Older People with Cognitive Decline at home Pushing the Limits

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					Older People with
Cognitive Decline at home:
Pushing the Limits

    Dr Ronald Morgan
         Some important facts

 What is dementia? (cf delirium)
 How to diagnose
 Classification
 What tests should I carry out?
 How might it be managed
          What is dementia?

Global impairment of memory, intelligence
  (attention, language, problem solving) and
  personality in the setting of clear
  consciousness and of greater than 3 months
Prevalence of dementia

Over 65s        5%

Over 80s        20%
         What about delirium?
Recent onset of:

 Fluctuating awareness
 Impairment of memory & attention
 Disorganised thinking
              Delirium cont.
In addition there may be:

 Hallucinations
 Disturbance of sleep – wake cycle
  Confusion Assessment Method
1. Acute onset & fluctuating course
2. Inattention
3. Disorganised thinking
4. Altered level of consciousness

Diagnosis requires 1 and 2 plus either 3 or 4
 How do you recognise dementia?
 Abbreviated Mental Test Score (AMTS)

 Mini Mental State Examination (MMSE)

 Clock drawing test

1. Age                  6. Recall
2. Date of birth        7. Recognition 2 people
3. Year                 8. Monarch
4. Time (nearest hr.)   9. WW1 or 2
5. Place                10. Count 20 to 1
AMTS interpretation

No half marks to be given

A score of 7 or less is abnormal, but is not
  diagnostic of any condition
30 point score:

Orientation in time    5
Orientation in place   5
Attention & calc.      5
Registration           3
Recall                 3
          MMSE continued
Language                9
  naming            2
  repetition        1
  3 stage command   3
  reading           1
  writing           1
  copying           1
MMSE interpretation
Greater than 24 is normal
Less than 20 is abnormal
20 – 24 may indicate dementia

NB Hearing, eyesight, education

Do serial tests if unsure
            Clock drawing test

Draw in the numbers and
  hands on the clock face
  setting the time to 10
  past 11
Clock test – simple interpretation
Circle                     1
Numbers in correct order   1
Numbers in special order   1
Hands                      1
10 past 11                 1

4 or 5 is normal
        Types of dementia (1)


 Alzheimers (35%)
 Vascular (20%) – many types
 Dementia with Lewy bodies (15%)
 Alcoholic
        Types of dementia (2)
Less common:
 Creutzfeldt – Jakob (sporadic & new variant)
 Huntingdons
 AIDS related
 Parkinson’s disease
 Frontotemporal (Pick’s disease) – 5%
 Down’s syndrome
 Trauma or toxic injury
          Types of dementia (3)
Treatable (about 5% of total):
 Hypothyroidism
 Vitamin B12 deficiency
 Folate deficiency
 Normal pressure hydrocephalus
 Tumour (1º, 2º or paraneoplastic)
 Depressive pseudodementia
 Syphilis
    What tests should I carry out?
FBC, U & Es, LFTs, calcium, B12, folate, TSH,


(but do examine the patient first!)
 Aspirin, statin, antihypertensive for vascular

 Cholinesterase inhibitors for Alzheimers
  (but see NICE guidelines)
                 Ethical issues
 Capacity
 Right to self determine
 Patient’s rights versus rights of family & neighbours
 Advance directives (advance statements, living wills)
 Food & drink refusal – swallow normal
                            swallow abnormal
 Do not resuscitate
 Do not admit to hospital
                     Case study 1
1 MS, an 84 year old woman brought into hospital for
   emergency repair of strangulated hernia. Very confused
   both pre and post op. MMSE 5/30. Her short term memory
   is virtually non existent.

Transferred to Sydenham House for ‘rehab.’
Physically very well though has no recollection of operation or why
   she isn’t at home.
Wanders around the unit asking to be taken home.
Family extremely concerned about her return home, saying she is
   at risk.
1 Does she have capacity to determine her future?
2 How would you assess her ability to manage at home ?
                      Case study 2
 2 FH is an 86 year old woman who has suffered a left sided
    CVA which has left her with some expressive dysphasia.
    Her comprehension of language seems to be intact. She is
    physically well. She expresses a desire to go home but her
    3 sons think she should go into Residential Care. ( 1 son in
    France, 1 in Yorkshire, 1 local but doesn’t drive). In the
    past she has refused carers
   She is taken on a home visit (lives in sheltered housing) and
    becomes distressed at home as she equates home with the
    family home that she lived in for many years but hasn’t lived in
    for several years now.
   1 Does she have capacity?
   2 Should her wish to go home be honoured
   3 Are her sons acting in her best interests?
                    Case study 3

 3 You are asked to see an 80 year old woman resident at
  one of the local Care homes. She has a 5 year history of
  Alzheimer’s disease and remains physically quite well. The
  carers tell you that she is refusing to eat (& sometimes to
  drink), other than a few tea spoons. Mostly she just pushes
  away the person who tries to feed her.

