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Dementia

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					Dementia




             Prepared by
              Ross Bills
           GP, Queanbeyan
Dementia
Dementia Assessment

• Acute versus Chronic/Delirium versus Dementia/Reversible
  versus Irreversible
• Functional (Delirium) versus Structural (Dementia)
• Not a disease, but a group of symptoms caused by a range of
  different disease processes
• Classically of insidious slow onset, over years - beware the
  rapid onset or fluctuating patient
Dementia
Broad groups of Dementia

•   Alzheimer's Disease (commonest)

•   Vascular (cerebrovascular disease, multi infarct dementia - associated
    with diabetes, high blood pressure, high cholesterol)

•   Other, including Head Injury, Infection (HIV), Neurological Disease
    such as Parkinson’s Disease (c. 25%), Huntington’s Chorea (almost all)
    [the subcortical dementias]

•   Reversible - sort of a long delirium - includes infections of the brain,
    tumours, B12 deficiency, Alcohol related, Endocrine including Thyroid
    (These are about 10% of the total
Dementia
Dementia Incidence

•   the “silent” epidemic
•   Dementia increases with age
•   120,000 cases in Australia in the early 90’s
•   In the western world 1 in 150 people
•   1 in 20 over 65, 1 in 5 over 80
•   Almost half of all nursing home residents
•   Risk doubles every five years after age 60
Dementia
When is it Dementia?

• the term ‘benign forgetfulness’ is a reminder that not all who
  forget are demented

• Dementia is far from benign
        •   in later stages there may be apparent unconcern on the part of the patient, but certainly during
            the early stages they may be profoundly upset, to the point of depression and suicide, or anger
            and violence directed at selves, as well as partners/carers
Dementia
When is it Dementia?
• normal aging
       •   most people have minor symptoms of memory loss, and aging of the body and nervous system.
           When does it become significant?

• abnormal changes
       •   when there is loss of the ability to function independently or as a part of a caring community
       •   what are those abilities
              –   feeding, toileting, dress
              –   safety - gas/electricity/strangers
              –   remember they may/or not be frail
              –   partner (the other patient)

• cultural issues
       •   ethnic groups may have special needs
       •   tolerance is often an issue with the elderly
Dementia
Assessment 1
• Memory changes are the predominant feature of Dementia
        •   A tape recorder that no longer records, and has trouble playing back the most recently recorded
            information

• Some easy screening tips

ASK, AND ASK A RELATIVE, NOT JUST THE PATIENT IF:
        •   forgetfulness is interfering with their life and getting progressively worse
        •   they forget words or names
        •   they have trouble doing calculations
        •   they find it hard to follow a story plot
Dementia
Assessment 2
• Clues
•   Presenting Problems
          •   ill defined changing symptoms
          •   persistent relapse of physical disorders
          •   suspected poor therapy compliance
          •   persecutory complaints (grain of salt, please)
•   Identified by Questioning
          •   not coping with ADL’s
          •   losing items, keys, bank books
          •   forgetting names, dates, tablets
          •   night time confusion
•   Observations
          •   inconsistent disorganised history
          •   “loses the thread”
          •   minimises problems
          •   unconcerned or evasive attitude
Dementia
Assessment 3
           Early Symptoms
•   Behaviour
           •    loss of initiative/persistence
           •    decreased role performance
           •    poorly focussed/sustained behaviour
           •    uncharacteristic/disinhibited behaviour
•   Thinking
           •    absent minded, intermittent forgetfulness
           •    disorientation
           •    difficulty mastering new tasks
           •    poor planning and organising
           •    impaired judgement
•   Speech
           •    reduced fluency/vocabulary
           •    difficulty starting new topics
           •    perseveration, clichés
           •    mundane, concrete conversation
•   Emotions
           •    vague uncertainty, insecurity
           •    easily aroused, readily changeable affect (not Parkinson's disease)
           •    excessive emotion
           •    catastrophic reactions
•   Personality
           •    inconsiderate, self occupied
           •    social withdrawal
           •    deteriorating appearance/hygiene
Dementia
Assessment 4
•   A careful medical history
         •   progression of changes
         •   medications
         •   drug and alcohol intake
         •   behaviour/personality changes
         •   hallucinations/delusions

•   Physical assessment
         •   to exclude reversible causes (Delirium)
         •   to direct suitable investigations (eg: anaemia, thyroid disease)

•   ADL’s
         •   dressing, feeding, bathing
         •   money handling
         •   mobility
         •   continence

•   Special Tools (MMSE)
•   Environment of the home
         •   consider hazards
         •   consider access
         •   availability of support
Dementia
Assessment 5

A flexible approach to diagnosis

•   a decline in two mental abilities, memory, learning, orientation, attention
•   a deterioration in at least one mental skill, abstraction, judgement, calculation,
    comprehension, language
•   loosening of emotional control, personality change
•   difficulties in family, social or work functioning
Dementia
Assessment 6

