Dementia – How has it influenced my Outlook on Medicine?

Hello! My name is Sarayu Shankar and I am a current Year 12 student with an aspiration to study medicine. In this article, I will be exploring Dementia, Alzheimer’s Disease in particular, and how it has influenced my outlook on Medicine. 

Firstly, what is Dementia? The NHS defines dementia as: “a syndrome (a group of related symptoms) associated with an ongoing decline of brain functioning”. This includes problems with memory loss, thinking speed, cognitive abilities, speech and language, understanding, judgement and mood.1 However this article will be discussing Alzheimer’s Disease, as it is more prevalent than other variations of dementia. 

What is Alzheimer’s Disease? 

Alzheimer’s Disease is the most common form of dementia and it accounts for approximately 50-70% of the 850,000 diagnoses in the UK.10 It is a permanent and gradually progressive brain disorder which affects a person’s cognitive abilities including the capability to use speech and language, memory as well as experiencing difficulty carrying out simple tasks, without assistance. Alzheimer’s Disease is very common amongst elderly individuals and the diagnosis rate of those aged 65 or over estimated to have dementia is 67.6% as of 31st January 2020. There is research to suggest that changes in the brain, which eventually lead to a person displaying symptoms of Alzheimer’s Disease, can occur up to 10 years beforehand. These symptoms usually become more detrimental as time progresses. 

The Pathology behind Alzheimer’s Disease 

Alzheimer’s Disease is predominantly a reduction in a chemical neurotransmitter, known as acetylcholine (ACh). The function of a neurotransmitter is to transfer information between neurones and so, a reduction in ACh leads to ineffective transmission of information, and thus leading to a reduction in a person’s cognitive capabilities.  

Alzheimer’s is commonly characterised by two main occurrences: amyloid plaques and Tau tangles (or neurofibrillary tangles). Neurofibrils are delicate threads found in the cytoplasm of a nerve cell. The tau tangles are caused by intracellular accumulations of hyperphosphorylated Tau proteins. Hyperphosphorylation occurs when a biological molecule with multiple phosphorylation sites is fully saturated. Phosphorylation sites are found in specific areas of a molecule which undergo the supplement or elimination of a phosphate group (PO4). The process of phosphorylation is crucial for many cellular processes. 

The second microscopic characteristic of Alzheimer’s is the formation of amyloid plaques. Amyloid is a naturally occurring protein in the body. When the amyloid precursor protein (APP) is cut by enzymes, amyloid beta (or Aβ) molecules are formed. These Aβ amyloids in Alzheimer’s patients can form insoluble plaques which deposit around the vessels, leading to amyloid angiopathy. Amyloid angiopathy is a condition in which amyloid plaques deposit on the lining of the walls of blood vessels, in the central nervous system. This causes blood vessels to severely deteriorate over time, reducing blood supply to neurons and eventually resulting in neuronal death. 

This also explains the link between Down’s Syndrome and early onset Alzheimer’s Disease. Individuals with Down’s syndrome have an extra copy of Chromosome 21. On this chromosome, the gene that codes for APP (the protein that results in the formation of Aβ molecules) is present. Patients with Down’s syndrome can also develop an excess of Aβ. This makes them much more likely to develop Alzheimer’s Disease at an earlier stage. 

Aside from the neurofibrillary tangles and amyloid beta plaques, Alzheimer’s Disease is also characterised by the degeneration of the basal nucleus of Meynert as well as the hippocampus. The basal nucleus of Meynert is a group of neurones which are rich in the neurotransmitter, ACh and the hippocampus is a region of the brain which is primarily connected with memory. This explains the decline in memory and brain function, during the progression of Alzheimer’s. 

How is Alzheimer’s Disease diagnosed and measured?

After researching through the appropriate procedures for diagnosing and treating Alzheimer’s Disease, I further looked into the specifics of this using the National Institute for Health and Care Excellence’s (NICE) guidelines for Dementia. I have incorporated recommendations from NICE into the following sections to further enhance this information. 

Diagnosing dementia takes into account various aspects of a patient’s health and wellbeing from cognitive ability, to behavioural and psychological symptoms and many more. This is all done through assessments and tests which can include physical examinations, the use of cognitive instruments and also tests on substances from the body. (More information on testing and diagnosing standard dementia can be found on the NICE website under the section of Dementia).2

With regards to further testing for Alzheimer’s Disease, healthcare professionals can perform specialist PET scans as well as an examination of cerebrospinal fluid for the presence of certain Tau protein and amyloid beta molecules. These further tests can help health care professionals to confirm that the patient is experiencing Alzheimer’s Disease, rather than other dementia forms. 2

When Alzheimer’s Disease is diagnosed, additional testing including measuring the severity of the Alzheimer’s Disease is also conducted. To measure the level of cognitive impairment and thus the severity of Alzheimer’s, a Mini Mental State Examination (MMSE) score is used. The MMSE measures cognitive ability and aims to identify cognitive damage. This is then used to determine the severity of Alzheimer’s. The range in which the score lies in depicts the level of cognitive impairment. The ranges used by healthcare professionals are displayed below:

