Gender and Dementia

What is Dementia?

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The word dementia is derived from two Latin words meaning "away" and "mind". Dementia is not a specific disease but a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain.

Dementia involves an acquired chronic deterioration of intellectual function and other cognitive skills severe enough to interfere with one’s ability to perform activities of daily living (ADLs) and one’s ability to maintain relationships ^[1].

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines dementia as "a general progressive deterioration of cognitive status in comparison to previous level of functioning that is often accompanied by changes in psychological and emotional states such as depression, agitation, aggression and apathy" ^[2].

Dementia is a major medical, social and economic problem that will get worse in the future as the number of older people in the population increases.

Dementia is often confused with Delirium

For more comparisons between dementia and delirium, follow this link.

Don't forget - memory loss in isolation does not always mean dementia!

Prevalence Rates

Dementia is a growing health care problem ^[5]. Figure 1 shows the DOUBLING rule - dementia rates double every 5 years after the age of 65.

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The Canadian Study of Health and Aging Working Group (CSHA) estimates that in 2011, there will be 145,300 new cases of dementia, and of these new cases, 92, 900 will be women and 52, 400 will be men ^[6]. This estimate shows that dementia rates are twice as high in women compared to men, making dementia an important health care issue for women. More research is needed to gain sex-specific data in the pathophysiology, clinical presentation and treatment of dementia. Currently, most sex-based data that is available has been gathered via post hoc analysis.

Sex and Dementia Rates

Dementia is an important issue for older women and men. The population is aging in Canada and across most of the world and thus the proportion of older people will rise over the next few decades. The most rapid increase will be in those over 85 years of age, a group identified by the term the "oldest old" ^[7]. As the average life expectancy is longer for women than men, there will be a higher proportion of women in this oldest age group. As age is a major risk factor for the development of dementia, these women will be at a much higher risk. As shown in the figure below, in the 85 plus age group, women far outnumber men for the prevalence of Alzheimer’s Disease. On the other hand, vascular dementia is more prevalent in men.

caption

Alzheimer’s Disease is the most common form of dementia ^[8]. The other common sub-types of dementia are also shown below.

caption

For more Canadian statistics from Alzheimer Toronto,follow this link.

Making the Diagnosis of Dementia

In order to make an accurate diagnosis you must:

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• rule out other conditions that may have similar symptoms as dementia but may be treatable e.g. hypothyroidism, depression, vitamin deficiencies etc.

• rule out other possible causes of confusion such as poor vision or hearing, side effects of drugs etc.

An accurate diagnosis of dementia is important in order to:

• implement an appropriate treatment plan

• access information and support from the heath care system and the community support groups

• assist the patient and family to plan and make arrangements for the future

Dementia is commonly under-diagnosed in primary health care settings because of the multiple etiologies and the wide range of symptoms at the time of presentation ^[9].

DSM-IV Diagnostic Criteria for Dementia

• short term memory impairment (amnesia)

and at least one of:

• language disturbance (aphasia)

• impaired ability to carry out motor activities or ADLs (apraxia)

• failure to recognize/identify familiar objects (agnosia)

• poor executive functioning (planning, organizing, abstracting, disinhibition and inappropriate behaviour) ^[10]

Diagnosis

Currently, there is no single test that is available to detect and diagnose dementia in clinical practice. Instead the diagnosis of dementia is based on a combination of history taking and physical and neurological exams. Further investigations, such as lab tests and imaging studies, assist to differentiate the types of dementia.

History Taking Tips

• build a rapport with the patient and their family/caregivers
• obtain information on the time of onset, progression, pattern of decline of cognition and function, family history of dementia etc.
• assess problem solving abilities, behavioural changes and psychiatric symptoms

The interviewer must modify her or his style to accommodate the patient being interviewed. For example, if the patient has cognitive deficits, the clinician will need to change the style and extent of history taking and interview to the patient’s capacity while respecting boundaries and preserving patient dignity at all times ^[11].

Obtain permission to talk with other care providers and the family physician if you not the primary care provider yourself.

