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Should We Conduct Research on Persons with Dementia

Should We Conduct Research on Persons with Dementia

Teaser: 

Michael Gordon, MD, MSc, FRCPC
Vice President of Medical Services,
Baycrest Centre for Geriatric Care,
Professor of Medicine,
University of Toronto,
Toronto, ON.

The husband looked to his wife when he was asked if he would allow me to refer him to participate in a research trial. He admitted that he had some "memory" problems but was not really aware of the degree of his cognitive decline. His wife said she would consider it and discuss it with her husband and their children. She was distraught about the diagnosis of Alzheimer's disease and the future implications for his function and the requirements for his care. She wanted to know if the trial might help him. I explained the principles of a double-blind randomized drug trial and suggested that she discuss her concerns with the researcher conducting it.

Without research there is no progress in Medicine. Most people support the concepts of, and need for, medical research. Throughout history, some form of medical research has occurred. As an outcome of the horrific experiments done on involuntary subjects during the Nazi regime, and the more contemporary American studies on poor black syphilis victims in the Tuskegee experiment and the Willowbrook hepatitis study, a more rigorous and protective approach to human research has been developed.

Contemporary medical researchers are expected to understand the basic ethical principles that govern clinical research.

The Missing Link: Can the Treatment of Hypertension Prevent Dementia

The Missing Link: Can the Treatment of Hypertension Prevent Dementia

Teaser: 

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

Dementia and hypertension are two of the most common conditions affecting older adults. A number of recent studies suggest that dementia is one of the long-term complications of hypertension. Studies also suggest that the treatment of hypertension may prevent dementia. This brief review will focus on the relationship between hypertension and dementia in older adults.

Epidemiology of Dementia
Eight percent of Canadians who are over the age of 65 suffer from dementia, with Alzheimer's disease being the most common cause (approximately 60% of cases).1 Dementia is age-related, with the prevalence increasing from 2.4% of those from 65-74 years of age, to 34.5% of those 85 and older. Sixty thousand new cases occur each year in Canada.2 The cost of providing care to these patients is substantial, at 3.9 billion dollars/year, in 1991 dollars.3 Vascular dementia is the second most common cause of dementia in Canada, accounting for 20% of cases. When discussing vascular dementia, it is important to recognize that the classic pattern of multiple infarcts is found only in approximately 1/3 of the cases. The other cases consist of patients who have changes in their white matter (likely on the basis of small vessel ischemia) with or without lacunar infarcts, or, rarely, single strategic strokes.

Managing Your Patient’s Libido

Managing Your Patient’s Libido

Teaser: 


Medications May be of Limited Use for Treatment of Sexual Aggression in Dementia

Kiran Rabheru, MD, CCFP, FRCP(C)
Active Staff, Geriatrics
Psychiatry, London Psychiatric Hospital, London, ON

Until recently, most studies in dementia have focussed almost exclusively on cognitive dysfunction, rather than on the behavioural and psychological disturbances that occur in dementia (BPSD), which are often far more disturbing to the patient's caregivers. Specifically, there is very little published literature on inappropriate sexual behaviour in dementia (ISBsD). A stereotypic view of older adults as sexless, as well as relative disinterest in studying their patterns of sexual behaviour, have probably contributed to this lack of research into this important area.

From the neurologic viewpoint, the limbic system is the source of libido. Illnesses that damage the limbic system, with few exceptions, reduce the libido. Hence, in up to one third of patients with dementia, the change in sexual behaviour is one of sexual apathy. However, in patients with Alzheimer's dementia, hypersexuality and inappropriate sexual expression can also occur, and has been reported in 2 to 7% of these patients. Changes in the frontal lobe can cause alterations in personality such as disinhibition. Damage to the bilateral temporal lobe as a result of trauma, Herpes simplex, encephalitis, infarctions, and rarely, Alzheimer's or frontal lobe dementia (FLD) (e.g.

Treatment for End-Stage Dementia: Palliative Rather than Curative

Treatment for End-Stage Dementia: Palliative Rather than Curative

Teaser: 

An estimated 1.8 million people in the US alone are in the final stages of a dementing illness. A recent study in JAMA determined that patients with advanced dementias, who develop a superimposed acute illness such as a hip fracture or pneumonia, have a very poor prognosis. Given the limited life expectancy of these patients the study suggests that interventions should be palliative rather than curative.

Source

  1. Morrison, R.S. and Siu, A.L. JAMA. 2000. 284:47-52.

Atypical Antipsychotics (including Risperidone and Olanzapine): Indications in Dementia

Atypical Antipsychotics (including Risperidone and Olanzapine): Indications in Dementia

Teaser: 

Philip Dopp, BSc

Dementia manifests itself in many ways within elderly populations. Given that symptoms associated with dementia, such as psychosis or behavioral disturbances, are common reasons for nursing home placement, it is not surprising that between 40% and 90% of residents of such institutions have some degree of dementia.1,2 In recent years, atypical antipsychotics such as risperidone and olanzapine have been used with increasing frequency to deal with these distressing symptoms of dementia. Because of their favorable side effect profile, when compared to typical antipsychotics, and because studies have shown them to have equal, if not greater efficacy than typical antipsychotics, many geriatric psychiatrists recommend atypical antipsychotics as first-line treatment for psychosis and aggression in dementia.

