Week 10: What are the non-medication treatment approaches? - Part I

Medication is not the only treatment option

Non-medication therapies may be considered first or at least concurrently with medication. Make sure medical conditions that contribute to behavioral disturbances, including pain, infection, and side effects of medication are treated. Unmet needs, such as thirst, hunger, or desire for attention, must be addressed. Also, avoid disturbing environmental factors, including strong smells, loud noises, and poorly lit condition. Most non-medication therapies have been studied in a series of smaller studies compared to the much larger randomized controlled trials of medications. Here are some examples of the non-medication treatments that have been studied.

• Stimulation/activities including massage/touch therapy.
Improvement in nutritional intake and hand massage, when combined with positive encouragement during a meal, may produce a short-term positive effect on agitation.

• Music therapy.
Listening to music selected by a patient’s family based on patient preference, classical music, pleasant sounds such as ocean waves, and even comforting prayer and stories recorded by family members may be effective for agitation.

• Exercise
This benefits patients of all ages and stages of illness, even those with terminal disease. There is a positive effect of physical activities on behaviors ranging from wandering to aggression and agitation. Activities include indoor exercises, group gentle stretches, and a volunteer-led walking program that encouraged hand holding and singing.

• Pet therapy
In addition to stimulating a social response, patients may benefit from the presence of therapy animals because of:
Reduced agitation. Agitation behaviors may be reduced in the presence of a dog.
Physical activity. Depending on a patient’s mobility, he or she may be able to groom the animal, or even go for a short walk.
Improved eating. Patients have been shown to eat more following a dog’s visit.
Pleasure. Patients may simply enjoy the presence of the dog and its companion, as well as the tricks therapy dogs can do.

• Reminiscence therapy or Life-review
This involves stimulating memories of the past by looking at personal photos/newspaper clippings and discussing the past. It is usually well received by patients and caregivers.

• Cognitive stimulation
This consists of activities such as reviewing current events, drawing, associating words, discussion of hobbies, and planning daily activities. This type of therapy has been shown to improve cognition in patients, as well as well-being and quality of life.

Week 9: What are the common medications used to treat dementia?

Written by Dr. Herrmann, MD FRCPC

Lewar Chair in Geriatric Psychiatry

Professor, Faculty of Medicine, University of Toronto

Head, Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre

 

Medications for Dementia

As mentioned previously, there are no drugs or treatments that can prevent or cure dementia. At the present time there are only 4 drugs approved in Canada to treat Alzheimer’s disease, and they only provide modest benefit for the symptoms of the illness.

 

Three of the drugs (donepezil, galantamine, rivastigmine) work the same way, and act to increase the amount of a brain chemical called acetylcholine. This chemical or “neurotransmitter” is dramatically reduced in the brains of patients with Alzheimer’s disease and some other dementias including Dementia with Lewy Bodies. These drugs can occasionally improve concentration, memory and other brain functions for short periods of times, though ultimately the disease progresses even with ongoing treatment. They all have similar side-effects which can include upset stomach, nausea, diarrhea, loss of appetite and slowing of the heart rate. A trial of one of these medications is generally recommended for all patients diagnosed with Alzheimer’s disease. 

 

The fourth drug, memantine, works on a different brain chemical called glutamate, which is also effected in Alzheimer’s disease. This drug, used with or without one of the medications above, is generally more helpful in the more advanced stages of the illness. It is well tolerated with few side-effects.

Because up to 90% of patients with Alzheimer’s disease will have some type of emotional or behavioral symptom at some point in their illness, many of these people will require treatment with other drugs. Symptoms such as depression, anxiety, agitation, aggression, hallucinations, and insomnia are all common and are frequently treated with medications like antidepressants, antipsychotics and sleeping pills. There is increasing concern that these medications have limited benefits and can potentially cause significant and serious side-effects.

 

Clearly, there is a desperate need for better treatments and ultimately medications that can prevent the illness before it begins to cause symptoms. There is active research ongoing in these areas.

