Dementia: Difference between revisions

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* [[Alzheimers disease|Alzheimer disease]] is characterized by widespread atrophy of the [[Cerebral Cortex|cortex]] and deposition of amyloid plaques and tangles of hyperphosphorylated tau protein in the [[Neurone|neurons]] which contribute to their degeneration. A genetic basis has been established for both early and late-onset AD. Certain factors like depression, traumatic head injury, cardiovascular disease, family history of dementia, smoking, and the presence of APOE e4 allele have been shown to increase the risk of development of AD.
* [[Alzheimers disease|Alzheimer disease]] is characterized by widespread atrophy of the [[Cerebral Cortex|cortex]] and deposition of amyloid plaques and tangles of hyperphosphorylated tau protein in the [[Neurone|neurons]] which contribute to their degeneration. A genetic basis has been established for both early and late-onset AD. Certain factors like depression, traumatic head injury, cardiovascular disease, family history of dementia, smoking, and the presence of APOE e4 allele have been shown to increase the risk of development of AD.
* [[Lewy Body Disease|Lewy body dementia]] is characterized by the intracellular accumulation of Lewy bodies (which are insoluble aggregates of alpha-synuclein) in the neurons, mainly in the cortex.  
* [[Lewy Body Disease|Lewy body dementia]] is characterized by the intracellular accumulation of Lewy bodies (which are insoluble aggregates of alpha-synuclein) in the neurons, mainly in the cortex.  
* [[Frontotemporal Dementia|Frontotemporal dementia]] is characterized by the deposition of ubiquitinated TDP-43 and hyperphosphorylated tau proteins in the [[Frontal Lobe|frontal]] and [[Temporal Lobe|temporal lobe]]<nowiki/>s leading to dementia, early personality, and behavioral changes, and [[aphasia]].  
* [[Frontotemporal Dementia|Frontotemporal dementia]] is characterized by the deposition of ubiquitinated TDP-43 and hyperphosphorylated tau proteins in the [[Frontal Lobe|frontal]] and [[Temporal Lobe|temporal lobe]]<nowiki/>s leading to dementia, early personality, and behavioral changes, and [[aphasia]].
* Vascular dementia is caused by ischemic injury to the brain (e.g., [[stroke]]), leading to permanent neuronal death.<ref name=":6" />
* Vascular dementia is caused by ischemic injury to the brain (e.g., [[stroke]]), leading to permanent neuronal death.<ref name=":6" />


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</ref>
</ref>


ANU Alzheimer's Disease Risk Index (ANU-ADRI) is an evidence-based, validated, tool aimed at assessing an individual's exposure to risk factors known to be associated with an increased risk of developing Alzheimer's disease in late-life(> 60 years)
See [[Dementia: Risk factors]]
 
