Dementia in Older Adults: Assessment, Treatment & Ethics

Mental Health Issues in the Elderly

Old age is a natural occurrence for every human being — a stage of growth accompanied by several changes, some of which can be identified as problems. Among these problems are a rise in morbidity, mortality, hospitalization, and loss of functional status. A large body of evidence associates these problems with common mental disorders to which the elderly are prone. A combination of depression and anxiety is very common in the elderly; so prevalent, in fact, that one-half of elderly patients report significant anxiety or depressive symptoms (Parkar, 2015). The changing nature of contemporary society has redefined the social role of the elderly within the family and community, eliminating the traditional life-sustaining and nurturing influences that older adults once contributed. As a result, many elderly individuals are socially isolated. Many are committed to nursing homes or institutions where the only available social links are other equally alienated older adults.

The contributions of the elderly to families and society, while sometimes limited, are not irrelevant. Older adults aged 60 and above still make valuable contributions as family members, community volunteers, and active participants in the workforce. However, the effectiveness of these contributions can be limited by an individual's mental health condition. While most elderly people have good mental health, there is a high risk of developing mental disorders as age advances. According to the World Health Organization (2017), over 20% of adults aged 60 and over suffer from a mental or neurological disorder (excluding headache disorders), and mental and neurological disorders account for 6.6% of all disabilities (disability-adjusted life years — DALYs) in this age group. The three most common mental and neurological disorders in the world's older population are depression, dementia, and anxiety, conditions that affect 7%, 5%, and 3.8% of the world's older population, respectively.

Mental health conditions are often unrecognized by healthcare professionals and by the elderly individuals who suffer from them. Even when accurately identified, many sufferers are reluctant to seek professional help due to the stigma linked with these conditions. This paper focuses on dementia as a mental health issue that significantly affects the elderly.

Understanding Dementia: Definition and Prevalence

Dementia is considered a syndrome — a group of symptoms — that is either chronic or progressive, interfering with cognitive function (the ability to process thought) and exhibiting mental ability deterioration beyond what might be expected from normal aging. Dementia affects several mental faculties, including thinking, memory, orientation, calculation, learning capacity, comprehension, language, and judgment, while consciousness itself is not affected. Symptoms such as deterioration in emotional control, social behavior, and motivation commonly precede the manifestation of cognitive impairment, but occasionally occur alongside it (WHO, 2020). The resulting loss of personal ability caused by dementia is recognized as the leading cause of dependency among the elderly worldwide. Poor understanding of this condition has led to its association with stigma — a social factor that can interfere with diagnosis and care. The impact of dementia on the patient, the family, and society can be physical, psychological, social, and economic.

Although not a normal aspect of aging, dementia is most prevalent in older adults. An estimated 50 million people worldwide live with dementia, with 60% of that population distributed in low- and middle-income countries. The total number of dementia patients worldwide is projected to rise to 82 million in 2030 and 152 million in 2050 (WHO, 2017). In addition to the high economic cost of medical, social, and informal care, the families and carers of dementia patients are subject to great physical and emotional stress. Support from health, social, financial, and legal systems is therefore required for dementia patients, their carers, and their families alike.

Causes and Risk Factors

The following factors are recognized as the most common causes of dementia (Livingston et al., 2020):

Degenerative neurological diseases — such as Alzheimer's disease, Parkinson's disease, Huntington's disease, and certain variants of multiple sclerosis. These neurological diseases are characterized by increasing severity over time.

Vascular disorders that impair the circulation of blood to the brain.

Brain injuries caused by trauma during a car accident, fall, concussion, or similar event.

Certain infections of the central nervous system, such as meningitis, HIV, and Creutzfeldt-Jakob disease.

Persistent use of drugs or alcohol.

Certain types of hydrocephalus — a build-up of fluid in the brain.

The risk of developing dementia is also influenced by physical and lifestyle factors, including age; a family history of dementia; the existence of underlying illnesses such as diabetes, Down syndrome, heart disease, and sleep apnea (Shi et al., 2018); poor diet and a lack of exercise; and cognitive inactivity, social isolation, and depression.

Symptoms and Disease Progression

There is variance in how dementia manifests in each person, based on factors such as the illness's impact and the individual's personality prior to being affected (WHO, 2020). However, the progression of dementia follows a sufficiently similar pattern for three distinct stages to be identified.