For more information on how to conduct a proper patient history, consult the Practical Guide to Clinical Medicine Website.^[12]

Examination

In the case of dementia a complete examination includes:

• full physical examination, including neurological exam
• cognitive assessment including mini mental status examination (MMSE)

For more information on how to conduct full physical and neurological exams consult the Practical Guide to Clinical Medicine Website[11].

This video reviews the neurological exam in patients with dementia

Cognitive Assessment

Mini Mental State Examination

The most commonly used test to screen cognition is the Mini Mental State Examination (MMSE). The MMSE looks at various cognitive domains such as learning, language and short term memory.

The MMSE is a valid and reliable screening instrument. The sensitivity of MMSE for dementia ranges from 71 to 92%, and the specificity ranges from 56 to 96% ^[13]. A literature review from 1990 to 1999 showed that the MMSE provides a global score of cognitive ability that correlates with daily function ^[14]. Hence, the results of the MMSE in conjunction with a history and physical assessment can assist in differential diagnosis of cognitive impairment resulting from various dementia sub-types ^[15]. However, limitations of the MMSE include it is not reliable when administered through an interpreter to non-English speaking patients; and it lacks sensitivity in picking up very mild cognitive changes ^[16]. Full instructions and test questions in PDF form can be accessed online through the Regional Geriatric Assessment Programme of Ottawa-Carleton.

Montreal Cognitive Assessment

The Montreal Cognitive Assessment (MoCA) is another test that was designed as a rapid screening instrument for mild cognitive dysfunction ^[17]. It assesses different cognitive domains including attention and concentration, executive functioning, memory and orientation. It takes about 10 minutes to administer making it a practical tool to use in a clinical setting. It is available in a number of languages. Sensitivity and specificity studies have also been performed on the MoCA ^[18]. To access the results of these studies and the instructions on administration of the test, click on the MoCA website.

Other Investigations

• routine labs: complete blood count, fasting blood sugar, thyroid stimulating hormone, calcium, electrolytes, urea and creatinine
• specific labs: B12, folate levels, liver function tests
• for most patients who have a clinical presentation consistent with AD with typical cognitive symptoms or presentation, only the above basic set of tests need to be completed
• extensive investigations are not required unless a reversible cause of dementia is suspected ^[19]

Brain Imaging

• Computerized Tomography (CAT): role in detecting certain causes of dementia such as VaD, tumor, NPH or subdural hematoma
• Magnetic Resonance Imaging (MRI): helps to visualize white matter lesions
• Functional Imaging: Positron Emission Technology (PET scans) and Functional Magnetic Resonance Imaging (fMRI): mainly used for research purposes only and not in clinical settings

Image:UCSLGZJM.jpg

for more information on neuroimaging, follow this link.^[20]

Others

• EEG: used in patients in whom seizure disorder is suspected
• lumbar puncture to analyze the cerebrospinal fluid (CSF): used to rule out infection, inflammation, malignancy
• in complex cases, a referral to specialists such as geriatrics, psychogeriatrics or neurology may be required

How well do you know your diagnostic tools ?

Differential Diagnosis

The recognition of dementia is a two-step process. Clinicians must first determine whether dementia exists or not. In order to do so, other possible disorders such as those described below must first be ruled out. Once this has occurred, specific causes of dementia can be identified ^[21].

Delirium

• acute confusional state that develops over a short period of time
• disturbance of consciousness with reduced attention span
• change in cognition present i.e. memory deficit, disorientation, language disturbance
• there is usually evidence of a medical cause e.g. drugs, infections, metabolic disorder and electrolytes/fluid imbalance ^[22]

Depression

• very common in the elderly population
• symptoms of weight loss or depressed mood lasting at least two weeks and a change from previous level
• plus any 4 of the following: weight loss, insomnia/hypersomnia, fatigue, feelings of worthlessness/guilt, psychomotor agitation, decreased concentration, recurrent thoughts of death or suicidal ideation
• may have patchy cognitive losses on testing ^[23]

Mild Cognitive Impairment (MCI)

• impairment in memory only
• all other cognitive functions are spared
• preserved basic day to day functioning
• no other obvious medical or psychiatric explanation for the memory problems
• 10-15% of patients with MCI will progress to dementia per year, particularly the amnesic type MCI ^[24]

