Review Identifies Current Diagnostic and Treatment Approaches to Dementia

Medical history, cognitive and physical examination, laboratory testing, and brain imaging can help identify causes of dementia, and several pharmacologic and nonpharmacologic approaches can help manage the disease, a review study in JAMA reports.

Dementia is a common public health problem. Approximately 47 million people have dementia, a number that is expected to increase to roughly 131 million by 2050. Therefore, researchers from Rush University Medical Center performed a literature review, focusing on 22 observational studies and 5 randomized clinical trials published between 2013 and 2019. All included studies reported on the diagnosis and management of dementia.

The most common setting for clinical evaluation and management of dementia is primary care, where a brief evaluation of a patient’s medical history as well as a cognitive and neurologic examination are typically performed to assess possible dementia. A family member or close acquaintance may also accompany the patient during a medical appointment to discuss medical history or history of forgetfulness. This history should describe the nature and course of cognitive changes as well as the severity of these changes. Medical conditions and medications that could affect cognition, such as vascular disease risk factors and sleep aides, should be discussed during a medical history evaluation.

A neurologic examination focuses on objective evidence of neurocognitive issues, including agnosia, apraxia, and aphasia. Behaviors that are abnormal to the individual’s usual activities/personality should be assessed, and any issues performing normal daily tasks should be identified.

Specialist referral may be necessary in patients whose dementia-like presentation is not consistent with Alzheimer disease. Further, the literature supports the performance of positron emission tomography (PET), including amyloid PET, in these cases to identify brain changes suggestive of the disease. One study noted that in >60% of patients, amyloid PET scan results caused a change in management plan. Evidence of Alzheimer disease can also be obtained from cerebrospinal fluid testing.

In terms of the management of dementia, the literature suggests an overall goal of a reducing the distress caused by declining cognition and reducing the progression of cognitive decline. Evidence from some studies has suggested a benefit to cognitive training, music or art therapy, reminiscence therapy, and physical activity in patients with dementia. These nonpharmacologic management strategies are generally low cost and associated with few adverse effects. Pharmacologic methods for Alzheimer disease typically consist of the use of acetylcholinesterase inhibitors or N-methyl-D-aspartate receptor antagonists.

According to the researchers, there are currently few approved drugs for other dementia etiologies, and there is no such treatment for Lewy body disease or frontotemporal dementia. “At this time,” the researchers wrote, “more than 100 drugs are being investigated for dementia and cognition, including potential disease-modifying agents.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Arvanitakis Z, Shah RC, Bennett DA. Diagnosis and management of dementia: review. JAMA. 2019;322(16):1589-1599.