by definition) after the age of 65, was pathologically identical with Alzheimer's disease occurring in people under age 65 and therefore should not be treated differently.[361] Katzmann thus suggested that Alzheimer's disease, if taken to occur over age 65, is actually common, not rare, and was the fourth- or 5th-leading cause of death, even though rarely reported on death certificates in 1976. A helpful finding was that although the incidence of Alzheimer's disease increased with age (from 5–10% of 75-year-olds to as many as 40–50% of 90-year-olds), no threshold was found by which age all persons developed it. This is shown by documented supercentenarians (people living to 110 or more) who experienced no substantial cognitive impairment. Some evidence suggests that dementia is most likely to develop between ages 80 and 84 and individuals who pass that point without being affected have a lower chance of developing it.[citation needed] Women account for a larger percentage of dementia cases than men.[362] This can be attributed in part to their longer overall lifespan and greater odds of attaining an age where the condition is likely to occur.[363] Much like other diseases associated with aging, dementia was comparatively rare before the 20th century, because few people lived past 80. Conversely, syphilitic dementia was widespread in the developed world until it was largely eradicated by the use of penicillin after World War II. With significant increases in life expectancy thereafter, the number of people over 65 started rapidly climbing. While elderly persons constituted an average of 3–5% of the population prior to 1945, by 2010 many countries reached 10–14% and in Germany and Japan, this figure exceeded 20%. Public awareness of Alzheimer's Disease greatly increased in 1994 when former US president Ronald Reagan announced that he had been diagnosed with the condition. In the 21st century, other types of dementia were differentiated from Alzheimer's disease and vascular dementias (the most common types). This differentiation is on the basis of pathological examination of brain tissues, by symptomatology, and by different patterns of brain metabolic activity in nuclear medical imaging tests such as SPECT and PET scans of the brain. The various forms have differing prognoses and differing epidemiologic risk factors. The main cause for many diseases, including Alzheimer's disease, remains unclear.[364] Terminology Dementia in the elderly was once called senile dementia or senility, and viewed as a normal and somewhat inevitable aspect of aging.[365][366] By 1913–20 the term dementia praecox was introduced to suggest the development of senile-type dementia at a younger age. Eventually the two terms fused, so that until 1952 physicians used the terms dementia praecox (precocious dementia) and schizophrenia interchangeably. Since then, science has determined that dementia and schizophrenia are two different disorders, though they share some similarities.[367] The term precocious dementia for a mental illness suggested that a type of mental illness like schizophrenia (including paranoia and decreased cognitive capacity) could be expected to arrive normally in all persons with greater age (see paraphrenia). After about 1920, the beginning use of dementia for what is now understood as schizophrenia and senile dementia helped limit the word's meaning to "permanent, irreversible mental deterioration". This began the change to the later use of the term. In recent studies, researchers have seen a connection between those diagnosed with schizophrenia and patients who are diagnosed with dementia, finding a positive correlation between the two diseases.[368] The view that dementia must always be the result of a particular disease process led for a time to the proposed diagnosis of "senile dementia of the Alzheimer's type" (SDAT) in persons over the age of 65, with "Alzheimer's disease" diagnosed in persons younger than 65 who had the same pathology. Eventually, however, it was agreed that the age limit was artificial, and that Alzheimer's disease was the appropriate term for persons with that particular brain pathology, regardless of age. After 1952, mental illnesses including schizophrenia were removed from the category of organic brain syndromes, and thus (by definition) removed from possible causes of "dementing illnesses" (dementias). At the same, however, the traditional cause of senile dementia – "hardening of the arteries" – now returned as a set of dementias of vascular cause (small strokes). These were now termed multi-infarct dementias or vascular dementias. Society and culture Dementia impacts not only individuals with dementia, but also their carers and the wider society. Among people aged 60 years and over, dementia is ranked the 9th most burdensome condition according to the 2010 Global Burden of Disease (GBD) estimates.[311] The societal cost of dementia is high, especially for caregivers.[369] According to research conducted in the UK, almost two out of three carers of people with dementia feel lonely. Most of the carers in the study were family members or friends.[370][371] Family carers of people with dementia are at higher risk of developing psychological and physical conditions.[372] National policies on dementia The World Health Organization's (WHO) global action plan on the public health response to dementia (2017-2025) set a target for 75% of WHO Member States (194 countries) to develop a policy or plan for dementia by 2025.