Abi Rayner, MD, MPH, Buller Medical Service, Westport, New Zealand.

Hallucinations and delusions increase the risk of developing dementia, delirium, functional impairment, and of death. The differential diagnosis includes isolated hallucinations, delirium, depression with psychotic symptoms, late-onset schizophrenia, and unrecognized dementing disorder, including Lewy Body disease and frontotemporal dementia. Optimum management requires diagnosis, assessment of the goals of treatment, and understanding the risks and benefits associated with psychoactive medications. Atypical neuroleptics are appropriate first-line agents for most patients with dementia and psychotic symptoms. Response to medications is modest and a second agent (including acetylcholinesterase inhibitors, antidepressants, and anticonvulsants) may be necessary to reduce behaviour to acceptable levels. In addition, decline in cognitive status and increased risk of cerebrovascular events and death are associated with the use of antipsychotic medications. Change in functional status and time alter the impact of behavioural symptoms. Periodic reassessment and reduction of medication dosage over time appears safe, usually without re-emergence of symptoms.
Key words: psychotic symptoms, older adult, dementia, antipsychotics, behavioural disturbance.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

David B. Hogan MD, FACP, FRCPC, Professor and Brenda Strafford Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

A number of agents are available for treatment of Alzheimer’s disease (AD). They include drugs with a specific indication for AD, nutritional supplements, herbal preparations, and drugs approved for other conditions. Cholinesterase inhibitors (ChEIs) such as donepezil, galantamine, and rivastigmine are modestly effective for mild to moderate stages of AD. Memantine has a slight, beneficial effect on moderate to severe stages of AD. As ChEIs and memantine have different mechanisms of action, they can be used together. Antioxidants, B vitamins, anti-inflammatories, HMG-CoA reductase enzyme inhibitors, and sex steroids can not be recommended for the treatment of AD at the present time.
Key words: Alzheimer’s disease, drug therapy, cholinesterase inhibitors, memantine, dementia.

Holly A. Tuokko, PhD, RPsych, CIHR Institute of Aging Senior Investigator; Professor, University of Victoria, Victoria, BC.

Impairments in cognition and everyday activities are primary risk factors for increases in need for care. Even before cognitive impairment is of sufficient severity to be considered dementia, complex, high-level, everyday activities may be notably impaired. As cognitive impairment increases, so too does the type and magnitude of difficulties in performing everyday tasks. When the severity of cognitive impairment and level of dependency for everyday tasks exceeds that which can be provided at home in the community, long-term care facility admission may need to be considered.
Key words: mild cognitive impairment, dementia, everyday functioning, long-term care facility admission.

Abi V. Rayner MD MPH, Buller Medical Service, Westport, New Zealand.

Psychotic symptoms, hallucinations, and delusions, arising de novo in older adults, represent a major risk factor for the development of dementia, illness, delirium, functional impairment and death. These symptoms and associated behavioural manifestations overlap with depressive disorders and may be signs of cognitive impairment or dementia. Symptoms may be vague or legitimized so that the psychosis is unrecognized by family and physicians. Specific queries regarding the nature of the symptoms and the impact on function will provide diagnostic clues. Several brief assessment tools can be used in primary care, specifically the NPI-Q and Blessed Dementia Scale.
Key words: psychosis, hallucinations, delusions, dementia, depression.

Shailaja Shah, MD, Clinical Assistant Professor, Assistant Director Geriatric Psychiatry Fellowship, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Gautam Rohatgi, DO, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.
Daniela Ganescu, MD, Geriatric Psychiatry Fellow, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, Piscataway, NJ, USA.

Alzheimer’s disease (AD) is the most common cause of dementia, affecting nearly 18 million people around the world. Alzheimer’s disease is characterized by cognitive, functional, and behavioural decline. As the condition progresses the affected individual becomes increasingly dependent on others for assistance in performing all activities of daily living. Neuropsychiatric symptoms (NPS) such as agitation, psychosis, and apathy are very common in dementia and especially in AD. Agitation and apathy contribute to a tremendous amount of caregiver distress. Treatment guidelines recommend utilizing nonpharmacologic behavioural approaches in all instances. When behavioural interventions fail or when the behaviour is severe, medications are recommended. At present, no psychotropic agent presently available within the United States is FDA-approved for use in dementia complicated with behaviour disturbance.
Key words: agitation, apathy, behaviour interventions, atypical antipsychotics, dementia.

Chris MacKnight, MD, MSc, FRCPC, Associate Professor, Department of Medicine, Dalhousie University, Halifax, NS.

Three cholinesterase inhibitors are available in Canada for the treatment of mild and moderate Alzheimer’s disease. As the three agents differ in their pharmacology, switching among them does sometimes make sense. Switching may be necessary because of intolerance, lack of response, and occasionally loss of response. This article will describe how and when to switch cholinesterase inhibitor.
Key words: Alzheimer’s disease, treatment response, cholinesterase inhibitors, switching, dementia.

