Dementia

Definition
Acquired (A decline form prev level of functioning)
Progressive
Cognitive Impairment (memory +/- apraxia or agnosia or aphasia or exec
dysfunction)
In clear consciousness
With associated dysfunction (multiple domains)

Mild Cognitive impairement

Definition (original)

1. Memory complaint, preferably qualified by an informant

2. Memory impairment for age and education
3. Preserved general cognitive function
4. Intact activities of daily living
5. Not demented
Definition (refined)

Not normal, not demented (does not meet DSM IV-TR/ICD-10 criteria for a dementia
syndrome)
Cognitive decline
Self and/or informant report and impairment on objective cognitive tasks

And/or
Evidence of decline over time on objective cognitive tasks
Preserved basic activities of daily living/minimal impairment in complex instrumental
functions

Nosology of Dementia
DSM IV
Specific disorders rather thn a syndrome
Subtypes

Alzheimers disease ( early onset/late onset)

Vascular disease
Specific medical conditions
Substance induced
Dementia due to multiple aetiologies
Dementia NOS

ICD 10
Syndromic approach
First defines demntia in general
Subtypes

Alzheimer disease
Vascular dementia
Dementia in other diseases
Dementia (Unspecified)

Severity categorization is there

Other classifications
Alz disease ( NINDS ADRDA)
Vascular dementia (AIREN)

Epidemiology
Aging population
Prevalance doubles every 5 years

5-8% 65 -70 years

15 20% 75-80 years
40-50% >85 years

Pattern
1. Alz D (50 75%)
2. LBD (15 35%)
3. Vas D ( 5 20%)

Risk factors
1. Old age
2. Female sex
3. Vascular risks ( not only for the Vas D)
a. DM
b. Dyslipidemia
c. CVA
d. AI disease
e. CCF/ AF
4. Excess alcohol
5. Smoking
6. Saturated fat

Aetiology

Neurodegenerative Alzheimer's disease

Dementia with Lewy bodies
Frontotemporal dementia
Parkinson's disease
Huntington's disease
Vascular

Infarction
Binswanger's disease
Hemodynamic insufficiency

Neurological
disease

Multiple sclerosis
Normal-pressure hydrocephalus
Brain tumor (primary or metastatic)

Endocrine

Hypothyroidism
Hypercalcemia
Hypoglycemia

Nutritional

Vitamin B12 deficiency

Thiamine deficiency
Niacin deficiency

Infectious

Human immunodeficiency disease

Prion disease (Creutzfeldt-Jakob disease, bovine spongiform encephalitis,
Gerstmann-Strassler syndrome)
Neurosyphilis
Cryptococcus

Metabolic

Hepatic insufficiency
Renal insufficiency
Wilson's disease
Metachromatic leukodystrophy
Neuroacanthosis

Traumatic

Subdural hematoma
Dementia pugilistica

Exposure

Alcohol
Heavy metals
Irradiation
Anticholinergic medications
Carbon monoxide

Evaluation of cognitive assessment

Memory

Does he or she have difficulty remembering recent conversations?

Is he or she frequently repetitive?

Is he or she aware of current events?
Does he or she misplace or lose things?
Does he or she forget to turn off the stove?
Language and aphasia
Does he or she have difficulty finding the correct word?
Is it sometimes difficult for others to understand him or her?
Orientation
Does he or she know where he or she is?
Is he or she oriented to time (date, month, and year)?
Does he or she forget upcoming holidays, birthdays, when to attend
church, tax day, etc.?
Agnosia
Does he or she have difficulty recognizing people or places?
Activities of daily living Does he or she have difficulty handling small sums of money?
Does he or she have difficulty remembering short lists for shopping?
Does he or she need assistance with eating, bathing, transfer in and out
of bed, walking, toileting, grooming, or dressing?
Apraxia
Does he or she have difficulty using familiar objects (e.g., toaster)?
Does he or she have difficulty performing simple tasks at home (e.g.,
making coffee, setting the table, operating the television, vacuum,
etc.)?
Problem-solving abilities Does he or she have difficulty relating to newspapers or television?
Executive functioning
Is he or she still able to manage finances, the checkbook, or taxes?
Social, community, and Has he or she lost special skills, interests, or hobbies (e.g., reading,
intellectual function
sewing, cards, or gardening) for reasons other than physical?
Does he or she engage in socially inappropriate behavior?
Judgment
Does he or she show problems in judgment (e.g., letting a stranger into
the house)?

