Abhilash Desai

Activities of daily living in patients with dementia: clinical relevance, methods of assessment and effects of treatment.

Disability, characterised by the loss of ability to perform activities of daily living (ADL), is a defining feature of dementia that results in growing caregiver burden and the eventual need for alternative care or nursing home placement. Functional decline in patients with dementia can also result from causes other than dementia, such as comorbid medical and psychiatric illnesses and sensory impairment. ADL consists of instrumental ADL (IADL) [complex higher order skills, such as managing finances] and basic ADL (BADL) [self-maintenance skills, such as bathing]. Assessment of IADL and BADL is recommended to establish a diagnosis of dementia. Functional assessment also helps the healthcare provider to offer appropriate counselling regarding safety concerns and need for custodial care. Functional capacity measures have been used increasingly in pharmacological trials of patients with Alzheimer’s disease (AD) and related dementias, although at the present time these measures are generally not primary outcome measures. Functional impairment is not a uniform construct; rather, it is multifaceted and can be measured with various clinical instruments. Many scales have been validated for use in patients with AD for characterising functional impairment and evaluating the efficacy of treatment. Research to date indicates that cholinesterase inhibitors have the potential for modest but meaningful beneficial effects on ADL in patients with mild-to-moderate AD. Memantine also has promising beneficial effects on functional abilities in persons with moderate-to-severe AD. Assessment of ADL as a primary efficacy measure using a validated scale that is non-gender biased and cross-nationally relevant is recommended in new treatment trials of patients with AD and related dementias.

Behavioral disturbance in dementia.

Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night–day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.

Herbals and Botanicals in Geriatric Psychiatry

There is high prevalence of herbal medicine use among elderly people. Most patients do not reveal their herbal use to their physicians and pharmacists. The authors describe some commonly used herbal remedies in terms of their potential benefits and known adverse effects. The review also highlights the potentially serious risk of herb-drug interactions and discusses communication issues and regulatory concerns associated with use of herbal medicines. Health practitioners should remember to include herbal use history in their routine drug histories and remain informed of the beneficial and harmful effects of these treatments.

Review of rivastigmine and its clinical applications in Alzheimer's disease and related disorders.

Rivastigmine (Exelon™, Novartis) is a novel intermediate-acting reversible and non-competitive carbamate acetylcholinesterase (AChE) that was recently introduced for the treatment of Alzheimer’s disease (AD). Preclinical studies have shown that rivastigmine has many similarities to other currently available cholinesterase inhibitors (ChEIs) and some important differences. The drug has been evaluated for this use in two well designed, published, adequately powered, Phase III, 26 week clinical trials that included a total of more than 1500 rivastigmine and 700 placebo recipients. Most of these patients had concomitant disorders that were being treated with numerous other drugs. These studies indicate that rivastigmine (6 - 12 mg/day) usually produces cognitive, global and functional changes that indicate significantly less deterioration than was observed with placebo in patients with mild-to-moderate AD, with higher doses producing more benefits. Rivastigmine is beneficial in all three domains (namely cognition, daily activities and behaviour) of AD. Data on long-term efficacy support continued benefits of rivastigmine beyond 6 months. Rivastigmine is generally well-tolerated with no requirement for routine electrocardiogram (ECG) or blood monitoring. Rivastigmine causes adverse events that are generally those expected from a ChEI and mainly involve gastrointestinal system. They are usually mild-to-moderate, of short duration and responsive to dosage reduction. They occur mostly during the dosage titration phase and decrease during the maintenance phase. Clinically significant drug-drug interactions are unlikely. The consistent efficacy in treating all three domains (cognition, daily functioning and behaviour) and good tolerability, particularly with slow titration, makes rivastigmine a good first-line ChEI therapy for the treatment of AD. Therapeutic dose range is 6 - 12 mg/day. Rivastigmine should be started at 1.5 mg b.i.d. with meals and increased at 2 - 4 week intervals to achieve the highest tolerated dose.

