Dementia

Original Editors - Leana Louw

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

Definition

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, behaviour, and functional activities of everyday life. In addition, affected patients have memory loss and lack of insight into their problems.

Pathophysiology

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 (AD) 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.

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, 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.

Epidemiology

Dementia affects approximately 47 million people worldwide and is projected to increase to 75 million in 2030 and 152·8 (130·8–175·9) million by 2050. Dementia is generally associated with age but early onset dementia also occurs. A study conducted by Alzheimer's society showed that 1 in 1400 individuals aged between 40-65 years, 1 in 100 individuals aged between 65-70 years, 1 in 25 individuals aged between 70-80 years and 1 in 6 individuals aged 80+ suffer from dementia.

Etiology

Epidemiology, young-onset dementia

Damage to brain cells causes changes to cognitive, behavioural and emotional functions, causing dementia. Different types of dementia have different causes. Common types of dementia are:

• Alzheimer's Disease: most common type. It accounts for 60-70% of cases of dementia
• Vascular Dementia: second most common type (following cerebrovascular accident)
• Lewy Body Dementia
• Fronto-Temporal Lobar Degeneration Dementia

• Huntington's Disease
• Alcohol related dementia (Korsakoff's syndrome)

• Creutzfeldt-Jacob Disease

Risk Factors

Dementia risk factors can be categorised into modifiable and non-modifiable risk factors.

Modifiable risk factors include:

• Physical inactivity.
• Tobacco use.
• Unhealthy diets.
• Harmful use of alcohol.
• Social isolation.
• Cognitive inactivity.

Non-modifiable risk factors include:

• Age- is the primary risk factor for dementia
• Genetics.

Certain medical conditions are associated with an increased risk of developing dementia, including hypertension, diabetes, hypercholesterolemia, obesity and depression.

See Dementia: Risk Factors

Clinical Presentation

Early signs of dementia are normally subtle, sometimes mimicking other patterns of ageing.

It can include the following:

• Progressive and frequent memory loss (mostly short-term)
• Confusion
• Personality changes
• Apathy and withdrawal
• Loss of functional abilities to perform activities of daily living
• Agitation, aggression, distress and psychosis
• Depression and Anxiety
• Sleep problems
• Parkinson's
• Pain
• Falls
• Diabetes
• Urinary Incontinence
• Sensory impairment
• Paratonia,it is defined as motor abnormality induced by dementia. It has a devastating impact on the patient quality of life.

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.

Diagnostic Procedures

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

• Taking a history including cognitive, behavioural and psychological symptoms, and their impact on daily life. Ideally, a history should be taken from the individual with dementia symptoms
• 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. 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 or examining cerebrospinal fluid. 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. 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.

Differential Diagnosis

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

• Vitamin B12 Deficiency
• Hormone Deficiencies (e.g. thyroid problems)
• Depression
• Medication side-effects
• Alcohol Abuse
• Overmedication
• Infections
• Brain Tumours

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 the 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.

FDA-approved medications to improve cognitive functions include cholinesterase inhibitors and memantine. Cholinesterase inhibitors prevent the breakdown of acetylcholine and can slow or delay the worsening of symptoms. Memantine is an NMDA agonist and decreases the activity of glutamine. Donepezil is approved for all stages of Alzheimer's disease, galantamine, and rivastigmine for mild to moderate stage and memantine for moderate to severe stage.

Behavior symptoms include irritability, anxiety, and depression. Antidepressants like SSRI, antipsychotics, and anxiolytics can help with these symptoms. In addition, non-drug approaches like supportive care, memory training, physical exercise programs, mental and social stimulation must be employed in symptom control.

Treatment of sleep symptoms must be an important consideration in patients with dementia. Medication options include amitriptyline, lorazepam, zolpidem, temazepam, quetiapine, etc., Non-drug approaches include daily exercise, light therapy, sleep routine, avoiding caffeine and alcohol, pain control, biofeedback, and multicomponent cognitive behavioural therapy.

There are many other drugs that are still under investigation, such as anti-tau protein agents. So far, these have not shown promising results.

Patients and their families should be counselled about the disease and its consequences. They should be provided with all the necessary information in regards to what to expect and how to react to it. Patients and their families should also be encouraged to seek social service consultations and to register with support groups and societies such as the Alzheimer's society. Driving restrictions may have to be imposed.

The NICE Guideline for Dementia discusses pharmacological management of dementia according to subtype in depth.

Non-medical Management

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

Non-pharmacological Management

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

Lifestyle Modifications

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

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, well-rounded knowledge of dementia is important in the management of patients with dementia presenting to physiotherapy for other conditions. A study suggests that a high-intensity functional exercise program has positive outcomes on balance in these 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. This can lead to improved quality of life and slowing down of functional decline expected with the disease process. There is also some evidence that exercise therapy can improve the ability of people with dementia in performing activities of daily living. 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. A randomized controlled trial 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.

Occupational Therapy

Occupational therapy can be a valuable source of assistance for patients with dementia and their family. An occupational therapist (OT) works with clients to increase their level of independence in their daily tasks.

Occupational therapy interventions may include:

• ADL training or activity modification to improve or maintain ADL performance.
• Errorless learning and prompting strategies to improve ADL performance.
• Ambient music and multisensory interventions to improve short-term behavior.
• Exercise-based interventions to improve or maintain ADL performance, including functional mobility and sleep.Monitoring devices to prevent falls in the home.
• Communication skills training to promote caregiver quality of life and well-being.
• Multicomponent psychoeducational interventions (education, skill training, and coping strategies) to improve caregiver well-being and moderate evidence to delay nursing home placement.

Deterrence and Patient Education

The diagnosis of dementia can be stressful and overwhelming for the patients and their families. Patient education must be an important part of the clinical management of patients with dementia. Counselling must be given about regular clinic visits, medication compliance, a healthy diet, exercise, and sleep hygiene. Support groups can help with the reduction of issues like anxiety, frustration, anger, loneliness, and depression. The patient should be counselled about the diagnosis and the prognosis. Creating an individualized care plan can empower the patient.

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

Prognosis

The prognosis with dementia is poor. Dementia is often a progressive condition with no cure or treatment. 1-year mortality rate was 30-40% while the 5-year mortality rate was 60-65%. Men had a higher risk than women. Mortality rates among admitted patients with dementia was higher than those with cardiovascular diseases.

Outcome Measures

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

Mood

• Cornell Scale for Depression in Dementia
• Geriatric Depression Scale

Quality of Life

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

Health-related Quality of Life

• EQ-5D

Activities of Daily Living

• Lawton – PSMS & IADL
• Alzheimer’s Disease Cooperative Study – Activities of Daily Living Inventory
• Bristol Activities of Daily Living Scale
• The disability assessment for dementia

Pain

• Abbey Pain Scale
• VAS

Behaviour

• Revised Memory and behaviour problems checklist
• Neuropsychiatric Inventory
• Neuropsychiatric Inventory (Nursing Home)
• CAMI

Reaction to Behaviour

• Revised Memory and behaviour problems checklist
• Neuropsychiatric Inventory with Caregiver Distress Scale
• Neuropsychiatric Inventory in Nursing Homes

Carer Mood

• Hamilton Depression Rating Scale
• General Health Questionnaire
• Centre for Epidemiological Studies – Depression Scale

Carer Burden

• Zarit Burden Interview
• Sense of competence scale
• Relative Stress Scale

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.

Resource Utilisation

• Client Service Receipt Inventory
• The Resource Utilization in Dementia (RUD) Instrument

Staff Carer Morale

• Maslach Burnout Inventory

Resources 

• NICE Guideline for Dementia
• Outcome Measures