MANAGEMENT OF DEMENTIA

Presenter: Dr Pavan kumar Chair-Person: Dr Denzil Pinto

Introduction

Dementia - disease process marked by progressive cognitive impairment in clear consciousness. dementia - global impairment of higher cortical functions including memory, the capacity to solve problems of day-to-day living, the performance of learned perceptuo-motor skills, the correct use of social skills, all aspects of language and communication and the control of emotional reaction, in the absence of clouding of conciousness. Dementia results in decreased ability to perform activities of daily living & is usually accompanied by the development of behavioural disturbances.

 An estimated 5 10 % of adult population aged 65 years and older is affected by a dementia disorder. The prevalence doubles (increase exponentially) every 5 years among people in this age group. As of 2010, there are an estimated 35.6million people with dementia worldwide, with incidence of approximately 1% per year . By 2050, it is projected to increase to over 115million. According to the Dementia India report 2010, there are 3.7million Indians with dementia.

Screening for dementia

The U.S. Preventative Service Task Force doesnt recommend for or against screening for dementia in the primary care setting. Testing is warranted if patients or family members report memory problems. Dementia is associated with higher rates of delirium, adverse drug reactions and falls, so that recognizing dementia earlier in the course, might raise awareness and target preventive efforts to try to avoid these potential complications.

large scale community screening (Time-min)

brief assessment tools in the doctor's office (Time-min)

Informant Questionnaire on Cognitive MMSE (8-13), Modified MMSE (10-15) Decline in the Elderly, IQCODE (10-12) Cognitive Abilities Screening Instrument, IQCODEShort Form (<10) CASI(1520) Short Memory Questionnaire, SMQ(5) Short Test of Mental Status, STMS(5)

Dementia Questionnaire, DQ(20)

Minnesota Cognitive Acuity Screen, MCAS(<20)

Cognitive Assessment Screening Test, CAST(15)

General Practitioner Assessment of Cognition, GPCOG(5) 7Minute Screen (7-15) Abbreviated Mental Test, AMT(5) MiniCog(3-4), DemTect (8-10) Time and Change(1)

Addenbrooke's Cognitive Examination Revised, ACE-R(16)

Other Screening tools for cognitive impairment include:

Mini mental state examination - accuracy depends upon age, education, and ethnicity of the individual. Short Portable Mental Status Questionnaire, Hopkins Verbal Learning Test, The AD8 Montreal cognitive assessment Mini cog Brief Alzheimer screening Clock drawing test Screening tests not only useful in screening, but also in differentiating subtypes.

Assessment of dementia

The treatment of Alzheimer's dementia and related dementias is inherently, multidisciplinary and multimodal. It is guided by the stage of illness and is focused on the specific symptoms manifested by the patient. Management of dementia: A) DETERMINING THE SITE OF TREATMENT AND FREQUENCY OF VISITS. B) PSYCHIATRIC MANAGEMENT C) DEVELOPMENT AND IMPLEMENTATION OF STAGE SPECIFIC PLAN D) SUB-TYPE SPECIFIC DEMENTIA TREATMENT

B)Psychiatric Management

1) Establish and maintain therapeutic alliance with the patient and the family 2) Diagnostic evaluation clinical assessment investigation 3) Stages of dementia 4) Pharmacological Treatments General principles ACEIs, Memantine, Ergoloid mesylates and others 5) Treatment of Neuropsychiatric Manifestations 6) Treatment of co-morbidity.

7) Non-pharmacological Management Psychosocial Psychotherapy Behavioral Management Cognitive Retraining Stimulation-oriented Therapies and others 8) Assessing and monitoring psychiatric status 9) Monitor and enhance safety of patients . 10) Advice patient and family concerning activities (driving) harmful to others 11) Provide education and support to the families 12) Advise the family to address financial and legal issues

Frequency of visits Determined by The patients clinical status. The rate of functional decline. The current treatment plan. Need for specific monitoring of treatment effects. Reliability and skills of the patients caregivers. If patients are clinically stable: follow-up once in 3-6months. Patients requiring active treatment of psychiatric complications & requiring dose adjustment and reduction- require frequent assessments.