# [[Diabetes Mellitus Type 2|'''Diabetes mellitus''']]:is a major vascular risk factor for developing dementia through mechanisms such as glucose-mediated toxicity which causes microvascular abnormalities and neurodegeneration<ref>Qiu C, Sigurdsson S, Zhang Q, et al. Diabetes, markers of brain pathology and cognitive function: the Age, Gene/Environment Susceptibility-Reykjavik Study. Ann Neurol 2014; 75: 138–46. 74</ref>; also, evidence of impaired insulin receptor activation in Alzheimer’s disease <ref>Frölich L, Blum-Degen D, Bernstein HG, et al. Brain insulin and insulin receptors in aging and sporadic Alzheimer’s disease. J Neural Transm (Vienna) 1998; 105: 423–38.</ref> has led to suggestions that it might represent an insulin-resistant brain state.<ref>Biessels GJ, Staekenborg S, Brunner E, Brayne C, Scheltens P. Risk of dementia in diabetes mellitus: a systematic review. Lancet Neurol 2006; 5: 64–74</ref> It has been shown from several studies that the presence of type 2 diabetes in midlife is associated with increased risk of dementia, alzheimer’s disease, vascular dementia and cognitive impairment. Dementia risk with diabetes is further increased with longer duration and greater severity of diabetes. In a review of relevant studies, it was found that diabetes was associated with a 47% increased risk of any dementia, a 39% increased risk of Alzheimer’s disease, and a 138% increased risk of vascular dementia.<ref>Lu FP, Lin KP, Kuo HK. Diabetes and the risk of multi-system aging phenotypes: a systematic review and meta-analysis. 2009,4(1)</ref>
# '''Physical inactivity''': Exercising more in midlife is associated with a reduced risk of dementia.<ref>Andel R, Crowe M, Pedersen NL, Fratiglioni L, Johansson B, Gatz M. Physical exercise at midlife and risk of dementia three decades later: a population-based study of Swedish twins. J Gerontol A Biol Sci Med Sci 2008; 63: 62–66.</ref> Exercise is postulated to have a neuroprotective effect, potentially through promoting release of brain-derived neurotrophic factor (BDNF),<ref>Vaughan S, Wallis M, Polit D, Steele M, Shum D, Morris N. The effects of multimodal exercise on cognitive and physical functioning and brain-derived neurotrophic factor in older women: a randomised controlled trial. Age Ageing 2014; 43: 623–29.</ref><ref>Leckie RL, Oberlin LE, Voss MW, et al. BDNF mediates improvements in executive function following a 1-year exercise intervention. Front Hum Neurosci 2014; 8: 985.</ref> reducing cortisol, and reducing vascular risk. However, exercise alone does not seem to improve cognition in healthy older adults.<ref>Young J, Angevaren M, Rusted J, Tabet N. Aerobic exercise to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev 2015; 4: CD005381.</ref> Report from a meta-analysis<ref>Sofi F, Valecchi D, Bacci D, et al. Physical activity and risk of cognitive decline: a meta-analysis of prospective studies. J Intern Med 2011; 269: 107–17</ref> of 15 prospective cohort studies showed that physical activity had a significant protective effect against cognitive decline, with high levels of exercise being the most protective. In a study<ref>Kirk I  Erickson, Michelle W. Voss, Ruchika Shaurya Prakash, Chandramallika Basak, <sup>e</sup> Amanda Szabo et al. (2011). Exercise training increases size of hippocampus and improves memory. ''Proceedings of the National Academy of Sciences of the USA, 108'', 3017-3022</ref> looking at the impact of physical activity on different brain structures in 120 older adults assigned to either a moderate-intensity walking group or a stretching and toning group. In over a year, the stretching and toning group showed an age-appropriate reduction in the volume of their hippocampal region while the walking group showed an ''increase'' in the volume of their hippocampal region. This evidence demonstrates that increased physical activity can result in the growth of certain areas of the brain. The researchers also reported a significant increase in the memory function of the walking group.
# [[Depression|'''Depression''']]: Depression doubles as a risk factor and a symptom of dementia. It is biologically probable that depression increases dementia risk as it affects stress hormones, neuronal growth factors, and hippocampal volume.<ref>Alexopoulos GS. Vascular disease, depression, and dementia. J Am Geriatr Soc 2003; 51: 1178–80</ref> Cohort studies<ref>Dotson VM, Beydoun MA, Zonderman AB. Recurrent depressive symptoms and the incidence of dementia and mild cognitive impairment. Neurology 2010; 75: 27–34.</ref> with extended follow-up times show a link between number of depressive episodes and risk of dementia, which further reinforces the assertion that depression is a risk factor for dementia. However, a cohort study<ref>Singh-Manoux A, Dugravot A, Fournier A, et al. Trajectories of depressive symptoms before diagnosis of dementia a 28-year follow-up study. JAMA Psychiatry 2017</ref> suggests that midlife depression is not a risk factor for dementia.
# '''Smoking''': Smoking is believed to be associated with dementia and cognitive decline<ref>Durazzo TC, Mattsson N, Weiner MW, Alzheimer's Disease Neuroimaging Initiative. Smoking and increased Alzheimer's disease risk: a review of potential mechanisms. Alzheimer's & Dementia, 2014;10(3):S122–S145.