REVIEW URRENT C OPINION

Dementia in intellectual disability Rory Sheehan a,b, Afia Ali a, and Angela Hassiotis a,b

Purpose of review Dementia is emerging as a significant condition in the population with intellectual disability. This review is aimed at clinicians working in the field. We revisit what is known on the subject and expand on this with results from recent research. The emphasis of this review is on the clinical research rather than laboratory or molecular research. Recent findings Research has encompassed all aspects of dementia in intellectual disability, from epidemiology, assessment and diagnosis, through to management. There remains a lack of evidence concerning both pharmacological and nonpharmacological treatment of dementia in people with intellectual disability. Recent research has tended to focus on dementia in Down syndrome. Summary More research is necessary in order to translate improvements in the understanding of the neuropathology of intellectual disability and dementia into effective treatments. There is also a need to investigate the optimum environment in which to provide holistic care for individuals affected. Keywords assessment, dementia, diagnosis, intellectual disability, treatment

INTRODUCTION Advances in medical care and public health mean that more people with intellectual disability (ID) are living into older age. With this is an attendant increase in the incidence of age-related disorders, including dementia. Dementia is defined as a progressive loss of cognitive ability and functional decline. It is associated with significant morbidity and mortality, and imposes considerable costs.

PREVALENCE AND INCIDENCE OF DEMENTIA IN INTELLECTUAL DISABILITY Adults with intellectual disability of all causes, including Down syndrome, are at higher risk of developing dementia than the general population. The relative risk of having a diagnosis of dementia is between four to five times higher in people with intellectual disability compared with an agematched and sex-matched non-ID comparison group in one Canadian study [1].

Dementia in Down syndrome Down syndrome is often considered separately from other causes of intellectual disability in dementia research due to its strong association with

Alzheimer’s dementia, which tends to present at an earlier age than in the general population [2]. Dementia is the most important cause of morbidity and mortality in this group [3 ]. There has been a remarkable increase in life expectancy amongst people with Down syndrome over the past half century. One recent study found the median life expectancy of people with Down syndrome increased by 1.8 years per year between 1969 and 2003. There was a related increase in the reported rate of dementia, which the authors concluded was due to changes in population structure and better recognition [4 ]. In a 14-year longitudinal study, 77 women over the age of 35 with Down syndrome and moderate-to-severe intellectual disability were screened annually for symptoms of dementia [5 ]. Just under 90% developed the condition. The mean age of diagnosis was 55.4 years, which is comparable &

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Mental Health Sciences Unit, University College London and bCamden Learning Disabilities Service, London, UK Correspondence to Dr Afia Ali, Mental Health Sciences Unit, University College London, 2nd Floor, Charles Bell House, 67-73 Riding House Street, London W1W 7EY, UK. Tel: +44 207 679 9334; e-mail: afia. [email protected] Curr Opin Psychiatry 2014, 27:143–148 DOI:10.1097/YCO.0000000000000032

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ASSESSMENT OF DEMENTIA IN INTELLECTUAL DISABILITY

KEY POINTS  People with intellectual disability have a high risk of developing dementia as they age.  The assessment and diagnosis of dementia in people with intellectual disability is complicated by the preexisting cognitive and functional deficit.  Guidelines for best-practice management have been produced.  There is little evidence base to guide treatment in people with intellectual disability and dementia.

Assessment of dementia in people with intellectual disability is complicated by preexisting impairment in cognition and function. Common screening tests (such as the Mini Mental State Examination [12]) assume premorbid functioning within the normal range and are often not informative in this group. Several instruments to aid diagnosis have been developed. A review identified 114 different instruments, including 79 direct assessment tools and 35 informant-based instruments [13 ]. The authors conclude that the plethora of available tests has made achieving a consensus a difficult task. An attempt to address this has been made by the National Task Group in Intellectual Disabilities and Dementia Practices (NTG) in North America. The group has devised an early detection instrument for dementia in the form of a questionnaire, suitable for use by carers: ‘the NTG-early detection screen for dementia’ (NTG-EDSD) [14]. The tool was adapted from several sources and it can be used both as a prospective screening test during annual health checks and where concerns around possible dementia have been raised. Although there is no ’gold standard’ diagnostic tool, the consistent use of at least one standardized instrument during assessment and follow-up is recommended for the purposes of providing a baseline marker against which further decline can be measured [15 ]. National Institute for Health and Care Excellence (NICE) suggests the Dementia Questionnaire for Mentally Retarded Persons (DMR) [16] or Dalton’s Brief Praxis Test (BPT) as suitable for this purpose [17,18]. &

