General practitioners should also recommend that legal issues are addressed while the patient is still competent to do so. This includes a will, power of attorney for financial matters , guardianship for health decisions and advance care planning. However, workforce shortages and the increasing burden of care of the elderly mean that ACAT ACAS in Victoria teams may not be able to manage patients with early dementia who are not yet eligible for packaged care, which includes a case manager.
General practitioners may therefore need to refer such patients to other support services Table 3. It is possible that the practice nurse may familiarise herself with local service providers and coordinate care to some extent.
As dementia is a chronic disease, a care plan with regular review is an appropriate way to monitor the patient. The practice nurse may be able to assist with reviews of cognitive function, depression and activities of daily living scales. The number of people with dementia in Australia is growing rapidly. Inevitably this will increase the dementia patient-load for GPs. Additionally, as aged care services are stretched, the management of this group with chronic and complex care needs will fall to GPs and the extended primary care team.
General practitioners have a role in promoting reduction of cardiovascular risk factors and encouragement of exercise, socialisation and cognitive training in all older patients, including those with dementia. Clarification of the diagnosis facilitates access to services and may increase the support available to patients and their carers.
General practitioners should be aware of the assessment and management of this disease and ways in which they can best enable their patients to access available services. To open click on the link, your computer or device will try and open the file using compatible software. To save the file right click or option-click the link and choose "Save As Follow the prompts to chose a location. These files will have "PDF" in brackets along with the filesize of the download. If you do not have it you can download Adobe Reader free of charge. These will have "DOC" in brackets along with the filesize of the download.
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See table The following assessments will help in making a clinical diagnosis of dementia : See the flow chart below. History taking is the main tool in eliciting and evaluating the nature and progression of cognitive decline. Choose an informant who knows about the person's current and past personal, social and occupational functioning. A reliable informant should be interviewed separately in person.
This will allow discussion of a certain information which may otherwise be difficult in the presence of the patient. While doing the assessments, one has to be mindful of the family's culture, values, primary language, literacy level and also the decision making process. A thorough history should include details like the mode of onset of cognitive decline which affects multiple cognitive domains. The pattern progression, clinical manifestations of cognitive dysfunction, behavioral as well as personality changes will have to be enquired into. Subjects or informants can be asked if the person is forgetful about recent events; especially amnesia for events which happened hours or days back.
Does the person tend to ask the same questions repeatedly even though this was answered many times. A review of current medication is very important. Enquire if there is worsening of cognitive symptoms after initiation of a certain new medication. Details regarding the use of all medications, including over-the-counter products, may be collected. See if the person is on medications with anti-cholinergic effects which can worsen cognitive functions.
Delirium is an important differential diagnosis of dementia. Patients with pre-existing dementia could present for the first time with superimposed delirium.
Sudden worsening of cognitive functions and appearance of behavioural symptoms should alert the clinician to the possibility of delirium. Delirium is a medical emergency signs that needs to be identified early and evaluated immediately.
A diagnosis of dementia cannot be made if the cognitive deficits occur exclusively during the course of delirium. Delirium is characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence from the history, examination or investigations that the delirium is a direct consequence of a general medical condition, substance intoxication or withdrawal.
Clouding of consciousness, i. Disturbance of sleep or the sleep-wake cycle, manifest by at least one of the following:. Objective evidence from history, physical and neurological examination or laboratory tests of an underlying cerebral or systemic disease other than psychoactive substance-related that can be presumed to be responsible for the clinical manifestations in A-D. Drugs particularly those with anticholinergic side effects e. Clinician should take care, not to misdiagnose Delirium as Dementia and also not to miss the diagnosis of Delirium when it is superimposed on dementia.
When there is clinical suspicion of delirium, the efforts should focus on identifying the causes. The evaluations need to be comprehensive so that all common causes can be ruled out. Prolonged delirium could lead to more neuronal damage and accelerate cognitive decline by impacting the cognitive reserve. Delirium and dementia are two major causes for cognitive impairment in later years of life.
Though these two conditions had been conceptualized as distinct, mutually exclusive entities, it can be difficult at times to differentiate between them. Delirium in late life is often superimposed on pre-existing dementia and can be the reason for help seeking. Dementia is the leading risk factor for delirium in an older person. Occurrence of delirium in turn is a risk factor for subsequent dementia in older people without pre-existing dementia.
The clinician needs to differentiate between three possible scenarios namely Delirium with no features suggestive of pre-existing dementia dementia with no features suggestive of delirium dementia with superimposed delirium. See table-2 for broad guidelines for making this distinction, which by no means, will be easy in a given clinical setting. When faced with uncertainty, it is better to attribute the symptoms to delirium and manage it as delirium. Presence of BPSD, especially delusions with or without hallucinations in mild to moderate dementia can resemble schizophrenia or other psychotic conditions in late life.
