Advertisement

Advertisement

dementia

Recognition of the Non-Alzheimer’s Dementias: Highlights from the University of Toronto Behavioural Neurology Clinic Day

Recognition of the Non-Alzheimer’s Dementias: Highlights from the University of Toronto Behavioural Neurology Clinic Day

Teaser: 

David J. Gladstone, BSc, MD, FRCPC; Lorne Zinman, MD, FRCPC; Jodie Burton, MD; Leanne Casaubon, MD; David Chan, MD; Neil Cashman, MD, FRCPC; Sandra E. Black, MD, FRCPC; Morris Freedman, MD, FRCPC.
From the Division of Neurology, University of Toronto, Toronto, ON.

At the Third Annual University of Toronto (U of T) Behavioural Neurology Clinic Day for residents, fellows and other trainees, presentations were given by faculty members from the U of T Department of Medicine (Divisions of Neurology and Geriatric Medicine) and the Department of Psychiatry. Highlights of this educational event are summarized herein by residents in the neurology training program.
Key words: dementia, diagnosis, fronto-temporal dementia, dementia with Lewy bodies, Creutzfeld-Jakob disease, vascular dementia.

The Experience of Implementing Nursing Best Practice Guidelines for the Screening of Delirium, Dementia and Depression in the Older Adult

The Experience of Implementing Nursing Best Practice Guidelines for the Screening of Delirium, Dementia and Depression in the Older Adult

Teaser: 

Rola Moghabghab, RN, MN,1 Lori Adler, RN, MHSc,2 Carol Banez, RN, MAN,1 Faith Boutcher RN, MSc,3 Athina Perivolaris, RN, MN,3 Donna-Michelle Rancoeur, RN, MSc(A),3 Donna Spevakow, RN, MSN,3 Sandra Tully, RN, MAEd,1 Susan Wallace, RN, MSc3 and Kevin Woo, RN, MSc.4

1Advanced Practice Nurse, University Health Network; 2Administrative Director, Regional Geriatric Program, Toronto Rehabilitation Institute; 3Advanced Practice Nurse, Toronto Rehabilitation Institute; 4Advanced Practice Nurse, Mount Sinai Hospital; Toronto, ON.

Confusion related to dementia, delirium and/or depression is a common concern in the older adult. The Registered Nurses Association of Ontario Best Practice Guideline (BPG),"Screening for Delirium, Dementia and Depression in the Older Adult", was implemented as a pilot project by Advanced Practice Nurses on eight different units at Toronto Rehabilitation Institute, University Health Network and Mount Sinai Hospital. This article describes the development of the BPG and its implementation, including the design of an education program and a screening process to assist nurses. Discussion focuses on the facilitators and barriers to BPG implementation and effecting sustainable change in practice.

The Long-term Prognosis of Delirium

The Long-term Prognosis of Delirium

Teaser: 

Jane McCusker, MD, DrPH, Professor, Epidemiology and Biostatistics, McGill University; Head, Clinical Epidemiology and Community Studies, St. Mary's Hospital, Montreal, QC.

Nine published studies of the outcomes of delirium with at least six months of follow-up were reviewed. The results indicate that: 1) the symptoms of delirium are more persistent than previously thought; up to 15% of those without dementia and 49% of those with dementia continued to have core symptoms of delirium 12 months after the initial diagnosis; 2) a diagnosis of delirium is an independent predictor of increased mortality for up to three years after diagnosis and; 3) a diagnosis of delirium predicts continued poorer cognitive and physical functioning for up to 12 months after diagnosis.
Key words: delirium, prognosis, dementia, functioning, cognitive status.

Cerebrovascular Pathologies in Alzheimer Disease

Cerebrovascular Pathologies in Alzheimer Disease

Teaser: 

John Wherrett, MD, FRCPC, PhD, Division of Neurology, Toronto Western Hospital and the University of Toronto, Toronto, ON.