Use of psychopharmacologic agents in the elderly

Most psychiatric disorders in elderly patients are amenable to treatment, provided that intervention is thorough and intensive. Appropriate and judicious use of psychopharmacologic agents has a potential for dramatically improving the quality of life and functional status of many elderly patients with psychiatric disorders. The decision to prescribe a psychopharmacologic agent in elderly patients is a serious and complex issue. Several basic principles need to be followed (Table 6). Although some strides have been made in the last decade regarding safety and efficacy of many psychopharmacologic agents in elderly [table: see text] patients, for many psychopharmacologic agents, large randomized controlled studies to evaluate efficacy and safety in elderly patients are lacking. Sparse data are available regarding the long-term effects of psychopharmacologic agents in elderly patients. Important gaps remain in our knowledge concerning the optimal duration of treatment for most psychiatric disorders in elderly patients. The treatment data deficiency is most striking among the oldest old (patients aged 85 and older), frail medically ill elderly patients (such as nursing home residents), and ethnic minority groups. Future research should focus on these and other relevant issues related to the use of psychopharmacologic agents in elderly patients.

Rivastigmine for Alzheimer’s disease

Alzheimer’s disease is the most common form of neurodegenerative dementia and poses considerable health challenges to both patients and their families. Rivastigmine is a powerful slow-reversible, noncompetitive carbamate cholinesterase inhibitor that is approved for the treatment of mild-to-moderate Alzheimer’s disease. Randomized, double-blind, placebo-controlled trials of up to 6 months duration have shown beneficial effects of rivastigmine compared with placebo in measures of cognition and global functioning. Less rigorous but growing data suggest that the beneficial effects may endure for up to 5 years, extend to more advanced stages of Alzheimer’s disease and may occur in noncognitive domains, such as activities of daily living and the behavioral symptoms of Alzheimer’s disease. Evidence from controlled studies also supports the use of rivastigmine for cognitive and behavioral symptoms in Alzheimer’s disease associated with vascular risk factors, dementia with Lewy bodies and Parkinson’s disease dementia. Early and continued treatment of Alzheimer’s disease with rivastigmine maximizes the observed beneficial effects. The most prominent adverse effect of rivastigmine is centrally mediated cholinergic gastrointestinal events, which can be minimized by slower dose-escalation intervals and administration with a full meal. Therapeutic dosing is 6–12 mg/day given twice daily, with higher doses having the potential for greater benefits.

Healthy Brain Aging: What Has Sleep Got To Do With It?

Sleep plays an important role in learning, memory encoding, and cognition. Insufficient quantity or quality of sleep leads not only to short-term neurocognitive dysfunction but also to permanent changes to the central nervous system. Sleep disorders are common in the geriatric population. The hypoxemia and sleep fragmentation resulting from obstructive sleep apnea are the most likely pathophysiology responsible for damage to the brain. Because treatment of these sleep disorders can lead to improved cognitive function, it is becoming increasingly important for physicians to be able to correctly recognize and treat these disorders in patients presenting with memory or cognitive complaints.

Management of Behavioral and Psychological Symptoms of Dementia

Management of behavioral and psychological symptoms of dementia (BPSD) is a critical component of comprehensive, state-of-the-science dementia care. BPSD are complex, associated with substantial heterogeneity in terms of etiology, clinical presentation and treatment outcome and are the subject of extensive research. Consequently, it can be challenging for health care providers to stay up to date with the clinically most relevant findings and know how to best manage BPSD and respond to concerns of person’s with dementia (PWD) and their family. This is a narrative review that proposes an evidence-informed systematic approach for management of BPSD and aims to summarize key findings from research to date on psychosocial environmental and psychopharmacological interventions for management of BPSD. Early and comprehensive management of BPSD has the potential to not only promote the dignity and safety of PWD but also to improve their caregiver’s quality of life and reduce costs on society by preventing visits to emergency departments, hospitalizations and premature institutionalization.

