A review of currently available treatments suggests a number
of areas for further study. Several of these are in the realm of
evaluation and assessment. Better detection and evaluation of dementia,
especially in the prodromal and early stages, will be particularly
important if treatments are developed that slow progression. Identification
of specific biomarkers and refinements in imaging techniques may
facilitate diagnosis and treatment planning as well as provide insight into
categorization of dementia syndromes (13, 14).
Earlier and more accurate detection of noncognitive symptoms may
facilitate optimal intervention.
More accurate assessments of potentially dangerous behaviors
such as driving are needed (54, 61). The
development of more clinically meaningful outcome measures and more
refined neuropsychological tests, the development of functional
assessments, and wider use of "hard" endpoints,
such as institutionalization and mortality, would allow for more
confidence in making treatment recommendations.
In the realm of pharmacological treatments, there is a critical
need for medications with greater ability to improve cognition or
halt the progression of dementia (547). Among the leads
being actively studied are agents that prevent plaque deposition,
inhibit beta and gamma secretase, remove plaque and insoluble amyloid
fragments, and prevent the formation of and remove neurofibrillary
tangles (tau deposition); other approaches currently being studied
include neuroprotective strategies, neurotropic approaches such
as use of nerve cell growth factors and cell transplants, and use of
antioxidants (548, 549). In addition,
medications that directly enhance cognition by activating intact
cognitive systems might improve performance and function. As the
understanding of other dementing disorders advances, targeted therapies
must be developed and tested for these illnesses as well. Efforts
to prevent stroke and to decrease its destructive effect on brain
tissue are particularly important avenues for dementia prevention
(550, 551).
Another arena is the optimal pharmacological treatment of
behavioral and neuropsychiatric symptoms, including psychosis, agitation,
depression, and sleep disturbance (225, 552).
Many current recommendations are extrapolated from small uncontrolled
studies of agents no longer in common use and/or at doses
well above those used in current practice. There is a critical need
for well-designed, randomized, controlled trials of potential treatments
for these neuropsychiatric symptoms.
Further research into psychosocial, psychotherapeutic, and
behavioral interventions is also needed (116). Randomized
controlled trials or alternative methods that apply randomized controlled
trial methods to the study of behavioral interventions are of particular
importance. One aspect of dementia care that deserves further study
is the rehabilitation model, which focuses on identifying and maximizing
remaining abilities as a way to maximize function. Further research
into this and other strategies may help to identify specific aspects
of these therapies that benefit persons with dementia. Similarly,
research is needed to better characterize the aspects of nursing
homes and other environments most likely to improve patient outcomes.
Research is needed on models of care delivery for patients with
dementia and their family (4). There is also a need
to study how changes in payment for health services affect the care
of individuals with dementia.
Research is also needed to identify which patients will benefit
from alternative living environments and supplemental caregiving
and to support the development of treatment sites that are more
comfortable, less costly, and equally safe and effective for the
care of individuals with moderate to severe dementia (553).
Further studies of caregivers should identify the most effective
interventions for relieving burden and identifying those caregivers
at highest risk for developing adverse outcomes (554).