Dementia illnesses / dementia. Therapy
Which treatment methods are available for dementia?
Knowledge – even though today still very limited – of the possible treatments for dementia has greatly improved in recent years. Today, numerous non-medicinal forms of treatment and newly developed medicinal products are available for delaying cognitive dysfunction and counteracting the loss of everyday competence. A major breakthrough in the treatment of dementia, with the possibility of halting the advancing degenerative process, has not yet been achieved however. There are three different areas to the treatment of dementia:
- Medicinal therapy
- Psychological interventions
- Ecological and social interventions
Dementia. Diagnostics & Therapy
Diagnostics. How is dementia identified?
Whether there really is a case of dementia, and what its cause may be, should best be investigated by a neurologist, psychiatrist or neuropathologist. To this aim, the patient first undergoes a neurological examination. The neurologist determines the symptoms by examining, among other things, the reflexes, coordination, memory, speech and orientation of the patient. Cognitive testing is often carried out by using short, standardised questionnaires (DemTect, Mini-Mental State), or more extensive and thus more time-consuming test methods (CERAD, ADAS) performed by a neuropsychologist. In addition, an ECG, blood tests for determining e.g. blood salts, and liver and kidney function tests, should be carried out. Special examinations are undertaken which involve imaging procedures, i.e. computed tomography or magnetic resonance imaging, liquor withdrawal (lumbar puncture) for determining inflammatory values and certain proteins (protein tau and beta-amyloid 42 protein).
Computed tomography/magnetic resonance imaging for suspected dementia.
Computed tomography (CT) or magnetic resonance imaging (MRI) of the head enables layered images of the brain, bones and blood vessels to be produced. The radiologist can identify whether there have been any circulatory disorders (stroke) or shrinkage (atrophy) of the brain.
PET for early diagnosis of dementia.
Dementias, such as Alzheimer's, can be detected early on by using positron emission tomography (PET). During PET, radioactively labelled substances called radiotracers are used to visualise certain functional processes in the brain, e.g. the metabolism of oxygen and sugar. A reduction in brain activity can thus be predicted before the structural examination clearly fails. A new procedure now also enables identification of the protein deposits called beta-amyloid in the brain, which are characteristic of Alzheimer dementia. Such methods are not yet routine in clinical practice, however.
Ultrasound examinations for suspected dementia.
Further examinations involve ultrasound tests (Doppler sonogram) of the blood vessels in the neck and head. The doctor can thus ascertain, whether and to what extent the vessels are blocked, e.g. by arteriosclerosis, or whether the flow of blood to the brain is normal. An ultrasound of the heart (echocardiography) reveals changes in the heart which may cause blood clots to form.
A lumbar puncture involves the insertion of a tiny needle between the usually easily palpable lower region of the spinal cord and the subarachnoid space. A few millilitres of a mostly clear fluid (liquor) is withdrawn and tested for the presence of inflammatory cells. Further parameters (e.g. glucose, protein content) are measured. To differentiate between various forms of dementia, the content of what is known as protein tau and beta-amyloid 42 protein can be measured.
Therapy. Medication for the treatment of dementia
The objective of currently available pharmacological treatments for dementia illnesses is to alleviate the disease and improvement the quality of life of those affected. Alzheimer dementia is characterised by disruptions to the (cholinergic) system associated with the mediator acetylcholine which is held responsible for the development of impaired memory and cognitive functions, concentration difficulties and a disrupted sleep-wake cycle. Memantine plays an important role in non-cholinergic therapeutic concepts. It is a medication which influences the glutamate system, playing an important part in the development of memory. Memantine has a side effect profile which is regarded as unproblematic, with proof of efficacy available not only for mild and moderate, but also severe dementia. Positive effects could also be established in vascular dementia. Disputed: During physiological aging processes and in neurodegenerative diseases, highly reactive forms of oxygen can emerge which may have both desirable and undesirable toxic effects on the body tissue. This process, known as oxidative stress, can contribute to the death of nerve cells. Antidementives which can reduce oxidative stress are e.g. ginkgo biloba, selegiline and vitamin E. Furthermore, a number of older medications known as nootropics are approved in the indication of cerebral dysfunction and dementia. Nootropics are pharmacologically active substances which aim to improve higher cortical functions.
Medicinal treatment for Alzheimer dementia.
The medicinal concept for treating the cognitive symptoms of Alzheimer dementia is directed at the deficiency of the neurotransmitter acetylcholine in the cerebral cortex and probably also the underlying regions of the brain. This cholinergic deficit, as it is known, which is closely correlated to the clinical severity of dementia, should be reduced by acetylcholinesterase inhibitors. By using medications which belong to the class of acetylcholinesterase inhibitors, a symptomatic improvement in cognitive losses with mostly tolerable side effects is possible in the case of mild to moderate Alzheimer dementia. Non-cognitive disorders such as depression, delusions and psychomotor disruption can be favourably influenced by such a medication.
Therapy. Psychological treatment in dementia
Psychological interventions in dementia.
