Neurology Book

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Dementia Management

Aka: Dementia Management
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  1. See Also
    1. Dementia
  2. Evaluation: Tools
    1. See Dementia for diagnostic criteria
    2. Cognitive Scales
      1. Mini-Mental State Examination
      2. St. Louis University Mental Status (SLUMS)
        1. http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
    3. Behavior and agitation scales
      1. Cohen-Mansfield Agitation Inventory (CMAI)
        1. http://www.dementia-assessment.com.au/symptoms/CMAI_Scale.pdf
    4. Daily Function
      1. Activities of Daily Living Scale (ADL)
      2. Instrumental Activities of Daily Living Scale (IADL)
      3. Functional Activities Questionnaire
    5. Caregiver assessment
      1. Caregiver Burden Scale
    6. Scales used in research
      1. Alzheimer's Disease Assessment Scale (Cognitive)
      2. Behavioral Pathology in Alzheimer's (BEHAVE-AD)
      3. Neuropsychiatric Inventory Questionnaire (NPI-Q)
      4. Clinical Global Impression of Change
  3. Management: Specific concerns in Dementia
    1. Dementia Related Malnutrition
    2. Behavior Problems in Dementia
    3. Agitation in Dementia
    4. Sleep Problems in Dementia
    5. Wandering Behavior in Dementia
  4. Management: Protocol (monitor cholinesterase inhibitors)
    1. Confirm diagnosis of Alzheimer's Disease
      1. See Dementia
      2. See Altered Level of Consciousness
    2. Complete baseline scales
      1. St. Louis University Mental Status (SLUMS)
        1. http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
      2. Mini-Mental State Examination
      3. Activities of Daily Living Scale (ADL)
      4. Instrumental Activities of Daily Living Scale (IADL)
    3. Implement non-pharmacologic measures
      1. Educate patient and family regarding diagnosis
      2. See specific concerns in Dementia above
      3. Regular Exercise improves quality of life
        1. Teri (2003) JAMA 290:2015-22
    4. Start acetylcholinesterase inhibitor (see below)
      1. Titrate medication to most effective dose
      2. Informed consent with patient and family
        1. Set reasonable expectations
        2. Medications offer only modest benefit at best in function
        3. Rate of cognitive decline and outcomes including Nursing Home placement are not affected
    5. Re-evaluate at 6 month intervals
      1. Repeat scales performed at baseline (MMSE, ADL, IADL)
      2. Indicators to continue acetylcholinesterase inhibitor
        1. Patient improved or stable on current agent
      3. Indicators to switch to other agent
        1. Decline in MMSE (>2 points)
        2. Decline in ADL or IADL
      4. Indicators to discontinue cholinesterase inhibitors
        1. Persistent decline in MMSE and ADL or IADL
        2. Intolerable side effects
        3. MMSE <10 with dependency in all ADLs
        4. Severe Dementia with minimal functional capacity (bedridden, non-verbal)
  5. Management: Medications
    1. Acetylcholinesterase Inhibitors
      1. Efficacy
        1. Improve neuropsychiatric scores 7 points
          1. Seven point improvement equals ~1 year of decline
          2. Benefits may persist for 1-2 years
          3. Rogers (1998) Arch Intern Med 158:1021-31
        2. Meta-analysis shows marginal benefit to risk ratio
          1. Where NNT is Number Needed to Treat
          2. NNT for global improvement: 10
          3. NNT for cognitive improvement: 12
          4. NNT for significant side effects to stop med: 16
          5. Lanctot (2003) CMAJ 169:557-64
      2. Agents
        1. Donepezil (Aricept): Preferred agent
          1. Delays Nursing Home placement by 17-21 months
          2. Geldmacher (2003) J Am Geriatr Soc 51:937-44
        2. Galantamine (Reminyl)
        3. Rivastigmine (Exelon)
          1. Adverse effects limit use (new patch may be better tolerated)
        4. Tacrine (Cognex)
          1. Not used now due to hepatotoxicity
    2. N-Methyl-D-Aspartate (NMDA) Receptor Blocker