The key differentiating features here are history of progressive cognitive decline which has onset prior to the development of psychotic symptoms the presence of clinically significant impairment in multiple cognitive domains on clinical evaluation. This distinction is rather easy when there is long duration of illness starting from adulthood. But it could be difficult when psychotic symptoms have onset after the age of 60 years and also in situations where it is difficult to test cognitive functions due to active psychotic symptoms.
One could also come across individuals who after many years of illness with onset during adulthood, either schizophrenia or bipolar disorder, present with cognitive decline and clinical features suggestive of dementia. In such situations an additional diagnosis of dementia can be made apart from the diagnosis of the pre existing mental health condition.
See table-3 for some clinical tips. The differentiation between early dementia and mild cognitive impairment can be difficult at times but efforts to make that distinction is always warranted. ICD 10 does not have specific criteria. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains complex attention, executive function, learning and memory, language, perceptual motor, or social cognition based on:.
Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and. A modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. The cognitive deficits do not interfere with capacity for independence in everyday activities i.
The cognitive deficits are not better explained by another mental disorder e. Behavioral disturbance e. There is also the controversy about the best way to objectively measure memory loss. Early recognition of the condition may help the clinician to monitor the progression of cognitive and other symptoms and the later conversion to dementia.
This might allow potential use of evidence based preventive interventions as and when they become available. The recognition of MCI as a diagnostic allows us to have a better understanding of the nature of mild memory loss, which is far more common than dementia among the older segments of the population.
Table-4 lists out the main differences between the two clinical conditions. We need to rule out delirium and mild cognitive disorder before we make a clnical diagnosis of dementia. Then one should apply and see if the person meets the diagnostic criteria for Dementia. If that is met, then there is a need to make further evaluations. The next part of evaluation is aimed at establishing the cause for the dementia syndrome.
Dementia is a syndrome which can be caused by many diseases. After the clinical recognition of dementia syndrome, the evaluations shall focus on identifying the cause of dementia. Thus the evaluation for all potentially reversible conditions which cause dementia syndrome is the first most important step in the assessment of dementia syndrome and this is essential in all cases presenting with features of dmentia.
The type of investigations can be decided based on the clinical features and context of care. Patients who seek help in clinical settings often do not represent cases prevalent in the community. Reversible causes thus may be much more common in clinical settings than in community settings. CT scan or MRI scan, at times, can be a very useful investigation in the differential diagnosis of dementia. A reliable, detailed history will guide us in identifying the causes of dementia. We have to rule out common reversible causes and the eminently reversible causes first. See table-5 for the list.
Investigations to rule out less common causes may be needed when the clinical features indicate a high index of suspicion of reversible dementia. Dementia syndrome is linked to many underlying causes and diseases of the brain. The most common causes accounting for vast majority of cases are due to Alzheimer's disease, Vascular dementia, Dementia with Lewy Bodies and Fronto-temporal dementia.
STEP 3 Evaluation after recognition of the syndrome of dementia look for medical problems. Cognitive assessment can be made as part of detailed examination of higher functions. Addenbrooke's Cognitive Examination ACE is a more detailed test battery for assessing cognitive functions. Assessment of the activities of daily living is very important. This information is essential in formulating the individualized plan of intervention.
Use of simple instruments like the Clinical Dementia Rating Scale can help in assessing the severity of dementia in routine clinical practice. Assessment of non-cognitive symptoms like Behavioural and Psychological Symptoms of Dementia BPSD is yet another important part of clinical assessment. ICD- 10 clinical criteria may be used for diagnosis of Dementia and subtyping.
Alterantively one could use the DSM-5 criteria too. You may use the consensus clinical diagnostic criteria. After detailed assessment usually, the clinician would be in a position to judge the cause of the dementing illness. Clinical recognition of the subtypes of dementia is important and is easier during the early part of the illness.
Such differentiation is feasible in clinical practice by using clinical criteria for these subtypes. The clinicians might choose any standard criteria for making clinical diagnosis of dementia, especially common sub-types. See Table 6 for the criteria which may be useful in clinical practice.
The impairment applies to both verbal and non-verbal material. The decline should be objectively verified by obtaining a reliable history from an informant, supplemented, if possible, by neuropsychological tests or quantified cognitive assessments. The severity of the decline, with mild impairment as the threshold for diagnosis, should be assessed as follows:. Mild : a degree of memory loss sufficient to interfere with everyday activities, though not so severe as to be incompatible with independent living.
