Dementia

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

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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