Management of Dementia

Dementia treatment
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All or almost all forms of dementia are treatable, in that medication and supportive measures are available to help with management of the demented patient. However, most types of dementia remain incurable or irreversible and only modest benefits from treatment are realized. Some disorders which may be successfully treated with return to a normal or pre-morbid state might include:.

Dementias that are largely irreversible, but may still be at least partially responsive to medications currently available for memory loss or modification of behavior include:. Depression can co-exist with mild cognitive impairment MCI a condition which is being increasingly recognized as an important entity.

Coping with dementia

Mild cognitive impairment MCI is a controversial entity but remains a useful construct in terms of targeting interventions to prevent dementia. However SMC is heterogeneous in its etiology and poorly predicts medium-term dementia risk. The differentiation of early dementia from MCI depends on the level of cognitive impairment and the resultant disability. Cognitive impairment in dementia causes significant impairment in instrumental activities of daily living and this is known to increase with time.

Most diagnostic criteria use the resultant disability as an important differentiating feature. However reliance on informant reports can be problematic as that could be influenced by the social context, expectations of the informant and his or her ability to know and the current level of functioning of the older person. Dementia is a syndrome due to disease of the brain, usually chronic, characterized by a progressive, global deterioration in intellect including memory, learning, orientation, language, comprehension and judgment.

It mainly affects older people, after the age of 65 years. Then onwards, the prevalence doubles with every five year increment in age. Dementia is one of the major causes of disability in late-life. People with dementia have difficulty in living independently and have difficulties in social and occupational functioning. The disabilities progress with the severity of dementia. Cognitive changes that are part of normal aging process has to be differentiated from the dementia syndrome.

This is difficult in early stages of dementia. Age related changes are more frequent in those who are in their eighties and nineties. Propensity to develop transient cognitive problems like delirium increases with age and in the presence of cognitive impairment. Cognitive symptoms can be due to many conditions and dementia is only one of them. Delineation of the syndrome of dementia and differentiating it from other cognitive disorders is the first task. Other assessments can then follow. The suggested assessments are best carried out as part of the initial evaluation though it might take a few sessions to complete.

The following assessments will help in making a clinical diagnosis of dementia: See the flow chart below. History taking is the main tool in eliciting and evaluating the nature and progression of cognitive decline. Choose an informant who knows about the person's current and past personal, social and occupational functioning. A reliable informant should be interviewed separately in person.

This will allow discussion of a certain information which may otherwise be difficult in the presence of the patient. While doing the assessments, one has to be mindful of the family's culture, values, primary language, literacy level and also the decision making process.

A thorough history should include details like the mode of onset of cognitive decline which affects multiple cognitive domains. The pattern progression, clinical manifestations of cognitive dysfunction, behavioral as well as personality changes will have to be enquired into. Subjects or informants can be asked if the person is forgetful about recent events; especially amnesia for events which happened hours or days back. Does the person tend to ask the same questions repeatedly even though this was answered many times.

A review of current medication is very important. Enquire if there is worsening of cognitive symptoms after initiation of a certain new medication. Details regarding the use of all medications, including over-the-counter products, may be collected. See if the person is on medications with anti-cholinergic effects which can worsen cognitive functions.

Delirium is an important differential diagnosis of dementia. Patients with pre-existing dementia could present for the first time with superimposed delirium. Sudden worsening of cognitive functions and appearance of behavioural symptoms should alert the clinician to the possibility of delirium. Delirium is a medical emergency signs that needs to be identified early and evaluated immediately.

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A diagnosis of dementia cannot be made if the cognitive deficits occur exclusively during the course of delirium. Delirium is characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence from the history, examination or investigations that the delirium is a direct consequence of a general medical condition, substance intoxication or withdrawal.

Clinician should take care, not to misdiagnose Delirium as Dementia and also not to miss the diagnosis of Delirium when it is superimposed on dementia. When there is clinical suspicion of delirium, the efforts should focus on identifying the causes. The evaluations need to be comprehensive so that all common causes can be ruled out. Prolonged delirium could lead to more neuronal damage and accelerate cognitive decline by impacting the cognitive reserve. Delirium and dementia are two major causes for cognitive impairment in later years of life.

Though these two conditions had been conceptualized as distinct, mutually exclusive entities, it can be difficult at times to differentiate between them. Delirium in late life is often superimposed on pre-existing dementia and can be the reason for help seeking.

Dementia is the leading risk factor for delirium in an older person. Occurrence of delirium in turn is a risk factor for subsequent dementia in older people without pre-existing dementia. The clinician needs to differentiate between three possible scenarios namely Delirium with no features suggestive of pre-existing dementia dementia with no features suggestive of delirium dementia with superimposed delirium.

See table-2 for broad guidelines for making this distinction, which by no means, will be easy in a given clinical setting. When faced with uncertainty, it is better to attribute the symptoms to delirium and manage it as delirium. Presence of BPSD, especially delusions with or without hallucinations in mild to moderate dementia can resemble schizophrenia or other psychotic conditions in late life.

The key differentiating features here are history of progressive cognitive decline which has onset prior to the development of psychotic symptoms the presence of clinically significant impairment in multiple cognitive domains on clinical evaluation. This distinction is rather easy when there is long duration of illness starting from adulthood. But it could be difficult when psychotic symptoms have onset after the age of 60 years and also in situations where it is difficult to test cognitive functions due to active psychotic symptoms. One could also come across individuals who after many years of illness with onset during adulthood, either schizophrenia or bipolar disorder, present with cognitive decline and clinical features suggestive of dementia.

