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Pharmacologic Treatment of Agitation and Apathy in Dementia

Pharmacologic Treatment of Agitation and Apathy in Dementia

Teaser: 


Shailaja Shah, MD, Clinical Assistant Professor, Assistant Director Geriatric Psychiatry Fellowship, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Gautam Rohatgi, DO, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Daniela Ganescu, MD, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.

Switching Cholinesterase Inhibitors: When and How

Switching Cholinesterase Inhibitors: When and How

Teaser: 


Chris MacKnight, MD, MSc, FRCPC, Associate Professor, Department of Medicine, Dalhousie University, Halifax, NS.

Three cholinesterase inhibitors are available in Canada for the treatment of mild and moderate Alzheimer’s disease. As the three agents differ in their pharmacology, switching among them does sometimes make sense. Switching may be necessary because of intolerance, lack of response, and occasionally loss of response. This article will describe how and when to switch cholinesterase inhibitor.
Key words: Alzheimer’s disease, treatment response, cholinesterase inhibitors, switching, dementia.

The Latest in Drug Therapy for Dementia: Gleanings from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia

The Latest in Drug Therapy for Dementia: Gleanings from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia

Teaser: 

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

David B. Hogan MD, FACP, FRCPC, Professor and Brenda Strafford Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

A number of agents are available for treatment of Alzheimer’s disease (AD). They include drugs with a specific indication for AD, nutritional supplements, herbal preparations, and drugs approved for other conditions. Cholinesterase inhibitors (ChEIs) such as donepezil, galantamine, and rivastigmine are modestly effective for mild to moderate stages of AD. Memantine has a slight, beneficial effect on moderate to severe stages of AD. As ChEIs and memantine have different mechanisms of action, they can be used together. Antioxidants, B vitamins, anti-inflammatories, HMG-CoA reductase enzyme inhibitors, and sex steroids can not be recommended for the treatment of AD at the present time.
Key words: Alzheimer’s disease, drug therapy, cholinesterase inhibitors, memantine, dementia.

An Update on Pharmacotherapy for Dementia

An Update on Pharmacotherapy for Dementia

Teaser: 

Those who read my brief introductions to Geriatrics & Aging each month know that I am very interested in dementia. Every geriatrician is involved in managing patients with dementia, but that is very different from being “interested.” I think for many of us “Johnny Come Lately” types (I include myself in that group), the topic became popular when the first of the cholinesterase inhibitors became available for clinical use. Although they are hardly miracle drugs, they do make a difference and, even more importantly, they inspire hope in patients, families, and doctors. The enhanced monitoring of these patients sparked by these medications means better general medical care and hence better outcomes than can be ascribed to the medications alone. As a result, in the original drug trials, patients treated with placebo did better than historical controls with Alzheimer disease. Another improvement in care has resulted from multidisciplinary memory clinics. The skills and knowledge of occupational therapists, social workers, nurses, and others are now often available to patients with dementia, further improving their outcomes and relieving some of the incredible stress that families and caregivers experience.

Nevertheless, it is still frustrating that we do not have more efficacious pharmacological treatments for dementia such as are available for another common degenerative neurological disorder, namely, Parkinson’s disease. However, research is ongoing, and there is now more light shining at the end of the tunnel. The theme of this edition of Geriatrics & Aging is, therefore, new drug treatments for the management of dementia.

We start off with our CME article focused on “The Latest in Drug Therapy for Dementia: Gleanings from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia” by Dr. David Hogan, former president of the Canadian Geriatrics Society (CGS). A general overview of what we are likely to see in the coming years as far as drug therapy is concerned is covered in the article “Emerging Drug Therapies in Alzheimer’s Disease” by my colleague Dr. David Tang-Wai. However, recognizing that cholinesterase inhibitors are still the mainstay of pharmacological management we also have an article on “Switching Cholinesterase Inhibitors: When and How” by Dr. Chris MacKnight, a former president of the CGS. Although as doctors we tend to focus on the cognitive issues in dementia, for families the behaviour of individuals with dementia is often the “make or break” problem that leads to institutionalization. This topic is addressed in the article “Pharmacologic Treatment of Agitation and Apathy in Dementia” by Drs. Shailaja Shah, Gautam Rohatgi, and Daniela Ganescu.