</ref> due to its effect on cardiovascular pathology. A meta-analysis<ref>Zhong G, Wang Y, Zhang Y, Guo JJ, Zhao Y. Smoking Is Associated with an Increased Risk of Dementia: A Meta-Analysis of Prospective Cohort Studies with Investigation of Potential Effect Modifiers.2015</ref> has shown that current smoking increased the risk of dementia (from any cause) by a significant amount (34% for every 20 cigarettes consumed per day). However, former smokers were found to have a similar risk profile to those who had ''never'' smoked. This suggests that by giving up smoking, individuals can potentially reduce their dementia risk to that of someone who has never smoked.
# Midlife Hypertension: has also been associated with increased risk of dementia in late life<ref>Kivipelto M, Mangialasche F, Ngandu T, World Wide Fingers Network. World Wide Fingers will advance dementia prevention. Lancet Neurology. 2017. 17(1):27.</ref>. 
# Midlife [[Obesity: A Clinical Approach|obesity]]: is also linked to an increased risk of cardiovascular disease, vascular dementia, and Alzheimer's disease. This has been shown from a recent systematic review and meta-analysis of observational studies conducted on about 600 000 individuals. Result showed that obesity (but not overweight) at mid-life increases the risk of dementia (RR = 1.33; 95% CI: 1.08–1.63)<ref>Albanese E, Launer LJ, Egger M, Prince MJ, Giannakopoulos P, Wolters, FJ et al. Body mass index in midlife and dementia: systematic review and meta-regression analysis of 589,649 men and women followed in longitudinal studies. Alzheimer's & Dementia. 2017 8:165–178.</ref>
# Low educational attainment: Education has been related to lower dementia risk as it appears to protect the brain from cognitive decline. A study by Roe et al 2008<ref>Catherine M. Roe, Mark A. Mintun, Gina D’Angelo, Chengjie Xiong, Elizabeth A. Grant, John C. Morris. Variation of Education Effect With Carbon 11–Labeled Pittsburgh Compound B Uptake. Arch Neurol. 2008;65(11):1467-1471</ref> showed completing more years of education provides protection from the emergence of the cognitive symptoms of Alzheimer’s disease. The concept of cognitive reserve describes how education and cognitive stimulating may lower cognitive impairment.
# '''[[Hearing in the Elderly|Hearing loss]]''': it has also been associated with an increased risk for dementia or cognitive decline.<ref>Lin FR, Yaffe K, Xia J, Xue QL, Harris TB, Purchase-Helzner E et al. Hearing loss and cognitive decline in older adults. JAMA Internal Medicine.(2013) 173(4):293–299.</ref> A recent meta-analysis of prospective cohort studies showed that the relative risk of hearing impairment on incident Alzheimer’s and MCI was 2.82 (95% CI: 1.47–5.42)<ref>Zheng Y, Fan S, Liao W, Fang W, Xiao S, Liu J . Hearing impairment and risk of Alzheimer’s disease: a meta-analysis of prospective cohort studies. Neurological Sciences.(2017) 38(2):233–239</ref>.  In addition, a meta-analysis published by the Lancet Commission showed that hearing loss can almost double the risk of incident dementia (RR = 1.94, 95% CI: 1.38–2.73)<ref>Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D et al. (2017). Dementia prevention, intervention, and care. Lancet. 390(10113):2673–2734.</ref>
# '''Social Isolation''': Social disengagement has been shown to increase risk of cognitive impairment and dementia in older individuals<ref>Fratiglioni L, Paillard-Borg S, Winblad B . An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurology.2004: 3(6):343–353.</ref>. A systematic review and meta-analysis of longitudinal cohort studies showed that lower social participation, less frequent social contact and loneliness were associated with higher rates of incident dementia.<ref>Kuiper JS, Zuidersma M, Voshaar RCO, Zuidema SU, van den Heuvel ER, Stolk RP et al. Social relationships and risk of dementia: a systematic review and meta-analysis of longitudinal cohort studies. Ageing Research Reviews. 2015: 22:39–57.</ref>
== Clinical Presentation ==
== Clinical Presentation ==
Early signs of dementia are normally subtle, sometimes mimicking other patterns of ageing<ref name=":3" />. It can include<ref name=":1">Alzheimer's association. What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia (accessed 26/09/2018).</ref><ref name=":0">Dementia Australia. What is dementia? https://www.dementia.org.au/about-dementia/what-is-dementia (accessed 26/09/2018).</ref>:
Early signs of dementia are normally subtle, sometimes mimicking other patterns of ageing<ref name=":3" />. It can include<ref name=":1">Alzheimer's association. What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia (accessed 26/09/2018).</ref><ref name=":0">Dementia Australia. What is dementia? https://www.dementia.org.au/about-dementia/what-is-dementia (accessed 26/09/2018).</ref>:
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* Infections
* Infections
* [[Brain Tumors|Brain tumours]]
* [[Brain Tumors|Brain tumours]]
== Outcome Measures ==
