Dementia Care Program

Cognitive impairment and dementias are the clinical expression of three large groups of processes that involve a compromise of the cerebral cortex or its connections and includes aging of the brain, brain diseases and systemic diseases that affect the brain. Our clinic has as a universe of work the study and the attention of all the illnesses that induce compromise of the cognitive functions, but it makes particular emphasis in the approach of the dementias of degenerative stock.
For this reason, in the last 10 years, an experience has been accumulated that includes the evaluation of more than 600 patients with dementia of this type, where Alzheimer's disease predominates, dementia associated with parkinsonism, taupathies and other fronto-dementia variables. temporary.
In 1990, there was no alternative for pharmacological or surgical treatment of Alzheimer's disease, which forced the creation and development of a comprehensive dementia care program, which began in 1991 with the creation of a service located in the Basic Area. where more than 100 patients with Alzheimer's disease were admitted and a program of cognitive training and behavioral rehabilitation was developed in more than 40 patients. It was found that this type of multidisciplinary approach benefited patients by increasing their functional capacity, improving some particular processes such as attention and memory and decreasing the intensity of cognitive deficit by up to 30%.
Towards 1993 this hypothesis, supported by Stanley et al, collected evidence when demonstrated in biomodels due to injury of fimbria fornix and excitotoxic lesion of Meyner's basal nucleus in which training by learning techniques promoted in rodents increased synaptic activity in areas cortical and denervated hippocampus.
In 1994, studies were published showing the lower incidence of the disease in people of higher intellectual level or with a higher level of education, experiences that are reproduced later in the same year and in 1995 by Rosemberg et al, who reestablish it as a negative risk factor to develop the disease to university professionals in the exercise of their work for more than 30 years, without differences in sex. A bibliographic review of the state of knowledge on the subject resulted in the acquisition of information that allowed us to speculate that an option to oppose the cognitive deterioration induced by these diseases could be based on the stimulation of the cerebral reserve.
With the advent of new techniques for functional exploration of upper nervous activity, including neurophysiological and psychophysiological studies, positron emission tomography and functional magnetic resonance imaging, it has been demonstrated that the modifications observed in the range of decline of cognitive functions in Alzheimer's patients. when comparing intellectuals with manual workers, a greater preservation of the inhibitory mechanisms of the brain and a greater facilitation for the activation of cortical temporoparietal areas in the former are related. These findings allow us to suppose that prolonged mental training can stimulate neuroplastic mechanisms linked to learning and / or function recovery (plasticity dependent use).
More recent studies in models for chemical lesion of the basal nucleus of Meynert and a transgenic model of Alzheimer, as well as a study of human brains obtained from patients with Alzheimer's disease and healthy subjects have shown that the synaptic loss and the consequent retrograde axonal alteration are the first pathological changes observed in the disease and that occur long before appearing of neuronal population and / or abnormal accumulation of proteins (senile plaques with amyloma deposit, fibrillar rings, Irano bodies, etc).
It has also been shown that this synaptic loss directly correlates with the degree of cognitive impairment of affected subjects with Alzheimer's disease, with which it seems evident that one of the main etiopathogenic events of the genesis of cognitive deterioration associated with age is synaptic loss. , more than the neuronal loss itself.
Two articles have recently been published that show that there are evidences of neuroplastic changes and of the expression of molecular mechanisms linked to neuronal plasticity in the brains of patients with Alzheimer's disease, specifically to increase the reactive synaptogenesis (increase in the concentration of cinapofisin, synaptobremin and other synaptic contact proteins) all these elements argue that the synaptic loss is the cause of most of the cognitive disorders and spontaneously there is a compensatory increase in the neuroplastic mechanisms that for reasons that are not very clear, abort or is insufficient in the advanced stages of the disease. This is linked to the fact that the greater brain reserve, or what is the same, the higher density and synaptic efficiency, there is a slower rate of progression in sick subjects, so the stimulation of that brain reserve in the stages early illnesses and complaints of other dementias po day to be beneficial in the evolutionary periods of the disease. While this is not reliably demonstrated by our initial results and 10 years' experience, they suggest that this is possible.
