ITEMS IN AFP WITH MESH TERM:
ABSTRACT: The family physician's holistic approach to patients forms the basis of good health care for adults with Down syndrome. Patients with Down syndrome are likely to have a variety of illnesses, including thyroid disease, diabetes, depression, obsessive-compulsive disorder, hearing loss, atlantoaxial subluxation and Alzheimer's disease. In addition to routine health screening, patients with Down syndrome should be screened for sleep apnea, hypothyroidism, signs and symptoms of spinal cord compression and dementia. Patients with Down syndrome may have an unusual presentation of an ordinary illness or condition, and behavior changes or a loss of function may be the only indication of medical illnesses. Plans for long-term living arrangements, estate planning and custody arrangements should be discussed with the parents or guardians. Because of improvements in health care and better education, and because more people with this condition are being raised at home, most adults with Down syndrome can expect to function well enough to live in a group home and hold a meaningful job.
ABSTRACT: Family physicians play a key role in assessing and managing patients with Alzheimer's disease and in linking the families of these patients to supportive services within the community. As part of comprehensive management, the family physician may be responsible for coordinating assessments of patient function, cognition, comorbid medical conditions, disorders of mood and emotion, and caregiver status. Suggestions for easily administered and scored assessment tools are provided, and practical tips are given for supporting primary caregivers, thereby increasing efficiency and quality of care for patients with Alzheimer's disease.
ABSTRACT: Once the clinical diagnosis of Alzheimer's disease has been made, a treatment plan must be developed. This plan should include cholinesterase inhibitor therapy to temporarily improve cognition or slow the rate of cognitive decline, management of comorbid conditions, treatment of behavioral symptoms and mood disorders, provision of support and resources for patient and caregiver, and compliance with state-mandated reporting requirements for driving impairment and elder abuse. The primary caregiver can be a valuable ally in communication, management of care, and implementation of the care plan. Patient symptoms and care needs change as Alzheimer's disease progresses. In the early stage of the disease, the family physician should discuss realistic expectations for drug therapy, solicit patient and family preferences on future care choices, and assist with advance planning for future care challenges. In the middle stage, the patient may exhibit behavioral symptoms that upset the caregiver and are difficult to manage. When the patient is in the advanced stage of Alzheimer's disease, the caregiver may need support to provide for activities of daily living, help in making a difficult placement decision, and guidance in considering terminal care options. Throughout the course of the disease, routine use of community resources allows care to be provided by a network of professionals, many of whom will be specialists in Alzheimer's disease.
ABSTRACT: Gait instability, urinary incontinence, and dementia are the signs and symptoms typically found in patients who have normal pressure hydrocephalus. Estimated to cause no more than 5 percent of cases of dementia, normal pressure hydrocephalus often is treatable, and accurate recognition of the clinical triad coupled with radiographic evidence most commonly identifies likely responders. Magnetic resonance imaging or computed tomography typically demonstrates ventricular dilation with preservation of the surrounding brain tissue. The abnormality in normal pressure hydrocephalus occurs secondary to an abnormality in fluid removal, leading to an increase in ventricular size and encroachment of enlarged ventricles on adjacent brain tissue. The pressure exerted on the cerebral parenchyma by immense fluid-filled cavities deforms white matter tracts, instigating gait abnormalities and incomplete control of the bladder, as well as difficulties in processing incoming stimulation and in producing expeditious responses. Signs and symptoms often occur as sequelae to an imbalance between the expected ongoing production of cerebrospinal fluid and continuous efflux. Ventriculoperitoneal shunting is used to relieve excess ventricular fluid not absorbed by normal physiologic channels. Multiple studies have explored various techniques to identify patients with normal pressure hydrocephalus in an effort to predict likely benefit from shunting. However, the effectiveness of cerebrospinal fluid diversion has never been proven in a randomized controlled trial comparing use of a shunt versus no shunt.
