Guylaine Ferland, PhD,Département de Nutrition, Université de Montréal; Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.
Carol E. Greenwood, PhD,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, and Kunin-Lunenfeld Applied Research Unit, Baycrest, Toronto, ON.
Bryna Shatenstein, PhD, PDt, Département de Nutrition, Université de Montréal; Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.

Abstract
While prospective epidemiologic studies have provided strong evidence linking higher intakes of many nutrients with slower rates of cognitive decline and reduced dementia risk, randomized controlled trials on supplementation with individual nutrients have largely been disappointing. In contrast, recent research points to substantial benefits for brain aging and cognition from consumption of a varied diet centred on plant-source foods, whole grains and fish, and avoidance of foods rich in saturated and trans fats. An unhealthy dietary pattern, in conjunction with obesity, low physical activity, and smoking, could contribute to a pro-inflammatory state and oxidative stress which could exacerbate risk for development of cognitive decline the metabolic syndrome, diabetes, and cardiovascular disease.
Keywords: nutrition, dementia, Alzheimer's disease, nutrients, dietary patterns.

Michael Gordon, MD, MSc, FRCPC, FRCP Edin, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
Natalie Baker, MSc, Project Coordinator, Baycrest Geriatric Health Care System, Toronto, On.

Abstract
Physicians and other health care providers have learned to approach end-of-life care issues in individuals suffering from malignant disease quite effectively. Palliative approaches are widely accepted for this population. In contrast, individuals suffering from end-stage dementia may also benefit from suitably tailored palliative care which is much less often considered or provided. It is incumbent on health care professionals responsible for treating those with end-stage dementia to offer palliative care. This must be preceded by proper discussions between afflicted individuals, their families and their health care providers to assure that they understand the progress and prognosis of end-stage dementia.
Keywords: dementia, palliative care, end-of-life care.

Mary A. Corcoran, OTR, PhD, Professor of Clinical Research and Leadership, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.

There is an average delay of 20 months between the first recognition of symptoms of Alzheimer’s disease or a related disorder (ADRD) and the seeking of physician help. One reason for this delay is tendency for families to miss early symptoms until the onset of behavioural disturbances. Families may provide more timely accounts with prompted questions. It is important to diagnose cognitive impairment early since there are potential benefits to early treatment. The purpose of this article is to help guide caregivers in identifying a list of symptoms that reflect first indicators of ADRD, based on a study of 68 spouse caregivers of patients with ADRD.
Key words: Alzheimer’s disease, dementia, caregivers, diagnosis, primary care.

Ellen Costello, PT, PhD, Assistant Professor of Physical Therapy, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.
Mary A. Corcoran, OTR, PhD, Professor of Clinical Research and Leadership, The George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.

Bathing individuals with dementia has been reported as one of the most difficult activities of daily living and often results in unwanted behaviours. A review of the literature on bathing practices for those with dementia resulted in few empirically tested bathing techniques. Based on this review and the authors’ clinical experience, the following guidelines are presented: (1) consider a towel/bed bath in lieu of a shower/tub bath—be flexible; (2) educate the caregiver (improved outcomes are noted)—communication is key; and (3) optimize the environment to meet the needs of the individual and to maintain safety.
Key words: dementia, Alzheimer’s disease, bathing, caregiver, hygiene.

L’apathie dans la démence est un important défi comportemental

Conférencière : Tiffany Chow, M.D., Clinicienne-chercheure, Institut de recherche Rotman ; Professeure adjointe, Neurologie et psychiatrie gériatrique, Université de Toronto, Toronto, ON.

La D^re Tiffany Chow a commencé par exprimer toute son estime, en tant que neurologue, à l’égard de ses collègues en gériatrie, dont elle admire la défense d’une approche plus holiste des patients atteints de démence, et de l’importance du travail d’équipe.
Elle a défini des aspects fondamentaux de la qualité de vie des personnes atteintes de démence : ne pas avoir de douleurs ; se sentir en sécurité ; pouvoir participer à des activités intéressantes ; et être à même de conserver le plus haut degré possible d’autonomie. La D^re Chow a également décrit des facteurs de qualité de vie pour les aidants : des liens affectifs ; la capacité d’aider le patient (p. ex., en le nourrissant) ; passer de bons moments ensemble ; et savoir que tout ce qui peut être fait est fait.

