Severe dementia: A review on diagnoses, therapeutic management and ethical issues

Schafirovits-Morillo, Lilian; Suemoto, Cláudia Kimie

doi:10.1590/S1980-57642010DN40300003

Abstract

North American data show that in the year 2000 around 4.5 million people had a diagnosis of dementia and more than a half were at moderate or severe stages of the disease. There is inevitable cognitive and functional decline caused by all etiologies of irreversible dementia as well as many behavioral symptoms that compromise the quality of life of both patients and caregivers. Few published studies have investigated issues concerning severe dementia such as predictors of mortality and life expectancy, nutrition, end of life issues and palliative care in terminal dementia, as well as best pharmacological and non-pharmacological treatments. Due to the complexity that characterizes advanced dementia, it is important that this discussion starts as early as possible allowing some decisions to be taken, preferably when the patients can still express their opinion.

Key words:
dementia; Alzheimer's disease; severe

Resumo

Dados Norte-Americanos apontam que o contingente de portadores de DA no ano 2000 era de cerca de 4,5 milhões de pessoas e são esperados em torno de 13 milhões para o ano 2050 sendo mais da metade em fase moderada e grave da doença. Além do declínio cognitivo e funcional, são muito comuns diferentes sintomas comportamentais, que muito diminuem a qualidade de vida de pacientes e cuidadores. São escassos os estudos para o desenvolvimento de fármacos, conhecimento de medidas não-farmacológicas, estudos epidemiológicos que averiguam fatores que interferem na história natural da doença, formas de abordar o fim de vida, além de questões como nutrição e linguagem. O longo curso desta doença de prognóstico temporal incerto traz consideráveis dúvidas quanto às decisões a serem tomadas. A visão do conforto e proporcionalidade das ações e do princípio do não-malefício podem servir de guia para a tomada de decisão.

Palavras-chave:
demência; doença de Alzheimer; grave

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References

Schmitt FA, Wichems CH. A systematic review of assessment and treatment of moderate to severe Alzheimer's disease. J Clin Psychiatry 2006;8:158-159.
Herrmann N, Gauthier S. Diagnosis and treatment of dementia: 6. Management of severe Alzheimer's disease. CMAJ 2008;179:1279-1287.
Larson EB, Shadlen MF, Wang L, et al. Survival after initial diagnosis of Alzheimer disease. Ann Intern Med 2004;140:501-509.
Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.
Saxton J, McGonigle-Gibson KL, Swihart AA, et al. Assessment of the severely impaired patient: description and validation of a new neuropsychological test battery. Psychol Assess 1990;2:298-303.
Reisberg B, Doody R, Stoffler A, et al. Memantina in moderate-to-severe Alzheimer's disease. N Engl J Med 2003;348: 1333-1341.
Reiberg B. Functional Assessment Staging (FAST). Psychopharmacol Bull 1988;24:653-659.
Reisberg B, Ferris SH, Leon MJ, et al. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139:1136-1139.
Morris, JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993;43:2412-2414.
Harrell LE. The Severe Mini-Mental State Examination: a new neuropsychologic instrument for the bedside assessment of severely impaired patients with Alzheimer disease. Alzheimer Dis Assoc Disord 2000;14:168-175
Nitrini R, Lefèvre BH, Mathias SC, et al. Testes neuropsicológicos de aplicação simples para o diagnóstico de demência. Arq Neuropsiquiatr 1994;52:457-465.
Cumming J, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatry Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.
Alexopoulos GS, Abrams RC, Younge RC, Shamoian CA: Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.
Tariot PN. Medical management of advanced dementia. J Am Geriatr Soc 2003;51:S305-S313.
Tariot PN. Treatment of agitation in dementia. J Clin Psychiatry 1999;60(Suppl.):11-20.
Verkaik R, van Weert JC, Francke AL. The effects of psychosocial methods on depressed, aggressive and apathetic behaviors of people with dementia: a systematic review. Int J Geriatr Psychiatry 2005;20:301-314.
Livingston G, Johnston K, Katona C, et al. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry 2005; 162:1996-2021.
Gauthier S, Cummings J, Ballard C, et al. Management of behavioral problems in Alzheimer's disease. Int Psychogeriatr 2010;22:346-372.
Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294: 1934-1943.
Wang PS, Schneeweiss S, Avorn J, et al. Risk of death in elderly users of conventional vs. atypical antipsychotic medications N Engl J Med 2005;353:2335-2341.
Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA 2005; 293:596-608.
Feldman H, Gauthier S, Hecker J, et al. A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer's disease. Neurology 2001;57:613-620.
Tariot PN, Cummings JL, Katz IR, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of donepezil in patients with Alzheimer's disease in the nursing home setting. J Am Geriatr Soc 2001;49:1590-1599.
Bullock R, Touchon J, Bergman H, et al. Rivastigmine and donepezil treatment in moderate to moderately-severe Alzheimer's disease over a 2-year period. Curr Med Res Opin 2005;21:1317-1327.
Winblad B, Kilander L, Eriksson S, et al. Donepezil in patients with severe Alzheimer's disease: double-blind, parallel-group, placebo-controlled study. Lancet 2006;367:1057-1065.
Black SE, Doody R, Li H, et al. Donepezil preserves cognition and global function in patients with severe Alzheimer's disease. Neurology 2007;69:459-469.
Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev 2006;25:CD005593.
Winblad B, Poritis N. Memantine in severe dementia: results of the 9M-Best Study (Benefit and efficacy in severely demented patients during treatment with memantine). Int J Geriatr Psychiatry 1999;14:135-146.
Tariot PN, Farlow MR, Grossberg GT, et al. Memantine treatment in patients with moderate to severe dementia already receiving donepezil: a randomized controlled trial. JAMA 2004;291:317-324.
Jones RW, Bayer A, Inglis F, et al. Safety and tolerability of once-daily versus twice-daily memantine: a randomized, double-blind study in moderate to severe Alzheimer's disease. Int J Geriatr Psychiatry 2007;22:258-262.
Livingston G, Katona C. The place of memantine in the treatment of Alzheimer's disease: a number needed to treat analysis. Int J Geriatr Psychiatry 2005;20:459-464.
Shuster J Jr. Palliative Care for Advanced Dementia. Clin Geriatr Med. 16: 373-86, 2000.

