Dementia

Introduction

It is normal for people to become more absent minded, forgetful and experience mild cognitive impairment as they grow older. This is often described as age associated memory impairment that causes people to experience gradual memory loss in daily activities like remembering names, phone numbers or misplacing objects. Although a certain degree of memory decline is associated with normal aging, their intellectual functioning will still remain intact. Normal memory loss due to aging is also not an indication for onset of Alzheimer’s disease. However, when people start to get lost in familiar place, begin repeating the recent conversations and experiences difficulty to perform familiar tasks it could signal the beginning of more serious problems like dementia or Alzheimer’s disease. Dementia will cause memory loss and a decline of cognitive abilities in patients. Although the prevalence of dementia increases with age, young people are also known to be affected by problems of dementia. A medical professional can help by accessing the cognitive impairment in a patient and recommend the type of treatment. The available drugs cannot repair brain damage or cure dementia but they can help to slow down the dementia progress and improve its symptoms. This aim of this article is to use current literature for describing the best practices and multidisciplinary approach for identification, assessment and management of dementia. The article will first begin by offering a brief explanation about what is dementia. It will then proceed to discuss about the processes involved in the identification of dementia in patients. This will be followed by a discussion on how the assessment of dementia is being performed. The article will then proceed to discuss on the best approaches for managing the behavioral and psychological symptoms shown by patients with dementia.

About dementia

Dementia is a condition that is characterized by memory impairments and multiple cognitive deficits. It occurs when degeneration of brain cells takes place in the region of the brain called cerebral cortex. This is the part of the brain that is responsible for our memories, thoughts, personality and actions (Sue et al., 2008). The most common cause for dementia is Alzheimer’s disease. Between 50% and 75% of dementia cases are found to be cause by Alzheimer’s disease. Other common causes for dementia are Lewy body dementia caused by the presence of abnormal protein chunks in the brain and vascular dementia that is caused by reduced blood flow to the brain (Sue et al., 2008). Dementia is also caused by fronto-temporal dementia, Huntington’s disease, brain injury and Creutzfeldt-Jakob disease (Weiner and Lipton, 2008). Dementia is an incurable progressive condition that affects the functional ability and the quality of life of a person (Chang and Johnson, 2008). People with dementia gradually lose their ability to think well which results in being unable to perform normal activities like eating or getting dressed. They also experience personality change, hallucinate, become easily agitated and experience mood disturbances (Miller, 2009).

About 4.5 million people in US had been diagnosed with Alzheimer’s disease in 2003 and this figure was estimated to reach 14 million by 2050 (Sue, et al. 2008). Similarly the prevalence of dementia in Australia is also expected to be increasing by four-fold over the next 40 years (Terpening, Hodges and Cordato, 2011). There had been 210,000 cases of confirmed diagnosis for dementia in Australia during 2006 (Chang and Johnson,2008).This could be attributed to the fact that Australia’s aging population of people over 65 years is expected to double by middle of this century (Kohsaka, 2012.). Incidence of dementia is known found to double every five years between the ages of 65 and 90 years. Prevalence of dementia in people who live beyond 90 has also been found to rise exponentially (Corrada, Brookmeyer, Paganini-Hill, Berlau and Kawas, 2010). This condition is expected to produce a growing burden on public healthcare for coping with incidence of dementia in an aging population.