The main function affected is the learning of new material. For example, the individual has difficulty in registering, storing and recalling elements in daily living, such as where belongings have been put, social arrangements, or information recently imparted by family members. Moderate : A degree of memory loss which represents a serious handicap to independent living. Only highly learned or very familiar material is retained. New information is retained only occasionally and very briefly.
The individual is unable to recall basic information about where he lives, what he has recently been doing, or the names of familiar persons. Severe : a degree of memory loss characterized by the complete inability to retain new information. Only fragments of previously learned information remain. The subject fails to recognize even close relatives. Evidence for this should be obtained when possible from interviewing an informant, supplemented, if possible, by neuropsychological tests or quantified objective assessments.
Deterioration from a previously higher level of performance should be established. The decline in cognitive abilities causes impaired performance in daily living, but not to a degree making the individual dependent on others. More complicated daily tasks or recreational activities cannot be undertaken. The decline in cognitive abilities makes the individual unable to function without the assistance of another in daily living, including shopping and handling money.
Within the home, only simple chores are preserved. Activities are increasingly restricted and poorly sustained. The decline is characterized by an absence, or virtual absence, of intelligible ideation. The overall severity of the dementia is best expressed as the level of decline in memory or other cognitiveabilities, whichever is the more severe e. Preserved awarenenss of the environment i.
When there are superimposed episodes of delirium the diagnosis of dementia should be deferred. A decline in emotional control or motivation, or a change in social behaviour, manifest as at least one of the following:. For a confident clinical diagnosis, G1 should have been present for at least six months; if the period since the manifest onset is shorter, the diagnosis can only be tentative.
Comments: The diagnosis is further supported by evidence of damage to other higher cortical functions, such as aphasia, agnosia, apraxia. Judgment about independent living or the development of dependence upon others need to take account of the cultural expectation and context. Dementia is specified here as having a minimum duration of six months to avoid confusion with reversible states with identical behavioural syndromes, such as traumatic subdural haemorrhage S There is no evidence from the history, physical examination or special investigations for any other possible cause of dementia e.
B12 or folic acid deficiency, hypercalcaemia , or alcohol- or drug-abuse. Comments: The diagnosis is confirmed by post mortem evidence of neurofibrillary tangles and neuritic plaques in excess of those found in normal ageing of the brain. The following features support the diagnosis, but are not necessary elements: Involvement of cortical functions as evidenced by aphasia, agnosia or apraxia; decrease of motivation and drive, leading to apathy and lack of spontaneity; irritability and disinhibition of social behaviour; evidence from special investigations that there is cerebral atrophy, particularly if this can be shown to be increasing over time.
In severe cases there may be Parkinson-like extrapyramidal changes, logoclonia, and epileptic fits. Specification of features for possible subtypes. Because of the possibility that subtypes exist, it is recommended that the following characteristics be ascertained as a basis for a further classification: age at onset; rate of progression; the configuration of the clinical features, particularly the relative prominence or lack of temporal, parietal or frontal lobe signs; any neuropathological or neurochemical abnormalities, and their pattern.
Dementia symptom management - SCIE
The division of AD into subtypes can at present be accomplished in two ways: first by taking only the age of onset and labeling AD as either early or late, with an approximate cut-off point at 65 years. Unequal distribution of deficits in higher cognitive functions, with some affected and others relatively spared. Thus memory may be quite markedly affected while thinking, reasoning and information processing may show only mild decline. There is clinical evidence of focal brain damage, manifest as at least one of the following:.
There is evidence from the history, examination, or tests, of a significant cerebrovascular disease, which may reasonably be judged to be etiologically related to the dementia e. Neuropsychology: impairment on frontal lobe tests without severe amnesia, aphasia, or perceptuospatial disorder. Electroencephalography: normal on conventional EEG despite clinically evident dementia.
Revised criteria for the clinical diagnosis of probable and possible dementia with Lewy bodies DLB. Essential for a diagnosis of DLB is dementia, defined as a progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational functions, or with usual daily activities.
Prominent or persistent memory impairment may not necessarily occur in the early stages but is usually evident with progression. Deficits on tests of attention, executive function, and visuoperceptual ability may be especially prominent and occur early.
Core clinical features The first 3 typically occur early and may persist throughout the course. One or more spontaneous cardinal features of parkinsonism: these are bradykinesia defined as slowness of movement and decrement in amplitude or speed , rest tremor, or rigidity. Severe sensitivity to antipsychotic agents postural instability; repeated falls; syncope or other transient episodes of unresponsiveness; severe autonomic dysfunction, e. Abnormal low uptake iodine-MIBG myocardial scintigraphy.