The behavioral problems associated with dementia can be categorized as either non-aggressive or aggressive. Nonaggressive behavior includes wandering, pacing, bossiness, complaining and attention-seeking acts, while aggressive behavior includes hitting, pushing, scratching, biting, kicking and screaming. Management of these problems depends upon both the severity of the problem and the potential for the patient to harm themselves or others. In all cases, nonpharmacologic interventions, such as distracting the patient from the problem behavior, creating a structured environment for the patient and developing support groups for the caregiver, are appropriate.

CCCAD: More Effort to be Spent on Distribution

CCCAD: More Effort to be Spent on Distribution

Teaser: 

A. Mark Clarfield, MD

In 1989 the first Canadian Consensus Conference on the Assessment of Dementia (CCCAD) met in Montreal to try to come to grips with the vexed question of dementia assessment. In those days, there was still a lively debate going about the extent to which dementia should be worked up in an attempt to find the "reversible" cases.

Nearly ten years later in 1998, the group reconvened to look at assessment again but extended its mandate as well. What follows is a brief "compare and contrast" essay which examines what the two meetings had in common as well as how they differed.

To start off, they were both held in the beautiful city of Montreal, in 1989 under the joint chairmanship of myself and Dr. Serge Gauthier. In 1998, Dr. Gauthier was still in charge but this time Dr. Chris Patterson of McMaster University joined as the co-chair. (In 1992, I had moved to Israel, but was honoured to be invited back.)

In 1989 before (or perhaps at the beginning of) the extensive government cutbacks, we were able to fund the meeting with 50% government money, both federal and Quebec provincial. The rest of the support came from private sources, mainly drug companies. By 1998 it seems that government wanted no part of consensus meetings at least in the field of the dementias, and they did not participate in the funding this time.

A decade ago the 38 participants were mainly Canadian with four American visitors.

Canadian Consensus Conference on Dementia

Canadian Consensus Conference on Dementia

Teaser: 

Christopher Patterson, MD, FRCPC
Division of Geriatric Medicine
McMaster University
Hamilton, ON

  • What do you do when an older man complains that his wife is more forgetful than one year ago?
  • Can you distinguish depression from dementia in an older women who is having difficulty looking after herself?
  • How do you manage an individual with dementia who resides in a nursing home and becomes aggressive?

Approaches to these and other clinical situations are addressed in the recently published conclusions from the Canadian Consensus Conference on Dementia.1 This work built upon the earlier recommendations of the Canadian Consensus Conference on the Assessment of Dementia which was published in 1991.2 For the recent con- ference, a more comprehensive view of dementing conditions was undertaken. A panel of Canadian experts in the areas of Geriatric Medicine, Geriatric Psychiatry, Neurology, Family Medicine and other disciplines undertook an evidence-based approach to the recognition, assessment and management of dementing disorders. Recommendations are targeted towards primary care physicians in Canada.

Are Canadian MDs Overprescribing Anti-psychotics in Nursing Homes?

Are Canadian MDs Overprescribing Anti-psychotics in Nursing Homes?

Teaser: 

Anna Liachenko, BSc, MSc

Although anti-psychotic medications produce substantial side effects in the elderly, these drugs are extensively prescribed in nursing homes. Nursing home studies conducted in the United States in the 1980s showed that anti-psychotics were often used to manage disturbing behavior that did not fall into the clinical definition of psychosis. In 1987, the use of anti-psychotics was restricted by the Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA87). The reform spelled out the exact guidelines for the use of each anti-psychotic drug in the elderly, thereby substantially reducing the amount of prescribed medication in nursing homes. Whether Canadian physicians also overprescribe anti-psychotic drugs is not clear. At present, clinical studies are being conducted to estimate the extent of anti- psychotic use and to find strategies to safely reduce the amount of medication when possible.

Mental illnesses, dementia in particular, are often accompanied by behavioral disturbances. This is often the primary reason for placing the older person in a nursing home. Thus, the prevalence of behavioral disturbances in nursing home residents is high and is estimated to be close to 60%. Only 10% of these behaviors are psychotic, i.e. accompanied by "delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature" (DSM-IV).

Young People Should Not be Afraid of Aging: Profile of Dr. Serge Gauthier

Young People Should Not be Afraid of Aging: Profile of Dr. Serge Gauthier

Teaser: 

Olya Lechky


Dr. Serge Gouthier

Canada now has the distinction of being in the international forefront of research into the causes and treatment of Alzheimer's Disease (AD). This is due in no small measure to the efforts of Dr. Serge Gauthier and colleagues Drs. Judes Poirier and Rémi Quirion who in 1997 won the prestigious Prix Galien Canada. The award is bestowed annually in recognition of outstanding research contributions in basic science and clinical care.

Dr. Gauthier, director of the Alzheimer's Disease research unit at the McGill Centre for Studies in Aging in Montreal, has been immersed in AD research for over two decades. He has published 175 scientific papers in a host of scientific journals and was the editor of 52 contributions to a textbook called The Clinical Diagnosis and Management of Alzheimer's Disease. "This is the number one textbook on AD in the world right now. So Canada is very much in the forefront in this field.