The following list is from a [http://www.neurodegenerationresearch.eu/wp-content/uploads/2015/10/JPND-Report-Fountain.pdf review] of useful outcome measures for dementia.
=== Mood ===
* [http://www.primaris.org/sites/default/files/resources/Depression/depression_cornell%20scale%20for%20depression%20final.pdf Cornell Scale for Depression in Dementia]
* [http://dementiapathways.ie/_filecache/0c8/57e/37-gds.pdf Geriatric Depression Screening Scale]
=== Quality of life ===
* Quality of Life in Alzheimer’s Disease
* The Dementia Quality of Life Instrument
* [https://www.bsms.ac.uk/_pdf/cds/demqol-questionnaire.pdf DEMQoL]
* [https://www.toronto.ca/legdocs/mmis/2009/ha/bgrd/backgroundfile-24240.pdf QUALID]
=== Health-related quality of life ===
* [[EQ-5D]]
=== Activities of daily living ===
* [https://consultgeri.org/try-this/general-assessment/issue-23.pdf Lawton – PSMS & IADL]
* [http://www.medafile.com/cln/ADCSADLm.htm Alzheimer’s Disease Cooperative Study – Activities of Daily Living Inventory]
* [http://www.wellnessofmind.com/wp-content/uploads/2015/12/Bristol-Activities-of-Daily-Living-Scale.pdf Bristol Activities of Daily Living Scale]
* [https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Geriatrie/MA_TNC_DAD_scale.pdf The disability assessment for dementia]
=== Pain ===
* [https://apsoc.org.au/PDF/Publications/Abbey_Pain_Scale.pdf Abbey Pain Scale]
* [[Visual Analogue Scale|VAS]]
=== Behaviour ===
* [https://www.alz.org/national/documents/C_ASSESS-RevisedMemoryandBehCheck.pdf Revised Memory and behaviour problems checklist]
* [https://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/CONT/A/CONT_21_3_2015_02_26_KAUFER_2015-10_SDC2.pdf Neuropsychiatric Inventory]
* [http://www.dementiamanagementstrategy.com/file.axd?id=c9f7405f-3596-4f5f-9f8d-f322e5188678 Neuropsychiatric Inventory (Nursing Home)]
* CAMI
=== Reaction to behaviour ===
* [https://www.alz.org/national/documents/C_ASSESS-RevisedMemoryandBehCheck.pdf Revised Memory and behaviour problems checklist]
* [https://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/CONT/A/CONT_21_3_2015_02_26_KAUFER_2015-10_SDC2.pdf Neuropsychiatric Inventory with Caregiver Distress Scale]
* [http://www.dementiamanagementstrategy.com/file.axd?id=c9f7405f-3596-4f5f-9f8d-f322e5188678 Neuropsychiatric Inventory in Nursing Homes]
=== Carer mood ===
* [http://www.assessmentpsychology.com/HAM-D.pdf Hamilton Depression Rating Scale]
* General Health Questionnaire
* [http://www.chcr.brown.edu/pcoc/cesdscale.pdf Centre for Epidemiological Studies – Depression Scale]
=== Carer burden ===
* [http://dementiapathways.ie/_filecache/edd/c3c/89-zarit_burden_interview.pdf Zarit Burden Interview]
* Sense of competence scale
* Relative Stress Scale
=== Carer health-related quality of life ===
* [[36-Item Short Form Survey (SF-36)|SF-36]]
* [http://www.who.int/substance_abuse/research_tools/en/english_whoqol.pdf WHOQoL-Bref]
* [[EQ-5D]]. A cross-sectional study suggests that the EQ-5D-3L could be a useful tool for quality of life assessment in nursing home residents with cognitive impairment<ref>Pérez-Ros P, Martínez-Arnau FM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400476/ EQ-5D-3L for Assessing Quality of Life in Older Nursing Home Residents with Cognitive Impairment.] Life. 2020 Jul;10(7):100.</ref>.
=== Resource utilisation ===
* [https://www.pssru.ac.uk/csri/files/2017/10/TYOCPA-CSRI-v2.pdf Client Service Receipt Inventory]
* [https://rudinstrument.files.wordpress.com/2016/08/rud-3-2-sample.pdf The Resource Utilization in Dementia (RUD) Instrument]
=== Staff carer morale ===
* Maslach Burnout Inventory
== Management ==
== 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. A study suggests the need for optimal assessment, better communication among health care professionals for treating patients with dementia with multiple impairments<ref>Wolski L, Leroi I, Regan J, Dawes P, Charalambous AP, Thodi C, Prokopiou J, Villeneuve R, Helmer C, Yohannes AM, Himmelsbach I. [https://www.ncbi.nlm.nih.gov/pubmed/31791251 The need for improved cognitive, hearing and vision assessments for older people with cognitive impairment: a qualitative study.] BMC geriatrics. 2019 Dec 1;19(1):328.</ref>.
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. A study suggests the need for optimal assessment, better communication among health care professionals for treating patients with dementia with multiple impairments<ref>Wolski L, Leroi I, Regan J, Dawes P, Charalambous AP, Thodi C, Prokopiou J, Villeneuve R, Helmer C, Yohannes AM, Himmelsbach I. [https://www.ncbi.nlm.nih.gov/pubmed/31791251 The need for improved cognitive, hearing and vision assessments for older people with cognitive impairment: a qualitative study.] BMC geriatrics. 2019 Dec 1;19(1):328.</ref>.
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See the Physiopedia guides for carers [[Promoting Independence for Persons with Dementia|here]] and [[Carers guide to dementia|here]] for further information on supporting carers of people with dementia.
See the Physiopedia guides for carers [[Promoting Independence for Persons with Dementia|here]] and [[Carers guide to dementia|here]] for further information on supporting carers of people with dementia.


