Table 6–13 outlines key principles for the management of dementia. Optimizing therapy for comorbid conditions in the context of dementia, counseling families about the stages of dementia and avoidance of certain drugs and excessive alcohol, discussing strategies to manage behavioral symptoms if they arise and advance directives, and planning for the future are critical early steps in management.
Table 6–13. Key Principles in the Management of Dementia ||Download (.pdf)
Table 6–13. Key Principles in the Management of Dementia
Optimize the patient's physical and mental function through physical activity and mind plasticity principals and activities
Treatment underlying medical and other conditions (eg, hypertension, Parkinson disease, depression [Chap. 7])
Avoid use of drugs with central nervous system side effects (unless required for management of psychological or behavioral disturbances—see Chap. 14)
Assess the environment and suggest alterations, if necessary
Encourage physical and mental activity
Avoid situations stressing intellectual capabilities; use memory aids whenever possible
Prepare the patient for changes in location
Emphasize good nutrition
Identify and manage behavioral symptoms and complications
Depression (see Chap. 7)
Agitation or aggressiveness
Psychosis (delusions, hallucinations)
Incontinence (see Chap. 8)
Provide ongoing care
Reassessment of cognitive and physical function
Treatment of medical conditions
Provide information to patient and family
Nature of the disease
Extent of impairment
Provide social service information to patient and family
Local Alzheimer's Association
Community health-care resources (day centers, homemakers, home health aides)
Legal and financial counseling
Use of advance directives
Provide family counseling for:
Setting realistic goals and expectations
Identification and resolution of family conflicts
Handling anger and guilt
Decisions on respite or institutional care
Ethical concerns (see Chap. 17)
Consideration of palliative and hospice care (see Chap. 18)
Although complete cure is not available for the vast majority of dementias, optimal management can provide improvements in the ability of these patients to function, as well as in their overall well-being and that of their families and other caregivers.
If causes of reversible or partially reversible forms of dementia are identified (see Table 6–6), they should be specifically treated. Small strokes (lacunar infarcts), which can cause further deterioration of cognitive function in patients with AD, as well as those with vascular dementia, may be prevented by controlling hypertension; thus, hypertension should be treated in patients with dementia as long as side effects can be avoided. Other specific diseases such as Parkinson disease and diabetes should be optimally managed. The treatment of these and other medical conditions is especially challenging because drug side effects may adversely affect cognitive function.
Pharmacological Treatment of Dementia
There are four basic approaches to the pharmacological treatment of dementia:
Avoid drugs that can worsen cognitive function, mainly those with strong anticholinergic activity
Agents that enhance cognition and function
Drug treatment of coexisting depression
Pharmacological treatment of complications such as paranoia, delusions, psychosis, and behavioral symptoms such as agitation (verbal and physical)
Drug treatment of depression may provide substantial benefits in patients with dementia (Lyketsos et al., 2003) and is discussed in detail in Chapter 7. The use of antipsychotics to treat the neuropsychiatric symptoms of dementia is highly controversial (Sink, Holden, and Yaffe, 2005; Schneider et al., 2006; Ayalon et al., 2006; Maher et al., 2011). Most experts and guidelines recommend avoiding these drugs and using nonpharmacological strategies unless patients are a danger to themselves and others or if nonpharmacological interventions have failed. Atypical antipsychotics are associated with weight gain and now have black box warnings from the U.S. Food and Drug Administration because of the increased risk of death associated with their use. Moreover, the U.S. Centers for Medicare and Medicaid Services have begun a campaign to improve the appropriateness and reduce the use of these drugs in nursing homes. Patients with new or worsening behavioral symptoms associated with dementia should have a medical evaluation to identify potentially treatable precipitating conditions. Pain may be especially hard to detect. For severely demented patients who develop physical or verbal agitation without an obvious underlying cause, empiric treatment with acetaminophen has shown some efficacy (Husebo et al., 2011). Nonpharmacological approaches should be used before psychotropic drugs are prescribed, unless patients are clearly psychotic and/or an immediate danger to themselves or others around them. Pharmacological treatments, including antipsychotics, are discussed further in Chapter 14.