La D^re Chow a mis en garde contre les effets de l’apathie chez les patients atteints de démence, qui peut avoir des répercussions sur toutes les dimensions de la qualité de vie décrites précédemment. L’apathie est un symptôme commun et important de la démence. Bien que l’apathie puisse signifier une dépression, elle peut aussi survenir en l’absence de dépression, et chacune peut exacerber l’autre. L’apathie peut empêcher les patients atteints de démence d’être motivés à prendre physiquement part à des activités quotidiennes et, du fait du manque de stimulation, cet état peut hâter le déclin cognitif.¹ L’apathie intensifie aussi le désarroi de l’aidant, et nuit au lien affectif avec le patient. Elle diminue également l’adhésion au traitement (pharmacologique ou autre, p. ex. ludothérapie). L’apathie peut contribuer au placement en établissement ; des études ont révélé des taux plus bas d’apathie parmi les patients résidant dans leur communauté.

La D^re Chow a expliqué qu’il existe plusieurs réseaux neuronaux qui gèrent notre façon de prioriser ce que nous avons à faire et à ne pas faire, et une tentative de localiser l’apathie dans le cerveau a été faite (Figure 1). La recherche sur l’apathie a mis en évidence son lien avec le lobe temporal droit, le lobe frontal droit, le noyau caudé, la circonvolution cingulaire antérieure (ou le cortex frontal médian supérieur), et le cortex orbito-frontal.²

 

Dans leur étude récente,³ la D^re Chow et ses collègues ont cherché à déterminer de façon empirique des groupements de symptômes d’empathie, chez des patients atteints de démence, pour voir si les symptômes affectifs, comportementaux ou cognitifs de l’apathie avaient tendance à se produire ensemble ou de façon isolée, et si l’apathie se ma-nifestait typiquement en cooccurrence avec d’autres types de désordres comportementaux.

La D^re Chow a montré des données provenant de Baycrest, Sunnybrook [Centre des Sciences de la Santé], UC San Francisco, et UCLA, combinées pour donner les résultats de l’Inventaire neuropsychiatrique (NPI). Dans la section du NPI traitant de l’apathie, des patients sont interrogés sur l’activité spontanée, la spontanéité conversationnelle, la participation à leurs anciennes activités et à d’anciennes tâches, la démonstration de leur intérêt pour autrui, leur relations avec leurs amis et leur famille, et le degré d’affection.
Les résultats ont montré que, chez ceux qui présentaient soit une DFT, soit une démence de type Alzheimer (DTA), le type d’apathie le plus courant était, le cas échéant, une diminution de l’activité spontanée. Une comparaison du pourcentage d’apathie dans les deux types de démence a montré qu’il y avait plus de patients atteints de DFT (72 %) qui présentaient aussi une apathie que ceux qui avaient une DTA (56 %).

Ils ont également fait apparaître tous les types d’apathie : apathie affective (émoussement émotionnel) ; apathie comportementale (manque d’activation spontanée) ; et apathie cognitive (manque d’intérêt à s’engager dans une nouvelle activité cognitive). De nombreux patients présentaient les trois types, et presque tous en présentaient au moins deux. Et c’était le cas pour les deux types de démence.

Ils ont recherché sur le NPI une association entre l’apathie et d’autres variables non liées à l’apathie, comme l’impulsivité, l’angoisse de séparation et le comportement de résistance, et ont trouvé que ceux qui présentaient une apathie de type affectif étaient plus susceptibles d’avoir ces symptômes que ceux présentant d’autres types d’apathie ou aucune apathie.

Elle a parlé des résultats d’une étude de Robert et coll.⁴ qui indiquent que l’apathie peut être un prédicteur, en vertu duquel des patients ayant un trouble cognitif léger (TCL) évoluent en DTA.

Deux groupes, l’un en Amérique du Nord, l’autre en Europe, travaillent à faire inscrire l’apathie au DSM-V (Manuel diagnostique et statistique des troubles mentaux). Les critères en seraient le manque de motivation (relativement aux conditions initiales), le manque d’acti-vités dirigées vers un but (apathie cognitive), le manque d’intérêts ou de buts, et des réponses émotionnelles affaiblies (émoussement émotionnel).

Il convient d’envisager le traitement de l’apathie selon le type d’apathie.^1,5 Pour ceux qui présentent une apathie affective, un antidépresseur pourrait être de rigueur. On peut utiliser les psycho-stimulants dans l’apathie comportementale. Les inhibiteurs de la cholinestérase ont démontré une efficacité sur l’apathie cognitive. On a montré l’efficacité et la bonne tolérance de psychostimulants comme le méthylphénidate ; bien que la dextroamphétamine appartienne à la même classe thérapeutique, on ne dispose de preuves suffisantes que pour l’usage du premier. Des antidépresseurs et des agents dopaminergiques ont également été utilisés.

