Values of design variables for optimal solution.
\r\n\t
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Kalinin",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11782.jpg",keywords:"Variety of Traits, Historical Remarks, Modern Definitions and Descriptions, Personality Disorders, Comorbid Psychopathology, Depression, Anxiety, Obsessions, Delusion, Treatment of Personality Disorders, Phenomenology of Personality Traits, Delusional Symptoms",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 9th 2022",dateEndSecondStepPublish:"May 12th 2022",dateEndThirdStepPublish:"July 11th 2022",dateEndFourthStepPublish:"September 29th 2022",dateEndFifthStepPublish:"November 28th 2022",remainingDaysToSecondStep:"5 days",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:'A researcher with over 300 publications in psychopathology, psychopharmacology, neuropsychiatry, and epileptology, a member of the Russian Society of Psychiatry, and the Russian Society of Epileptology. Dr. Kalinin\'s biography is included in Marquis "Who’s Who in Medicine and Healthcare" (2006-2007); Who’s Who in Science and Engineering 2008-2009"; "Who’s Who in the World" (2010, 2011), and in the Cambridge International Biographical Centre.',coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"31572",title:null,name:"Vladimir V.",middleName:null,surname:"Kalinin",slug:"vladimir-v.-kalinin",fullName:"Vladimir V. Kalinin",profilePictureURL:"https://mts.intechopen.com/storage/users/31572/images/system/31572.png",biography:"Vladimir V. Kalinin was born in1952 into a family of physicians in Orenburg (Russian Federation). He obtained an MD from Moscow State Medical Stomatological University in 1976. In 1976-1977 he completed an internship in Psychiatry. 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Prof. Kalinin has authored 228 publications, including research articles in professional journals (in Russian and English), three monographs in Russian, and four monographs in English.",institutionString:"Moscow Research Institute of Psychiatry – The Branch of Serbsky's National Center of Psychiatry and Narcology of Ministry of Health",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"4",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"21",title:"Psychology",slug:"psychology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"444312",firstName:"Sara",lastName:"Tikel",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/444312/images/20015_n.jpg",email:"sara.t@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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As a result, the number of person-hours in post-casting processing can be decreased, reducing cost and shortening delivery times. However, the occurrence of residue defects, which is a phenomenon unique to the full mold casting method, is a major problem in the manufacture of large castings by this method. This is a serious issue that significantly impairs the quality of the product because the unresolved part of the foam model is mixed in with the product.
As a measure against defects in residue at the casting site, the pouring temperature can be increased to facilitate the thermal decomposition of a foam model. However, due to the high temperature inside the product, the volume shrinkage due to solidification increases and shrinkage nests tend to occur. On the other hand, if the pouring temperature is lowered to prevent shrinkage cavity, the foam model cannot be thermally decomposed efficiently and residue defects are generated. Although there is also a method of installing multiple gates, which are the inlets to the product, to improve the molten metal turnover, a flow of metal that rolls in the foam model is generated, and residue defects are more likely to occur.
Traditionally, these casting conditions and schemes have been determined based on the experience and intuition of skilled workers. In recent years, however, the use of computational fluid dynamics (CFD)-based simulations has made it possible to study appropriate conditions and solutions in advance based on the analytical results of the melt flow and solidification processes, thereby reducing the cost and time required for trial manufacture and experimentation. Particularly, solidification simulations are used to study casting conditions and solutions for shrinkage cavity defects, which can be estimated with high accuracy by comparison and verification with experiments [1]. The authors have also been optimizing the shapes of the runners in die castings by using CFD simulation and the shape optimization method for molten metal flow [2].
In recent years, the full mold casting method and the vanishing model casting method have been actively researched. Maruyama et al. have collected, analyzed, and investigated the pyrolysis products generated during the filling of molten metal in the vanishing model casting process [3]. Koroyasu et al. reported on the adiabatic properties of a coating in the vanishing model casting method and conducted a simple simulation of molten aluminum alloy flow in that method to investigate the influence of the air permeability of the coating, the presence or absence of depressurization, and casting methods on molten metal flows [4]. Karimian et al. investigated the influences of the coating thickness on product quality. When the coating film is thin, the amount of pyrolysis gas emitted from the foamed model is higher, and the amount of residue due to pyrolysis is reduced [5]. In addition, studies on the analysis of molten metal flow behavior in vanishing model casting have been actively conducted using CFD simulation [6, 7].
This study proposes a new casting design for the production of large castings by full mold casting. In this method, a residue trap is installed at the product part to prevent the occurrence of residue defects, and the optimal design of the residue trap is realized by using CFD simulation and the shape optimization method. The effectiveness of this method is demonstrated through casting experiments using an actual full mold casting.
In general castings such as sand casting, molten metal is poured into a hollow mold. In contrast, in full mold casting, molten metal replaces a foam model. Therefore, because the flow of metal differs greatly between full mold casting and normal casting, it is necessary to understand the phenomena that actually occur in the mold.
In full mold casting, the heat of the molten metal decomposes the foam model and generates gaseous pyrolysis products. The thermal decomposition products are successively discharged through the coating mold into the sand mold. If the gas layer of the pyrolysis products is thin, the rate of heat transfer from the molten metal to the foam model will increase, as will the rate of molten metal flow. Conversely, the thicker the gas layer of the pyrolysis products, the lower the heat transfer rate and the lower the flow rate of molten metal. Therefore, the flow metal is determined by the complex interaction of multiple factors such as the metal’s temperature, its position in the mold, the material and morphology of the foam model, and the thickness and composition of the coating mold.
In the CFD software used in this study, a foam model is represented as an obstacle that disappears when heated. Therefore, the flow of molten metal is hardly affected by pressure and inertia, but depends on the heat transfer phenomenon. Specifically, the heat transferred from the metal to the foam model at their interface is calculated. Subsequently, depending on the amount of heat, the foaming model disappears and the metal migrates. Therefore, the average inflow velocity
where
In the full mold casting, the heat of the metal decomposes the foam model and generates gaseous pyrolysis products. The pyrolysis products are discharged into the sand mold through the coating process. These products are smaller than the metal when the metal is above the foam model. Therefore, the thickness of the gas layer between the metal and the foam model due to the pyrolysis products is reduced. Therefore, the heat transfer rate is expected to be high. On the other hand, when the metal is located below the foaming model, the thickness of the gas layer between the metal and the foaming model is increased and the heat transfer rate is considered to be low. In the CFD simulator used in this study, considering this effect in the gravity direction, the flow rate of metal in the gravity direction is defined by Eqs. (2) and (3) using the parameter
where
CFD simulation model for identification experiment.
The metal was FC300 gray cast iron, and the pouring temperature was set at 1683 K. Foamed polystyrene with a foaming factor of 60 times was used for the model. A water-based mold coating agent for full-molded cast iron was used for the coating, and the coating film was about 2 mm thick. Silica sand with an AFS grain size index of 36.7 was used as the casting sand. A stopper system was used for pouring the metal. The arrival time of the metal was measured by inserting a touch sensor into the end of the model; this sensor emitted. The experimental results show that the start to the finish of pouring was 7.2 s. The casting weight was 35 kg.
Next, CFD simulations were performed. The parameters in Eq. (3) were set to ρ = 16.7 kg/m3 and Cp = 2100 J/(kg-K). In order to make the arrival time of the metal consistent with that of the experiment and the simulation, the parameter H0 was adjusted based on the definition of Eq. (3), and good results were obtained at H0 = 5500 W/(m2-K) and Eg = 0.5. We therefore use these values in the simulations in this study.
