Dementia: Difference between revisions

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== Clinically Relevant anatomy ==
== Clinically Relevant Anatomy ==
'''Hippocampus'''<ref name=":1">Alzheimer's association. What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia (accessed 26/09/2018).</ref>
'''Hippocampus'''
* Centre of memory and learning
* Centre of memory and learning
* Cells in this region are normally first to be damaged, resulting in the most common symptom of memory loss  
* Cells in this region are normally first to be damaged, resulting in the most common symptom of memory loss  
* Changes in hippocampal volume (a reduction) are seen with ageing but are exacerbated in Alzheimers<ref>den Heijer T, van der Lign F, Koudstaal PJ, Hofman A, van der Lugt A, Krestin GP, Niessen WJ, Breteler MMB. [https://academic.oup.com/brain/article/133/4/1163/312623 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.
</ref>
== Epidemiology & Etiology ==
== Epidemiology & Etiology ==


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== 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" /><ref name=":0" />:
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" />:
* Progressive and frequent memory loss (mostly short-term)
* Progressive and frequent memory loss (mostly short-term)
* Confusion
* Confusion
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== Outcome Measures ==
== Outcome Measures ==
The following list is from a  
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
* Mood
** [http://www.primaris.org/sites/default/files/resources/Depression/depression_cornell%20scale%20for%20depression%20final.pdf Cornell Scale for Depression in Dementia]
** [http://www.primaris.org/sites/default/files/resources/Depression/depression_cornell%20scale%20for%20depression%20final.pdf Cornell Scale for Depression in Dementia]
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* Staff carer morale
* Staff carer morale
** Maslach Burnout Inventory
** Maslach Burnout Inventory
<ref>Neurodegeneration Research. Dementia outcme measures: Charting new territory. Report of a JPND Working Group on Longitudinal Cohorts. 2015.http://www.neurodegenerationresearch.eu/wp-content/uploads/2015/10/JPND-Report-Fountain.pdf (accessed 30/09/2018).</ref>
== Medical Management ==
== Medical Management ==
Medical management should be obtained as soon as symptoms start appearing, as some of the causes are treatable, and early diagnosis and management can slow down or treat the disease process to allow most benefit from available treatments<ref name=":1" />.
Medical management should be obtained as soon as symptoms start appearing, as some of the causes are treatable, and early diagnosis and management can slow down or treat the disease process to allow most benefit from available treatments<ref name=":1" />.
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== Physiotherapy Management ==
== Physiotherapy Management ==
Physiotherapy is not a modality used to treat dementia, but a well rounded knowledge about the condition is very important in the management of patients presenting to physiotherapy for other conditions, with the co-morbidity of dementia. Therapeutic management can include cognitive stimulation therapy, that can be administrated by any one working with dementia patients - carers, nurses or occupational therapists<ref>Cognitive Stimulation Therapy. An Introduction to Cognitive Stimulation Therapy.http://www.cstdementia.com/ (accessed 30/09/2018).</ref>.
Physiotherapy is not a modality used to treat dementia, but a well rounded knowledge about the condition is very important in the management of patients presenting to physiotherapy for other conditions, with the co-morbidity of dementia. Therapeutic non-drug treatment may include cognitive stimulation therapy<ref>Km K, Han JW, So Y, Seo J, Kim YJ, Park JH, Lee SB, Lee JJ, Jeong H, Lim TH, Kim KW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5639131/ Cognitive Stimulation as a Therapeutic Modality for Dementia: A Meta-Analysis]. Psychiatry Investig. 2017. 14; 5: 626–639. Accessed 26 November 2018.</ref> which has been shown to be as clinically effective and cost effective as acetylcholinesterase inhibitors<ref>Knapp M, Iemmi V, Romeo R. [http://eprints.lse.ac.uk/45540/1/Knapp_Dementia_care_costs.pdf Dementia care costs and outcomes: a systematic review]. Int J Geriatr Psychiatry 2013;28:551-61. Accessed 26 Novmeber 2018.</ref>. Cognitive stimulation therapy can be administrated by anyone working with dementia patients; carers, nurses or occupational therapists<ref>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. </ref>.


=== Exercise Therapy ===
=== Exercise Therapy ===

Revision as of 03:44, 26 November 2018

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, Ewa Jaraczewska, Carina Therese Magtibay, Aya Alhindi, Kalyani Yajnanarayan and Safiya Naz  

Description/Definition[edit | edit source]

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[edit | edit source]

Hippocampus

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

Epidemiology & Etiology[edit | edit source]

Epidemiology[edit | edit source]

Dementia is more common in the population above 65[3].

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:

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

Clinical Presentation[edit | edit source]

Early signs of dementia are normally subtle, sometimes mimicking other patterns of ageing[1]. It can include[4][3]:

  • Progressive and frequent memory loss (mostly short-term)
  • Confusion
  • Personality change
  • 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[3].

Diagnostic Procedures[edit | edit source]

There are no clear test to diagnose dementia. To make the diagnosis of dementia, at least two of the core mental functions need to be significantly impaired[4]:

  • Memory
  • Communication and language skills
  • Concentration and focus
  • Reasoning and judgment
  • Visual perception

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. Neurologists or geropsychologist normally assist in the diagnosis of the specific types of dementia[4].

Differential Diagnosis[edit | edit source]

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

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

Outcome Measures[edit | edit source]

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

Medical Management[edit | edit source]

Medical management should be obtained as soon as symptoms start appearing, as some of the causes are treatable, and early diagnosis and management can slow down or treat the disease process to allow most benefit from available treatments[4].

Medication [3][edit | edit source]

Antidepressants[edit | edit source]

Effectiveness is normally only seen after 2-3 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 disease)

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

Lifestyle Modifications[edit | edit source]

  • Regular exercise/active lifestyle:
    • Very effective in the management of the depression component of dementia
  • Stimulating daily activities

[3]

Physiotherapy Management[edit | edit source]

Physiotherapy is not a modality used to treat dementia, but a well rounded knowledge about the condition is very important in the management of patients presenting to physiotherapy for other conditions, with the co-morbidity of dementia. Therapeutic non-drug treatment may include cognitive stimulation therapy[5] which has been shown to be as clinically effective and cost effective as acetylcholinesterase inhibitors[6]. Cognitive stimulation therapy can be administrated by anyone working with dementia patients; carers, nurses or occupational therapists[7].

Exercise Therapy[edit | edit source]

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[8][9]. This can lead to improved quality of life and slowing down of functional decline expected with the disease process[9].

Resources [edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Robinson L, Tang E, Taylor J. Clinical review. Dementia: timely diagnosis and early intervention. BMJ. 2015;350:h3029. Accessed 26 November 2018.
  2. ↑ 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.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Dementia Australia. What is dementia? https://www.dementia.org.au/about-dementia/what-is-dementia (accessed 26/09/2018).
  4. ↑ 4.0 4.1 4.2 4.3 Alzheimer's association. What is dementia? https://www.alz.org/alzheimers-dementia/what-is-dementia (accessed 26/09/2018).
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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. 
  8. ↑ Ko MH. Exercise for Dementia. Brain & Neurorehabilitation 2015;8(1):24-8.
  9. ↑ 9.0 9.1 Rolland Y. Exercise and Dementia. Pathy's Principles and Practice of Geriatric Medicine 2012;1:911-21.
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