Nice guidelines 2006

Definition

Widespread deterioration in cerebral function without impairment of consciousness.

Occurs across a widespread of abilities Memory – learning new materials Analytical thought Judgement and planning Handling of language and spatial abilities Social responsiveness Conduct and feeling Basic tasks of self care

Diagnosis

Clinical picture at anytime is determined by Persons previous personality and intellectual endowment

The nature of the pathological process and the stage it has reached

History

Age Family history Progress of condition Associations – myoclonus or

seizures Exposure to toxins – alcohol,

lead drugs (barbiturates)

Examination

Exclude dysphasia as a cause for apparent dementia

Look for neurological signs Find information about the

patient’s social functioning which would not be normal for dementia

Cognitive tests

Should include tests for Attention and concentration Orientation Short and long term memory Praxis Language Executive function

Cognitive tests

MMSE 6-Item cognitive impairment test General Practitioner assessment of

cognition 7-minute screen Take into account educational level,

skills, prior level of functioning and attainment, language, sensory impairment, psychiatric illness and physical or neurological problems

Investigations

Fbc esr – anaemia, vasculitis T4 TSH – hypothyroidism Biochemical screen – hypo or

hypercalcaemia U&E’s - renal failure, dialysis dementia Fasting blood glucose B12 folate – vitamin deficiency

dementia Lft’s

Investigations

Other investigations if appropriate MSU if suspect delirium Syphylis serology HIV – in a young person Caeruloplasmin – Wilson’s disease

Specialist investigations CSF – Jacob Creuztfelt disease Brain biopsy Imaging

MRI best if not available then CT scan

SPECT scan to differentiate Alzheimer's, vascular and fronto-temporal dementia

Types

Alzheimer's Vascular dementia Dementia with Lewy bodies

Frontotemporal dementia

Referral

Refer all patients with abnormal scores on cognitive testing to specialist memory clinic. This provides More detail cognitive assessment Imaging to exclude other disorders Social support for patient and carer’s Support groups Medico-legal issues Education about illness

Management

Mild to moderate dementia Offer opportunity to participate in a

structured group cognitive stimulation program

Drugs Acetylcholinesterase inhibitors should be

considered for those with moderate alzheimer’s disease mmse 10-20 points. Should be started by a specialist. They should not be used in vascular dementia or in MCI

Management

Non cognitive symptoms Hallucinations Delusions Anxiety Marked agitation Aggressive behaviour Wandering Hoarding Sexual disinhibition Disruptive vocal behaviour Apathy

Management

For non cognitive symptoms Only consider medication if severe distress or risk of harm to the person or others

Management

Fro distressing non cognitive symptoms assess and treat Physical health Depression Possible undetected pain or discomfort Side effects of medication Psychosocial factors Physical environmental factors

Management

For co-morbid agitation consider Aromatherapy Multisensory stimulation Therapeutic use of music and or dancing

Animal assisted therapy massage

Management

Antipsychotics Do not use in mild to moderate

non cognitive symptoms in Lewy body dementia as risk severe

reaction Alzheimer’s, vascular or mixed

dementia’s because of increased risk of cerebrovascular adverse events and death

Management

Antipsychotics Consider for severe non cognitive

symptoms only if (seek advice from dementia specialist first) Risks and benefits fully discussed Target symptoms have been quantified and

are being regularly assessed and recorded Co-morbid conditions such as depression

have been assessed The dose is low and titrated upwards and of

time limited duration

Management

Behaviour that challenges Environmental, physical health and

psychosocial factors that might cause it Overcrowding Lack of privacy Lack of activities Inadequate staff attention Poor communication with patient Conflicts between staff and carers

Management

Depression CBT Reminescence therapy Multisensory stimulation Animal assisted therapy Exercise

Drugs SSRI’s – citalopram start 10mg also

helps agitation

Ethics and consent

Always seek valid consent, explain options, check understanding.

Use mental capacity act 2005 if person lacks capacity

Only disclose personal information without consent in exceptional circumstances

Discuss advanced statements, advanced decisions to refuse treatment, power of attorney.