Dementia Flashcards
Definition
An acquired chronic brain syndrome characterised by a decline from a previous level of cognitive functioning with impairment in ≥ 2 cognitive domains (such as memory, executive functions, attention, language, social cognition and judgement, psychomotor speed, visuo-perceptual or visuospatial abilities) - sufficient to impair ADLs
IN CLEAR CONSCIOUSNESS
The cognitive impairment is not entirely attributable to normal aging and significantly interferes with independence in the person’s performance of activities of daily living.
Epidemiology
Incidence increases with age
<65yo = early-onset dementia
Females > males affected
Symptoms
1st: forgetfulness (stepwise or progressive)
2nd: disorientation (time à place à person) à management problems…
- Wandering
- Sleep-disturbance
- Delusions
- Hallucinations
- Calling out
- Inappropriate behaviour / aggression
Investigations
Cognitive Assessment:
Screening -> AMTS, GPCOG
- AMTS (score <7 suggests cognitive impairment)
- GPCOG (GP Assessment of Cognition)
Detailed -> Addenbrooke’s (ACE-R), MMSE, MoCA
- MMSE = 30 questions [old, not widely used]
- ACE-R = 100 questions
Dementia/delirium screen:
- TFTs (hypothyroid -> cognitive decline)
- LFTs (Korsakoff’s)
- U&Es and dipstick (infection, diabetes)
- HbA1c (diabetes)
- Vitamin B12 and folate
Further Tests:
Alzheimer’s: FDG-PET, CSF, MRI (grey matter atrophy, wide ventricles & sulci, temporal lobe atrophy)
Vascular: ECG (AF with emboli), MRI/CT
Lewy Body: 123I-FP-CIP SPECT (DaTScan; a tracer 123I-FP-CIP used in Single Photon Emission CT), I-MIBG
Frontotemporal: FDG-PET, perfusion SPECT, MRI (frontal lobe shrinkage)
Memory Assessment Clinic referral (after GP): Delirium vs. Dementia
- Take a collateral history and check bloods - Confusion Assessment Method (CAM)
- Risk assess the patient - Observational Scale of Level of Arousal (OSLA)
- Cognitive assessment – MMSE
- Brain scan (check organic pathology)
Management of confirmed dementia
- Provide a single named care manager/ coordinator
- Optimise Physical Health
- Treat sensory impairment (hearing aids, glasses)
- Exclude superimposed delirium
- Treat underlying risk factors
- Review all medication
- Specialist Non-Pharmacological Interventions
- Structured group cognitive stimulation programs
- Memory Reminiscence therapy with discussion of past experiences
Tools such as life histories, shared memories, familiar objects from the past- usually in a group setting
Complications
- Disability, dependency, and morbidity
- Behavioural and psychological symptoms of dementia (BPSD)
- Institutionalisation
- Carer morbidity
- Financial hardship
AChEi side effects:
- N+V, diarrhoea, anorexia
- Fatigue, dizziness, headache
- Muscle cramps
- Sludge- cholinergic crisis
AChEi contraindications:
- GI disease
- Recent pancreatitis
- Bradycardia, sick sinus syndrome, significant AV block
- Asthma/ COPD
Prognosis
Life-limiting condition
Length of time between diagnosis and death varies widely
Dementia found to progress more rapidly after an episode of delirium
Behavioural and Psychological Symptoms of Dementia (BPSD)
Dementia plus something that wasn’t there before
- May fluctuate
- May last for ≥ 6 months
Include:
- Psychosis
- Agitation and emotional lability
- Depression and anxiety
- Withdrawal or apathy
- Disinhibition
- Motor disturbance- wandering, restlessness, pacing, repetitive activity
- Sleep cycle disturbance or insomnia
- Tendency to repeat phases or questions
- Difficulties with ADLs
- Neglect household tasks
- Neglect nutrition (causing weight loss)
- Neglect personal hygiene and grooming
- Increasingly making mistakes at work
Management of BPSD
1st line: Behavioural management techniques - e.g., changing environment/ staff support
Sensory stimulation
2nd line: Risperidone
3rd line: Olanzapine
4th line: Lorazepam
Adaptations for Patients
- Always carry ID, address and contact number in case they get lost
- Dossett boxes/ blister packs to aid medication compliance
- Reality orientation (visible clocks, calendars)
- Environmental modifications (e.g. patterned carpets can predispose to hallucinations)
- Assistive technology (e.g. door mat buzzers)
- Do a home safety assessment and ensure that adaptations are made to home (fires, floods, falls)
- Optimise physical health
- Consider occupational therapy
- Triggers for risky behaviour identified
- Driving and the DVLA
If diagnosed, a driver MUST inform the DVLA and insurers
Social Support
- Personal care, meal preparation and medication prompting
- Day centres provide enjoyable daytime activities and social contact
- Day hospitals enable daily psychiatric care for more complex patients
- OT imp to make home easier to live in
Wishes for Future Care whilst Mental Capacity still Intact
- Advance statements
- Advance decisions
- Lasting Power of Attorney
- Preferred place of care
Support Carers
- Emotional support
- Offer carer’s assessment
- Educate about dementia
- Train to manage common problems
- Provide respite care
- Admiral nurses support whole fam with dementia
Patient Information:
- Alzheimer’s Research UK
- The Alzheimer’s Society
- The Lewy Body Society
- Frontotemporal Dementia Support Group
- Carers UK
Pseudodementia
Depression vs Dementia
Dementia progresses slowly- takes time for patients to notice symptoms -> usually others who notice symptoms
Dementia -> remember significant life events which occurred many years earlier, first memory issues are usually related to loss of short-term memory and inability to remember new things
Features suggestive more of Depression
- Short history
- Rapid onset (< 6 months)
- Biological symptoms
- Patients are worried about poor memory
- Reluctant to take tests- disappointed with results
- Mini-mental test score is variable
- Global memory loss (whereas dementia is recent memory loss)
- MMSE scores
24-30= no cognitive impairment
18-23= mild cognitive impairment
0-17= severe cognitive impairment
RULE of THUMB for MMSE
Depression- answer with “I don’t know”
Alzheimer’s- have a go and get it wrong
