Comprehensive Geriatric Assessment in Patients with Cognitive Decline
14.3 CGA in Dementia and Clinical Decision-Making
Once dementia is diagnosed and in its mild and moderate stages, patients are overtly forgetful and disoriented, neglect their disorder, and are not able to judge its conse- quences. Later on, during the course of the disease, patients lose their ability to communicate, fail to recognize loved ones, become bedridden, and require continu- ous care, with 12–17 years living with disability [9]. Dementia is indeed known to increase mortality, but contributing factors are not well established, although some variables, such as being male, neuropsychiatric symptoms, comorbidity, and the development of functional disability during follow-up, have been associated with a decrease in survival [2, 9]. In the absence of disease-modifying drugs and of dis- abling behavior disorders, the decision of using symptomatic antidementia drugs, such as acetylcholinesterase inhibitors (AChEIs) (tacrine, donepezil, galantamine, and rivastigmine) and the N-methyl-D-aspartate (NMDA) receptor antagonist memantine as well as the use of antipsychotics needs to be taken in a very calibrated way. While antidementia drugs may delay nursing home placement alone or in com- bination and may reduce mortality for patients living in nursing homes and in the community [15], decision-making for therapeutical, including non- pharmacological options in older patients with dementia, is a major challenge for health practitioners, particularly in frail older patients with comorbidity and high mortality risk. Use of CGA allows the identification of resources and problems in several personal domains potentially able to negatively affect cognitive impairment progression (Fig. 14.2), but there is a paucity of systematic data on the real effect of the perfor- mance of CGA in the dementia population.
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14.3.1 Drug Treatments in Dementia: The Role of CGA
There is a huge debate on use of antidementia drugs (donepezil, galantamine, riv- astigmine, and/or memantine) with respect to increase of survival in older community- dwellers subjects with dementia and particularly frail. Studies con- ducted in different settings showed that antidementia drugs can delay nursing home placement alone or in combination [16]; however, the effect on mortality is uncer- tain. More recently, two observational studies showed that AChEIs can delay a move to a nursing home, but have no effect on life expectancy [18], and that AChEI use alone or AChEI plus memantine use were not associated with time to death [17].
A cohort study in 7073 AD patients in the Swedish Dementia Registry suggested that AChEIs were associated with a lower risk of death and myocardial infarction [18] confirming a positive effect of donepezil on lifetime expectancy after onset of AD in a Japanese retrospective observational study [19]. On the contrary, in other large observational studies, cumulative antidementia drugs or memantine alone did not prolong overall survival in patients with AD [16], and memantine was also asso- ciated with greater risk of all-cause mortality in the Medicare and Danish cohorts suggesting that sicker individuals were selected for memantine therapy [20, 21].
It is not surprising that data on effectiveness of antidementia drugs is conflicting.
Antidementia drugs have been tested in RCTs typically excluding real-life patients indeed receiving those drugs. In clinical experience, subjects treated with antide- mentia drugs are very old, mostly women, and suffer from vascular comorbidities.
Antidementia RCTs, in contrast, exclude very old, frail, multimorbid patients and might be not representative of the population. In addition, it is questionable whether prolongation of life or a few points in ADAS-Cog changes must be considered index of efficacy in such a devastating disorder like dementia, in which quality of life and
Older patient with dementia
Moderate and severe dementia
Mild dementia
Co-manage with neurologist, identify geriatric syndromes and resources; pay special attention to
• Prognosis
• indication for antidementivum
• prevention of immobility and pressure sores, dysphagia, delirium, aggression, pain and falls, malnutrition, dehydratation
• Comfort and caregiver information CGA
Patient and caregiver Information Intervention; Follow up
• Neurological and full neuropsycological testing in co- management
• Comorbidities? Cardiovascular and metabolic control? Medication reconciliation?
• Social needs? Isolation?
Withdrawal? Caregiver and social- financial support?
Fig. 14.2 CGA of the older patient with dementia
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functionality in advanced age might constitute more relevant endpoints. Due to the high variability and heterogeneity of disease severity and comorbid status, consen- sus is growing that mortality risk stratification in older patients should be based on information on comorbidity and functional status and integrate information of sev- eral domains of health and function. According to the definition of CGA, this type of multidimensional prognostic evaluation should be targeted to improved cost- effective clinical decision-making and to patient-centered care oriented to the appropriate prescription of the appropriate (symptomatic) drug.
Recently, a Multidimensional Prognostic Index (MPI) derived from a standard- ized CGA has been developed and validated for mortality risk assessment in several independent cohorts of hospitalized and community-dwelling older subjects with acute or chronic diseases (see Chap. 8). The CGA assessment was carried out according to the Standardized Multidimensional Assessment Schedule for Adults and Aged Persons (SVaMA), the officially recommended multidimensional assess- ment schedule used since 2000 by the health personnel of the Veneto Regional Healthcare System to perform a multidimensional assessment in community- dwelling older persons to establish accessibility to some healthcare resources (homecare services or nursing home admission). Further information on MPI use and calculation can be downloaded from the following address: http://www.mpiage.
eu/home/about-mpi-svama.
As survival after diagnosis of dementia is known to vary considerably, depending on numerous factors and their complex interactions, and it may directly influence prevalence and service needs, the MPI has been validated also in dementia and has been shown to accurately predict mortality in hospitalized patients [22] and to predict mortality and hospitalization risk in outpatients [23]. In particular, in an observational prospective cohort study of 340 outpatients with cognitive impairment, the probability of death and hospitalization was nine- and sixfold higher, respectively, in patients with MPI-3 compared to patients with MPI-1, supporting the MPI’s ability to disclose risk for mortality and hospitalization also in older cognitively impaired community dwell- ers [24]. Due to the high validity, accuracy, and reliability of the MPI (see Chap. 8), a multicentric European study is ongoing which includes existing cohorts of older mul- timorbid subjects as well as a prospective study (www.mpiage.eu). The retrospective analysis of data from over 6800 older community dwellers with dementia shows that these subjects have a mean age of 84 years and are mostly women, a large percentage (about 80%) have vascular comorbidities, and only 20% receive treatment with anti- dementia drugs; however, preliminary survival curves show that antidementia treat- ment is associated with prolongation of life only for subjects with low and moderate mortality risk and not for subjects at high risk of mortality [25]. Taken together, these data suggest not only that dementia among older community dwellers is underdiag- nosed and undertreated but also that it is very frequently associated with vascular disease and that the relatively few patients treated might not even be those who really benefit from the treatment at least in terms of life prolongation. These and other MPI_
Age results (see Chap. 8) strongly support the hypothesis that clinical decisions in older multimorbid subjects should be taken multidimensionally and individually based on prognosis.
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14.4 Future Perspective: The Key Role of CGA to Prevent