In this study, a capstan drum (Figure 2) is used as the product shape. Also, a casting runner with a diameter of 30 mm is used for the solution. The capstan drum was analyzed for metal flow using the two gating systems shown in Figure 2(a) and (b).
Shape of capstan drum and gating systems.
Gating system A has a gate directly on the arm, which is considered to be prone to many residue defects. Since an enormous amount of time would be required to analyze everything from the pouring to the filling of the product part, a simple model in which metal flows into the product part at a constant pressure from the gate was used. The inflow pressure was set at 1.425 × 105 Pa in absolute pressure, and the temperature of the pouring molten metal was set at 1623 K. The pouring temperature of the metal was set at 1.425 × 105 Pa in absolute pressure. In addition, since the shape was symmetrical, we were able to cut the analysis area in half to reduce the analysis time.
The results of the CFD analysis are shown in Figure 3(a). As shown by the dashed ellipses, the metal flows by gravity from top to bottom. Due to the difference between the density of the metal and the density of the gas and residue generated by the pyrolysis, the metal would entrain the gas and residue, which would affect the occurrence of residue defects.
Results of flow analysis for capstan drum.
Then, gating system B is modified to install gates at the rim and hub to improve the flow of gating system A. To prevent the formation of defects in the residue, the pouring temperature was increased by 20 K to 1643 K.
A molten metal flow analysis was performed on the drum using this gating system B. The results of the analysis are shown in Figure 3(b). The flow in the rim proceeds gradually from the bottom to the top, which makes it difficult for the metal to entrain gas and residue. In addition to the increase in temperature, these flows may actually reduce the number of residue defects.
In other words, if a gate is installed on the arm as in gating system A, a drop-in flow occurs, leading to the generation of residue defects, so the gate must be installed on the bottom of the hub and rim as in gating system B. If the pouring temperature is increased to prevent residue defects, the temperature at the completion of filling will also be high, and therefore, to prevent shrinkage defects the pouring temperature should not be increased. Therefore, to prevent both residue defects and the formation of a shrinkage cavity, a new casting plan that allows the suppression of residue defects without increasing the pouring temperature is required.
By installing a gate at the bottom of the rim, the metal cannot avoid merging in the rim. If the pouring temperature cannot be increased, residue defects are more likely to occur. This requires the discharge of metal that contains residue from the rim. Therefore, we propose a new gating system: foam residue traps. For shrinkage nests, this system allows us to lower the temperature of the pouring metal. Although lowering the pouring temperature may increase the number of defects in the residue, a trap is installed on the side of the rim at the position where the metal joins with the metal to collect the residue, and the metal that is free from residue is recovered. This makes it possible to reduce residue defects.
In order to verify the effect of discharging molten metal entrapped by residue traps, a gating system was designed as shown in Figure 4. CFD analysis was performed for this. The analysis conditions are the same as in the previous section, except that a residue trap was installed.
Capstan drum with traps for preventing foam residues.
The results of the CFD analysis are shown in Figure 5. The results of the analysis are velocity vectors of the metal, which are cross-sections based on the center of the height of the capstan drum. Horizontal cross-sections are set at −120 mm, 0 mm, and 120 mm height, respectively. At the 0 mm and 120 mm cross-sections, there is a vector of the flow from the inside of the residue trap to the rim. Therefore, metal that is entrapped in the residue may flow into the rim. Since the interface between the foam model and the metal is filled with molten metal with resistance due to combustion, it is considered that convection is formed by a flow that has no place to go. Therefore, it is necessary to design an appropriate casting plan to prevent the backflow of metal to the rim side due to convection inside the residue trap.
The velocity vectors on the horizontal sections for the foam residue trap.
Based on the results of the analysis in the previous section, the bottom of the rim is considered the best location for the gate, but in any case, residue defects will be generated by molten metal joining in the rim. In this study, a residue trap is proposed as a gating system for collecting molten metal that can join together and directly collect metal that is entrained with residue, and a new casting method for large castings is presented.
The optimal design of the residue trap is used for the capstan drum shown in Figure 2. In optimization, the dimensions defined as design variables are varied within a set range to find the optimal combination. This combination increases with the number of design variables, and the time required for optimization becomes enormous. Therefore, the number of design variables must be set to the minimum necessary.
The basic shape of the residue trap and the locations where the design variables were set are shown in Figure 6. The design variables were defined with five variables,
Foam residue traps of capstan drum and design variables.
Three objective functions are defined as evaluation indices for optimization. The first objective function,
where
The second objective function,
The smaller the value of
The third objective function,
The smaller the value of
Based on these definitions, we added geometric constraints and finally formulated this optimization problem.
We applied NSGA-II [9], a multi-objective genetic algorithm, to this optimization problem. The algorithm was set up with 50 individuals per generation, congestion tournament selection as the selection method, and BLX-α as the mating method. We also decided to terminate the optimization when the percentage of individuals generated more than 2 generations ago in the population of the focused generation exceeded 70%, or when the number of generations reached 30.
The distribution of all the individuals generated by the optimization for the objective function values is shown in Figure 7.
Distribution of all analyzed individuals in optimization.
The total number of individuals generated was 775. This figure shows that the volume fraction of residue
Optimized shape of foam residue trap. (a) Foam residue trap. (b) Whole shape of casting.
11.58 | 76.50 | 108.82 | 27.05 | 57.57 |
Values of design variables for optimal solution.
6.906 × 10−1 | 3.257 × 10−3 | 7.456 × 10−4 |
Values of objective functions for optimal solution.
In order to verify the effectiveness of the optimal shape, CFD analysis was performed and compared between the conventional method without a residue trap and the residue trap method with the optimal shape. The flows for the conventional and residue-trapping methods are shown in Figures 9 and 10, respectively.
Fluid behavior without foam residue trap.
Fluid behavior with shape-optimized foam residue trap.
In the conventional gating system, the metal flow shows that the residue is spreading inside the rim, and it is thought that the following factors influence the development of residue defects. The volume fraction of the residue in this case was
Casting experiments were conducted to verify the effectiveness of the optimally designed residue trap.
In this study, two types of capstan drums were cast: one with a conventional method without a residue trap and the other with an optimized residue trap method. The temperature of the metal was set to 1623 K, and the other conditions were the same as in the experiments in Section 2. After casting and cooling, the product was cut to make a test specimen, and the cut surface was color-checked to compare the defects. As shown in Figure 11, the position where the product part was cut was set to a horizontal plane 10 mm downward from the top of the rim because the residue tends to accumulate on the top of the rim.
Cross section of capstan drum for experiments.
The experimental results of the conventional plan and the corresponding simulation results are shown in Figure 12. This result suggests that this was caused by the residue of the foam model generated during the filling of the molten metal and remaining in the rim of the drum. The simulation results in Figure 12(b) indicate that residue defects are more likely to occur around the specimen, although the simulation does not fully predict the distribution of residue.
Evaluation of foam residue defect for casting without foam residue trap. (a) Experimental result. (b) Flow analysis result.
Figure 13 shows the experimental results of a residue trapping method using the optimal shape and the corresponding simulation results.
Evaluation of foam residue defect for casting with shape-optimized foam residue trap. (a) Experimental result. (b) Flow analysis.
Slight shrinkage nests were observed in the specimens, but no residue defects were observed. Similarly, in the simulation results, there was almost no residue around the specimen. Therefore, the residue traps were also cut in the same way as the test specimens, and the color inside each trap was checked. The results and the corresponding simulation results are shown in Figure 14. Residue defects were observed in the residue trap, indicating that the residue generated inside the product was captured well by the trap. Therefore, this study confirms that the residue trapping method using the optimal shape effectively reduces residue defects.
