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Dementia

What's new

Updated 2024 ESPEN guidelines for nutritional management in patients with dementia.

Background

Overview

Definition
Dementia is a clinical syndrome characterized by a progressive cognitive decline that interferes with the ability to function independently.
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Pathophysiology
Dementia is mostly caused by Alzheimer's disease (60-80%), vascular injury (stroke; 20%), Lewy bodies (5-15%), and frontotemporal impairment (Pick's disease).
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Disease course
Alzheimer's disease, vascular injury, Lewy body deposition, and frontotemporal lobe impairment result in dementia, which causes clinical manifestations of gradual, persistent, and progressive decline in cognition and function. Cognitive deficits may present as memory loss, communication and language impairments, agnosia, apraxia, and impaired executive function (reasoning, judgment, and planning). Dementia progression may lead to behavioral and psychological symptoms including wandering, hoarding, sexual disinhibition, eating inappropriate objects, repetitive behaviors, restlessness, agitation, apathy, aggression, psychosis, hallucinations, and delusions causing considerable distress and safety risk for the patient and their caregivers.
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Prognosis and risk of recurrence
Annual mortality associated with dementia in men and women is 38.3% and 30.5%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of dementia are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2018), the European Society for Clinical Nutrition and Metabolism (ESPEN 2024), the World Health Organization (WHO 2023), the U.S. Preventive Services Task Force (USPSTF 2020), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA ...
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Screening and diagnosis

Indications for screening: as per AAFP 2024 guidelines, insufficient evidence to recommend screening asymptomatic older adults for cognitive impairment.
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  • Screening tools

  • Diagnostic criteria

Diagnostic investigations

Initial assessment
As per AAFP 2018 guidelines:
Obtain further evaluation to quantify the degree of impairment in patients screening positive for cognitive impairment on brief screening tests.
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Use the Mini-Cog, the General Practitioner Assessment of Cognition, or the Ascertain Dementia 8-Item Informant Questionnaire to determine the need for further evaluation in patients with suspected dementia.
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  • Diagnostic imaging (CT)

  • Diagnostic imaging (MRI)

  • Diagnostic imaging (PET/SPECT)

  • Diagnostic imaging (functional MRI)

  • Diagnostic imaging (amyloid imaging)

  • Diagnostic imaging (MRS)

  • Diagnostic imaging (other imaging)

  • Laboratory tests

  • Screening for malnutrition

  • Evaluation of driving risk

Medical management

General principles: as per APA 2016 guidelines, provide a documented comprehensive treatment plan including appropriate person-centered nonpharmacological and pharmacological interventions as indicated in patients with dementia.
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  • Cholinesterase inhibitors (initiation)

  • Cholinesterase inhibitors (discontinuation)

  • NMDA antagonists

  • Antidepressants

  • Other agents

  • Management of agitation

  • Management of sleep disturbances

Nonpharmacologic interventions

Physical activity: as per WHO 2023 guidelines, advise physical exercise 3-4 times per week for 30-45 minutes for > 12 weeks in patients with dementia.
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  • Psychotherapy

  • Nutritional support (general principles)

  • Nutritional support (oral feeding)

  • Nutritional support (appetite stimulants)

  • Nutritional support (enteral nutrition)

  • Nutritional support (parenteral nutrition)

  • Dietary supplements

  • Psychosocial care for caregivers

  • Driving cessation

  • Long-term care issues

Therapeutic procedures

Tube feeding: as per AGS 2015 guidelines, avoid percutaneous feeding tubes in patients with advanced dementia; offer oral assisted feeding instead.
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Specific circumstances

Patients with early onset dementia: as per CGS 2012 guidelines, refer all patients with early onset dementia to a memory clinic, preferably one with access to genetic counseling and testing when appropriate.
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  • Patients with rapidly progressive dementia

Patient education

General counseling
As per APA 2007 guidelines:
Educate patients and families about the illness, its treatment, and sources of additional care and support.
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Advise patients and their families of the need for financial and legal planning due to the patient's eventual incapacity.
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Preventative measures

Management of hypertension: as per AAPA/ABC/ACC/ACPM/AGS/AHA/APhA/ASH/ASPC/NMA/PCNA 2018 guidelines, consider lowering BP in adult patients with hypertension to prevent cognitive decline and dementia.
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Follow-up and surveillance

Indications for specialist referral: as per CGS 2012 guidelines, obtain head MRI when a radiologist/neuroradiologist and/or a cognitive specialist can interpret patterns of atrophy and other features that May provide added diagnostic and predictive value.
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  • Follow-up