 IP facility is needed for the treatment of: Psychosis, affective or behavioural symptoms, especially based on symptom severity, intensity & availability of services needed. Treatment of GMCs occurring with psychiatric condition.

Frail patients.

Psychiatric management

Concurrent administration of a broad range of tasks. 1) Establish and maintain an alliance with the patient and the family A good communication between the patients psychiatrist and primary care physician ensures maximum co-ordination of care, may minimize polypharmacy and improve patient outcome. A solid therapeutic alliance is critical to the treatment of a patient with dementia.

2)Diagnostic evaluation Clinical assessement A)A thorough history from both the subject and the reliable informant. Relevant aspects in history: Age and mode of onset, course of progression, pattern of cognitive impairment The degree of functional impairment job performance, disengagement from usual activities and interests, trouble maintaining social relationships and social roles, and difficulty performing instrumental ADL and, later ADL.

Evaluation of Cognitive Impairment (CERAD) Memory Does he or she have difficulty remembering recent conversations? Is he or she frequently repetitive? Is he or she aware of current events? Does he or she misplace or lose things? Does he or she forget to turn off the stove? Language and aphasia Does he or she have difficulty finding the correct word? Is it sometimes difficult for others to understand him or her? Orientation Does he or she know where he or she is? Is he or she oriented to time (date, month, and year)? Does he or she forget upcoming holidays, birthdays, when to attend church, tax day, etc.?

Agnosia Does he or she have difficulty recognizing people or places? Activities of daily living Does he or she have difficulty handling small sums of money? Does he or she have difficulty remembering short lists for shopping? Does he or she need assistance with eating, bathing, transfer in and out of bed, walking, toileting, grooming, or dressing? Apraxia Does he or she have difficulty using familiar objects (e.g., toaster)? Does he or she have difficulty performing simple tasks at home (e.g., making coffee, setting the table, operating the television, vacuum, etc.)?

Problem-solving abilities Does he or she have difficulty relating to newspapers or television? Executive functioning Is he or she still able to manage finances, the checkbook, or taxes? Social, community, and intellectual function Has he or she lost special skills, interests, or hobbies (e.g., reading, sewing, cards, or gardening) for reasons other than physical? Does he or she engage in socially inappropriate behavior? Judgment Does he or she show problems in judgment (e.g., letting a stranger into the house)?

History of behavioural and neuropsychiatric manifestations

90% of pts with dementia develop a neuropsychiatric or behavioral symptom during the course of disease. Among the neuropsychiatric symptoms that require assessment are depression (including major depression and other depressive syndromes), suicidal ideation or behavior, hallucinations, delusions, agitation, aggressive behavior, disinhibition, sexually inappropriate behavior, anxiety, apathy, and disturbances of appetite and sleep.

 Other psychiatric history, substance use Medical and neurological history Vascular risk factors, medical illness, head trauma, HIV risk factors..etc. social history-level of education Family history Premorbid personality

B)Mental state examination Level of consciousness Appearance and grooming Speech- fluency, and comprehension Affect- apathy, anxious, depressed Thought or perceptual disturbances. Cognitive assessment

Cognitive assessment

For memory, inquire about short-term, long-term, and remote memory. For language, inquire about word-finding difficulties and remembering names of family members and friends. For praxis, inquire about use of familiar tools or machines, maintenance of previously acquired skills, and dressing or feeding apraxias. For agnosia, inquire about recognition of familiar objects and insight into their condition and limitations. Inquiring into executive function involves assessing ability to perform complex tasks or solve problems.