We have an assortment of other articles on issues of importance to older patients. The Cardiovascular Disease column is “Treatment of High-Risk Older Adults with Lipid-Lowering Drug Therapy” by Dr. Wilbert Aronow, a frequent contributor to this journal and also one of the world’s best-known specialists in geriatric cardiology. Not surprisingly, our Dementia column “Dementia: Recognition of Psychotic Symptoms among Older Adult”’ by Dr. Abi Rayner and our Caregiving column “Everyday Functioning across the Spectrum of Cognitive Impairment” by Dr. Holly Tuokko are also related to this month’s focus theme. Our Men’s Health column is entitled “Why Men Die Younger than Women” by Dr. Bridget Gorman & Dr. Jen’nan Ghazal Read. Dr. Timothy O. Lipman thoroughly reviews “The Role of Herbs and Probiotics in GI Wellness for Older Adults” for our Nutrition column. Our final article is a case study on a topic that I have found to be absolutely fascinating, having reviewed the literature at one point after seeing a couple of affected patients in my clinic. It is entitled “Visual Hallucinations among Older Adults: The Charles Bonnet Syndrome” by Dr. Nages Nagaratnam, with peer commentary by Dr. François Sirois.

Enjoy this issue,
Barry Goldlist

Dementia: A Systemic Approach to Understanding Behaviour

Dementia: A Systemic Approach to Understanding Behaviour

Teaser: 


Sylvia Davidson, MSc, BSc, Dip Ger, OT Reg.(Ont.), Psychogeriatric Resource Consultant, Toronto Rehabilitation Institute, Toronto, ON.

Caregivers frequently struggle to manage challenging behaviours associated with dementia, often without a good understanding of why these behaviours occur. This article presents a simple framework to help build understanding as well as a systematic approach to dealing with resistance to care.
Key words: dementia, caregiver, systematic approach, understanding behaviour, resisting care.

Vascular Dementia and Alzheimer’s Disease: Diagnosis and Risk Factors

Vascular Dementia and Alzheimer’s Disease: Diagnosis and Risk Factors

Teaser: 


Elise J. Levinoff, MSc, BSc, University of Ottawa, Faculty of Medicine, Ottawa, ON.

Dementia is a neurological disease that is associated with aging. The incidence and prevalence of dementia is increasing as the population continues to age. The two most common forms of dementia are Alzheimer’s disease (AD) and vascular dementia (VaD). Although these two forms of dementia represent different pathologies and different clinical presentations, they share similar risk factors. It is important to distinguish between the two forms of dementia because of the differing treatments, and because the risk factors for each are often preventable. This article will discuss the classification, risk factors, and diagnosis of AD and VaD, and present distinguishing characteristics between them.
Key words: dementia, Alzheimer’s disease, vascular dementia, stroke, memory.

The Genetic Profile of Dementia

The Genetic Profile of Dementia

Teaser: 


Yosuke Wakutani, MD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.
Peter St. George-Hyslop, MD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.
Ekaterina Rogaeva, PhD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.

There are ~200 human diagnostic categories presenting as or accompanying dementia (interested readers may investigate the database Online Mendelian Inheritance in Man, a catalog of human genes and genetic disorders, at www.ncbi.nlm.nih.gov/ genome/guide/human/). Many forms of dementia are associated with deposition of different aberrant proteins in the brain. Familial aggregation in Alzheimer’s disease (AD), frontotemporal dementia (FTD), and other forms of dementia implies the presence of inherited susceptibility factors. Many forms of dementia remain genetically unexplained; however, linkage analyses suggest that most of them are complex disorders with several underlying genetic factors. Here we provide an update on known genes responsible for dementia with the strongest focus on AD and FTD, which are the most common forms of dementia.
Key words: dementia, Alzheimer’s disease, gene, APP, APOE, frontotemporal dementia.

Is Cholesterol a Memory Thief?

Is Cholesterol a Memory Thief?

Teaser: 


D. Larry Sparks, PhD, Senior Scientist and Head, Roberts Laboratory for Neurodegenerative Disease Research, Sun Health Research Institute, Sun City, AZ, USA.

The primary care physician is often pressed with first-line treatment of Alzheimer’s disease (AD). A number of FDA-approved therapies are available. Emerging data indicate that circulating cholesterol levels may influence progression of the dementing disorder. A recent pilot, proof-of-concept, placebo-controlled clinical trial suggests that the cholesterol-lowering medication atorva-statin provides benefit in treating mild-to-moderate AD. Although not approved for the treatment of AD, statin therapy might be considered in the setting of elevated cholesterol levels--even when LDL/HDL ratios are acceptable.
Key words: Alzheimer’s disease, cholesterol, statins, dementia, atorvastatin.

Improving Detection Rates and Management of Dementia in Primary Care through Educational Interventions

Improving Detection Rates and Management of Dementia in Primary Care through Educational Interventions

Teaser: 


Kristin Casady, Editorial Director, Geriatrics & Aging.

A recent study examined the effectiveness of educational interventions in improving detection and management of dementia in the primary care setting (BMJ 2006;332:692-6). Achieving improved detection rates and advances in the provision of ongoing care for demented individuals is facilitated by the integration of decision support systems and practice-based workshops, the study’s authors concluded.