 

For more information on the medications to treat dementia, please refer to Dr. Herrmann’s Memory Doctor Blog at http://health.sunnybrook.ca/memory-doctor/alzheimers-disease-drugs-effective/

 

Week 8: Can we prevent cognitive decline?

 

Treatment of dementia depends on its cause. In the case of most progressive dementias, including Alzheimer's disease, there is no cure and no treatment yet that meaningfully slows or stops its progression. Some of the most active areas of research in risk reduction and prevention include cardiovascular factors, mentally stimulating activities, physical fitness, and diet.

Cardiovascular risk factors:

The brain is nourished by one of body's richest networks of blood vessels. Anything that damages blood vessels anywhere in the body can damage blood vessels in the brain, depriving brain cells of vital nourishment and oxygen. Blood vessel changes in the brain are directly linked to vascular dementia, but they often are present along with changes caused by other types of dementia, including Alzheimer's disease and dementia with Lewy bodies. These changes may interact to cause faster decline or make impairments more severe. So do not smoke, keep blood pressure, cholesterol and blood sugar within recommended limits, and maintain a healthy weight.

Mentally stimulating activities:

Participating in active, mentally stimulating activities may delay onset and slow progression of dementia. Some examples of mentally stimulating activities include:

1. Sing songs. Play music.

2. Do arts and crafts, such as painting or knitting.

3. Organize household items, clean the house, particularly if the person used to take pleasure in such tasks.

4. Engage in discussions, attend lectures, socialize with friends and family.

5. Regular trips outside the home; e.g. visit a botanical garden.

6. Read the newspaper or magazines.

7. Look at books the person used to enjoy.

8. Cook or bake simple recipes together.

9. Work on puzzles. 

10. Avoid watching too much TV – that is a passive type of activity.

Physical exercise:

Regular physical exercise may help lower the risk of some types of dementia. Evidence suggests exercise may directly benefit brain cells by increasing blood and oxygen flow to the brain among many other potential benefits. Exercise should include both cardiovascular (walking, running, swimming) and resistance (light weights, yoga) type activities.

Diet:

Our diet may have a great impact on brain health in the same way it effects heart health. The best current evidence suggests that heart-healthy eating patterns, such as the Mediterranean diet, also may help protect the brain. A Mediterranean diet includes relatively little red meat and emphasizes whole grains, fruits and vegetables, fish and shellfish, and nuts, olive oil and other healthy fats.

 

Week 7: How do we treat dementia?

1) Ensure proper diagnosis of dementia

There is no single one test to diagnose if someone has dementia. The diagnoses of Alzheimer's and other types of dementia are based on a careful medical history, a physical examination, cognitive testing, laboratory tests, the characteristic changes in thinking, function and behavior associated with each type of dementia and the possible use of brain scans (CT scan and MRI). To determine that a person has dementia with a high level of certainty is easier but it is harder to determine the exact type or cause of dementia because the symptoms and brain changes of different dementias can overlap. Sometimes the family doctor may need to refer the patient to the specialists like neurologists, psychiatrists or geriatric medical specialists.

2) Assess safety

The behavior of the patient with dementia needs to be closely monitored, especially to make sure patient does not pose harm to self or others.  Family members and general practitioner need to pay attention in the areas of wandering, neglect, abuse and driving.

3) Assess and treat co-morbid medical illness

Patients with dementia still require regular checkups and health assessments like other patients. Many common illnesses can make the dementia worse.

4) Caregiver education and support

To look after a family member with dementia can be demanding and exhausting. It is important the caregiver understands the disease. Education and support for the caregivers are vital.

5) Community resource

Alzheimer’s Society will be a good resource to patients, caregivers and health care providers. Day programs, home supports, respite care, long term care can be all appropriate treatment options depending on the stage of disease.

6)    Behavioural problems

Behavioural problems like agitation, aggression, depression and anxiety can be challenging and may require the help of a specialist.

7) Cognitive decline

Treat (prevent?) cognitive decline---please refer to the following week.