C) complete physical and neurological examination Sufficient information should be gathered to apply the diagnostic criteria

D) Assessment tools & neuropsychological testing

1)Brief Screening Tests The AD8 Mini Mental State Exam Montreal Cognitive Assessment Mini Cog

2)Caregiver-based Tests Behavioral Pathology in Alzheimers Disease Rating Scale (BEHAVE-AD) Neuropsychiatric Inventory (NPI). 3) Cognitive Tests Alzheimers Disease Assessment Scale, cognitive subsection (ADAS-cog) Blessed Information-Memory-Concentration Test (BIMC) Cambridge Neuropsychological Test Automated Battery (CANTAB) Consortium to Establish a Registry for Alzheimers Disease (CERAD) Mini-Mental Status Examination (MMSE)

4) Functional Assessment Functional Assessment Questionnaire (FAQ) Instrumental Activities of Daily Living (IADL) Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Physical Self-Maintenance Scale (PSMS) Progressive Deterioration Scale (PDS) 5) Behavioural assessments Cohens Mansfield agitation inventory Cornell scale for depression in dementia

6) Quality of life: Resource utilization in dementia Caregiver activity survey 7) Global Tests Clinical Global Impression of Change (CGIC) Clinical Interview-Based Impression (CIBI) Global Deterioration Scale (GDS) 8) Assessment of severity: FAST CDR

E) Laboratory tests
Rule out correctable or contributory causes of dementia, such as nutritional deficiencies, infection, metabolic disorders, drug effects, and so forth. Blood count to investigate anemia, infection Serum electrolytes levels, glucose to investigate metabolic disease Serum chemistry panel, including liver function tests, renal function tests Thyroid panel to rule out hypothyroidism Serum vitamin B12, folate to rule out deficiency Neurosyphilis serology, HIV titer ESR, screens for connective tissue disease CSF analysis Urinalysis and microcopy Urine toxicology & Serum toxicology (for alcohol, medications, drugs, etc.)

F)Neuroimaging- structural and functional

Brain imaging (X-ray, CT, SPECT, PET, MRI) Rule out CVAs, SDH, mass lesions, tumors, and hydrocephalus functional imaging (fMRI, PET) MRI is currently the radiological modality of choice.

G) EEG role in dementia evaluation if concern about a seizure disorder or delirium, EEG in CJD, SSPE shows periodic complexes. H) Biomarkers- A and MAPT proteins in CSF in AD I) Genetic testing- inherited forms of dementia K) Neuropathology A definitive diagnosis of dementia type can only be made with neuropathological inv of the brain through either brain biopsy or autopsy. There is no clinical indication for brain biopsy, so postmortem evaluation of the brain is the only way to provide definitive diagnosis of dementia type.

DIAGNOSIS

DIFFERENTIAL DIAGNOSES

DD Delirium acute confusional state, characterised by reduced ability to maintain attention, but unlike dementia, the cognitive deficits tend to fluctuate

MCI Amnestic disorder

lesser degree than dementia and without significant functional impairment. MCI may represent a prodromal state of dementia
characterised by impairment in memory, but other cognitive domains remain intact.

Age related characterised by a mild decline in cognitive functioning occurring Cognitive with ageing. However it doesnt reach threshold on formal testing Impairment and does not lead to functional impairment.

DD Mental Retardation

occurs before 18yrs, and is characterised by below average general intellectual functioning. The cognitive impairment is static and is not a decline from a previous level

Schizophrenia cognitive impairment prior or proximate to onset of psychotic (dementia precox) syndrome in young adulthood & relatively constant thereafter associated with complaints of memory impairment, difficulty Major Depressive in concentration and a reduced intellectual ability, sometimes Disorder referred to as pseudo-dementia course and onset of depressive symptoms as well as response to treatment may be the distinguishing features

DD Substance use disorders Medical Conditions Medications

particularly alcohol abuse and dependence, can cause dementia. There may be some improvement with abstinence.
General medical conditions that can cause or exacerbate dementia must be ruled out Many medications, alone or in combination, can cause cognitive impairment, which may mimic dementia. Medications with anti-cholinergic properties are major culprits

Stages of dementia

1st phase: lasts for 2-3yrs. Dominated by forgetfulness, difficulty in completing tasks of everyday life & spatial disorientation. Changes in mood depression & anxiety. 2nd phase: confusional state. Intellectual & personality deterioration. Accent on the parietal lobe. Extrapyramidal symptoms.

