Monday, March 26, 2018

Which interventions benefit patients with dementia?

- Jennifer Middleton, MD, MPH

The prevalence of dementia continues to rise, and, according to "Evaluation of Suspected Dementia" in the latest issue of AFP, it's estimated that 14 million adults will be affected by 2050. This increasing prevalence brings increasing concern for many aging adults about developing dementia along with concern by families about how to support their loved ones. Several recent studies provide guidance; although information about diagnosing and caring for dementia patients is relatively robust, the evidence base is weaker regarding interventions that can slow cognitive decline.

Many patients and families worry about impending dementia when early signs of memory loss appear, but mild cognitive impairment (MCI) does not always lead to a dementia diagnosis. In a 2014 study, researchers followed 357 patients with MCI diagnoses over a 3 year period and found that only 22.4% of them progressed to a dementia diagnosis during this time. The majority of patients had stable symptoms that did not worsen.

For those patients who do receive dementia diagnoses, they and their caregivers may ask about interventions to decrease symptom progression. A recent series of systematic reviews explored several options. Despite earlier studies suggesting at least a small benefit from dementia medications, a 2018 systematic review examining the use of different medications (including dementia medications, antihypertensives, non-steroidal anti-inflammatory medications, aspirin, and statins) found that none delayed cognitive decline. Another systematic review examining the role of over-the-counter supplements found similarly; omega-3 fatty acids, various vitamins, soy, and gingko biloba all failed to demonstrate an effect. Turning to non-pharmacologic interventions, cognitive training increases cognitive abilities in normal adults, but studies have not, to date, supported a role in preventing or slowing dementia progression. Of all potential interventions, only physical activity has been found to slow cognitive decline, but the evidence behind this assertion is of low quality.

Although limited options are currently available to slow dementia's progress, several interventions do exist to help patients and families cope. Case managers can assist family physicians with meeting the most common needs of patients with dementia and their caregivers, early diagnosis and disease education, by providing education, connecting families to local resources, developing care plans, and coordinating social services. Caregivers who interacted with case managers reported increased confidence in caring for their family members. AAFP also has an online Cognitive Care Kit that includes cognitive evaluation tools, management resources, caregiver resources, and tools for discussing end of life planning. Shared group visits can offer patients and caregivers support and can increase practices' efficiency in caring for these often complex patients.

There's an AFP By Topic on Dementia if you'd like to read more; it includes these pro and con editorials regarding routine screening for cognitive impairment (about which the United States Preventive Services Task Force has issued an "I" statement). The AFP article on "Evaluation of Suspected Dementia" includes links to several assessment tools; I've added the Mini-Cog test and the Saint Louis University Mental Status Examination (SLUMS) to my AFP Favorites page for easy access at the point-of-care.

What resources and tools have you found useful in caring for patients with dementia?