Dementia can be defined as a deterioration in
cognitive abilities that impairs
activities of
daily living. It results
from disorders of cerebral neuronal circuits due to neuronal loss. The
most
common causes of
Dementia are Alzheimer’s disease and vascular
dementia. Less common causes are vitamin deficiencies, head trauma,
endocrine and other organ failure, chronic infections like HIV, and
brain neoplasm’s. Management:
Investigations- routine
1. Complete blood count
2. Electrolytes.
3. VDRL.
4. Thyroid function tests.
5. Vitamin B12, and folate estimation.
6. Urine.
7. CT/ MRI of the brain 8. EEG- This may help distinguish delirium from dementia Behavioural
and psychological symptoms associated with dementia (BPSD) consist of
many symptoms and an attempt should be made to identify specific
syndromes with careful mental status examination. The
diagnosis of dementia and delirium is facilitated by the use of the
Mini-Mental Status Examination test (MMSE). A score of 24 or less
indicates cognitive impairment. A rapid decline within days or
weeks is associated with delirium.
Dementia can result from a variety of degenerative, vascular,
traumatic, neoplastic, infectious, and metabolic disorders. The three
most common types are Alzheimer's disease, vascular dementia
(previously referred to as multi-infarct dementia), and Lewy body
dementia.Alzheimer's disease is the most common cause of
dementia. The typical course is that of progressive decline. Early in
the disease,
patients often worry about their cognition and try to
cover for their deficits. Depression is common. With further
progression, patients become disoriented to place and time, develop
apraxias and are at risk for getting lost due to wandering. The
cause of death is usually an intercurrent infection. The
physical examination should focus on cognitive, emotional, and
neurological findings but must also look for signs of hypothyroidism,
congestive heart failure, and diabetes.The most commonly used
cognitive tests in clinical practice is the MMSE i.e., Folstein
Mini-Mental Status Examination. The MMSE tests for memory, orientation,
attention, and language skills. Other useful screening tools
are the Clock Test, the Yesavage Geriatric Depression Scale, and the
Activities of Daily Living (ADL) and Instrumental Activities of Daily
Living (IADL) rating scores.Agitation, hallucination,
delusion, and confusion are difficult to treat. Drugs like
phenothiazines, haloperidol, and benzodiazepenes may reduce the
Behaviour problems but can have side effects like sedation, rigidity,
and dyskinesia. The following is the commonly used
treatment methods: AntipsychoticsLow-dose
haloperidol (0.5-2mg). When patients do not respond, it is a mistake to
progress to higher doses or use anticholinergics or sedatives like
barbiturates or bezodiazepenes. Risperidone and olanzapine are
newer antipsychotics and have a lower incidence of extrapyramidal side
effects compared with other drugs of this class. Therefore, despite
their higher cost, they are the drugs of choice.It is
important to have a stopping rule when starting an antipsychotic drug
in older people with dementia. Treatment should not be prescribed for
longer than 3-6 months.
Cholinesterase inhibitorsPatients with Alzheimer’s disease
(AD) often have cholinergic deficits in association with the disease.
The cholinesterase inhibitors donepezil hydrochloride, galantamine
hydrobromide, and rivastigmine tartrate are the preferred treatment for
patients with AD. Although none of the cholinesterase inhibitors has
been approved for treatment of patients in advanced stages of AD,
patients with less severe forms of the disease have had beneficial
cognitive effects with all three agents. When administered with
caution, galantamine, rivastigmine, and donepezil are generally
well-tolerated pharmacologic treatment options. However, cholinesterase
inhibitor treatment is sometimes associated with deterioration in
behaviour.
BenzodiazepinesBenzodiazepines should be avoided in older people with dementia.
AntidepressantsIf a clinically significant depressive
or anxiety disorder occurs in a person with dementia, they should be
treated. The best evidence exists for sertraline. The usual
starting dose is 25 mg daily. If the treatment is effective, it should
continue for about 12 months, or longer if there is a history of
recurrent depression. With sertaline there is less depression,
behaviour disturbance and improved activities of daily living, but not
improved cognition.AnticonvulsantsCarbamazepine and
sodium valproate have been used in the management of agitated behaviour
with dementia. The evidence favours carbamazepine, despite its
relatively greater tendency for side effects, including drug-drug
interactions. Anticonvulsants, however, should only be prescribed for a
limited time. Treating Coexisting ConditionsCoexisting
medical conditions and infections should be diagnosed and treated early
to avoid any exacerbation. This may include, thyroid replacement,
vitamin replacement, antibiotics and appropriate treatment for CNS
neoplasms. Management of aggressionPhysical
aggression is common in dementia, particularly towards caregivers.
Sometimes aggression can be managed by modifying the behaviour of the
caregiver or by modifying the environment in some other way. However,
pharmacological intervention is often required, particularly when there
is a risk of physical injury to the patient or their caretaker.In
an emergency, aggressive behaviour in a patient with dementia may need
to be treated with antipsychotic medication. If oral treatment is
feasible, risperidone or haloperidol should be tried. If parenteral
treatment is required, the short-term use of intramuscular haloperidol
(initial dose of 1-2 mg) or olanzapine (initial dose of 2.5 mg) is
given. Non-pharmacological therapy:Music, especially
classical music, has been shown to decrease aggressive outbursts,
agitation, and anxiety and to foster a positive outlook. Music invites
social opportunities that can foster and reinforce meaningful
interactions. When music therapy is combined with dance or movement
therapy, patients show improved orientation and ability for
self-expression. It is also useful to stress familiar routines,
short-term tasks, brief walks and simple physical exercises. Wandering
can become a significant problem for patients, who can get lost or
injured. The best approach is to provide a safe environment in
which patients can wander at will. If the patient is at home,
caregivers can provide supervised exercise several times a day with
engaging activities between exercise periods. All wandering patients
should wear an identification bracelet or anklet and be enrolled in the
Alzheimer's Association Safe Return Program. National support groups like the Alzheimer’s Disease and Related Disorders Association may help. Conclusion
The dementias with challenging behaviours can be devastating and
debilitating. However, early diagnosis and proper treatment including
non-pharmacological treatment and institutionalisation in select cases
can help patients, their caregivers, and society at large.
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