“Dementia” is a syndrome of cognitive deficits caused by a variety of underlying neuropathologies. The most common cause of dementia is Alzheimer’s disease, but other causes include Lewy body disease and vascular disease. The prevalence of dementia in adults age 71 and older has been estimated to be 14%, with rates increasing to 24% for individuals age 80-89 and 37% for those individuals age 90 and older (Plassman et al., 2007). The two most prominent diagnostic guidelines are those put forth by the National Institute on Aging / Alzheimer’s Association (McKhann et al., 2011) and the DSM-5 (American Psychiatric Association, 2013). The DSM-5 had adopted the term “Neurocognitive Disorder” to replace “dementia,” although it is noted that the term can continue to be used. One reason for this change is to reflect how this disorder can occur in adults of any age, whereas “dementia” is typically associated with older adults. Traumatic brain injuries, for instance, are one of the causes of neurocognitive disorders and occur in adults of all ages. The DSM-5 also designates neurocognitive disorders as mild or major, to incorporate the reality that this disorder occurs on a spectrum from mild deficits (also known as Mild Cognitive Impairment [MCI]) to major disorders at severe levels.
Both the McKhann et al. (2011) and DSM-5 criteria emphasize the important of neuropsychological assessment in the diagnosis of dementia. Alzheimer’s disease (AD), the most common cause of dementia, most often causes deficits in memory, which manifests most clearly as impaired recall of information after a delay of 10-30 minutes on neuropsychological testing. AD also leads to deficits in word-finding and other components of language, impaired executive functioning, and poor visuospatial skills, but the disease causes variable effects in every patient. If neuropsychological assessment is not feasible, both sets of criteria offer less formal methods of assessing cognitive functioning. Neuropsychological assessment has been found to be highly accurate in the detection of AD found on autopsy, as reviewed in Lezak and colleagues (2012), and Salmon and Bondi (2009).
Researchers are currently striving to find biomarkers of AD. “Biomarkers” include genetic tests, neuroimaging findings, and cerebrospinal fluid measures. Two key measurements under study include markers of brain amyloid-beta (Aβ) protein deposition and markers of downstream neuronal degeneration or injury such as measures of tau. The use of biomarkers in diagnosis is currently limited by limited standardization of biomarkers across sites, a dearth of normative data, and lack of access for many patients (McKhann et al., 2011) and neither set of guidelines advocates for their use in routine clinical diagnosis as of 2013. Eventually the use of these will enable more precise detection of disease processes and detection at earlier timepoints, when treatment may be more effective. Biomarker diagnosis along with neuropsychological assessment will enable diagnostic clarity and also assessment of the cognitive functioning of each patient. The disease has variable effects on each patient, and often patients require assessment of capacity or the ability to manage everyday activities of daily living such as financial management or the ability to make important medical or legal decisions.
Interventions
Neuropsychiatric symptoms (NPS), i.e., behavioral and psychological symptoms, are highly associated with dementia with approximately 80% of individuals with dementia exhibiting at least one neuropsychiatric symptom from the onset of their cognitive symptoms (Lyketsos et al., 2002). Neuropsychiatric symptoms associated with dementia cause a great deal of suffering for individuals with dementia and their family members, contribute to increased health care costs, increased likelihood for nursing home placement and caregiver burden (Beeri, Werner, Davidson, & Noy, 2002). Neuropsychiatric symptoms can include agitation, apathy, depression, aggressiveness, and other challenging behaviors such as wandering, hoarding, and refusal of care.