The primary pharmacological approach to the treatment of AD has been the use of cholinesterase inhibitors. Their effectiveness in improving function and quality of life remains controversial, and the potential benefits of these drugs versus their risks and costs must be weighed carefully in individual patients. Some evidence suggests that these drugs may also have some efficacy for multi-infarct dementia and DLB. There are four approved drugs of this class on the market: tacrine, donepezil, rivastigmine, and galantamine. Randomized placebo-controlled clinical trials suggest that these drugs can have positive effects on cognitive function and may improve or prevent decline in overall function and potentially delay nursing home admission (Ritchie et al., 2004; Carson, McDonagh, and Peterson, 2006; Winblad et al., 2006). The clinical importance of these improvements may be marginal in many patients (Raina et al., 2008). Tacrine is potentially hepatotoxic and is generally not prescribed for this reason. Gastrointestinal side effects can be problematic and include nausea, vomiting, and diarrhea; nightmares can be bothersome as well. However, the benefits of these drugs include slight improvements in cognitive function and up to a several-month delay in the progression of cognitive impairment and the development of related behavioral symptoms. While these drugs have been used to help manage behavioral symptoms associated with dementia, at least one controlled study of one of them (donepezil) failed to demonstrate efficacy for this purpose (Howard et al., 2007).
Other drugs, including estrogen (in women), vitamin E, ginkgo biloba, and nonsteroidal anti-inflammatory drugs, have been used to prevent and/or treat dementia. There is, however, no evidence that these drugs are effective in preventing or treating dementia (most evidence suggests they are not). There is also no evidence that vitamin B12, vitamin B6, or folic acid supplementation improves cognitive function (Balk et al., 2007).
A variety of supportive measures and other nonpharmacological management strategies are useful in improving the overall function and well-being of patients with dementia and their families (see Table 6–13). These interventions range from specific recommendations for caregivers, such as alterations in the physical environment, the use of memory aids, the avoidance of stressful tasks, and preparation for the patient's move to another living setting with a higher level of care, to more general techniques, such as providing information and counseling services (Ayalon et al., 2006). Resources are available through the Alzheimer's Association and the Rosalyn Carter Institute's Savvy Caregiver Program to assist caregivers (see websites at end of chapter). Many nursing homes have developed special care units for dementia patients. However, there is little evidence that such units improve outcomes (Phillips et al., 1997; Rovner et al., 1996). Nonpharmacologic treatment of agitation can, however, be effective in this setting (Cohen-Mansfield, Libin, and Marx, 2007). Assisted-living facilities have also developed specialized dementia units, with specially designed environments, trained staff, and intensive activities programming, and without the more hospital-like environment typical of many nursing homes. The effectiveness of such units and whether people with advanced dementia can optimally be cared for in them have not been well studied.
Symptoms commonly associated with moderate to severe cognitive impairment, such as memory loss, aphasia, motor apraxia, visual agnosia, and apathy, make it challenging for caregivers to interact, motivate, and implement restorative care interventions. In addition to functional and motivational challenges, problematic behavioral symptoms, such as verbal and physical aggression, sleep disturbance, depression, delusions, hallucinations, and resistance to care, occur in at least 50% to 80% of individuals diagnosed with dementia at some time during the course of their illness. Caregivers in home settings commonly suffer from severe stress, and caregiving for people with dementia can impair the caregiver's quality of life and health. Thus, recommending and assisting in locating resources to reduce caregiver burden are essential aspects of managing dementia. Nursing assistants, who provide the majority of hands-on care in long-term care settings, are frequently challenged by the agitated and uncooperative behaviors of cognitively impaired residents. There are, however, a variety of techniques that have been shown to be effective in engaging these individuals in functional activities while managing behavioral problems. These include such things as getting to know individuals and drawing on their past experiences and patterns (eg, memory boxes outside rooms in dementia units, giving a housewife household activities to do), using humor, providing simple repetitive activities, encouraging mimicking by demonstrating the behavior/activity that you want the individual to perform, communicating face on, and using multiple sources of input (eg, verbal and written).