[373] These plans recognize that people can live well with dementia for years, as long as the right support and timely access to a diagnosis are available. However, in 2025, only 23% of Member States (45 countries) have a national policy for dementia.[374] In England, according to an economic model, population-level interventions that target risk factors for dementia (such as high blood pressure, smoking and obesity) could save money and give people extra years in good health. For example, reduced salt in food could give 39,433 quality-adjusted life-years and save £2.4 billion.[375][376] Financial costs The financial costs of care in people with dementia are high and tend to increase toward death. Long-term care facility and informal care costs are among the highest cost components, while non-White ethnicity, female sex, married status, higher education level, more severe dementia, and higher number of chronic conditions are associated with higher costs.[372] The global costs of dementia was around US$818 billion in 2015, a 35.4% increase from US$604 billion in 2010.[311] By 2050 the estimated global cost will be $9.12 trillion.[377] In 2015, the annual cost per person with Alzheimer's in the United States was around $19,144.36.[372] The total costs for the country was estimated to be about $167.74 billion. By 2030, it is predicted the annual socioeconomic cost will total to about $507 billion, and by 2050 that number is expected to reach $1.89 trillion.[377] The total cost of dementia care in the UK is projected to increase by 172%, from £34.7 billion in 2019 to £94.1 billion in 2040.[372] The estimated costs of dementia in low- and middle-income countries (LMICs) are lower compared to high-income countries, with indirect costs making up the largest proportion in LMICs. However, these estimates are likely an underrepresentation, as there have been limited research studies on dementia costs in LMICs, particularly low-income countries.[378] Awareness Despite ongoing efforts, there still remains relatively little public understanding of dementia. For example only 42% of surveyed public in England knew that dementia is a terminal condition.[379] There is also persistent stigma, which can be a barrier for people seeking help for dementia[380] and accessing care.[381] 88% of people living with dementia report experiencing discrimination.[382][383] Stigma is worse among those who have limited knowledge of the condition or contact with people affected by dementia,[380][383] and is likely to shape the stigma held by people affected by dementia.[383] Over 64% of the general public believe people with dementia are impulsive and unpredictable.[383] According to Alzheimer’s Disease International’s 2024 survey consisting of more than 40,000 responses from people living with dementia, carers, health and care practitioners, and the general public from over 166 countries and territories, 80% of general public and 65% of health and care professionals incorrectly believe dementia is a normal part of ageing.[383] Celebrities have used their platforms to raise awareness for the different forms of dementia and the need for further support, including former First Lady of California Maria Shriver,[384] actor Samuel L. Jackson, editor-in-chief of ELLE Magazine Nina Garcia, professional skateboarder Tony Hawk, and others.[385] Additional Alzheimer's awareness has been raised through the diagnoses of high-profile persons themselves, including actors Bruce Willis[386] and Robin Williams,[387] actress and pin-up model Rita Hayworth,[388] activist Rosa Parks,[389] former US President Ronald Reagan,[390] TV host Wendy Williams,[391] musicians Tony Bennett[392] and Maureen McGovern.[393] Philanthropy In 2015, Atlantic Philanthropies announced a $177 million gift aimed at understanding and reducing dementia. The recipient was Global Brain Health Institute, a program co-led by the University of California, San Francisco and Trinity College Dublin. This donation is the largest non-capital grant Atlantic has ever made, and the biggest philanthropic donation in Irish history.[394] In October 2020, the Caretaker's last music release, Everywhere at the End of Time, was popularized by TikTok users for its depiction of the stages of dementia.[395] Caregivers were in favor of this phenomenon; Leyland Kirby, the creator of the record, echoed this sentiment, explaining it could cause empathy among a younger public.[396] On November 2, 2020, Scottish billionaire Sir Tom Hunter donated £1 million to dementia charities, after watching a former music teacher with dementia, Paul Harvey, playing one of his own compositions on the piano in a viral video. The donation was announced to be split between the Alzheimer's Society and Music for Dementia.[397] Other Driving with dementia can lead to injury or death. Doctors should advise appropriate testing on when to quit driving.[398] The United Kingdom DVLA (Driver & Vehicle Licensing Agency) states that people with dementia who specifically have poor short-term memory, disorientation, or lack of insight or judgment are not allowed to drive, and in these instances the DVLA must be informed so that the driving license can be revoked. They acknowledge that in low-severity cases and those with an early diagnosis, drivers may be permitted to continue driving.