This commentary addresses current views about the interaction of vascular disorders and Alzheimer disease, including vascular pathologies that may be intrinsic to the Alzheimer process as identified through demonstration of amyloid plaques and neurofibrillary tangles. The common cerebrovascular pathologies accompanying aging, mainly atherosclerosis and arteriosclerosis, will coincide in varying proportions with the Alzheimer pathology, also a concomitant to aging. Because interventions are available to modify both risks and complications of these vasculopathies, an important goal of dementia research is to develop means to characterize the contribution of cerebrovascular disease in Alzheimer and other dementias. Realization of this goal is confounded by the recognition that Alzheimer pathology, usually considered a parenchymal process, involves important vascular changes.
Key words: Alzheimer disease, dementia, cerebrovascular, pathology, imaging.

Falls in Older People with Dementia

Falls in Older People with Dementia

Teaser: 

Fiona E. Shaw, MRCP, PhD, Consultant Physician and Geriatrician, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, UK.

Older people with dementia are at increased risk of falls and their adverse consequences. Postural instability (impaired gait and balance), medication, environmental hazards and neurocardiovascular instability, in particular orthostatic hypotension, are commonly identified as risk factors for falls in this patient group. It is possible to modify risk factors for falls in older people with dementia. However, to date it has not been possible to demonstrate conclusively that intervention can prevent falls in patients with dementia.
Key words: accidental falls, dementia, cognitive impairment, postural instability, neurocardiovascular instability (syncope).

Blood Pressure and Dementia: An Ambiguous Relationship

Blood Pressure and Dementia: An Ambiguous Relationship

Teaser: 

An air of ambiguity surrounds the relationship between blood pressure and dementia. While some studies indicate that hypertension increases the risk of Alzheimer disease (AD) or other dementias, others seem to show that low blood pressure confers a higher dementia prevalence. The two observations are not necessarily contradictory, as demonstrated by a recent study at the Aging Research Center in Stockholm, Sweden. A community-based, longitudinal trial, the Kungsholmen Project was conducted to explore whether low blood pressure is prospectively associated with the occurrence of AD and dementia in the elderly.

The study population consisted of 1,270 dementia-free subjects (as determined by the MMSE) older than 75 years. At first follow-up of three years, 772 remained dementia-free and were tracked for the subsequent three years. During six-year follow-up, 339 of these patients developed dementia. The two groups did not differ significantly in their frequency of vascular disease or average systolic, diastolic or pulse pressures.

However, when statistically analysed, high systolic blood pressure (>180mmHg) conferred a significant increased risk for dementia (adjusted relative risk of 1.6) and for AD (adjusted relative risk of 1.5). High diastolic pressure (> 90mmHg) was not related to increased risk, but very low diastolic pressure (= 65mmHg) was related to an increased risk for both dementia and AD (adjusted relative risk of 1.5 and 1.7, respectively). Patients undergoing antihypertensive therapy at baseline were less likely to develop AD or other dementias than those who were not. Interestingly, though the use of antihypertensive medication did not significantly affect the association of dementia risk with systolic pressure, dementia risk was correlated with low diastolic pressure in patients using antihypertensive drugs.

The study confirms previous findings that high systolic blood pressure may be a risk factor for increased dementia incidence. Antihypertensive therapy appears to be largely protective against AD and dementia in the elderly. However, subjects with high systolic pressure remain in danger of developing dementia despite treatment, and subjects with low diastolic pressure may in fact be harmed cognitively by using antihypertensive drugs.

These results may reflect the contribution of high systolic and low diastolic pressure to arterial stiffness and widespread atherosclerosis, pathologies previously correlated with dementia and AD. The association between cognitive disease and low diastolic pressure may be further explained by previous studies, which have suggested that cerebral hypoperfusion may precede neurodegenerative pathological changes.