Evaluation of foam residue defect in foam residue trap. (a) Experimental result. (b) Flow analysis result.
In this study, a new residue trapping method is proposed to suppress defective residues, which are a problem in manufacturing large castings by the full mold casting method. To maximize the performance of the residue trap, the shape of the trap was optimized by using CFD simulation. The effectiveness of the optimized residue traps was verified by casting experiments, which showed that the effectiveness of the optimized traps can reduce residue defects better than those without traps.
Parkinson’s disease dementia (PDD) is a well-known complication of Parkinson’s disease (PD), with an annual incidence of around 10% of patients with PD and a cumulative prevalence of 75–90% of those with a disease duration of 10 years or more [1, 2, 3]. Dementia is an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform independent activities of daily living (IADLs) [4]. Symptoms of dementia can be seen in most of the neurodegenerative diseases, such as Alzheimer’s disease (AD), vascular dementia (VD), dementia with Lewy bodies (DLB), Creutzfeldt-Jakob disease (CJD), frontotemporal dementia, Huntington’s disease, normal pressure hydrocephalus [5, 6]. The general risk factors for dementia include lower education, hypertension, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, low social contact, excessive alcohol consumption, traumatic brain injury, and air pollution [7]. It is devastating for both patient and family or caretaker when a patient with PD develops dementia because both PD and dementia have a protracted course, with progressive but insidious development of disability [8]. Primary care physicians (PCPs) stand in a unique position for caring for patients from early to terminal stage of their life and play an important role in the management of PDD patients, including in screening, diagnosis, and treatment. It is important to provide individual, realistic, and affordable options of care to every unique patient and his/her family [9, 10].
PD impacts people in different ways. Not everyone will experience all the symptoms of PD at the same time or follow the same pattern. But PCPs should be familiar with the common symptoms or typical patterns of progression in PD that are defined in stages [11, 12, 13]. PCPs should also know the risk factors that make PD patients more likely to experience dementia because the clinical symptoms of both syndromes can overlap to a high degree. PCPs should always consider seeking reversible medical conditions that can affect mental function in PD patients. A flowsheet (Table 1) for screening generated here should help PCPs and their team to achieve this goal during a patient’s routine annual wellness visit (AWV) or general visit.
Items | Purpose |
---|---|
Age | recognize this is a risk factor |
Stage of PD | severity of motor impairment from PD, another risk factor for PDD |
cognitive functions | search cognitive function stage including attention, executive, and visuospatial functions |
Dementia Screen Indicator [14] | screening possible high-risk patients. If it is negative, follow up periodically. If it is positive, further investigation is needed. |
Geriatric Depression Scale [15, 16] | search for mood disorders |
PHQ-9 screen for depression [17, 18] | further evaluation of depression |
MoCA [19] | early detection of cognitive impairment |
Qmci [20] | differentiating MCI and NC |
MMSE + CDT [21, 22] | to stage mental dysfunction, better specificity and sensitivity |
For routine AWV in PD patient in addition to routine questionnaire.
AWV: annual wellness visit; PHQ-9: patient health questionnaire-9; MCI: mild cognitive impairment; NC: normal cognitive. MoCA: Montreal cognitive assessment; Qmci: quick mild cognitive impairment; MMSE: mini-mental state examination. CDT: clock drawing test.
The information needed to arrive at the diagnosis requires the clear demonstration that cognitive impairment negatively impacts daily living. This issue is determined by the patient and caregiver interview, and generally focuses on the patient’s autonomy, the ability to manage finances, to cope in social situations, and to utilize equipment that is part of daily living.
In addition to above mentioned risk factors [7], genetic risk factors are concerning too. One gene, identified to be a risk factor, is the apolipoprotein E gene which presents in three allelic forms (ε2, ε3, and ε4), of which the ε4 allele is a risk factor for AD [23, 24]. Recognizing some other factors in PD patients is also important for early diagnosis of PDD [25, 26]. Those other factors include advanced age at time of diagnosis of PD, experiencing excessive daytime sleepiness, hallucinations before the onset of other dementia symptoms, a history of mild cognitive impairment, more severe motor impairment symptoms than most people with PD, having a specific PD symptom that causes a person to have difficulty starting to take a step or to halt mid-step while walking.
It is important to search for reversible medical conditions affecting mental dysfunction that may mimic dementia. Electrolyte imbalance, such as hyponatremia or hypernatremia, may cause neuropsychiatric manifestations [27, 28, 29]. A personality change such as increasing irritability may be a symptom of hypernatremia, hypercalcemia, hypocalcemia, hypophosphatemia, or hypomagnesemia. In most instances, correction of such underlying electrolyte imbalance will alleviate the psychiatric symptoms. PCPs should pay close attention to age-related limitations of fluid homeostasis, especially in PD patients because that can change the mental function in PD patients gradually and insidiously. Vitamin D deficiency has been associated with neuropsychiatric conditions such as PD, schizophreniform disorder, multiple sclerosis (MS), AD and autism spectrum disorder [30]. PCPs should always be alerted that the side effects of medications can also cause various symptoms and signs of mental disorders that can mimic dementia [31]. Those common drugs include anxiolytics (Benzodiazepines), antiseizure medications (e.g. carbamazepine), antidepressants (e.g. tricyclics), narcotics (e.g. hydrocodone), certain medications for PD (e.g. pramipexole, ropinirole), some hypertension medications (e.g. beta-blockers), sleeping medications (non-benzodiazepine, zolpidem.), medications for incontinence (anticholinergics, oxybutynin.), and some antihistamines (first generation, e.g. hydroxyzine and diphenhydramine).
It is unclear whether early detected cognitive impairment and interventions for dementia patients have a significant effect on their long-term outcomes [32, 33]. But early detection of cognitive impairment can allow for identification and treatment of reversible causes. It also may help patients understand and adhere to medical treatment plans and provide a basis for advance planning for patients and their families [34]. Unfortunately, underdiagnosis of Alzheimer’s and other dementias in the primary care setting is not uncommon [35].
Many screening tools have been developed for medical providers to identify dementia patients earlier. These can be used for screening in PD patients. These tools are summarized in Table 2. A dementia screening indicator is generated to help PCPs plan the next steps of management [14]. First, it starts with three simple questions if you think your patient may have cognitive impairment based on (1) your observations, (2) concerns of the patient or (3) concerns of family or others. If the answer is yes for one of these three questions, the patient should be screened for cognitive impairment. Second, is the patient 80 or older? If yes, the patient should be screened for cognitive impairment. If not 80 or older, the dementia screening indicator should be administered. The dementia screening indicator consists of 7 items that include (1) age, (2) years of education, (3) body mass index (BMI), (4) history of type 2 diabetes, (5) history of stroke, (6) function of management of money or medication and (7) depression. If the total point score is more than 22, the patient should be screened for cognitive impairment, with an instrument such as those described below [14].
Screening tool | Characteristic | Usage |
---|---|---|
Screen Indicator [35] | simple, easily administered in PCP settings. | identify high risk patients for MCI and dementia |
MoCA [14] | early detection of cognitive impairment | High specificity and sensitivity for screening MCI |
Qmci [19] | needs more administrate effort | more sensitive in differentiating MCI and NC |
MMSE [20] | comprehensive evaluation | Able to stage dementia, but less sensitive to screen MCI |
Comparison of different screening tools for mental status.
