|Year : 2018 | Volume
| Issue : 1 | Page : 10-15
Bringing dementia-care back into psychiatry
Department of Psychiatry, PGIMER, Chandigarh, India
|Date of Web Publication||27-Jun-2018|
Department of Psychiatry, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
Dementia with over 46 million people suffering from it has become an illness which cannot be ignored. The confusion regarding whether dementia is a neurological or a psychiatric illness has been existing for a long. Conventionally, dementia has been viewed as a neurological illness with the organicity of the same being given utmost importance. However, we cannot ignore the vast contribution of psychiatry in the discovery of dementia. Furthermore, the new concept regarding psychiatric and neurological illnesses has challenged the fact that dementia is a completely neurological illness, especially considering the vast similarities between psychiatric disorders and dementia. This confusion regarding whether it is a neurological or a psychiatric illness has created difficulty in the management of these patients. The similarities between dementia and psychiatric disorders are visible at the level of localization of lesions, the symptoms, especially the behavioral and the psychotic symptoms, the methods of diagnosis, and the treatment strategies, especially the nonpharmacological ones, which are in fact more effective than the pharmacological strategies. The nonpharmacological aspects include not only behavioral strategies but also focus on breaking the bad news and addressing the caregiver burden and the legal aspects. All this puts a psychiatrist at an advantage in treating these patients, when compared to other specialists, given our expertise with history taking, mental status examination, pharmacological management of the behavioral issues, and especially nonpharmacological aspects.
Keywords: Care, dementia, India
|How to cite this article:|
Avasthi A. Bringing dementia-care back into psychiatry. J Geriatr Ment Health 2018;5:10-5
| Introduction|| |
The word dementia has been derived from a Latin word “dementatus,” which means “out of one's mind.” According to Sadock et al., it is a disease process marked by progressive cognitive impairment in clear consciousness.
The common subtypes of irreversible dementia are Alzheimer's disease (AD), vascular dementia, Lewy body dementia More Details, and frontotemporal dementia (FTD). AD, the most common among them (50%–75%), has gradual onset impairment in memory, with cortical amyloid plaques and neurofibrillary tangles being the main pathological characteristics. Vascular dementia (20%–30%) has more prominent mood fluctuations and strong history of cardiovascular complications. It is characterized by the stepwise progression, single infarcts in critical brain regions or a more diffuse, multi-infarct picture. 5%–10% of the patients suffer from FTD, which is characterized by affective, behavioral, or psychotic symptoms manifesting ahead of frank memory deterioration and often gets misdiagnosed as major depressive disorder (MDD) or psychosis before memory changes manifest. Lewy body dementia with <5% prevalence, in which alpha-synuclein cortical Lewy bodies can be seen in the brain, presents with cognitive fluctuations, visual hallucinations, neuroleptic sensitivity, and parkinsonian features.
In patients aged <65 years, as per Harvey et al., 34% of patients suffered from Alzheimer's dementia, 18% from vascular dementia, 12% from FTD, 10% from alcohol-related dementia, 7% from Lewy body dementia, 5% from dementia due to Huntington's disease, and 14% due to other causes.
Over 46 million people worldwide have been affected by dementia, and it has a 5%–7% prevalence in >60 years age group, which further increases to 15%–20% in the 75–80 years age group and 40%–50% in the >85 years age group. According to the World Alzheimer Report 2015, one new case of dementia is being diagnosed every 3 s, with the majority of patients residing in mostly low- and middle-income nations (58%). In fact, the same report predicts that this pattern is only going to continue, with the figures increasing to 63% in 2030 and 68% in 2050. Nearly 22.9 million people with dementia live in Asia, followed by 10.5 million in Europe, 9.4 million in the Americas, and 4 million in Africa. A meta-analysis by Prince et al. in 2013 showed that the maximum standardized prevalence of dementia is in Eastern Europe (6.92/1000), followed closely by Australasia (6.91), Southeast Asia (6.38), and the Americas. Many studies have evaluated the prevalence of dementia in India also. A systematic review by Das et al., 2012 revealed that prevalence rates as per various studies vary from 0.8% to 3.54% in the geriatric population, with increasing rates of prevalence being reported from the southern states.,,,,,
As per the World Alzheimer Report 2015, the total worldwide estimated cost as of 2015 is nearly 818 million US dollars, and the cost is expected to skyrocket to nearly 2 trillion US dollars by 2030.