 3rd phase - Dementia phase Profound apathetic dementia. Bed-ridden & doubly incontinent. Gross neurological disability Primitive reflexes CPS/Grandmal seizures

pharmacological treatment - general principles

Elderly individuals decreased renal clearance and slowed hepatic metabolism, which alter the pharmacokinetics of many medications. may have multiple coexisting GMCs and may take multiple medications imp to consider how these GMCs and assoc medications may interact to further alter absorption, serum protein binding, metabolism, & excretion of medication. low starting doses, small dose increases, and long intervals between dose increases are necessary Orthostasis is common in elderly, medications are sedative. Patients with AD, Parkinsons disease , and DLB- susceptible to EPS

a. Treatments for Cognitive and Functional Losses no cure for most cases of dementia, the primary goal of medication treatment for cognitive symptoms in dementia to delay the progression of symptoms, with the hope that this delay will translate into a preservation of functional ability, maintaining the patient for as long as possible at a particular level of symptom severity.

The only FDA-approved medications for dementia or cognitive impairment are the cholinesterase inhibitors (tacrine, donepezil, rivastigmine, and galantamine), memantine, and the combination of ergoloid mesylates (approved for nonspecific cognitive decline).

 1. Cholinesterase inhibitors In 1993 tacrine became the first agent approved specifically for the treatment of cognitive symptoms in Alzheimers disease. Tacrine is a reversible cholinesterase inhibitor thought to work by increasing the availability of intrasynaptic acetylcholine in the brains of patients with AD The FDA approved other cholinesterase inhibitorsdonepezil, rivastigmine, and galantaminein 1997, 2000, and 2001, respectively, for treatment of cognitive decline in mild to moderate Alzheimers disease. These agents are now preferred over tacrine because of tacrines reversible hepatic toxicity and the requirement that it be given 4 times per day.

NICE guidance on anticholinesterases

The three acetylcholinesterase inhibitors donepezil, galantamine, and rivastigmine are recommended as options in the management of people with Alzheimers disease of moderate severity (MMSE score of between 10 and 20). Patients who continue on the drug should be reviewed every 6 months by MMSE score and global, functional and behavioural assessment. The drug should only be continued if the MMSE remains at or above 10 and the drug effect is considered to be worthwhile.

2) Memantine Noncompetitive NMDA receptor antagonist. Approved by FDA for moderate to severe dementia. Studies ( MEM-MD, study 99679, MEM-BEST study, MMM300, MMM500) 3)Combination therapy

Donepezil

Rivastigmine

Galantamine

Memantine

 Cholinesterase inhibitors should be used with caution in patients with gastric ulcer disease, sick sinus syndrome or conduction defects, asthma or chronic obstructive pulmonary disease, or cerebrovascular disease. The only contraindication is hypersensitivity

others

Ergoloid Mesylates (Hydergine) ginkgo biloba Vitamin E Folic Acid Selegiline Omega 3 supplementaion Dimebon HRT

Anti- amyloid agents: Tamiprosate Colostrinin Cloquinal Vaccination Imatinib mesylate Statins Anti-tau agents AL-108 Tau kinase inhibitors: e.g; lithium Tau aggregation inhibitor: methylthionium chloride

Treatment of psychosis and agitation

When deciding if treatment is indicated, it is critical to consider the safety of the patient and those around him or her. A careful evaluation for general medical, psychiatric, environmental, or psychosocial problems that may underlie the disturbance should be undertaken. Underlying causes should be treated first . If this does not resolve the symptoms, and if they do not cause significant danger or distress to the patient or others, such symptoms are best treated with environmental measures, including reassurance and redirection