MCI: mild cognitive impairment; NC: normal cognitive. MoCA: Montreal cognitive assessment; Qmci: quick mild cognitive impairment; MMSE: mini-mental state examination.
One commonly used screening tool is the Montreal Cognitive Assessment (MoCA; range 0–30; follow-up evaluation to screening recommended if score is <26). MoCA requires about 10–15 minutes to administer and is useful in early detection of cognitive impairment, including MCI with executive dysfunction [19].
The quick mild cognitive impairment (Qmci) has six domains with total score 100; five orientation items (country, year, month, day, and date with a maximum score of 10), five registration items (score ≤ 5) and a clock drawing test (score ≤ 15), each scored within 1 min. It also has a delay recall (DR) section (timed at 20 seconds with score ≤ 20), a verbal fluency (VF) test (in 60 seconds with score ≤ 20) and a logical memory (LM) test with 30 seconds for administration and 30 seconds for response (score ≤ 30). It can be administered and scored in ~5 minutes. The Qmci is more sensitive than the Standard Mini-Mental State Examination (SMMSE) in differentiating MCI and normal cognition (NC), making it a useful test, for MCI in clinical practice, especially for older adults [20].
The Mini-Mental State Examination (MMSE) that was developed more than 4 decades ago is still a gold standard exam for comparison. It is a brief test, taking ~7 to 10 minutes to complete. The pooled estimate across 15 studies resulted in 89 percent sensitivity (95% CI, 0.85 to 0.92) and 89 percent specificity (95% CI, 0.85 to 0.93) to detect dementia at a cutoff of ≤23 or ≤ 24 [21]. It is less sensitive to the presence of MCI and less thoroughly evaluated in the domains of executive function, higher-level language skills, and complex visuospatial processing. The most sensitive combination of screening tools is the MMSE and Pfeffer Functional Activities Questionnaire (PFAQ) (94.1%). The best specificity is the combination of the MMSE and Clock Drawing test (CDT) [22, 36].
After the clinical bedside screening test with suspicious PDD as shown in Table 1, orchestrating further investigations as outlined in Table 3 should be the next step to obtain more evidence to make the diagnosis of PDD. Laboratory studies and imagining studies should be carried out before making the diagnosis. Obtaining basic laboratory data on complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH) should be done to understand the basic homeostatic condition of the patients. Checking the levels of vitamin B12, B1, and B6 is proper to search for a reversible pathological cause of mental function change. Brain imaging studies, MRI or CT, will help to distinguish common pathological conditions, including hydrocephalus, atrophy of the brain, vascular disease, or tumor [37, 38].
Items needed to be done | Purpose |
---|---|
Review list of medications that patient is taking | search for side effects of medications. |
Laboratory investigation: CMP, CBC, lipid, TSH, B12, CRP | search for reversible causes of mental function change. |
Imaging study (MRI of head) | rule out other pathology, identify atrophy of the brain. |
Referral for neurological consultation | confirm diagnosis |
nonpharmacological intervention | improve symptoms |
Pharmacological treatment | prevent or delay the progression of dementia |
Health maintenance care | preserve the ability for daily activities |
Palliative care/hospice | improve quality of life |
Steps for management of suspected PDD patient.
Criteria to establish the diagnosis of PDD are depicted in Figure 1. There are feature domains in these criteria, including features of PD and dementia as well as uncertain features. In the end, a collaborative neurological consultation should be considered to make the diagnosis of PDD [39, 40, 41, 42, 43].
Criteria for diagnosis of PDD patient.
The fundamental goals of treatment for PPD patients are to reduce suffering caused by the cognitive and accompanying symptoms, while delaying progressive cognitive and physical decline. How to reach these goals is a challenge to medical providers, patients, and families because the severity of PD, mood disorders, hearing defects, and mental function declining can overlap and affect each other. That needs comprehensive evaluation, planning, and cooperation/coordination with neurologists. An algorithm shown in Figure 2 will help PCPs to orchestrate the treatment plan with patients and their families.
Algorithm workflow for management of PDD patient.
The non-pharmacological interventions that combine diet, exercise, cognitive training, and vascular risk monitoring improve cognition in people at risk for cognitive decline [44, 45, 46]. Physical exercise, both aerobic (walking, swimming) and anaerobic/conditioning (resistance training, Tai chi), improves cardiovascular health through benefits on blood pressure and stroke risk [47]. Some trials suggest these interventions may positively affect cognitive and physical function and promote patients’ functional independence, improve their well-being and that of their caregivers. Cognitive training and activities such as reading and playing cognitively engaging games (e.g., chess, bridge) may help maintain cognition and function, improve processing speed, and reduce daytime sleepiness [48].
Music therapy may help maintain cognition or improve quality of life, as some studies revealed that recovery of verbal memory and focused attention improved significantly in patients who listened to their favorite music daily. Besides the improvement in cognitive functions, there was also a substantial mood improvement in this group of patients [49]. Falls have several psychosocial impacts, including fear of falling and reduced self-efficacy, leading to decreased independence, reduced social participation and diminished health-related quality of life [50]. Prescribing cane, walker, or physical and occupational therapies for prevention of falling is one of the responsibilities of PCPs. Moderate intensity outdoor group activities like Nordic Walking and Walking seem to improve motor and non-motor symptoms in patients with Parkinson’s disease [51]. Physical activity may assuage the degeneration of motor skills, lessen depression, and increase the quality of life of PDD patients.
As described above, PCPs should oversee all medications that PDD patients take before considering pharmacologic treatment for dementia symptoms in PDD patients, because PDD patients usually take medications for PD and other comorbidities. PCP should be familiar with the most common pharmacologic therapies for PD patients, although these are usually initiated by neurologists. These medications include carbidopa-levodopa, monoamine oxidase-B inhibitors, and dopamine agonists. Knowing the effects and side effects of these medications will help PCP to recognize when mental status changes in PD patients are attributable to medication side effects or interactions of medications. It will also help PCPs avoid the interaction of medications when prescribing therapeutic medications either for symptoms of dementia or for other medical conditions. Before any medication is prescribed, potential side effects should be counseled, fully disclosed, and well explained (to the best of your knowledge) to patients and their families or caregivers. This would be critical for those with limited mental capacity to increase compliance and to decrease avoidable incidents. In addition, based on our clinical experience, for lower body mass patients, low-dose initiation of medication and slow titration should be considered. Effective treatment monitoring requires periodic reevaluation of cognition, function, neuropsychiatric and behavioral symptoms, and medication reconciliation. Five drugs, 4 of which are currently available for prescription in the United States, yield modest symptomatic benefit for cognitive symptoms of AD dementia [38]. These drugs may be also beneficial for PDD patients. Their usages are discussed below and summarized in Table 4.