Summary of the 3 D’s

Diagnostic Disclosure

Making the disclosure of a dementia diagnosis to the patient and family, taking into account the risk of depression, is essential and can be challenging for physicians. A qualitative study was conducted with 30 patients and caregivers to examine the disclosure process ^[27]. Based on the findings on this study, ten recommendations to improve the process of disclosure of dementia were made. They are as follows:

• an overwhelming majority of patients and caregivers supported full disclosure. Gradual disclosure with upfront discussion of possibilities and giving information through the assessment process was the preferred method of full disclosure
• professionals need to be prepared for the emotional response of the patient and caregiver
• provide a non-threatening setup for the meeting, comfortable chairs, circle setup etc.
• ensure caregivers are there for support and provide follow up as needed
• ensure there are familiar providers/professionals who can establish a link with the patient during disclosure (i.e. in specialty settings)
• the treating physician should be the person disclosing, other team members (e.g. nurse) can also play a major role during disclosure
• use/show empathy, provide a balance of hope and realism
• ensure enough information is provided, use plain language and avoid jargon
• use diagrams or flow charts if possible, and provide a written summary of findings
• offer resources and follow up for more information on disease process

Special Considerations

Other factors that a physician should consider include:

• initiation of therapy for cognitive, behaviour and mood symptoms
• referral to groups such as the Alzheimer’s Society of Canada and Community Care Access Centers which offer services, education and support groups for patients and their families or caregivers
• legal issues including updating of documents such as wills, advanced directives for medical care and designation of power of attorney
• vocational issues for those who may still be employed
• driving capacity needs to be assessed and other safety concerns may need to be examined^[28]
• planning for future care needs of the patient

Alzheimer’s Disease (AD)

• first described by Alois Alzheimer in 1907
• the most common type of dementia accounting for 50-60% of all dementias ^[29]

• neurofibrillary tangles are also present as a result of abnormal tau protein production (hyper-phosphorylation of tau protein) which impede the delivery of neurotransmitters along the axons and cause cell death ^[30]
• widespread cortical atrophy is associated with the above changes; the medial temporal lobes are particularly affected in AD
• there are 2 types of AD: 1) sporadic type which is the most common form that occurs after the age of 65 and accounts for 90-95% of all cases and 2) familial autosomal dominant type which occurs as early as age 30 and accounts for 5-10% of all cases ^[31]
• common signs and symptoms include memory loss, language deficits, decreased executive functioning and personality changes
• for more information on living with AD, click on Alzheimer’s Society Website
• there is an abnormal processing of the amyloid precursor protein in the brain cells which leads to the accumulation of beta amyloid and the formation of neuritic plaques (shown here) that cause cell death ^[32]

Vascular Dementia (VaD)

• the second most common type of dementia accounting for 5-10% of all dementias ^[33]
• VaD can result from a number of syndromes associated with cerebrovascular disease and is characterized by an abrupt onset and a stepwise decline ^[34]
• can occur as a result of either a ischemic, hypoperfused or hemorrhagic brain lesion ^[35]
• subcortical ischemic vascular dementia refers to lesions that involve the basal ganglia, cerebral white matter and the brainstem and is the most common cause of cognitive decline and VaD in the elderly ^[36]
• it occurs as a result of two mechanisms which often can overlap: 1) ischemic injury leading to complete infarction i.e. lacunar infarcts and microinfarcts or 2) incomplete infarctions of the cerebral white matter ^[37]
• Roman et al (2002) note that a significant proportion of subcortical lacunes are clinically silent and unnoticed until cognitive function deteriorates; this signifies the importance of primary prevention ^[38]
• common signs and symptoms include loss of executive functioning, decreased memory (particularly retrival problem), mood disorders, slowed thinking and gait disturbances

Mixed Type

• increasing evidence shows that VaD and AD often coexist in older patients and is called mixed dementia
• cardiovascular disease (CVD) is the pathology and VaD is the disorder and VaD with no AD pathology is relatively uncommon as shown in the figure below

