Dementia and Alzheimer's Disease - Treatment options

Age related illnesses | May 23, 2014 | Author: The Super Pharmacist

alzheimers, memory, dementia, aricept, ebixa, exelon

Dementia and Alzheimer's Disease - Treatment options

What is Dementia?

Dementia is defined as disturbances of cognitive functions or memory, typically associated with advancing age. These disturbances can affect job performance and activities of daily living. Cognitive functions include:
  • The ability to reason and judge.
  • The ability to understand and solve problems.
  • Language and communication skills.
  • The ability to make and execute decisions.
  • The ability to recognise familiar situations, surroundings and faces.
Dementia may include one or all of these disturbances and is usually associated with a certain degree of memory impairment. The result is confused thinking, memory lapses, unusual behavior, personality changes and communication problems, all of which affect a person’s ability to cope with daily life situations. While dementia is typically associated with advancing age, it has to be understood that it is not an essential feature of aging. A majority (almost 80%) of the people who suffer from dementia have underlying Alzheimer’s disease which is a progressive irreversible condition. Alzheimer’s disease is so commonly the cause of dementia; the two terms are often used interchangeably. However it should be kept in mind that there are other causes of dementia as well and some of them are reversible.

Causes of Dementia:

The most common cause of progressive dementia:
  • Alzheimer’s disease.
Some reversible causes of dementia:
  • Vitamin B12 deficiency.
  • Vitamin B1 deficiency (alcoholism).
  • Hypothyroidism.
  • Certain medications.
  • Infections such as neurosyphilis.
  • Brain abscess or tumor.
  • Subdural hematoma.
  • Dementia secondary to liver or kidney disease.
Some causes of progressive dementia:
  • Vascular dementia1: the second most common cause of progressive dementia.
  • Lewy body dementia.
  • Frontotemporal dementia.
  • Huntington’s disease.
  • HIV-associated dementia.2
  • Creutzfeldt-Jakob disease.
It is important to identify the cause of dementia. If the cause is reversible, the dementia is treatable. If it is a progressive cause, cure is currently not achievable. Treatment options still exist for progressive dementia to slow progression of the disease process, alleviate patient symptoms and solve patient problems.

Management Goals for Dementia and Alzheimer’s Disease:

The emphasis in treatment options for dementia especially Alzheimer’s disease is care not cure. However as a first step, it is absolutely essential to rule out reversible and hence curable causes of dementia. This can be done by the attending physician through a proper history, physical examination, mental state examination and a panel of appropriate investigations.
  • For the reversible dementias the key is to find and treat the underlying cause. If this is done, there will be a remarkable improvement in the patient’s symptoms and if the cause can be fully cured, so can the dementia.
  • For the progressive dementias, most common of these being Alzheimer’s disease, there is no cure. But much can be done for the care of these patients. This means appropriate medications and non-pharmacological interventions such as certain lifestyle changes, adequate social support, cognitive therapies and a trial of alternative approaches may improve overall quality of life. Correct identification of the underlying etiology is still important as different causes of dementia would differ in specific treatment plans. Some general management measures are helpful in all cases of dementia irrespective of cause.
A prudent management plan for progressive dementias, including Alzheimer’s disease, would consider:
  • Planning for the future.
  • Lifestyle changes.
  • Social support and caretakers.
  • Medications.
  • Alternative approaches.

Planning for the future

Dementia such as Alzheimer’s disease is a chronic progressive condition. While this means that the condition worsens over time, it is a gradual process, spanning over years and it offers opportunity to the patient and caregivers to plan and prepare in advance. Some of the steps that can make a real difference in the long run are:
  • Financial preparedness: As cognitive functions decline over time, effective handling of financial matters becomes more and more difficult. Financial preparedness is important. This includes an assessment of current and future expenses and knowing how these will be met. A plan should be in place to take care of ongoing treatment costs. Suitable medical insurance cover should be sought and avenues of financial assistance explored.
  • Legal preparedness: An appropriate lawyer can assist with preparation of important legal documents. Examples of such documents are advance directives such as “do not resuscitate” (DNR) orders and living wills. Power of attorney for health supervision and for finances should be documented.

Lifestyle changes

  • Keeping a journal.
  • Regular exercise.
  • Healthy diet.
  • “Brainy” activities.
  • Quit smoking.3
  • Avoid excessive alcohol.4

Social support and Caretakers

  • Social activity and increased social support delays the onset of Alzheimer’s disease and slows its progress.
  • Caretakers themselves will need training to be able to take better care of dementia patients. Taking care of a dementia patient can be challenging and caretakers should have access to information, assistance and counseling.
  • Community services such as day-cares, assisted living facilities and nursing homes have a vital role to play.

