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Nice guidelines 2006. Dementia. 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

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Definition
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


Diagnosis
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


History
History

  • Age

  • Family history

  • Progress of condition

  • Associations – myoclonus or seizures

  • Exposure to toxins – alcohol, lead drugs (barbiturates)


Examination
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


Cognitive tests
Cognitive tests

  • Should include tests for

    • Attention and concentration

    • Orientation

    • Short and long term memory

    • Praxis

    • Language

    • Executive function


Cognitive tests1
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


Investigations
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


Investigations1
Investigations

  • Other investigations if appropriate

    • MSU if suspect delirium

    • Syphylis serology

    • HIV – in a young person

    • Caeruloplasmin – Wilson’s disease


Specialist investigations
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


Types
Types

  • Alzheimer's

  • Vascular dementia

  • Dementia with Lewy bodies

  • Frontotemporal dementia


Referral
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


Management
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


Management1
Management

  • Non cognitive symptoms

    • Hallucinations

    • Delusions

    • Anxiety

    • Marked agitation

    • Aggressive behaviour

    • Wandering

    • Hoarding

    • Sexual disinhibition

    • Disruptive vocal behaviour

    • Apathy


Management2
Management

  • For non cognitive symptoms

    • Only consider medication if severe distress or risk of harm to the person or others


Management3
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


Management4
Management

  • For co-morbid agitation consider

    • Aromatherapy

    • Multisensory stimulation

    • Therapeutic use of music and or dancing

    • Animal assisted therapy

    • massage


Management5
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


Management6
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


Management7
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


Management8
Management

  • Depression

    • CBT

    • Reminescence therapy

    • Multisensory stimulation

    • Animal assisted therapy

    • Exercise

  • Drugs

    • SSRI’s – citalopram start 10mg also helps agitation


Ethics and consent
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.


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