La D^re Chow a examiné si certains de ces médicaments, comme les neuroleptiques ou d’autres calmants, pouvaient occasionner une apathie en cas de démence. Avec ses collègues, elle a examiné ce point au cours d’une étude transversale chez 69 patients atteints de DFT. Sur les quatre médicaments de ce groupe les plus couramment utilisés – les anti-inflammatoires non stéroïdiens (probablement contre les symptômes de douleurs arthritiques), les inhibiteurs sélectifs du recaptage de la sérotonine, les inhibiteurs de la cholinestérase et les neuroleptiques – elle n’en a trouvé aucun qui augmente le risque d’apathie.

La D^re Chow a recommandé les articles de Robert et coll., 2009⁶ et de van Reekum et coll., 2005¹ à ceux qui désirent en apprendre d’avantage sur l’apathie.

Références:

1. van Reekum R, Stuss DT, and Ostrander L. Apathy: why care? J Neuropsychiatry Clin Neurosci 2005;17:7–19.
2. Mendez J, Lauterbach EC, and Sampson, SM. An evidence-based review of the psychopathology of frontotemporal dementia: a report of the ANPA Committee on Research. J Neuropsychiatry Clin Neurosci 2008;20:130–49.
3. Chow TW, Binns MA, Cummings JL, et al. Apathy symptom profile and behavioural associations in frontotemporal dementia vs. Alzheimer’s disease. Arch Neurol 2009;In press.
4. Robert PH, Berr C, Volteau M, et al. Importance of lack of interest in patients with mild cognitive impairment. Am J Geri Psych 2008;16:770–6.
5. Malloy PF and Boyle PA. Apathy and its treatment in Alzheimer’s disease and other dementias. Psychiatric Times 2005;XXII(13).
6. Robert P, Onyike CU, Leentjens AF, et al. Proposed diagnostic criteria for apathy in Alzheimer’s disease and other neuropsychiatric disorders. European Psychiatry 2009;24:98–104.

Apathy in Dementia Is a Significant Behavioural Challenge

Speaker: Tiffany Chow, MD, Clinician-Scientist, Rotman Research Institute; Assistant Professor, University of Toronto, Neurology & Geriatric Psychiatry, Toronto, ON.

Dr. Tiffany Chow began with expressing her appreciation, as a neurologist, for her colleagues in geriatrics, whom she honoured for promoting a more holistic approach to patients with dementia, and stressed the importance of working together.

She identified fundamental aspects of quality of life for people with dementia: being pain-free; safe; able to participate in meaningful activities; and able to maintain the greatest degree of autonomy possible. Dr. Chow also described contributors to quality of life for caregivers: emotional connection; the ability to aid the patient (e.g., in feeding); having good downtime together; and the knowledge that everything that can be done is being done.

Dr. Chow cautioned against the effects of apathy in patients with dementia, which can impact all dimensions of life quality described above. Apathy is a common and significant symptom in dementia. While apathy can signify depression, it can also occur in depression’s absence, and each can worsen the other. Apathy can keep patients with dementia from being physically motivated to participate in everyday activities and, due to lack of stimulation, this state can hasten cognitive decline.¹ Apathy also intensifies caregiver distress and thwarts emotional connection to the patient. It also diminishes treatment compliance (pharmacological or other, e.g., recreational therapy). Apathy may contribute to institutionalization; studies have found lower rates of apathy among community-dwelling patients.

Dr. Chow explained that there are several neuronal networks that manage how we prioritize what we need to do and not do, and they have attempted to localize apathy in the brain (Figure 1). Research into apathy has identified its association with the right temporal lobe, right frontal lobe, caudate, anterior cingulate gyrus (or superior medial frontal cortex), and the orbital-frontal cortex.²

 

In their recent study,³ Dr. Chow and her colleagues set out to localize clusters of apathy symptoms empirically, with actual patients with dementia, to see whether the affective, behavioural, or cognitive apathy symptoms tended to occur together or in isolation, and whether apathy typically co-occurs with other types of behavioural disturbances.

Dr. Chow showed combined data from Baycrest, Sunnybrook [Health Sciences Centre], UC San Francisco, and UCLA, showing results on the Neuropsychiatric Inventory (NPI). On the section of the NPI that deals with apathy, patients are questioned on spontaneous activity, spontaneity in conversation, participation in former activities, participation in former chores, demonstration of interest in others, investment in friends and family, and degree of affection.

Results showed that, for those with either FTD or Dementia of Alzheimer’s type (DAT), the most common type of apathy, when present, was a decrease in spontaneous activity. Comparing the percentage of apathy in the two types of dementia, more of the patients with FTD (72%) had apathy than those with DAT (56%).

They also demonstrated all the types of apathy: affective apathy (emotional blunting); behavioural apathy (lack of spontaneous activation); and cognitive apathy (lack of interest in engaging in new cognitive activity). Many patients had all three types, and almost all had at least two. This was true for both types of dementia.

