Care of the elderly - dementia

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Care of the elderly - dementia

• Dafydd Rees 24/2/09

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Dementia - definition

• Chronic condition
• Difficulties in
• Memory
• Language
• Psychological and psychiatric changes
• Impairments in activities of daily living

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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

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Management

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

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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.

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Subtyping of dementia

• Alzheimers disease (50)
• Vascular dementia (25)
• Mixed alzheimers and vascular
• Lewy body dementia (15)
• Others (5) frontotemporal, focal, PD,
  intracranial lesions
• Explain Alzheimers disease to a patient/carer.

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Alzheimers 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

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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

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Prevention

• No cause identified
• Some genetic influence, Downs syndrome
• Brain healthy - seven signposts
• Keep brain active
• Healthy diet
• Physical activity
• CV risk factors
• Social activities
• Dont smoke, moderate alcohol
• Avoid head injury

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Treatment

• Acetylcholinesterase inhibitors
• Moderate disease (MMSE 10-20)
• Donepezil, galantamine, rivastigmine
• Review every 6/12
• Contine if score gt10 and worthwhile effect

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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

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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

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Non-cognitive symptoms

• Examination - infection,pain
• Depression?
• Adverse drug effects
• Environmental factors
• Care plan approach - aromatherapy, music, pets,
  massage
• Carer input is critical

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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

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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

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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

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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

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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

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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

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References

• Dementia Burns,Iliffe BMJ.2009338b75
• Alzheimers disease Burns,Iliffe
  BMJ.2009338b158
• NICE guidelines on dementia (2006) nice.org.uk
• Alzheimers society alzheimers.org.uk