With the approval of the Federal Drug Administration in 1995 by the THA, the history and prognosis of the disease was modified. Indeed, for the first time there is a therapeutic agent capable of reversing the cognitive deficit and memory loss of these patients.
Since then, new drugs based on blocking the degradation of acetylcholine through the inhibition of the enzyme acetylcholinesterase or cholinergic receptor agonists (nicotinic or muscarinic) that together improve the synaptic concentration of the neurotransmitter acetylcholine, have shown efficacy in the treatment of these patients in the early stages of light or moderate disease, including long-term effects in the delay of institutionalization of patients linked to disability and dependence, when studying the why of these phenomena it has been suggested that both acetyl inhibitors and nicotinic agonists have a primary effect of stimulating the post-synaptic neuron have a more presynaptic effect on the reception of the neurotransmitter and the energy balance of said synaptic terminal.
In this way now by chemical stimulation the fact that synaptic preservation is a strategic point in the recersion of symptoms and in the protection of the neuron against degeneration is repeated.
On the other hand, the fact that there is a specific treatment that stops the cognitive deterioration and increases the functional capacity of the individual must modify the conception of the patient's attention because now it is possible to extend the life expectancy maintaining quality of life independence and self-validation time before.
The double hypothetical capacity of cognitive training to train the brain reserve by neuroplastic mechanisms and to act cynergically with drugs to improve the functional capacity of these patients, allow us to suppose that their rational use with an appropriate design could improve the cognitive and functional capacity of patients. with Alzheimer's disease more than the isolated use of drugs. Simultaneously the activity of cognitive rehabilitation can avoid at least temporarily the sensory and social deprivation that these patients usually suffer in relation to the social, familiar and emotional isolation to which they are subjected by virtue of the dogma of the irremediable of the cognitive deterioration.
Based on the evidences and hypothesis previously raised, we have decided to propose a revised and improved cognitive training program for the treatment of light and moderate stages of dementia.
The specialized training of the main cognitive domains in special memory and attention, can diminish the intensity of the cognitive deterioration, the speed of the progression of said deterioration and favorably enhance the effect of the acetylcholinesterase inhibitors.
Composition and duration of the program:
The Neurological Restoration or Rehabilitation program includes a week of evaluation during which a specialized clinical evaluation of the demential syndrome is performed, a general clinical evaluation of the patient's health status, a quantification by international scales to measure neurological condition, cognitive capacity, Functional and quality of life, neurophysiological studies specialized in exploration of upper nervous activity, structural and functional imaging studies by Computed Axial Tomography, Nuclear Magnetic Resonance, Simple Photonic Emission and biochemical and molecular studies.
This evaluation is complemented with a specialized neuropsychological evaluation and the application of international instruments to determine the degree of disability or objectify the neurological defect to be modified.
The information obtained by this comprehensive evaluation is analyzed collectively by specialists from various disciplines and a unique program is designed in stages, with specific objectives that are set according to the patient's possibilities and the experience previously accumulated.
The Neurological Restoration or Rehabilitation program is executed by therapeutic cycles of 4 weeks (28 days) that includes hygienic-dietetic measures to improve the general condition, and pharmacological adjustment to control as much as possible the manifestations of memory loss and attention and improve the support trophic and nutritional nervous system. In parallel, disorders of sleep, appetite, blood pressure and other autonomic or mental disorders that usually coexist with the progression of the disease are controlled.
A comprehensive rehabilitation program is also developed that includes cognitive training using an automated system designed at the CNC and adapted at CIREN for such purposes, supplemented with physical and functional conditioning techniques and behavioral adjustment techniques.
It has been determined in an open clinical trial that the effectiveness of the comprehensive care program is 83% and the improvement rates obtained for cognitive ability are approximately 7% and for functional capacity of approximately 33%. In more than 200 patients treated to date there have been no complications, accidents or adverse events that compromise life or leave sequelae. The rate of adverse effects or transient complications is less than 10%.

Neuro-Rehabilitation Therapeutic Program
Multifactorial Intensive Custom
International Center for Neurological Restoration. CIREN

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