They looked for an association between apathy and other non-apathy variables on the NPI, including impulsivity, separation anxiety, and resistant behaviour, and found that those with the affective type of apathy were much more likely to experience these symptoms than those with other types of apathy or no apathy.

She discussed the results of a study by Robert et al.⁴ that showed that apathy could be a predictive factor for which patients with mild cognitive impairment (MCI) will convert to DAT.

There are two groups, one in North America and one in Europe, who are working to get apathy added to the DSM-V (Diagnostic and Statistical Manual of Mental Disorders). The criteria would be lack of motivation (relative to baseline), lack of goal-directed activity (cognitive apathy), lack of interests or goals, and diminished emotional responses (emotional blunting).

Treatment for apathy should be considered on the basis of type of apathy.^1,5 For those with affective apathy, an antidepressant might be in order. For behavioural apathy, psychostimulants might be used. For cognitive apathy, cholinesterase inhibitors have shown efficacy. Psychostimulants such as methylphenidate have been shown to be effective and well-tolerated; while dextroamphetamine is in the same drug class, there is only sufficient evidence supporting use of the former. Antidepressants and dopaminergic agents have also been used.

Dr. Chow has looked at whether some of these drugs, for example antipsychotics or other sedatives, might cause apathy in dementia. She and her colleagues investigated this in a cross-sectional study on 69 patients with FTD. Of the four most commonly used medications in this group—nonsteroidal anti-inflammatories (probably for arthritic pain symptoms), selective serotonin reuptake inhibitors, cholinesterase inhibitors, and antipsychotics—none was found to contribute to a higher risk of apathy.

For those interested in learning more on the subject of apathy, Dr. Chow recommended articles by Robert et al., 2009⁶ and van Reekum et al., 2005.¹

References:

1. van Reekum R, Stuss DT, and Ostrander L. Apathy: why care? J Neuropsychiatry Clin Neurosci 2005;17:7–19.
2. Mendez J, Lauterbach EC, and Sampson, SM. An evidence-based review of the psychopathology of frontotemporal dementia: a report of the ANPA Committee on Research. J Neuropsychiatry Clin Neurosci 2008;20:130–49.
3. Chow TW, Binns MA, Cummings JL, et al. Apathy symptom profile and behavioural associations in frontotemporal dementia vs. Alzheimer’s disease. Arch Neurol 2009;In press.
4. Robert PH, Berr C, Volteau M, et al. Importance of lack of interest in patients with mild cognitive impairment. Am J Geri Psych 2008;16:770–6.
5. Malloy PF and Boyle PA. Apathy and its treatment in Alzheimer’s disease and other dementias. Psychiatric Times 2005;XXII(13).
6. Robert P, Onyike CU, Leentjens AF, et al. Proposed diagnostic criteria for apathy in Alzheimer’s disease and other neuropsychiatric disorders. European Psychiatry 2009;24:98–104.

Dylan Harris, MBBCh(Hons), MRCP, DipPallMed, Specialist Registrar in Palliative Medicine, Princess of Wales Hospital, Bridgend, UK.

Dementia is a progressive incurable illness. In the advanced stages of the disease, decisions need to be made whether to withhold or withdraw life-sustaining treatment. This article reviews the principles of deciding a patient’s best interests when he or she lacks mental capacity, the role of advance statements, and principles for the practising physician to consider in common withholding/withdrawing treatment scenarios that arise in clinical practice, such as artificial feeding, cardiopulmonary resuscitation, and antibiotics for pneumonia.
Key words: dementia, palliative care, withholding and withdrawing treatment, artificial feeding, resuscitation, antibiotics.

Eric Widera, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
Alex Smith, MD, Division of Geriatrics, University of California at San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.

This article highlights the complex challenges seen when managing pain in patients with moderate or advanced dementia. Recent evidence demonstrates that pain is often poorly recognized and treated in patients with cognitive impairment. The progressive decline in cognitive function often leads to difficulties in expressing and recalling painful experiences. Making pain assessments routine and combining patient reports, caregiver reports, and direct observation may help alleviate this poor recognition of pain. Once pain is confirmed, a comprehensive history and physical examination are central in determining the underlying cause of pain and in choosing the best modality to treat the pain.
Key words: dementia, cognitive impairment, pain, opioids, assessment.

Michael J. Passmore, MD, FRCPC, Clinical Assistant Professor, Department of Psychiatry, Geriatric Psychiatry Program, University of British Columbia, Vancouver, BC.

The following review uses case studies to illustrate the importance of a biopsychosocial approach to the assessment and management of behavioural and psychological symptoms of dementia (BPSD). Practical BPSD assessment strategies are reviewed, in addition to evidence-based and guideline-supported recommendations for acute and long-term BPSD management.
Key words: dementia, behaviour, agitation, antipsychotic, memantine.