== Outcome Measures ==
The following list is from a [http://www.neurodegenerationresearch.eu/wp-content/uploads/2015/10/JPND-Report-Fountain.pdf review] of useful outcome measures for dementia.
Mood
*[http://www.primaris.org/sites/default/files/resources/Depression/depression_cornell%20scale%20for%20depression%20final.pdf Cornell Scale for Depression in Dementia]
*[http://dementiapathways.ie/_filecache/0c8/57e/37-gds.pdf Geriatric Depression Screening Scale]
Quality of life
* Quality of Life in Alzheimer’s Disease
* The Dementia Quality of Life Instrument
*[https://www.bsms.ac.uk/_pdf/cds/demqol-questionnaire.pdf DEMQoL]
*[https://www.toronto.ca/legdocs/mmis/2009/ha/bgrd/backgroundfile-24240.pdf QUALID]
Health-related quality of life
*[[EQ-5D]]
Activities of daily living
*[https://consultgeri.org/try-this/general-assessment/issue-23.pdf Lawton – PSMS & IADL]
*[http://www.medafile.com/cln/ADCSADLm.htm Alzheimer’s Disease Cooperative Study – Activities of Daily Living Inventory]
*[http://www.wellnessofmind.com/wp-content/uploads/2015/12/Bristol-Activities-of-Daily-Living-Scale.pdf Bristol Activities of Daily Living Scale]
*[https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Geriatrie/MA_TNC_DAD_scale.pdf The disability assessment for dementia]
Pain
*[https://apsoc.org.au/PDF/Publications/Abbey_Pain_Scale.pdf Abbey Pain Scale]
*[[Visual Analogue Scale|VAS]]
Behaviour
*[https://www.alz.org/national/documents/C_ASSESS-RevisedMemoryandBehCheck.pdf Revised Memory and behaviour problems checklist]
*[https://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/CONT/A/CONT_21_3_2015_02_26_KAUFER_2015-10_SDC2.pdf Neuropsychiatric Inventory]
*[http://www.dementiamanagementstrategy.com/file.axd?id=c9f7405f-3596-4f5f-9f8d-f322e5188678 Neuropsychiatric Inventory (Nursing Home)]
* CAMI
Reaction to behaviour
*[https://www.alz.org/national/documents/C_ASSESS-RevisedMemoryandBehCheck.pdf Revised Memory and behaviour problems checklist]
*[https://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/CONT/A/CONT_21_3_2015_02_26_KAUFER_2015-10_SDC2.pdf Neuropsychiatric Inventory with Caregiver Distress Scale]
*[http://www.dementiamanagementstrategy.com/file.axd?id=c9f7405f-3596-4f5f-9f8d-f322e5188678 Neuropsychiatric Inventory in Nursing Homes]
Carer mood
*[http://www.assessmentpsychology.com/HAM-D.pdf Hamilton Depression Rating Scale]
* General Health Questionnaire
*[http://www.chcr.brown.edu/pcoc/cesdscale.pdf Centre for Epidemiological Studies – Depression Scale]
Carer burden
*[http://dementiapathways.ie/_filecache/edd/c3c/89-zarit_burden_interview.pdf Zarit Burden Interview]
* Sense of competence scale
* Relative Stress Scale
Carer health-related quality of life
*[[36-Item Short Form Survey (SF-36)|SF-36]]
*[http://www.who.int/substance_abuse/research_tools/en/english_whoqol.pdf WHOQoL-Bref]
*[[EQ-5D]]. A cross-sectional study suggests that the EQ-5D-3L could be a useful tool for quality of life assessment in nursing home residents with cognitive impairment<ref>Pérez-Ros P, Martínez-Arnau FM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400476/ EQ-5D-3L for Assessing Quality of Life in Older Nursing Home Residents with Cognitive Impairment.] Life. 2020 Jul;10(7):100.</ref>.
Resource utilisation
*[https://www.pssru.ac.uk/csri/files/2017/10/TYOCPA-CSRI-v2.pdf Client Service Receipt Inventory]
*[https://rudinstrument.files.wordpress.com/2016/08/rud-3-2-sample.pdf The Resource Utilization in Dementia (RUD) Instrument]
Staff carer morale
* Maslach Burnout Inventory
== Resources ==
== Resources ==
* [https://www.nice.org.uk/guidance/ng97 NICE Guideline for Dementia]
* [https://www.nice.org.uk/guidance/ng97 NICE Guideline for Dementia]

