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Dementia

Dementia (from Latin de- "apart, away" + mens (genitive mentis) "mind") is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal aging. Although dementia is far more common in the geriatric population, it may occur in any stage of adulthood. This age cutoff is by definition, as similar sets of symptoms due to organic brain dysfunction are given different names, such as developmental disorders, in populations younger than adulthood.

In dementia, affected areas in cognition may be memory, attention, language, and problem solving. Especially in the later stages of the condition, affected persons may be disoriented in time (not knowing what day of the week, day of the month, month, or even what year it is), in place (not knowing where they are), and in person (not knowing who they are).

Symptoms of dementia can be classified as either reversible or irreversible depending upon the etiology of the disease. Less than 10 percent of cases of dementia are due to causes which may presently be reversed with treatment. Dementia is a term for a non-specific illness syndrome (set of symptoms) which is caused by many different specific disease processes, in the same way that symptoms of organ dysfunction such as shortness of breath, jaundice, or pain are attributable to many etiologies.

Without careful assessment of history, the short-term syndrome of delirium can easily be confused with dementia, because many of the symptoms of these are also present in dementia. Some mental illnesses including depression and psychosis may also produce symptoms which must be differentiated from both delirium and dementia.

Current Research

For current research articles click - here

Epidemiology

The prevalence of dementia is rising as the global life expectancy is rising. Particularly in Western countries, there is an increasing concern about the economic impact that dementia will have in future, older populaces. In Australia, the 2006 estimated prevalence of dementia is 1.03% of the population as a whole. Though reports of some of the longest living people claim them to be free of it (e.g. Yone Minagawa), it is a disease which is strongly associated with age; 1% of those aged 60-65, 6% of those aged 75-79, and 45% of those aged 95 or older suffer from the syndrome.

Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g. a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist. However, there exist some brief (5-15 minutes) that have reasonable reliability and can be used in the office or other setting to screen cognitive status for deficits which are considered pathological. Examples of such tests include the abbreviated mental test score (AMTS), the mini mental state examination (MMSE), Modified Mini-Mental State Examination (3MS), the Cognitive Abilities Screening Instrument (CASI), and the clock drawing test.

An AMTS score of less than six (out of a possible score of ten) and an MMSE score under 24 (out of a possible score of 30) suggests a need for further evaluation. Scores must be interpreted in the context of the person's educational and other background, and the particular circumstances; for example, a person highly depressed or in great pain will not be expected to do well on many tests of mental ability.

Mini-Mental State Examination

The U.S. Preventive Services Task Force (USPSTF) reviewed tests for cognitive impairment and concluded:

MMSE:

Sensitivity 71% to 92%
Specificity 56% to 96%

A copy of the MMSE can be found in the appendix of the original publication.

Modified Mini-Mental State Examination (3MS)

A copy of the 3MS is online. A meta-analysis concluded that the Modified Mini-Mental State (3MS) examination has:

Sensitivity 83% to 94%
Specificity 85% to 90%

Abbreviated Mental Test Score

A meta-analysis concluded:

Sensitivity 73% to 100%
Specificity 71% to 100%

Other Examinations

Many other tests have been studied including the clock-drawing test example form). Although some may emerge as better alternatives to the MMSE, presently the MMSE is the best studied. However, access to the MMSE is now limited by enforcement of its copyright (details).

Another approach to screening for dementia is to ask an informant (relative or other supporter) to fill out a questionnaire about the person's everyday cognitive functioning. Informant questionnaires provide complementary information to brief cognitive tests. Probably the best known questionnaire of this sort is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

Further evaluation includes retesting at another date, and administration of other (and sometimes more complex) tests of mental function, such as formal neuropsychological testing.

Laboratory Tests

Routine blood tests are also usually performed to rule out treatable causes. These tests include vitamin B12, folic acid, thyroid-stimulating hormone (TSH), C-reactive protein, full blood count, electrolytes, calcium, renal function and liver enzymes. Abnormalities may suggest vitamin deficiency, infection or other problems that commonly cause confusion or disorientation in the elderly. The problem is complicated by the fact that these cause confusion more often in persons who have early dementia, so that "reversal" of such problems may ultimately only be temporary.

Chronic use of substances such as alcohol can also predispose the patient to cognitive changes suggestive of dementia.