 Antipsychotics: based on the relationship between side effect profile and characteristics of the individual patient The usual maximum dosages of these agents for patients with dementia are 2 mg/day of haloperidol, 1.52 mg/day of risperidone, 75100 mg/day of clozapine, 200300 mg/day of quetiapine, 10 mg/day of olanzapine, and 15 mg/day of aripiprazole Role of benzodiazepines. Longterm use avoided, but particularly useful on an occasional as-needed basis for patients Given the risk of disinhibition and consequent worsening of target behaviors, oversedation, falls, and delirium, their use should be kept to a minimum, with a max of 13 mg of lorazepam (or equivalent doses of other BZDs) in 24 hours

 Anti- convulsants- a therapeutic trial of carbamazepine or valproate may be considered in individual cases. others Beta blockers. Lithium Trazodone Behaviour oriented treatment.

Treatment of depression

Choice of agent depends on the side effect profile. SSRI s are preferred. Bupropion , Venlafaxine and Mirtazapine. Unilateral ECT

 Treatment of sleep disturbances (fragmented nocturnal sleep, multiple and prolonged awakenings, relative decrease in slowwave sleep percentage, and increased daytime napping) Some clinicians prefer 25100 mg of trazodone at bedtime for sleep disturbances, whereas others prefer the nonbenzodiazepine hypnotics such as zolpidem (510 mg at bedtime) or zaleplon (510 mg at bedtime). BZDs for short term sleep problems.

Treatment of sexually inapproprite behaviour.

Treatment of comorbid conditions

General medical conditions Chronic general conditions commonly coexist with dementia. The memory impairment and disabilities associated with dementia will hamper the patients ability to provide a reliable description of symptoms. Family and caregivers involvement is essential in evaluation.

 Delirium Patients with dementia are at a much higher risk of developing delirium. Among the common causes of delirium in demented individuals include the presence of general medical conditions, neurological disorders and drugs, including all psychotropic medications. To diminish the prevalence and morbidity of delirium : - avoid unnecessary medications,

- use the lowest effective doses of drugs, - recognise changes from baseline behaviour and\ - treat underlying causes.

 Parkinsons disease Dementia coexisting with Parkinsons disease requires a different treatment approach. The dopaminergic agents may predispose to the development of visual hallucinations and other psychotic symptoms. The minimal dose needed to control the motor symptoms should be used. If the psychotic symptoms result in distress or danger, antipsychotic treatment should be used judiciously. The use of atypical antipsychotic agents is favoured. Clozapine has been best studied to date. Patients with Parkinsons disease may have coexisting depression, which can be misdiagnosed as dementia. A careful evaluation is required.

 Stroke Patients with a history of stroke, irrespective of whether it contributes to dementia, need to be evaluated to determine the aetiology of the stroke. Control of vascular risk factors, including the use of antiplatelet agents/anticoagulants as prophylaxis may be appropriate

Non pharmacological interventions

Standard therapies: Psychotherapy Behavioral Management Cognitive Retraining Stimulation-oriented Therapies and others Validation therapy Reminiscence therapy

Behavioral treatments widely employed in clinical practice identify antecedents and consequences of problem behaviors and then effect changes in the environment to alter the behaviors For example, scheduled toileting can reduce the frequency of urinary incontinence.

Cognitive Retraining

Cognitive skills training exercises, focused on maintaining specific cognitive skills, and reality orientation, focused on improving orientation generally short-lived may actually be detrimental- several studies have reported anger, frustration, and depression in patients and depression in caregivers with these cognitiveoriented approaches

Stimulation-oriented Therapies

aimed at enhancing pleasurable activities have some support from clinical trials recreational therapy (i.e., crafts, games), art therapies (i.e., music, dance, art), pet therapy, multisensory stimulation, simulated presence, aromatherapy, bright light therapy and exercise. Brief psychotherapies: CBT and inter-personal therapy

Assess and monitor psychiatric status

Both cognitive and noncognitive neuropsychiatric and behavioral symptoms of dementia tend to evolve overtime, so regular monitoring allows detection of new symptoms and adaptation of treatment strategies to current needs. Important for the psychiatrist to periodically assess for the presence of noncognitive psychiatric symptoms as well as for the progression of cognitive symptoms. Assessment of functional status may also aid the clinician in documenting and tracking changes over time as well as providing guidance to the patient and caregivers.

