David F. Tang-Wai, MDCM, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; University Health Network Memory Clinic, University of Toronto, Toronto, ON.
Naida L. Graham, PhD, Research Associate, Department of Speech-Language Pathology, University of Toronto; University Health Network Memory Clinic, University of Toronto; Toronto Rehabilitation Institute, Toronto, ON.

Impairment in language is a common finding among individuals with dementia and can be a presenting symptom, particularly in Alzheimer’s dementia and primary progressive aphasia. Early recognition of language dysfunction can help with an accurate diagnosis, management, and prognosis. There are numerous established and validated language evaluation protocols. This article provides a simple means for the primary care physician to identify and evaluate language disorders in dementia, but it is not meant to replace established protocols.
Key words: aphasia, dementia, primary progressive aphasia, semantic dementia, Alzheimer’s disease.

Eran Metzger, MD, Associate Director of Geropsychiatry, Hebrew SeniorLife, Boston; Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA, USA.

The management of depression among individuals with dementia can be one of the more challenging problems in geriatric practice. Depression in dementia is common regardless of the type of dementia and compounds the impairment of the underlying dementing illness. Some symptoms of dementia, including apathy, impaired concentration, and decreased food intake, may be difficult to distinguish from similar symptoms of depression. This article presents background information on the epidemiology and pathophysiology of depression in dementia followed by recommendations for a systematic approach to diagnosis. Treatment modalities including psychotherapy, pharmacotherapy, and electroconvulsive therapy are reviewed.
Key words: dementia, depression, Alzheimer’s disease, psychotherapy, psychopharmacology.

Tarek Rajji, MD, Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Benoit H. Mulsant, MD, MSc, FRCPC, Western Psychiatric Institute and Clinic and Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA; Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto, Toronto, ON.
Hiroyuki Uchida, MD, PhD, PET Centre, Centre for Addiction and Mental Health, Toronto, ON.
David Mamo, MD, MSc, FRCPC, PET Centre and Geriatric Mental Health Program, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto; Centre for Addiction and Mental Health, Toronto, ON.

Antipsychotics are increasingly being prescribed to older patients for the management of a variety of neuropsychiatric conditions. Available evidence supports the use of second-generation antipsychotics (SGAs) when treating these conditions. However, given their modest clinical effect for certain conditions (e.g., behavioural and psychological symptoms of dementia), their adverse effects, and their safety profile, a careful analysis of their risks and benefits is needed before initiating treatment with an SGA for an older patient. Among SGAs, choice of medication should be guided by their respective clinical indications and adverse effect profile, with use of lower initial and target doses (compared to younger adults) and periodic reviews of whether or not their continued use is warranted.
Key words: antipsychotics, older adults, dementia, delirium, schizophrenia.

Andrea Németh, MA, Managing Editor, Geriatrics and Aging.

Current research indicates that some 67% of dementia-related deaths occur in long-term care (LTC) facilities.¹ The Alzheimer’s Association, a voluntary health organization that provides Alzheimer’s care, support, and research in the United States, recently released the third phase of its evidence-based Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes, which covers end-of-life care practices and issues.

An interdisciplinary team of dementia experts (including physicians, researchers, social workers, and nurses) agreed that communication and advance planning are central to quality care because they “permit residents to receive the care that they would want if they could speak for themselves, and enable families to make the best possible decisions on behalf of their loved ones.”² The timing of communication about end-of-life and care planning meetings, establishing a proxy decision maker, and educating the resident and family about care and treatments are discussed in detail, and special attention is given to matters such as weighing risks and benefits of pharmacotherapy for residents at the end of life. The guide’s section on physical symptoms urges training of direct care workers, who are often the first to notice changes in residents’ behaviour or symptoms, to recognize and report symptoms that may suggest pain or distress. The recommendations regarding behavioural symptoms remind the care team that behavioural interventions should only be pursued if the behavioural symptom is distressing to the resident involved or poses a risk to the resident or others, and after the source of the behaviour has been determined not to be untreated pain, dehydration, or some other physical symptom.

The recommendations foreground support for the family of patients with dementia. Long-term care facilities are advised to make staff available to educate, counsel, and comfort family members about the signs of approaching death, what will happen when death occurs, and the multiple-stage grieving process that takes place when a loved one dies with dementia.

