There are few preventative treatments currently available in geriatric neurology due to a lack of ability to predict risk and time frames for each individual. Secondary prevention after the start of dementia symptoms is the mainstay of therapy.
Pharmacological Treatment of Dementia
Symptomatic treatment by pharmacological agents is typically effective for a few years.
– Drug treatments for dementia:
o AD: FDA Approved drugs for Alzheimer disease include two classes of medications. Acetyl-Choline Esterase Inhibitors ACHEI (such as donepezil or Aricept, rivastigmine or Exelon, galantamine), and NMDA Receptor Blockers (memantine or Namenda). Combination of the two classes (Namzaric) is researved for moderate stage of dementia or later.
o FTD: No FDA-approved medications currently available. FTD patients are more likely to use antipyschotics, antidepresseants, and sedatives/anxiolytics.
o Dementia with Lewy Bodies: No FDA-approved medications currently available. Treatment focuses on hallucination and agitation management.
o Vascular Dementia: No FDA-approved treatments currently available. Prevention of risk factors such as hypertension is important.
o Parkinson?s Disease Dementia (PDD): Rivastigmine and donepezil are the widely accepted medications for treatment of PDD.
o Psuedobulbar affect (PBA): Nuedexta
Psycho-pharmacology and Dementia.
– Treatment effectiveness depends on correct diagnosis, use of an effective drug, and persistence with the therapeutic trial until achievement of desired effect.
– Psychotropic drug use depends on whether the symptoms are primary or secondary.
– Differences among age-peers involve pharmacokinetics and pharmacodynamics
– Pharmacokinetics: The way drugs move through the body. Depends on absorption, distribution, metabolism, and excretion as well as drug half-life.
– Pharmacodynamics: The effect of the drug at the receptor. Depends on receptor number and affinity, signal transduction, cellular response, and homeostatic regulation.
– The pharmacodynamics, drug interactions, adverse effects, indications, and clinical uses of antipsychotics, antidepressants, anxiolytics, sedatives, and mood stabilizers are reviewed.
– Definitions and treatments for anxiety disorders and substance abuse disorders are reviewed. For both, initial treatments should be non-pharmacological.
Non-Pharmacological Treatments of Dementia
– Dementia patients commonly exhibit neuropsychiatric and behavioral symptoms such as physical and nonphysical aggression, anxiety, irritability, dysphoria, aberrant motor behavior, disinhibition, delusions, and hallucinations.
– Behavioral problems are associated a worse prognosis that can diminish the quality of life for both the patient and the caregiver and is one of the main reasons for institutionalization.
– Most dementia-related behavior problems are linked to confusion, delirium, medication induced delirium, pain, environmental factors, and the intrusive aspects of caregiving.
– Models of nonpharmacological treatments include good care/comfort care, unmet needs, environmental intervention, learning theory, antecedent control, family and caregiving education and training, and psychosocial and individualized therapies.
– Treatments for Specific Dementias
o AD: antecedent control strategies are more effective than consequence-oriented learning, especially in advanced stages.
o VaD: Variability in clinical presentation and severity makes it difficult to prescribe a certain treatment. Those with higher cognitive ability may benefit from social learning approaches.
o LBD: Environmental and antecedent control techniques may be most effective. Caregiver education and training also help to manage LBD behaviors. Physical restlessness may be addressed with ?on the run? care.
o FTDs: Environmental and behavioral treatments are most recommended, including ?on the run? care.
o PD: Environmental, psychoeducational, and counseling-oriented interventions are most recommended. Research suggests that caregivers speak and act slowly with frequent repetition, avoid multi-tasking, and make use of compensatory strategies.
Art Therapy and Dementia.
– Expressive art therapies work to improve quality of life, enhance self-worth, and promote human dignity; all which contributes to better health.
– Music and Art therapies has been shown to significantly improve social participation, communication, gait, and mood while reducing symptoms of depression, anxiety, and agitation.
– Dance and movement therapies combine movement with counseling and rehabilitation to reduce stress and improve ambulation.
– Drama, poetry, and bibliotherapy have been shown to improve both physical and psychological symptoms through self-expression and reflection.