• Mild Alzheimer’s disease: MMSE score between 21–26
• Moderate Alzheimer’s disease: MMSE score between 10–20
• Moderately severe Alzheimer’s disease: MMSE score between 10–14
• Severe Alzheimer’s disease: MMSE score of less than 10.3

Treatment for Alzheimer’s Disease

Currently, there is no cure for Alzheimer’s Disease however, there are medications and treatments which can help control symptoms. Some of the main medications and therapies used in the treatment of Alzheimer’s include: 

Pharmacological Interventions

• Acetylcholinesterase (AChE) Inhibitors – These medications act to increase the levels of the chemical neurotransmitter, ACh, and help improve communication between neurones. These can currently only be prescribed by specialist doctors such as neurologists and psychiatrists, but they may be available from a GP on the advice of a specialist or from GPs that have professional expertise in this form of medication.4 The common types are donepezil, galantamine and rivastigmine. These are recommended by NICE to be used for managing mild to moderate Alzheimer’s.5
• Memantine – This medication acts by blocking the receptors in the brain that glutamate (another neurotransmitter) would normally bind too. Large quantities of glutamate are released when the neurones are damaged by Alzheimer’s Disease. Excessive glutamate can excite nerve cells to their death which is referred to as a process called “excitotoxicity”.9 Therefore, memantine helps to protect neurones by blocking the effects of too much glutamate.4 Memantine has a marketing authorisation in the UK to be administered to patients with moderate to severe Alzheimer’s.5

Further guidance from NICE recommends considering memantine, in addition to AChE Inhibitors, if patients have moderate disease but offering it to those who have severe disease. 

• Medicines to treat challenging behaviour – In the latter stages of dementia, people will develop behavioural and disinhibitory symptoms of dementia. These can include: increased agitation, wandering and aggression. Medications can be given to reduce these behaviours, which can be difficult for both the Alzheimer’s patient as well as their carers to manage.4 Before starting pharmacological and non-pharmacological interventions, healthcare professionals must explore the possible reasons for their distress as well as checking and addressing causes such as pain, delirium or inappropriate care. These actions are recommended by NICE for the purpose of understanding for care givers.5

Non-Pharmacological Interventions 

Non-pharmacological interventions are used to help relieve the common symptoms associated with dementia. They are typically focused on people with mild to moderate Alzheimer’s Disease. Strategies include:

• Cognitive Stimulation Therapy (CST) – this involves engaging in group activities and exercises which are specifically devised to improve speech and language, memory and problem solving abilities. All three of these skills are heavily impacted by Alzheimer’s. 
• Cognitive Rehabilitation – this method involves a dementia patient working with a healthcare professional, carer or a relative/family member to achieve personal goals. These can be very simple such as using the kettle or any other everyday task. The aim of this therapy is to use the sections of the brain which are working to help stimulate the sections which are currently impaired. 
• Reminiscing and life story recollection – this procedure involves talking through the patient’s life with them. Photos, videos, artefacts, journals and other stimulants might be utilised to evoke the memories of a dementia patient. This has proven to be effective in improving the mood and wellbeing of dementia patients. 4

How effective are Cognitive and Psychological Therapies? 

There are varied interpretations and indications to say whether cognitive and psychological therapies are effective or not. In this sub-section, I will be exploring this argument, accompanying it with evidence from my research. 

Research shows that there is some beneficial impact with the use of cognitive and psychological therapies. A Cochrane review of 15 studies looking at cognitive stimulation found that these activities were shown to improve the quality of life and better communication and interaction between patients, but there was no evidence of improvement in the participants’ ability to take care of themselves or function individually. Furthermore, difficult behaviour was not found to reduce either. These trials consisted of people with mild to moderate dementia and it does not appear to be appropriate for people with severe dementia. This report concludes by saying that more research is needed to find out how long the effects of cognitive stimulation last for and if it is beneficial to continue this. 6

An article entitled “Non-Pharmacologic Interventions for Persons with Dementia”, published by the Journal of the Missouri State Medical Associations, states that evidence-based pharmacological interventions are helpful in enhancing the quality of patient’s lives. These are also low-cost and are without any physical side-effects. Whilst further study is still required to determine the most practical method of delivering these interventions, these findings still suggest that these strategies do provide an answer to the necessity of life interferences. 7

Finally, a systematic review conducted by the University of Cambridge examines the current non-pharmacological interventions in place which include the cognitive and psychological interventions discussed previously and many more. Other therapeutics examined in this review also included aromatherapy and multisensory therapies. The conclusions from this report were that all of these approaches were driven towards patient centred forms of care which allowed for a greater understanding of the individual’s experience and what methods should be implemented to have a positive impact on their lives. Another conclusion derived from these investigations showed that the involvement of families, professional carers and organisations are essential for driving these strategies and also obtaining valid information as to what is working and what needs to be changed.8 

A common theme in all of these articles/reviews, that I have mentioned above, expresses that the available evidence for these methods still remains very limited. There is still no significant evidence that cognitive and psychological therapies fully assist with the treatment of dementia (or in particular Alzheimer’s Disease) but they have proven to be successful in alleviating common symptoms of dementia as well as improving the patient’s well being. Some of these reviews had limitations which meant that the certainty of their findings are low. Overall, further study and comparison is required to come to a definite conclusion for this scenario.