Early stage: This stage can be difficult to identify because the onset is gradual. Identifiable symptoms during this period include forgetfulness, a poor awareness of time, and becoming lost in familiar places.

Middle stage: As dementia advances, symptoms become more evident and more serious. The affected individual becomes increasingly forgetful of recent events and people's names, becomes lost even at home, has greater difficulty communicating, requires help with personal care, and may experience behavioral changes such as wandering and repeated questioning.

Late stage: At this stage, the affected individual becomes nearly totally dependent and inactive. Severe memory disturbances occur, and physical symptoms become very pronounced. The individual will become unaware of time and place, have difficulty recognizing relatives and friends, become increasingly dependent on others, have difficulty walking, and may exhibit behavioral changes including aggression.

Screening, Assessment, and Diagnosis

The diagnosis of dementia requires a thorough clinical assessment covering medical history, a cognitive and mental state examination, physical examination, and other relevant investigations (Panegyres, Berry, & Burchell, 2016). The patient's assessment should be completed with input from a knowledgeable informant, as information from an unreliable patient is not sufficient on its own. Informant-based assessments provide greater sensitivity than the MMSE (Mini-Mental State Examination) in detecting dementia and changes in biomarker profiles of Alzheimer's disease, particularly in the early symptomatic stages.

Various tests are available to screen for cognitive decline. The Mini-Mental State Examination (MMSE) is the most widely used, taking approximately 15 minutes to complete and rated on a scale of 0 to 30, with the resulting value indicating the current level of cognitive impairment (Panegyres et al., 2016).

The Montreal Cognitive Assessment (MoCA) is a screening tool used for a similar function — detecting cognitive impairment — but only in mild cases. This test requires approximately 10 minutes to complete. Two additional cognitive tests that are considered as clinically and psychometrically robust as the MMSE are the General Practitioner Assessment of Cognition (GPCOG) and Mini-Cog testing.

The current ability to complete day-to-day activities without observable impairment must be determined when assessing for dementia. The testing tool used for this purpose is the Functional Activities Questionnaire (FAQ) — a brief standardized assessment used to obtain objective evidence from an informant, such as a family member or spouse, regarding the patient's competence in completing daily activities.

Certain medications can interfere with the assessment of dementia in a patient. Given the common occurrence of polypharmacy in the elderly, this interference is a significant risk. Therefore, a full review of all medications — prescribed or over-the-counter — must be completed. Common drug classes that can impair cognitive function include opioids, tricyclic antidepressants, anticholinergics, muscle relaxants, antihistamines, antiepileptics, benzodiazepines, and non-benzodiazepine hypnotics (Panegyres et al., 2016). Information regarding a history of alcohol consumption, smoking, and illicit drug use is also essential.

A neurological evaluation is required to diagnose dementia. This evaluation should include assessments of vision, speech, hearing, and movement. The presence of an abnormality in any of these functions can indicate a health condition capable of causing dementia. A speech impediment might indicate the presence of Parkinsonism, while poor motor skills can suggest frontotemporal dementia (FTD), Parkinsonism, normal pressure hydrocephalus, or stroke. Any history of head injury or neurological disorder must be acknowledged, as traumatic brain injury and epilepsy are risk factors for early cognitive decline (Vossel et al., 2017). The patient's sleep patterns can also indicate cognitive decline, particularly if the patient suffers from sleep apnea or restless legs syndrome.

An examination of a person's social history can be used to detect changes in cognitive function. Relevant factors include education, hobbies, occupation, home life, and available supports.

Structural imaging technology — preferably MRI — can identify potentially reversible causes of dementia such as stroke, subdural hematomas, hydrocephalus, and intra-axial and extra-axial tumors (Montgomery, 2020). In compliance with UK, European, and American medical guidelines, structural imaging should be used during the initial investigation of dementia patients. The recommended options are non-contrast CT and MRI, with MRI being the preferred choice.

Subtypes of neurodegenerative dementia can be differentiated by assessing neuronal function. Positron emission tomography (PET) using 18-F-fluorodeoxyglucose (FDG) and SPECT using 99mTc-hexamethyl propylene amine oxime (99mTc-HMPAO) are both techniques available for this purpose.

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