• any patients have overlap of AD and significant CVD
• over 60% of patients diagnosed with AD also have incomplete white matter infarction on imaging ^[39]
• cerebral ischemia and amyolid deposits may synergize to produce AD and vascular changes in the brain ^[40]
• a great deal of research is currently being conducted to clarify these mechanisms

Lewy Body Dementia (LBD)

• first described by Dr. Levi in 1912
• a form of progressive dementia identified by abnormal structures in neurons called “Lewy bodies“ which are composed mainly of a protein called alpha synuclein and are distributed in the cortex and the midbrain ^[41]
• the mechanism that leads to the formation of Lewy bodies is unknown
• cerebral atrophy is present along with neurofibrillary tangles, however, minimal neuritic plaques are seen
• LBD has a greater frequency of depressive and psychotic symptoms with a fluctuating level of consciousness and cognitive symptoms occurring within one year of the onset of Parkinsonian motor symptoms ^[42]
• more information can be obtained on the Lewy Body Dementia Association website

Frontotemporal Dementia (FTD)

• effects primarily the frontal and temporal lobes of the brain and has a more rapid progression than the other subtypes of dementia ^[43]
• neuropathology shows marked lobar atrophy of the frontal and temporal lobes as shown here ^[44]

• Pick’s Disease is one type of FTD; the cerebral cortex has ballooned cells called Pick cells with intraneuronal inclusions called Pick bodies ^[45]
• symptoms show behavioural changes such as as loss of social awareness, disinhibition and other frontal release signs such as the grasp sign on physical exam
• cause is still unknown, however there is a strong genetic component as FTD tends to run in families and approximately 40% of cases are believed to be hereditary ^[46]
• more information can be obtained from the Pick’s Disease Support Group

Cheat Sheet for Dementia Subtypes

As there are numerous subtypes of dementia, it can be difficult to distinguish between the subtypes. The following table summarizes four subtypes of dementia on various domains. ^[47][48]

Sex, Gender and Pathology

Female sex, among many other risk factors in dementias, has been associated with an increased risk of the development of AD.

Barnes et al (2004) used data from 141 older Catholic clergy members to assess clinico-pathological correlation between two sexes [1]. The subjects in the study underwent an annual examination and a brain autopsy at death. Their results showed that:

• women tended to have more global AD pathology and neurofibrillary tangles but the same amount of neuritic plaques ^[49]
• the relation of global AD pathology to clinical diagnosis differed between men and women as each additional unit of AD pathology was associated with a three fold increase in odds of clincial AD in men compared to 20 fold increase in odds of clinical AD in women ^[50]
• hence, this data suggests that AD pathology is more likely to be clinically expressed as dementia in women than in men ^[51]

Further research needs to be conducted to look at pathology in other dementia sub-types. New methods need to be developed that are sensitive in diagnosing pathological gender differences early on in the disease process to allow for intervention and maximize quality of life.

Sex, Gender and Risk Factors

The cause of dementia is unknown but certain risk factors have been shown to be linked in its development. Women have two times a higher risk of developing dementia, specifically AD, than men. The main risk factors for dementia are age, family history and APOE status and the presence of traditional vascular risk factors such as hypertension, diabetes mellitus (DM) and hypercholesterolemia. New risk factors that are emerging and currently being researched include increased homocysteine levels, obesity, estrogen use and metabolic syndrome ^[52].

Age

• age is the strongest risk factor for dementia as the prevalence of AD doubles every 5 years beyond the age of 65 ^[53]
• the rates of dementia are higher among women as women tend to live longer and compromise a greater proportion of those in the "oldest old" age group

Family History

• first degree relatives with dementia have a 10-30% risk of developing AD ^[54]
• in familial autosomal dominant AD, a genetic connection has been shown as in certain families, it is passed directly from one generation to another through a dominant inheritance pattern
• follow this link to find out more about heredity: Alzheimer Society Information on AD and heredity

