Managing Alzheimer disease: Diagnosing and treating dementia-related problems

Alzheimer disease (AD) is a syndrome with cognitive, functional, and behavioral aspects that significantly affect patients, family members and professional caregivers over the long term. Home care is often followed by nursing home placement. The BCMA discussion paper, “Building Bridges: A Call for a Coordinated Dementia Strategy,” takes a comprehensive look at how we can improve care for people with dementia in BC and provides a systematic overview with important recommendations.

In a previous issue (BCMJ September 2004;46[7], “The new era of treatable Alzheimer disease”) we provided a current view of Alzheimer disease and emphasized the availability of symptomatic treatments that have a positive impact on cognition, on function and, likely, on behavior. Regarding the latter, when patients are started on cholinesterase inhibitors (ChEIs), families are often struck by the return of interest in social and other activities that had been neglected. (“Dad is back” is a comment heard recently from the daughter of one patient.) In addition, there are data suggesting that an hour of caregiver time can be saved when the person with AD is able to function a little more independently.[1] In our editorial in the September 2004 issue we noted that BC is one of a small number of provinces in Canada without public funding for cholinesterase inhibitor medications, meaning these drugs are only available to those who can afford them. This situation continues.

The first article in this issue shows how the differential diagnosis of dementia becomes increasingly important in terms of understanding therapeutic response. Age is a risk factor for dementia and with age comes the possibility that more than one pathological entity may be affecting the brain and causing symptoms. An intriguing subject of clinical and research focus is the role of vascular factors in neurodegenerative disease. Treating systolic hypertension has been shown to have a significant impact on dementia incidence.[2] Recently it has been reported that statins can have a similar effect.[3,4] Not all neurodegenerative disease, however, is Alzheimer disease or mixed vascular-Alzheimer disease. Additionally, the role of other pathologies (e.g., Lewy bodies) alone or in combination must be taken into consideration. Frontotemporal syndromes occur and require different treatment than AD. There are also more unusual syndromes that can be identified by neuropathological examination but may not always be suspected clinically, making attention to the nuance of clinical presentation and the judicious management of multiple medical problems of critical importance. Neuropathological confirmation of diagnoses should be pursued when possible.

Two other articles in this issue consider the spectrum of behavioral problems caused by AD and the approach to the later stages of the disease when patients are often in nursing homes. Difficult behaviors must be identified and managed appropriately. Functional impairment requires appropriate help from persons with the right skills to allow individuals to do what they can for themselves and to receive timely assistance when needed.

Medical practice in 2005 requires skill in managing chronic diseases. Successfully and compassionately caring for persons with AD can be very rewarding.

—B. Lynn Beattie, MD, FRCPC
Professor, Division of Geriatric Medicine, UBC
Director, Clinic for Alzheimer Disease and Related Disorders 
UBC Hospital
—Howard Feldman, MD, FRCPC
Professor and Head, Division of Neurology, UBC
Director, UBC Alzheimer Clinical Trials Unit
UBC and Vancouver General Hospital

Competing interests
Dr Feldman has received grant/research support, has acted as a consultant, and has been on the speakers bureau or CME programs of many major pharmaceutical companies. He is not a stock shareholder of any of these pharmaceutical companies. Similarly, Dr Beattie has been a co-investigator for pharmaceutical companies and participated in CME programs, but is not a stock shareholder.