There are numerous non-medicinal interventional strategies in dementia which can have positive effects on disease management, well-being and quality of life of the person affected as well as his or her carer. At the onset of dementia in particular, cognitive, behavioural and reality-orientation treatments are possible, such as behavioural competence training (BCT), validation, self-maintenance therapy (SMT), autobiographical memory therapy or music/dance/painting therapy. Though the efficacy of non-medicinal interventions in many cases has not been adequately proven empirically, they are regarded in practice certainly as helpful and beneficial to the patient, and thus are an essential component of the treatment plan for dementia sufferers.
Ecological and social interventions in dementia.
Dementia sufferers are particularly reliant on a material environment which changes as the disease progresses and is both protective and stimulating in its nature. The ideal material environment for dementia sufferers should:
- Be clear, conveying safety and security
- Support functionality and competence as well as guarantee maximum freedom of movement
- Stimulate (e.g. by separating the day and treatment rooms from the hallways with glass partitions or very wide doors, using pleasant aromas, stimulating »background noises«, a mixture of touchable surfaces)
- Achieve continuity, reference to the context of one's life so far (without a hospital or institutional context) and radiate a warm, homely environment with individual furnishings.
- Adapt physical environmental factors such as lighting, temperature, smells and noises to the patient (diffused shadow-free light of at least 500 lux at eye level, »warm« light quality and preferably uniform luminous intensity in all rooms, temperature between 21 and 23°C, sometimes appropriate choice of background music, no disturbing sounds which are difficult to localise)
- Support orientation (e.g. items such as fittings, mirrors are placed where they are expected – »anything which is mechanically plausible is easier to use« – and meet with the habits of the elderly individual)
- Promote social interaction and visits from relatives
- Facilitate animal contact (e.g. aviary in a large room)
- Offer the possibility of retreat and provide special »quiet rooms« for very agitated, acutely »disruptive« dementia sufferers
New treatment approaches for dementia.
In light of increasing problems with hospitalised treatment for elderly persons with dementia, new treatment concepts have been developed recently in which the above mentioned recommendations are considered.
Smaller, homogenous, community care units have been introduced which appear to better meet the needs of dementia sufferers. Similarly, concepts for long-term hospitalised care have increasingly incorporated specific handling and communication methods, spatial designs appropriate to dementia, as well as special measures in terms of organisation and daytime structure. In implementing new concepts for treating persons with dementia in residential homes, excellent insight has been gained from the experience made in Hamburg. Within the framework of such a concept, the care approach involves:
- the domus philosophy: only persons suffering from dementia live together in a residential area and are cared for around the clock
- the integration philosophy: persons suffering from dementia live with non-sufferers and are jointly cared for during the day.
The nursing staff are specially trained in order to better cope with the needs of dementia sufferers. Activities are on offer in small groups, and the home environment is adapted to the needs of the dementia patients.
What is self-maintenance therapy in dementia?
Self-Maintenance Therapy (SMT) was developed at the beginning of the 1990s by Dr. Barbara Romero. The overriding goal of this healthcare concept is to maintain one's self.
The "self" is essential in this regard for absorbing, processing and maintaining information about oneself and one's surroundings. It provides the conditions for predicting the "development" of situations, making decisions, assuming ideas and attitudes and orientating oneself. It is reliant on the one's own self-worth, self-assurance and independence. A stable "self" has a positive impact on self-esteem and identity, and thus also influences the mood and behaviour of individuals. Experiences which damage the "self" (e.g. conflicts, failures, lack of experience) trigger negative feelings (anxiety, shame, aggression, depression) which can then manifest themselves in disruptive behaviour (e.g. outbreaks of aggression, severe unrest, tendency to run away). The objective of SMT is to maintain this "self".
Content and objectives of the self-maintenance strategies in dementia.
Maintaining continuity: In short, this means "avoiding avoidable changes" (Romero, 1998).
- Maintaining identity: Particular events such as physical exhaustion after a walk, visiting the hairdresser or receiving a gift promote the feeling of identity.
- Maintaining coherence: "Coherence" describes characteristics which enable a person to remain physically healthy despite tremendous strain. Coherence comprises three elements: comprehension, confidence and purpose.
- Maintaining self-knowledge: By exercising biographical, self-related knowledge a contribution is made towards maintaining and reactivating such knowledge. The "external memory" is thereby complemented e.g. by old photos, songs or poems. During therapy sessions, the dementia sufferer is again encouraged to "talk freely".
SMT is practised in a hospitalised setting at the Alzheimer's Therapy Centre, founded in 1999, of the Schön Klinik Bad Aibling. The inpatient treatment programme lasts four weeks and involves the admission of the dementia sufferer and his or her carer. The focus of treatment is to review the diagnosis, medicinal therapy and the SMT. On a daily basis, within a period of five hours, single and group therapies are available (including therapy for maintaining biographical knowledge, art therapy, sport, everyday and leisure activities). These activities are complemented by consultations which cover subjects such as individual planning of everyday activities and organising life at home, or the possibilities of receiving outside help (e.g. outpatient care, daycare facilities, self-help groups).
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