Dementia

Definition

Dementia describes a complete decline in memory and other cognitive impairments that are severe enough to reduce the ability to carry out daily activities. Notably, cognitive function deteriorates slowly and steadily. Patients with schizophrenia have psychological problems behavior and functional activities of daily living. In addition, affected patients lack memory and insight into their problems.[1]

[2]

Pathophysiology

Bipolar disorder is poorly understood. Most forms of psychosis are caused by the accumulation of proteins in the brain with the exception of vascular dementia.

• Alzheimer’s disease is characterized by widespread atrophy of the cerebral cortex, amyloid plaque deposits and tangles of hyperphosphorylated tau protein in neurons, leading to neuronal degeneration. A genetic basis has been established for both early-onset and late-onset AD. certain factors such as Depression, traumatic head injury, cardiovascular disease, family history of dementia, smoking, and the presence of the APOE e4 allele have been shown to increase the risk of AD.
• Dementia with Lewy bodies is characterized by the intracellular accumulation of Lewy bodies (insoluble aggregates of alpha-synuclein) in neurons located primarily in the cortex.
• Frontotemporal dementia is characterized by ubiquitinated TDP-43 and hyperphosphorylated tau deposits in the frontal and temporal lobes, leading to early dementia personality and behavioral changes and aphasia.
• Vascular dementia results from ischemic injury to the brain (e.g. stroke) resulting in permanent neuronal death.[1]

But the hippocampus is often involved and contributes to the well-known symptoms of memory loss. Cells in this region are often the first to be damaged in Alzheimer’s Disease[3] leading to the most common symptoms of memory loss. Changes in hippocampal volume (decrease) are often observed processes of aging but increased in Alzheimer’s disease[4]

Epidemiology

Mental illness affects approximately 47 million people worldwide and is expected to increase to 75 million by 2030 and 132 million by 2050[5]. Dementia is usually age-related but early-onset dementia also occurs. A study by the Alzheimer’s disease association found that 1 in 1400 individuals aged 40-65 1 in 100 individuals aged 65-70 1 in 25 individuals aged 70-80 and 1 in 6 people aged 80+ suffer from dementia.

Etiology

Epidemiology, young-onset dementia

Damage to brain cells causes changes in cognitive behavior and cognitive functions leading to dementia. The causes of depression vary. The most common forms of mental illness are:

• Alzheimer’s Disease: the most common form[6][5] It is responsible for 60-70% of dementia[5].
• Vascular Dementia: the second most common (after cerebrovascular accidents).[6]
• Lewy Body Dementia
• Fronto-Temporal Lobar Degeneration Consciousness

[7]

• Huntington’s Disease
• Alcohol-related dementia (Korsakoff syndrome) .

[8]

• Creutzfeldt-Jacob Disease

[9]

Risk Factors

Risk factors for dementia can be divided into modifiable and non-modifiable risk factors. Modifiable risk factors include inactivity tobacco tobacco use of unhealthy foods and harmful alcohol consumption. Additionally some medical conditions are associated with an increased risk of dementia including diabetes mellitus diabetes hypercholesterolemia obesity and depression. Other potentially variable risk factors may include social isolation and cognitive inactivity.[10][11][12] Non-modifiable risk factors for schizophrenia include age and genetics. Age is the main risk factor for dementia[5]. although it is not a consequence of aging while genetics can also increase the risk. [13] .

See Dementia: Risk Factors

Clinical Presentation

Early symptoms of depression are often subtle, sometimes mimicking other aging processes[6]. It may include[14][15]:

• Slow and common memory loss (mostly temporary) .
• Confusion
• Personality changes
• Apathy and withdrawal
• Loss of functional ability to perform activities of daily living
• Agitation Aggressive Distress and Psychosis
• Depression and Anxiety
• Sleep problems
• Parkinson’s
• Pain
• Falls
• Diabetes
• Urinary Incontinence
• Sensory impairment[16]

While some cases of dementia are reversible (such as hormone or vitamin deficiencies), most are progressive, with a slow gradual onset. Certain symptoms, primarily behavioral and psychological, may result from drug interactions, environmental factors, unreported pain, and other disorders [15].