 Research in genetics and neuropathology is yielding new targets for therapeutic interventions, which can modify the course of the disease.

with previous studies on the topic [6]. A 45-year longitudinal study of a mixed-sex group of 30 people with Down’s syndrome found that at the age of 45, 22% (n ¼ 8) were confirmed as or suspected of suffering cognitive deterioration [7 ]. The neuropathology underlying the association of Down syndrome with dementia is not clear, although triplication of genes on chromosome 21, including the amyloid precursor protein (APP) gene, has been implicated [8]. &

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Dementia in intellectual disability, excluding Down syndrome Less is known about the epidemiology of dementia in people with intellectual disability excluding Down syndrome. Previous studies have shown both increased and similar rates compared with the general population [9,10]. Strydom et al. [11 ] followed a cohort of 222 people with intellectual disability (not due to Down syndrome) for an average of 2.9 years. The incidence of dementia in this group was found to be up to five times higher than in the general population. The authors cite the ‘brain reserve hypothesis’ as a possible explanation for this, proposing that people with preexisting cognitive compromise are less resilient to developing symptoms when age-related neuropathological damage occurs. The importance of environmental factors (including cognitive stimulation) in mitigating the effect of progressive physical deterioration of the brain is also highlighted. Given the increased incidence of dementia in people with intellectual disability (both due to Down syndrome and not due to Down syndrome), it may be useful to screen this high-risk population [11 ]. &&

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PRESENTATION OF DEMENTIA IN INTELLECTUAL DISABILITY AND DIFFERENTIAL DIAGNOSIS Dementia often presents differently in adults with intellectual disability and varies depending on the nature and severity of intellectual disability. In Down syndrome, changes reflective of frontal lobe dysfunction (personality, emotion and behaviour changes) are often noted before changes in language ability or memory. In non-Down syndrome intellectual disability, the most common early sign of dementia reported by caregivers is general deterioration, followed by emotional and behavioural change [9]. Premature onset of other medical comorbidities could also affect cognitive function. One study of 198 case records of people with intellectual disability presenting with a decline in cognition and behaviour found that 40% had another primary medical cause, and the Volume 27  Number 2  March 2014

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majority had comorbid medical conditions such as constipation [19]. Higher rates of depression are found amongst older adults with Down syndrome, although one study found no difference in rates between those with and without comorbid dementia [5 ]. People with Down syndrome are more likely to develop visual and hearing impairments, adultonset seizures, and thyroid dysfunction with increasing age. The prevalence of such physical conditions, as well as dementia, increases sharply after 40 years of age [20 ]. It is important that thorough assessment and appropriate treatment of these (often modifiable) conditions is not overlooked. In addition to physical comorbidities, life events (such as bereavement) or changes in an individual’s circumstances (change in residence or staff members) could result in a decline in behaviour and cognition that is incorrectly attributed to dementia [21]. &

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DIAGNOSIS OF DEMENTIA IN INTELLECTUAL DISABILITY One of the difficulties for researchers has been determining the validity of standardized criteria for dementia when applied to people with intellectual disability. Neither the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) [22] nor the International Classification of Diseases, 10th revision (ICD-10) [23] criteria for dementia explicitly reference the disease in people with intellectual disability. Evidence suggests that the prevalence of dementia differs depending on which diagnostic criteria are employed [9]. Some researchers have advocated the use of ICD-10 as it emphasizes ‘noncognitive’ aspects of dementia, such as emotional lability, irritability and apathy [24]. In a study reviewing the diagnosis of dementia in 64 individuals with Down syndrome, strict adherence to the DSM-IV-TR and ICD-10 criteria were found to exclude some people who had received a clinical diagnosis of dementia. Further research is needed to discern how standardized systems should be adapted for people with intellectual disability [25 ]. Despite these problems, a recent study concluded that dementia diagnostic criteria in ICD-10 and DSM-IV showed substantial reliability and satisfactory validity in people with intellectual disability, although the diagnoses were less stable than in the general population [26 ]. Specific diagnostic criteria developed or adapted for people with intellectual disability have been produced, including the Diagnostic Criteria for Psychiatric Disorders For Use With Adults With &