| The Gray Zone: Is Dementia a Neurological or a Psychiatric Disease?|| |
Neurological and psychiatric illnesses often have very deceptive boundaries, with each often slipping into the realm of the other. The difficulty in distinguishing between the two is therefore quite understandable. Neurological illnesses have been classically assumed to be “organic”/disorders of the brain, with close links to biology and similarity to internal medicine, clear-cut neuroanatomical and neurophysiological correlates, and mostly require neuroimaging techniques (magnetic resonance imaging [MRI], single photon emission computed tomography) or biomarkers to establish the diagnosis. However, on the other hand, psychiatric disorders are supposed to have no structural basis, are defined as “disorders of the mind,” and have close links to socioeconomic, familial, and interpersonal relationships, with symptoms not corresponding to known neurological pathways and diagnosis mostly based on history and mental status examination. When we go by this concept, being a degenerative brain disease involving deposition of proteins or vascular changes (so-called structural changes), neuroanatomical and neurophysiological correlates, and often requiring neuroimaging techniques to diagnose, dementia fulfills the criteria to be diagnosed as a “neurological” disease. Or so it was assumed to be.
However, the importance of psychiatry in the evolution of dementia cannot be underestimated. As we trace the roots of dementia, it was the founder of Modern Psychiatry, Philippe Pinel (1745–1826) who was one of the first to describe this illness. Jean Etienne Dominique Esquirol, the famous French psychiatrist who belonged to the 19th century, described it in his treatise, Mental Maladies: A Treatise on Insanity, and attempted to distinguish between the cognitive impairment due to dementia and that secondary to mental illness. He also described hallucinations, delusions, aggressive behavior, and motor impairments in patients with dementia and his famous words, “a demented man has lost the goods he used to enjoy; he is a wealthy person turned poor” reveals the destruction wrought by this illness. It was Wilhelm Griesinger, German Neurologist and Psychiatrist, in 1845 who first postulated that dementia is a disease of the cerebral arteries, alluding to the vascular causes of dementia, a fact that has been demonstrated thoroughly. Emil Kraepelin, who famously dedicated his life to the study of schizophrenia, was Griesinger's student. Kraepelin differentiated senile dementia from that arising due to psychoses with cerebral arteriosclerosis (dementia praecox/schizophrenia). Pick, a Czech Psychiatrist, described in 1892 Pick's disease, and in 1907, Alois Alzheimer, German Psychiatrist and Neurologist, was the first to identify specific histopathological changes associated with progressive degenerative dementia. Thus, if we retrospect, then it is justified to suggest that dementia could not have been discovered if not for psychiatry.
Furthermore, the above-mentioned “classical” concept of distinguishing between psychiatric and neurological illnesses has gone through a rather extensive and much-awaited change over the years, owing to years of research and progress involving the two fields, psychiatry in particular. The current concept of the distinction between psychiatric and neurological disorders is far different from the old concept. The firm distinction between the two specialties seems to be blurring with scientific advancement. The current understanding can be surmised as follows:,,,,
- Distinction between structural and functional disorders appear less clear and morphologic correlates of most psychiatric illnesses have been identified.
- The old concept considered that only neurology has close links to biology and similarity to internal medicine. The current understanding unveils that both are close to biology, and as in psychiatry, socioeconomic, familial, and interpersonal relations are important in neurology too
- It was considered that neurological illnesses have defined neuroanatomical and neurophysiological correlates, while psychiatric symptoms do not correspond to known neurological pathways. However, as suggested before, structural correlates of psychiatric illnesses exist. However, it is prudent to explain that one-to-one association is rare and that overall, psychiatric illnesses are more complex by nature and origin, whereas neurological disorders and brain regions have a more one-to-one correlation. It has been shown through voxel-based morphometry as per a meta-analysis by Crossley et al. in 2014 that basal ganglia, insula, motor plus sensory pathways, and dorsal prefrontal region involvement are more suggestive of a neurological disorder, whereas medial prefrontal region, visual association cortex, and lingual cortex involvement are more suggestive of psychiatric disorder 
- In neurological disorders, motor, sensory, and cognitive changes are more significant, and diagnosis depends largely on examination, neuroimaging, and biomarkers, whereas psychiatric disorders focus mostly on the behavioral abnormalities, affective, and cognitive changes and diagnosis is largely dependent on history and mental status examination. Neuroimaging, especially the more advanced and finer techniques such as functional MRI, is useful in psychiatric disorders, though psychiatrists seldom rely solely upon them for treatment or diagnosis. Research is underway on making biomarkers and newer techniques such as imaging genetics a viable diagnostic option for diagnosing psychiatric disorders, and the progress is slow but promising
- Management of neurological and psychiatric disorders is quite different from each other.