Estrogen

• cognitive decline is often accelerated in women after menopause as studies show that there are sex-based differences in the ageing of the brain
• it is possible that estrogen may function as a mild vasodilator and increase the blood flow in the brain, hence having a protective effect in pre-menopausal women ^[55]
• results of various longitudinal stuides suggested a beneficial effect of estrogen therapy on cognitive function in symptomatic post-menopausal women; however, the results of a large recent clinical trial, the Women’s Health Initiative Study (WHIMS) does not support this in women over 65 years ^[56]
• this trial demonstrated an increased occurrence of dementia in postmenopausal women who received combined estrogen-progestin therapy ^[57]
• hence, the routine therapeutic use of estrogen in women over age 65 is not justified based on the existing evidence ^[58]

APOE (Apolipoprotein E epsilon) Gene

• the APOE gene is carried on chromosome 19 and has 3 alleles: APOE e2, APOE e3 and APOE e4 and is the most significant known genetic risk factor for dementia ^[59][60]

• APOE e4 is associated increasing the likelihood of late onset AD, raising total cholesterol levels and shifting the age onset an average of 5-20 years earlier depending on the number of alleles present ^[61][62]

• this genotype seems to have greater effects on women with respect to hippocampal pathology and memory performance

Vascular Risk Factors

• prevalence of hypertension(HTN) is greater in men than in women until age of 60 years and then it is higher in women; women also have a higher rate of silent ischemia and cerebral white matter changes associated with HTN and diabetes making them more vulnerable to development of dementia [5]
• low BP may be associated with cognitive impairment implying that a certain level of BP is needed to maintain adequate cerebral perfusion to preserve cognitive ability ^[63]
• the Kunghsholmen project which had a proportion of 81.7% women in their sample size showed that diastolic BP <70 mmHg in those greater than 75 years was associated with increased incidence of AD and dementia ^[64]
• diabetes has been associated with lower levels of cognitive function and greater cognitive decline in those over 65 and this is a concern for women as diabetes is increasing in frequency to a greater extent in women than in men ^[65]

Other Risk Factors

• obesity in the middle age increases the risk of future dementia; for every one point gain in BMI, the risk of temporal lobe atrophy increased by 13 to 16% ^[66]
• homocysteine has been shown to be a risk factor for stroke, heart disease and VaD through its association with small blood vessel and endothelial dysfunction
• increased levels of homocysteine are a strong independent risk factor for the development of dementia based on the Framingham Study ^[67]
• presence of Mild Cognitive Impairment (MCI)

Stages of Alzheimer’s Disease

The analogy of one’s mind as a multi-layered onion is one way of thinking of dementia ^[68]. Starting in childhood, successive layers are added over the years as one acquires new memories and skills. Dementia results in the slow peeling away of the onion layers, in which the more recently acquired items are lost first, followed by the more remote memories and skills and eventually even the most basic skills including eating, walking and speaking are peeled away and lost ^[69]. This process is also called retrogenesis.

A number of staging systems have been developed to help understand how the disease progresses and for making future plans. One staging system classifies Alzheimer’s Disease in three stages: early, middle and late. Another staging system, known as the Reisberg Scale, divides the disease into seven stages ^[70]. The length of each stage will vary and stages may overlap.

Early Stage

• loss of short term memory
• inability to learn and recall new information
• language deficits (e.g. inability to find words, lose track of conversation)
• mood swings and personality changes
• person can compesate for cognitive deficits and continue to function independently ^[71]

Middle Stage

• decreased long term memory
• supervision and increased assistance required for ADLs and IADLs
• agitation, hostility, aggressiveness, uncooperativeness, apathy
• "sundowning" i.e. increased behavioural problems in the evenings such as fatigue, disrupted sleep/wake cycles
• wandering, rummaging and repetitive behaviour
• altered appetite, sleep and sexual behaviour
• delusional thinking i.e. suspiciousness of family and friends
• hallucinations may occur in 10-15% of patients ^[72]

Late Stage

• can’t recognize self or family
• complete deterioration of personality
• little capacity for self care
• patients eventually become bed-ridden and unable to function ^[73]

Living the Diagnosis

In 1995 American artist William Utermohlen was diagnosed with Alzheimer’s Disease.^[74] He began a series of self portraits that vividly portray the effect of the disease. An article in the New York Times has a number of the portraits and a slide show available. Mr. Utermohlen’s medical findings and an analysis of his work are available in a 2001 paper published in The Lancet^[75].