Medications commonly used in PCP setting for the pharmacologic management of PDD | ||
---|---|---|
| ||
1 | Donepezil (Aricept) | first line to choose, it should be taken after dinner to lessen the impact of GI side effects. |
2 | Rivastigmine (Exelon) | Topical patch, Rivastigmine will decrease GI side effects and oral medication burden |
| ||
1 | Memantine (Namenda) | for moderate to severe dementia, combined with Cholinesterase inhibitor showing better efficacy and less GI side effects |
| ||
1 | Quetiapine (Seroquel) | commonly first to choose for relative safety profile for sedation and wider dosing range to titrate |
2 | Olanzapine (Zyprexa) | effective against psychiatric symptoms but less favorable metabolic impacts |
3 | Risperidone (Risperdal) | usually considered when Quetiapine and Olanzapine failed |
| ||
| ||
1 | Escitalopram (Lexapro) | low dose initiation, better option towards anxious clinical manifestation |
2 | Citalopram (Celexa) | good alternative for Escitalopram |
3 | Sertraline (Zoloft) | long clinical usage and experience for positive psychiatric symptoms |
4 | Fluoxetine (Prozac) | long clinical usage and experience for negative psychiatric symptoms |
| ||
1 | Mirtazapine (Remeron) | well adopted in geriatric population for hypnotic and appetite enhancement profiles |
2 | Trazodone | classical and safe sleep aid in low dose |
3 | Bupropion (Wellbutrin) | less sexual function disturbance and stamina boosting characters considered |
4 | Venlafaxine (Effexor) | good feature for general anxiety symptoms |
5 | Nortriptyline (Pamelor) | well adopted for muscle relaxing, hypnotic and appetite boost but alert on anticholinergic side effect in geriatric population |
| ||
1 | Buspirone | less clinical effectiveness but very safety profile favored on anxiety background management |
2 | Valproic acid (Depakote) | mood stabilizer or clinical symptoms complicated with epilepsy |
3 | Carbamazepine (Tegretol) | mood stabilizer or clinical symptoms complicated with epilepsy |
4 | Gabapentin (Neurontin) | mood stabilizer or clinical symptoms complicated with neuropathic pain |
5 | Zolpidem (Ambien) | most widely used hypnotic agent but alert in sleeping walk reported often |
6 | Zaleplon (Sonata) | short acting for helping waking up in the middle of night |
7 | Eszopiclone (Lunesta) | effective hypnotic but dizziness and fainting caution in geriatric population |
8 | Ramelteon (Rozerem) | quite safe agent but efficacy limited to certain population |
9 | Suvorexant (Belsomra) | relatively new in market and quite safe agent but efficacy limited in higher dose |
Common medications for PDD patients.
This class of medications can exhibit significant clinical impact in mild to moderate dementia patients and can also benefit severe dementia patients. Acetylcholinesterase inhibitors, including Donepezil, Rivastigmine and Galantamine, inhibit the brain enzyme acetylcholinesterase, thereby promoting relative increases in acetylcholine abundance at the synaptic cleft for cholinergic neurotransmission. Donepezil 5 to 10 mg can be taken once a day orally. This is the one most widely used. Side effects of nausea, gastrointestinal (GI) cramps, and dizziness could be minimized by being taken after dinner. Rivastigmine 1.5 to 6 mg twice daily orally, or 4.6 to 9.5 mg transdermal patch once a day is another option. Clinical trials in DLB and PDD have established this agent’s clinical efficacy better than other drugs in this class. Another cholinergic drug is Galantamine 4 to 12 mg twice a day orally or extended release 8 to 24 mg once a day orally. This agent has shown less consistent benefit on function and behavior. Tacrine is no longer being used clinically because of liver toxicity, and the above newer agents have better tolerance profiles.
Memantine is one of the N-methyl-D-aspartate (NMDA) non-competitive antagonists which might slow down the neurodegenerative process by blocking Glutamate’s overstimulation of the NMDA receptors, and thus reduce excitotoxicity. Memantine alone or combined with Donepezil is another option commonly used for moderate to severe Alzheimer’s disease. A meta-analysis reported that use of memantine to treat behavioral and psychological symptoms of dementia (BPSD) yielded modest decreases in scores on the Neuropsychiatric Inventory Questionnaire and improvement of symptoms, although sedation was reported to be a major side effect [38]. Memantine can be taken 5 to 10 mg twice a day orally or extended-release form 7 to 28 mg once a day orally. This agent should be considered to initiate at the moderate to severe stages of PDD, because severe dementia in PD most commonly has concomitant AD pathology. In addition to the above 2 categories of drugs, the following other medications that are commonly used in PDD patients are also addressed in below and in Table 4.
Selegiline 5 mg twice a day orally is also commonly used. Despite lack of confirmatory outcome data, some believe that this anti-Parkinsonian disease medication may have a neuroprotective effect against PDD, based largely on animal models.
Agitation, aggressive behavior, psychosis, and especially visual hallucinations are often encountered in the early stages, particularly in PDD compared to other types of dementia like AD or VD. For this reason, this class of medicines may be more often required in the early stage PDD compared to other types of dementia, but needs to be dosed and monitored closely. The second-generation antipsychotic agents or atypical antipsychotic agents are currently preferred due to their relatively tolerable side effect profiles with less risk of ‘neuroleptic sensitivity’, (i.e., motor, and cognitive deterioration) [52]. Also, metabolic abnormalities, especially serum glucose increases, need to be closely monitored during treatment. Over sedation caused by high dose or frequent dosing should be discussed with family members or caregivers for adjusting neuroleptic doses promptly and safely. Institutional abuse of this class of medicine has been reported. These are common second-generation neuroleptics agents: (1) Quetiapine (Seroquel) 12.5 to 100 mg per day orally; (2) Olanzapine (Zyprexa) 2.5 to 10 mg per day orally; (3) Risperidone (Risperdal) 0.25 to 1 mg per day orally; (4) Aripiprazole (Abilify) 10 to 30 mg per day orally; (5) Ziprasidone (Geodon) 20 to 160 mg per orally.
Geriatric depression is a common and treatable comorbidity in patients with dementia. Several tools are validated to screen for depression in older patients. The five-item Geriatric Depression Scale is brief and sensitive. It is as effective as the 15-item Geriatric Depression Scale and does not require clinician administration [52]. In patients with depression and dementia, treatment for depression should usually be initiated first. Pseudodementia, or depression causing cognitive impairment, is diagnosed if the impairment resolves with treatment of the depression. These antidepressant medications have been widely used for mild to moderate uncomplicated depression disorders in the primary care setting [53, 54]. Selective serotonin reuptake inhibitors (SSRIs) are the first line treatment of choice. Patients who do not respond to two or more SSRI agents may choose agents from the other group of antidepressants. These are commonly prescribed SSRI antidepressant medications: (1) Escitalopram 5 to 10 mg per day orally; (2) Citalopram 10 to 20 mg per day orally; (3) Sertraline 25 to 100 mg per day orally; (4) Fluoxetine 10 to 40 mg per day orally. Other antidepressants include: (1) Mirtazapine 7.5 to 30 mg before bedtime orally; (2) Trazodone 50 to 150 mg before bedtime orally; (3) Bupropion 75 to 300 mg per day orally; (4) Venlafaxine 25 to 300 mg per day orally; (5) Nortriptyline 10 to 100 mg before bedtime orally. Three new antidepressants are currently available. One is Vilazodone (Viibryd) that can be started at an initial dose of 10 mg orally once a day for 7 days, followed by 20 mg orally once a day for an additional 7 days, then a maintenance dose of 40 mg orally once a day. Second one is Levomilnacipran (Fetzima) with initial dose of 20 mg orally once a day for 2 days, then increased to 40 mg orally once a day; Maintenance dose: 40 to 120 mg orally once a day. The third novel antidepressant is Vortioxetine (Trintellix) with dosage of 5 to 10 mg per day orally.
In advanced disease stages, a significant portion of these patients develop behavioral disorders which are sometimes severe enough to incur a big burden, although not sensed well by patients themselves but mainly by caregivers and family members. Symptoms include anger with exploding tantrums, wandering, suspiciousness or paranoia, wakefulness at nighttime and incontinence, and inappropriate sexual behavior [55, 56].