Those who read my brief introductions to Geriatrics & Aging each month know that I am very interested in dementia. Every geriatrician is involved in managing patients with dementia, but that is very different from being “interested.” I think for many of us “Johnny Come Lately” types (I include myself in that group), the topic became popular when the first of the cholinesterase inhibitors became available for clinical use. Although they are hardly miracle drugs, they do make a difference and, even more importantly, they inspire hope in patients, families, and doctors. The enhanced monitoring of these patients sparked by these medications means better general medical care and hence better outcomes than can be ascribed to the medications alone. As a result, in the original drug trials, patients treated with placebo did better than historical controls with Alzheimer disease. Another improvement in care has resulted from multidisciplinary memory clinics. The skills and knowledge of occupational therapists, social workers, nurses, and others are now often available to patients with dementia, further improving their outcomes and relieving some of the incredible stress that families and caregivers experience.

Nevertheless, it is still frustrating that we do not have more efficacious pharmacological treatments for dementia such as are available for another common degenerative neurological disorder, namely, Parkinson’s disease. However, research is ongoing, and there is now more light shining at the end of the tunnel. The theme of this edition of Geriatrics & Aging is, therefore, new drug treatments for the management of dementia.

We start off with our CME article focused on “The Latest in Drug Therapy for Dementia: Gleanings from the Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia” by Dr. David Hogan, former president of the Canadian Geriatrics Society (CGS). A general overview of what we are likely to see in the coming years as far as drug therapy is concerned is covered in the article “Emerging Drug Therapies in Alzheimer’s Disease” by my colleague Dr. David Tang-Wai. However, recognizing that cholinesterase inhibitors are still the mainstay of pharmacological management we also have an article on “Switching Cholinesterase Inhibitors: When and How” by Dr. Chris MacKnight, a former president of the CGS. Although as doctors we tend to focus on the cognitive issues in dementia, for families the behaviour of individuals with dementia is often the “make or break” problem that leads to institutionalization. This topic is addressed in the article “Pharmacologic Treatment of Agitation and Apathy in Dementia” by Drs. Shailaja Shah, Gautam Rohatgi, and Daniela Ganescu.

We have an assortment of other articles on issues of importance to older patients. The Cardiovascular Disease column is “Treatment of High-Risk Older Adults with Lipid-Lowering Drug Therapy” by Dr. Wilbert Aronow, a frequent contributor to this journal and also one of the world’s best-known specialists in geriatric cardiology. Not surprisingly, our Dementia column “Dementia: Recognition of Psychotic Symptoms among Older Adult”’ by Dr. Abi Rayner and our Caregiving column “Everyday Functioning across the Spectrum of Cognitive Impairment” by Dr. Holly Tuokko are also related to this month’s focus theme. Our Men’s Health column is entitled “Why Men Die Younger than Women” by Dr. Bridget Gorman & Dr. Jen’nan Ghazal Read. Dr. Timothy O. Lipman thoroughly reviews “The Role of Herbs and Probiotics in GI Wellness for Older Adults” for our Nutrition column. Our final article is a case study on a topic that I have found to be absolutely fascinating, having reviewed the literature at one point after seeing a couple of affected patients in my clinic. It is entitled “Visual Hallucinations among Older Adults: The Charles Bonnet Syndrome” by Dr. Nages Nagaratnam, with peer commentary by Dr. François Sirois.

Enjoy this issue,
Barry Goldlist

Sylvia Davidson, MSc, BSc, Dip Ger, OT Reg.(Ont.), Psychogeriatric Resource Consultant, Toronto Rehabilitation Institute, Toronto, ON.

Caregivers frequently struggle to manage challenging behaviours associated with dementia, often without a good understanding of why these behaviours occur. This article presents a simple framework to help build understanding as well as a systematic approach to dealing with resistance to care.
Key words: dementia, caregiver, systematic approach, understanding behaviour, resisting care.

Elise J. Levinoff, MSc, BSc, University of Ottawa, Faculty of Medicine, Ottawa, ON.

Dementia is a neurological disease that is associated with aging. The incidence and prevalence of dementia is increasing as the population continues to age. The two most common forms of dementia are Alzheimer’s disease (AD) and vascular dementia (VaD). Although these two forms of dementia represent different pathologies and different clinical presentations, they share similar risk factors. It is important to distinguish between the two forms of dementia because of the differing treatments, and because the risk factors for each are often preventable. This article will discuss the classification, risk factors, and diagnosis of AD and VaD, and present distinguishing characteristics between them.
Key words: dementia, Alzheimer’s disease, vascular dementia, stroke, memory.

Yosuke Wakutani, MD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.
Peter St. George-Hyslop, MD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.
Ekaterina Rogaeva, PhD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.

There are ~200 human diagnostic categories presenting as or accompanying dementia (interested readers may investigate the database Online Mendelian Inheritance in Man, a catalog of human genes and genetic disorders, at www.ncbi.nlm.nih.gov/ genome/guide/human/). Many forms of dementia are associated with deposition of different aberrant proteins in the brain. Familial aggregation in Alzheimer’s disease (AD), frontotemporal dementia (FTD), and other forms of dementia implies the presence of inherited susceptibility factors. Many forms of dementia remain genetically unexplained; however, linkage analyses suggest that most of them are complex disorders with several underlying genetic factors. Here we provide an update on known genes responsible for dementia with the strongest focus on AD and FTD, which are the most common forms of dementia.
Key words: dementia, Alzheimer’s disease, gene, APP, APOE, frontotemporal dementia.