Neuropsychiatric manifestations

1. Behavioural disturbance
a.

In the DSM-IV-TR, there are separate codes within the criteria for dementia of the
Alzheimer's type and dementia due to other general medical conditions for with or
without behavioral disturbance. For vascular dementia, there is a specifier for with
behavioral disturbance. Behavioral disturbances include disinhibition, agitation,
aggressive behavior, uncooperative behavior, and wandering. Agitation, particularly
worsening in the evening hours, is common.

2. Mood changes
a. MDD 10%
b. Depressive symptoms 50%
3. Anxiety (60%)
4. Personality changes
5. Psychosis
6. Sleep disturbance (50%)

Rating Scales

Clinical Dementia rating Scale (CDR)

Functional assessment staging ( FAST)
o MCI / Mild dementia / MMSE >24/ CDR 0.5/ FAST stage 2 -3
Mild to questionalble functional difficulty
Memory or other complaints
o Mild dementia/ MMSE = 20/ CDR 1/ FAST stage 4
Mild instrumental difficulty in ADL
o Moderate dementia/ MMSE 10-18/ CDR 2/ FAST stage 5 or 6
Impaired basic functions
o Severe dementia/ MMSE <10/ CDR 3/ FAST stage 7
Considerable to total assistance

Investigations
1.
2.
3.
4.
5.
6.

Laboratory investigations ( whole battery)

Structural neuroimaging
Functional neuroimaging
EEG
NPI
Neuropathology

DDx
1. Delirium
2. MCI
3. Age related cognitive decline

4. MR
5. Schizophrenia
6. Depression
7. Factitious disorder
8. Alcohol
9. Medical conditions
10.Medication

Course and prognosis

Usually insidious onset except due to a CVA

Duration usually years(CJD- 6/12 to AD 15 yrs)
Progressive cog decline
Progressive func impairment
Usually terminal
Need to look for treatable causes

Management Aspects
1. Manage the acute problem
2. Psychoeducation
3. Pharmacological modality
4. Non pharmacological modality
5. Legal and finance planning
6. Abuse and neglect prevention
7. Maintenance of safety
8. Driving
9. Caregiver support
10.End-of-life issues (DNR)

Diagnosis of Alzheimers Disease (NINDSARDA)

A. Alzheimer's disease is characterized by progressive decline and ultimately loss of
multiple cognitive functions, including both:
o Memory impairmentimpaired ability to learn new information or to recall

previously learned information

o And at least one of the following:

Loss of word comprehension ability, for example, inability to respond to

Your daughter is on the phone (aphasia)

Loss of ability to perform complex tasks involving muscle coordination,

for example, bathing or dressing (apraxia)

Loss of ability to recognize and use familiar objects, for example, clothing
(agnosia)

Loss of ability to plan, organize, and execute normal activities, for

example, going shopping

B. The problems in A represent a substantial decline from previous abilities and cause
significant problems in everyday functioning.
C. The problems in A begin slowly and gradually become more severe.
D. The problems in A are not due to:
o Other conditions that cause progressive cognitive decline, among them stroke,
Parkinson's disease, Huntington's chorea, brain tumor, etc.
o Other conditions that cause dementia, among them hypothyroidism, human
immunodeficiency virus infection, syphilis, and deficiencies in niacin, vitamin
B12, and folic acid
E. The problems in A are not caused by episodes of delirium.
F. The problems in A are not caused by another mental illness: Depression, schizophrenia,
etc.
Criteria for Diagnosis of Probable Alzheimer's Disease
Dementia established by clinical examination, documented by a standard test of cognitive
function (e.g., Mini-Mental State Examination, Blessed Dementia Scale, etc.), and confirmed by
neuropsychological tests
Significant deficiencies in two or more areas of cognition, for example, word comprehension and
task-completion ability
Progressive deterioration of memory and other cognitive functions
No loss of consciousness
Onset from age 40 to 90, typically after 65
No other diseases or disorders that could account for the loss of memory and cognition