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Learning Disabilities/Mental Retardation (DC-LD) [27] and the Diagnostic Manual-Intellectual Disability (DM-ID) [28]. One small study highlighted that when DC-LD criteria were applied, fewer patients received a diagnosis of dementia, compared with the use of clinical judgement alone [29 ]. However, the patients were not followed up. The concept of mild cognitive impairment (MCI) has gained currency in the general population as a ‘preclinical’ stage of dementia in which the cognitive and functional losses are greater than would be expected as part of normal ageing, but are not sufficient to warrant formal diagnosis. The validity of this term has been questioned, even within the normal population, and there are practical difficulties of applying it to people with intellectual disability [30]. &

NEUROIMAGING FOR DEMENTIA IN PEOPLE WITH LEARNING DISABILITIES With greater demands placed on healthcare services, routine brain scanning for people being investigated for dementia has come under increasing scrutiny. One review concluded that the use of neuroimaging in dementia in people with intellectual disability should be used with caution as imaging is likely to be abnormal in this group, making accurate interpretation of results difficult [31]. A study comparing the results of MRI scans in people with Alzheimer’s dementia with and without Down syndrome found that both groups had significant reductions in the volume of the whole brain, the hippocampus and the temporal lobes and a significant increase in volume of the lateral ventricle. However, the degree of volume loss was proportionately greater in the group without Down syndrome [32]. Neuroimaging results for people with Down syndrome may produce ‘false positives’ for Alzheimer’s disease from an early age if the standards derived from the general population are used [33].

IMPACT OF DEMENTIA IN PEOPLE WITH INTELLECTUAL DISABILITY Two recent studies have shown dementia to be associated with poor physical health outcomes. In one cross-sectional study of people with intellectual disability living in the Netherlands, those with a diagnosis of dementia were found to be more physically frail [34 ]. The authors postulate that this may indicate a greater propensity to future negative health outcomes. Using population-based registers, dementia was found to be a contributing cause

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of death in 30% of older people with Down syndrome [4 ]. &

One recent study investigated the use of memantine in people with dementia and Down’s syndrome [44 ]. In this prospective doubleblind randomized controlled trial, memantine was compared against placebo. Cognitive performance and function after 1 year of therapy were the primary outcome measures. There were no differences in the outcomes between the control and treatment groups and the authors concluded that memantine is not an effective drug in people with Down syndrome and dementia. Despite this result, the trial was heralded a success as it demonstrated that large clinical trials are possible in people with intellectual disability [45]. A pilot case–control study comparing rivastigmine with no drug treatment for Alzheimer’s dementia in Down syndrome found that the groups treated with rivastigmine showed borderlinesignificant (P ¼ 0.048) less decline over the 6-month period in cognitive and global function and significantly less decline in noncognitive and behavioural problems [46 ]. However, this study was small in size (n ¼ 40) and measured outcomes at only 6 months. There was no difference between oral and transdermal rivastigmine, but the patches were found to have better compliance and fewer side-effects than the oral formulation. Conversely, there have been several trials exploring the use of antidementia drugs in young people with Down syndrome without dementia in the hope that they will improve cognition [43,47]. These, again, have largely failed to demonstrate improvements in cognitive performance and functioning. Nevertheless, this may be a more successful strategy in the longer term, as intervening before cognitive impairment has become observable could potentially reduce the propensity to early dementia in this group [48]. &&

DELIVERY OF CARE Delivery of care for adults with dementia and intellectual disability is challenging, on both individual and organizational levels. A lack of research in all aspects of dementia caregiving is the main finding of a systematic literature review [35]. The authors call for an international research agenda to address this gap in knowledge. Guidelines for structuring dementia care for people with intellectual disability have been published by the National Task Group on Intellectual Disabilities and Dementia Practices [36 ]. Suggestions for best practice are divided by stage of dementia (early, mid, and late/end-stage) and into recommended actions, symptoms, care focus, environmental modifications, training (carers) and outcomes. The focus is on holistic, person-centred care and strategic planning to support home and community living for as long as possible. This is consistent with other imperatives for ‘ageing in place’ as a means of maintaining quality of life and delaying institutionalization of people with dementia [37]. Components of good quality care for people with dementia and intellectual disability living in group homes have been investigated [38]. Deficits in staff knowledge of dementia processes and limited management strategies were reported by staff supporting people with Down syndrome and Alzheimer’s disease in group homes [39 ]. &&

