Rather than talking about dementia, a term that is too stigmatizing, today we prefer to talk about neurocognitive disorders. The latter designate an acquired reduction in one or more cognitive abilities (memory, language, coordination of gestures, etc.). There are two stages: mild, there is no impact on the person’s autonomy, and major, the impact on the person’s daily life is considerable and they are losing autonomy. “It is a persistent, non-regressive disorder, often with progression over time. These disorders are not explained by a cause such as depressiontaking toxins or even medications”, explains Dr. Jean Roche, psychiatrist and geriatrician.
Neurocognitive disorders: which areas can be affected?
Different cognitive functions can be affected, and this varies depending on the diagnosis made: memory, language, coordination of gestures, visual recognition of objects, the environment, faces. “This can also affect executive functions, complex functions which include planning (organizing a project or a weekend for example), inhibition and decision-making abilities..”, adds the specialist. But cognitive disorders also have a behavioral impact, on mood and affect. “Brain lesions linked to cognitive disease have an impact on the way we are with others. The brain is the interface with the world and when it malfunctions, the first signs can be increased anxiety and withdrawal. explains Dr. Roche.
Cognitive disorders: what are the most common causes in the elderly?
The causes of neurocognitive disorders are very numerous, there are around a hundred of them. Alzheimer’s disease is one of the most common, especially among the elderly, although it can also affect people under 60 years old. Other common neurocognitive disorders are Lewy body disease (particularly a source of early hallucinations) and frontotemporal lobar degeneration (with executive and behavioral problems which may be at the forefront). A vascular origin of neurocognitive disorders is also possible, either alone or in association with the other causes previously mentioned.
Impairment of cognitive functions: what are the symptoms and which signs appear first?
“Often the early stages of neurodegenerative diseases are wrongly confused with normal aging, leading to a delay in diagnosis. These are diseases that evolve over at least ten years after the appearance of the first symptoms, signs that we do not necessarily pay attention to.”, explains the psychiatrist.
Symptoms of the disorders vary depending on the cause. In the case of vascular etiology, it also depends on the location of the lesions. These symptoms evolve and cognitive areas that were not initially affected may become affected as the disease progresses. “In Alzheimer’s disease, for example, memory problems often occur first, but other difficulties appear over time (difficulties in language and communication, when using new objects, in judgment, management skills, etc.)..”, adds Dr Roche.
The diagnosis of neurocognitive disorders will be based on a range of arguments sought by the specialist: the history of the disease, the clinical examination, the assessment of daily discomfort, the neurocognitive assessment, the paraclinical (biology, imaging, etc.) .
Memory problems
In Alzheimer’s disease in particular, people forget facts or recent events, have difficulty finding their way, finding their way in an environment that is unfamiliar at the start of the disease and then in the usual environment. . “There are also difficulties with temporal orientation, less precision on the chronology of events”, adds Dr Roche. At a very early stage, these are just occasional micro-errors, then they become more and more frequent.
“People may have difficulty following conversations, a film, a book, and experience difficulty with everyday tasks, for example when they have to use new objects. They need to be explained to them several times, write everything down”, explains the psychiatrist. The more the disease progresses, the more we may observe a decline in daily autonomy abilities.
Behavioral problems
If memory disorders are often at the forefront, attention to the behavioral axis is another way to identify cognitive disorders. “We observe a slight change in personality, with a little more anxiety and irritability, or on the contrary detachment”, explains Dr. Roche. “If patients often have anosognosia, that is to say an inability to realize their difficulties, it is not constant. Anxiety can therefore be increased by occasional awareness of problems, a feeling of failure”, adds the doctor.
Social withdrawal, depression
Among other signs of cognitive disorders, progressive social withdrawal but also depressive symptoms are frequently observed in these patients. “In a 75-80 year old person with no previous history depressionthese mood disorders are one in two times the first symptoms of cognitive disorders”, explains Dr. Roche.
Neurocognitive disorders: the importance of prevention
It is possible to act on numerous factors in order to limit the development of neurocognitive disorders or delay the appearance of the first signs:
- Maintaining social ties: we know that isolation is a factor in the earlier development of neurocognitive disorders.
- Hearing problems: not hearing well often leads to fewer social interactions and therefore sensory isolation, a source of less brain stimulation.
- Depression: treatment of depression also plays a role in prevention.
- The level of education: several studies, including Works from Inserm published in 2018 found that increasing the level of education was associated with better cognitive performance. “We don’t all have the same cognitive reserve. And the higher the level of education, the more a person is able to compensate and therefore delay the clinical expression of disorders.”, observes Dr. Jean Roche.
- Limit alcohol intake: do not exceed a maximum of 10 units of alcohol per week and 2 days per week without alcohol
- Physical exercise: regularly practicing physical activity has a very significant effect on the brain and cognition.
- Limit the impact of vascular risk factors: diabetes, hypertension, dyslipidemia, excess weight, tobacco, etc.
- Prevent the occurrence of head trauma.
There are also factors on which it is not really possible to act, such as air pollution or heredity in the case of early forms of Alzheimer’s disease (rare).
Treatment of cognitive disorders: what medications are available?
There is no drug capable of curing patients suffering from Alzheimer’s disease or Lewy body disease, but certain molecules can slow the progression of these diseases or improve certain behavioral disorders.
Alzheimer’s disease
“Although they are no longer reimbursed, anticholinesterase drugs can still be prescribed in the treatment of Alzheimer’s disease. Among the other molecules available, memantine is indicated in the advanced stages of this disease. The objective of these molecules is to facilitate neuronal functioning, but they do not act on the causes of the disease.”, explains Dr. Roche.
In the United States, anti-amyloid treatment is commercially available, but this is not the case in Europe. Others are under development. “These are treatments recommended for early forms and mild stages of Alzheimer’s disease. This treatment is effective and results in a 25% reduction in cognitive decline. But like any treatment, it is necessary to evaluate the benefit-risk, in particular with known side effects which can occur in around 10% of cases (edema and/or cerebral micro-hemorrhages (ARIA)). explains the psychiatrist. These treatments require very regular clinical and paraclinical monitoring (control brain MRI).
Lewy body disease
Anticholinesterase drugs may also be of benefit in patients with Lewy body disease, particularly to reduce visual hallucinations.
Frontotemporal lobar neurocognitive diseases and neurocognitive disorders of vascular origin
There are currently no marketed medications for the treatment of the cause of frontotemporal lobar disease.
For vascular disorders, the treatment is that of the cause with management of the patient’s cardiovascular risk factors.
Non-drug treatment of neurocognitive disorders
The management of these disorders is not just medication.
“Speech therapy can be useful for working on language and memory mechanisms. And it is also essential for these patients to stimulate their brain regularly by varying their activities but also by maintaining a social life.”, recalls Dr Roche. Housing adaptations can also be made with the help of occupational therapists.
Cognitive stimulation also involves maintaining physical activity but also why not practicing music therapy, art therapy or even animal therapy…
Dr Roche also emphasizes the importance of intervening in the training of family and professional caregivers so that they are better equipped to face everyday difficulties and can support patients in the best conditions.
Thanks to Dr Jean Roche Psychiatrist – Geriatrician (Lille University Hospital)