Introduction
There is a huge treatment gap in dementia especially in
countries like India [1]. Early diagnosis will help both the
patient and caregivers to mobilize resources. Diagnosis should
be made after proper assessment and evaluation for
treatable causes. The care provided shall be evidence
informed. Support shall include support for the person with
dementia, family memebers or other caregivers. We should offer
long term care and support. Periodic follow up visits are
important in dementia care. Do review at least once in 2-3
months. Encourage caregivers to report earlier if they need to
discuss management issues with the clinician. It is important
that we offer support and care during crisis/difficult times.
Management shall include caregiver education and guidance to
manage difficult symptoms. Caregivers may need emotional
support and guidance to manage their own health and social
affairs. Caring for carers is important. Clinicians shall
be mindful of caregiver needs and try to initiate
caregiver support.
Identification of Cases
Dementia is a syndrome where memory impairment, behavioral
symptoms and impairement in activities of daily living
are common symptoms. Dementia mainly affects older
people, usually after the age of 65 years.The prevalence
doubles with every five year increment in age. People with
dementia may have difficulty in living independently which
affects social and occupational functioning. The disabilities
progress with the severity of dementia.
When a person has the following clinical features, we need to
consider dementia:
1. History of cognitive decline over a period of
months (There is a remarkable change in cognitive function
over this period).
2. The current level of cognitive functioning is
significantly different from his or her previous level of
functioning and also significantly different from the level
of cognitive functioning of people of the same
age.
3. This change has led to impairment in activities of daily
living especially instrumental activities of daily living.
These 3 features namely definite cognitive decline;
cognitive functions not normal for age and presence of
disability indicate that the person has the syndrome of
dementia.
Dementia and delirium
Before confirming the clinical diagnosis of dementia, we need
to rule out "delirium" which is another major cognitive
disorder. Delirium unlike dementia is acute in onset and
characterized by clouding of sensorium and disturbance in
orientation and memory. Delirium is considered as an important
differential diagnosis of dementia. Patients with pre-existing
dementia may present for the first time to clinical
settings with superimposed delirium. Dementia is a leading
risk factor for delirium in elderly [2]. Delirium is a medical
emergency and early intervention is needed. The
sensorium fluctuate during the course of the day. We
should not misdiagnose Delirium as Dementia and should not
miss the diagnosis of Delirium when it is superimposed on
dementia. When there is clinical suspicion of delirium, we
should identify the causes. Delirium in old people are
usually multifactorial in etiology and evaluation of the
underlying conditions would help to manage them.
Prolonged delirium could lead to neuronal damage which can
accelerate cognitive decline .
Dementia and mild cognitive impairment
The differentiation between early dementia and mild cognitive
impairment may be difficult at times but efforts to make that
distinction is always needed [3]. Significant impairment in
functional ability is required for the diagnosis of dementia
which will not be there in people with mild cognitive
impairment. The recognition of MCI allows us to have a better
understanding of the nature of mild memory loss, which is more
common than dementia among the older population. Not all MCI s
progress on to dementia [4].
Reversible causes
Some causes of dementia are reversible. Though reversible
causes are rare, its very important that we rule out these
causes in the initial assessment itself [4]. Complete blood
count, serum/blood levels of urea, electrolytes, calcium and
phosphate, renal, liver and, thyroid function tests,
erythrocyte sedimentation rate, urine analysis, VDRL and Serum
B12, and Folate levels will help us to rule out common
reversible causes. MRI or CT scan, can be useful
investigation in ruing out reversible causes of
dementia. Investigations for testing the HIV status, Chest
radiograph, Electroencephalogram, ECG, Neuropsychological
assessment etc can also be considered.
Common reversible causes are:
* Hypothyroidism
* Subdural Hematoma, Resectable Masses, Normal Pressure
Hydrocephalus
* Drug induced (Drugs with Anticholinergic side effects)
* Nutritional Deficiencies
* Central Nervous System Infections
After ruling out reversible causes we need to consider whether
this person is suffering from cerebrovascular disease. This
has to be ruled out by detailed history, examination and
investigations like neuroimaging.
After ruling out reversible causes and vascular dementia, we
can consider neurodegenerative disorders like Alzheimer's
dementia, dementia with Lewy Body and other Frontotemporal
dementias.
Assessment scales
Mini-Mental State Examination (MMSE) is commonly used for
assessing cognitive functions [6]. Addenbrooke's Cognitive
Examination (ACE) is a more detailed test battery for
assessing cognitive functions [7]. Other scales used are
Montreal Cognitive Assessment (MoCA) and Clock Drawing Test
[8,9].
Everyday Activities Scale for India (EASI) can be used to
assess the activities of daily living [10].