Treatment of Dementia

• there is currently no cure for most dementias nor treatment that can restore mental function
• current treatment focuses on correcting all reversible factors and slowing down the irreversible factors to help improve function ^[76]
• treatment can be divided into pharmacological and non-pharmacological therapies

Pharmacological Therapy

Cholinesterase Inhibitors (ChEI’s)

• several medications are available for patients with AD that ease symptoms by slowing down the decline of memory, language and thinking abilities [11]
• the Canadian Consensus Conference on Dementia recommends that cholinesterase inhibitors (ChEIs) be used for standard symptomatic treatment of mild to moderate AD [11]
• ChEIs focus on correcting the cholinergic deficiency in the central nervous system ^[77]

• currently three ChEIs are marketed for treatment of AD; these are donepezil, rivastigmine, galantamine for treatment of cognitive symptoms of mild to moderate AD ^[78]
• usually improved cognitive abilities are seen in the fist 2-3 months, followed by a slowing down of the progression of the symptoms ^[79]
• a recent meta-analysis of 16 randomized, double blind, placebo-controlled trials examined the effect on ChEIs on cognitive status confirmed that AD patients treated with ChEIs have a modest but significant therapeutic effect ^[80]
• a more recent review of 19 randomized controlled trials concluded that the methodological quality of the trials being reviewed was poor with missing data on patient dropout from the treatment arm and affecting intention to treat analysis, thereby the beneficial effects of previously described may not be as strong ^[81]
• future studies are clearly needed that look at long term effects of these drugs in both sexes as well as clinical outcomes such as function and behaviour and delaying institutionalization and the reduction of caregiver burden

Side effects of ChEIs

A recent meta-analysis of 16 randomized, double blind, placebo-controlled trials examined the side effects and adverse events caused by the use of ChEIs^[82] found that:

• AD patients treated with ChEIs have a significantly higher rate of adverse events ^[83] (examples of adverse events include nausea, vomiting, diarrhea, abdominal pain, fatigue and weight loss etc.)
• the tolerability of ChEIs was an issue and the proportion of patients in whom adverse events emerged during treatment was 8% higher than those receiving placebo ^[84]
• there is weak evidence that women experience more adverse effects than men, possibly due to a lower body weight ^[85]
• ChEIs can also have a vagotonic effect on the SA and AV nodes, leading to bradycardia and heart block especially in those patients with coexisting cerebrovascular disease ^[86]

Memantine

Memantine was approved for sale in Canada in 2004 for use in moderate to severe dementia, it is an uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist that blocks the effects of excessive glutamate while still preserving physiologic activation of NMDA receptors required for learning and memory ^[87]

• by blocking the effects of abnormal glutamate activity, memantine prevents neuronal cell death and cognitive dysfunction ^[88]
• in a 1999 randomized, placebo controlled trial of 150 patients with AD or VaD, the treatment group showed better functional outcomes and reduced care dependence as compared to placebo group ^[89]
• memantine is well tolerated and safe in reported trials and can be co-administered with ChEIs safely
• the most common reported side effect is dizziness ^[90]

Vascular Dementia

Treatment for VaD involves controlling the vascular risk factors such as blood pressure, cholesterol levels, diabetes etc.

• the strongest evidence available to date involves the use of anti-hypertensive agents - randomized placebo controlled trials (PROGRESS, HOPE trials) have found that anti-hypertensive agents reduce the incidence of dementia in elderly patients ^[91]
• each 1 mmHg decrease in BP in mid-life is equal to a 1% less chance of developing dementia in later years ^[92]
• a recent meta-analysis found that ChEis are associated with differential risks for death in VaD, from no risk to substantially increased risk - this is likely due to the heterogeneity of risk factors in VaD and further studies are required to know the overall effectiveness and safety of these drugs and what patient benefits the most ^[93]