A diagnosis of probable Alzheimer's disease is supported by:

Progressive deterioration of specific cognitive functions: Language (aphasia), motor skills
(apraxia), and perception (agnosia)
Impaired activities of daily living and altered patterns of behavior
A family history of similar problems, particularly if confirmed by neurological testing
The following laboratory results:
Normal cerebrospinal fluid (lumbar puncture test)
Normal electroencephalogram (EEG) test of brain activity
Evidence of cerebral atrophy in a series of computed tomography (CT) scans
Other features consistent with Alzheimer's disease:
Plateaus in the course of illness progression
CT findings normal for the person's age
Associated symptoms, including depression, insomnia, incontinence, delusions, hallucinations,
weight loss, sex problems, and significant verbal, emotional, and physical outbursts
Other neurological abnormalities, especially in advanced disease, including increased muscle
tone and a shuffling gait
Features that decrease the likelihood of Alzheimer's disease:
Sudden onset
Such early symptoms as seizures, gait problems, and loss of vision and coordination

Diagnosis of Vascular Dementia (NINDS

AIREN)
I.

The criteria for the clinical diagnosis of probable vascular dementia include all of the
following:
o

Dementia defined by cognitive decline from a previously higher level of

functioning and manifested by impairment of memory and of two or more
cognitive domains (orientation, attention, language, visuospatial functions,
executive functions, motor control, and praxis), preferably established by clinical
examination and documented by neuropsychological testing; deficits should be
severe enough to interfere with activities of daily living not due to physical effects
of stroke alone.

Exclusion criteria: Cases with disturbance of consciousness, delirium, psychosis,

severe aphasia, or major sensorimotor impairment precluding neuropsychological
testing. Also excluded are systemic disorders or other brain diseases (such as
Alzheimer's disease) that in and of themselves could account for deficits in
memory and cognition.

Cerebrovascular disease, defined by the presence of focal signs on neurological

examination, such as hemiparesis, lower facial weakness, Babinski sign, sensory

deficit, hemianopia, and dysarthria consistent with stroke (with or without history
of stroke), and evidence of relevant CVD by brain imaging (CT or MRI)
including multiple large-vessel infarcts or a single strategically placed infarct
(angular gyrus, thalamus, basal forebrain, or PCA or ACA territories), as well as
multiple basal ganglia and white matter lacunes, or extensive periventricular
white matter lesions, or combinations thereof.
o

II.

A relationship between the above two disorders, manifested or inferred by the

presence of one or more of the following: (1) onset of dementia within 3 mos
following a recognized stroke; (2) abrupt deterioration in cognitive functions, or
fluctuating, stepwise progression of cognitive deficits.

Clinical features consistent with the diagnosis of probable vascular dementia include the
following:
o

Early presence of gait disturbance (small-step gait or marche a petits pas, or

magnetic, apraxic-ataxic, or parkinsonian gait)

History of unsteadiness and frequent, unprovoked falls

Early urinary frequency, urgency, and other urinary symptoms not explained by
urological disease

Pseudobulbar palsy

Personality and mood changes, abulia, depression, emotional incontinence, or

other subcortical deficits including psychomotor retardation and abnormal
executive function

b. Features that make the diagnosis of vascular dementia uncertain or unlikely include:
o