Imaging

A CT scan or magnetic resonance imaging (MRI scan) is commonly performed, although these modalities (as is noted below) do not have optimal sensitivity for the diffuse metabolic changes associated with dementia in a patient who shows no gross neurological problems (such as paralysis or weakness) on neurological exam. CT or MRI may suggest normal pressure hydrocephalus, a potentially reversible cause of dementia, and can yield information relevant to other types of dementia, such as infarction (stroke) that would point at a vascular type of dementia. However, the functional neuroimaging modalities of SPECT and PET have shown similar ability to diagnose dementia as clinical exam. The ability of SPECT to differentiate the vascular cause from the Alzheimer's disease cause of dementias, appears to be superior to differentiation by clinical exam.

Types

Cortical Dementias

Alzheimer's Disease
Vascular dementia (also known as multi-infarct dementia), including Binswanger's disease
Dementia with Lewy bodies (DLB)
Alcohol-Induced Persisting Dementia
- Korsakoff's syndrome
- Wernicke's encephalopathy
Frontotemporal lobar degenerations (FTLD), including Pick's disease
- Frontotemporal dementia (or frontal variant FTLD)
- Semantic dementia (or temporal variant FTLD)
- Progressive non-fluent aphasia
Creutzfeldt-Jakob disease
Dementia pugilistica
Moyamoya disease

Subcortical Dementias

Dementia due to Huntington's disease
Dementia due to Hypothyroidism
Dementia due to Parkinson's disease
Dementia due to Vitamin B1 deficiency
Dementia due to Vitamin B12 deficiency
Dementia due to Folate deficiency
Dementia due to Syphilis
Dementia due to Subdural hematoma
Dementia due to Hypercalcaemia
Dementia due to Hypoglycemia
AIDS dementia complex
Pseudodementia (associated with clinical depression and bipolar disorder)
Substance-induced persisting dementia (related to psychoactive use and formerly Absinthism)
Dementia due to multiple etiologies
Dementia due to other general medical conditions (i.e. end stage renal failure, cardiovascular disease etc.)
Dementia not otherwise specified (used in cases where no specific criteria is met)

Dementia and early onset dementia have been associated with neurovisceral porphyrias. Porphyria is listed in textbooks in the differential diagnosis of dementia. Because acute intermittent porphyria, hereditary coproporphyria and variegate porphyria are aggravated by environmental toxins and drugs the disorders should be ruled out when these etiologies are raised.

Treatment

Except for the treatable types listed above, there is no cure to this illness, although scientists are progressing in making a type of medication that will slow down the process. Cholinesterase inhibitors are often used early in the disease course. Cognitive and behavioral interventions may also be appropriate. Educating and providing emotional support to the caregiver (or carer) is of importance as well (see also elderly care).

A Canadian study found that a lifetime of bilingualism has a marked influence on delaying the onset of dementia by an average of four years when compared to monolingual patients. The researchers determined that the onset of dementia symptoms in the monolingual group occurred at the mean age of 71.4, while the bilingual group was 75.5 years. The difference remained even after considering the possible effect of cultural differences, immigration, formal education, employment and even gender as influences in the results.

Snoezelen rooms that provide patients with a soothing and stimulating environment of light, color, music and scent have been used in the therapy of dementia patients.

Medications

Acetylcholinesterase inhibitors

Tacrine (Cognex), donepezil (Aricept), galantamine (Reminyl), and rivastigmine (Exelon) are approved by the United States Food and Drug Administration (FDA) for treatment of dementia induced by Alzheimer's Disease. They may be useful for other similar diseases causing dementia such as Parkinson's or vascular dementia.

N-methyl-D-aspartate Blockers

Drugs within the class known as N-methyl-D-aspartate (NMDA) blockers include memantine (Namenda), which has been approved by the FDA for the treatment of moderate-to-severe dementia.

Amyloid deposit inhibitors

Minocycline and Clioquinoline, antibiotics, may help reduce amyloid deposits in the brains of persons with Alzheimer's Disease.

Antipsychotic drugs

Haloperidol (Haldol), risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) are frequently prescribed to help manage psychosis and agitation. Treatment of dementia-associated psychosis or agitation is intended to decrease psychotic symptoms (for example, paranoia, delusions, hallucinations), screaming, combativeness, and/or violence.

Antidepressant drugs

Depression is frequently associated with dementia and generally worsens the degree of cognitive and behavioral impairment. Antidepressants may be helpful in alleviating cognitive and behavior symptoms by reuptaking neurotransmitter regulation through reuptake of serotonin, noradrenaline and dopamine.

Antianxiety drugs

Many patients with dementia experience anxiety symptoms. Although benzodiazepines like diazepam (Valium) have been used for treating anxiety in other situations, they are often avoided because they may increase agitation in persons with dementia or are too sedating. Buspirone (Buspar) is often initially tried for mild-to-moderate anxiety.