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PHARMACOLOGICAL TREATMENT OF DEMENTIA IN PEOPLE WITH INTELLECTUAL DISABILITY Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) and N-methyl-D-aspartate receptor antagonists (memantine) are currently approved for use in dementia by NICE in the UK and the Food and Drug Administration (FDA) in the United States. However, there have been few clinical trials assessing the potential benefits of these agents in people with intellectual disability and dementia [40–42]. It may be insufficient to simply extrapolate generic study data and apply it to those with intellectual disability. Most of the trials that have been conducted have studied dementia in Down syndrome only and the results have generally shown no benefit to treatment [43]. Current practice is therefore variable and use of medication in this group remains controversial. 146

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NON-PHARMACOLOGICAL TREATMENT OF DEMENTIA IN PEOPLE WITH INTELLECTUAL DISABILITY There is a paucity of research that has addressed the applicability of nonpharmacological interventions such as cognitive training, cognitive stimulation, aromatherapy, music therapy, and physical exercise programmes in people with dementia and intellectual disability. One small study compared a dementiaspecific residential unit utilizing a multicomponent intervention (based on a person-centred approach and optimization of environmental factors) with two control groups (day centre and nursing home). The intervention group showed some improvement in cognition and stabilization of functioning and Volume 27  Number 2  March 2014

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behaviour compared with the control group after 3 years [49]. The multicomponent nature of the intervention makes the results difficult to interpret, but the results are promising. The emerging interest in the role of reminiscence therapy to improve behavioural and cognitive symptoms in people with intellectual disability has been reviewed [50]. Although the therapy has not yet been fully evaluated in people with intellectual disability and dementia, initial studies indicate that it is acceptable to participants and staff.

FUTURE RESEARCH There are a number of promising areas of research, which may have clinical benefit in the future. These are highlighted below.

Biomarkers A sample of 346 adults with Down syndrome were followed up for 10 years with annual blood tests. Controlling for other factors, the investigators found a significant increase in the mean corpuscular volume in those diagnosed with dementia and postulate that this measure could potentially be used as a biomarker for Alzheimer’s dementia in Down syndrome [51 ]. &

Mouse models Transgenic mice have been developed with genetic defects that approximate several human genetic conditions. The success of such models in aiding understanding of the cellular and molecular mechanisms responsible for abnormal phenotypes, including neurodegeneration in Down syndrome, has already been significant (for a review see [52]). Extended use of mouse models of intellectual disability promises further insights into the neuropathology of dementia in intellectual disability and will help to identify new targets for intervention.

CONCLUSION As the population of people with intellectual disability ages, dementia is emerging as a common clinical condition. Practitioners need to be aware of the features of the illness unique to people with intellectual disability, the complexities inherent in assessment and diagnosis, and principles of best-practice management. Further investigation is needed to develop effective pharmacological and nonpharmacological interventions. This is an exciting time, as advances in knowledge of neurophysiology and pathology are yielding new targets for treatment. Future agents should aim to

maximize ability in younger life, and prevent the development of dementia in later life. In the future, validated biomarkers may help with risk-stratification, early diagnosis and instituting treatment at the most effective time. Acknowledgements None. Conflicts of interest There are no conflicts of interest.

