Dementia

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Dementia is "progressive decline in two or more cognitive domains that is severe enough to interfere with the performance of everyday activities."[1]

Deficits in cognitive function contribute to impaired functional status.[2] The deficits in the domains of cognitive function are[3]:

  • Agnosia - "Failure to recognize or identify objects despite intact sensory function"[3]
  • Aphasia - "Deterioration of language function"[3]
  • Apraxia - "Impaired ability to execute motor activities despite intact motor abilities, sensory function, and comprehension of the required task"[3]
  • Disturbance in executive functioning - "The ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior"[3]

Classification

Vascular dementia can affect both cortical and subcortial locations.

Cortical dementias

Among the many causes of cortical dementia, common causes are:

Subcortical dementias

Among the many causes of subcortical dementia, common causes are:

Epidemiology

22.2% of individuals in the United States age 71 years or older have cognitive impairment without dementia (Dementia Severity Rating Scale score of 6 to 11). 12% of these patients progress to dementia annually. Progression is more common among patients with subtypes of prodromal Alzheimer disease and cerebrovascular disease.[4]

Subcortical dementias

Among the many causes of subcortical dementia, common causes are:

  • Vitamin B12 deficiency

Diagnosis

Studies on diagnosing dementia are compromised by the lack of a true reference standard for comparison.[5]

A number of systematic reviews, including ones by the U.S. Preventive Services Task Force (USPSTF)[6], Rational Clinical Examination[3], and others[7], have summarized the diagnostic accuracy of screening tests.

Mini-mental state examination

The Mini-mental state examination (MMSE) is the most studied test.[3] A systematic review concluded that the accuracy of the MMSE is:[6]:

A copy of the Mini-mental state examination can be found in the appendix of the original publication.[8]

Modified Mini-Mental State examination (3MS)

A meta-analysis concluded that the Modified Mini-Mental State (3MS) examination has:[7]

A copy of the 3MS is online.[9]

Abbreviated mental test score

A meta-analysis concluded:[7]

sensitivity 73% to 100%
specificity 71% to 100%

Clock drawing task

Dementia type CLOX1
(Executive control) 		CLOX2
(Posterior cortical) 		Pentagons copying
on MMSE 		Total MMSE score
Posterior cortical and
diffuse cortical
dementias 		Abnormal Abnormal Abnormal Abnormal
Subcortical and
frontal cortical
dementias 		Abnormal Normal Normal Normal

The Clock drawing task (CLOX) consists of two tests and is available online at PubMed Central.[10] The CLOX1 task has the subject draw a clock face without any prompting other than the instructions "Draw me a clock that says 1:45. Set the hands and numbers on the face so that a child could read them". The CLOX1 is tests executive function and correlates with the EXIT25 test of executive function. The CLOX2 task has the subject copy a clock face from an example, does not test executive function and correlates with the MMSE.

The CLOX may avoid the bias of the MMSE toward cortical dementias.[10] In addition, "as Alzheimer’s disease affects posterior cortical regions before invading the frontal cortex, isolated ECF impairment (CLOX1) is not likely to represent early Alzheimer’s disease."[10] Thus, isolated abnormalities of the CLOX1 may be able to detect reversible dementias such as subcortical stroke, depression, vitamin B12 deficiency, polypharmacy, and hypothyroidism.[10]

Other examinations

Many other tests have been studied [11][12][1] including the Executive Interview (EXIT)[13].

Consequences of labeling

In one study, learning of having mild cognitive impairment reduced stress.[14]

Treatment

"Actively involving caregivers in making choices about treatments" my be the most important way to delay institutionalization of patients with dementia.[15]

Behavior management techniques (BMT)

Behavior management techniques (BMT) might help.[16] More specifically, " interventions that address behavioral issues and unmet needs" may help.[17]

Disease management team / care managers

The use of care managers may help.[17][18]

Medications

" Treatment of dementia with cholinesterase inhibitors and memantine can result in statistically significant but clinically marginal improvement in measures of cognition and global assessment of dementia" according to a systematic review for a clinical practice guideline by the American College of Physicians.[19] According to the clinical practice guideline, "the evidence is insufficient to compare the effectiveness of different pharmacologic agents for the treatment of dementia."[20]

Cholinesterase inhibitors

Available cholinesterase inhibitors drugs are donepezil, galantamine, rivastigmine, and tacrine.