This new concept regarding the distinction between neurologic and psychiatric disorders makes one rethink whether dementia falls in the realm of neurology, as suggested explicitly by the classical concept, or psychiatry. The brain regions involved/structural correlates, the symptoms, the mode of diagnosis, and the management in dementia can help one attempt to resolve this confusion.
Relationship between brain regions and symptoms
Like psychiatric disorders, wherein there is no one-to-one relation between the brain regions and the symptoms, it is very difficult to attribute the symptoms of dementia to one particular brain region. Often, patients present with a multitude of symptoms that are quite confusing and difficult to pinpoint to discrete brain regions.
As stated before, neurological disorders involve more of motor, sensory, and cognitive changes, whereas psychiatric disorders focus mainly on the behavioral abnormalities and affective and cognitive changes. The symptomatology of dementia involves cognitive, behavioral, affective, and psychotic symptoms, similar to psychiatric disorders. Nearly all elderly individuals with dementia will develop psychiatric symptoms within 5 years, which commonly includes apathy, depression, anxiety, and often, combinations of these and other symptoms. In a study conducted by Tractenberg et al. in 2003, agitation and psychotic symptoms were found in 77% and 69% of the sample (n = 148.), As per a critical review by Seignourel et al. in 2008, 5%–21% and 8%–71% of dementia patients have anxiety disorders and symptoms, respectively. 11.8%–25% of patients were found to have MDD and 78% were found to have depressive symptoms according to a few older studies. FTD presents as a combination of socially offensive behaviors, such as indifference, impatience, carelessness, jocularity, intrusiveness, and distractibility, and in fact, many patients do not have noticeable cognitive deficits until illness is fully established, which may take months to years. Furthermore, in Lewy body dementia, visual illusions and hallucinations develop early, are persistent, and are associated with misidentification, paranoia, delusions, and anxiety.,
It is well established that medical risk factors are significant in the development of dementia. For instance, there is an exponential increment in the prevalence of dementia with age (doubles with every 5-year increase); 75% of people diagnosed are of female gender, genetic predisposition in the form of presence of αβ precursor protein, presenilin 1, and presenilin 2 with <5% cases of AD being familial (autosomal dominant) and apolipoprotein e4 being a genetic risk modifier. The presence of vascular risk factors is of supreme significance, with hypertension (odds ratio [OR] = 1.97), obesity (OR = 2.09), dyslipidemia (OR = 1.89), diabetes mellitus (hazard ratio [HR] = 1.5), smoking (HR = 2.14), and heart diseases being well-established risk factors. Surprisingly, research has also shown that psychiatric risk factors for dementia also exist. It has been found to be linked to isolation and loneliness, poor sleep, and history of depression.,, As per Zilkens et al., there is increased risk of developing dementia in patients who suffer from psychiatric disorders, including unipolar depression, bipolar disorder, dysthymia, schizophrenia spectrum disorder, anxiety disorder, and alcohol dependence, with maximum risk with bipolar disorder (OR = 6.56). There is increased risk of dementia with some personality disorders (Narcissistic and Cluster C) too.