My Experience with Dementia Patients and how it has changed my Outlook on Medicine

During the summer of Year 10, I was very lucky to go on a memorable work experience placement at a care home near where I live. This care home specialised in caring for dementia patients and I was able to meet many wonderful individuals who were suffering from dementia, as well as other patients. My placement lasted 5 days (Monday to Friday) and I can tell you it was definitely one of my favourite work experiences. 

During this placement, I was able to engage in activities with the patients such as bingo, puzzles and board games. There were specifically designed sessions for the patients to communicate with one another (and their carers) such as pamper sessions, team games and karaoke afternoons. These activities encouraged the patients to speak to one another and use their memory as well as problem solving skills.

I was fortunate to spend a lot of time with a few patients, on a personal level, and I got to know them very well. For example, they would select a few of their beloved objects/pictures or recollect a memory and they would then tell me the stories behind them. On one day, we took a few patients on a walk around one of the famous abbeys in my area. This was an initiative which allowed them to reminisce over where they grew up and some of the memories they had such as eating ice-cream at an ice-cream parlour, walking along the same paths and taking the same routes to get to places. I also experienced some of the challenging aspects that dementia brings such as wandering, loss of coordination as well as the detrimental effect it has on memory. This was displayed when some of the patients became confused as to where they were or what they were doing. I observed the carers explaining to the patients in a calm and collective manner but also how difficult it was for some of the elderly individuals to understand this. 

This experience has allowed me to see patient care in a very holistic approach and it has exhibited that providing medication is not the only way a person can be brought to better health, and thus a better state of mind. 

Although the patients were continuously on medications and treatments, the small and supportive ideas and initiatives, created by the staff and key workers at the care home, really made a significant improvement in how content the patients were. I was able to observe this every single day of my placement! I believe that even though non-pharmacological motivations are not as efficient as pharmacological interventions, as studies portray, these small measures of happiness do make a visible difference to the way a patient feels and behaves. Making patients smile and laugh is precious, and it is a crucial part in the process of giving care, to make the patient feel comfortable and do what is best for them. 

It was evident that the presence of a strong and trusting carer to patient relationship increased the wellbeing of the patient in an external way, putting their mind at ease. This involvement has taught me about the importance of supporting the patient’s wellbeing from the perspective of a closer individual, not just a doctor. But more of a friend or someone who listens to what they have to say. The idea of patient-centred care also played a huge role in this experience as when I witnessed the staff putting the patient as the focus of all their tasks, it made me appreciate that at the heart of medicine was in fact the patient. 

Written by Sarayu Shankar

References

1. NHS (2020). About Dementia, Dementia Guide. Available at: https://www.nhs.uk/conditions/dementia/about/ (Accessed: 07/06/2020) 
2. National Institute for Health and Care Excellence (NICE) (2018). Dementia: assessment, management and support for people living with dementia and their carers, Recommendations. Available at: https://www.nice.org.uk/guidance/ng97/chapter/Recommendations (Accessed: 22/06/2020)
3. National Institute for Health and Care Excellence (NICE) (2011). Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease, section 2: Clinical need and practice, subsection 2.6. Available at: https://www.nice.org.uk/guidance/ta217/chapter/2-Clinical-need-and-practice (Accessed: 22/06/2020)
4. NHS (2018). Treatment – Alzheimer’s disease. Available at: https://www.nhs.uk/conditions/alzheimers-disease/treatment/ (Accessed: 25/06/2020) 
5. National Institute for Health and Care Excellence (NICE) (2011) Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease, The technologies. Available at: https://www.nice.org.uk/guidance/ta217/chapter/3-The-technologies (Accessed: 26/06/2020)
6. Cochrane (2012). Can cognitive stimulation benefit people with dementia? Available at: https://www.cochrane.org/CD005562/DEMENTIA_can-cognitive-stimulation-benefit-people-with-dementia (Accessed: 28/06/2020) 
7. Missouri Medicine, The Journal of the Missouri State Medical Association (2017). Non-Pharmacologic Interventions for Persons with Dementia. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140014/ (Accessed: 28/06/2020) 
8. Cambridge University Press (2018). Non-pharmacological interventions in dementia. Available at: https://www.cambridge.org/core/journals/advances-in-psychiatric-treatment/article/nonpharmacological-interventions-in-dementia/CB4C6A081FFB24A29106998463D8D8BC/core-reader (Accessed: 28/06/2020) 
9. Journal of Neural Transmission (2014). Glutamate as a neurotransmitter in the healthy brain. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133642/ (Accessed: 01/07/2020) 
10. Alzheimer’s Society (2019). Facts for the media. [online] Alzheimer’s Society. Available at: https://www.alzheimers.org.uk/about-us/news-and-media/facts-media (Accessed: 15/02/2021)