|Year : 2016 | Volume
| Issue : 1 | Page : 6-9
Epidemiology of neurocognitive disorders in elderly and its management with special reference to dementia: An overview
Nisha M Pandey1, VK Singh2, SC Tiwari3
1 Department of Geriatric Mental Health, King George's Medical University, Lucknow, India
2 Department of Medicine, Psychiatry Unit, MLN Medical College, Allahabad, India
3 Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||6-May-2016|
S C Tiwari
Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Elderly with neuro-cognitive disorders (NCDs) present with variable level of severity of cognitive deficits which may be related to some or more domains of cognitive abilities. These domains include memory, orientation, learning, comprehension, judgment, emotional control, inability to initiate/ perform an activity etc. NCDs are categorized as delirium, dementia, amnestic, and other cognitive disorders in Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition, Text Revision (DSM-IV TR); further, given a new diagnostic category of NCDs in DSM-5 and the subsections incorporated delirium, major NCDs (which were earlier labeled as dementia), and a new category of mild NCD. Dementia is one of the most common NCD and its prevalence show a frightening statistics. As the illness progresses the condition of patients worsen and at times care givers experience significant burden. Early recognition and consultation generally leads to a better management and thus, familiarity with issues related to cognitive decline as well as its epidemiology, screening, and management in handling the catastrophe is very much needed. The present article provides a comprehensive overview on the issue.
Keywords: Cognitive decline, epidemiology, neurocognitive disorders, screening and management
|How to cite this article:|
Pandey NM, Singh V K, Tiwari S C. Epidemiology of neurocognitive disorders in elderly and its management with special reference to dementia: An overview. J Geriatr Ment Health 2016;3:6-9
|How to cite this URL:|
Pandey NM, Singh V K, Tiwari S C. Epidemiology of neurocognitive disorders in elderly and its management with special reference to dementia: An overview. J Geriatr Ment Health [serial online] 2016 [cited 2019 Sep 23];3:6-9. Available from: http://www.jgmh.org/text.asp?2016/3/1/6/181909
| Introduction|| |
Cognitive decline is often accepted as a normal feature of later life, and thus, generally people neither understand nor recognize the problem in its early stages and notice it only when the symptoms get worse. An elderly with complaints of memory problems may have a significant impairment on testing of their memory and other cognitive abilities. Early recognition and consultation generally leads to a better management and thus, familiarity with issues related to cognitive decline as a normal part of aging and cognitive impairment due to neurocognitive disorders (NCDs) is essentially required to manage such problems of elderly.
It is well established that in later stages of life degeneration starts, and some of the cognitive changes take place due to alterations in anatomy and physiology of the brain. It will be worth mentioning that causes for NCDs are more specific than any of the other mental health disorders. NCDs are categorized as delirium, dementia, amnestic, and other cognitive disorders in Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition, Text Revision (DSM-IV TR);  which further were given a new diagnostic category in DSM-5 and termed as NCDs and the subsection of this diagnostic category incorporate delirium, major NCDs (which were earlier labeled as dementia), and a new category of mild NCD.  The distinction between major and minor NCDs is related with cause and severity. A description regarding the classification of NCDs is narrated in detail by the work group in an article by Ganguli et al., 2011 and this may be accessed from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076370.
People with NCDs present with variable level of severity of cognitive deficits and this may be related with some or more domains of cognitive abilities like impairment of memory, orientation, learning, comprehension and judgment, emotional control; impairment in initiation of behavior; impaired controls over appearance, maintaining hygiene, sexual behavior; impaired receptive/expressive communication, visio-spatial ability etc. Thus, there is a need to understand the epidemiology of the problem. Present article discusses the epidemiology of the most common and complex NCDs of aging which is dementia.
The word dementia is derived from two words de (out from) + mens (the mind). It is a syndrome due to disease of the brain, usually chronic, irreversible characterized by a progressive, global deterioration in intellect including memory, learning, orientation, language, comprehension, and judgment. It mainly affects older people, it is reported that 5% of people ages 65 years or older have dementia, off these Alzheimer's disease (AD) is the most common.  Dementia occurs gradually and therefore, during onset, the patient remains alert and attuned to environment. In dementia, cognitive decline takes place slowly and continually. It is a group of various disorders and in DSM-5, is denoted by the term major NCDs. There are many different disorders, which are known to cause dementia,  the most common being AD. , This is difficult to identify in early stages of dementia.  Age-related changes are more frequent in later stages of life. , Propensity to develop transient cognitive problems such as delirium increases with age and in the presence of already existing cognitive impairment. Dementia is one of the major causes of disability in late-life. People with dementia have difficulty in living independently and have difficulties in social and occupational functioning. The disabilities progress with increasing severity of dementia. To make diagnosis of dementia comprehensive screening and assessment is essential.
