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Care of the elderly - dementia

Care of the elderly - dementia. Dafydd Rees 24/2/09. Dementia - definition. Chronic condition Difficulties in Memory Language Psychological and psychiatric changes Impairments in activities of daily living. Background. Aging population, common

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Care of the elderly - dementia

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  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 • 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: • 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: • 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

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