IJGG Journal

Introduction

Cognitive dysfunction is an increasingly prevalent issue among geriatric populations, due to the aging global population and the rise in age-related neurodegenerative diseases, like Alzheimer’s disease and other forms of dementia [1,2]. Cognitive dysfunction encompasses a broad range of conditions, from mild cognitive impairment (MCI) to more severe forms of dementia, that can negatively impact older adults’ independence, daily functioning, and quality of life [3,4]. The management of cognitive dysfunction in the elderly is complex, as it often involves multiple healthcare professionals, care settings, and interventional approaches. A multidisciplinary approach is essential for effectively managing cognitive dysfunction in geriatric populations [5]. This approach combines pharmacological and non-pharmacological interventions tailored to individual needs, and focuses on optimizing cognitive function, promoting independence, and improving the overall quality of life for older adults with cognitive dysfunction [6,7]. Such an approach requires close collaboration among healthcare professionals, patients, and caregivers to ensure comprehensive assessment, individualized care planning, and continuous monitoring of patient progress [8].

This narrative review aims to provide an overview of the multidisciplinary approach to managing cognitive dysfunction in geriatric populations, discussing the roles of various healthcare professionals, pharmacological and non-pharmacological interventions, and the importance of individualized care. The review will also highlight areas for future research to improve our understanding and management of cognitive dysfunction in older adults.

Cognitive dysfunction in geriatric populations has significant implications for both individuals and society. The World Health Organization (WHO) estimates that the prevalence of people with dementia worldwide will triple by 2050, reaching 152 million [1]. In addition to the personal and emotional toll of cognitive dysfunction, the economic burden is substantial, with global costs projected to exceed $2 trillion by 2030 [9].

Materials and Methods

This narrative review aims to provide an overview of the multidisciplinary approach to managing cognitive dysfunction in geriatric populations, focusing on pharmacological, nonpharmacological, and emerging therapies. The methodology for this review is as follows:

Literature search

 A comprehensive search of electronic databases, including PubMed, MEDLINE, and the Cochrane Library, was conducted to identify relevant articles published up to March 2023. The search was performed using a combination of keywords and MeSH terms, such as “cognitive dysfunction,” “geriatrics,” “Alzheimer’s disease,” “dementia,” “mild cognitive impairment,” “pharmacological interventions,” “non-pharmacological interventions,” “multidisciplinary approach,” “emerging therapies,” “cognitive stimulation,” “physical activity,” “nutrition,” “social support,” “brain stimulation,” and “disease-modifying therapies.”

Inclusion and exclusion criteria

Only those articles were included that focused on pharmacological or non-pharmacological interventions for cognitive dysfunction in geriatric populations or discussed emerging therapies in this field. Articles were excluded if they were not in English, had a primary focus on non-geriatric populations, or did not provide relevant information on the management of cognitive dysfunction.

Study selection

Initially, titles and abstracts of the identified articles were screened for relevance. Full-text articles were then assessed for eligibility based on the inclusion and exclusion criteria. The reference lists of the articles included were combed for additional pertinent studies.

Data extraction and synthesis

Data from the included studies were extracted and synthesized to provide an overview of the multidisciplinary approach to managing cognitive dysfunction in geriatric populations. The extracted information included the type of intervention, study population, main outcomes, and key findings. The results were organized into sections covering pharmacological interventions, non-pharmacological interventions, and emerging therapies.

Quality assessment

The methodological quality of the included studies was evaluated using relevant appraisal tools, such as the Cochrane risk of bias tool for randomized controlled trials and the NewcastleOttawa Scale for observational studies. The overall strength of the evidence was considered when discussing the findings and drawing conclusions.

Pharmacological management

The management of cognitive dysfunction in the elderly often involves pharmacological interventions, such as cholinesterase inhibitors (e.g., donepezil, rivastigmine, and galantamine) and memantine, which have shown modest benefits in slowing cognitive decline and improving daily functioning in Alzheimer’s disease [6,7]. Cholinesterase inhibitors work by increasing the levels of acetylcholine that is a neurotransmitter involved in memory and learning, in the brain [10]. Memantine, on the other hand, modulates the activity of glutamate, another neurotransmitter, which plays a role in learning and memory [11].