Limit distractions and noise—turn off the radio or TV, close the curtains or shut the door, or move to quieter surroundings. Before speaking, make sure you have her attention; address her by name, identify yourself by name and relation, and use nonverbal cues and touch to help keep her focused. If she is seated, get down to her level and maintain eye contact. State your message clearly. Use simple words and sentences.
Speak slowly, distinctly, and in a reassuring tone. Refrain from raising your voice higher or louder; instead, pitch your voice lower. Use the names of people and places instead of pronouns he, she, they or abbreviations. Ask simple, answerable questions. Ask one question at a time; those with yes or no answers work best. Refrain from asking open-ended questions or giving too many choices. Listen with your ears, eyes, and heart. Watch for nonverbal cues and body language, and respond appropriately. Always strive to listen for the meaning and feelings that underlie the words.
Break down activities into a series of steps. This makes many tasks much more manageable. Using visual cues, such as showing him with your hand where to place the dinner plate, can be very helpful.
Pain Management in Dementia
When the going gets tough, distract and redirect. If your loved one becomes upset or agitated, try changing the subject or the environment. For example, ask him for help or suggest going for a walk. It is important to connect with the person on a feeling level, before you redirect. People with dementia often feel confused, anxious, and unsure of themselves. Further, they often get reality confused and may recall things that never really occurred. Avoid trying to convince them they are wrong.
Stay focused on the feelings they are demonstrating which are real and respond with verbal and physical expressions of comfort, support, and reassurance. Sometimes holding hands, touching, hugging, and praise will get the person to respond when all else fails. Remember the good old days. Remembering the past is often a soothing and affirming activity.
Many people with dementia may not remember what happened 45 minutes ago, but they can clearly recall their lives 45 years earlier. Therefore, avoid asking questions that rely on short-term memory , such as asking the person what they had for lunch. Maintain your sense of humor. Use humor whenever possible, though not at the person's expense.
People with dementia tend to retain their social skills and are usually delighted to laugh along with you. Handling Troubling Behavior Some of the greatest challenges of caring for a loved one with dementia are the personality and behavior changes that often occur. To start, consider these ground rules: We cannot change the person.
For example, if the person insists on sleeping on the floor, place a mattress on the floor to make him more comfortable. Remember that we can change our behavior or the physical environment. Consider installing new locks that require a key. Position locks high or low on the door; many people with dementia will not think to look beyond eye level. Keep in mind fire and safety concerns for all family members; the lock s must be accessible to others and not take more than a few seconds to open.
Try a barrier like a curtain or colored streamer to mask the door. Place a black mat or paint a black space on your front porch; this may appear to be an impassable hole to the person with dementia. Consider installing a home security system or monitoring system designed to keep watch over someone with dementia.
Some individuals will not go out without certain articles. Have your relative wear an ID bracelet and sew ID labels in their clothes. Always have a current photo available should you need to report your loved one missing. Establish a routine for using the toilet. Try reminding the person or assisting her to the bathroom every two hours. Schedule fluid intake to ensure the confused person does not become dehydrated. Know that some drinks coffee, tea, cola, or beer have more of a diuretic effect than others. Limit fluid intake in the evening before bedtime.
A commode, obtained at any medical supply store, can be left in the bedroom at night for easy access. Incontinence pads and products can be purchased at the pharmacy or supermarket. A urologist may be able to prescribe a special product or treatment. Use easy-to-remove clothing with elastic waistbands or velcro closures, and provide clothes that are easily washable.
Maintain structure by keeping the same routines. Keep household objects and furniture in the same places. Familiar objects and photographs offer a sense of security and can suggest pleasant memories. Try gentle touch, soothing music, reading, or walks to quell agitation. Speak in a reassuring voice. Do not try to restrain the person during a period of agitation.
Allow the person to do as much for himself as possible—support his independence and ability to care for himself. Tell him you understand his frustration. Distract the person with a snack or an activity. Allow him to forget the troubling incident. Confronting a confused person may increase anxiety. Avoid reminding them that they just asked the same question.
Learn to recognize certain behaviors. An agitated state or pulling at clothing, for example, could indicate a need to use the bathroom. Take time to explain to other family members and home-helpers that suspicious accusations are a part of the dementing illness. Try nonverbal reassurances like a gentle touch or hug.
Respond to the feeling behind the accusation and then reassure the person.
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Increase daytime activities, particularly physical exercise. Discourage inactivity and napping during the day.