World Alzheimer’s Day: Effective management during middle age is critical

HYDERABAD: World Alzheimer's Day, observed annually on September 21, challenges the misconception that dementia is a normal process of aging, as per the World Alzheimer Report- 2019.

This alone demonstrates the significance of public awareness initiatives, such as World Alzheimer's Month, in changing perceptions and increasing current public knowledge concerning Alzheimer's disease and dementia.

"The increasing number of dementia patients has necessitated the need for proactive measures to identify and mitigate associated risk factors related to the disease by 2050," said Dr M. Jayasree Consultant Neurologist, KIMS Hospitals, Secunderabad.

This year's theme 'Never too early, never too late' emphasises the importance of addressing key risk factors and risk reduction strategies in delaying and potentially preventing dementia onset.

This includes continued risk reduction for those who have already been diagnosed with Alzheimer's disease (AD), a neurodegenerative condition of unknown cause that primarily affects older adults and is the leading cause of dementia.

Alzheimer's disease initially manifests as selective memory loss, with mild impairment in early stages. Early Alzheimer's is characterised by significant impairment in recent event memory, which develops insidiously and progresses slowly over time.

The patient may appear less organised or motivated, often compromising their multitasking abilities, which may be noticed by family members and coworkers. As the disease progresses, patients often struggle with tasks, often underestimating their deficits and providing explanations when they are pointed out.

Interviewing a family member who has known the patient over time is crucial as they often bring the complaint of cognitive impairment to medical attention, according to Dr M Jayasree, Consultant Neurologist, KIMS Hospitals.

The doctor added that, "Loss of insight in Alzheimer's disease may be linked to behavioral disturbances, with neuropsychiatric symptoms being prevalent in the middle and late stages of the disease. The symptoms can start with subtle ones like apathy, social disengagement, and irritability."

Patient management becomes more challenging due to the emergence of behavioral disturbances like agitation, aggression, wandering, and psychosis (hallucinations, delusions, misidentification syndromes).

A concomitant medical illness, medication toxicity, and other causes of delirium should be considered whenever new behavioral disturbances arise, especially if acute or subacute.

Risk factors

A variety of polygenic or acquired factors influence risk for dementia and perhaps specifically the risk for AD, including hypertension, dyslipidemia, cerebrovascular disease, altered glucose metabolism, and brain trauma.

Aggressive management of vascular risk factors during midlife is crucial for reducing the risk, progression, and severity of Alzheimer's Disease and other dementia forms. Environmental risk factors like second hand smoke, air pollution, and pesticides contribute to cognitive decline and dementia, while physically active individuals have a lower incidence.

The Alzheimer's Association and the World Dementia Council conducted a review of the evidence for modifiable risk factors for cognitive decline and dementia and concluded that there was sufficient evidence to support the link between regular physical activity and management of cardiovascular risk factors (diabetes, obesity, smoking, and hypertension) and a lower risk of cognitive decline and possibly dementia.

They also discovered compelling evidence that a good diet and lifelong learning (cognitive training) may lower the risk of cognitive deterioration.

Evaluation

Neuroimaging, particularly MRI, is recommended for assessing patients suspected of having Alzheimer's Disease (AD). Brain MRI can reveal potential diagnoses like cerebrovascular disease, structural diseases, and regional brain atrophy, potentially suggesting frontotemporal dementia or other neurodegenerative diseases.

Cerebrovascular disease, other structural diseases (chronic subdural hematoma, cerebral neoplasm, normal pressure hydrocephalus), and regional brain atrophy suggestive of frontotemporal dementia (FTD) or other types of neurodegenerative disease can all be documented using brain MRI.

Structural MRI findings in Alzheimer's disease (AD) typically reveal generalised and focal atrophy, as well as white matter lesions, but these findings are generally nonspecific. The primary feature of Alzheimer's Disease (AD) is the reduction in hippocampal volume or atrophy of the medial temporal lobe.

Functional brain imaging using 18-F fluorodeoxyglucose positron emission tomography (FDG-PET) or single-photon emission computed tomography (SPECT) reveals distinct regions of hypometabolism and hypoperfusion in Alzheimer's Disease.

Amyloid PET imaging measures brain amyloid lesion burden, aiding in the diagnosis of Alzheimer's Disease (AD) and distinguishing it from other dementia causes.

Genetic testing — Genetic testing is not recommended in the routine evaluation of patients with AD. APOE genotyping adds marginally to the predictive value of clinical criteria for AD and may stratify the risk of progression of amnesic MCI to AD, but both false positives and negatives occur.

Treatment

Mild to moderate dementia — For patients with newly diagnosed mild to moderate Alzheimer's disease dementia, we recommend a cholinesterase inhibitor trial. In patients with mild to moderate dementia (eg, MMSE 10 to 26; MoCA 4 to 16; CDR 1 or 2), cholinesterase inhibitors provide a slight improvement in cognition, neuropsychiatric symptoms, and activities of daily living (ADLs).

Moderate to severe Alzheimer disease: We suggest the use of memantine in combination with a cholinesterase inhibitor in patients with advanced AD.

The combination of memantine and a cholinesterase inhibitor leads to modest improvements in cognition and global outcomes in patients with advanced disease.

Aducanumab is a recombinant monoclonal antibody directed against amyloid beta. The US Food and Drug Administration (FDA) has approved aducanumab for the treatment of mild AD.

Vascular risk factor management

Identification and treatment of risk factors for stroke, cardiovascular disease, and dementia may represent an important strategy for slowing the progression of cognitive decline.

Non pharmacologic and supportive care

Nutrition — Dementia patients may experience weight changes, especially in advanced stages, and consulting a dietician can optimise their nutritional intake for both subsets. Insufficient nutrition is linked to an increase in both morbidity and mortality rates. To boost nutritional intake, consider implementing environmental modifications like a relaxed home-style setting and allowing patients to eat with family members or long-term care residents. Subsequent interventions like assisted feeding and oral nutritional supplements may enhance weight and fat-free mass.

Geriatric care managers — Geriatric care managers, usually specially trained nurses or social workers, provide a key service in a geriatric referral practice. They offer guidance to patients and families regarding how to anticipate the need for in-home or nursing home care and are knowledgeable about community resources, health benefits, and caregiver support services.

Families can benefit from legal resources for financial and other decisions, including appointing power of attorney, developing a financial plan, and managing advanced directives.

Exercise programmes — Doctors suggest that dementia patients should engage in regular exercise programmes, such as walking with family members or senior centers, thrice or more times per week.

Cognitive rehabilitation — Cognitive rehabilitation aims to help patients in the early stages of dementia to maintain memory and higher cognitive function and to devise strategies to compensate for declining function.

Alcohol use — Alcohol can worsen cognitive dysfunction and behavioral disturbance in dementia patients, especially those with mild Alzheimer's Disease, who may occasionally overindulge because they lose track of how many drinks have been consumed. Patients and caregivers are advised to limit alcohol consumption to one drink per sitting and avoid after-dinner alcohol due to its negative impact on sleep.

Advance care planning — Advance care planning is crucial for managing patients with advanced dementia and should be implemented throughout the disease process.

Support for caregivers

Dementia patients' caregivers often experience significant stress, especially as cognitive function declines or behavioral symptoms worsen. Counseling, support groups, and encouraging caregivers to share the caregiving burden with family members or paid caregivers can be beneficial. Respite care and elder daycare can provide caregivers with relief, allowing them to return refreshed and rested.

(With inputs from Dr. M. Jayasree, Consultant Neurologist, KIMS Hospitals, Secunderabad)