Cognitive impairment/decline without impairment in consciousness is the core feature ,,,, (including memory impairment) which is either direct effects of degeneration, or a general medical condition or persisting effects of a substance or multiple etiology (e.g. combined effects of cerebrovascular disease and AD).
| Epidemiology of dementia|| |
Dementia is one of the most incapacitating disease of old age and shares 1/6 th of all disability adjusted life years in elderly (aged 60 years and above).  In 2008, the number of people with dementia was reported to be 30 million worldwide and is estimated to be increased up to 59 million in 2030 and 104 million in 2050.  Studies reveal that the cases of dementia will increase rapidly in low and middle income countries. Studies from India also reveal a frightening status regarding older adults to be suffering with dementia. However, the available prevalence studies indicate variable prevalence of dementia in India as compared to developed countries. The prevalence of dementia in India has been reported to be variable, from 1.4% to 9.1%. ,,,, It is estimated that there are already about 3.01 million people affected by dementia in India. 
The hospital-based studies have reported varying but high prevalence of dementia - 34.3%,  33.6%.  Amongst these about half of the patients (48.8%) were having senile dementia. A retrospection of the departmental records of memory/dementia clinic shows that highest number of patients with organic/cognitive disorders were found in the age group of 80 years and above (74.3%) followed by 70-79 years (49.4%) and 60-69 (28.8%). 
| Assessment of dementia|| |
Dementia needs an early detection. In early stages dementia often remains unidentified/ undetected as it begins imperceptibly and therefore, is overlooked. Some medical illnesses like congestive heart failure, pneumonia, surgery or social events may appear and worsen dementia. If it can be recognized at early stages care burden may be reduced, management may become easier and treatment gap may also be reduced. And thus awareness for the disease is essentially required. Dementia may start in many ways. It may start with primarily memory impairment (AD); with personality changes (FTD); with mixed features of memory impairment and personality changes (AD, FTD, Pick's, others); with memory, personality and neurological features (Lewy Body's Dementia); with paranoid/ depressive features (AD) etc. Early stage detection of dementia is important as it is not only useful in management and treatment but also in minimizing the cost of management. Early detection of such cases provide much time for careful interventions and management of the disease, which obviously is beneficial for the clinician, patient and their care givers. And as a result, early recognition and detection of dementia may improve quality of life and well-being of the patients of dementia and their families.
| Screening/Assessment Tools for Dementia|| |
A number of screening/assessment tools are used for assessment of cognitive status of patients with dementia. In general hospital practice or primary care settings, a brief screening test is found to be useful. For nonspecialist care providers, a number of instruments were identified by the WHO is accessible at http://www.alz.org/documents_custom/141209-CognitiveAssessmentToo-kit-final.pdf. Shaji et al.  reported that according to WHO following four instruments to be brief and useful to apply in the primary care settings for diagnosing dementia.
- General practitioner assessment of cognition
- Memory impairment screen
- Vellore screening instrument for dementia.
In addition to the above four instruments, clock drawing test is also a useful bedside instrument for quick assessment of cognitive functioning. An observation list for detecting early signs of dementia is also available, which can be used to screen the probable cases. Like this, there are many tools which contain domain-wise items for assessment of cognitive decline and to rule out NCDs.
Many factors need to be considered for making assessments of cognitive decline in older people. It is well known that many times positive screening may occur because of many reasons like subjects literacy status, exposure etc. To control these biases one need to be careful during selection of screening and assessment tools.
| Management of dementia|| |
There are three stages of dementia - mild, moderate, and severe. In mild dementia - a person does not face much difficulties, and he/she is able to carry out work by making notes of work, remembering things with little effort. In moderate dementia - a person is not able to carry out work and needs guidance/support/help to perform his work. In severe dementia - the person is totally handicapped and needs full help/support and attention for carrying out his/her work. To manage the patients with dementia, one needs to deal with activity, behavior, and cognition/problem triangle of dementia.
Cognition is most important domain in this triangle and improvements in cognition makes functional as well as behavioral activity better. However, management of cognitive domain of dementia is still being researched. Management of dementia needs a multidimensional approach. Proper assessment provides clue for the management of dementia. First of all, one needs to identify and treat the possible reversible causes of dementia. Failing which the management will become difficult. The management includes both pharmacological and nonpharmacological approaches. Careful pharmacological interventions are needed, and management becomes easier applying nonpharmacological interventions.
Studies indicate that nonpharmacological interventions significantly reduce the burden of care and management. It is reported that degree of cognitive impairments is usually related to the degree of brain damage. However, the study reports that people having active lifestyle along with favorable life situations and involved in higher mental function tasks have enhanced resistance to mental and behavioral decline. ,, In day to day clinical practice, authors also experience that person-centered interventions in patients with dementia provide encouraging results. During carrying out postdoctoral fellowship, one of the authors carried out nonpharmacological interventions on patients with dementia and found it a positive vehicle for improving the cognition, if applied carefully considering cognitive, functional, and social domain of the patient.  Further, caregiver support in managing the problem plays a vital role. Almost everyone related to old age care believes that caregivers play an important role in care and management of dementia. Thus, they also need to make aware about the course and outcome of the disease. It is reported that majority of caregivers generally not understand the problem and its management strategies. 