Early onset of memory deficit and progressive worsening of memory deficit and
progressive worsening of memory and other cognitive functions such as language
(transcortical sensory aphasia), motor skills (apraxia), and perception (agnosia), in
the absence of corresponding focal lesions on brain imaging

Absence of focal neurological signs, other than cognitive disturbance

Absence of cerebrovascular lesions on brain CT or MRI

c. Clinical diagnosis of possible vascular dementia may be made in the presence of

dementia (section I-1) with focal neurological signs in patients in whom brain imaging
studies to confirm definite CVD are missing; or in the absence of a clear temporal
relationship between dementia and stroke; or in patients with subtle onset and variable
course (plateau or improvement) of cognitive deficits and evidence of relevant CVD.

d. Criteria for diagnosis of definite vascular dementia are as follows:

o

Clinical criteria for probable vascular dementia

Histopathological evidence of CVD obtained from biopsy or autopsy

Absence of neurofibrillary tangles and neuritic plaques exceeding those expected

for age

Absence of other clinical or pathological disorder capable of producing dementia

e. Classification of vascular dementia for research purposes may be made on the basis of
clinical, radiological, and neuropathological features, for subcategories or defined
conditions such as cortical vascular dementia, subcortical vascular dementia, bipolar
disorder, and thalamic dementia.
The term Alzheimer's disease with CVD should be reserved to classify patients fulfilling the
clinical criteria for possible Alzheimer's disease and who also present clinical or brain imaging
evidence of relevant CVD. Traditionally, these patients have been included with vascular
dementia in epidemiological studies. The term mixed dementia, used hitherto, should be avoided.

Non pharmacological management of

Dementia
Summary of Findings
Key Question #1. How do non-pharmacological
treatments of behavioral symptoms compare in
effectiveness with each other, with
pharmacological approaches, and with no
treatment?

Cognitive/Emotion-oriented Interventions
Reminiscence Therapy:
Reminiscence therapy involves the discussion of past activities, events, and
experiences with another person or a group of people. Two previous systematic
reviews identified seven small randomized control trials (RCTs) of reminiscence
therapy. This limited body of evidence does not support the use of reminiscence
therapy for the treatment of behavioral symptoms of dementia.
Simulated Presence Therapy (SPT):
SPT involves the use of audiotapes made by family members containing a scripted
conversation about cherished memories about the patients life. Overall, wellconducted studies are lacking, the evidence that SPT reduces behavioral symptoms
of dementia is inconsistent, and SPT may have adverse effects in some patients.
Validation Therapy:
Validation therapy is intended to give the individual an opportunity to resolve
unfinished conflicts by encouraging and validating expressions of feeling. Four
systematic reviews examined the effects of validation therapy in three RCTs as well
as other study designs, and found mixed effects. Overall, there is insufficient
evidence to draw conclusions about the efficacy of validation therapy for behavioral
symptoms, depression, and emotional state associated with dementia.

Sensory Stimulation Interventions

Acupuncture:
Acupuncture is an ancient Chinese treatment that has been used for over 3,000
years. One systematic review found no rigorously conducted RCTs. There is no good
quality evidence indicating benefit or harm of acupuncture for the treatment of
behavioral symptoms for dementia.

Aromatherapy:
Aromatherapy consists of the use of fragrant oils from plants, and has been used to
promote sleep and reduce behavioral symptoms in individuals with dementia.
Overall, there is insufficient evidence that aromatherapy may be an effective
treatment for agitation and other behavioral symptoms.