      1. Memantine (Namenda, Ebixa in Europe)
        1. Dose: Start 5 mg PO qd and titrate to 10 mg PO bid
        2. Indicated only in moderate to severe Dementia
          1. Can improve cognition and function
          2. Consider as alternative to cholinesterase inhibitor (e.g. Aricept) if side effects limit use
            1. Memantine may be better tolerated than cholinesterase inhibitors
          3. Previously added on to cholinesterase inhibitor protocol for added benefit
            1. Combination therapy no longer recommended due to low efficacy (only helped 1 in 12)
            2. Combination therapy is associated with gastrointestinal side effects, Bradycardia and Syncope
        3. References
          1. (2012) Presc Lett 19(5):28
          2. Tariot (2004) JAMA 291:317-24
          3. Howard (2012) N Engl J Med 366:893-903
    3. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Treat comorbid depression
      2. Significant impact on quality of life
      3. References
        1. Lyketsos (2003) Arch Gen Psychiatry 60:737-46
    4. Light Alcohol consumption (1-6 drinks per week)
      1. Appears to have protective effect against Dementia
      2. However also has negative cognitive effects
      3. Mukamal (2003) JAMA 289:1405-13
    5. Sleep Disturbance
      1. Trazodone 25 to 150 mg PO qhs
  6. Management: Medications to avoid (due to risk or lack of benefit)
    1. NSAIDs: No benefit in prospective trials
      1. Netherlands Study (n=6989 over age 55, for 8 years)
        1. Continuous NSAID use decreased Alzheimer's risk
        2. Relative Risk Reduction 80% for >2 years of use
        3. Aspirin did not confer same benefit as NSAID use
        4. Veld (2001) N Engl J Med 345:1515-21
      2. Johns Hopkins Retrospective study (n=209)
        1. NSAIDS (n=32) slowed Alzheimer's progression
        2. Based on MMSE, Boston Naming, and Benton scales
        3. Rich (1995) Neurology 45:51-5
      3. Recent evidence does not support routine use
        1. Cummings (2004) N Engl J Med 351:56-67
    2. Vitamin E 400 to 1000 IU bid
      1. Initial studies showed slower functional decline
        1. Sano (1997) N Engl J Med 336:1216-22
      2. Insufficient evidence to recommend by Cochrane
        1. Tabet (2003) Cochrane Database Syst Rev, CD002854
    3. Selegiline (Eldepryl) 10 mg PO qd
      1. Meta-analysis with not enough evidence to support
        1. Birks (2003) Cochrane Database Syst Rev, CD002854
    4. Hormone Replacement Therapy
      1. Testosterone Replacement
      2. ` Risk of adverse effects and no significanr benefit demonstrated to date
        1. Lu (2006) Arch Neurol 63(2): 177-85
      3. Estrogen Replacement
        1. Initial studies showed possible benefit
        2. Recent studies have shown no benefit or worsening
        3. References
          1. Buckwalter (2004) J Am Geriatr Soc 52:182-6
          2. Espeland (2004) JAMA 291:2959-68
    5. Ginkgo Biloba 40 mg PO tid
      1. No significant longterm benefit despite initial studies suggesting possible mild improvement
      2. Case reports of coma, bleeding, and Seizures
      3. High drop out rate in studies
      4. References
        1. Le Bars (1997) JAMA 278: 1327-32
        2. Oken (1998) Arch Neurol 55:1409-15
    6. Coconut oil (Axona)
      1. In theory, brain has altered Glucose Metabolism, and Triglycerides offer alternative nutritional source
      2. No significant evidence to support this use
      3. Risk of increased fat (and calorie intake) - 12 grams of fat per tablespoon
      4. Radenahmad (2011) Br J Nutr 105(5):738-46
    7. Bacopa monnieri (Brahmi)
      1. No significant evidence to support use
      2. Herbal
  7. References
    1. Cummings (2002) Am Fam Physician 65(12):2525-34
    2. Cummings (2004) N Engl J Med 351:56-67
    3. Delagarza (2003) Am Fam Physician 68(7):1365-72
    4. Delagarza (1998) Am Fam Physician 58(5):1175-82
    5. Sloane (1998) Am Fam Physician 58(7):1577-86
    6. Tariot (1997) Postgrad Med 101(6):73-90
    7. Winslow (2011) Am Fam Physician 83(12): 1403-12

