Dementia

Original Editors - Leana Louw

Top Contributors - Leana Louw and Lauren Lopez  

Definition

Dementia refers to a group of symptoms associated with a decline in mental ability. It is caused by disorders affecting the brain, and are described by a collection of symptoms affecting the brain. Dementia has an effect on thinking, behaviour and social interaction, as well as functional abilities[1].

Clinically Relevant Anatomy

Symptoms of dementia depend on the area of the brain affected by the underlying pathology e.g. vascular disease affecting particular vessels supplying a particular lobe of the brain. The hippocampus though is often involved and contributes to the well-known symptoms of memory loss.

Hippocampus

  • Centre of memory and learning
  • Cells in this region are normally first to be damaged in Alzheimer's disease[2], resulting in the common symptom of memory loss
  • Changes in hippocampal volume (a reduction) are seen with common patterns of ageing but are exacerbated in Alzheimers[3]

Epidemiology and Etiology

Epidemiology

Dementia affects approximately 47 million people worldwide and is projected to increase to 75 million in 2030 and 132 million by 2050[4]. Dementia is generally associated with age but early onset dementia also occurs.

Etiology

Damage to brain cells causes changes to cognitive, behavioural and emotional functions, causing dementia.

Different types of dementia has different causes. Common types of dementia are:

  • Fronto-temporal lobar degeneration dementia
  • Alcohol related dementia (Korsakoff's syndrome)
  • Creutzfeldt-Jacob disease

Risk Factors

Age is the primary risk factor for dementia[4]. While genetics can also increase risk[5] there are noncommunicable, and often modifiable, diseases and lifestyle factors that increase the risk of dementia. These include: physical inactivity, obesity, unbalanced diets, tobacco use, harmful alcohol intake, diabetes mellitus and mid-life hypertension[4].

Clinical Presentation

Early signs of dementia are normally subtle, sometimes mimicking other patterns of ageing[1]. It can include[6][7]:

  • Progressive and frequent memory loss (mostly short-term)
  • Confusion
  • Personality changes
  • Apathy and withdrawal
  • Loss of functional abilities to perform activities of daily living

Although some cases of dementia are reversible (e.g. hormonal or vitamin deficiencies), most are progressive, with a slow, gradual onset. Certain symptoms, mostly behavioural and psychological, can result from drug interactions, environmental factors, unreported pain and other illnesses[7].

Diagnostic Procedures

General practitioners are usually the first port of call for diagnosis of dementia[1]. Making a diagnosis can be challenging. The NICE guidelines for dementia recommend the following process for making a diagnosis.

  • Take a history including cognitive, behavioural and psychological symptoms, and their impact on daily life. A history should be taken from the individual with dementia symptoms ideally also
  • A physical examination with blood and urine tests to exclude reversible causes of cognitive decline
  • Cognitive testing using a validated brief structured cognitive instrument such as: the 10-point cognitive screener (10-CS) the 6-item cognitive impairment test (6CIT) the 6-item screener the Memory Impairment Screen (MIS) the Mini-Cog Test Your Memory (TYM).

Diagnosis of the dementia subtype is critical for clinical management and anticipating the course of disease[1]. Certain types of dementia are diagnosed by medical history, physical examination, blood tests, and characteristic changes in thinking, behaviour and the effect on performance of activities of daily living. The diagnosis of the dementia subtype can be difficult to diagnose as many of the symptoms and brain changes overlap. Secondary care services normally assist in the diagnosis of the specific subtypes of dementia with the use of imaging[1] or examining cerebrospinal fluid[8].

Differential Diagnosis

Dementia can have different causes, and the following conditions need to be treated and/or excluded first:

  • Vitamin B12 deficiency[1]
  • Hormone deficiencies (e.g. thyroid problems)[1]
  • Depression[1]
  • Medication side-effects
  • Alcohol abuse
  • Overmedication
  • Infections
  • Brain tumours

Outcome Measures

The following list is from a review of useful outcome measures for dementia.

Management

Medical management should be sought as soon as symptoms start appearing, as some of the causes are treatable, and early diagnosis and management can minimise the disease process to allow most benefit from available treatments.

Symptoms include[8]:

  • Agitation, aggression, distress and psychosis
  • Depression and anxiety
  • Sleep problems
  • Parkinson's disease
  • Pain
  • Falls
  • Diabetes
  • Incontinence
  • Sensory impairment

Medication

The NICE guideline for dementia discusses pharmacological management of dementia according to subtype in depth. The following describes medications used to treat the symptoms of dementia[7]. It is important to note that not every individual with dementia will be prescribed every medication.

Antidepressants

Effectiveness is normally only seen after two to three weeks.