Light Therapy:
Light stimulation aims to improve the circadian disturbances in the sleep-wake
cycles experienced by individuals with dementia. Two systematic reviews identified
six studies, including two RCTs. Although some studies found beneficial effects of
bright light therapy on agitation and nocturnal restlessness, studies were generally
limited by small sample size and poor quality. The limited body of evidence is
insufficient to draw definitive conclusions about the effects of bright light therapy in
managing sleep, behavior, or mood disturbances associated with dementia.
Massage and Touch:
Massage and touch therapies aim to reduce depression, anxiety, and other
behavioral symptoms of dementia. A systematic review identified two small RCTs
that reported increased calorie and protein intake in a study that compared touch
combined with verbal encouragement during meals to verbal encouragement alone,
and reduced agitation in a study that compared hand massage with calming music
and with no treatment. This limited body of evidence suggests that, compared with
no treatment, hand massage and touch therapy may have beneficial effects.
Music Therapy:
Individuals with dementia may retain the ability to sing old songs, and musical
abilities appear to be preserved in some individuals despite aphasia and memory
loss. Music interventions range from activities administered by a professional music
therapist to the presentation of recorded music by caregivers to patients in an
individual or group setting. We identified four systematic reviews that examined a
variety of study designs. Three RCTs reported reduced aggression, agitation, and
wandering while listening to music; and other studies found similar reductions in
behavioral symptoms, although there was no evidence of long-term effects. All
studies were limited by methodological issues. Overall, well-conducted studies are
lacking, but music interventions have potential for reducing agitation in patients
with dementia in the short term.
Snoezelen Multisensory Stimulation Therapy:
Multisensory stimulation (MSS), otherwise known as Snoezelen therapy, combines
the therapeutic use of light, tactile surfaces, music, and aroma. MSS is based on
the premise that neuropsychiatric symptoms may result from periods of sensory
deprivation. There were six RCTs identified among four systematic reviews.
Although the evidence did not consistently demonstrate a durable effect of MSS
therapy on behavioral symptoms, preliminary findings of short-term benefits and
the reported pleasantness of the treatment suggest that future research is
warranted.
Transcutaneous Electrical Nerve Stimulation (TENS):

TENS is a non-invasive analgesic technique that is most often used for pain control
and occasionally for neurological and psychiatric conditions, such as drug/alcohol
dependency, headaches, and depression. A systematic review combined data from
three RCTs in individuals with dementia and found no significant effects on sleep
disturbances or behavioral symptoms, evaluated immediately after treatment or at
six-week follow-up. Although some short-lived improvements in neuropsychological
symptoms of dementia have been observed with TENS, definite conclusions on the
possible benefits of this intervention cannot be made.

Behavior Management Techniques

Behavior management techniques include a wide variety of behavioral
interventions such as functional analysis of specific behaviors, token economies,
habit training, progressive muscle relaxation, communication training, behavioral or
cognitive-behavioral therapy, and various types of individualized behavioral
reinforcement strategies. Findings from three systematic reviews including seven
RCTs and two additional more recent trials provide some support for behavior
management techniques as effective interventions for behavioral symptoms of
dementia. However, mixed study results, the variety of specific interventions across
studies, and methodological concerns in many studies suggest that additional
research in this area replicating results is warranted.

Other Psychosocial Interventions

Animal-assisted Therapy:
There were no RCTs evaluating the effectiveness or harm of pet therapy. Nine nonrandomized studies demonstrated decreases in agitated and disrupted behaviors,
increases in social and verbal interactions, decreases in passivity, and increases in
nutritional intake. The findings suggest that pet therapy has potential for benefit,
but more rigorous studies are needed to establish benefit, harms, and feasibility for
implementation in VA settings.
Exercise:
Three systematic reviews of 59 studies showed inconsistent effects of exercise
interventions on behavioral symptoms and functional status. Variations in intensity
of exercise intervention, severity of dementia at baseline, and outcome measures
make it difficult to draw a firm conclusion. Many of the included studies were small
and did not use rigorous methodology. The most consistent evidence showed that
exercise did increase sleep duration and decrease nighttime awakenings. While the
impact of improved sleep on distal health outcomes remains uncertain, there may
be an additional benefit to caregivers who are disproportionally affected by
dysfunctional sleep.