 Whenever there is an acute worsening of cognition, functioning, behavior, mood, or psychosis, the clinician should bear in mind that elderly persons in general and patients with dementia in particular are at high risk for delirium associated with medications, general medical problems, and surgery. Before undertaking an intervention, the psychiatrist should enlist the help of caregivers in carefully characterizing the target symptoms. Their nature, intensity, frequency, precipitants, and consequences should be reviewed and documented. This approach also assists caregivers in beginning to achieve some mastery over the problematic symptom.

Monitor and enhance the safety of the patient and others

The psychiatrist should 1) assess suicidality, 2) assess the potential for aggression and agitation, 3) make recommendations regarding adequate supervision, 4) make recommendations regarding the prevention of falls and choking, 5) address nutritional and hygiene issues, and 6) be vigilant regarding neglect or abuse.

Suicidal ideation

All patients (and their caregivers) should be asked about the presence of wishes for death, suicidal ideation, suicide plans, as well as a history of previous selfinjurious behavior. If suicidal ideation occurs in patients with dementia, it tends to be earlier in the disease, when the insight is more likely to be preserved.

 Interventions to address suicidal ideation are similar to those for patients without dementia and include: psychotherapy; pharmacotherapy; removal of potentially dangerous items such as medications, guns, or vehicles;

increased supervision; and hospitalization.

Falls

Psychiatrists caring for patients with dementia should be aware that falls are a common and potentially serious problem for all elderly individuals, especially those with dementia. Falls can lead to hip fracture, head trauma, and a variety of other injuries, including subdural hematomas, which may further worsen cognitive function.

Management:

One of the most efficacious is withdrawing medications that are associated with falls, central nervous system sedation, or cardiovascular side effects (especially orthostatic hypotension), when appropriate. If gait disturbances are present, canes, walkers,or other supports may be helpful unless they are otherwise contraindicated (e.g., if their use poses a hazard to others). Patients at high risk for falling may need to be closely supervised while walking. Environmental modifications can also help reduce the risk of falls. The use of lower beds, night-lights, bedside commodes, and/or frequent toileting may help prevent falls at night. Bed and chair monitors- alerting caregivers. Programs for muscle strengthening and balance retraining

Abuse and neglect

Individuals with dementia are at particular risk for abuse because of : Their limited ability to protest, their lack of comprehension, and the significant demands and emotional strain on caregivers. Corroborating evidence (e.g., from physical examination) should be sought in order to distinguish delusions, hallucinations, and misinterpretations from actual abuse.

Wandering

Wandering may be due to: inability to find their way back, lack the judgment to recognize and deal with dangerous situations. It has also been associated with depression, delusions, hallucinations, sleep disorders, neuroleptic medication use, and male gender. Boredom Trying to fulfill a physical need

Management:

Regular time for exercise. Use of more complex or less accesible door latch. Positioning of locks high or low on the door. Use of barrier or curtain to mask a door. Installing home security system. Electronic locks Sewing or pinning identifying information. Placing medical alert bracelets. Filing photographs with local police. Informing neighbours about the patients wandering behaviour and making sure they have the caregivers contact information.

Advice the patient and family concerning driving & other activities that can cause harm to others.

Dementia, even when mild, impairs driving performance. Concomitant neurological symptoms, sensory deficits, deficits in judgement, coordination, processing speed and reaction time, increase the risk of accidents. GMC and use of sedatives- impairs driving.

Referrals for driving evaluations.