Neuropeptide-modifier

Memantine is a neuropeptide-modifier that acts on the N-Methyl-D-Aspartate (NMDA) receptors for the neurotransmitter glutamate.

Anti-psychotics

The newer, atypical anti-psychotics (olanzapine, quetiapine, risperidone), were found to have "adverse effects offset advantages in the efficacy of atypical antipsychotic drugs for the treatment of psychosis, aggression, or agitation in patients with Alzheimer's disease."[21]

Withdrawing psychotropics mediations may prevent falls.[22]

Investigational therapies

Ginkgo biloba has conflicting evidence regarding its efficacy.[23][24][25]

Prevention

Physical activity

Most[26][27][28], but not all[29] studies find that physical activity is associated with reduced risk of dementia. These observational studies cannot prove cause and effect.

Mental activity

Mental activity is associated with reduced the risk of dementia in an observational study.[29]

Screening

In 2003, a clinical practice guideline by the U.S. Preventive Services Task Force (USPSTF) gave a grade I recommendation, indicating "the evidence is insufficient to recommend for or against routine screening for dementia in older adults".[30]

References

  1. ↑ 1.0 1.1 Karlawish, J. & Clark, C. (2003). "Diagnostic evaluation of elderly patients with mild memory problems". Ann Intern Med 138 (5): 411-9. PMID 12614094.
  2. ↑ Royall DR, Lauterbach EC, Kaufer D, Malloy P, Coburn KL, Black KJ (2007). "The cognitive correlates of functional status: a review from the Committee on Research of the American Neuropsychiatric Association". The Journal of neuropsychiatry and clinical neurosciences 19 (3): 249–65. DOI:10.1176/appi.neuropsych.19.3.249. PMID 17827410. Research Blogging.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Holsinger T, Deveau J, Boustani M, Williams JW (2007). "Does this patient have dementia?". JAMA 297 (21): 2391–404. DOI:10.1001/jama.297.21.2391. PMID 17551132. Research Blogging.
  4. ↑ Plassman, B. L., Langa, K. M., Fisher, G. G., Heeringa, S. G., Weir, D. R., Ofstedal, M. B., et al. (2008). Prevalence of cognitive impairment without dementia in the united states, Ann Intern Med, 148(6), 427-434. http://annals.org/cgi/content/abstract/148/6/427
  5. ↑ Erkinjuntti T, Ostbye T, Steenhuis R, Hachinski V (December 1997). "The effect of different diagnostic criteria on the prevalence of dementia". N. Engl. J. Med. 337 (23): 1667–74. PMID 9385127. [e]
  6. ↑ 6.0 6.1 Boustani, M.; Peterson, B.; Hanson, L.; Harris, R.; & Lohr, K. (2003). "Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force". Ann Intern Med 138 (11): 927-37. PMID 12779304.
  7. ↑ 7.0 7.1 7.2 Cullen B, O'Neill B, Evans JJ, Coen RF, Lawlor BA (2007). "A review of screening tests for cognitive impairment". J. Neurol. Neurosurg. Psychiatr. 78 (8): 790–9. DOI:10.1136/jnnp.2006.095414. PMID 17178826. Research Blogging.
  8. ↑ Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of psychiatric research 12 (3): 189-98. DOI:10.1016/0022-3956(75)90026-6. PMID 1202204. Research Blogging.
  9. ↑ Hogan DB, Ebly EM (2000). "Predicting who will develop dementia in a cohort of Canadian seniors". The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 27 (1): 18–24. PMID 10676583. [e] [Appendix: The Modified Mini-Mental State (3MS)]
  10. ↑ 10.0 10.1 10.2 10.3 Royall, D.; Cordes J.; & Polk M. (1998). "CLOX: an executive clock drawing task". J Neurol Neurosurg Psychiatry 64 (5): 588-94. PMID 9598672. Full text at PubMed Central Example form
  11. ↑ Sager, M.; Hermann, B.; La Rue, A.; & Woodard, J. (2006). "Screening for dementia in community-based memory clinics". WMJ 105 (7): 25-9. PMID 17163083.
  12. ↑ Fleisher, A.; Sowell B.; Taylor C.; Gamst A.; Petersen R.; & Thal L. (2007). "Clinical predictors of progression to Alzheimer disease in amnestic mild cognitive impairment". Neurology 68 (19): 1588-95. PMID 17287448.