New Drugs for Alzheimer's Disease - Article
ABSTRACT: Alzheimer's disease is characterized by degeneration of various structures in the brain, with development of amyloid plaques and neurofibrillary tangles. Deficiencies of acetylcholine and other neurotransmitters also occur. Pharmacologic treatment of the disease generally seeks to correct the histopathology, the biochemical derangements or their effects. The only drugs labeled to date for the treatment of cognitive symptoms in patients with Alzheimer's disease are two cholinesterase inhibitors that prevent the breakdown of acetylcholine in the synapse. Both medications are associated with modest improvements in cognitive function. However, all benefit is lost when these drugs are discontinued; the disease then progresses to the level seen in placebo-treated patients. Tacrine, the first cholinesterase inhibitor to be so labeled, must be taken four times daily and is associated with hepatic toxicity. Donepezil is taken once daily. Side effects of the cholinesterase inhibitors include nausea, vomiting and diarrhea, which tend to subside after the titration period. Other drugs that have shown some promise in the treatment of Alzheimer's disease are vitamin E, estrogen, selegiline and a mixture of ergoloid mesylates. Anti-inflammatory drugs and nicotine are also being studied for their effects as neuroprotectors or neurotransmitter enhancers. The caregivers of patients with Alzheimer's disease may see little effect from these or other investigational agents, but nursing home placement may be delayed.
ABSTRACT: Management of the most common type of dementia--Alzheimer's disease--is becoming increasingly sophisticated. Differentiation of Alzheimer's disease from vascular dementia has become therapeutically important, since the choice of treatments depends on the diagnosis. Two cholinesterase inhibitors, donepezil and tacrine, are labeled for use in patients with Alzheimer's disease. Other therapies, such as estrogen, nonsteroidal anti-inflammatory drugs and vitamin E, are sometimes used and show promise in delaying the progression of this dementia. Behavior problems, which often accompany the disease, can be managed using environmental modification, alterations in caregiving and medication. In the terminal phase of the illness, quality care involves implementing advance directives, communicating with the family, individualizing care and attending to patient comfort.
Early Diagnosis of Dementia - Article
ABSTRACT: Until recently, the most significant issue facing a family physician regarding the diagnosis and treatment of dementia was ruling out delirium and potentially treatable etiologies. However, as more treatment options become available, it will become increasingly important to diagnose dementia early. Dementia may be suspected if memory deficits are exhibited during the medical history and physical examination. Information from the patient's family members, friends and caregivers may also point to signs of dementia. Distinguishing among age-related cognitive decline, mild cognitive impairment and Alzheimer's disease may be difficult and requires evaluation of cognitive and functional status. Careful medical evaluation to exclude treatable causes of cognitive impairment is important. Patients with early dementia may benefit from formal neuropsychologic testing to aid in medical and social decision-making. Follow-up by the patient's family physician is appropriate in most patients. However, a subspecialist may be helpful in the diagnosis and management of patients with dementia with an unusual presentation or following an atypical course.
ABSTRACT: Alzheimer's disease is characterized by the development of senile plaques and neurofibrillary tangles, which are associated with neuronal destruction, particularly in cholinergic neurons. Drugs that inhibit the degradation of acetylcholine within synapses are the mainstay of therapy. Donepezil, rivastigmine, and galantamine are safe but have potentially troublesome cholinergic side effects, including nausea, anorexia, diarrhea, vomiting, and weight loss. These adverse reactions are often self-limited and can be minimized by slow drug titration. Acetylcholinesterase inhibitors appear to be effective, but the magnitude of benefit may be greater in clinical trials than in practice. The drugs clearly improve cognition, but evidence is less robust for benefits in delaying nursing home placement and improving functional ability and behaviors. Benefit for vitamin E or selegiline has been suggested, but supporting evidence is not strong. Most guidelines for monitoring drug therapy in patients with Alzheimer's disease recommend periodic measurements of cognition and functional ability. The guidelines generally advise discontinuing therapy with acetylcholinesterase inhibitors when dementia becomes severe.
Mild Cognitive Impairment in the Elderly - Editorials