Pharmacotherapy For Aids Dementia

Before the routine use of zidovudine (AZT), the course of AIDS dementia was often rapid after cognitive decline emerged. Currently, patients receiving zidovudine may exhibit signs of the cognitive and motor changes for months to years before dying 249 . Additionally, health care utilization rates increase as patients with AIDS dementia live longer 250 , placing even more emphasis on the development of safe and effective treatments for this condition. Investigational treatments for AIDS dementia...

Dementia the Challenge for the Next Decade

After a long career in psychiatric research, it is remarkable to note how dementia is now in the forefront of biological, clinical and epidemiological interest rather than remaining an unmentioned, untreatable condition that 1 Institute of Psychiatry, Kings College London, De Crespigny Park, London SE5 8AF, UK made some older people senile. Its importance as a source of disability and cost in the developed world has been amply shown in Henderson and Jorm's tables. Even more alarming is the...

Food and Drug Administration FDAs Requirements for Clinical Trials in AD

In the United States, the FDA has guidelines for AD therapeutics 1 . The clinical trials must be randomized, double-blind, parallel-group studies with placebo controls. Patients must fulfill established diagnostic criteria, such as those by the National Institute of Neurological and Communicative Disorders Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA), for probable AD 2 . The trial must last at least 3 months and demonstrate superiority over placebo in the effect on...

Syndromes

Neuropsychological assessment involves the observation of an individual's behaviour in relation to a given stimulus, selected for its likelihood to provoke an abnormal response in the face of damage to specific neuroana-tomical structures. The theoretical basis of neuropsychological assessment is derived, on the one hand, from cognitive psychology, which is concerned with the development of cognitive tests for the demonstration of theoretical models of normal cognitive functioning, and on the...

Pharmacotherapy For Dementia With Lewy Bodies

DLB patients may benefit from cholinesterase inhibitors. A cholinergic deficit has been shown in DLB in fact, the relative decline in CAT is greater in DLB than in AD 245 . Patients receiving a short trial of tacrine improved in verbal initiation and digit span 246 . We explain to patients and their families that there are no current FDA-approved drugs to treat the cognitive disturbances found in DLB. We empirically offer a trial of cholinesterase inhibitors to these patients. Over 50 of...

The Characteristic Clinical Course of Retrogenic Dementias

Although the characteristic clinical course of AD, as outlined most clearly with the FAST staging procedure, is very different from many other dementing conditions, it is also interesting and of diagnostic relevance that many dementias of diverse etiology occasionally, or more frequently, follow the characteristic FAST sequential progression of AD more or less precisely. The advances in understanding of the etiopathogenic mechanisms of AD provide an explanation for the observed clinical...

Premorbid Level of Functioning

The pre-morbid functioning may be assumed as normal when there is no relevant knowledge in the individual patient. It may also be predicted on the basis of demographic data such as age, level of education, profession, interests, history of intellectual or professional development. Such formulae of prediction can be found in the literature (see e.g. 2,3 ). In addition, pre-morbid functioning may be assessed using specific tests such as the New Adult Reading Test (NART, 4 ) or other tests based,...

Effects of Cholinesterase Inhibitors on Disturbed Behaviour in AD

Anticholinergic agents can contribute to delirium with agitation, paranoid delusions and visual hallucinations. Therefore cholinergic agents are expected to be helpful to alleviate these common behavioural disturbances seen in AD patients with cholinergic deficiency. There is emerging evidence that cholinesterase inhibitors may have non-cognitive benefits for AD patients. These effects may be mediated by limbic and paralimbic structures 215 . In an analysis of the Knapp et al. trial,...

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I I Tactile sucking 1 1 Palmar grasp 1 Plantar grasp mil Plantar extensor H Summary measure I I Tactile sucking 1 1 Palmar grasp 1 Plantar grasp mil Plantar extensor H Summary measure Figure 2.6 Prevalence of five reflexes in continent and incontinent ambulatory Alzheimer's disease patients with deficits in activities of daily living (ADL). Differences in percentages of reflex measures between the groups of patients are significant for all measures (p < 0.001). FAST, Functional Assessment...

Areas Still Open to Research

Cholinesterase inhibitors may alter the course of AD. They may delay nursing home placement or reduce mortality in AD patients. Future large-scale prospective studies are required to test these possibilities. After cholinesterase inhibitor therapy is stopped, AD patients may decline to the levels of a placebo group. However, open-label studies suggest that patients treated with the newer cholinesterase inhibitors may not return to the projected placebo group values even 2 years after treatment...

Developmental Variance

The clinical diagnosis of dementia is usually not a problem. As Reisberg et al note in their elegantly referenced review, the term dementia has been both used and useful for over two millennia. The existence of two related phenomena with their own equally useful names, delirium and depression'', is noteworthy for clinicians. They alert us to the fact that, although clinical diagnosis of dementia is not usually a problem, patients, especially elderly patients, often have more than one condition....

Statins

Epidemiological evidence suggests that individuals taking statin drugs for lowering cholesterol had a decreased risk of developing AD 228-230 . When indication bias (that healthier people take statins) is addressed, the epidemiological relationship remains 231 . There does not appear to be an influence from APOE genotype, African American race, education, history of heart disease, stroke or diabetes 232 . Statins appear to reduce the Abeta levels in cell culture and guinea pigs 233 . Future...

Dementia Syndromes

Numerous dementia syndromes can occur in the elderly. The most common is Alzheimer's disease (AD), followed by vascular dementia, mixed dementia, Lewy body dementia and then the fronto-temporal dementias. Dementia in Alzheimer's Disease (AD) Until around 1970, AD was thought to be a rare dementia affecting people under 65. At that time, the common senile dementia of the elderly was believed to be due to arteriosclerosis causing a slow strangulation of the brain's blood supply. However,...

