Dementia

This chart on A4Medicine discusses the initial assessment and management of people presenting with – complains of deteriorating memory. This starts with a description of risk factors and the common variants like Alzheimer’s. Assessment is not limited to, addressing memory alone using various tools as MMSE or GPCOG but emphasizes on exploring other limitations and symptoms ( eg behavioral and psychological symptoms of dementia ). Investigations to r/o reversible causes are part of the initial assessment. Once a diagnosis is established the clinician is encouraged to focus on advance care planning while keeping in mind DVLA guidance. Website www.mylivingwill.org .uk can guide patients and clinicians to address this complicated issue.

An irreversible and progressive condition characterized by a global deterioration of a persons cognitive abilities

Dementia is not curable so the focus is on

♦ Risk reduction
♦ Timely diagnosis
♦ Early intervention
 There remains some uncertainty as to future scale of dementia epidemic- population ageing destined to play greatest role ( affects 800,000 people in UK and this number set to double by 2040 )
 GP often the first point of contact for people with dementia and their families
 Population screening is not envisaged ( no single test and does not satisfy the WHO screening criteria )
 Most expensive health-care issue in the UK- worldwide most important contributor to dependence and disability
 Dementia is 
chronic brain 
failure and 
delirium is acute 
brain failure

ICD 10 Memory decline – evident in learning new information Decline in atleast one other domain of cognition such as
♦ judging and thinking
♦ planning and organizing
to a degrees that interferes with daily functioning Some change in one or more aspects of social behaviour eg
♦ emotional liability
♦ irritability
♦ apathy
♦ coarsening of social behavior There should be corroborative evidence that the decline has been present for atleast 6 months

Risk factors-Age- most important risk factor
for eg Alzheimers disease increases in prevalence from < 1 % below the age of 60 to > 40 % above 85 yrs of age Mild cognitive impairment – convert to dementia at a rate of approximately 10 % / year Genetics Cardiovascular disease ( modifiable )
○ diabetes
○ smoking
○ hypercholestorolemia ( good evidence )
○ hypertension
○ obesity

Physical activity ( even low intensity such as walking ) has protective effect ( CKS NHS) 
( BMJ 2017- Physical activity , cognitive decline and risk of 
dementia 28 year follow-up of Whitehall II cohort study found no evidence of a neuroprotective effect of physical activity )
 Depression – inconsistent evidence
A recent study has shown that dementia does not seem to increase the risk for dementia , but depressive symptoms in later life could be a feature of dementia preclinical phase ( BMJ 2017) Stroke ( good evidence ) Mid- life hearing loss ( BBC July 2017 ) Excessive alcohol consumption Living near major roads ( BMJ 2017 ) Parkinsons disease Multiple sclerosis HIV Learning disabilities (Association between Alzheimers dis and Down’s synd ) Social status , education ( failure to complete secondary education )

Delirium and depression are the most common DD Identify / Address 
modifiable risk factors-
 RISK REDUCTION an imp public
 health measure

alzheimers disease-Accounts for approximately 60 % of cases of dementia Onset usually insidious ( can be over 6-7 yrs )
 Early impairment of episodic memory
○ memory loss of recent events
○ repeated questioning
○ difficulty learning new information
○ forgetting names of people and places
○ forgetting appointments
 If relatives cannot date when the symptoms started
then AD is more likely NICE recommends use of NINCDS / ADRDA diagnostic criteria for assessment of Alzheimers disease
 Diagnosing can be 
difficult- insidious onset , 
symptoms may resemble 
normal ageing and diversity
 of other presenting 
symptoms 

widespread cortical atrophy Affected neurons develop surrounding amyloid plaques , neurofibrillary tangles and Acetylcholine production is reduced Irreversible global progressive impairment of brain function

Vascular dementia –Accounts for 10-20 % of dementia Caused by cerebrovascular conditions including 
○ large or multiple small infarcts
○ cerebral amyloid angiopathy
○ CADASIL Symptoms can vary greatly depending on extent , location and severity of cerebrovascular disease Deteriorations may be sudden or gradual but tend to progress in a stepwise manner Small vessel disease is common in older people alongside AD Can co-occur with Alzheimers disease- Mixed dementia

Dementia with Lewy bodies-Cortical and subcortical Lewy bodies Shares symptoms with both Alzheimers disease and parkinson’s disease Around 10 -15 &% of dementia cases In Lewy body dementia- dementia comes first and Parkinsonism often develops later ( often without tremor ) In dementia in Parkinson’s disease PD comes first and 1 in 6 patients with PD develop dementia later Fluctuating cognition ( can be difficult to separate from delirium ) , complex visual hallucinations Autonomic symptoms like postural hypotension may occur 

As many as
 80 % of patients with Parkinson’s develop dementia

Memory-Memory issues Receptive or expressive dysphasia Difficulty with co-ordinated movements 
( eg dressing ) Disorientation and unawareness of the time and place Impairment of executive function 
( eg planning and problem solving )

problems with activities of daily living – adl Neglect of household tasks Nutrition Personal hygiene Grooming Problems with dressing , eating and walking may get affected ( later stages ) Behavioral and psychological symptoms of Dementia
 ( BPSD ) Agitation and emotional insyability Depression and anxiety Apathy or withdrawal Repetitive questioning Psychosis Aggression Sleep problems Motor disturbances -wandering, restlessness , pacing and repetitive activity Disinhibition

 Assess
 
 cognitionMini-mental state examination General practitioner assessment of cognition
GPCOG ( takes no longer than 5 mins ) 6-Item cognitive impairment test 
(takes 3-4 mins 0-8 is normal >= 8 suggest cognitive impairment ) Mini-cog assessment instrument ( takes 2-4 mins ) Memory impairment screen ( around 4 mins ) Abbreviated mental test score History from person / carers/ relatives Assess co-morbidities Risk factors Medications Look for focal neurological signs Gait and balance disturbances CVS signs as hypertension and arrhythmias Weight loss ( neglect ) Vision , hearing FBC ESR Urea and electrolytes Hba1c TFT Calcium Vit B12 and folate MSU , CXR and ECG if clinically indicated

Severely disturbed Health safety issue Detention under Mental Health Act 2007 may be needed Complex physical and psychiatric problems Younger than 65 Focal neurological signs Rapid cognitive decline Genetic cause suspected Have learning difficulties Have mild cognitive impairment and symptoms worsening Parkinson’s disease and suspected Lewy Dody Dementia Suspected fronto-temporal dementia Atypical presentation or course ( may indicated focal dementia or a brain tumour ) High risk situations such as challenging behaviour , psychosis or other risks Safeguarding concerns Potentially contentious legal issues Associated significant psychiatric morbidity or history Suspected alcohol related dementia

advance care planning Donepezil Galantamine Rivastigmine

Mild to moderate Alzheimers disease

Little difference in effectiveness or SEs – cheapest used first Memantine

Moderate to severe AD or those with intolerance to acetylcholinesterase inhibitors

 


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