Dementia

“It occurred to me that at one point it was like I had two diseases – one was Alzheimer’s, and the other was knowing I had Alzheimer’s.”

— Terry Pratchett

What is Dementia?

Dementia is an ‘umbrella term’ that encompasses Alzheimer’s dementia (60-70%) and vascular dementia (10-20%) and a few other, rarer, diseases. The diagnosis of “mixed dementia” is increasing, as the two most common types co-exist frequently.

The Enriched Model of Dementia is based on Kitwood's theory of Personhood and Person-centred care. He described dementia as comprising 5 components (Personality, Biography, Physical health, Neurological impairment & Social psychology)

• More details can be found on the E-learning modules on Dementia Awareness Categories A and B on  (this is for UHL staff only)

Alzheimer’s dementia:  Insidious onset and has unknown cause.

• Risk factors: Age, Family history, Midlife hypertension, Head injury, Type 2 Diabetes, High cholesterol, ?Social isolation, ?Female.

Vascular dementia: Caused by stroke and/or small vessels diseases in the brain due to fatty deposits and ischemia, characterised by step-wise progressions and more sub-acute presentation.

• Risk factors: Age, Smoking, Diabetes, Hypertension & High cholesterol.

How to diagnose Dementia

(DSM V Criteria)

Significant impairment in at least one of the following area:

1. Memory (short-term memory mainly. Test Tools: MMSE, MOCA, CAMCOG)

2. Language (e.g. word finding difficulty. Test Tools: MMSE, MOCA, RBANDS, CAMCOG)

3. Executive function (e.g. dealing with finances. Test Tools: MOCA, FAB)

4. Attention (Test Tools: as above)

5. Perceptual-motor function (e.g. getting lost in familiar places. Test Tools: Clock drawing)

6. Social cognition (e.g. how we interpret other people’s feelings and emotions)

And...

• Acquired

• Interferes with independence in daily activity

• Insidious onset and progressive (mostly)

• Delirium must be excluded. (delirium is more acute presentation that could last up to 6 months)

• Mental disorders must be excluded

Investigations

Cognitive tests and CT/MRI brain scan.

No routine lab tests available but make sure to rule out reversible causes of memory impairment (e.g. B12 & folate deficiency and abnormal thyroid function).

Remember: Dementia is a clinical diagnosis, there is no definitive diagnostic test.

Management

There is no cure at the moment but some drugs available that may slow the progression of Alzheimer’s dementia (e.g. Aricept).

Psychological therapies, physical exercise, healthy diet, smoking cessation, social engagement all play the role in prevention of disease and its progression.

“Also it is important to recognise the stress on the patient’s caregivers and offer supports, such as Day Care services, Respite services etc.”

ED Pitfalls:

1. Collateral History – It is part of assessment to take collateral history from patient’s relatives/caregivers, however be vigilant about who is giving the story: there may be a hidden family dynamic, and depending on who you take the history from, the story can vary significantly.
2. Social Services – There seems to be some discrepancy between clinical team in acute care settings and social service team in terms of the decisions made on community support for patients who presented to acute care in UHL. This can cause a significant delay in patient’s discharge. We will need to look into this topic in the future to find a solution for more effective collaboration.

Resources

• Myths and MSUs

• American Delirium Society

• British Geriatrics Society

• Alzheimers.org.u

Nottingham.ac.uk eLearning:

1. Communication

2. Dementia Care

3. Dementia in Hospital

Adapted from the Acute Frailty Inter-Professional Education session on 20th November 2015.
Edit and Peer Review by Jamie Sillett