Identification of dementia

From a clinical perspective, the identification of dementia has shifted from the diagnosis of a full-blown dementia to an early diagnosis of dementia causing illnesses so that they could be treated before it causes the irreversible state of dementia (Weiner and Lipton, 2008). Early diagnosis of dementia will help the patients to plan for their future by making necessary arrangements with their caregivers and preparation of legal matters like authorizing power of authority to a trustworthy person. Although it has been found that more than two thirds of the people who have noticed symptoms of their cognitive decline will consult with a physician to be evaluated, over 90% of mild dementia cases had been missed during primary care assessment (Terpening, Hodges and Cordato, 2011).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a standard that is published by American Psychiatric association to help standardize the criteria and categories for psychiatric diagnosis. The DSM-IV-TR helps to list major etiological categories that cause dementia into general medical conditions, substance-induced persisting dementia, multiple etiologies and unspecified dementia (Sue et al., 2008). General medical conditions that are described will include Alzheimer’s disease, Parkinson Disease, cerebro-vascular disease or brain trauma. DSM-IV-TR uses clusters of symptoms to meet threshold levels to identify specific subtype of mental disorder. This is important because it enables guided prognosis and appropriate treatment plan. However its minimal threshold level can reduce the sensitivity of the diagnosis which can cause failed early detection and delayed disease modifying treatment (Weiner and Lipton, 2008).

A reliable diagnosis for dementia needs full mental assessment, comprehensive history record and physical examination. A detailed neuropsychological test may be the best tool for diagnosis but it is only available to specialist psychologists, will be time consuming and costly (Terpening, Hodges and Cordato, 2011). Brief screening instruments like mini-mental state examination (MMSE) can be used to evaluate patients with cognitive complaints but it is also reported to have many shortcomings like lacking in diagnostic specificity, being unsystematic and unable to detect milder cognitive impairment (Zarit, Blazer, Orrell and Woods, 2008). It may be unrealistic to rely on brief screening tools for diagnosing dementia but it can become a more accurate instrument when used alongside a reliable clinical history. Screening tools like Addenbrooke’s MMSE help to detect mild cognitive impairment and it is already being used in Australia (Lonie, Tireney and Ebmeier, 2009). Other tools used for diagnosing dementia in Australia are Addenbrooke’s Cognitive Examination–Revised (ACE-R), General Practitioner Assessment of Cognition (GPCog) and Rowland Universal Dementia Assessment Scale (RUDAS) (Terpening, Cordato, Hepner, et al., 2011). These tools contain statements that are systematically developed as being best practice guidelines for identification of dementia and achieving better health outcomes.

Assessment of dementia

The diagnosis of dementia will need to identify two deficits consisting of memory impairment and a functional disability (Ham, 2007). Therefore the assessment of patients with symptoms for dementia will include examining their cognitive status, functional status, medical condition, behavioral issues and other forms of regular assessments. These assessments must also consider the capacity of a patient for decision making, address the support system available to the patient and identify a primary caregiver.

The assessment of cognitive status by a clinician will begin with a review of the patient’s attentiveness and alertness (Ham, 2007). If any deficit is found, a further assessment of cognitive status for a suspected dementia patient can be done using the MMSE (Zarit, Blazer, Orrell and Woods, 2008) and for mild cognitive impairments the Addenbrooke’s MMSE can be used by physicians (Lonie, Tireney and Ebmeier, 2009). The MMSE will test for five domains consisting of the patient’s orientation, memory, attention, language and praxis (Ham, 2007).

Assessment of a patient’s functional status will include domains of psychological, physical and socioeconomic status. It is used to determine if the patient is having any functional disability that is being caused by a cognitive impairment (Ham, 2007). This assessment can be more difficult to perform in a primary care environment because it requires information from someone close to the patient to determine their baseline for comparing with the present functional performance. It helps determine the capacity of the patient for living independently and self care.

The suspected dementia patient should also be assessed for other medical conditions that can begin with a structured interview with the patient or a reliable informant to understand their past medical history. Laboratory tests can be done to find for medical illnesses that can contribute to cognitive impairment. Physical examination is also done to determine presence of neurological conditions that can suggest disorders like Alzheimer’s or Parkinson’s disease. The types of medications taken by the patient should also be examined to identify drugs that are sedative or having anti-cholinergic side effects (Ham, 2007).