Immunotherapy

• abnormal accumulation of proteins in the brain is associated with dementia
• immunization against amyloid-beta in Alzheimer’s disease to prevent the onset of amyloid-beta accumulation is currently under investigation
• in transgenic mouse models, active immunization with amyloid-beta results in the removal of amyloid-beta plaques via the generation of amyloid-beta antibodies resulting in improvement in cognitive function ^[94]
• an active peptide vaccine consisting of amyloid-beta antibodies was halted in 2002 because 6 percent of participants developed complications such as neurological decline, lymphocytosis of the cerebrospinal fluid and altered signal intensities in cerebral white matter ^[95]
• active immunization schedules are being developed to minimize T lymphocyte reactions and to maximize antibody production and passive immunization protocols are being devised ^[96]
• immunotherapy for removal of the proteins which accumulate in other neurodegenerative disorders associated with dementia such as prion proteins and synuclein are in the early stages of development ^[97]

Other Medications

• anti-depressants such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and monamine oxidase inhibitors (MAOIs) have all been used
• medications to treat behavioural symptoms of dementia i.e. agitation, psychosis, mood swings etc. such as antipsychotics, neuroleptics are also commonly used to try and help people with dementia

Non-pharmacological Approaches

• open communication between patients, families and health care professionals with clear discussion of diagnosis, prognosis and treatment options
• educating and providing support to patients, families and caregivers
• creating supportive environments with structure and routine, such as day hospitals and respite care, to allow patients to function to their maximum capacity
• referral to allied health professionals such as occupational therapists to assist patients and families with daily routines and for other cognitive and behavioural strategies; physical therapists to help patients maintain mobility; and social workers to assist patients and families with future planning
• Luijpen et al (2003) showed that physical activity and tactile stimulation had a positive effect on cognitive functioning and on the patient-caregiver relationship, making this an important non-pharmacological therapy that can be used ^[98]
• discussion of the future with respect to issues such as medical directives, institutionalization, power of attorneys, finances etc. needs to occur in the early to mid stages of dementia to allow the patient to take part and express their wishes

Ensuring a safe environment for all seniors

This Virtual Homevisit was created by Dr. Gustavo Duque and the McGill Molson Medical Informatics group, it is used with permission. The safety issues highlighted in this game are important for all seniors, especially those with cognitive impairment.

The reading material links from the game are not working at the moment. The following links will take you to the documents:

• Reading Material 1 ^[99]
• Reading Material 2
• patient handout from Health Canada and the Public Health Agency of Canada^[100]
• patient handout from the Centre for Disease Control in the USA.^[101]

Behavioural Issues

Behavioural and psychological symptoms are common in those with dementia and can impair the quality of life of the patient and caregiver.

• 50% of those with dementia display depressive symptoms and 60-80% exhibit agitated behaviour at some point during the course of the disease ^[102] these issues can be very distressing for family and friends to witness and can lead to the institutionalization of the demented
• wandering is a common behaviour in those with dementia and is related to short term memory loss and the inability to reason or to make judgments ^[103]
• wandering can occur at any time of the day or night and may appear to be aimless or may be focused on pursuing a particular goal or destination ^[104]
• Safely Home is a nationwide program and registry developed by the Alzheimer Society of Canada in partnership with Royal Canadian Mounted Police to help find the person who is lost and help them return home safely, for more information on this registry program and how to register follow this link.

Ethical Issues

• the loss of insight and decreased ability to make decisions must always be balanced against preservation of patient autonomy ^[105]
• important issues requiring decisions include: informed consent and decision making in care and medical management, participation in research trials, end of life decisions etc. ^[106]
• always use standardized tools for the assessment of patient capacity and competency^[107]
• the wishes of the person with dementia should be respected and guide all end of life care decisions

The Alzheimer Society of Canada publishes an excellent resource called "Tough Issues" which deals with many of these difficult issues and more information can be found on their website