Provide education and support to patients and families

A)Educate the Patient and Family About the Illness and available treatments. Often the first step is to communicate and explain the diagnosis of dementia, including the specific dementia etiology, if known. Patients vary in their ability and desire to understand and discuss their diagnosis. Most mildly and some moderately impaired individuals are able to discuss the matter at some level, but the discussion must be adapted to the specific concerns and abilities of the patient. The issue of disclosure of the diagnosis to the patient is complex because many patients cannot recognize their deficits. In most cases, the psychiatrist will have an explicit discussion with family members regarding the diagnosis, prognosis, and treatment options, adapted to the unique concerns of the patient and family.

 It is important to educate the patient and family about the range of symptoms that could develop in the current stage of dementia or that may develop in the future. The family should be educated regarding basic principles of care, including: 1) recognizing declines in capacity and adjusting expectations appropriately 2) bringing sudden declines in function and the emergence of new symptoms to professional attention, 3) keeping requests and demands relatively simple, 4) deferring requests if the patient becomes overly upset or angered, 5) avoiding overly complex tasks that may lead to frustration,

 6) not confronting patients about their deficits, 7) remaining calm, firm, and supportive and providing redirection if the patient becomes upset, 8) being consistent and avoiding unnecessary change, and 9) providing frequent reminders, explanations,and orientation cues.

 b. Refer the Family to Appropriate Sources of Care and Support Family members often feel overwhelmed by the combination of hard work and personal loss associated with caring for an individual with dementia. The caring and pragmatic attitude of the psychiatrist may provide critical support. Programs have been developed that reduce the burden and lessen the stress and depression associated with longterm caregiving. Respite care allows the caregiver periods of relief from the responsibilities of dementia care. It provides essential physical and emotional support, serving the dual purposes of decreasing the burden of care and allowing caregivers to continue to work, participate in recreational activities, or fulfill other responsibilities.

 c. Watch for Signs of Caregiver Distress Caregiver burden associated with caring for a loved one with dementia is great Caregiving is physically and emotionally demanding, because the patient has less ability to communicate, eventually may not recognize the caregiver, and frequently exhibits inappropriate and difficult behaviors Caregivers also frequently become isolated from their social supports as patients can no longer engage in their usual social functions Signs of caregiver distress include increased anger, social withdrawal, anxiety, depression, exhaustion, sleeplessness, irritability, poor concentration, increased health problems, and denial.

 Psychiatrists caring for patients with dementia should be vigilant for these conditions in caregivers, because they increase the risk of substandard care, neglect, or abuse of patients and are a sign that the caregivers themselves are in need of care. Interventions shown to reduce caregiver burden include psychoeducation about dementia and comprehensive support including individual and family counseling and support groups

d. Support Families During Decisions About Institutionalization.

Advise the family to address financial and legal issues

Patients and their families should be encouraged to pursue legal planning and about testamentary capacity. To warn the family members the vulnerability of individuals with dementia to unscrupulous individuals seeking charitable contributions, selling appropriate goods etc. Clinician should remain vigilant for evidence of exploitation of patients.

Development of stage specific treatment plan

1. Mildly Impaired Patients At the early stages of a dementing illness, patients and their families are often dealing with acceptance of the illness and recognition of associated limitations. They may benefit from pragmatic suggestions for how to cope with these limitations. Patients benefit from referral to health promotion activities & recreation clubs. Identify specific impairments and highlight remaining abilities. Patients often experience a sense of loss & perceived stigma assoc with illness. Addressing the issue of driving cessation, assigning a durable power of attorney and addressing other legal and financial matters and caregiver well-being.

 Patients with early Alzheimers disease should be offered a trial of one of the three available cholinesterase inhibitors approved and commonly used for the treatment of cognitive impairment (i.e., donepezil, rivastigmine,galantamine), after a thorough discussion of their potential risks and benefits. Patients with moderate to severe major depression who do not respond to or cannot tolerate antidepressant medications should be considered for ECT. Mildly impaired patients should also be carefully assessed for suicidality, even if they are not obviously depressed.