In such situations an additional diagnosis of dementia can be made apart from the diagnosis of the pre existing mental health condition. See table-3 for some clinical tips. The differentiation between early dementia and mild cognitive impairment can be difficult at times but efforts to make that distinction is always warranted. ICD 10 does not have specific criteria. There is also the controversy about the best way to objectively measure memory loss.

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Early recognition of the condition may help the clinician to monitor the progression of cognitive and other symptoms and the later conversion to dementia. This might allow potential use of evidence based preventive interventions as and when they become available. The recognition of MCI as a diagnostic allows us to have a better understanding of the nature of mild memory loss, which is far more common than dementia among the older segments of the population. Table-4 lists out the main differences between the two clinical conditions. We need to rule out delirium and mild cognitive disorder before we make a clnical diagnosis of dementia.

Then one should apply and see if the person meets the diagnostic criteria for Dementia. If that is met, then there is a need to make further evaluations. The next part of evaluation is aimed at establishing the cause for the dementia syndrome. Dementia is a syndrome which can be caused by many diseases. After the clinical recognition of dementia syndrome, the evaluations shall focus on identifying the cause of dementia.

Thus the evaluation for all potentially reversible conditions which cause dementia syndrome is the first most important step in the assessment of dementia syndrome and this is essential in all cases presenting with features of dmentia. The type of investigations can be decided based on the clinical features and context of care. Patients who seek help in clinical settings often do not represent cases prevalent in the community. Reversible causes thus may be much more common in clinical settings than in community settings. CT scan or MRI scan, at times, can be a very useful investigation in the differential diagnosis of dementia.

Clinical Practice Guidelines for Management of Dementia

A reliable, detailed history will guide us in identifying the causes of dementia. We have to rule out common reversible causes and the eminently reversible causes first. See table-5 for the list. Investigations to rule out less common causes may be needed when the clinical features indicate a high index of suspicion of reversible dementia. Dementia syndrome is linked to many underlying causes and diseases of the brain.

The most common causes accounting for vast majority of cases are due to Alzheimer's disease, Vascular dementia, Dementia with Lewy Bodies and Fronto-temporal dementia. STEP 3 Evaluation after recognition of the syndrome of dementia look for medical problems. Cognitive assessment can be made as part of detailed examination of higher functions. Addenbrooke's Cognitive Examination ACE is a more detailed test battery for assessing cognitive functions. Assessment of the activities of daily living is very important.

This information is essential in formulating the individualized plan of intervention.

Use of simple instruments like the Clinical Dementia Rating Scale can help in assessing the severity of dementia in routine clinical practice. Assessment of non-cognitive symptoms like Behavioural and Psychological Symptoms of Dementia BPSD is yet another important part of clinical assessment. ICD- 10 clinical criteria may be used for diagnosis of Dementia and subtyping. Alterantively one could use the DSM-5 criteria too. You may use the consensus clinical diagnostic criteria. After detailed assessment usually, the clinician would be in a position to judge the cause of the dementing illness.

Clinical recognition of the subtypes of dementia is important and is easier during the early part of the illness. Such differentiation is feasible in clinical practice by using clinical criteria for these subtypes. The clinicians might choose any standard criteria for making clinical diagnosis of dementia, especially common sub-types.

Guidelines for the Management of Cognitive and Behavioral Problems in Dementia

See Table 6 for the criteria which may be useful in clinical practice. The impairment applies to both verbal and non-verbal material. The decline should be objectively verified by obtaining a reliable history from an informant, supplemented, if possible, by neuropsychological tests or quantified cognitive assessments. The severity of the decline, with mild impairment as the threshold for diagnosis, should be assessed as follows:. The main function affected is the learning of new material.

For example, the individual has difficulty in registering, storing and recalling elements in daily living, such as where belongings have been put, social arrangements, or information recently imparted by family members. A degree of memory loss which represents a serious handicap to independent living. Only highly learned or very familiar material is retained. New information is retained only occasionally and very briefly.

The individual is unable to recall basic information about where he lives, what he has recently been doing, or the names of familiar persons. Only fragments of previously learned information remain.

Guidelines for the Management of Cognitive and Behavioral Problems in Dementia

The subject fails to recognize even close relatives. Evidence for this should be obtained when possible from interviewing an informant, supplemented, if possible, by neuropsychological tests or quantified objective assessments. Deterioration from a previously higher level of performance should be established. The decline in cognitive abilities causes impaired performance in daily living, but not to a degree making the individual dependent on others.

More complicated daily tasks or recreational activities cannot be undertaken.

The Role of the Family Physician in Treating Dementia

The decline in cognitive abilities makes the individual unable to function without the assistance of another in daily living, including shopping and handling money. Within the home, only simple chores are preserved. Activities are increasingly restricted and poorly sustained. The decline is characterized by an absence, or virtual absence, of intelligible ideation.

The overall severity of the dementia is best expressed as the level of decline in memory or other cognitiveabilities, whichever is the more severe e. Preserved awarenenss of the environment i. When there are superimposed episodes of delirium the diagnosis of dementia should be deferred. A decline in emotional control or motivation, or a change in social behaviour, manifest as at least one of the following:. For a confident clinical diagnosis, G1 should have been present for at least six months; if the period since the manifest onset is shorter, the diagnosis can only be tentative.

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Dementia — Comprehensive overview covers symptoms, causes and Most types of dementia can't be cured, but there are ways to manage. Before we examine the management of dementia, let us look at the issues related to the clinical diagnosis of dementia. Mental health problems and disablement.

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