Transcript Dementia
Nice guidelines 2006 DEMENTIA 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 frontotemporal 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.