A major limitation of this study is that blood pressure was assessed only at baseline. Therefore, the results can only be used to determine whether blood pressure at a given point is a determinant of incident dementia, but not the direct effect of blood pressure fluctuations on dementia development.

In light of the observed results, antihypertensive therapy should be considered as a preventative for dementia with caution. Further studies are required to assess the precise points at which systolic and diastolic pressures most effectively minimise the risk for dementia. If such an ideal is established, perhaps the fine-tuning of blood pressure from an early stage in life can prevent cognitive decline further along the road.

Source

  1. Chengxuan Q, von Strauss E, Fastbom J, et al. Low blood pressure and risk of dementia in the Kungsholmen project. Arch Neurol 2003;60:223-8.

Diagnosis and Management of Creutzfeldt-Jakob Disease

Diagnosis and Management of Creutzfeldt-Jakob Disease

Teaser: 

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax. NS.

Creutzfeldt-Jakob disease (CJD) is rare, occurring in one per million people. It is difficult to eradicate from contaminated instruments, and so is important to recognise for infection control reasons. As well, there is much interest in possible changes in the epidemiology of this disease, and so familiarity is necessary among all physicians. Sporadic CJD presents in the young-old with a rapidly progressive dementia, while variant CJD presents in younger patients, initially with psychiatric symptoms. Electroencephalography, MRI and 14-3-3 protein testing are all helpful in the diagnostic process. There is no recognised therapy as yet.
Key words: Creutzfeldt-Jakob disease, variant Creutzfeldt-Jakob disease, prion, dementia.

Folate Deficiency, Homocysteine and Dementia

Folate Deficiency, Homocysteine and Dementia

Teaser: 

Sudeep S. Gill, MD, FRCP(C), Research Fellow, Division of Geriatric Medicine, University of Toronto and Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Folate deficiency is relatively common in older adults. There is now growing interest in the roles played by folate and B vitamins in the metabolism of homocysteine. Recent studies have suggested a link between elevated levels of homocysteine and the risk of Alzheimer disease. In this article, we will focus on the physiology and pathophysiology related to folate and homocysteine metabolism. We have also included a discussion of the laboratory evaluation of these compounds. Finally, we review the evidence supporting the relationships between folate deficiency, hyperhomocysteinemia and the development of dementia.
Key words: folic acid, vitamin B12, deficiency diseases, homocysteine, dementia.

Vitamin B12 Deficiency in the Elderly

Vitamin B12 Deficiency in the Elderly

Teaser: 

12 Deficiency in the Elderly

Sudeep S. Gill, MD, FRCP(C), Research Fellow, Division of Geriatric Medicine, University of Toronto and Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, Department of Medicine, University Health Network, Toronto, ON.

Vitamin B12 deficiency is a common disorder in older adults, but its diagnostic work-up and management can be complex. In this article, we review the metabolic pathways involving vitamin B12 and the various pathologies that can interfere with these pathways. This discussion provides a framework to understand the following section, which outlines an approach to the clinical examination, laboratory evaluation and treatment of subjects with suspected vitamin B12 deficiency.
Key words: vitamin B12, folic acid, deficiency diseases, dementia, aging.

The Relationships Between Alcohol and Dementia

The Relationships Between Alcohol and Dementia

Teaser: 

Ron Keren, MD, FRCPC, Clinical Director, University Health Network and Whitby Mental Health Centre Memory Clinics; Assistant Professor, University of Toronto, Toronto, ON.

In recent years, a number of observational studies have shown that when consumed in moderation, alcohol may contribute to healthy living, reducing the risks of both coronary artery disease and dementia. While the ill effects of excessive drinking on cognition have been extensively described, there are no clinical or pathological consensus criteria defining alcohol-induced dementia. In fact, its existence as a distinct entity is controversial. More research on the effects of alcohol on the brain is needed in order to advise patients on the potential risks and benefits of alcohol consumption.
Key words: alcohol consumption, dementia, prevention, cognition, Wernicke-Korsakoff.