Dementia

Neuropsychology contributes greatly to the diagnosis of dementia it documents significant cognitive decline and reveals patterns of cognitive dysfunction that suggest the cause of the dementia 1 . That is why Almkvist's review is so important. Together with the medical history given by the patient and more importantly by a close informant, the somatic and psychiatric assessment, and with imaging, neuropsychological assessment is much more contributory than laboratory analyses or...

Dementia the Public Health Challenge

In their review, Henderson and Jorm have set the stage for a full discussion of the multi-faceted nature of the disorders we call dementia. Reliable and valid definitions of the syndrome and its sub-groups are essential in order to understand the scope and impact of these disorders on the world population. As much as a 10-fold difference in prevalence is dependent on the diagnostic criteria for dementia. Moreover, with significant therapeutic advances on the horizon, differentiation of...

Risk And Protection Factors For Dementia

One way of stemming the rising tide of dementia cases would be to find effective methods of preventing the diseases that result in dementia. A reduction in the prevalence rate for dementia would help to counteract the increase due to an ageing population. We must therefore ask whether prevention of dementia is a possibility. If the causes of dementia in the elderly were understood, it would be possible to use this knowledge to develop preventive strategies. However, even in the absence of a...

Pharmacotherapy For Alzheimers Disease Ad

Clinical manifestations of AD include disturbance in the areas of memory and language, visual spatial problems and higher executive dysfunction. Non-cognitive behavioural manifestations may include changes in personality, deterioration in judgment, wandering, psychosis, mood disturbance, agitation or sleep-wake cycle abnormalities. Pharmacological interventions in these areas are at various developmental stages. For example, cholinesterase inhibitors and the antioxidant vitamin E are the...

Prospects For Prevention Of Dementia

In considering the prevention of diseases common in old age, it is useful to make a distinction between age-dependent and age-related diseases 106 . Age-dependent diseases are those in which the disease process is an intrinsic part of ageing. Everyone would develop these diseases if they lived long enough. Age-related diseases, on the other hand, may become more common with age, but are not necessarily related to the ageing process. Age-related diseases can be prevented if an individual is not...

Differential Diagnostic Import of the Characteristic Clinical Course of AD

As indicated by the study of Rockwood et a and numerous other studies, including those reviewed in the preceding sections, AD has a characteristic ordinal and temporal course which can be differentiated from other dementing entities. This characteristic course of AD is charted most clearly with the FAST staging procedure in terms of both its ordinal progression and the usual temporal course. Some entities characterized by dementia, or in which dementia may occur, differ strikingly from the...

Clinical Diagnosis Of Dementing Disorder

Dementia is a term which refers to a general mental deterioration 1 , The term has Latin roots. De is a prefix derived from Latin, signifying separation, cessation or contraction, and mens denotes mind 1,2 , Consequently, in dementia there is a contraction of the mind. Chronicity has generally been implicit in the term dementia. Although legal implications of what we now term dementia can be traced to Greek writings of Solon and Plato, the earliest known usage of the term dementia comes from...

Dementia Some Controversial Issues

Esquirol began to distinguish between acute, chronic and senile dementia in 1814, and he regarded the last one as resulting from aging and consisting in a loss of the faculties of understanding. In 1906, Alois Alzheimer reported the case of a 51-year-old woman with cognitive impairment, hallucinations, delusions and focal symptoms, whose brain was found on post mortem to show plaques, tangles and arteriosclerotic changes. In the 8th edition of Kraepelin's Textbook, he coined the term...

Methods of Assessment

Neuropsychological tests are described comprehensively elsewhere. For details of test descriptions, the interested reader is recommended to consult textbooks (e.g. 8 ). Below, a short description of some standard tests is provided. The most well-known neuropsychological test batteries for global cognition are the original and the revised version of Wechsler Adult Intelligence Scale (WAIS 9 WAIS-R 6 ). The WAIS and WAIS-R have been translated to many European and other languages. The WAIS...

References

Esquirol J.E. (1845) A treatise on insanity. In Documentary History of Psychiatry. A Source Book on Historical Principles (Ed. C.E. Goshen), pp. 314-369, Lea and Blanchard, New York. 2. Caine E.D., Grossman H., Lyness J.M. (1995) Delirium, dementia, and amnestic and other cognitive disorders and mental disorders due to a general medical condition. In Comprehensive Textbook of Psychiatry (Eds H.I. Kaplan, B.J. Sadock), pp. 705-754, Williams and Wilkins, Baltimore. 3. World Health Organization...

Dementia Diagnosis Progression and Retrogression

Reisberg has addressed a number of concepts in relation to dementia in his review. He begins with a history of the term dementia, from its Latin roots about 2000 years ago, and goes on to discuss the clinical progression of Alzheimer's disease AD , in particular the functional decline as charted by the Functional Assessment Staging FAST procedure. He argues that the pattern of decline in AD is a reversal of neurodevelopment in childhood and refers to it as retrogenesis, implicating...

Reflections on Retrogenesis

Reisberg et al's excellent review on the clinical diagnosis of dementia presents a very powerful and lucid account of the idea of retrogenesis that he and his colleagues have developed over the last few years. In essence, this highlights the similarities between progression in Alzheimer's disease AD and reversal of development, such that in cognitive function, functional impairment, behaviour and social interactions, the more severely demented a patient becomes, the more similar he appears to...