Benzodiazepines can be carefully prescribed to the patients with agitation and anxiety, using a short acting agent, and on an as needed basis. While prescribing this class of medication, caution must be considered in high priority to balance potential side effects and clinical benefit. Best practices include starting with low dose treatment, while continually monitoring for fall incidence, declines in renal and hepatic function, lethargy, and any other undesirable side effects, especially in elderly patients.
The most important aspect of the management of PDD is to maintain PDD patients’ general health in terms of preventive medicine, and to keep them as independent as possible in activities of daily living (ADL).
Since PDD, like PD itself, is not curable nor reversible, long-term or chronic ongoing care is the highlight of primary care practice. More than 30% of Parkinson’s disease patients will eventually develop dementia symptoms [57]. Therefore, early counseling and a scientific based clinical prediction to detect the subtle clinic symptoms of incipient dementia in this group of patients is an advantage that PCPs have over subspecialty physicians during their daily care and more frequent routine encounters. In the last decade, the guidelines for the Annual Wellness Visit (AWV) from Center for Medicare and Medicaid Service (CMS) has provided a good essential structure for PCPs to screen, predict, detect, and manage dementia among PD patients in daily proactive care [58, 59]. During an AWV visit, the companion of family members or caregivers is highly informative and sensitive to obtain information about patients’ daily routine life patterns and memory status, and to detect subtle changes in their logical thinking and judgment. Current well-equipped telemedicine setups can provide an even better way of looking into patients’ living environment and other real-life situations around them. Periodic proactive monitoring, educational discussions, and prognosis counseling are the cornerstones for taking care of those patients and their family or caregivers. Disease burden, no doubt, is detrimental to the patient. However, family and caregivers’ stress and frustration cannot be ignored or underestimated during long-term, chronic stage, ongoing patient management. Especially, advanced PDD patients show hallucinations, wandering, suspiciousness and incontinence, and other behavioral symptoms. The management of these symptoms require tremendous efforts and resources from the caregiver [4, 8]. Early counseling and anticipating this potential development will prepare them psychologically in advance and help alleviate their stresses later. Also, making early arrangements to prepare for catastrophic happenings can lead to better solutions using wider resources and options, and can help avoid caregiver burnout. All these tasks are within the scope of the PCP’s practice. The following are the major tasks that PCPs should take care of for PDD patients from the beginning of disease to the end of their lives.
The mission for PCPs is to promote human beings’ wellbeing in aspects of general health and quality of life [60]. According to CMS requirement, recommendations from the United States Preventive Task Force and every professional specialty association practice guideline, all patients including those with PDD must be routinely and properly screened yearly according to their age group. This includes mammograph for breast cancer; fecal occult blood test, Cologuard or colonoscopy accordingly for colon cancer, low dose chest CT for patients at high risk of lung cancer, PSA for high risk of prostate cancer, CBC for leukemia, AFP and liver sonography for liver cancer and so on, even though some clinical benefits are debatable. In most situations, all these cancer screenings are recommended to be held off at age 75 and above [58, 59, 60]. However, like anything in life, exceptions should be kept in mind for any individual whose lifespan could be more than 10 years from the day when the PCP performs these screening visits.
This group of PDD patients is predominantly within the category of senior citizens. They should follow the recommendation for immunizations per CMS guidelines (summarized in Table 5), based on the CDC’s Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2021 [61].
Vaccine | Starting time | Interval |
---|---|---|
Influenza vaccine | Starting in autumn, until next spring at any age | 1 dose annually |
Pneumovax | Starting at age 65 or younger with other comorbidities. | Prevnar 13 and Pneumovax 23; one dose each within one year apart. Boost dose every 5 years |
Zoster vaccine, recombinant Shingrix vaccine | Starting at age of 50 | 2-dose series RZV (Shingrix) 2–6 months apart |
Tetanus, diphtheria, and pertussis vaccination (Tdap, Td) | Tdap followed by 1 dose Td or Tdap at least 4 weeks after Tdap and another dose Td | Td or Tdap every 10 years |
COVID-19 vaccine | Starting at any age | Pfizer and Moderna mRNA are given two doses with a 3- or 4-week interval. Johnson & Johnson’s is given one dose.* |
Schedule updating immunization [61].
Boost dose may be needed according to the update information.
Maintenance care for chronic illnesses, like hypertension, dyslipidemia, COPD, diabetes mellitus, depression, and chronic pain syndrome, should be routinely monitored. Relevant examination and adjustment of medications should be done as needed on an individual basis. The following should be considered accordingly: RetinaVue and urine microalbumin assay for diabetic retinopathy and nephropathy screening, spirometry for COPD evaluation, office-based tonometry for glaucoma screening, bone density measurement for females aged 65 and above and for males 70 years and above, or for those who have a history of a fracture before the ages specified in the guidelines above [60].
The biggest efforts should be made to communicate thoroughly with patients and their families regarding disease pathophysiology, prognosis, updated treatment guidelines and current options, potential consequences, or complications, and to patiently answer all questions sincerely and honestly in a professional manner [8, 19, 60]. A lengthy and respectful discussion with patients and their family members should be provided. For better results and efficiency, instruction should be given to patients or their families before the appointment, so that they can prepare their questions and do further research if they so choose. During the conference, attention should be paid politely. Use appropriate verbal and body languages and a comfortable office setting. Physicians should try to answer every single question, however, if time is limited or some difficulty arises, it is better to set up another appointment or location for further conversations, and to collect different perspectives. In this situation, listening is far more important than lecturing. Through this, PCPs might be able to understand a patients’ or families’ deep concern and real need, to recognize their under-the-table concerns, their inner voice, and agenda. At the end of the meeting, PCPs should make a summary and give a clear detailed picture of the treatment plan. Avoid using academic medical terminology whenever possible. Try to make sure that all medical information is delivered precisely and correctly, using lay language. Patients and their families should be well informed, allowing them to be part of the care team, and given many opportunities to be involved in the treatment, management, and planning. They should be convinced that everyone, including the patient, family, primary care provider, office supporting staff, and specialists are working together towards one goal of providing the best possible care to this individual patient and family.
General support is important, not just for PDD patients, but also for their families. Nutritional status should be evaluated, addressed, and emphasized [62]. Nutrition cannot be overemphasized and should be discussed with the caregiver and family. A well-balanced high protein diet, with adequate daily calories, and liquid intake is essential. A handbook with detailed instructions for care planning should be provided for the caregivers. The Mediterranean diet, both alone and in combination with the Dietary Approach to Systolic Hypertension (DASH) diet, may be beneficial for the prevention of cognitive decline. Further research is needed to rule out potential confounds and to better characterize the mechanisms underlying the role of nutrition in cognitive outcomes. Cessation of alcohol and cigarette smoking should be instructed. Supplement of vitamins, especially vitamin D and minerals (calcium, magnesium, zinc) should be discussed and encouraged.
Hearing loss and dementia often occur together, and hearing loss may be an independent but modifiable risk factor for subsequent dementia [63, 64]. PCPs should screen for hearing impairment and manage hearing aids for those who require them to help prevent faster deterioration of cognitive function. Patients should be encouraged to actively take part in socializing activities to maintain cognitive stimulation, such as cooperating with caregivers, family members, support networks, community resources and adult day care facilities. Patients should be arranged to participate in cognitively stimulating activities, e.g., reading, games, etc., and personally meaningful social activities, such as playing music, conversational interactions with others, family events, etc.
Over the past decade, insomnia has variably been associated with deficits in objective cognitive functioning, increased risk of dementia, and reductions in gray matter volume and white matter integrity in networks essential for cognitive functioning [65]. Sleep pattern and sleep hygiene guidance should be discussed in detail. Proper personal hygiene improves quality of life for patients, and also avoids irritation of the oral mucosa, the perineum area, and underneath the breasts, which can also improve the quality of sleep.