However, the efficacy of these medications varies among individuals, and they may not be effective for all types of dementia or cognitive impairment [8]. For instance, cholinesterase inhibitors have been shown to provide limited benefits for patients with vascular dementia and mixed dementia, and their effectiveness in treating MCI is still a topic of ongoing research [12,13]. Furthermore, pharmacological interventions may have side effects, such as gastrointestinal symptoms, dizziness, and headache, which can affect patients’ adherence to treatment and overall quality of life [14].

Therefore, it is essential to consider individualized treatment plans and monitor the patient’s response to therapy [9]. This may involve regular assessments of cognitive function, daily functioning, and potential side effects, as well as communication among healthcare providers, patients, and caregivers to ensure the appropriate use of medications and adjust treatment plans as needed [8].

In addition to cholinesterase inhibitors and memantine, other pharmacological approaches have been investigated for the management of cognitive dysfunction in geriatric populations. For example, antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs), have been used to manage depression and anxiety in older adults with cognitive dysfunction, as these comorbid conditions can exacerbate cognitive decline [15]. Antipsychotic medications, such as risperidone and olanzapine, may be prescribed to manage behavioral and psychological symptoms of dementia (BPSD), including agitation, aggression, and psychosis; however, their use should be closely monitored due to potential side effects and increased risk of adverse events in older adults [16,17].

Furthermore, medications targeting vascular risk factors, such as hypertension, hyperlipidemia, and diabetes, may indirectly contribute to the management of cognitive dysfunction by reducing the risk of cerebrovascular events and promoting brain health [18]. As such, a comprehensive pharmacological approach that addresses both cognitive symptoms and comorbid conditions is crucial for optimizing the management of cognitive dysfunction in geriatric populations.

In summary, pharmacological interventions play an essential role in managing cognitive dysfunction in older adults; however, their effectiveness varies among individuals and may be limited in certain types of dementia or cognitive impairment. It is crucial to adopt individualized treatment plans, monitor the patient’s response to therapy, and consider the potential benefits and risks of medications. Integrating pharmacological interventions with nonpharmacological approaches and emerging therapies may further enhance the effectiveness of treatment and improve the standard of life for the elderly with cognitive dysfunction.

Non-pharmacological Interventions

Non-pharmacological interventions play a significant role in the management of cognitive dysfunction in geriatric populations. These interventions are often used in conjunction with pharmacological treatments to optimize cognitive function, enhance daily functioning, and improve the overall quality of life for older adults with cognitive dysfunction.

Cognitive stimulation and training

Cognitive stimulation and training involve engaging older adults in mentally stimulating activities to enhance cognitive function [19]. These activities can range from simple memory exercises to complex problem-solving tasks. Several studies have demonstrated the effectiveness of cognitive stimulation and training in improving cognitive function and delaying cognitive decline in older adults with MCI and dementia [20,21]. Additionally, these interventions have been shown to be beneficial for both the individual with cognitive dysfunction and their caregivers, improving their communication and overall quality of life [22].

Physical activity

Regular physical activity has been shown to have numerous benefits for older adults with cognitive dysfunction, including improved cognitive function, reduced risk of cognitive decline, and enhanced physical and mental well-being [23,24]. Physical activity programs tailored to the individual’s abilities, preferences, and health conditions have been recommended as part of a comprehensive approach to managing cognitive dysfunction in geriatric populations [25].

Nutrition and dietary interventions

A healthy diet has been associated with better cognitive function and reduced risk of cognitive decline in older adults [26]. Some evidence suggests that certain dietary patterns, such as the Mediterranean diet, which is rich in fruits, vegetables, whole grains, and healthy fats, may have protective effects against cognitive decline and dementia [27,28]. Nutritional interventions targeting specific nutrient deficiencies, such as vitamin B12 or omega-3 fatty acids, may also be beneficial for older adults with cognitive dysfunction [29].