Similar to psychiatric disorders, diagnosis of dementia is based on not only neuro-imaging, but requires a detailed history-taking and mental status examination, often not only from the patient but also from the caregivers. A detailed history taking and mental status examination will facilitate one in identifying the emotional disturbances which often precede the memory changes as in FTD, help in picking up Mild Cognitive Impairment (MCI), which must not be missed. MCI has 10%–20% prevalence; 5%–10% of MCI in community progress to dementia compared to only 1%–2% in normal population. It is of mainly two types: amnestic which progresses to AD in 90% and nonamnestic type, which is a forerunner to other dementias. It is also imperative that one should rule out depression and reversible effects such as medication which can also confound the diagnosis. Neuropsychological assessment and testing are also important as is the evaluation of behavioral and psychotic symptoms. Psychiatric symptoms predict more rapid progression and death as well as poorer quality of life and increased caregiver burden. As demonstrated by Onyike in 2016, a good history and mental status examination are of infinite use in making a complete diagnosis and distinguishing between different subtypes of dementia. Use of different rating scales is important to assess the patients. AD Assessment Scale–Cognitive Subscale, AD Cooperative Study-Activities of Daily Living, Clinician's Interview-Based Impression of Change Plus, Functional Assessment Staging, Mini-Mental State Examination, Neuropsychiatric Inventory, Neuropsychiatric Inventory–Clinician Rating Scale, Severe Impairment Battery, BEHAVE-AD, Cohen Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia, Apathy Inventory, Global Deterioration Scale, etc., are among the scales that can be used for assessing the patients of dementia. It also can be suggested that better history-taking abilities and more focus on behavioral and cognitive changes put a psychiatrist at an advantage of diagnosing dementia than other specialists.,,,,,
Treatment of dementia involves the treatment of risk factors, cognitive deficits, as well as management of the neuropsychiatric symptoms. Early detection of reversible conditions and care of risk factors such as vascular issues improve outcome. Early initiation of cognitive rehabilitation including mnemonics, association strategies, and computer-assisted training programs has been found to be useful in the management and psychosocial interventions can be applied.
Specific pharmacological agents for cognitive reversal
Multiple agents have been tried for reversing the cognitive changes in dementia. However, majority of the experimental drugs have not proven effective for management of the same. The agents with no evidence of action are Ginkgo biloba, piracetam, melatonin, nicotine, Vitamin B6, E, and B1, folic acid, selegiline, and nonsteroidal anti-inflammatory drugs, whereas those with some benefits are antidepressants and nimodipine.
The main agents with at least established modest effectiveness are the cholinesterase inhibitors (CHEIs) such as donepezil, galantamine, and rivastigmine and N-methyl-D-aspartate antagonists such as memantine. A meta-analysis by Hansen et al. in 2007 involving nearly 14 studies, as well as others, has revealed that these agents offer only modest/significant but small effect improvement over placebo, with number needed to treat of 12 in mild-to-moderate dementia. Studies on severe dementia are too few and not positive. The long-term follow-up studies are lacking. It also has to be noted that none of the agents are approved for MCI and that they are not very useful in vascular dementia or for neuropsychiatric symptoms. Worsening of behavioral changes in FTD with CHEIs has been noted. They also have cardiorespiratory and gastrointestinal adverse effects, dizziness, headache, and sleep disturbances as the main side effects, which are lowest with donepezil and highest with rivastigmine. There has been evidence indicating that these agents increase extrapyramidal symptoms when combined with dopamine antagonist blockers. Most observational studies also indicate that 50% or more of patients discontinue CHEI therapy within 1 year of initiation due to adverse effects. The US Food and Drug Administration has approved CHEIs for mild-to-moderate stage of AD; expanded the indication for donepezil and rivastigmine transdermal patches to include severe AD. In the UK and other European countries, CHEI is licensed for the treatment of mild-to-moderate AD only. These agents have not been found to be cost-effective when cost is compared to the improvement. Overall, the CHEIs and memantine have limited role in the management of dementia. The pharmacological management of dementia for all specialties end with this, except for psychiatry, as mostly only the psychiatrists have the training and disposition for further management and most patients at this juncture are, in fact, referred to psychiatrists.,,,,,
| Nuances of Management|| |
Breaking the bad news
Suffering from dementia is stigmatizing to the patients. Shame, discrimination, rejection, social isolation, loss of the sense of control, and altered self-image following symptom presentation are quite common and have significance in management as well as to improve the quality of life. Studies suggest that diagnostic disclosure in dementia is inconsistent, with up to 50% of clinicians routinely withholding a diagnosis of dementia. A sensitive, compassionate patient-centered full disclosure is essential and the therapist needs to focus on providing realistic hope by highlighting individual variation in disease manifestation and progression, availability of treatment options that might delay decline for a while, and ongoing progress in dementia research. Again, the diagnosis of dementia is quite similar to many chronic psychiatric illnesses and the psychiatrist thus has more experience in such situations.