Selegiline, a drug used primarily in the treatment of Parkinson's disease, appears to slow the development of dementia. Selegiline is thought to act as an antioxidant, preventing free radical damage. However, it also acts as a stimulant, making it difficult to determine whether the delay in onset of dementia symptoms is due to protection from free radicals or to the general elevation of brain activity from the stimulant effect.

Prevention

Since there is no cure for dementia, the best an individual can do is to prevent it from developing in the first place.

The main method to prevent dementia is to live an active life, both mentally and physically. It appears that the regular moderate consumption of alcohol (beer, wine or distilled spirits) may reduce risk.

Furthermore, there are medications which might contribute to prevent the onset of dementia, including hypertension medications, anti-diabetic drugs and NSAIDs.

Risk to Self & Others

Driving with Dementia could lead to severe injury or even death to self and others. Doctors should advise appropriate testing on when to quit driving

Services

Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Adult daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers.

(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Dementia)

Findings From Current Research

Decision-Making Involvement of Individuals with Dementia

Authors: Menne HL, Whitlatch CJ.

Address all correspondence to Heather L. Menne, Margaret Blenkner Research Institute, Benjamin Rose Institute, 11900 Fairhill Road, Suite 300, Cleveland, OH 44120-1053. hmenne@benrose.org.

PURPOSE: Research underscores how autonomy and decision-making involvement may help to enhance the quality of life of older adults; however, individuals with dementia are often excluded from decision making that is related to their daily functioning. In this study we use a modified version of the Stress Process Model to consider the stress process of individuals with chronic illness, and in particular to explore the predictors of decision-making involvement among individuals with dementia (n = 215). DESIGN AND METHODS: We collected data from individual with dementia (IWD)-family caregiver dyads. Relying primarily on data from the IWD, we used hierarchical multiple regression analysis to determine the predictors of the IWD's decision-making involvement. RESULTS: Results indicate that individuals who report more decision-making involvement are younger, female, have more education, have a nonspousal caregiver, have fewer months since their diagnosis, exhibit fewer problems with activities of daily living and fewer depressive symptoms (based on caregiver report), and place more importance on autonomy/self-identity. IMPLICATIONS: In our discussion we examine the importance of autonomy and impairment levels for understanding the decision-making involvement of persons with dementia.

Journal: Gerontologist. 2007 Dec;47(6):810-9.
Adapted from PubMed; click here to access full journal article.

Impact of Adult Day Services on Behavioral and Psychological Symptoms of Dementia

Authors: Femia EE, Zarit SH, Stephens MA, Greene R.

S-211 Henderson Building, The Pennsylvania State University, University Park, PA 16802. exk12@psu.edu or z67@psu.edu.

PURPOSE: This study explored whether adult day service (ADS) use was associated with reductions in behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia. DESIGN AND METHODS: We used a quasi-experimental design to compare a group of 133 persons with dementia (PWDs) who initially enrolled in an ADS program to a control group not using these services (n = 68). Caregivers used a 24-hour log on multiple, consecutive days to report on five domains of BPSD. RESULTS: We used growth-mixture modeling techniques to model change in the BPSD domains over a 2-month period as well as to handle the preponderance of zeros that were inherent in the data. Results showed a relationship between ADS use and caregivers' report of fewer nighttime sleep-related problems for their PWDs. We found trends for other domains, specifically depressive symptoms and agitated behavior, but no significant group differences emerged for these and the other domains. IMPLICATIONS: The findings of ADS use on PWDs' duration of nighttime sleep problems provide some evidence of the benefits of ADS; the findings also support its utility as part of the continuum of care for PWDs and their caregivers. For other behavior domains, enhanced or more targeted behavioral strategies coupled with ADS might offer caregivers and their PWDs the best possible combination for ameliorating BPSD.

Journal: Gerontologist. 2007 Dec;47(6):775-88.
Adapted from PubMed; click here to access full journal article.

Spontaneous Social Behaviors Discriminate Behavioral Dementias From Psychiatric Disorders and Other Dementias

Authors: Rankin KP, Santos-Modesitt W, Kramer JH, Pavlic D, Beckman V, Miller BL.

From the Department of Neurology, University of California, San Francisco.