  • Types:
    • Tricyclic (amitriptyline, imipramine or dothiepin)
      • Side-effects:
        • Worsening confusion
        • Dry mouth
        • Blurry vision
        • Constipation
        • Dizziness in upright position (thus not recommended in Alzheimer's disease, as it can cause falls and injuries)
        • Difficulty with urination
    • Newer types of antidepressants have less side-effects
      • First line treatment: Fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram and escitalopram
      • Side-effect
        • Headaches
        • Nausea
  • Commonly prescribed:
    • Antidepressants:
      • Amitriptyline (Endep) 
      • Citalopram (Cipramil, also Celapram, Ciazil, Talam, Talohexal) 
      • Dothiepin (Prothiaden, also Dothep) 
      • Doxepin (Sinequan, also Deptran)
      • Escitalopram (Lexapro) 
      • Fluoxetine (Prozac, also Lovan, Auscap, Fluohexal, Fluoxebell, Zactin) 
      • Fluvoxamine (Faverin, also Movax, Luvox, Voxam) 
      • Imipramine (Tofranil, also Tolerade) 
      • Mirtazipine (Avanza, Axit, Mirtazon, Remeron) 
      • Nortriptyline (Allegron) 
      • Paroxetine (Aropax, Paxtine, Oxetine) 
      • Reboxetine (Edronax) 
      • Sertraline (Zoloft, Xydep, Eleva, Concorz) 
      • Venlafaxine (Efexor)
      • Lithium carbonate (Lithicarb, Quilonum) - mood stabilizer

Antipsychotics

  • Neuroleptics/major tranquillisers such as:
    • Amisulpride (Solian) 
    • Chlorpromazine (Largactil)  
    • Fluphenazine (Modecate) 
    • Haloperidol (Haldol, Serenace) 
    • Moclobemide (Auroix) 
    • Olanzapine (Zyprexa) 
    • Promazine (Promazine) 
    • Quetiapine (Seroquel) 
    • Risperidone (Risperdal) 
    • Sulpiride (Dolmatil, Sulparex, Sulpitil) 
    • Trifluoperazine (Stelazine) 
    • Zuclopenthixol (Clopixol)
  • Treat agitation, aggression and psychotic symptoms
  • Side-effects:
    • Sedation
    • Dizziness
    • Unsteadiness
    • Shakiness, slowlessness, stiffness of limbs (resembles Parkinson's disease)

Hypnotics

  • Treatment of sleep disturbances
  • Side-effects:
    • Excessive sedation
    • Increased confusion
    • Unsteadiness
    • Long-term use: Tardive dyskinesia
  • Commonly prescribed:
    • Chloral hydrate (Welldorm) 
    • Clomethiazole (Heminevrin) 
    • Flurazepam (Dalmane) 
    • Nitrazepam (Mogadon also Alodorm) 
    • Temazepam (Femaze, Temtabs, Normison) 
    • Zopiclone (Imrest, Imovane) 
    • Zolpidem (Stilnoct)

Anxiety-relieving drugs

  • Benzodiazepine - short periods of anxiety
    • Short duration: Lorazepam, oxazepam
    • Long duration: Chlordiazepoxide, diazepam
  • Long term use not recommended
  • Side-effects:
    • Excessive sedation
    • Unsteadiness
    • Accentuation of confusion and memory deficits
  • Commonly prescribed:
    • Alprazolam (Xanax, also Alprax, Kalma, Zamahexal) 
    • Buspirone (Buspar) 
    • Diazepam (Valium also Antenex, Valpam, Ducene) 
    • Lorazepam (Ativan) 
    • Oxazepam (Alepam, Serepax, Minelax)

Anticonvulsants

  • Commonly prescribed:
    • Sodium valproate (Epilim also Valpro) 
    • Carbamazepine (Tegretol)
  • Reduce aggression and agitation

Cholinesterase inhibitors

  • Donepezil, galantamine, rivastigmine
  • Effects:
    • Improve memory and ability to perform activities of daily living (especially in Alzheimer's disease)
    • Slight effect on behavioural symptoms, mood, confidence, delusions, hallucinations
  • Side-effects (high dosages):
    • Increased agitation
    • Insomnia with nightmares

Non-medical Management

Alongside drug interventions, non-pharmacological interventions are used to treat the symptoms of dementia.

Non-pharmacological Management

  • Cognitive stimulation therapy[8][9] for mild to moderate dementia which has been shown to be as clinically effective and cost effective as acetylcholinesterase inhibitors[10]. Cognitive stimulation therapy can be administrated by anyone working with dementia patients; carers, nurses or occupational therapists[11].
  • Reminiscence therapy for mild to moderate dementia[8][12].
  • Cognitive rehabilitation or occupational therapy (working on functional goals of the individual and/or their carers[8]).
Lifestyle Modifications
  • Regular exercise and an active lifestyle[7]. Very effective in the management of the depression component of dementia.
  • Stimulating, personalised daily activities[8].
Exercise Therapy
Physiotherapy Management

Physiotherapy is not a modality used to treat the underlying cause of dementia, but exercise can be used in the prevention of dementia and minimising the effects of dementia e.g. reduced mobility and pain. In addition, a well rounded knowledge of dementia is important in the management of patients with dementia presenting to physiotherapy for other conditions.

