What are the causes and risk factors of age-related dementia (Alzheimer's disease)?

From the Guidelines

Age-related dementia is a malignant and devastating condition that invariably leads to dependence and death, and its management should prioritize a multifaceted approach to improve quality of life and reduce morbidity and mortality. The condition is characterized by global cognitive impairment, decline in memory, and at least one other cognitive domain, such as language, visuospatial, or executive function, as defined by the ESPEN guidelines on nutrition in dementia 1. The strongest risk factor for dementia is age, which explains the increasing burden of cognitive disorders in the years to come, with other risk factors including genetic predisposition, cardiovascular health, and lifestyle factors 1.

Key Considerations

• Dementia causes a high burden of suffering for patients, their families, and society, leading to increased anxiety, depression, and dependency, and complicating other comorbid conditions 1.
• The annual societal cost of dementia is huge, due to healthcare and related costs as well as lost wages for patients and family caregivers 1.
• Minor cognitive disorders, such as Mild Cognitive Impairment (MCI), and major cognitive disorders, such as dementia, are only a later and terminal stage and clinical expression of the longstanding and progressive changes occurring in the brain 1.

Management Approach

• Non-pharmacological approaches, including regular physical exercise, cognitive stimulation, social engagement, proper nutrition, and good sleep hygiene, are equally important in managing dementia symptoms 1.
• Creating a structured routine, simplifying the home environment, and ensuring safety measures are in place can help manage daily challenges.
• Medications like cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and memantine can temporarily improve symptoms or slow progression, with standard dosing including donepezil starting at 5mg daily, potentially increasing to 10mg; rivastigmine patches at 4.6mg/24hr, potentially increasing to 9.5mg/24hr; and memantine starting at 5mg daily, gradually increasing to 10mg twice daily.

Prioritizing Quality of Life

• Early diagnosis allows for better symptom management and planning for future care needs, and is crucial in improving quality of life and reducing morbidity and mortality 1.
• The transition from a normal asymptomatic state over mild cognitive impairment to early, mild to moderate, and finally severe dementia, should be closely monitored and managed to ensure the best possible outcomes for patients and their families 1.

From the Research

Age-Related Dementia

• Dementia is an acquired loss of cognition in multiple cognitive domains sufficiently severe to affect social or occupational function, with 47 million people living with dementia worldwide, expected to increase to 131 million by 2050 2.
• Alzheimer's disease is a common cause of dementia, affecting 5.8 million people in the United States, and is usually accompanied by other neuropathology, often cerebrovascular disease such as brain infarcts 2.
• Diagnosis of dementia requires a history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, in addition to a thorough mental status examination by a clinician 2.

Treatment and Management

• Treatment of dementias represents an important but relatively neglected part of neurological care of the elderly population, with individual therapeutic interventions making only small changes to the quality of life of individuals afflicted with dementia 3.
• Nonpharmacologic approaches, including cognitively engaging activities, physical exercise, and socialization, can provide benefits for patients with dementia 2.
• Pharmacologic approaches, such as cholinesterase inhibitors (donepezil, galantamine, and rivastigmine), can provide modest symptomatic relief for patients with Alzheimer's disease and other dementias 2, 4, 5.
• Donepezil, galantamine, and rivastigmine have been shown to have a slight beneficial effect on cognition in people with vascular cognitive impairment, although the size of the change is unlikely to be clinically important 4.

Integrative Approach to Dementia Care

• An integrative approach to dementia care, incorporating interventions to increase quality of life within the caregiver-patient dyad, may aid in attenuating the pervasive psychological and physical impacts of this disease 6.
• Interventions that provide neural and physical stimulation, such as exercise, music, art and creativity, nutrition, psychosocial engagement, memory training, and acupuncture, may facilitate quality of life in persons with dementia 6.
• Person-centered care is fundamental to integrative medicine, and approaches such as these may be reviewed alongside other treatments to facilitate optimal cognition and quality of life outcomes 6.