Diagnostic Procedures

A general practitioner is usually the first point of call for a diagnosis of dementia [6]. Making a diagnosis can be challenging. The NICE dementia guidelines recommend the following diagnostic process.

• Take a medical history including cognitive behavioral and psychological symptoms and their impact on daily life. Ideally, a medical history should also be obtained from individuals with symptoms of dementia
• Physical examination with blood and urine tests to rule out reversible causes of cognitive decline
• Take cognitive tests using short, validated cognitive tools such as the 10-Point Cognitive Screening (10-CS) 6-Item Cognitive Impairment Test (6CIT) 6-Item Screening Memory Impairment Screen (MIS) Mini-Cog Test your memory (TYM).

Diagnosis of dementia subtypes is critical for clinical management and prediction of disease course [6]. Certain types of dementia are diagnosed by history, physical examination, blood tests, and characteristic changes in thinking, behavior, and effects on activity performance daily life. Dementia subtypes can be difficult to diagnose because of the overlapping of many symptoms and brain changes. Secondary care services often use imaging [6] or examination of cerebrospinal fluid [16] to assist in the diagnosis of specific subtypes of dementia. a pilot The study developed a research protocol aimed at aiding in the early detection of dementia using the timed-start (TUG) test and the verbal task of naming different animals [17]. Poor vision leads to poorer executive function, which in turn leads to more Inadequate balance control thus demonstrates the importance of assessing executive functions in addition to vision and balance in older adults with Alzheimer’s dementia [18].

Differential Diagnosis

Dementia can have different causes and the following need to be treated first and/or ruled out:

• Vitamin B12 Deficiency[6]
• Hormone deficiencies (such as thyroid problems) [6]
• Depression[6]
• Medication side-effects
• Alcohol Abuse
• Overmedication
• Infections
• Brain Tumours

Management

Medical management should be sought once symptoms begin, as some causes are treatable, and early diagnosis and management can minimize disease progression to maximize benefit from available treatments. A study reveals the need to optimize assessment for better communication Treatment of dementia patients with multiple impairments among healthcare professionals [19].

Drugs approved by the FDA to improve cognitive function include cholinesterase inhibitors and memantine. Cholinesterase inhibitors prevent the breakdown of acetylcholine and may slow or delay the worsening of symptoms. Memantine is an NMDA agonist that reduces the activity of glutamine. donepezil Galantamine and rivastigmine, which are approved for all stages of Alzheimer’s disease, are used in mild to moderate stages, and memantine is used in moderate to severe stages.

Behavioral symptoms include restlessness, anxiety, and depression. Antidepressants such as SSRI antipsychotics and anxiolytics can help relieve these symptoms. In addition, nonpharmacologic approaches must be employed, such as supportive care, memory training, physical exercise programs, mental and social stimulation Symptom control.

Treatment of sleep symptoms must be an important consideration in patients with dementia. Drug options include amitriptyline, lorazepam, zolpidem, temazepam, quetiapam, and others. Non-drug approaches include daily exercise light therapy sleep routine avoidance of caffeine and alcohol pain management Biofeedback and Multivariate Cognitive Behavioral Therapy.

There are many other drugs that are still being studied, such as anti-tau drugs. None of these have shown promising results so far.

Patients and their families should be informed about the disease and its consequences. They should be given all the necessary information to know what to expect and how to respond. Patients and their families should also be encouraged to seek advice from social services and Register with support groups and associations, such as the Alzheimer’s Association. Driving restrictions may have to be implemented [1].

The NICE dementia guidelines discuss in depth the drug management of dementia by subtype.

Non-medical Management

In addition to pharmacological interventions, nonpharmacological interventions are also used to treat the symptoms of dementia.

Non-pharmacological Management

• As an acetylcholinesterase inhibitor, cognitive stimulation therapy [16][20] has been shown to be clinically effective and cost-effective [21]. Cognitive stimulation therapy can be administered to anyone who works with someone with dementia; caregiver nurse or professional Therapist [22].
• Recall therapy for mild to moderate dementia [16][23].
• Cognitive rehabilitation or occupational therapy (focusing on the functional goals of the individual and/or their caregivers) [16].