Pharmacological interventions, typical and atypical antipsychotic medications, are commonly used to treat NPS, but they are not FDA approved for managing challenging behaviors due to dementia (Maher & Theodore, 2012). Studies also suggest they are only modestly effective while having serious adverse effects such as mortality, and effects that may significantly increase risk of injury due to falls, such as sedation, Parkinsonism, and orthostatic hypotension (Maher & Theodore, 2012). Nonpharmacological interventions, including behavior and environment modification, are suggested first line approaches (Turnham, Esq., OBRA 1987 summary) due to these numerous serious adverse risks and emerging research support for their effectiveness in reducing challenging behaviors (Ayalon, Gum, Feliciano, & Arean, 2006). Ayalon et al. (2006), in their review, found that the majority of nonpharmacological interventions were possibly efficacious pending further replication. Interventions in their review included the unmet needs interventions, which requires careful assessment of underlying motivations behind the NPS and designing an intervention that helps meet the need; behavioral interventions address NPS by contingency management such as removing reinforcements of behaviors or reinforcing positive behaviors or behavioral redirection (Heard & Watson, 1999); caregiving interventions include approaches that use education or support for the caregiver, which can include educating caregivers on unmet needs or behavioral approaches (Teri, McCurry, Logsdon, & Gibbons, 2005); and environmental and reduced stress-threshold models, which modifies environmental triggers or factors such as light therapy (Lovell, Ancoli-Israel, & Gevirtz, 1995). There is need for further research that use more rigorous methodology such as randomized controlled trials or more large-scale single case designs. However, the literature, to date, suggests that non-pharmacological interventions, particularly those that are individually-tailored, hold a great deal of promise.
Written by Brian Yochim, PhD and J.W. Terri Huh, PhD, from the VA Palo Alto Health Care System and Stanford University
GENERAL
Allery, A. J., Aranda, M. P, Dilworth-Anderson, P., Guerrero, M., Haan, M. N., Hendrie, H., Hinton, L., Iris, M. A., Jackson, J. S., Jervis, L. L., Lampley-Dallas, V., Manly, J. J., Radebauth, T. S., Robinson, J. W., Tang, P., Valle, R., & White, L. (2004). Alzheimer’s disease and communities of color. In K. E. Whitfield (Ed), Closing the gap: Improving the health of minority elders in the new millennium (pp. 81-86).
Allery, A. J., Aranda, M. P, Dilworth-Anderson, P., Guerrero, M., Haan, M. N., Hendrie, H., Hinton, L., Iris, M. A., Jackson, J. S., Jervis, L. L., Lampley-Dallas, V., Manly, J. J., Radebauth, T. S., Robinson, J. W., Tang, P., Valle, R., & White, L. (2004). Alzheimer’s disease and communities of color. In K. E. Whitfield (Ed), Closing the gap: Improving the health of minority elders in the new millennium (pp. 81-86).
Alzheimer’s Association. (2012) 2012 Alzheimer’s Disease Facts and Figures. Chicago, IL: Alzheimer’s Association. See more at: http://www.usagainstalzheimers.org/activists-learn-more#_ftn4
Alzheimer’s Association. (2012) 2012 Alzheimer’s Disease Facts and Figures. Chicago, IL: Alzheimer’s Association. See more at: http://www.usagainstalzheimers.org/activists-learn-more#_ftn4
Alzheimer’s Prevention Registry recruiting 250,000 volunteers: The Alzheimer’s Prevention Registry (www.endalznow.org), launched in October, 2012 by the Banner Alzheimer’s Institute, is a new online community of people who want to help scientists find treatments to slow, halt, or prevent the memory-robbing disorder.
Alzheimer’s Prevention Registry recruiting 250,000 volunteers: The Alzheimer’s Prevention Registry (www.endalznow.org), launched in October, 2012 by the Banner Alzheimer’s Institute, is a new online community of people who want to help scientists find treatments to slow, halt, or prevent the memory-robbing disorder.
American Psychiatric Association. (2013). DSM 5. American Psychiatric Association.
American Psychiatric Association. (2013). DSM 5. American Psychiatric Association.
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Beeri, M. S., Werner, P., Davidson, M., & Noy, S. (2002). The cost of behavioral and psychological symptoms of dementia (BPSD) in community dwelling Alzheimer’s disease patients. International Journal of Geriatric Psychiatry, 17(5), 403-408. doi: 10.1002/gps.490
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ASSESSMENT OF DEMENTIA
American Psychological Association Task Force to Update the Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline. (2010). Guidelines for the evaluation of dementia and age-related cognitive change. Washington, DC: American Psychological Association. http://www.apa.org/pi/aging/resources/dementia-guidelines.pdf
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MEASURES OF DEMENTIA
Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.
TREATMENT OF DEMENTIA
Ayalon, L., Gum, A. M., Feliciano, L., & Arean, P. A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188. doi: 10.1001/archinte.166.20.2182
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