The recommendations conclude that improving the conditions for individuals dying with dementia in long-term care will become more and more important as the population ages; implementation of these practices will contribute to the experience of a comfortable, dignified death for the individual and a caring, supportive environment for their family.

References

1. Mitchell SL, Teno JM, Miller SC, et al. A national study of the location of death for older persons with dementia. J Am Geriatr Soc 2005;53:299-305.
2. Tilly J, Fok A. Quality end of life care for individuals with dementia in assisted living and nursing homes and public policy barriers to delivering this care. Alzheimber’s Association 2007.

Evelyn Hutt, MD, Associate Professor of Medicine, University of Colorado at Denver and Health Sciences Center; Director, Colorado Research in Care Coordination, VA Eastern Colorado HCS, Denver, CO, USA.
Martha D. Buffum, DNSc, APRN, BC, CS, Associate Chief Nurse for Research, VA Medical Center, San Francisco; Associate Clinical Professor, School of Nursing, University of California, San Francisco, CA, USA.
Regina Fink, RN, PhD, FAAN, Research Nurse Scientist, University of Colorado Hospital, Aurora, CO, USA.
Katherine R. Jones, RN, PhD, FAAN, Sarah Cole Hirsh Professor and Associate Dean for Evidence-Based Practice, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA.
Ginette A. Pepper, PhD, RN, FAAN, Professor and Helen Lowe Bamberger Colby Endowed Chair in Gerontological Nursing Associate Dean for Research and PhD Program, University of Utah College of Nursing, Salt Lake City, UT, USA.

Pain is common among long-term care residents and is often undertreated. A high prevalence of dementia, sensory impairment, and disability, as well as structural issues such as staffing patterns and turnover in long-term care facilities make assessment and management of pain challenging. An overview of the evidence regarding the assessment and treatment of pain in individual residents, and recommendations for improving the overall quality of pain management in the long-term care setting, is presented.
Key words: pain, dementia, long-term care, pain assessment, pain management.

Ashok Devasenapathy, MD, Assistant Professor of Medicine and Neurology, Penn State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
Rathna Muthukumaran, MD, Graduate Student, Faculty of Psychology, Penn State University, Harrisburg, PA, USA.
Vladimir Hachinski, MD, Distinguished Professor Emeritus, Professor of Neurology, Clinical Neurosciences, University of Western Ontario, London, ON.

The term “vascular dementia” should be considered obsolete, a reflection of the 20th century concept that dementia does not respond to preventive measures, is always a neuro-degenerative disease, is not reversible, and has no treatment. A new approach necessitates the redefinition of vascular dementia as vascular cognitive impairment (VCI), with “dementia” as the terminal manifestation of a treatable process. Vascular cognitive impairment encompasses the vascular component of all dementias and is hence the only treatable element of a disease that has a highly significant impact on the health of older adults at risk for both strokes and coronary artery disease (cardiovascular disease).
The principal aim of this article is to illustrate the relationship between cognitive loss among older adults with vascular risk factors, stroke, and cardiovascular disease. Such an approach should help in understanding the basis for VCI, its prevention, and treatment.
Key words: vascular cognitive impairment, preventable senility, brain at risk, dementia, stroke.

Angela K. Troyer, PhD, CPsych, Department of Psychology, Baycrest Centre for Geriatric Care, Toronto, ON.
Kelly J. Murphy, PhD, CPsych, Department of Psychology, Baycrest Centre for Geriatric Care, Toronto, ON.

Functional decline in dementia causes increased dependence on others and negatively impacts quality of life. Emerging evidence indicates that functional debility can be delayed or minimized by promoting an active lifestyle and using memory strategies. Older adults with active lifestyles maintain higher cognitive abilities and have reduced risks of developing dementia. Furthermore, individuals with dementia show improved cognitive and functional abilities following participation in physically and mentally stimulating activities. Memory strategy application can improve situation-specific memory performance in individuals with mild cognitive impairment and dementia, and has been shown to positively impact perceptions of well-being and functional ability in these individuals.
Key words: active lifestyle, dementia, memory intervention, mild cognitive impairment, rehabilitation.