Management of agitation and aggression
Best evidence for the management of agitation and aggression exists for antipsychotics. As per the studies, there is modest response to citalopram, carbamazepine, and CHEIs. Benzodiazepines are also used. However, there are multiple reports of mortality with the use of antipsychotics in dementia and the risk has been found to be dose dependent. Thus, expertise while prescribing antipsychotics/psychotropics is essential. Psychiatrists are more experienced in handling these agents. Behavioral interventions in the form of identification and avoidance of precipitating factors, appropriate communication techniques (including calm approach, simple, clear commands), acceptance or validation of false statements/inappropriate requests, distraction techniques as well as ruling out pain and delirium are very effective and long-lasting when compared to the pharmacological management.,,,,,,,
Management of anxiety and depression
Antidepressants have been found to be useful with maximum evidence for sertraline and citalopram. Antidepressants with increased anticholinergic properties are not preferred. Electroconvulsive therapy can be used also in case of increased severity. Nonpharmacological techniques are the first line in case of symptoms not severe enough to fulfill the diagnosis of MDD. These include daily routine, instituting pleasant activities, caregiver education, and supportive strategies.,,
Caregiver support and burden
Caregiving for patients with dementia is burdensome and stressful, more importantly in developing countries such as India. It involves financial, social, emotional, and physical aspects. It also results in increased physical disorders, substance use, anxiety, and depressive disorders in the caregiver, as well as worsening of relationship between caregiver and patient. These caregivers are in need of respite care in form of friends, family, or paid staff., Problem-solving and coping strategies, behavioral management therapy, multicomponent therapy, and other modalities can provide considerable relief to the caregivers, making the difficult time easier. Support groups of caregivers also provide valuable feedback as well moral and tangible support.,,
Other nonpharmacological strategies in patients with dementia
These strategies are valuable and free of side effects. These are the main modalities: behavioral therapy, in which triggers, behaviors, and reinforces are identified with the involvement of patient and caregivers; reality orientation therapy which involves reminding patients of facts about themselves and their environment including signposts, notices, and other behavioral aids; validation strategy which attempts to communicate by empathizing with the feelings and meanings hidden behind confused speech and behavior, identifying the emotional content of what is being said over the person's orientation to the present; and reminiscence therapy in which well-being, social interaction, and cognitive stimulation are stressed upon, reliving of past events that are positive and emotionally significant. Other therapies such as aromatherapy and sensory stimulation techniques have also been studied.,,,
Decision-making/capacity, informed consent, advance directives, therapeutic privilege, testamentary capacity, end-of-life issues, including euthanasia, and do-not-resuscitate are important legal aspects of dementia that require careful consideration and sorting out. Treatment issues including surreptitiously giving medication and withholding treatment also are issues that can have legal implications. These are similar to the legal implications associated with chronic psychiatric illnesses, and the psychiatrists are again at an advantage in this aspect when compared to other specialties. Further discussion upon this aspect is beyond the scope of this address.,
| Conclusion|| |
Thus, as elaborated above, dementia appears to be more similar with respect to the structural aspects, symptomatology, diagnosis, as well as management to psychiatric disorders than to neurological disorders. However, the contribution of neurology in diagnosis and management of risk factors are of significant importance and cannot be ignored. There is dire need of a liaison between the two specialties as well as involvement of specialties such as psychology and speech therapy to deliver the best possible care to the patients who suffer from dementia as well as provide respite to the caregivers. However, to conclude, it needs to be remembered that we cannot dissect out psychiatry from treatment of dementia, as if we do so, then these patients will cease to be patients, they will become only cases.
My thoughts penned in this article are an outcome of a continuous and intense dialogue with my young colleague, Dr. Indu Surendran, Senior, in the Department of Psychiatry, PGIMER, Chandigarh.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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