OBJECTIVE: Changes in social behavior are often the first symptoms of neurodegenerative disease. Patients with frontotemporal lobar degeneration (FTLD) often go undiagnosed, or are misclassified as psychiatric patients, because in the absence of cognitive deficits, nonexperts fail to recognize these social changes as dementia symptoms. The object of this study was to improve screening for behavioral dementias in primary care and mental health settings by quantifying spontaneous social behaviors specific to FTLD. METHOD: In a university hospital dementia clinic, examiners blind to subject diagnosis performed 1 hour of cognitive testing, then completed the Interpersonal Measure of Psychopathy, an 18-item checklist of observed inappropriate behaviors. Patients then underwent a multidisciplinary evaluation to derive a neurodegenerative or psychiatric diagnosis. Data were collected from 288 subjects: 45 Alzheimer's Disease (National Institute of Neurologic and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association research criteria); 40 frontotemporal dementia, 21 semantic dementia, and 13 progressive nonfluent aphasia (Neary research criteria); 14 corticobasal degeneration and 21 progressive supranuclear palsy (Litvan research criteria); 37 dementia with Lewy bodies (McKeith research criteria); 16 vascular dementia (Ischemic Vascular Disease research criteria); 29 mixed vascular and Alzheimer's disease (Alzheimer's Disease Diagnostic and Treatment Centers criteria); and 35 primary psychiatric disorder (DSM-IV) patients and 17 normal older controls. The study was conducted from March 2002 to January 2005. RESULTS: Statistical item analyses demonstrated specific patterns of social behavior that differentiated both frontotemporal dementia and semantic dementia patients from (1) nondementing older adults, (2) nondementing individuals with psychiatric conditions, (3) individuals with cerebrovascular disease, and (4) individuals with other neurodegenerative disorders. Semantic dementia patients verbally and physically interrupted evaluations, spoke perseveratively and tangentially, and resisted clinician redirection. Frontotemporal dementia patients were apathetic or disinhibited and were unconcerned about meeting clinician expectations. CONCLUSION: Specific, abnormal, interpersonal behaviors can alert nonexperts to the need for specialized dementia referral.

Journal: J Clin Psychiatry. 2008 Jan 3;:e1-e14
Adapted from PubMed; click here to access full journal article.

Survival Times in People with Dementia: Analysis from Population Based Cohort Study with 14 Year Follow-Up

Authors: Xie J, Brayne C, Matthews FE; and the Medical Research Council Cognitive Function and Ageing Study collaborators.

Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge CB2 0SR.

OBJECTIVES: To provide estimates of survival after onset of dementia by age, sex, self reported health, disability, and severity of cognitive impairment. DESIGN: Analysis of participants from prospective population based cohort study in 1991-2003, with follow-up of dementia status in all individuals after two and six years (in one centre) and 10 years and in subsamples additionally at six and eight years and mortality until 2005. SETTING: Multicentre population based study in England and Wales: two rural and three urban centres. PARTICIPANTS: 438 participants who developed dementia from a population based study of 13 004 individuals aged 65 years and over drawn from primary care population registers. MAIN OUTCOME MEASURES: Sociodemographic factors, cognitive function, specific health conditions, and self reported health collected at each interview. Cox's proportional hazards regression models were used to identify predictors of mortality from the selected variables in people who received diagnosis of dementia according the study's criteria. RESULTS: By December 2005, 356 of the 438 (81%) participants who developed dementia during the study had died. Estimated median survival time from onset of dementia to death was 4.1 years (interquartile range 2.5-7.6) for men and 4.6 years (2.9-7.0) for women. There was a difference of nearly seven years in survival between the younger old and the oldest people with dementia: 10.7 (25th centile 5.6) for ages 65-69; 5.4 (interquartile range 3.4-8.3) for ages 70-79; 4.3 (2.8-7.0) for ages 80-89, and 3.8 (2.3-5.2) years for ages >/=90. Significant factors that predicted mortality in the presence of dementia during the follow-up included sex, age of onset, and disability. CONCLUSION: These analyses give a population based estimated median survival for incident dementia of 4.5 years. Such estimates can be used for prognosis and planning for patients, carers, service providers, and policy makers.

Journal: BMJ. 2008 Jan 10
Adapted from PubMed; click here to access full journal article.

Current Implications for the Managed Care of Dementia

Authors: Stefanacci RG.

Health Policy Institute, University of the Sciences in Philadelphia, 600 S 43rd St, Philadelphia, PA 19104, USA. r.stefan@usip.edu

Medicare Part D changes are becoming an increasingly complex issue, presenting a challenge to many physicians treating dementia patients. A 2006 American Medical Directors Association survey found that 70% of its members reported difficulty with the Medicare prescription drug plan, with 28% of all physicians having difficulty in accessing dementia medications. Concerns about medication access are worrisome, particularly in light of data demonstrating their positive effects on behavioral symptoms, which may result in reduced use of psychotropic medications. Strategies for improving access to antidementia medications in nursing homes and assisted living facilities are highlighted, including an overview of appropriate use of antidementia medications (cholinesterase inhibitors and glutamate pathway modifiers), use of nonpharmacologic interventions, risk reduction in patients with dementia, accounting for resident preferences, and proper documentation. Finally, end-of-life issues in advanced dementia and defining quality of life are also addressed in a brief commentary. Recognition and understanding of these issues may improve patient access to medication, leading to improved patient healthcare outcomes and reduced dementia-related healthcare costs.