Various Interventions Targeting a Specific Behavioral

Symptom
Wandering:
A variety of interventions for wandering were examined in four systematic reviews.
There were no RCTs on the effects of subjective visual barriers, such as mirrors, floor
grids, camouflage of doors or doorknobs, and concealment of view through door
windows. Two RCTs determined that exercise and walking therapies had no impact
on wandering. No evidence is available on the effects of wander gardens. Tracking
devices, motion detection devices, and home alarms were generally effective in
detecting wandering and locating lost patients in nonrandomized studies. Evidence
about the effects of sensory stimulation therapies, such as MSS, aromatherapy, and
music on wandering, is scant and inconclusive.
Agitation:
A systematic review of agitation identified 14 RCTs of a variety of interventions.
Three studies of sensory interventions (aromatherapy, thermal bath, calming music,
and hand massage) showed a statistically significant decrease in agitation when
combined in meta-analysis, but there was substantial variability in the type of
intervention, duration of exposure, and outcomes measured. Other interventions
including social contact, environmental modification, caregiver training, and
behavior therapy showed no effects on agitation. One recently conducted primary
study suggested to us by reviewers provided preliminary support for the
effectiveness of systematic individualized intervention in decreasing agitation,
though a lack of assessor blinding to condition limits the validity of these findings.
Inappropriate Sexual Behavior:
There were no systematic reviews that examined the topic of inappropriate sexual
behavior among individuals with dementia. Currently, the effectiveness of nonpharmacological treatments for inappropriate sexual behavior is unknown.
Comparative effectiveness among non-pharmacological interventions and between
pharmacological and non-pharmacological approaches None of the systematic
reviews captured in our search identified any head-to-head trials that directly
compared effectiveness among different non-pharmacological interventions, or
between non-pharmacological and pharmacological treatments.

Key Question #2.

How do non-pharmacological treatments of
behavioral symptoms compare in safety with each

other, with pharmacological approaches, and with

no treatment?
Cognitive/Emotion-oriented Interventions:
One study found that simulated presence therapy increased agitation and
disruptive behaviors in some patients. Reality orientation has been observed by
caregivers to increase distress, fear, and agitation in individuals with later stages of
dementia. Sensory Stimulation Interventions: For some individuals, the increased
stimulation from sensory stimulation therapies such as music therapy and
massage/touch therapy may cause increased agitation and aggression.
Consideration of the individual preferences in the use of these treatments should be
emphasized.
Behavior Management Techniques:
None of the systematic reviews nor the primary studies reviewed documented any
patient harm or safety concerns resulting from the use of behavior management
techniques.

Animal-assisted Therapy:
The American Veterinary Medical Association guidelines describe potential physical
and emotional harms associated with animal-assisted therapy, but the actual
incidence of harms has not been well-studied. Theoretical harms include human
injury, zoonotic disease, allergic reactions, and the risk of grief reaction if an animal
dies.
Exercise:
Potential harms of exercise programs include the increased risk of falls or physical
injuries, but risks associated with exercise have not been well studied.

Comparative Safety among Non-pharmacological

Interventions and between Pharmacological and
Non-pharmacological Approaches
None of the systematic reviews captured in our search identified any head-to-head
trials that directly compared safety among different non-pharmacological
interventions, or between nonpharmacological and pharmacological treatments.

Key Question #3:

How do non-pharmacological treatments of
behavioral symptoms compare in cost with each
other, with pharmacological approaches, and with
no treatment?
None of the systematic reviews or primary articles we retrieved identified direct
evidence on the cost-effectiveness of specific interventions. The costs associated
with the use of GPS tracking devices and other monitoring systems are high, but the
potential increases in patient safety and caregiver peace of mind associated with
the use of these devices are notable. The training and veterinary care required for
preparing and maintaining a live animal for animal-assisted therapy are costly.
Some forms of animal-assisted therapy such as the placement of aquariums in
dining areas may be less expensive than more individualized approaches. Behavior
management techniques can include a variety of individualized interventions, and
therefore expense for these techniques can vary greatly across individuals and
settings. Further studies are needed to determine the cost-benefits, harms, and
feasibility of these and other non-pharmacological interventions.