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Dementia Practical management
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Case 1 77 year old widow – no family
Referred by consultant geriatrician to outpatients Admitted 3 months ago with fall Noted to be confused – MMSE 21/30 PMH hypertension, hypothyroidism Bloods normal CT brain – ‘small vessel disease’
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Your thoughts Further assessment at that stage Differential diagnosis
Management
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What actually happened
Vascular dementia diagnosed GDS noted to be 9/15 Started on trazadone 50mg nocte Discharged with 1x/day care Referral to me for opinion/further treatment Copy of discharge letter to CPN
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Your thoughts Anything else you would have done?
Would you have done anything differently?
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What actually happened
Within one month GP arranges admission to nursing home Seen in clinic – distressed, no CPN contact, GDS 12/15
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Learning points Consider depression – treat appropriately
Arrange psychiatry liaison assessment whilst in-patient – facilitates appropriate CPN follow up Consider independent advocacy for vulnerable/isolated people Encourage GPs to seek specialist opinion before arranging institutionalisation Know how to diagnose Vascular dementia
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ICD-10 VaD Vascular (formerly arteriosclerotic) dementia, which includes multi-infarct dementia, is distinguished from dementia in Alzheimer's disease by its history of onset, clinical features, and subsequent course. Typically, there is a history of transient ischaemic attacks with brief impairment of consciousness, fleeting pareses, or visual loss. The dementia may also follow a succession of acute cerebrovascular accidents or, less commonly, a single major stroke. Some impairment of memory and thinking then becomes apparent. Onset, which is usually in later life, can be abrupt, following one particular ischaemic episode, or there may be more gradual emergence. The dementia is usually the result of infarction of the brain due to vascular diseases, including hypertensive cerebrovascular disease. The infarcts are usually small but cumulative in their effect.
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Liaison psychiatry Who Cares Wins Size of problem in 55-bed DGH
Size of problem in 55-bed DGH 330 older people 220 have a mental disorder 96 depression, 66 delirium, 102 dementia, 23 other major disorder
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Liaison Psychiatry referral
Assessment Diagnosis Behaviours Suicide risk Capacity (guardianship) Management Services & support on discharge
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Case 2 84 years male retired architect Seen in OPD ?DLB ?vascular
On holiday in France neighbours ring daughter in Greece Confused, poor self-care Flown home Not eating/cooking, confused, hallucinations Trying to get out of car whilst travelling at 60mph GP rings to arrange acute admission
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Case 2 (cont) No acute illness identified
Visual hallucinations of people Initially a little agitated & wandering MMSE 26/30 but variable Some Parkinsonian signs
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Your thoughts Further assessment at that stage Differential diagnosis
Management
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What actually happened
Background from daughter confirmed much worse over last 2 months OT assessment Variable dressing ability Very poor in kitchen Structural CT – ‘normal’ DAT scan – reduced DA uptake Neuropsychological assessment PD-like
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Your thoughts What next?
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What actually happened
Started rivastigmine Psychiatry referral for ongoing support Home ‘crisis care’ trial
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Learning points Assessment includes
Physical health Neuropsychology Imaging Psychiatry OT etc Disease course can be unpredictable Variability may need ‘trial’ assessments
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Neuropsychology referral
Normal or abnormal? Especially high pre-morbid IQ Aetiology – AD, VaD etc? Little point if does not affect management Little point if MMSE <<20 Any change – need at least 6-9 months e.g. in MCI Sensory impairments that may need visual/auditory tests
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Case 3 45 year old woman with Down syndrome
1 year increasing confusion Forgetting names More withdrawn & lacking interest Some disruption of sleep ADLs not quite so good Urinary incontinence Some faecal incontinence
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Case 3 (cont) Clinical psychology ambivalent – some evidence of decline, especially in social skills Examination – no focal signs or cardiovascular problems Blood tests all OK
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Your thoughts Further assessment at that stage Differential diagnosis
Management
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What actually happened
Further history from another carer indicated longer term faecal incontinence problems & UTIs District nurse involved Faecal continence improved Fewer UTIs Cognitive abilities & social skills returned to previous level
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Your thoughts Further management?
How would you have managed this patient had she been admitted on your acute take?
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What actually happened
Followed up at 3 months, 6 months & 1 year – all OK Not quite so good at 18 months Repeat clinical psychology at 2 years suggests decline Probable dementia – but happy & major risks of cholinesterase treatment At 3 years significantly worse & at risk of nursing home – starts treatment
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Learning points Cause & effect can be difficult to ascertain sometimes
Recurrent episodes of delirium can look like dementia, especially on background of intellectual disability Broadening corroborative history can be important Single accounts may be biased towards emphasis or omission Community assessment often useful
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The Community Learning Disability Team
Led by psychiatrist in learning disability Tends to end up managing physical problems if GP not engaged Specialist services may include Epilepsy clinic Clinical psychology Physiotherapy SLT Long term relationships with team often mean users are known very well Families often less involved
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Time for discussion & questions
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