Social support and environmental modifications

Providing adequate social support and making appropriate environmental modifications can help older adults with cognitive dysfunction maintain their independence and daily functioning [30]. Interventions such as support groups, respite care, and adult day care programs can provide emotional and practical support for individuals with cognitive dysfunction and their caregivers [31]. Environmental modifications, such as simplifying daily tasks, improving home safety, and using memory aids, can help older adults with cognitive dysfunction navigate their environment more effectively [32].

Multicomponent interventions

Some studies have explored the benefits of combining multiple non-pharmacological interventions, such as cognitive stimulation, physical activity, and nutritional counseling, to create a comprehensive and individualized care plan for older adults with cognitive dysfunction [33,34]. These multicomponent interventions have been shown to improve cognitive function, daily functioning, and quality of life in older adults with MCI and dementia [35].

Emerging Therapies

In addition to well-established pharmacological and non-pharmacological interventions, researchers are actively exploring novel therapies for managing cognitive dysfunction in geriatric populations. These emerging therapies aim to address the underlying causes of cognitive decline, provide symptomatic relief, and improve the overall quality of life for older adults with cognitive dysfunction.

One such emerging therapy is the use of non-invasive brain stimulation techniques, such as Transcranial Magnetic Stimulation (TMS) and transcranial Direct Current Stimulation (tDCS). These methods have shown promise in improving cognitive function and reducing symptoms of depression in older adults with mild cognitive impairment and dementia [36,37]. However, further research is needed to establish their long-term efficacy and safety profile.

The invention of disease-modifying therapies is a further promising field of research targeting the pathological processes underlying cognitive dysfunction, such as amyloid-beta accumulation and neuroinflammation. Several investigational drugs, including anti-amyloid monoclonal antibodies and small molecules targeting tau protein, are currently in clinical trials for the treatment of Alzheimer’s disease and other dementias [38,39]. Although some of these therapies have shown preliminary success in slowing cognitive decline additional research is required to corroborate their efficacy and safety.

Conclusion

The management of cognitive dysfunction disorders in geriatric populations requires a multidisciplinary approach that includes pharmacological and non-pharmacological interventions. While pharmacological management an improve cognitive function and delay disease progression, it has limited efficacy and can have side effects. Non-pharmacological management, including cognitive stimulation therapy, physical activity, and social engagement, can improve cognitive function and maintain quality of life. Occupational therapy and speech therapy can address functional impairments and communication difficulties associated with cognitive dysfunction disorders. Caregiver education and support are also important components of the management of cognitive dysfunction disorders. Emerging therapies, such as immunotherapy, gene therapy, and stem cell therapy, hold promise for disease modification and prevention. However, these therapies are still in early stages of development and require further research and clinical trials to determine their safety and efficacy.

Overall, a personalized approach that considers the unique needs and preferences of each individual is necessary for the effective management of cognitive dysfunction disorders in geriatric populations. Collaborative care models that involve patients, caregivers, and healthcare providers can promote effective disease management and improve patient outcomes. Further research is needed to identify optimal combinations of interventions and to develop personalized care strategies for different types of cognitive dysfunction. Moreover, public health initiatives should focus on promoting awareness of cognitive dysfunction, facilitating early detection and intervention, and fostering supportive environments for older adults with cognitive impairment and their caregivers. By integrating a multidisciplinary approach, healthcare professionals can effectively manage cognitive dysfunction in geriatric populations and help older adults maintain their independence and quality of life.

A multidisciplinary approach that encompasses pharmacological and non-pharmacological interventions tailored to individual needs. Current evidence supports the use of cognitive stimulation and training, physical activity, healthy diet and nutrition, and social support and environmental modifications as effective strategies for improving cognitive functioning and quality of life in older adults with cognitive dysfunction. Interdisciplinary collaboration among healthcare professionals is crucial to ensure comprehensive assessment, individualized care planning, and continuous monitoring of patient progress.

