Dementia: early diagnosis and intervention
Introduction
Throughout our program, we have learned about various types of dementia and have become familiar with a wide range of diagnostic/screening tools and interventions to manage and stabilize the symptoms associated with dementia. We also learned that early cognitive decline may often be related to reversible causes and should never be assumed to be dementia or age-related changes. “Cognitive impairment or loss should always be presumed to be due to a reversible cause until ruled out otherwise by physician” (Interior Health, 2006, p. 3).
I was curious to learn what impact early diagnosis and intervention of dementia might have on the outcomes for the patients.
What is dementia?
Health Canada defines dementia as “loss of mental function that affects daily activities. It is caused by a loss of cells in the brain and the breakdown of important nerve connections” (Public Health Agency of Canada, 2017). Hirst, Lane and Miller, 2015, define dementia as “the medical term that includes a group of brain disorders characterized by a gradual decline in cognitive abilities (e.g., memory, understanding, judgement, decision-making, communication) and changes in personality and behaviour” (p. 258). While there are varied definitions of dementia, there are a number of key characteristics that are consistently identified with relation to dementia: it refers to a group of symptoms rather than a specific disease and it is progressive and terminal (Alzheimer’s Society of Canada, 2017).
The four most common causes of dementia are Alzheimer’s disease, vascular dementia, Lewy Body and frontotemporal dementia (Hirst, Lane & Miller, 2015). While all share similar symptoms such as personality and cognitive changes and memory impairment, it can be difficult, if not impossible to identify the root cause of the dementia symptoms. Complicating diagnosis is the fact that there can be multiple types of dementia occurring concurrently, known as mixed dementia.
Diagnosis
Diagnosis of dementia can be difficult and is often delayed since there is no single test to identify dementia and frequently the early symptoms are assumed to be the result of other conditions or simply a normal part of aging.
Through the Ministry of Health document “Cognitive impairment – Recognition, diagnosis and management in primary care”, the British Columbia government recommends practitioners suspect cognitive impairment when there is functional decline in work and usual activities as reported by the patient and/or caregivers (2018). This suspicion should warrant further investigation including cognitive screening, a complete medical history, including a thorough medication review and obtaining collateral information from caregivers. Cognitive screening should include a Standardized Mini-Mental State Examination (SMMSE), a Clock Drawing Test and a Montreal Cognitive Assessment (MOCA) to collect objective data. Practitioners are also encouraged to rule out and treat any underlying and/or reversible causes for any noted cognitive changes. Some examples of reversible causes are: delirium, depression, electrolyte imbalance or dehydration, comorbidities including thyroid disorders or underlying infections, adverse drug effects or polypharmacy or alcohol dependency. In these recommendations, it is noted that routine screening for cognitive impairment is not necessarily beneficial but should be routinely performed for those with cerebrovascular disease.
When cognitive function is impaired but the criteria for mild dementia are not yet met, a diagnosis of mild cognitive impairment (MCI) may be made. While those with MCI are at higher risk of developing dementia, it does necessarily mean that progression to dementia is inevitable (Hirst, Lane & Miller, 2015). Once a diagnosis of MCI or dementia is reached, it is recommended that clinicians use the Global Deterioration Scale to stage the level of impairment.
Interventions
When a person is presented with a diagnosis of dementia, discussions should be held with the person and their caregiver regarding intervention and treatment options as soon as possible. These could include discussion and education around available pharmacological treatment options or psychosocial interventions, such as referrals to support groups, social workers, legal support, etc. As dementia progresses, a person’s ability to make decisions can be affected, so early discussions about treatment plans and advanced care planning can ensure the person is able to make their future wishes known (Harrison-Dening, 2013). It can also be helpful for a person to designate who will be their substitute decision maker, in the event their capacity to make decisions is compromised. The My Voice – Expressing my wishes for future health care treatment document produced by the Province of British Columbia is a resource that can be used to facilitate these discussions and decisions.
Pharmacological Interventions
While there are no medications to cure dementia, in Canada, there are several medications that have been approved that can provide some stabilization and/or improvement specific to Alzheimer’s disease. However, there is conflicting evidence as to the overall benefit of these medications and significant adverse effects have been noted to be common (Ministry of Health, 2018).
Currently, the approved medications fall into two categories: cholinesterase inhibitors (ChEI) or N-methyl-D-aspartate (NMDA) receptor antagonists. ChEIs include donepezil (Aricept), galantamine (Reminyl) and rivastigmine (Exelon). This classification of medications works by decreasing the breakdown of acetylcholine thereby increasing the amount in the brain. They may also work to increase the responsiveness of brain receptors to acetylcholine. Memantine (Ebixa) is the only NMDA receptor antagonist. When nerve cells are damaged, they leak glutamate, which, when reabsorbed causes toxicity and damages or kills more nerve cells. Ebixa works to prevent glutamate from interacting with receptors on nerve cells. This can slow the decline of memory and cognitive function in Alzheimer’s disease. As with many medications, effect varies from person-to-person. Currently, all three ChEIs are approved for use in mild to moderate Alzheimer’s while only Ebixa and Aricept are approved for moderate to advanced disease (Alzheimer’s Society of Canada, 2017).
Research by Buckley and Salpeter (2015) shows ChEIs can have a positive impact on cognition and function in patients with mild to moderate Alzheimer’s and Lewy body dementia with no significant benefit noted in vascular dementia. Efficacy appears to wane over time, with minimal benefit after one year. While there may be some benefit from ChEIs, evidence of adverse effects, especially cholinergic side effects such as weight loss and syncope, could be especially detrimental in the frail elderly. Memantine may provide some benefit to those with moderate to advanced Alzheimer’s or vascular dementia but shows little effect in those with mild or Lewy body dementia.