Patients are also assessed for physical and psychological behavioral problems. Their physical behavioral changes can include aggression, restlessness and wandering. Psychological changes associated with dementia are hallucinations, delusions, anxiety and sleeplessness (Krishnamoorthy, Prince and Cummings, 2010). It may be difficult to administer these assessment tests directly on the patient and gathering the data from family members or a reliable informant may be necessary. Since symptoms of dementia are progressive over time, a longitudinal monitoring of the patients with regular reassessments will also be required to access the progression of their condition and to review the treatment.

Managing behavioral symptoms of dementia

Although extensive research has been done on dementia, an effective form of treatment is yet to be found (Terpening, Hodges and Cordato, 2011). However, evidence from studies show that early diagnosis of dementia during its mild or early stage of cognitive decline enables for a more effective patient care plan. Non- pharmaceutical interventions are used to improve the cognitive outcomes of patients (Naismith, Glazier, Burke, et al, 2009). Such early intervention helps to improve patient and caregiver’s quality of life. It also delays a patient’s transition from their home to an institutional care (Gitlin, Kales and Lyketsos, 2012).

The cores features of behavioral symptoms in dementia are wandering, repetitive speech and disturbed sleep (Krishnamoorthy, Prince and Cummings, 2010). If these behaviors are not addressed and treated quickly, the progression of dementia becomes accelerated resulting in worsened quality of life and functional decline. The use of systematic screening for the detection of behavioral symptoms is a vital prevention strategy that enables early treatment for behavioral symptoms through the identification of underlying causes and tailored treatment plan (Gitlin, Kales and Lyketsos, 2012).

The recommended first line of treatment for dementia is often non-pharmacologic (Freeman and Joska, 2012) because the existing pharmacologic treatments have notable risks and only have modest effectiveness. These medications are not able to offer effective treatment for patient behaviors that are distressing to caregivers. Types of non-pharmaceutical treatment that can be provided include providing support and education for caregiver, problem solving training and therapy that is targeted at specific behavior’s underlying causes. Such non-pharmaceutical intervention helps to enhance the satisfaction and quality of life for both patient and the caregiver (Gitlin, Kales and Lyketsos, 2012).

Managing psychological symptoms of dementia

Psychological symptoms that are associated with dementia include hallucination, delusions, anxiety and sleeplessness (Krishnamoorthy, Prince and Cummings, 2010). Antipsychotic medication developed for psychotic disorders have been found to be useful for management of psychological symptoms in dementia like depression, psychotic issues, mood disorder and delirium. The judicious use of these antipsychotic drugs for treating symptoms of dementia has the support from research studies (Grossberg, Jarvik, Meyers and Sadavoy, 2004).

Depression can exacerbate functional and cognitive decline, increase mortality, impair quality of patient’s life and increase the burden of caregiver. Treatment of dementia with depression includes use of selective serotonin reuptake inhibitors. However the response to treatment may take longer that normal adult recovery. A high level of co-morbidity is also found between symptoms of anxiety and depression. Although there are limited guidelines for treatment of anxiety in dementia patients, clinicians recommend the use of antidepressants (Freeman and Joska, 2012). However, their use is cautioned against the risks of other side effects. Use of antipsychotic drugs is recommended for treatment of psychotic condition like hallucinations and delusions in dementia patients (Woodrow, Colbert and Smith, 2010). Selection of drugs used must weigh the individual need of patient against its benefit and risk profiles. Dementia patients can experience sleep disorders due to reversal of day-night or Rapid Eye Movement (REM). It is also found that people will require less sleep as they grow older. Intervention using anti-depressants has been found to help dementia patients will sleep problems. However use of benzodiazepines is strictly not recommended due to possible cognitive side effects (Freeman and Joska, 2012). Psycho education also helps to address sleep disturbances by better management of daily routine, sleep hygiene and avoiding daytime naps.