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Neurodevelopmental and neurocognitive disorders 14. Esralew L. NTG screening instrument. http://www.aadmd.org/ntg/screening. [Accessed 27 October 2013] 15. Moran JA, Rafii MS, Keller SM, et al. The National Task Group on Intellectual & Disabilities and Dementia Practices consensus recommendations for the evaluation and management of dementia in adults with intellectual disabilities. Mayo Clin Proc 2013; 88:831–840. This article provides up-to-date recommendations for clinicians in assessing and managing dementia in people with intellectual disabilities. 16. Evenhuis HM, Kengen MMF, Eurlings HAL. Dementia questionnaire for persons with mental retardation (DMR). Zwammerdam, The Netherlands: Hooge Burch; 1990. 17. Dalton AJ, Fedor BL. Onset of dyspraxia in aging persons with Down syndrome: longitudinal studies. J Intellect Dev Disabil 1998; 23:13–24. 18. National Institute for Health and Care Excellence. Dementia: supporting people with dementia and their carers in health and social care GC42. London: National Institute for Health and Care Excellence; 2006. 19. Charlot L, Abend S, Ravin K, et al. Nonpsychiatric health problems among psychiatric inpatients with intellectual disabilities. J Intellect Disabil Res 2011; 55:199–209. 20. Glasson EJ, Dye DE, Bittles AH. The triple challenges associated with age& related comorbidities in Down syndrome. J Intellect Disabil Res 2013. [Epub ahead of print] This article highlights the high prevalence of medical comorbidities that people with Down syndrome develop as they age. 21. Janicki MP, Heller T, Seltzer GB, Hogg J. Practice guidelines for the clinical assessment and care management of Alzheimer’s disease and other dementias among adults with intellectual disability. J Intellect Disabil Res 1996; 40:374–382. 22. American Psychiatric Association. Diagnostic and statistical manual of mental disorders DSM-IV-TR. 4th ed. Arlington, VA: American Psychiatric Association; 2000. 23. World Health Organization. The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. 1st ed. Geneva: World Health Organization; 1992. 24. Aylward EH, Burt DB, Thorpe LU, et al. Diagnosis of dementia in individuals with intellectual disability. J Intellect Disabil Res 1997; 41:152–164. 25. Sheehan R, Sinai A, Hassiotis A, et al. Dementia diagnostic criteria in people & with Down’s syndrome. Paper presented at: Royal College of Psychiatrists Faculty of Intellectual Disability Annual Meeting 2012. 27–28 September; Manchester, UK. This work demonstrates that clinician’s judgement outperforms DSM-IV or ICD-10 criteria in diagnosing dementia in people with Down syndrome at an early time point, which is not at the expense of including false positive diagnoses. 26. Strydom A, Chan T, Fenton C, et al. Validity of criteria for dementia in older & people with intellectual disability. Am J Geriatr Psychiatry 2013; 21:279– 288. This study found that DSM-IV and ICD-10 criteria showed substantial reliability and satisfactory validity when applied to people with intellectual disabilities, but the diagnoses were less stable than in the general population. 27. Royal College of Psychiatrists. DC-LD (Diagnostic criteria for psychiatric disorders for use with adults with learning disabilities /mental retardation). London: Gaskell Press; 2001. 28. Fletcher R, Loschen E, Stavrakaki C, First M. Diagnostic manual: intellectual disability (DM-ID) – a textbook of diagnosis of mental disorders in persons with intellectual disability. Kingston, NY: NADD Press; 2007. 29. Tully J, Schirliu D, Moran M. Application of DC-LD to an intellectual disability & population. Adv Mental Health Intellect Disab 2012; 6:259–264. This study found discrepancy between the rates of diagnosed mental illness, including dementia, before and after application of criteria from the DC-LD. 30. Krinsky-McHale SJ, Silverman W. Dementia and mild cognitive impairment in adults with intellectual disability: issues of diagnosis. Dev Disabil Res Rev 2013; 18:31–42. 31. Sullivan V, Majumdar B, Richman A, Vinjamuri S. To scan or not to scan: neuroimaging in mild cognitive impairment and dementia. Adv Psychiatr Treat 2012; 18:457–466. 32. Mullins D, Daly E, Simmons A, et al. Dementia in Down’s syndrome: an MRI comparison with Alzheimer’s disease in the general population. J Neurodev Disord 2013; 5:19–31. 33. Vicari S, Pontillo M, Armando M. Neurodevelopmental and psychiatric issues in Down’s syndrome: assessment and intervention. Psychiatr Genet 2013; 23:95–107.