  13. ↑ Royall DR, Mahurin RK, Gray KF. Bedside assessment of executive cognitive impairment: the executive interview. J Am Geriatr Soc. 1992;40:1221-6. PMID 1447438
  14. ↑ Carpenter, B. D., Xiong, C., Porensky, E. K., Lee, M. M., Brown, P. J., Coats, M., et al. (2008). Reaction to a dementia diagnosis in individuals with alzheimer's disease and mild cognitive impairment, Journal of the American Geriatrics Society, 56(3), 405-412. DOI:doi:10.1111/j.1532-5415.2007.01600.x. doi:10.1111/j.1532-5415.2007.01600.x.
  15. ↑ Spijker A et al. Effectiveness of Nonpharmacological Interventions in Delaying the Institutionalization of Patients with Dementia: A Meta-Analysis.J Am Geriatr Soc. 2008 Apr 11. PMID 18410323
  16. ↑ Teri L, Gibbons LE, McCurry SM, et al (2003). "Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial". JAMA 290 (15): 2015–22. DOI:10.1001/jama.290.15.2015. PMID 14559955. Research Blogging.
  17. ↑ 17.0 17.1 Ayalon L, Gum AM, Feliciano L, Areán PA (2006). "Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review". Arch. Intern. Med. 166 (20): 2182–8. DOI:10.1001/archinte.166.20.2182. PMID 17101935. Research Blogging.
  18. ↑ Vickrey BG, Mittman BS, Connor KI, et al (2006). "The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial". Ann. Intern. Med. 145 (10): 713–26. PMID 17116916. [e]
  19. ↑ Raina, Parminder et al. 2008. Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review for a Clinical Practice Guideline. Ann Intern Med 148, no. 5:379-397.
  20. ↑ Qaseem, Amir et al. 2008. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 148, no. 5:370-378.
  21. ↑ Schneider LS, Tariot PN, Dagerman KS, et al (2006). "Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease". N. Engl. J. Med. 355 (15): 1525–38. DOI:10.1056/NEJMoa061240. PMID 17035647. Research Blogging.
  22. ↑ Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM (1999). "Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial". J Am Geriatr Soc 47 (7): 850–3. PMID 10404930. [e]
  23. ↑ Birks J, Grimley Evans J (2007). "Ginkgo biloba for cognitive impairment and dementia". Cochrane Database Syst Rev (2): CD003120. DOI:10.1002/14651858.CD003120.pub2. PMID 17443523. Research Blogging.
  24. ↑ Solomon PR, Adams F, Silver A, Zimmer J, DeVeaux R (2002). "Ginkgo for memory enhancement: a randomized controlled trial". JAMA 288 (7): 835–40. PMID 12186600. [e]
  25. ↑ Le Bars PL, Katz MM, Berman N, Itil TM, Freedman AM, Schatzberg AF (1997). "A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for dementia. North American EGb Study Group". JAMA 278 (16): 1327–32. PMID 9343463. [e]
  26. ↑ Ravaglia G, Forti P, Lucicesare A, et al (2007). "Physical activity and dementia risk in the elderly. Findings from a prospective Italian study". Neurology. DOI:10.1212/01.wnl.0000296276.50595.86. PMID 18094335. Research Blogging.
  27. ↑ Larson EB, Wang L, Bowen JD, et al (2006). "Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older". Ann. Intern. Med. 144 (2): 73–81. PMID 16418406. [e]
  28. ↑ Abbott RD, White LR, Ross GW, Masaki KH, Curb JD, Petrovitch H (2004). "Walking and dementia in physically capable elderly men". JAMA 292 (12): 1447–53. DOI:10.1001/jama.292.12.1447. PMID 15383515. Research Blogging.
  29. ↑ 29.0 29.1 Verghese J, Lipton RB, Katz MJ, et al (2003). "Leisure activities and the risk of dementia in the elderly". N. Engl. J. Med. 348 (25): 2508–16. DOI:10.1056/NEJMoa022252. PMID 12815136. Research Blogging.
  30. ↑ U.S. Preventive Services Task Force (2003). "Screening for dementia: recommendation and rationale". Ann. Intern. Med. 138 (11): 925–6. PMID 12779303. [e]
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