Dementia

1. Nice guidelines 2006 Dementia

2. Definition • Widespread deterioration in cerebral function without impairment of consciousness. • Occurs across a widespread of abilities • Memory – learning new materials • Analytical thought • Judgement and planning • Handling of language and spatial abilities • Social responsiveness • Conduct and feeling • Basic tasks of self care

3. Diagnosis • Clinical picture at anytime is determined by • Persons previous personality and intellectual endowment • The nature of the pathological process and the stage it has reached

4. History • Age • Family history • Progress of condition • Associations – myoclonus or seizures • Exposure to toxins – alcohol, lead drugs (barbiturates)

5. Examination • Exclude dysphasia as a cause for apparent dementia • Look for neurological signs • Find information about the patient’s social functioning which would not be normal for dementia

6. Cognitive tests • Should include tests for • Attention and concentration • Orientation • Short and long term memory • Praxis • Language • Executive function

7. Cognitive tests • MMSE • 6-Item cognitive impairment test • General Practitioner assessment of cognition • 7-minute screen • Take into account educational level, skills, prior level of functioning and attainment, language, sensory impairment, psychiatric illness and physical or neurological problems

8. Investigations • Fbc esr – anaemia, vasculitis • T4 TSH – hypothyroidism • Biochemical screen – hypo or hypercalcaemia • U&E’s - renal failure, dialysis dementia • Fasting blood glucose • B12 folate – vitamin deficiency dementia • Lft’s

9. Investigations • Other investigations if appropriate • MSU if suspect delirium • Syphylis serology • HIV – in a young person • Caeruloplasmin – Wilson’s disease

10. Specialist investigations • CSF – Jacob Creuztfelt disease • Brain biopsy • Imaging • MRI best if not available then CT scan • SPECT scan to differentiate Alzheimer's, vascular and fronto-temporal dementia

11. Types • Alzheimer's • Vascular dementia • Dementia with Lewy bodies • Frontotemporal dementia

12. Referral • Refer all patients with abnormal scores on cognitive testing to specialist memory clinic. This provides • More detail cognitive assessment • Imaging to exclude other disorders • Social support for patient and carer’s • Support groups • Medico-legal issues • Education about illness

13. Management • Mild to moderate dementia • Offer opportunity to participate in a structured group cognitive stimulation program • Drugs • Acetylcholinesterase inhibitors should be considered for those with moderate alzheimer’s disease mmse 10-20 points. Should be started by a specialist. They should not be used in vascular dementia or in MCI

14. Management • Non cognitive symptoms • Hallucinations • Delusions • Anxiety • Marked agitation • Aggressive behaviour • Wandering • Hoarding • Sexual disinhibition • Disruptive vocal behaviour • Apathy

15. Management • For non cognitive symptoms • Only consider medication if severe distress or risk of harm to the person or others

16. Management • Fro distressing non cognitive symptoms assess and treat • Physical health • Depression • Possible undetected pain or discomfort • Side effects of medication • Psychosocial factors • Physical environmental factors

17. Management • For co-morbid agitation consider • Aromatherapy • Multisensory stimulation • Therapeutic use of music and or dancing • Animal assisted therapy • massage

18. Management • Antipsychotics • Do not use in mild to moderate non cognitive symptoms in • Lewy body dementia as risk severe reaction • Alzheimer’s, vascular or mixed dementia’s because of increased risk of cerebrovascular adverse events and death

19. Management • Antipsychotics • Consider for severe non cognitive symptoms only if (seek advice from dementia specialist first) • Risks and benefits fully discussed • Target symptoms have been quantified and are being regularly assessed and recorded • Co-morbid conditions such as depression have been assessed • The dose is low and titrated upwards and of time limited duration

20. Management • Behaviour that challenges • Environmental, physical health and psychosocial factors that might cause it • Overcrowding • Lack of privacy • Lack of activities • Inadequate staff attention • Poor communication with patient • Conflicts between staff and carers

22. Management • Depression • CBT • Reminescence therapy • Multisensory stimulation • Animal assisted therapy • Exercise • Drugs • SSRI’s – citalopram start 10mg also helps agitation

23. Ethics and consent • Always seek valid consent, explain options, check understanding. • Use mental capacity act 2005 if person lacks capacity • Only disclose personal information without consent in exceptional circumstances • Discuss advanced statements, advanced decisions to refuse treatment, power of attorney.