•   Differential Diagnosis

•   Remember Depression is the single commonest diagnosis mistaken for Dementia
    (Depressive Pseudodementia)
•   Other psychiatric disorders, including the schizophrenias, Korsakov’s Psychosis
•   Intellectual Retardation
•   Neurosis
•   Important to exclude common causes of altered function which may be reversible
           •   anaemia
           •   hypoxia secondary to heart/lung disease
           •   endocrine disorders (diabetes and thyroid)
           •   infections (Encephalitis, HIV, but even a UTI)
           •   space occupying lesions (tumours)
           •   neurological disorders (Parkinson’s, Huntington’s, Multiple Sclerosis)
           •   medications including overdose
Dementia
Assessment 7

• Organic Screening

•   may be non-cost effective
•   selective choice of tests remembering the discomfort to patient and
    inconvenience, as well as possible cost
•   suggested on basis of history and examination but consider:
          •   BP, Oximetry, random BSL, height/weight, urinalysis
          •   FBC, Renal Function, Liver Function, MSU, TSH (thyroid) BSL
          •   Imaging: CXR, perhaps CT Scan
          •   ECG, EEG, HIV, VDRL, B12/Folate levels may be useful
Dementia
Treatment 1

•   the other patient

•   care for the carer
•   ACAT, Alzheimer’s Association (Australia), Carers Association
           •   advice regarding pensions and support
           •   driving and dementia
           •   power of attorney
           •   managing carer stress
           •   home help, respite care, residential care
•   social workers as a resource
•   non drug treatment involves educating the carer and relatives about the diagnosis
•   establish a working relationship with carers and family
Dementia
Treatment 2
• pharmaceuticals - trial for 6 months and review
          •   Aricept (Donezipil), Exelon (Rivastigmine) and (new) Reminyl (Galantamine) although they do
              not cure, or even improve dementia may reduce the rate of deterioration in early disease
          •   clinical effectiveness has not been demonstrated in severe disease
•   best response with high doses, but these are less well tolerated (side effects are
    an issue)
•   side effects:
          •   diarrhoea, nausea, vomiting, anorexia, weight loss common

•   trials show only modest improvement overall
•   most studies are short term - 1 year or less in a disease spanning decades
•   long term benefits are still not clear, therefore
Dementia
Treatment 3

• pharmaceuticals
       •   Gingko Biloba - perhaps a six month delay in disease progression in one study
       •   VITAMIN E, Hormone Replacement Therapy, NSAID’s may have a role in prevention or risk
           reduction?
       •   One study of vitamin E showed a seven month delay of disease progression
Dementia
Treatment 4
• Pharmaceuticals

          •   Use of the sedative hypnotics/major tranquillisers may be indicated, but with care in psychotic
              or disturbed patients. Low initial doses are safer in the elderly, and especially in those with
              dementia.


•   Haloperidol (Serenace) (safer than Mellaril)
•   Olanzepine (Zypyrexa) and Risperidone (Risperdal) may be better tolerated
    again with fewer side effects
          •   taper at 3-6 months to determine if still needed when symptoms have stabilised
•   Benzodiazepines are best avoided, at least long term in the elderly
          •   side effects
          •   exacerbation of cognitive impairment
          •   dependence
          •   prn dosage
          •   aim to cease within 2 weeks
Dementia
Treatment 5
•   supportive therapy
•   the little things
              •   surround with familiar objects
              •   provide orientation cues (Clock, Calendar)
              •   Attention to lighting, access
              •   correct impairment, dentures, hearing aids, glasses
              •   sensory input - television, radio, music
              •   maintain activity - cardiovascular fitness, retarding of arthritis/osteoporosis
              •   basic physical needs (heating, cooling)
              •   ?Pet Therapy?
              •   the little things
              •   surround with familiar things
              •   orientation cues (clock, calendar)
              •   lighting, ease of mobility
              •   sensory issues (hearing aid, glasses, and dentures too)
              •   television, radio, music
              •   maintain basic activity levels - cardiovascular fitness, arthritis management
              •   physical needs - dress, heating, cooling
              •   pet therapy?
•   safety
              •   safety for the patient, safety for the carer, safety for the health worker.
              •   think about the risks and dangers, and work to prevent, not treat the consequences
•   respite
              •   when all else fails this is a break for the patient, the carer, and yes, the health worker too!!!
Dementia
Dementia Care

• It is a big job
        •   Rule One - on first arriving at the accident, check your own pulse!
        •   If you can’t care for yourself how can you care for others.
        •   Make sure you get the breaks you need to carry on.
        •   Be aware of supports.

• Share the load
Dementia
Web Links

• Carers Association
   –   http://www.carers.asn.au



• Alzheimer's Association (Australia)
   –   http://www.alzheimers.org.au
Dementia




             Further questions?

           Discuss with your GP or
                 Pharmacist

				
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