Dementia (C0497327)

Definition (MEDLINEPLUS)

Dementia is a word for a group of symptoms caused by disorders that affect the brain. It is not a specific disease. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there.

Memory loss is a common symptom of dementia. However, memory loss by itself does not mean you have dementia. People with dementia have serious problems with two or more brain functions, such as memory and language.

Many different diseases can cause dementia, including Alzheimer's disease and stroke. Drugs are available to treat some of these diseases. While these drugs cannot cure dementia or repair brain damage, they may improve symptoms or slow down the disease.

NIH: National Institute of Neurological Disorders and Stroke
Definition (MSH) An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D003704
ICD9 294.2, 290
ICD10 F03
SnomedCT 268675002, 52448006, 88339003, 192180006
DSM4 294.8
English Dementing neurological disease or syndrome, Dementia, neurological, Dementia, AMENTIA, Amentia, DEMENTIA, Dementia NOS, Dementia, NOS, Presenile dementia, NOS, Unspecified dementia, [X]Unspecified dementia, dementia (diagnosis), dementia, Amentias, [X]Unspecified dementia (disorder), Dementia [Disease/Finding], dementia disorder, dementia disorders, dementias, Dementia, unspecified, Dementia (disorder), amentia, [X]Primary degenerative dementia NOS, [X]Senile dementia NOS, [X]Senile psychosis NOS, [X] Primary degenerative dementia NOS, [X] Senile dementia NOS, [X] Senile dementia, depressed or paranoid type, [X] Senile psychosis NOS, [X] Unspecified dementia, Dementias
French DEMENCE, Démence SAI, Amentie, Démence
Portuguese DEMENCIA, Demência NE, Amência, Demência
Spanish DEMENCIA, Amencia, Demencia NEOM, [X]Primary degenerative dementia NOS, [X]Unspecified dementia, [X] Unspecified dementia, [X] Primary degenerative dementia NOS, [X]demencia no especificada, [X]demencia no especificada (trastorno), demencia (trastorno), demencia, Demencia
German DEMENZ, Amentia, Demenz NNB, Nicht naeher bezeichnete Demenz, Demenz
Dutch amentie, dementie NAO, Niet gespecificeerde dementie, dementie, Dementia, Dementie
Italian Demenza NAS, Amenzia, Amenza, Demenza
Japanese 認知症ＮＯＳ, アメンチア, ｱﾒﾝﾁｱ, ﾆﾝﾁｼｮｳNOS, ﾆﾝﾁｼｮｳ, 痴呆状態, 癡呆, 痴呆, 認知症
Swedish Demens
Czech demence, Amence, Demence NOS, Demence
Finnish Dementia
Russian DEMENTSIIA, DEMENTSIIA SENIL'NAIA PARANOIDNAIA, PARANOIDNAIA SENIL'NAIA DEMENTSIIA, SLABOUMIE, ДЕМЕНЦИЯ, ДЕМЕНЦИЯ СЕНИЛЬНАЯ ПАРАНОИДНАЯ, ПАРАНОИДНАЯ СЕНИЛЬНАЯ ДЕМЕНЦИЯ, СЛАБОУМИЕ
Korean 상세불명의 치매
Croatian DEMENCIJA
Polish Demencja, Otępienie, Otępienie przedstarcze, Otępienie starcze
Hungarian Dementia, Amentia, Dementia k.m.n.
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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