The focus of this issue is Altered Mood and Behaviour in the Older Adult. Although the most common diseases producing changes in mood or behaviour are depression and dementia, altered behaviour may also be the first indication of delirium. Whenever an older adult’s behaviour changes abruptly, delirium should be the first thought that comes to the clinician’s mind. I served as an expert witness several years ago at a coroner’s inquest for an older woman who died in long-term care. The nurse had meticulously detailed changes in behaviour that were classic signs of delirium, but did not understand the significance of these changes and so did not inform the attending physician of them. When the doctor arrived on her usual day to round on her patients, she immediately recognized the gravity of the situation and sent the patient to hospital, where she died shortly thereafter of sepsis and hyperglycemia. A totally preventable death would have been avoided had the staff understood the significance of the change in the patient’s behaviour. The Registered Nurses’ Association of Ontario has been very active in developing educational modules to help nurses distinguish delirium, dementia, and depression, to the great benefit of hospitalized patients.

Over the last few years, our understanding of vascular dementia has expanded beyond the mere presence of strokes in an individual with dementia, and we are now appreciating the more subtle manifestations of the disease. One of the most common behavioural issues that geriatricians see, “Post-Stroke Depression” is discussed by Drs. Lana Rothenburg, Nathan Herrmann, and Krista Lanctôt in their article, which serves as the basis for our CME module. The next piece, “Behavioural Disorders in Vascular Dementia” is by Drs. Rita Moretti, Paola Torre, and Rodolfo M. Antonello. For those of us particularly interested in the differential diagnosis of the type of dementia our patient has, the article “Clinical Differences among Four Common Dementia Syndromes” by Dr. Weerasak Muangpaisan will be especially helpful. Our regular column on dementia this month is “Behavioural Interventions Can Minimize Functional Decline in Mild Cognitive Impairment and Dementia” by Drs. Angela Troyer and Kelly Murphy.

We also have our usual collection of interesting articles on diverse topics. Our CVD article this month is “Diagnosis and Management of Mitral Valve Disease in Older Adults” by Drs. Indranil Dasgupta, Marc Tecce, and Bernard Segal. Dr. Mary Anne Huggins and Laura Brooks have provided the article “Discussing End-of-Life Care with Older Patients: What Are You Waiting For?” Our last two articles are particularly intriguing. Older adults today are often much wealthier than previous generations, and extensive travel is often common during retirement, making the article “Fever in the Returning Traveller” by Dr. Alberto Matelli, Dr. Anna Cristina Carvalho, and Dr. Veronica Dal Punta particularly relevant. Finally we are reminded that social and economic factors result in quite different experiences of aging in the article “Aging in Africa” by Dr. Irene Turpie and Leigh Hunsinger.

Enjoy this issue,
Barry Goldlist

Kerstin Stieber Roger, PhD, Assistant Professor, Department of Family Social Sciences, Faculty of Human Ecology, University of Manitoba, Winnipeg, MB.

This article discusses current research in the social sciences on end-of-life care and people living with dementia. Given the projected increase within the next twenty years of older adults living with dementia, end-of-life care for this demographic will become more relevant than ever before. The main themes emerging in the literature are discussed in this article: personhood, decision-making, counselling and spirituality, pain management, training for professionals, and settings of primary care. Recommendations for further research are offered.
Keywords: care, dementia, end-of-life, family, personhood.

Jennifer L. Martin, PhD, Assistant Research Professor, University of California, Los Angeles; Department of Medicine and Research Health Scientist, VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California, USA.

Caregivers often report sleep disturbances in persons with dementia. Older adults with dementia have more nighttime awakenings, less deep sleep, more daytime sleepiness and napping, and experience changing in the timing of sleep. Sleep disorders such as sleep disordered breathing, restless legs syndrome, periodic limb movement disorder, and REM behaviour disorder are more common among individuals with some types of dementia. Sleep problems are associated with difficulties in caregiving and quality of life. As a result, sleep problems should be evaluated and treated. Treatment should always consider nighttime environmental and daytime lifestyle factors.
Key words: sleep, dementia, Alzheimer’s disease, circadian rhythms, sleep disorders.