– Reminiscence and story-telling therapies promote communication and interaction using memorabilia, photographs, and narration of the patients? life history.
Dietary Factors for Preventing Dementia.
– Certain dietary factors may influence the risk or progression of AD, PD, and stroke. Research can be limited with conflicting results.
– High intake of Vitamin E, vegetables, B vitamins, n-3 PUFA, and fish may reduce risk of AD.
– High intake of vitamin E and caffeine, a moderate intake of CoQ, and low intake of dairy may reduce risk of PD.
– High intake of vitamin C, folate, tea, whole grains, and a low intake of sodium may reduce risk of stroke.
– Moderate consumption of alcohol and adherence to a healthy diet reduces risk for AD, PD, and stroke.
Exercise and Dementia Prevention
– Physical activity improves cardiovascular health, increases neurogenesis and neurotrophic factors, reduces inflammation, and maintains insulin-signaling pathways.
– Exercise is used as a method of prevention and intervention for cognitive decline in pre-clinical populations. After diagnosis, the efficacy of exercise therapies is unclear.
– Potential moderating factors include the age at intervention, genotype, gender, the intensity and type of exercise, stress, and depression.
– Mental activity and exercise are associated with a reduced risk of cognitive decline. After diagnosis, cognitive rehabilitation may improve several areas of cognitive function.
– Social activity and support has been linked to higher cognitive function and reduced risk of global cognitive decline and dementia.
Immunotherapy for Dementia.
– AD may be due to a disrupted balance between A[gb] production and clearance. Anti-A[gb] immunotherapy may help facilitate clearance using either active or passive immunization.
– Studies show that AD mice treated with anti-A[gb] antibodies shown greater cognitive performance compared to control AD mice. Antibodies against both soluble and insoluble A[gb] have been generated and studied.
– AN1792, a full-length A[gb], has been used for active vaccination in clinical studies (phase 1 and 2 trials). Subjects who developed sufficient antibody responses showed a slowing of decline, however there was an occurrence of meningeoencephalitis (ME). Follow-up studies showed that despite a high degree of plaque clearance in some subjects at autopsy, progressive dementia still continued. There is also evidence of potential long-term benefits from sustained, low levels of anti-A[gb] antibodies.
– Immunotherapy may be active or passive, each with relative advantages and disadvantages.
– Proposed mechanisms of Anti-A[gb] immunotherapy include microglial activation, catalytic disaggregation, and the ?peripheral sink?.
– Bapineuzumab is a well-documented immunotherapy currently undergoing clinical trial. Vasogenic Edema was observed as a side effect. Many other immunotherapies are also currently in clinical trials and in development.
– Immunotherapy may be most effective when started earlier during the preclinical and prodromal phases of AD.
Driving and Dementia
– Aging is associated with changes in sensory systems, mobility, and cognition, which affect driving ability.
– Drivers with dementia are at high risk for hazardous driving.
– Other medical conditions are also associated with impaired driving ability and medical assessments of vision, motor function, and cognition should be done to determine driving competence.
– Performance-based evaluations, simulators, and road tests are used as methods to assess and monitor older drivers.
– Social networks are heavily relied upon for transportation after cessation of driving. Depression, economic burden, and social withdrawal may develop if such networks are unavailable.
– Physicians face uncertainty regarding their responsibility to report unsafe drivers. Older individuals may also resist the revocation of their driving privileges.
Elder Abuse
– Physical, emotional, financial, and sexual abuse, along with neglect, are all types of elder abuse.
– Risk factors for mistreatment include: being female, advanced age, low income, comorbid medical issues, and social isolation.
– Elders with dementia and cognitive impairments are more likely to become victims perhaps due to decreased ability to communicate or defend themselves from their caregivers.
– Burnout, stress, and individual factors puts caregivers and nursing home staff at risk for becoming abusive.
– EM screening is recommended for all geriatric patients. Accurate documentation of history and recognition of physical signs of abuse are important in identifying elder abuse.
– Interventions for EM include education for both the patient and caregiver, adult protection services, support groups, and respite care.
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