 When you see her she is very amiable and on examination there
  are no abnormalities. You perform routine bloods and all is
  normal. In particular, you watch her drinking a cup of tea and
  her swallow seems to be intact.

 What do you do next? How will you manage the situation?
                     Case study 4

 4 Albert is a 75 year old man who has vascular dementia.
   He retains some insight into his condition, but has become
   a bit disinhibited. He telephones his son who lives nearby,
   about 15 times during the evening and night. If the
   neighbours are a bit noisy (they have teenage daughters)
   he bangs on the wall with a broom and swears vociferously.

 He regularly wanders in his garden in a state of undress
   and generally appears unkempt. His son ensures that he
   has food in the house but cannot provide more care as he
   looks after his own wife who has MS and their 2 teenage

 Devise an action plan to deal with this man.
    Criteria for decision making
 P must be able to comprehend the
  information relevant to the decision
 P must be able to retain this information
 P must be able to use and weigh the
  information in order to arrive at a choice
 P must be able to communicate their choice
    Capacity & Incapacity – general
 There is a legal presumption that adults have
  capacity to make decisions unless the
  contrary is proven
 Patients should not be regarded as incapable
  of making or communicating a decision
  unless all practical steps have been taken to
  maximise their ability to do so
 Greater evidence of capacity will be required
  for decisions that have serious implications
          Adults with Capacity

 Assume P has capacity unless proven
 Health teams not required to offer treatment
  that is inappropriate
 Where P requests life prolonging treatment
  that is able to achieve its physiological aim,
  there is an expectation that it will be provided
          Adults with capacity
 If P refuses life prolonging treatment then that
  refusal must be respected
 Requests for, or refusals of, artificial N & H
  should be respected
 P may plan for future care by making an
  advance decision or in E, W & S by
  appointing a welfare attorney
Adults with capacity - communication
 P should be given sufficient information to
  make an informed decision and should be
  encouraged to be involved in decision making
 P’s preferences about treatment should form
  a central part of deciding care plans
         Communication cont.
 Efforts should be made to comply with
  reasonable requests from P about the
  provision of life prolonging treatment
 Although health professionals may find it
  difficult when P refuses treatment, the
  decision of whether to accept or reject
  treatment offered rests with P
      Adults who lack capacity
Incapacity relates to the time when a decision
  has to be made & on the particular matter to
  which the decision relates.
Incapacity can be partial, temporary or even
A person may lack capacity in relation to one
  matter but not another.
 Adults who lack capacity – cont.
 Incapacity must be caused by an impairment
  of or disturbance in functioning of the mind or
 Can be caused by psychiatric illness, learning
  disability, dementia, brain damage or
 Determinations of a person’s capacity MUST
  NOT BE MADE merely on the basis of the
  person’s age, appearance or behaviour
Adults who lack capacity
In E & W an adult with capacity may appoint a
  welfare attorney to give or withhold consent
  to medical treatment on his or her behalf
  once capacity is lost.

Mental Capacity Act 2005 – in force from
 October 2007
 Lasting Power of Attorney (LPA)
Welfare attorneys acting under an LPA are
  bound by general principles of Mental
  Capacity Act:
 P is assumed to have capacity until proven
 P is not to be treated as unable to make
  decision unless all practical steps to help him
  to do so have been taken without success
        General principles cont.
 P is not to be treated as unable to make a
  decision merely because he makes an
  unwise decision
 A decision made under this Act for or on
  behalf of a person who lacks capacity must
  be in his best interests
 Before decision is made it must be clear that
  the result cannot be as effectively achieved in
  a way that is less restrictive of P’s rights and
  freedom of action
          Patients with an LPA
 If P has appointed a welfare attorney with
  authority to make medical decisions, this
  person must be consulted & give consent
  before treatment is provided (except in
 The authority of welfare attorneys only
  extends to life prolonging treatment if that is
  specifically stated in the LPA
 Where there is disagreement about best
  interests The Court of Protection may be
          Advance decisions

Where P has lost decision making capacity but
 has a valid advance decision refusing life
 prolonging treatment (including ANH) this
 must be respected
    Advance decisions - criteria for
 P was 18 years or older when it was made
 P had capacity when it was made
 Advance decision sets specific treatments to
  be refused and the circumstances in which
  the refusal is to apply
 Advance decision has not been withdrawn
 After making advance decision, P has not
  appointed an attorney to make the specified
               Criteria cont.

 P making the advance decision has not done
  anything clearly inconsistent with its terms

 At the time the advance decision is invoked P
  lacks capacity to make contemporaneous
  Additional criteria for refusal of life
         prolonging treatment
Advance decision:
 Must be in writing
 Must be signed
 Must be witnessed
 Must contain a signed & witnessed statement
  that it is to apply even where life is at risk
  Patients without an LPA or advance
 Clinician in charge of P’s care must decide
  whether treatment would be in P’s best
 Discussion should take place with the family
  or Independent Mental Capacity Advocate
  (IMCA) in assessing P’s best interests
 Where there is disagreement about best
  interests legal advice should be sought

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