Providing ongoing care is especially important in the management of dementia patients. Reassessment of the patient's cognitive abilities can be helpful in identifying potentially reversible causes for deteriorating function and in making specific recommendations to family and other caregivers about remaining capabilities. The family is the primary target of strategies to help manage dementia patients in noninstitutional settings. Caring for relatives with dementia is physically, emotionally, and financially stressful. Information on the disease itself and the extent of impairment and on community resources helpful in managing these patients can be of critical importance to family and caregivers. The local chapter of the Alzheimer's Association and the Area Agency on Aging are examples of community resources that can provide education and linkages with appropriate services. Anticipating and teaching family members strategies to cope with common behavioral problems associated with dementia—such as wandering, incontinence, day–night reversal, and nighttime agitation—can be of critical importance. Hazardous driving can result in car crashes and is an especially troublesome problem. Better validated screening methods for identifying individuals who may be unable to drive safely are now available (Carr et al., 2011). Several states require reporting patients with dementia who maintain drivers' licenses. Wandering may be especially hazardous for the dementia patient's safety and is associated with falls. Incontinence is common and often very difficult for families to manage (see Chapter 8). Books providing information and suggestions for family management techniques are very useful (see Suggested Readings). Support groups for families of patients with AD through the Alzheimer's Association are available in most large cities. Family counseling can be helpful in dealing with a variety of issues such as anger, guilt, decisions on institutionalization, handling the patient's assets, and terminal care. Dementia patients and their families should also be encouraged to discuss and document their wishes, using a durable power of attorney for health care or an equivalent mechanism early in the course of the illness (see Chapter 17). Family members should be encouraged to seek respite care periodically to provide time for themselves. Some communities have formal respite care programs available. In the absence of such programs, informal arrangements can often be made to relieve the primary family caregivers for short periods of time at regular intervals. Such relief will help the caregiver to cope with what is generally a very stressful situation. Often a multidisciplinary group of health professionals—made up of a physician, a nurse, a social worker, and, when needed, rehabilitation therapists, a lawyer, and a clergy member—must coordinate efforts to manage these patients and provide support to family and caregivers.
Dementia is now recognized as a terminal illness, and many diagnostic and therapeutic interventions have been shown to be burdensome without benefits on quality of life and function in patients with end-stage dementia. Advanced care planning and establishing advance directives with designated surrogate decision makers is a critical aspect of managing this patient population. Advanced dementia is the subject of a recent review by several experts in this area (Mitchell et al., 2012), and management of these patients is addressed in Chapters 16, 17, and 18.
- Assess for correctable underlying causes of delirium, dementia, and new or worsening behavioral symptoms associated with dementia.
- Carefully review medication regimens to determine if one or more medication can affect cognitive function and try to eliminate potential offenders.
- Screen for behaviors and symptoms that put demented patients at risk (eg, trying to cook unattended, driving, wandering at night).
- Screen older patients with dementia for depression, which can exacerbate cognitive impairment.
- Pay attention to the health and emotional status of caregivers.
- Discuss advance care planning and set realistic goals and expectations for patients and caregivers.
- Automatically do brain imaging in every patient with cognitive impairment.
- Use psychoactive drugs if they can be avoided in patients with cognitive impairment.
- Prescribe antipsychotics for behavioral symptoms associated with dementia unless underlying treatable conditions have been excluded and nonpharmacological interventions have failed or unless patients are an immediate danger to themselves or others around them.
- Use physical restraints in hospitalized older patients with delirium or dementia unless essential for their safety and medical care.
- Formal neuropsychological testing if the diagnosis is uncertain, or if the patient or family wants to better understand cognitive capabilities
- A trial of a cholinesterase inhibitor for older patients with dementia
- Judicious use of antidepressants for dementia patients with concomitant depression
- Referring family members for support groups, in-home help, and respite programs when appropriate