Revision as of 05:56, 20 September 2021

Original Editors - Leana Louw

Top Contributors - Vidya Acharya, Kim Jackson, Lucinda hampton, Leana Louw, Lauren Lopez, Simisola Ajeyalemi, Aminat Abolade, Tony Lowe, Naomi O'Reilly, Shaimaa Eldib, Safiya Naz, Ewa Jaraczewska, Carina Therese Magtibay, Aya Alhindi and Kalyani Yajnanarayan  

Definition[edit | edit source]

Dementia describes an overall decline in memory and other thinking skills severe enough to reduce a person's ability to perform everyday activities. It is characterized by the progressive and persistent deterioration of cognitive function. Patients with dementia have problems with cognition, behavior, and functional activities of everyday life. In addition, affected patients have memory loss and lack of insight into their problems.[1]

[2]

Pathophysiology[edit | edit source]

The pathophysiology of dementia is not understood completely. Most types of dementia, except vascular dementia, are caused by the accumulation of native proteins in the brain.

  • Alzheimer disease is characterized by widespread atrophy of the cortex and deposition of amyloid plaques and tangles of hyperphosphorylated tau protein in the neurons which contribute to their degeneration. A genetic basis has been established for both early and late-onset AD. Certain factors like depression, traumatic head injury, cardiovascular disease, family history of dementia, smoking, and the presence of APOE e4 allele have been shown to increase the risk of development of AD.
  • Lewy body dementia is characterized by the intracellular accumulation of Lewy bodies (which are insoluble aggregates of alpha-synuclein) in the neurons, mainly in the cortex.
  • Frontotemporal dementia is characterized by the deposition of ubiquitinated TDP-43 and hyperphosphorylated tau proteins in the frontal and temporal lobes leading to dementia, early personality, and behavioral changes, and aphasia.
  • Vascular dementia is caused by ischemic injury to the brain (e.g., stroke), leading to permanent neuronal death.[1]

The hippocampus though is often involved and contributes to the well-known symptoms of memory loss. Cells in this region are normally first to be damaged in Alzheimer's disease[3], resulting in the common symptom of memory loss. Changes in hippocampal volume (a reduction) are seen with common patterns of aging but are exacerbated in Alzheimer,s[4]

Epidemiology[edit | edit source]

Dementia affects approximately 47 million people worldwide and is projected to increase to 75 million in 2030 and 132 million by 2050[5]. Dementia is generally associated with age but early onset dementia also occurs.

Etiology[edit | edit source]

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:

[7]

  • Alcohol related dementia (Korsakoff's syndrome)

[8]

[9]

Risk Factors-[edit | edit source]

Dementia risk factors can be categorised into modifiable and non-modifiable risk factors. Modifiable risk factors include physical inactivity, tobacco use, unhealthy diets and harmful use of alcohol. Further, certain medical conditions are associated with an increased risk of developing dementia, including hypertension, diabetes, hypercholesterolemia, obesity and depression. Other potentially modifiable risk factors may include social isolation and cognitive inactivity.[10][11][12] Non-modifiable risk factors for dementia include age and genetics. Age is the primary risk factor for dementia[5], although it is not a consequence of ageing while genetics can also increase risk. [13]

See Dementia: Risk factors

Clinical Presentation[edit | edit source]

Early signs of dementia are normally subtle, sometimes mimicking other patterns of ageing[6]. It can include[14][15]:

  • 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[15].