Physiotherapists can play a role in customising exercise programmes. Research have shown positive effects that exercise can prevent or delay the onset of dementia, by slowing down the cognitive decline[13][14]. This can lead to improved quality of life and slowing down of functional decline expected with the disease process[14]. There is also some evidence that exercise therapy can improve the ability of people with dementia in performing activities of daily living[15].

Supporting Carers

People with dementia often live in independently in the community supported by formal and informal carers (family and friends). The burden on carers can be significant as dementia progresses in the individual cared for. As a result, carers report worse health outcomes compared to their peers[16][17]. Supporting carers is essential to helping people with dementia live in their own familiar homes and communities.

See the Physiopedia guides for carers here and here for further information on supporting carers of people with dementia.

Resources 

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Robinson L, Tang E, Taylor J. Clinical review. Dementia: timely diagnosis and early intervention. BMJ. 2015;350:h3029. Accessed 26 November 2018.
  2. Maruszak A, Thuret S. Why looking at the whole hippocampus is not enough—a critical role for anteroposterior axis, subfield and activation analyses to enhance predictive value of hippocampal changes for Alzheimer’s disease diagnosis. Front Cell Neurosci. 2014; 8: 95. Accessed 27 November 2018.
  3. den Heijer T, van der Lign F, Koudstaal PJ, Hofman A, van der Lugt A, Krestin GP, Niessen WJ, Breteler MMB. A 10-year follow-up of hippocampal volume on magnetic resonance imaging in early dementia and cognitive decline. Brain. 2010. 133; 4: 1163–1172. Accessed 26 November 2018.
  4. 4.0 4.1 4.2 4.3 4.4 World Health Organisation. Global action plan on the public health response to dementia 2017–2025. 2017. Accessed 27 November 2018.
  5. Loy CT, Schofield PR, Turner AM, Kwok JB. Genetics of dementia. Lancet. 2014. 383; 9919:828-40. Accessed 27 November 2018.
  6. Alzheimer's association. What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia (accessed 26/09/2018).
  7. 7.0 7.1 7.2 7.3 Dementia Australia. What is dementia? https://www.dementia.org.au/about-dementia/what-is-dementia (accessed 26/09/2018).
  8. 8.0 8.1 8.2 8.3 8.4 8.5 National Institute for Clinical and Health Excellence. Dementia: assessment, management and support for people living with dementia and their carers: NICE guideline [NG97]. 2018. Accessed 26 November 2018.
  9. Km K, Han JW, So Y, Seo J, Kim YJ, Park JH, Lee SB, Lee JJ, Jeong H, Lim TH, Kim KW. Cognitive Stimulation as a Therapeutic Modality for Dementia: A Meta-Analysis. Psychiatry Investig. 2017. 14; 5: 626–639. Accessed 26 November 2018.
  10. Knapp M, Iemmi V, Romeo R. Dementia care costs and outcomes: a systematic review. Int J Geriatr Psychiatry 2013;28:551-61. Accessed 26 Novmeber 2018.
  11. Streater A, Aguirre E, Spector A, Orrell M. Cognitive stimulation therapy for people with dementia in practice: A service evaluation. Br Jour Occup Ther. 2016. 79; 9: 574–580. Accessed 27 November 2018. 
  12. Woods B, O'Philbin L, Farrell EM, Spector AE, Orrell M. Reminiscence therapy for dementia. Cochrane Database Syst Rev. 2018; 3: CD001120. Accessed 27 November 2018.
  13. Ko MH. Exercise for Dementia. Brain & Neurorehabilitation 2015. 8; 1: 24-8. Accessed 27 November 2018.
  14. 14.0 14.1 Rolland Y. Exercise and Dementia. In: Sinclair AJ, Morley JE, Vellas B editors. Pathy's Principles and Practice of Geriatric Medicine. 2012;1:911-21. Accessed 27 November 2018.
  15. Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs for people with dementia. Cochrane Database of Systematic Reviews. 2015; 4: CD006489. Accessed 26 November 2018.
  16. Pinquart M, Sorenson S. Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. Psychol Aging. 2003. 1; 2: 250-67. Accessed 27 November 2018.
  17. Brodaty H, Green A, Koschera A. Meta-analysis of psychosocial interventions for caregivers of people with dementia. J Am Geriatr Soc. 2003. 51; 5: 657-64.