Further research is needed to identify optimal combinations of interventions and to develop personalized care strategies for different types of cognitive dysfunction. Moreover, public health initiatives should focus on promoting awareness of cognitive dysfunction, facilitating early detection and intervention, and fostering supportive environments for older adults with cognitive impairment and their caregivers. By integrating a multidisciplinary approach, healthcare professionals can effectively manage cognitive dysfunction in geriatric populations and help older adults maintain their independence and quality of life.

References

1. World Health Organization. Dementia: a public health priority. Geneva: World Health Organization; 2012.
2. United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2019: Highlights. New York: United Nations; 2019.
3. Petersen RC. (2004) Mild cognitive impairment as a diagnostic entity. J Intern Med 256: 183-194.
4. Prince M, Wimo A, Guerchet M, Gemma-Claire Ali, Wu Y-T, et al. (2015) World Alzheimer Report 2015: The Global Impact of Dementia. London: Alzheimer’s Disease International.
5. Reuben DB, Tinetti ME. (2020) The Geriatric Syndrome Approach to Improving Multimorbidity Care. J Am Geriatr Soc.68:1169-1173.
6. Kales HC, Gitlin LN, Lyketsos CG. (2015) Assessment and management of behavioral and psychological symptoms of dementia. BMJ 350: h369.                                                                                                                            