Medications

Medications are an important aspect of dementia and Alzheimer’s disease management. However it should be understood that dementia treatment involves many levels of care and the best results can be achieved when medications are combined with non-pharmacological interventions. The important drug groups are: Drugs for cognitive symptoms These do not cure but help improve symptoms and slow the progression of disease. They are typically used in treating Alzheimer’s disease but can help with the other dementias as well. There are two main categories:
  • Cholinesterase inhibitors, such as donepezil and rivastigmine, aim to improve symptoms by inhibiting breakdown of a brain neurotransmitter (acetylcholine) involved in cognitive functions and memory. These are the recommended initial drugs for mild to moderate Alzheimer’s disease.
  • Memantine5 blocks another neurotransmitter (glutamate) and has been widely used for moderate to severe Alzheimer’s disease.
Since the two drug groups differ in mechanism of action, they can be used in combination for added benefits.6 Drugs for mood and behavioural disorders As a rule the first thing to do is to determine what is upsetting or agitating the patient and take care of the problem. Behavioural and mood drugs are employed only after knowing that the patient’s needs are otherwise met.
  • Antidepressants such as citalopram and fluoxetine can be used for persistent low mood.
  • Antipsychotic medications such as risperidone are used for agitation, aggression, hallucinations or delusions.
  • Anxiolytics such as lorazepam are indicated for anxiety and restlessness. Sleep disorders often accompany progressive dementia.
Many steps can be taken to improve sleep hygiene before resorting to drugs. Antidepressants or anxiolytics may help with sleep problems too. If nothing else works, a “sleeping pill” such as temazepam can be tried.

Alzheimers depressionAlternative approaches

People with dementia and Alzheimer’s disease frequently present with depression, upset mood, agitation or restless behavior. A number of alternative approaches can help, with variable success, to soothe them, reduce their anxiety levels and improve their sense of well-being. These approaches include aromatherapy, using plant oil fragrances, music therapy and massage therapy.

Latest Trends in the Management of Dementia and Alzheimer’s Disease

Cognitive therapies: These are non-pharmacological interventions aimed at improving cognitive function and memory impairment.
  • Cognitive stimulation therapy (CST) involves providing triggers to assist in recall; mental stimulation and encouraging communication.
  • Cognitive training is about mental exercises and games that are intended to enhance brain activity.
  • Cognitive rehabilitation is individualized and employs learning strategies.
Cognitive therapies are the latest trend in the management of dementia and Alzheimer’s disease, with some studies claiming almost as good results as with medications. However, available evidence is still inconclusive and results of further studies are awaited.

Alzheimer’s disease research

Alzheimer’s disease is a significant global problem and therefore a focus of worldwide medical research. Amyloid plaques and neurofibrillary tangles are the histological hallmarks of Alzheimer’s disease and are being studied extensively to gain insight into the disease process. Some believe we are close to finding a vaccine or drug that will be able to cure Alzheimer’s disease for good.

Dietary therapy:

Many foods, dietary supplements and herbal remedies are presented as alternative treatments having beneficial effects on memory and cognitive brain functions. They are thought to be helpful for patients with dementia and Alzheimer’s disease.
References:
1.  Iemolo F, Duro G, Rizzo C, et al. Pathophysiology of vascular dementia. Immun Ageing. 2009;6:13.
2. Kaul M. HIV-1 associated dementia: update on pathological mechanisms and therapeutic approaches. Curr Opin Neurol. 2009;22(3):315–320. doi:10.1097/WCO.0b013e328329cf3c.
3. Peters R, Poulter R, Warner J, Beckett N, Burch L, et al. (2008) Smoking, dementia and cognitive decline in the elderly, a systematic review. BMC Geriatr 8: 36.
4. Ridley NJ, Draper B, Withall A. Alcohol-related dementia: an update of the evidence. Alzheimers Res Ther. 2013;5:3. doi: 10.1186/alzrt157.
5. Reisberg B, Doody R, Stöffler A, Schmitt F, Ferris S, Möbius HJ. Memantine in moderate-to-severe Alzheimer's disease.  N Engl J Med.2003;348:1333-1341.
6. Tariot PN, Farlow MR, Grossberg GT, Graham SM, McDonald S, Gergel I. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. JAMA 291:317-324(2004).
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