Prescribing hypnotic medications may be considered as needed. Benzodiazepines (BZDs) could be an option but should be used with caution. One study showed continuous exposure to BZDs and non-benzodiazepines (non-BZDs) may contribute to the development of cognitive impairment. One should be careful when prescribing BZD or non-BZD hypnotics to patients with long-term insomnia, especially for those that are aged between 50 and 65 years. Additionally, it is best to use short acting sedatives at the lowest dosage for the therapeutic benefit, because greater exposure to these medications leads to a higher risk of developing dementia [65, 66].
The above approaches require cooperation with patients, families, caretakers, or the assisting living facilities. Although there is no concrete data to prove that the above approaches will delay the deterioration of cognitive function, these approaches will assuredly improve the quality of life for PDD patients.
Polypharmacy is another significant and epidemic issue. PCPs are at a critical and unique central position for this matter. In this age group, patients with PD are most likely struggling with multiple medical conditions, such as hypertension, high cholesterol, osteoarthritis, diabetes, malnutrition, depression, etc. Patients often visit different subspecialists such as cardiologists, nephrologists, neurologists, psychiatrists, ophthalmologists, endocrinologists, and dentists. It is a challenge to be vigilant with patients who have impaired cognitive function and are under the care of multiple physicians. It is particularly important to manage their medications to avoid drug interactions, unnecessary pills, conflict among prescriptions from different subspecialties, drug overdose, compliance issues, financial difficulty, monitoring medication refills and reconciliation of medications. Some studies reveal that polypharmacy was associated with cognitive decline in patients with newly diagnosed PD. Those findings suggest that medication reduction might serve as a promising intervention to prevent the development of dementia in patients with early PD [67, 68]. For fixed income senior citizens, financial challenge for medications is an important, but pragmatic issue to discuss. A PCP can help disadvantaged patients get into assistance programs from public or private sources and the pharmaceutical industry.
Neurologists are dependable and reliable allies and consultants in the care of PDD patients, but high-level care should be individualized. Once physician and patient relationships are established long-term, PCPs should be at the center of care planning. PCPs have the advantage of knowing and understanding patients better in terms of their medical and personal history, personality, habits, family members, language, and cultural background. From that point of view, a PCP should be able to coordinate the best fitting specialists to take care of this individual within the guidelines of national and international standards [2, 8, 69].
PD and dementia are incurable neurological conditions. PD patients who develop dementia usually progress to the advanced stages of disease. PDD patients often experience specific, complex, and varying needs along their disease trajectory. A palliative approach to PDD should be discussed with patients, their caretakers, and families in advance regarding management of the advanced stages of PDD, especially at the terminal periods. PDD patients may have several needs in the four domains of palliative care (physical, psychological, social, and spiritual) in addition to specific needs for a peaceful, familiar environment, and practical support [70, 71, 72]. “Person-centered care, communication and shared decision making” is among the most important domains of palliative care in dementia [73]. An algorithm for the evaluation and management of PDD patients across the disease stages is depicted in Figure 2, summarizing much of the above recommendations.
Counseling for advance medical directive (AMD) or advance care planning (ACP) should be routine care tasks for PCPs. Medical and advance care directives (e.g., designation of power of attorney) should be discussed as early as possible while the mental functions of patients are still competent, allowing patients and their families to have enough time to discuss and plan. ACP is a special form of ongoing communication about preferred future health care [70]. Long-term health care planning (e.g., living arrangements in the late stage of dementia) and financial planning are other important issues for patients and families to discuss and plan well in advance. In California, the Physician Orders for Life-Sustaining Treatment form or POLST (pink form) is routinely used in the PCP’s office for the purpose of making the patients’ advanced directives clear and easily obtainable. Physicians should explain the meaning and the consequences of the decision making with patients and family in detail. This process should be highly informative and provide guidance so that patients may come to their informed decision comfortably.
To optimally promote quality of life and death of a person affected by a complex, incurable, and life-threatening health problem, such as dementia, care teams must address the person’s physical, emotional, psychosocial and spiritual needs, as summarized in the WHO definition of palliative care. Dementia usually occurs during the later stages in PD, when clinical symptoms could be progressing quite rapidly, complicated by aging and other comorbidities. Once PD reaches such an advanced stage, the approach towards care should shift towards palliative care, or its consideration. Palliative care can start in the form of ACP if the patient and family caregiver are willing to talk about the future soon after the diagnosis of PDD. The focus of care should be well planned, but simple with straightforward symptom management. Care of the person, not disease per se, is important. This approach includes attention to physical, mental, social, and spiritual aspects, especially since there are no cures available with current interventions. Figure 3 outlines a model for palliative care of PDD patients. The palliative care should be carried out by a comprehensive team which includes physicians as leaders, registered nurses, office supportive staff, social workers, religious leaders, family members and/or supporting network, a disease focus group and so forth. An in-home model of palliative care for homebound advanced PD and PDD patients was recently introduced in 2020, which highlights the importance of medication reconciliation, home safety assessments, and appropriate monitoring and treatment of orthostatic hypotension, a leading cause of falls [71]. At this stage not only patients’ needs, but also families’ needs should be addressed. Options like assisted living homes, boarding care, and skilled nurse facilities should be discussed when those needs arise. The goal at an advanced stage, which may eventually progress to the level of hospice care, is to minimize the suffering and improve the quality of life for both patients and their families or caregivers.
Model for palliative care of PDD patients.
Pain is often difficult to assess in people with advanced dementia due to loss of communicative ability [74]. This can result in patient concerns about pain not being heard or being misinterpreted. Communication difficulties are a challenge to practitioners because there may be several possible causes of distress and possibly no particular localizing behaviors or signs associated with pain in an individual with dementia [72]. Agitation is a frequent symptom in dementia patients and may be associated with untreated pain. Studies show that agitation and aggressive symptoms decrease when pain is effectively treated [75]. Proper and effective pain control and the judicious utilization of opioid and benzodiazepine medications during palliative care is a critical step in successful care. Pain is distressful for both patients and their families and can trigger a cascade of other symptoms. For best results, a specialized pain management team, trained nurse practitioner or physician assistant may be consulted or invited into the care team. Fortunately, in the current healthcare system of the United States of America, well designed palliative care/hospice enterprises are established, and widely available for primary care physicians to adopt and refer their patients and families. This facilitates a well-designed, professional, and individually tailored optimal palliative care plan for the many stresses and discomforts associated with end of life.
The burden of caring for a dementia patient may be physical/medical (e.g., neglect of caregiver’s own health, with potential medical complications), emotional and psychological (stress, burnout, depression), and/or financial. Prevention, early recognition, and treatment of these issues (e.g., referrals to social work for additional support), are integral to an effective management plan [76]. PCPs should engage the office staff, benefit and personnel specialists, and social workers in dealing with disease stage transitioning, personal financial issues, and interfamilial relationships. They, in many cases, need to activate available funding sources at the state and federal levels. Questions regarding the patient’s driving safety and privileges should be raised at the appropriate time and stage of the disease. PCPs are the advocates of patients in protecting their loved ones from becoming burned out due to the long term duties of caregiving. In the end, PCPs function as liaisons on behalf of patients and their caregivers in not only coping with but also fighting against this devastating disease.