7. Gitlin LN, Hodgson N. (2015) Caregivers as therapeutic agents in dementia care: the evidence-base for interventions supporting their role. In: Gaugler JE, Kane RL, editors. Family caregiving in the new normal. Philadelphia: Elsevier; 305-353.
8. Borson S, Frank L, Bayley PJ, Boustani M, Dean M, et al. (2013) Improving dementia care: the role of screening and detection of cognitive Alzheimers Dement. 9:151-159
9. Wimo A, Guerchet M, Ali GC, Wu YT, Prina AM, et al. (2017) The worldwide costs of dementia 2015 and comparisons with 2010. Alzheimers Dement. 13:1-7.
10. Birks JS, Harvey RJ. (2018) Donepezil for dementia due to Alzheimer’s disease. Cochrane Database Syst Rev. 6:CD001190.
11. McShane R, Areosa Sastre A, Minakaran N. (2006) Memantine for de Cochrane Database Syst Rev. CD003154.
12. Black S, Román GC, Geldmacher DS, Salloway S, Hecker J, et al. (2003) Efficacy and tolerability of donepezil in vascular dementia: positive results of a 24-week, multicenter, international, randomized, placebo-controlled clinical trial. Stroke.34:2323-30.
13. Petersen RC, Thomas RG, Grundman M, Bennett D, Doody R, et al. (2005) Vitamin E and donepezil for the treatment of mild cognitive im N Engl J Med.352:2379-2388.
14. Maidment ID, Fox CG, Boustani M, Rodriguez J, Brown RC, et al. (2008) Efficacy of memantine on behavioral and psychological symptoms related to dementia: a systematic meta-analysis. Ann Pharma 42:32-8.
15. Mowla A, Mosavinasab M, Haghshenas H, Haghighi AB. (2007) Does serotonin augmentation have any effect on cognition and activities of daily living in Alzheimer’s dementia? A double-blind, placebo-controlled clinical trial. J Clin Psychopharmacol. 27:484-7.
16. Maher AR, Maglione M, Bagley S, Suttorp M, Hu JH, et al. (2011) Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analy JAMA. 306:1359-69.
17. Ballard C, Waite J. (2006) The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev.CD003476.
18. Iadecola C, Gottesman RF. (2019) Neurovascular and cognitive dysfunction in hypertension. Circ Res.124:1025-1044.
19. Woods B, Aguirre E, Spector AE, Orrell M. (2012) Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev.15:CD005562.
20. Gates NJ, Sachdev PS, Fiatarone Singh MA, Valenzuela M. (2011) Cognitive and memory training in adults at risk of dementia: a systematic review. BMC Geriatr. 11:55.
21. Clare L, Woods RT, Moniz-Cook ED, Orrell M, Spector A. (2003) Cognitive rehabilitation and cognitive training for early-stage Alzheimer’s disease and vascular dementia. Cochrane Database Syst Rev. :CD003260.
22. Spector A, Orrell M, Davies S, Woods B. Can reality orientation be rehabilitated? Development and piloting. of an evidence-based programme of cognition-based therapies for people with dementia.Neuropsychological Rehabilitation.11:377-397.
23. Groot C, Hooghiemstra AM, Raijmakers PGHM, Berckel BNM V, Scheltens P, et al. (2016)The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials. Ageing Res Rev. 25:13-23.
24. Erickson KI, Kramer AF. (2900) Aerobic exercise effects on cognitive and neural plasticity in older adults. Br J Sports Med. 43:22-24.
25. Forbes D, Forbes SC, Blake CM Thiessen EJ, Forbes S. (2015) Exercise programs for people with dementia. Cochrane Database Syst CD006489.
26. Scarmeas N, Anastasiou CA, Yannakoulia M. (2018) Nutrition and prevention of cognitive impairment. Lancet Neurol. 17:1006-1015.
27. Sofi F, Valecchi D, Bacci D, Abbate R, Gensini GF, et al. (2011) Physical activity and risk of cognitive decline: a meta-analysis of prospective J Intern Med.269:107-117.
28. Psaltopoulou T, Sergentanis TN, Panagiotakos DB, Sergentanis IN, Kosti R, et al. (2013) Mediterranean diet, stroke, cognitive impairment, and depression: A meta-analysis. Ann Neurol. 74:580-591.
29. Smith AD, Refsum H. (2016) Homocysteine, B Vitamins, and Cognitive Annu Rev Nutr. 36:211-239.
30. Gitlin LN, Hodgson N. (2015) Caregivers as therapeutic agents in dementia care: the evidence-base for interventions supporting their role. In: Gaugler JE, Kane RL, editors. Family caregiving in the new normal. Philadelphia: Elsevier; 305-353.
31. Schulz R, Martire LM. (2004) Family caregiving of persons with dementia: prevalence, health effects, and support strategies. Am J Geriatr Psychiatry. 12:240-249.
32. Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck WW. (2010) A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: the COPE randomized trial. 304:983-91.
33. Olazarán J, Reisberg B, Clare L, Cruz I, Peña-Casanova J, et al. (2010) Nonpharmacological therapies in Alzheimer’s disease: a systematic review of efficacy. Dement Geriatr Cogn Disord. 30:161-178.
34. Karssemeijer EGA, Aaronson JA, Bossers WJ, Smits T, Olde Rikkert M GM et al. (2017) Positive effects of combined cognitive and physical exercise training on cognitive function in older adults with mild cognitive impairment or dementia: A meta-analysis. Ageing Res Rev. 40:75
35. Ngandu T, Lehtisalo J, Solomon A, Levälahti E, Ahtiluoto S, et al. (2015) A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet. 385:2255-63.
36. Cotelli M, Manenti R, Brambilla M, Petesi M, Rosini S, et al. () 2014Anodal tDCS during face-name associations memory training in Alzheimer’s patients. Front Aging Neurosci.6:38.
37. Luber B, Lisanby SH. (2014) Enhancement of human cognitive performance using transcranial magnetic stimulation (TMS). Neuroimage. 85:961-970.
38. Cummings J, Lee G, Ritter A, Sabbagh M, Zhong K. (2020) Alzheimer’s disease drug development pipeline: 2020. Alzheimers Dement (N Y). 6:e12050.
39. Hampel H, Mesulam MM, Cuello AC, Farlow MR, Giacobini E, et al. (2018) The cholinergic system in the pathophysiology and treatment of Alzheimer’s disease. Brain. 14:1917-1933.