Diagnostic Procedures[edit | edit source]

General practitioners are usually the first port of call for diagnosis of dementia[6]. 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[6]. 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 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[6] or examining cerebrospinal fluid[16]. A pilot study developed a study protocol aimed at aiding the early detection of dementia disorders using the Timed Up-and-Go (TUG) test with the verbal task of naming different animals[17]. A research study suggests that poor visual acuity resulted in poorer executive function, which further caused more inadequate balance control, thus demonstrating the importance of assessing executive functions besides vision and balance in older individuals living with Alzheimer's dementia[18].

Differential Diagnosis[edit | edit source]

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

Management[edit | edit source]

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. A study suggests the need for optimal assessment, better communication among health care professionals for treating patients with dementia with multiple impairments[19].

Symptoms include[16]:

Medication[edit | edit source]

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[15]. It is important to note that not every individual with dementia will be prescribed every medication.

Antidepressants[edit | edit source]

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[edit | edit source]

  • 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)

Hypnotics[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

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

Cholinesterase inhibitors[edit | edit source]

  • 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[edit | edit source]

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

Non-pharmacological Management[edit | edit source]

  • Cognitive stimulation therapy[16][20] for mild-to-moderate dementia has been shown to be clinically effective and cost-effective as acetylcholinesterase inhibitors[21]. Cognitive stimulation therapy can be administrated by anyone working with dementia patients; carers, nurses or occupational therapists[22].
  • Reminiscence therapy for mild to moderate dementia[16][23].
  • Cognitive rehabilitation or occupational therapy (working on functional goals of the individual and/or their carers)[16].

Lifestyle Modifications[edit | edit source]

  • Regular exercise and an active lifestyle[15]. Very effective in the management of the depression component of dementia.
  • Stimulating, personalised daily activities[16].

Physiotherapy Management[edit | edit source]

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, well-rounded knowledge of dementia is important in the management of patients with dementia presenting to physiotherapy for other conditions. A study[24] suggests that a high-intensity functional exercise program has positive outcomes on balance in theses patients.

Physiotherapists can play a role in customising exercise programmes. Research has shown positive effects that exercise can prevent or delay the onset of dementia, by slowing down the cognitive decline[25][26]. This can lead to improved quality of life and slowing down of functional decline expected with the disease process[26]. There is also some evidence that exercise therapy can improve the ability of people with dementia in performing activities of daily living[27]. The cross-sectional study published in Feb 2020 suggests a positive association between global cognitive function and self-paced gait speed in very old people[28]. A randomized controlled trial[29] suggests favorable outcomes with exercise and horticultural intervention programs for older adults with depression and memory problems. Another randomised controlled study suggests that action observation (motor-related information available through the visual function) with gait training provides more significant benefits for gait and cognitive performances in the elderly with mild cognitive impairment.[30]

Supporting Carers[edit | edit source]

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[31][32]. 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.

Outcome Measures[edit | edit source]

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

Mood

Quality of life

  • Quality of Life in Alzheimer’s Disease
  • The Dementia Quality of Life Instrument
  • DEMQoL
  • QUALID

Health-related quality of life

Activities of daily living

Pain

Behaviour

Reaction to behaviour

Carer mood

Carer burden

Carer health-related quality of life

  • SF-36
  • WHOQoL-Bref
  • EQ-5D. A cross-sectional study suggests that the EQ-5D-3L could be a useful tool for quality of life assessment in nursing home residents with cognitive impairment[33].