Buspirone in Alzheimer’s disease

Anxiety symptoms are experienced by the majority of patients with Alzheimer′s disease. Generalized anxiety disorder may occur in 5–6% of patients with Alzheimer′s disease. Anxiety symptoms may underlie agitation and aggression. Anxiety and agitation cause significant morbidity, caregiver distress and may even precipitate institutionalization. Benzodiazepines, although frequently used to treat anxiety and agitation in patients with Alzheimer′s disease, should be avoided because of the high morbidity associated with their use. Disturbances in serotonergic neurotransmission may underlie anxiety symptoms and agitation. Preliminary evidence suggests that buspirone may be a good nonsedating alternative to treat Alzheimer′s disease patients with persistent anxiety symptoms and agitation–aggression. Effective doses reported range from 15 to 60 mg/day is generally well-tolerated. Large, randomized controlled trials are needed to confirm the potential benefits of buspirone for anxiety symptoms and other behavioral disturbances in Alzheimer′s disease patients.

Propoxyphene Use in the Elderly

To the Editor: We have read with interest the article by Keller et al. on the prevention of weight loss in demented patients living in special care units (SCUs). Results show that body weight can be maintained in demented patients living in SCUs, where malnutrition is a frequent condition. We would like to contribute to the discussion with our own data, obtained from a prospective observational study of demented patients living in two SCUs. We determined the prevalence of malnutrition through biochemical and anthropometric data, evaluating nutritional changes with 6 and 18 months of follow-up after a nutritional intervention program. Study was performed on 40 elderly residents in SCUs (part of the Alzheimer Care Plan of Regione Lombardia, Italy); 31 were affected by Alzheimer’s disease (AD), four had vascular dementia (VD), four had mixed AD-VD, and one had Lewy Body disease. Patients were mainly female (72%), with severe cognitive impairment (mean Mini-Mental State Examination score standard deviation55.1 5.9), moderate to severe behavioral disturbances (neuropsychiatric inventory535.7 15.3), and functional impairment (Barthel Index, activities of daily living5 45.9 22.3); they were affected by multiple comorbid diseases (number of diseases54.9 2.9, burden of disease57.4 2.9) and experienced clinical adverse events the year before the study (number of infections52.3 1.6). A low number of neuroleptic drugs and antidepressants was prescribed (0.5 0.5 and 0.7 0.5, respectively), with behavioral interventions preferred over pharmacological treatment of behavioral and psychological symptoms of dementia. Nutritional status was analyzed using anthropometric (weight, body mass index) and biochemical (albumin, transferrin (total iron body capacity (TIBC)), cholesterol, and hemoglobin serum levels) indexes. An albumin level of 3.5 g/dL was used as the cutoff for malnutrition, as previously done in another study. To understand the characteristics of feeding difficulties, the Eating Behavioral Scale was introduced (range 0–18). This scale includes variables potentially influencing feeding, such as the ability to begin the meal and keep attention on food, the use of a knife, and the ability to chew and swallow without difficulty. Higher scores indicate greater levels of independence. Dental status, feeding time, and percentage of food eaten were also assessed for each patient (visual staff evaluation). At the beginning of the study, 19 of 40 patients (47.5%) were judged to be malnourished. Those patients underwent a nutritional program that consisted of modifications of diet composition and quality and consistency of food based on a patient’s preferences or ability to chew, swallowing difficulties, and dental status (soft diets). Time spent by nurses for feeding was increased, as was help feeding, ranging from stimulation to supervision to assisted feeding. Environmental modifications were performed to find the most comfortable place for each patient. Finally, nutritional supplements were prescribed for patients whose daily caloric intake was low (hypercaloric and hyperproteic diets). Nutritional oral supplement prescription was reviewed monthly. Nutritional parameters were assessed at 6 and 18 months of follow-up. After a 6-month intervention trial, the number of malnourished patients fell to 10 (25%). Baseline malnourished patients had a statistically significant improvement of albumin levels and a trend, still not significant, toward improvement of other nutritional parameters: cholesterol, TIBC, and hemoglobin (Table 1). Weight and body mass index did not show significant changes. At 18 months of follow-up, data confirmed the previous evaluation by showing a substantial stability in albumin levels. Similar results were obtained for TIBC and cholesterol, whereas body weight did not change significantly (Table 1). Survival rates at 18 months of follow-up were not different from those reported in the study by Keller et al.