 2. Moderately Impaired Patients As patients become more impaired, they are likely to require more supervision to remain safe, & safety issues should be addressed as part of every evaluation. Families should be advised about the possibility of accidents due to forgetfulness, of difficulties coping with household emergency and possibility of wandering. At this stage of the disease, nearly all patients should not drive. As a patients dependency increases, caregivers may begin to feel more burdened. A referral for some form of respite care (e.g., home health aid, day care, brief assisted living, or nursing home stay) may be helpful.

 Treatment for cognitive symptoms should also be considered. For patients with Alzheimers disease, currently available data suggest that the combination of a cholinesterase inhibitor plus memantine is more likely to delay symptom progression than a cholinesterase inhibitor alone during this stage. Delusions and hallucinations are prevalent in moderately impaired patients, as are agitation and combativeness.

 3. Severely and Profoundly Impaired Patients At this stage of the illness, patients are severely incapacitated and are almost completely dependent on others for help with basic functions, such as dressing, bathing, and feeding. Of the cholinesterase inhibitors, only donepezil has thus far been approved for use in late-stage disease, and some studies show that other members of this class may also be beneficial. Memantine, which has been approved for use in severe dementia, may provide modest benefits and has few adverse effects.

 Depression may be less prevalent and more difficult to diagnose at this stage but, if present, should be treated vigorously. Psychotic symptoms and agitation are often present and should be treated pharmacologically if they cause distress to the patient or significant danger or disruption to caregivers or to other residents of long-termcare facilities. At this stage, it is important to ensure adequate nursing care, including measures to prevent bedsores and contractures. The treatment team should help the family prepare for the patients death.

Sub-type specific dementia treatment

Sub type AD Specific treatment cholinesterase inhibitors (FDA approved)

VaD

no FDA-approved treatments for VaD AChEs, Memantine can be used. primary & secondary prevention and symptomatic treatment
AChEs for cognitive impairment and psychosis inDLB, Memantine not used. increase levels of arousal and attention by social interaction and environmental novelty may reduce the visual hallucinations and fluctuations in cognition and function no Rx for the cognitive deficits, symptomatic Rx dementia is untreatable. Genetic counseling is indicated best treated by identifying assoc med cond, instituting approp Rx, and managing behavior in the interim. Penicillin often improves cognitive de cits and corrects CSF abnormalities, but complete recovery is rare

DLB

FTD Huntingtons AIDS dementia

Dementia sec to neurosyphilis

Substance-Induced Those who remain sober do have some improvement in Persisting Dementia their mental state. Alcohol-Induced
Dementia due to Clinical improvement with shunting lateral ventricle to drain Other GMC NPH CSF into the chest or abdominal cavity. Wilsons Disease Chelating agents such as penicillamine, if administered early, can reverse CNS and non-neurological findings in about 50% of cases

Services in India

The sertvice gap- more than 90%. The Alzheimers and Related Disorders Society of India ( ARDSI) is dedicated to care, support and research dementia across the country.

Barriers for care

Recommendations

1 Make dementia a national priority 2 Increase funding for dementia research 3 Increase awareness about dementia 4 Improve dementia identification and care skills 5 Develop community support 6 Guarantee carer support packages 7 Develop comprehensive dementia care models 8 Develop new National Policies and Legislation for PwD

Future research

stop or reduce or change beta-amyloid production in the brain by altering secretases. drugs currently undergoing human trials hoping to change the way secretase works is Flurizan (R-flurbiprofen) anti-aggregants 1)Vaccines to mobilize the body's immune system to produce antibodies that attack beta-amyloid 2)Laboratory produced vaccines that produce antibodies for beta-amyloid ?caffeine intake not only appears to protect against Alzheimer's but may actually help those who already have the disease.

management of dementia multi-modal and multi-disciplinary (1) identification and, if possible, correction of the underlying cause; (2) environmental manipulation to reorient the patient; (3) intervention with the family by means of education, peer support, providing access to community organizations, discussing powers of attorney, living wills, and institutionalization if appropriate, and arranging therapy if indicated; and (4) pharmacological management of psychiatric symptoms and behavior Future research on disease modifying drugs