Publication Dates

Publication in this collection
Jul-Sep 2010

History

Received
09 Apr 2010
Accepted
20 June 2010

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] Schmitt FA, Wichems CH. A systematic review of assessment and treatment of moderate to severe Alzheimer's disease. J Clin Psychiatry 2006;8:158-159.

[2] Herrmann N, Gauthier S. Diagnosis and treatment of dementia: 6. Management of severe Alzheimer's disease. CMAJ 2008;179:1279-1287.

[3] Larson EB, Shadlen MF, Wang L, et al. Survival after initial diagnosis of Alzheimer disease. Ann Intern Med 2004;140:501-509.

[4] Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198.

[5] Saxton J, McGonigle-Gibson KL, Swihart AA, et al. Assessment of the severely impaired patient: description and validation of a new neuropsychological test battery. Psychol Assess 1990;2:298-303.

[6] Reisberg B, Doody R, Stoffler A, et al. Memantina in moderate-to-severe Alzheimer's disease. N Engl J Med 2003;348: 1333-1341.

[7] Reiberg B. Functional Assessment Staging (FAST). Psychopharmacol Bull 1988;24:653-659.

[8] Reisberg B, Ferris SH, Leon MJ, et al. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139:1136-1139.

[9] Morris, JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993;43:2412-2414.

[10] Harrell LE. The Severe Mini-Mental State Examination: a new neuropsychologic instrument for the bedside assessment of severely impaired patients with Alzheimer disease. Alzheimer Dis Assoc Disord 2000;14:168-175

[11] Nitrini R, Lefèvre BH, Mathias SC, et al. Testes neuropsicológicos de aplicação simples para o diagnóstico de demência. Arq Neuropsiquiatr 1994;52:457-465.

[12] Cumming J, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatry Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44:2308-2314.

[13] Alexopoulos GS, Abrams RC, Younge RC, Shamoian CA: Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23:271-284.

[14] Tariot PN. Medical management of advanced dementia. J Am Geriatr Soc 2003;51:S305-S313.

[15] Tariot PN. Treatment of agitation in dementia. J Clin Psychiatry 1999;60(Suppl.):11-20.

[16] Verkaik R, van Weert JC, Francke AL. The effects of psychosocial methods on depressed, aggressive and apathetic behaviors of people with dementia: a systematic review. Int J Geriatr Psychiatry 2005;20:301-314.

[17] Livingston G, Johnston K, Katona C, et al. Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry 2005; 162:1996-2021.

[18] Gauthier S, Cummings J, Ballard C, et al. Management of behavioral problems in Alzheimer's disease. Int Psychogeriatr 2010;22:346-372.

[19] Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005;294: 1934-1943.

[20] Wang PS, Schneeweiss S, Avorn J, et al. Risk of death in elderly users of conventional vs. atypical antipsychotic medications N Engl J Med 2005;353:2335-2341.

[21] Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA 2005; 293:596-608.

[22] Feldman H, Gauthier S, Hecker J, et al. A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer's disease. Neurology 2001;57:613-620.

[23] Tariot PN, Cummings JL, Katz IR, et al. A randomized, double-blind, placebo-controlled study of the efficacy and safety of donepezil in patients with Alzheimer's disease in the nursing home setting. J Am Geriatr Soc 2001;49:1590-1599.

[24] Bullock R, Touchon J, Bergman H, et al. Rivastigmine and donepezil treatment in moderate to moderately-severe Alzheimer's disease over a 2-year period. Curr Med Res Opin 2005;21:1317-1327.

[25] Winblad B, Kilander L, Eriksson S, et al. Donepezil in patients with severe Alzheimer's disease: double-blind, parallel-group, placebo-controlled study. Lancet 2006;367:1057-1065.

[26] Black SE, Doody R, Li H, et al. Donepezil preserves cognition and global function in patients with severe Alzheimer's disease. Neurology 2007;69:459-469.

[27] Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev 2006;25:CD005593.

[28] Winblad B, Poritis N. Memantine in severe dementia: results of the 9M-Best Study (Benefit and efficacy in severely demented patients during treatment with memantine). Int J Geriatr Psychiatry 1999;14:135-146.

[29] Tariot PN, Farlow MR, Grossberg GT, et al. Memantine treatment in patients with moderate to severe dementia already receiving donepezil: a randomized controlled trial. JAMA 2004;291:317-324.

[30] Jones RW, Bayer A, Inglis F, et al. Safety and tolerability of once-daily versus twice-daily memantine: a randomized, double-blind study in moderate to severe Alzheimer's disease. Int J Geriatr Psychiatry 2007;22:258-262.

[31] Livingston G, Katona C. The place of memantine in the treatment of Alzheimer's disease: a number needed to treat analysis. Int J Geriatr Psychiatry 2005;20:459-464.

[32] Shuster J Jr. Palliative Care for Advanced Dementia. Clin Geriatr Med. 16: 373-86, 2000.

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