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34. Evenhuis HM, Hermans H, Hilgenkamp TIM, et al. Frailty and disability in older adults with intellectual disabilities: results from the healthy ageing and intellectual disability study. J Am Geriatr Soc 2012; 60:934–939. This cross-sectional study found the onset of physical frailty to be at a younger age in people with intellectual disability and to be associated with a diagnosis of dementia. 35. Courtenay K, Jokinen NS, Strydom A. Caregiving and adults with intellectual disabilities affected by dementia. J Policy Pract Intellect Disabil 2010; 7:26–33. 36. Jokinen N, Janicki MP, Keller SM, et al. Guidelines for structuring && community care and supports for people with intellectual disabilities affected by dementia. J Policy Pract Intellect Disabil 2013; 10:1–24. This document provides a comprehensive guide to the management of people with intellectual disabilities who are affected by dementia at all stages. Recommendations are given for delivering individual care and structuring service provision at a population level. Key themes are incorporating person-centred principles and maintenance of community living. 37. Runge C, Gilham J, Peut A. Transitions in care for people with dementia: a systematic review of the literature [online]. Cat no AIHW 11074 Australian Institute of Health and Welfare, Canberra 2009; http://www.aihw.gov.au/ publication-detail/?id=6442468216. [Accessed 3 December 2013] 38. Janicki MP. Quality outcomes in group home dementia care for adults with intellectual disabilities. J Intellect Disabil Res 2011; 55:763–776. 39. Iacono T, Bigby C, Carling-Jenkins R, Torr J. Taking each day as it comes: staff & experiences of supporting people with Down syndrome and Alzheimer’s disease in group homes. J Intellect Disabil Res 2013. [Epub ahead of print] This qualitative study found care staff to be unprepared and under-resourced to confidently manage residents with Down syndrome who developed dementia. 40. Mohan M, Carpenter PK, Bennett C. Donepezil for dementia in people with Down syndrome. Cochrane Database Syst Rev 2009; 1:CD007178. 41. Mohan M, Bennett C, Carpenter PK. Rivastigmine for dementia in people with Down syndrome. Cochrane Database Syst Rev 2009; 1:CD0076598. 42. Mohan M, Bennett C, Carpenter PK. Galantamine for dementia in people with Down syndrome. Cochrane Database Syst Rev 2009; 1:CD007656. 43. de la Torre R, Dierssen M. Therapeutic approaches in the improvement of cognitive performance in Down syndrome: past, present, and future. Prog Brain Res 2012; 197:1–14. 44. Hanney M, Prasher V, Williams N, et al. Memantine for dementia in adults && older than 40 years with Down’s syndrome (MEADOWS): a randomised, double-blind, placebo-controlled trial. Lancet 2012; 379:528–536. This high-impact study found no improvement in cognition or adaptive function in people with Down syndrome and dementia who were treated with memantine. However, it demonstrated that high-quality trials are feasible in this population, a group often excluded from trials. 45. Strydom A, Livingston G. Improving Alzheimer’s disease outcomes in Down’s syndrome. Lancet 2012; 379:498–500. 46. Prasher VP, Sachdeva N, Adams C, Haque MS. Rivastigmine transdermal & patches in the treatment of dementia in Alzheimer’s disease in adults with Down syndrome: pilot study. Int J Geriatr Psychiatry 2013; 28:219– 220. This pilot study showed that rivastigmine might be effective in reducing the rate of cognitive and global decline in people with Down syndrome and Alzheimer’s disease. 47. Costa AC, Scott-McKean JJ. Prospects for improving brain function in individuals with Down syndrome. CNS Drugs 2013; 27:679–702. 48. Costa AC. Treatment of Alzheimer disease in Down syndrome. Nat Rev Neurol 2012; 8:182–184. 49. De Vreese LP, Mantesso U, De Bastiani E, et al. J Policy Pract Intellect Disabil. 2012; 9:92–102. 50. Stueber K, Hassiotis A. Reminiscence therapy for older service users. Learn Disab Prac 2012; 15:12–16. 51. Prasher V, Uppal H, Parveen S, Adams C. Ten year serial mean corpuscular & volume – a peripheral marker for Alzheimer’s disease in Down syndrome. Poster presented at: Royal College of Psychiatrists Faculty of Intellectual Disability Annual Meeting 2013, 26–27 September; Glasgow, UK. This study showed a statistically significant difference in mean corpuscular volume in people with Down syndrome who did and did not have a diagnosis of Alzheimer’s disease, which persisted even after controlling for possible confounders. 52. Ruparelia A, Pearn ML, Mobley WC. Aging and intellectual disability: insights from mouse models of Down syndrome. Dev Disabil Res Rev 2013; 18: 43–50. &

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Dementia in intellectual disability.

Dementia is emerging as a significant condition in the population with intellectual disability. This review is aimed at clinicians working in the fiel...
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