PCPs play an important role in the management of PDD patients. The art of practice for PCPs includes knowing when and how to introduce a comprehensive ongoing care plan for individual PDD patients. A comprehensive ongoing care plan includes (1) screening for changes in mental function regularly, (2) properly diagnosing PDD, (3) applying nonpharmacologic and pharmacologic interventions accordingly, (4) orchestrating multidisciplinary care, special therapies, and auxiliary support accordingly, (5) consulting advance medical directive and palliative care early. The optimal goal is to maintain relative independence for PDD patients, if this is safe. It is reasonable and proper to initiate palliative care and hospice for PDD patients in the advanced stage to provide better qualities of their later life experience.
The authors thank Micha Y.Z. Cheng, MPH, MD and Justin Cheng, MD for their assistance. This book chapter is partly supported by the 2021 Mid-Year Innovation Project from Sutter Independent Physician Medical Group.
The authors declare no conflict of interest.
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But physically, this replacement has a significant gain: a DBM is roughly equivalent to a hydrodynamic model supplemented by a coarse-grained model of the thermodynamic non-equilibrium (TNE) effects, where the hydrodynamic model can be and can also be beyond the NS. Via the DBM, it is convenient to perform simulations on systems with flexible Knudsen number. 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Using the example of a path-generating mechanism, it will be demonstrated that the suggested angle-based method for synthesizing a compliant mechanism with individually shaped hinges can be used to design high-precise and large-stroke compliant mechanisms. The approaches can be used for the accelerated synthesis of planar and spatial flexure hinge-based compliant mechanisms.",book:{id:"7794",slug:"kinematics-analysis-and-applications",title:"Kinematics",fullTitle:"Kinematics - Analysis and Applications"},signatures:"Sebastian Linß, Stefan Henning and Lena Zentner",authors:null},{id:"67535",title:"The General Kinematic Pair of a Cam Mechanism",slug:"the-general-kinematic-pair-of-a-cam-mechanism",totalDownloads:1267,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"At present, there are still increasing demands on the performance parameters of machinery equipment as well as cam mechanisms that belong to it. For this reason, the operating speeds and hence inertial effects of moving bodies, which limit the utilizable working frequency of machines, are increasing. These facts are the cause of higher wear and a decrease of the overall lifetime and reliability of machines. The force ratios in the general kinematic pair created by contact between the cam and the follower cause the contact stress. The generated stresses are transient and have a pulse shape. Fatigue damage of the cam working surface or the follower working surface may occur after exceeding a certain limit value of these stresses during the cam mechanisms running. This damage is in the form of cavities (pitting), which develop from cracks on the working surface. The chapter aim is to outline the issues of the dynamic stress of a general kinematic pair of a cam mechanism. One of the possible methods of the complex solution of the stress of the general kinematic pair is to use the possibilities of the finite element method in combination with the knowledge and conclusions of the contact mechanics.",book:{id:"7794",slug:"kinematics-analysis-and-applications",title:"Kinematics",fullTitle:"Kinematics - Analysis and Applications"},signatures:"Jiří Ondrášek",authors:null},{id:"66017",title:"Kinetostatic Nonlinear Stiffness Characteristic Generation Using the Kinematic Singularity of Planar Linkages",slug:"kinetostatic-nonlinear-stiffness-characteristic-generation-using-the-kinematic-singularity-of-planar",totalDownloads:841,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The theory of nonlinear stiffness characteristic by employing the kinematic limb-singularity of planar mechanisms with attached springs is proposed. After constructing the position formula with closed-loop form of the mechanism, the kinematic limb-singularity can be identified. The kinetostatic model can be obtained based on the principle of virtual work. The influences of spring stiffness on the force-displacement or torque-angle curve are analysed. Different spring stiffness results in one of four types of stiffness characteristic, which can be used to design an expected stiffness characteristic. After replacing corresponding joints with flexures, the pseudo-rigid-body model of the linkage with springs is obtained. The compliant mechanisms with nonlinear stiffness characteristic can further be synthesised based on the pseudo-rigid-body model.",book:{id:"7794",slug:"kinematics-analysis-and-applications",title:"Kinematics",fullTitle:"Kinematics - Analysis and Applications"},signatures:"Baokun Li and Guangbo Hao",authors:null},{id:"67222",title:"Kinematic Absolute Positioning with Quad-Constellation GNSS",slug:"kinematic-absolute-positioning-with-quad-constellation-gnss",totalDownloads:1007,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The absolute positioning technique is based on a point positioning mode with a single Global Navigation Satellite System (GNSS) receiver, which has been widely used in many fields such as vehicle navigation and kinematic surveying. For a long period, this positioning technique mainly relies on a single GPS system. With the revitalization of Global Navigation Satellite System (GLONASS) constellation and two newly emerging constellations of BeiDou Navigation Satellite System (BDS) and Galileo, it is now feasible to carry out the absolute positioning with quad-constellation of GPS, GLONASS, BDS, and Galileo. A combination of multi-constellation observations can offer improved reliability, availability, and accuracy for position solutions. In this chapter, combined GPS/GLONASS/BDS/Galileo point positioning models for both traditional single point positioning (SPP) and precise point positioning (PPP) are presented, including their functional and stochastic components. The traditional SPP technique has a positioning accuracy at a meter level, whereas the PPP technique can reach an accuracy of a centimeter level. However, the later relies on the availability of precise ephemeris and needs a long convergence time. Experiments were carried out to assess the kinematic positioning performance in the two different modes. The positioning results are compared among different constellation combinations to demonstrate the advantages of quad-constellation GNSS.",book:{id:"7794",slug:"kinematics-analysis-and-applications",title:"Kinematics",fullTitle:"Kinematics - Analysis and Applications"},signatures:"Lin Pan, Changsheng Cai, Jianjun Zhu and Xianqiang Cui",authors:null}],onlineFirstChaptersFilter:{topicId:"1393",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:8,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:286,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:9,numberOfPublishedChapters:101,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). 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He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. 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Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. Vice-chief of the editorial board of Chinses Journal of Mycology, China. Board Member and Chair of Mycology Group of Chinese Society of Dermatology.",institutionString:null,institution:{name:"Sichuan University",institutionURL:null,country:{name:"China"}}},editorTwo:null,editorThree:null},{id:"5",title:"Parasitic Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",isOpenForSubmission:!0,annualVolume:11401,editor:{id:"67907",title:"Dr.",name:"Amidou",middleName:null,surname:"Samie",slug:"amidou-samie",fullName:"Amidou Samie",profilePictureURL:"https://mts.intechopen.com/storage/users/67907/images/system/67907.jpg",biography:"Dr. Amidou Samie is an Associate Professor of Microbiology at the University of Venda, in South Africa, where he graduated for his PhD in May 2008. He joined the Department of Microbiology the same year and has been giving lectures on topics covering parasitology, immunology, molecular biology and industrial microbiology. 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His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. 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The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",annualVolume:11403,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",fullName:"Alexandros Tzallas",profilePictureURL:"https://mts.intechopen.com/storage/users/5886/images/system/5886.png",institutionString:"University of Ioannina, Greece & Imperial College London",institution:{name:"University of Ioannina",institutionURL:null,country:{name:"Greece"}}},{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",fullName:"Lulu Wang",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRX6kQAG/Profile_Picture_1630329584194",institutionString:null,institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}},{id:"225387",title:"Prof.",name:"Reda",middleName:"R.",surname:"Gharieb",fullName:"Reda Gharieb",profilePictureURL:"https://mts.intechopen.com/storage/users/225387/images/system/225387.jpg",institutionString:"Assiut University",institution:{name:"Assiut University",institutionURL:null,country:{name:"Egypt"}}}]},{id:"8",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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