From this research, it is clear that if a person wishes to pursue pharmacological treatment, early diagnosis and treatment is key, but requires education and careful consideration of the risk of adverse effects versus the potential short-term, short-lived benefits.
Psychosocial Interventions
Research shows that early intervention can improve the outcomes in those with MCI or dementia, especially in the earliest stages. After conducting their review of more than 150 research reports, Burgener, Buettner, Beattie and Rose identified a number of non-pharmacological interventions that may contribute to optimal outcomes for those with early-stage dementia. These reports were focused on early-stage support groups, cognitive training and enhancement programs, and programs dedicated to exercise and/or health promotion. Specifically, the paper recommends the following therapies and interventions, among others, to “promote continuing functioning, assist with independence, and maintain cognitive health” (p. 52):
• Physical exercise (aerobic if possible) to promote strength, balance and coordination
• Cognitive therapy, especially those that use cognitive training and rehabilitation or memory rehabilitation
• Comprehensive recreational therapies such as art, writing, social engagement and individualized hobbies
• Dietary modifications including foods rich in antioxidants
• Sleep hygiene programs
• Driving evaluations at least every 6 months
Further evidence to support positive outcomes from non-pharmacological interventions can be found when reviewing the results from “Cogs Clubs” in the UK (Tuppen, 2012). Jackie Tuppen is the founder of these clubs, which began in July 2011, after a pilot program utilizing cognitive stimulation therapy (CST) concepts to optimize individuals’ cognitive function. CST combines the most effective elements of reality orientation, reminiscence therapy and psychosocial therapies for dementia. While there is clear evidence of the benefits on maintaining cognitive abilities and maximizing potential with CST, the limitation of CST is that it is often a time-limited intervention. By extending the CST sessions, there was evidence that the positive effect could be maintained for up to six months.
Building on this information and the recognition that resources were lacking for on-going support, the idea for Cogs Clubs was born. Clinicians initially refer participants to the clubs, following completion of a CST program. The club programs are based around cognitive stimulation and music, and are run by volunteers rather than clinicians. Participants are able to continue attending as long as they wish or are able to participate meaningfully. Daily activities include music, reminiscence and orientation, which have been shown to improve a person’s sense of wellbeing. The sessions also include movement to promote oxygenation of the brain and activities that require more concentration or organizational processing. These clubs also provide some respite for the person’s caregiver. Upon review, the participants were found to have a positive response in interest, communication, enjoyment and mood, which improved their overall quality of life.
In fact, there is evidence that early non-pharmacological interventions are as effective in early stages of dementia as anti-dementia medications (Harrison-Dening, 2013). Interventions such as CST that focus on strategies to improve memory or cognitive behavioural therapy to affect mood were found to be beneficial. Benefits were also noted when communication abilities were assessed and deficits compensated for by providing assistive devices (e.g. glasses or hearing aids) or implementing environmental changes (e.g. reducing background noise; improved lighting).
While more evidence is needed, there are some indications that physical activity can delay the onset of dementia and slow cognitive decline in healthy older adults (Harrison-Dening, 2013). The Alzheimer’s Society also lists the following interventions that may reduce the risk of developing dementia and suggests implementing these changes in mid-life for maximum benefit:
• Keep your brain challenged and active; learn new activities; perform routine tasks differently
• Maintain social engagement
• Commit to a healthy lifestyle with healthy food choices, no tobacco use and limited alcohol use; routine assessments of blood pressure, blood sugar, cholesterol and weight by your health care professional
• Get active; participate in some form of physical activity daily
• Reduce stress
• Protect your head from injury
It has been recognized that most people may have brain changes 20 years before the onset of symptoms (Hirst, Lane & Miller, 2012). General improvements to public education and awareness could contribute to recognition of earlier symptoms and result in more timely diagnosis of dementia, thereby improving the chance to provide early intervention with more successful outcomes.
The Financial Impact of Early Diagnosis and Intervention
“It is estimated that the cost of caring for a single person with Alzheimer’s is $56,800 a year” (Touhy & Jett, 2012). Research into new treatments and interventions is ongoing with the hopes of finding a treatment that can prevent or cure Alzheimer’s. A hypothetical treatment that delays the onset of Alzheimer’s by five years could reduce the number of patients with Alzheimer’s by 57% and reduce projected costs by up to half. Outside of hypothetical cost savings, Dubois et al, 2015 reviewed cost benefit analysis of early diagnosis and intervention. Through this review, they found evidence that early diagnosis and intervention can significantly reduce the overall costs involved in dementia care. The savings were found to be a result of reduced institutional care as patients assessed and treated early were able to remain in the community longer.
Conclusion
It is clear that there are many positive outcomes when a person is presented with an early diagnosis of dementia and interventions and treatments are implemented in a timely manner. There are many treatment options available and having an early diagnosis allows a person the opportunity to be involved in decision-making and advanced care planning. By providing person-centered care that respects a person’s wishes for their on-going care, dignity and autonomy can be preserved, even when a person’s cognitive abilities may fail. Medications can provide some limited benefit but can also result in adverse effects, so their use must be carefully considered and recommendations and plans for duration of treatment should be discussed with a health care provider. There are many psychosocial interventions available that have been shown to provide positive benefits to cognition, mood and overall wellbeing. Additionally, early preventative measures can held reduce the overall risk of developing dementia. That in turn, could have significant impacts on the financial burden of providing care for those with dementia.
Currently there is no cure for dementia and it remains a progressive, terminal condition. Any interventions to delay onset or slow progression would have widespread benefits to society on the whole and also to the individual facing an uncertain future.