Conclusion

Dementia is a condition that is associated with memory impairment along with multiple cognitive declines. Although it is more common among aged patients, symptoms of dementia can also be found in young people. The incidence of dementia is expected to quadruple by the middle of this century and place additional burden on existing healthcare systems. Best practices guideline for the identification and assessment of dementia are available through standards like DVM-IV-TR or MMSE. DVM-IV-TR lists major etiological categories that cause dementia whereas the MMSE is used to assess cognitive impairments. Clinical assessment of dementia will include evaluation of cognitive status, functional status, medical condition, behavioral changes and psychological symptoms. A multidisciplinary approach is used to manage the symptoms of dementia. Behavioral symptoms are addressed by early detection to identify underlying causes and plan effective treatment. The first line of treatment for dementia is non pharmaceutical. It involves providing training to enhance the satisfaction and quality of life for caregiver and the patient. Psychological symptoms of dementia are often managed using medication. Anti depressant drugs are used for anxiety and depression whereas antipsychotic drugs are used for hallucination and delusion. However the drug prescription should weigh the medication’s benefit and risk profiles against the individual needs of the patient.

References

Cayton, H., 2008. Alzheimer’s and other dementias: Answers at your fingertips. London: Class Publishing Limited.

Chang, E. and Johnson, A.,2008. Chronic Illness and disability: Principles for nursing practice. Australia: Elsevier.

Corrada, M. M., Brookmeyer, R., Paganini-Hill, A., Berlau, D. And Kawas, C. H., 2010. Dementia incidence continues to increase with age in the oldest old: the 90+ study. Annals of Neurology, 67 (1), pp. 114 -121.

Freeman, C. and Joska, J., 2012. Management of behavioral and psychological symptoms of dementia. Continuing Medical Education, 30 (4), pp. 110 – 113.

Gitlin, L. N., Kales, H. C. and Lyketsos, C. G., 2012. Non-pharmacologic management of behavioral symptoms in dementia. The Journal of the American Medical Association, 308 (19), pp. 2020 – 2029.

Grossberg, G. T., Jarvik, L. F., Meyers, B. S. and Sadavoy, J., 2004. Comprehensive textbook of geriatric psychiatry. US: Norton Professional Books.

Ham. R. J., 2007. Primary care geriatrics: A case-based approach. US: Elsevier Health Sciences.

Kohsaka, A., 2012. Aging and economic growth potentials in the Pacific Region. US: Routledge.

Krishnamoorthy, E. S., Prince, M. J. and Cummings, J. L., 2010. Dementia: A Global Approach, Cambridge: Cambridge University Press.

Lonie, J. A., Tireney, K. M and Ebmeier, K. P., 2009. Screening for mild cognitive Impairment: A systematic review. International Journal of Geriatric Psychiatry, 24, pp. 902 – 915.

Miller, C., 2009. Nursing for wellness of older adults. China: Lippincott Williams & Wilkins.

Naismith, S., Glazier, N., Burke, D. et al., 2009. Early intervention in cognitive decline: Is there a role for multiple medical or behavioral interventions? Early Intervention Psychiatry, 3, pp. 19 – 27.

Payton, G., 2009. A caregiver’s journey: Dealing with the aspects of dementia. US: Xlibris Corporation.

Sue, D. and Sue, D. W. and Sue, S., 2008, Understanding Abnormal Behavior. US: Cengage Learning.

Terpening, Z., Cordato, N., Hepner, I, et al., 2011. Utility of the Addenbrooke’s Cognitive Examination: Revised for the diagnosis of dementia syndromes. Australasian Journal on Aging, 30, 113 – 118.

Terpening, Z., Hodges, J. R. and Cordato, N. J., 2011. Towards evidence – based dementia screening in Australia. Medical Journal of Australia, 194 (2), pp. 60 – 61.

Weiner, M. F. and Lipton, A. M., 2008. The Dementias: Diagnosis, Treatment and Research. US: American Psychiatric Publications.

Woodrow, R., Colbert, B. J. and Smith, D. M., 2010. Essentials of pharmacology for health occupations. US: Cengage Learning.

Zarit, S. H., Blazer, D., Orrell, M. and Woods,B., 2008. Throwing down the gauntlet, Can we do better than the MMSE? Aging and Mental Health, 12, pp. 411 – 412.