Driving

• driving demands quick reaction times, concentration and the ability to exercise good judgment and make quick decisions ^[108]
• all of these skills are impaired in those with dementia and thus there is an increased risk of motor vehicle crash
• loss of one’s license can lead to feelings of decreased independence, freedom and mobility which can have profound effects on the individual and place additional strain on caregivers who must now assume this responsibility ^[109]
• physicians are obligated to report any concerns about driving, however, it may be difficult for a physician to accurately assess a patient’s competency to drive in an office setting
• the Dementia Network of Ottawa Carleton provides an algorithm for family physicians to follow to assess driving and provides local community resources for formal assessment of driving skills

Transition to Institutionalized Care

A large number of people with dementia are cared for at home initially; however, as the disease progresses it may be overwhelming to meet the demands of care despite the help of community support services and support groups and alternate options may need to be considered. Possibilities include: respite care, group homes, retirement homes or long term care in nursing homes.

The decision to place a loved one usually occurs approximately 7 years into the course of the disease and can be a difficult one, often filled with anguish, self doubt and guilt.^[110]Women may be at higher risk for these feelings as they are traditionally seen by society as caregivers and will delay placement of a family member even at the expense of their own health and well being.^[111]

Caregiving in Dementia

Caregiving can include the monitoring of the status of a person in need, responsibility for accessing and communicating with health care professionals and the comprehensive direct care of the person (nutritional, organizational, functional, financial....).

• absence of caregiver(s) and higher perceived caregiver burden are major predictors of earlier institutionalization of those with dementia ^[112]
• caregiver burden is defined as the physical, emotional and financial toll of providing care that can lead to increased illnesses, depression and mortality in those providing care ^[113]
• up to 50% of caregivers experience psychiatric symptoms during their caregiving but many also report a sense of accomplishment in keeping their loved ones at home ^[114]
• The Alzheimer Society of Canada provides ten warning signs of caregiver stress along with strategies to help reduce this stress

Gender and Caregiving

Caregiving is gendered - the majority of caregivers are women

• social factors generally make women more likely to take on the caregiving role and be more heavily involved in caregiving activities than men ^[115]
• over 70% of informal caregivers are women, mostly wives, daughters and daughters in-law ^[116]
• 30% of female informal caregivers are also employed and working in the community and may also be providing care to their own family at the same time ^[117] this places unique stresses on women that are different from what is experienced by male caregivers
• a recent study found that female caregivers had lower scores on 7 out of the 8 scales on the SF-36 Quality of Life Questionnaire vs. males and an overall decreased quality of life as a result of more emotional and physical health problems ^[118]
• one of the future concerns for society is caregiving issues for the older female population with dementia

Resources

• Alzheimer’s Society - http://www.alzheimer.ca/
• Champlain Dementia Network - http://www.alzheimerott.org/network/network.htm
• Toronto Dementia Network - http://www.dementiatoronto.org/dementia.htm
• Ottawa-based Dementia Community Resources - http://www.alzheimerott.org/resources/res4.htm
• Regional Geriatric Program (Dementia Resources Online) - http://rgp.toronto.on.ca/article.pl?sid=02/03/06/2014229
• Dementia Education Network- http://www.dementiaeducation.ca/
• Canadian Geriatric Society- http://www.canadiangeriatrics.com

Module Credits

The Gender and Dementia module was created by the following people:
authors:
Reena Goindi - medical student University of Ottawa
Nahid Azad, MD, FRCPC
Associate Professor, Department of Medicine
Director, Office of Gender & Equity, Faculty of Medicine
University of Ottawa
contributor:
Shayna Watson, MD, CCFP, MEd
Assistant Professor, Queen’s University

References

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48. ↑ Dugue M, Neugroschl J, Sewell M, Marin D. Review of dementia. Mount Sinai Journal of Medicine 2003; 70:45-53.
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74. ↑ As well as the New York Times article you may find the following accounts of his work and exhibitions interesting: http://www.galerie-beckel-odille-boicos.fr/artistes/Utermohlen/page_anglais_utermohlen.htm http://www.news.harvard.edu/gazette/2005/10.20/11-alz.html http://news.bbc.co.uk/1/hi/health/1412428.stm http://www.canada.com/ottawacitizen/features/alzheimers/story.html?id=abc81e35-40fc-49c7-a435-f4ce8d5aa1a5&k=58772
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