1. Care of the elderly - dementia
Dafydd Rees 24/2/09

2. Dementia - definition Chronic condition Difficulties in
Memory
Language
Psychological and psychiatric changes
Impairments in activities of daily living

3. Background Aging population, common
637,000 in UK, annual cost £17bn, (heart disease 4bn, CVA 4bn, cancer 2bn)
Cost of care
Impact on carers
Do we deal with it well? Recognition, treatment, hopelessness, stigma
Push to increase awareness

4. Management Recognition Investigations Consider vascular RF, depression
Patient/family report
Informant history
Assess cognitive function - MMSE,6CIT
Investigations
Bloods: FBC,B12,folate,U+E,bone,Glc,LFT,TFT
Possibly: CXR,ECG, syphilis/HIV
Consider vascular RF, depression
Consent to discuss with family
Refer

5. 6 item cognitive impairment test (google 6CIT)
6 questions:
What year is it?
What month is it?
Give an address phrase with 5 components eg. John,Smith,42,High St,Bedford)
About what time is it? (within 1 hour)
Count backwards 20-1
Say the months of the year in reverse
Repetition:
Repeat address phrase.

6. Subtyping of dementia Alzheimer’s disease (50%)
Vascular dementia (25%)
Mixed alzheimer’s and vascular
Lewy body dementia (15%)
Others (5%) frontotemporal, focal, PD, intracranial lesions
Explain Alzheimer’s disease to a patient/carer.

7. Alzheimer’s disease
Chronic progressive neurodegenerative disorder - 3 groups of symptoms
Cognitive: memory, language, executive function
Psychiatric/behavioural (non-cognitive): depression,hallucinations,delusions,agitation
Problems with ADLs - instrumental/basic
Insidious onset

8. Mild cognitive impairment (MCI)
Subjective Sx (memory), ADLs OK
Observable several yrs before dementia
Not different from normal ageing
Not detectable in clinical encounter
May not progress, no test to identify
15 times more likely to develop dementia
Transition: detectable decline - 2 to 5 yrs

9. Prevention No cause identified Some genetic influence, Down’s syndrome
‘Brain healthy’ - seven signposts
Keep brain active
Healthy diet
Physical activity
CV risk factors
Social activities
Don’t smoke, moderate alcohol
Avoid head injury

10. Treatment Acetylcholinesterase inhibitors
Moderate disease (MMSE 10-20)
Donepezil, galantamine, rivastigmine
Review every 6/12
Contine if score >10 and ‘worthwhile effect’

11. Other causes Vascular dementia - days Depression - weeks
Lewy body dementia
PD type motor features
Visual hallucinations
Fluctuation in symptoms
Night time confusion
Adverse reactions to antipsychotics

12. Support Holistic approach, patient and family
Information: alzheimers.org.uk, local support services
Financial, legal and advocacy advice
Medico-legal issues - driving
? Vulnerable adult
Respite care
Aim: maximise independent activity

13. Non-cognitive symptoms
Examination - infection,pain
Depression?
Adverse drug effects
Environmental factors
Care plan approach - aromatherapy, music, pets, massage
Carer input is critical

14. Pharmacological interventions
First choice if severe distress/potential of harm
Otherwise second line only
Lowest effective dose
Oral before parenteral
Effect on relationship with patient/carers
Consider CV risk,sedation and risk of falls,cognitive decline

15. Medication options Mild agitation: Severe agitation/psychosis:
Trazodone, lorazepam, citalopram, valproate
Severe agitation/psychosis:
Quetiapine, risperidone,olanzapine
Depressive symptoms:
Citalopram, sertraline
Severe behavioural problems:
Haloperidol, small dose(0.5-4mg), time limited
Acute severe: lorazepam/haloperidol IM

16. End of life care Normal palliative approach Advance statements
Encourage to eat and drink for as long as possible
Do not use tube feeding
CPR is unlikely to succeed

17. Capacity Ability to: Decision specific and vary over time
Understand
Retain
Weigh up
Communicate decision
Decision specific and vary over time
May need a specialist opinion for big decisions
Lasting power of attorney, court of protection, living wills

18. Mental capacity Act 2005
Assume to have capacity unless proved otherwise
Must have all available support before concluding lack of capacity
Retain the right to make eccentric/unwise decisions
If no capacity - decisions in the best interests with minimum restrictions to rights and basic freedoms

19. Tips Consider dementia if memory problems Days, weeks, months/years
Occasional lapses of memory are common - review if in doubt
Suspect if they turn to spouse to answer a simple question
If suspicious - informant Hx
Low threshold for referral

20. References Dementia: Burns,Iliffe BMJ.2009;338:b75
Alzheimer’s disease: Burns,Iliffe BMJ.2009;338:b158
NICE guidelines on dementia (2006): nice.org.uk
Alzheimer’s society: alzheimers.org.uk