Management of dementia
Management will depend on the diagnosis (subtype of dementia).
Management includes both pharmacological and non
pharmacologicalinterventions [11].
Non pharmacological management
Non pharmacological management strategies have an important
role in the management of dementia. There are specific
nonpharmacological interventions for cognitive as well as
non-cognitive symptoms and challenging behaviours seen in
dementia. Non pharmacological interventions for cognitive
symptoms include programmes like cognitive stimulation therapy
and cognitive remediation. Non pharmacological intervention
for non cognitive symptoms should be tailored for each patient
with participation from caregivers. Caregiver interventions
are needed and forms the background for dementia care.
Psychosocial intervention include providing information and
education, promoting activities of daily living and
participation in social activities. The choice of
therapy can be made considering the availability along with
the person's preferences and skills. These interventions may
be delivered by health and social care staff and volunteers
with supervision and proper training. The response to each
form of therapy should be monitored and should be reviewed
from time to time as there can be individual variations in the
response to each of these modalities.
Pharmacological management
Cholinesterase inhibitors (Donepezil, Rivastigmine and
Galantamine) can be used for Dementia due to Alzheimer's
disease. Donepezil and Rivastigmine can be used in Dementia
due to Lewy Body disease and Parkinson's disease. The adverse
effects that are commonly noted to occur with Cholinesterase
inhibitors are primarily related to cholinergic effects
(nausea, vomiting, diarrhea, anorexia, weight loss,
bradycardia and falls). The most common adverse effects with
cholinesterase inhibitors are gastrointestinal side effects.
The cholinergic effects are usually dose related. The
tolerability appears to improve with dose education and slower
titration [12]. Selective serotonin reuptake inhibitors can be
used to control behavioral symptoms of Fronto-temporal
dementia. Mood stabilizers like Divalproex sodium and
Carbamazepine may be useful in the management of agitation.
Low dose atypical antipsychotics (Risperidone, Aripiprazole,
Quetiapine) can be considered for severe agitation, aggression
and psychotic symptoms. However, these drugs can cause serious
side effects and has to be used only for short periods under
supervision of a physician.
Conclusion
Managing dementia is challenging. The treatment plan for each
patient should be individualized. Caregiver support and
non-pharmacological interventions to manage symptoms like BPSD
are important. Relevant information, education and support to
caregivers, is very important in dementia care.
References
1. Dias A, Dewey ME, D'Souza J, Dhume R, Motghare DD, Shaji
KS, et al. (2008) The Effectiveness of a Home Care Program for
Supporting Caregivers of Persons with Dementia in Developing
Countries: A Randomised Controlled Trial from Goa, India. PLoS
ONE 3(6): e2333.
2. Davis DH, Muniz Terrera G, Keage H, et al. Delirium is a
strong risk factor for dementia in the oldest-old: a
population-based cohort study. Brain. 2012;135:2809-2816.
3. Schmidtke K, Hermeneit S. High rate of conversion to
Alzheimer's disease in a cohort of amnestic MCI patients. Int
Psychogeriatr 2008;20(1):96-108.
4. Bruscoli M, Lovestone S. Is MCI really just early dementia?
A systematic review of conversion studies. Int Psychogeriatr
2004;16(2):129-40
5. Tripathi M, Vibha D. Reversible dementias. Indian Journal
of Psychiatry. 2009 Jan;51(Suppl 1):S52-5.
6. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State. A
practical method for grading the cognitive state of patients
for the clinician. J Psychiatr Res 1975;12(3):189-98.
7. Mathuranath PS, Nestor PJ, Berrios GE, Rakowicz W, Hodges
JR. A brief cognitive test battery to differentiate
Alzheimer's disease and frontotemporal dementia. Neurology.
2000.
8. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal
Cognitive Assessment, MoCA: a brief screening tool for mild
cognitive impairment. J Am Geriatr Soc 2005;53(4):695-9.
9. Sunderland T, Hill JL, Mellow AM, et al. Clock drawing in
Alzheimer's disease. A novel measure of dementia severity. J
Am Geriatr Soc 1989;37(8):725-9.
10. Fillenbaum GG, Chandra V, Ganguli M, et al. Development of
an activities of daily living scale to screen for dementia in
an illiterate rural older population in India. Age Ageing.
1999;28:161-8.
11. Hogan DB, Bailey P, Black S, et al. Diagnosis and
treatment of dementia: 5. Nonpharmacologic and pharmacologic
therapy for mild to moderate dementia. CMAJ
2008;179(10):1019-26.
12. Stella F, Radanovic M, Canineu PR, et al. Anti-dementia
medications: current prescriptions in clinical practice and
new agents in progress. Ther Adv Drug Saf 2015;6(4):151-65.