Lifestyle Modifications

• Regular exercise and an active lifestyle [15]. Very effective in treating depression in dementia.
• Stimulate individualized daily activities [16].

Physiotherapy Management

Physiotherapy is not the modality used to treat the underlying cause of dementia, but exercise can be used to prevent dementia and minimize the effects of dementia, such as reduced mobility and pain. Furthermore, a comprehensive understanding of dementia is essential for managing people with Dementia receiving physical therapy for other conditions. A study [24] showed that a high-intensity functional exercise program had a positive effect on balance in these patients.

A physical therapist can play a role in customizing an exercise program. Studies have shown that exercise can prevent or delay the onset of dementia by slowing down cognitive decline, which has a positive effect [25][26]. This can improve quality of life and slow down expected functional decline and disease course [26]. There is also some evidence that exercise therapy can improve the ability of people with dementia to perform activities of daily living [27]. A cross-sectional study published in February 2020 showed that global cognitive function was associated with Self-rated gait speed in older adults [28]. A randomized controlled trial [29] showed that an exercise and gardening intervention program can lead to favorable outcomes for older adults with depression and memory problems. Another randomized controlled study showed that movement observation (exercise-related Information acquired through visual function) and gait training provided more significant benefits on gait and cognitive performance in older adults with mild cognitive impairment. [30]

Deterrence and Patient Education

A dementia diagnosis can be stressful and stressful for patients and their families. Patient education must be an important part of the clinical management of patients with dementia. Regular clinic visits, medication adherence, healthy eating and exercise, and sleep hygiene. Support groups can help reduce issues such as anxiety, frustration, anger, loneliness, and depression. Patients should be informed of the diagnosis and prognosis. Developing an individualized care plan empowers patients.

See the Physiology Guidelines for Caregivers here and here for more information on supporting caregivers of people with dementia.

Prognosis

The prognosis for dementia is poor. Dementia is usually a progressive disease with no cure or treatment. The 1-year mortality rate is 30-40% and the 5-year mortality rate is 60-65%. Men are at higher risk than women. Hospital admissions with dementia have a higher mortality rate than patients with dementia Cardiovascular disease[1]

Outcome Measures

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

Mood

• Cornell Scale for Depression in Dementia
• Geriatric Depression Screening Scale

Quality of Life

• Quality of life in patients with Alzheimer’s disease
• The Dementia Quality of Life Instrument
• DEMQoL
• QUALID

Health-related Quality of Life

• EQ-5D

Activities of Daily Living

• Lawton – PSMS & IADL
• Alzheimer’s Disease Collaborative Study – Activities of Daily Living Scale
• Bristol Activities of Daily Living Scale
• The disability assessment for dementia

Pain

• Abbey Pain Scale
• VAS

Behaviour

• Revised List of Memory and Behavioral Problems
• Neuropsychiatric Inventory
• Neuropsychiatric Scale (Nursing Homes)
• CAMI

Reaction to Behaviour

• Revised List of Memory and Behavioral Problems
• Neuropsychiatric Scale with Caregiver Distress Scale
• Nursing Home Neuropsychiatry Checklist

Carer Mood

• Hamilton Depression Rating Scale
• General Health Questionnaire
• Center for Epidemiological Research – Depression Inventory

Carer Burden

• Zarit Burden Interview
• Sense of competence scale
• Relative Stress Scale

Carer Health-related Quality of Life

• SF-36
• WHOQoL-Bref
• EQ-5D. A cross-sectional study suggested that the EQ-5D-3L may be a useful tool for assessing quality of life in nursing home residents with cognitive impairment [31].

Resource Utilisation

• Client Service Receipt Inventory
• Resource utilization in dementia (RUD) instruments

Staff Carer Morale

• Maslach Burnout Inventory

Resources 

• NICE Guideline for Dementia
• Outcome Measures