Introduction

Primary care practitioners play a role of fundamental importance in diagnosing dementia as they are the point of patients’ first medical contact. Practitioners must deliver prompt intervention and provide ongoing care for their patients receiving the diagnosis, yet inadequate detection and management have been widely documented. Further, it is observed that clinicians often face profound obstacles in executing this role. There may be difficulty in assessing the presence of dementia (for a recent discussion of the diagnosis and treatment of the older adult with cognitive complaints, see Myronuk L. Pitfalls in the diagnosis of dementia. Geriatrics Aging 2006;9:12-9). Challenges are reported to include such barriers as a lack of resources and insufficient cooperation among the general practitioner’s team, involved specialists, and community services.

Assessing Effective Diagnosis and Management: Study of U.K. Practices
Thirty-six general practices in the United Kingdom (central Scotland and London) were recruited as settings for an unblinded, cluster randomized, before-and-after controlled study organized around the provision of three educational interventions: one, a CD-ROM tutorial; two, decision-support software built into the practices’ electronic medical records; and three, practice-based workshops for the general practitioners (the curriculum used is available for download from the U.K.’s Alzheimer’s Society website, www.alzheimers.org.uk). Eight practices were randomly assigned to the electronic tutorial; eight to decision-support software; 10 to practice-based workshops; and 10 to control. Results were obtained from 450 valid and usable records. The design of the interventions was modeled to reflect different approaches to adult learning: the electronic tutorial for self-directed learning; decision-support software for real-time investigations of actual cases; and workshops to facilitate peer communication about the cases under consideration.

Based on searches of the record system for the terms dementia, confusion, memory loss, and cognitive impairment, all practices identified registered patients aged 75 and over who were diagnosed as having dementia or had been assessed as having probable dementia by a general practitioner or specialist.
Investigators audited detection rates prior to and approximately nine months after the intervention. Analysis was conducted of differences in baseline concordance scores with best-practice guidelines for the diagnosis and management of dementia, repeating the analysis for postintervention scores. The ten-item diagnosis concordance score gathered data on items that included whether clinicians took measures such as requesting blood tests at index consultation, took full histories, undertook cognitive testing, and completed scans, both at index consultation and then secondarily after index consultation (before diagnosis). Management concordance scores tracked items such as concerns of caregivers, behaviour problems, depression screening/treatment, referrals to social services, and initiation of pharmacological treatment regiments.

Outcome: Improved Rates of Detection

Regarding changes in rates of detection, diagnosis, and management, the study’s authors noted improved rates of detected dementia with decision-support software and practice-based workshops compared with control: individuals identified as having dementia after the interventions represented 31% of all cases diagnosed in the practice-based workshops arm, 20% in the electronic tutorial arm, 30% in the decision support software arm, and 11% in the control arm. Authors reported the positive effect of the decision-support software as particularly encouraging, with practitioners describing software as simple and practical to implement. However, no difference in concordance with guidelines regarding the management of dementia was noted. This outcome was ascribed to the modest number of cases identified after the intervention and the relatively few cases in the control arm. The result was also described as traceable to the investigators relying on the medical record for evidence of practice; they postulated that practitioners may have improved their practice but not noted it. The authors highlighted the value of focussed educational interventions directed at improving clinical record-keeping.

Conclusion
Successful management of dementing illnesses depends first on effective detection. This study affirms that interventions such as decision-support software and practice-based workshops can improve those rates. The authors highlight that future interventions aimed at improving concordance with recommended diagnosis or management may be furthered by the effect of combining locality initiatives with practice-based interventions, such as ones that incorporate local opinion leaders as well as encourage the direct involvement of patients and caregivers.

Dental Considerations for Persons with Dementia

Dental Considerations for Persons with Dementia

Teaser: 

Michael J. Sigal DDS, MSc, Dip Ped, FRCD(C), Professor and Head, Pediatric Dentistry, Faculty of Dentistry, University of Toronto; Director of Dental Services, Toronto Rehabilitation Institute; Dentist-in-Chief and Director, Dental Program for Persons with Disabilities; Mount Sinai Hospital, Toronto, ON.

Due to the increase in the older population, the management of individuals with dementia in long-term care settings will continue to present a challenge to the health care team. Many individuals with dementia will have some or all of their teeth upon admission due to improved dental care throughout their lives. Oral hygiene and oral care for individuals with dementia is generally poor in long-term care; however, the continuance of good oral health is essential both to maintain the demented individual’s quality of life and to prevent infections that may affect his/her general health. The maintenance of good oral health has the potential to reduce the incidence of long-term care-acquired pneumonia. This article presents an overview of the relationship between oral and general health in the demented patient and then provides an overview regarding oral assessment, treatment, and prevention of dental disease.
Key words: dementia, dental caries, dental plaque, aspiration pneumonia, oral hygiene.