Elderly are more susceptible to develop NCDs. In the present era, dementia has taken a place of catastrophe. Further, for managing an elderly with NCD comprehensive and specific as well as person-centered treatment approach will be essentially required. A team of multidisciplinary individuals (clinician, clinical psychologist, social worker, physiotherapist, occupational therapist, dietician, nursing care staff along with caregiver) should make a comprehensive management plan and such strategic plans need to be implemented by taking full care and precaution. These care plan need proper coordination and monitoring of the entire team including the care giver of the patient. Regular follow-up plans and reassurance to caregivers and patients makes that management and care better.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Frances A, Pincus H, First M. Diagnostic and Statistical Manual of Mental Disorders, 4 th
Edition, Text Revision (DSM-IV-TR). American Psychiatric Association Publishing, Arlington, USA Inc. 2000.
Reisberg B. Alzheimer′s disease. In: Comprehensive Review of Geriatric Psychiatry. 2 nd
ed. Wasington, DC: American Association for Geriatric Psychiatry; 1996. p. 401.
Avila-Funes JA. What is it behind Alzheimer′s disease? A pathophysiology review. Rev Invest Clin 2004;56:375-81.
Venneri A. Imaging treatment effects in Alzheimer′s disease. Magn Reson Imaging 2007;25:953-68.
Shaji K, Sumesh T, Nakulam A. Early detection and diagnosis in dementia. In: Geriatric Mental Health at a Glance. 1 st
ed. India: Ahuja Publishing House; 2014. p. 61-8.
Deary IJ, Corley J, Gow AJ, Harris SE, Houlihan LM, Marioni RE, et al.
Age-associated cognitive decline. Br Med Bull 2009;92:135-52.
Glisky EL. Changes in cognitive function in human aging. In: Riddle DR, editor. Brain Aging: Models, Methods, and Mechanisms. Boca Raton, FL: CRC Press/Taylor & Francis; 2007. [Frontiers in Neuroscience]. Available from: . [Last cited on 2016 Apr 05].
Das SK, Pal S, Ghosal MK. Dementia: Indian scenario. Neurol India 2012;60:618-24.
Ramachandran V, Menon MS, Ramamurthy B. Family structure and mental illness in old age. Indian J Psychiatry 1981;23:21-6.
Chandra V, Ganguli M, Pandav R, Johnston J, Belle S, DeKosky ST. Prevalence of Alzheimer′s disease and other dementias in rural India: the Indo-US study. Neurology 1998;51:1000-8.
Tiwari SC, Pandey NM. Status and requirements of geriatric mental health services in India: An evidence-based commentary. Indian J Psychiatry 2012;54:8-14.
Tiwari SC, Srivastava G, Tripathi RK, Pandey NM, Agarwal GG, Pandey S, et al.
Prevalence of psychiatric morbidity amongst the community dwelling rural older adults in Northern India. Indian J Med Res 2013;138:504-14.
Murray CL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. The Harvard School of Public Health on Behalf of the World Health Organization and the World Bank; 1996. Available from: bitstream/10665/41864/1/0965546608_eng.pdf. [Last cited on 2016 Apr 05].
Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM. Forecasting the global burden of Alzheimer′s disease. Alzheimers Dement 2007;3:186-91.
Venkoba Rao A. Geropsychiatry in India - An Overview. Proceedings of the First National Seminar on Geriatric Psychiatry, Kottayam; 1989.
Bhogale GS, Sudarshan CY. Geriatric patients attending a general hospital psychiatry clinic. Indian J Psychiatry 1993;35:203-5.
Prince M. The need for research on dementia in developing countries. Trop Med Int Health 1997;2:993-1000.
Yaffe K, Barnes D, Nevitt M, Lui LY, Covinsky K. A prospective study of physical activity and cognitive decline in elderly women: women who walk. Arch Intern Med 2001;161:1703-8.
Ding Q, Vaynman S, Souda P, Whitelegge JP, Gomez-Pinilla F. Exercise affects energy metabolism and neural plasticity-related proteins in the hippocampus as revealed by proteomic analysis. Eur J Neurosci 2006;24:1265-76.
Cotman CW, Berchtold NC. Exercise: A behavioral intervention to enhance brain health and plasticity. Trends Neurosci 2002;25:295-301.
Pandey NM. Developing Modules for Cognitive Enhancement for Illiterate Older Adults with Cognitive Deficits. Post Doctoral Fellowship Report Submitted to Indian Council of Social Science Research; 2015.
Pandey N, Tiwari SC, Misra G. Knowledge and understanding of care givers of illiterate older adults with cognitive deficit - A qualitative study. Int J Psychosoc Res 2014;3: 174-9.