Journal: Am J Manag Care. 2007 Dec;13 Suppl 8:S203-5; discussion S206-7.
Adapted from PubMed; click here to access full journal article.

Molecular Characterization of Novel Progranulin (GRN) Mutations in Frontotemporal Dementia

Authors: Mukherjee O, Wang J, Gitcho M, Chakraverty S, Taylor-Reinwald L, Shears S, Kauwe JS, Norton J, Levitch D, Bigio EH, Hatanpaa KJ, White CL, Morris JC, Cairns NJ, Goate A.

Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri.

Frontotemporal dementia (FTD) is a clinical term encompassing dementia characterized by the presence of two major phenotypes: 1) behavioral and personality disorder, and 2) language disorder, which includes primary progressive aphasia and semantic dementia. Recently, the gene for familial frontotemporal lobar degeneration (FTLD) with ubiquitin-positive, tau-negative inclusions (FTLD-U) linked to chromosome 17 was cloned. In the present study, 62 unrelated patients from the Washington University Alzheimer's Disease Research Center and the Midwest Consortium for FTD with clinically diagnosed FTD and/or neuropathologically characterized cases of FTLD-U with or without motor neuron disease (MND) were screened for mutations in the progranulin gene (GRN; also PGRN). We discovered two pathogenic mutations in four families: 1) a single-base substitution within the 3' splice acceptor site of intron 6/exon 7 (g.5913A>G [IVS6-2A>G]) causing skipping of exon 7 and premature termination of the coding sequence (PTC); and 2) a missense mutation in exon 1 (g.4068C>A) introducing a charged amino acid in the hydrophobic core of the signal peptide at residue 9 (p.A9D). Functional analysis in mutation carriers for the splice acceptor site mutation revealed a 50% decrease in GRN mRNA and protein levels, supporting haploinsufficiency. In contrast, there was no significant difference in the total GRN mRNA between cases and controls carrying the p.A9D mutation. Further, subcellular fractionation and confocal microscopy indicate that although the mutant protein is expressed, it is not secreted, and appears to be trapped within an intracellular compartment, possibly resulting in a functional haploinsufficiency. Hum Mutat 0, 1-10, 2008. (c) 2008 Wiley-Liss, Inc.

Journal: Hum Mutat. 2008 Jan 8
Adapted from PubMed; click here to access full journal article.

Efficacy of a Geriatrics Team Intervention for Residents in Dementia-Specific Assisted Living Facilities: Effect on Unanticipated Transitions

Authors: Bellantonio S, Kenny AM, Fortinsky RH, Kleppinger A, Robison J, Gruman C, Kulldorff M, Trella PM.

Baystate Medical Center/Tufts University School of Medicine, Springfield, Massachusetts, USA.

OBJECTIVES: To determine whether a multidisciplinary team intervention minimizes unanticipated transitions from assisted living for persons with dementia. DESIGN: Randomized trial. SETTING: Two dementia-specific assisted living facilities in Connecticut owned and managed by the same corporation. PARTICIPANTS: One hundred older adults with dementia who relocated to assisted living. INTERVENTION: Four systematic multidisciplinary assessments by a geriatrician, geriatrics advanced practice nurse, physical therapist, dietitian, and social worker during the first 9 months of relocation to assisted living. MEASUREMENTS: Permanent relocation to a nursing facility, emergency department (ED) visits, hospitalization, and death. RESULTS: Fifty-five residents experienced any unanticipated transition out of assisted living, on average 84 +/- 74 days after relocation; falls were the primary reason for transition. The intervention reduced the risk of any unanticipated transitions (13%), permanent relocation to a nursing facility (11%), ED visits (12%), hospitalization (45%), and death (63%), but the results did not meet statistical significance. In secondary analysis, more men experienced any unanticipated transition (P<.001), hospitalization (P<.001), or death (P<.001) than women. CONCLUSION: Although an untargeted multidisciplinary intervention did not significantly reduce the risk of transitions for individuals with dementia relocating to assisted living in this small sample, trends for decreasing hospitalization and death were found. The data further suggest that those at risk for falls and men may benefit from targeted clinical interventions to prevent unanticipated transitions, especially during the first 3 months after relocation.

Journal: J Am Geriatr Soc. 2008 Jan 4
Adapted from PubMed; click here to access full journal article.

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