Resource utilisation

Staff carer morale

  • Maslach Burnout Inventory

Resources [edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Emmady PD, Tadi P, Del Pozo E. Dementia (Nursing). Available: https://www.ncbi.nlm.nih.gov/books/NBK557444/ (accessed 20.9.2021)
  2. ↑ AlzheimersResearch UK What is dementia? Alzheimer's Research UK Available from https://www.youtube.com/watch?v=HobxLbPhrMc&feature=emb_logo
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 5.0 5.1 5.2 5.3 World Health Organisation. Global action plan on the public health response to dementia 2017–2025. 2017. Accessed 27 November 2018.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Robinson L, Tang E, Taylor J. Clinical review. Dementia: timely diagnosis and early intervention. BMJ. 2015;350:h3029. Accessed 26 November 2018.
  7. ↑ Alzheimer's SocietyWhat is frontotemporal dementia? - Alzheimer's Society (7)Available from https://www.youtube.com/watch?v=QuJFLr5Ib9k&feature=emb_logo
  8. ↑ Howcast.What Is Alcohol Dementia? | Alcoholism. Available from https://www.youtube.com/watch?v=nv6iC7he4Nc&feature=emb_logo
  9. ↑ Mayo Clinic.CJD Creutzfeldt-Jakob Disease - Mayo Clinic. Available from https://www.youtube.com/watch?v=lS9jKVM7ZXo&feature=emb_logo
  10. ↑ Kane RL, Butler M, Fink HA, Brasure M, Davila H, Desai P et al. (2017). Interventions to prevent age-related cognitive decline, mild cognitive impairment, and clinical Alzheimer’s-type dementia. Rockville (MD): Agency for Healthcare Research and Quality
  11. ↑ Prince M, Albanese E, Guerchet M, Prina M (2014). World Alzheimer Report 2014. Dementia and risk reduction: an analysis of protective and modifiable risk factors. London: Alzheimer's Disease International.
  12. ↑ Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D et al. (2017). Dementia prevention, intervention, and care. Lancet. 390(10113):2673–2734.
  13. ↑ Loy CT, Schofield PR, Turner AM, Kwok JB. Genetics of dementia. Lancet. 2014. 383; 9919:828-40. Accessed 27 November 2018.
  14. ↑ Alzheimer's association. What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia (accessed 26/09/2018).
  15. ↑ 15.0 15.1 15.2 15.3 Dementia Australia. What is dementia? https://www.dementia.org.au/about-dementia/what-is-dementia (accessed 26/09/2018).
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 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.
  17. ↑ Cedervall Y, Stenberg AM, Åhman HB, Giedraitis V, Tinmark F, Berglund L, Halvorsen K, Ingelsson M, Rosendahl E, Åberg AC. Timed Up-and-Go Dual-Task Testing in the Assessment of Cognitive Function: A Mixed Methods Observational Study for Development of the UDDGait Protocol. International journal of environmental research and public health. 2020 Jan;17(5):1715.
  18. ↑ Hunter SW, Divine A, Madou E, Omana H, Hill KD, Johnson AM, Holmes JD, Wittich W. Executive function as a mediating factor between visual acuity and postural stability in cognitively healthy adults and adults with Alzheimer’s dementia. Archives of Gerontology and Geriatrics. 2020 Apr 19:104078.
  19. ↑ Wolski L, Leroi I, Regan J, Dawes P, Charalambous AP, Thodi C, Prokopiou J, Villeneuve R, Helmer C, Yohannes AM, Himmelsbach I. The need for improved cognitive, hearing and vision assessments for older people with cognitive impairment: a qualitative study. BMC geriatrics. 2019 Dec 1;19(1):328.
  20. ↑ 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.
  21. ↑ 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.
  22. ↑ 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. 
  23. ↑ 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.
  24. ↑ Sondell A, Littbrand H, Holmberg H, Lindelöf N, Rosendahl E. Is the Effect of a High-Intensity Functional Exercise Program on Functional Balance Influenced by Applicability and Motivation among Older People with Dementia in Nursing Homes?. The journal of nutrition, health & aging. 2019 Dec 1;23(10):1011-20.
  25. ↑ Ko MH. Exercise for Dementia. Brain & Neurorehabilitation 2015. 8; 1: 24-8. Accessed 27 November 2018.
  26. ↑ 26.0 26.1 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.
  27. ↑ 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.
  28. ↑ Öhlin J, Ahlgren A, Folkesson R, Gustafson Y, Littbrand H, Olofsson B, Toots A. The association between cognition and gait in a representative sample of very old people–the influence of dementia and walking aid use. BMC geriatrics. 2020 Dec 1;20(1):34.
  29. ↑ Makizako H, Tsutsumimoto K, Makino K, Nakakubo S, Liu-Ambrose T, Shimada H. Exercise and Horticultural Programs for Older Adults with Depressive Symptoms and Memory Problems: A Randomized Controlled Trial. Journal of Clinical Medicine. 2020 Jan;9(1):99.
  30. ↑ Rojasavastera R, Bovonsunthonchai S, Hiengkaew V, Senanarong V. Action observation combined with gait training to improve gait and cognition in elderly with mild cognitive impairment A randomized controlled trial. Dementia & Neuropsychologia. 2020 Jun;14(2):118-27.
  31. ↑ 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.
  32. ↑ 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.
  33. ↑ Pérez-Ros P, Martínez-Arnau FM. EQ-5D-3L for Assessing Quality of Life in Older Nursing Home Residents with Cognitive Impairment. Life. 2020 Jul;10(7):100.
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