Transcript Care of the elderly - dementia

Care of the elderly - dementia
Dafydd Rees 24/2/09
Dementia - definition
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Chronic condition
Difficulties in
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Memory
Language
Psychological and psychiatric changes
Impairments in activities of daily living
Background
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Aging population, common
637,000 in UK, annual cost £17bn, (heart
disease 4bn, CVA 4bn, cancer 2bn)
Cost of care
Impact on carers
Do we deal with it well? Recognition,
treatment, hopelessness, stigma
Push to increase awareness
Management
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Recognition
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Investigations
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Patient/family report
Informant history
Assess cognitive function - MMSE,6CIT
Bloods: FBC,B12,folate,U+E,bone,Glc,LFT,TFT
Possibly: CXR,ECG, syphilis/HIV
Consider vascular RF, depression
Consent to discuss with family
Refer
6 item cognitive impairment test
(google 6CIT)
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6 questions:
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What year is it?
What month is it?
Give an address phrase with 5 components eg.
John,Smith,42,High St,Bedford)
About what time is it? (within 1 hour)
Count backwards 20-1
Say the months of the year in reverse
Repetition:
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Repeat address phrase.
Subtyping of dementia
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Alzheimer’s disease (50%)
Vascular dementia (25%)
Mixed alzheimer’s and vascular
Lewy body dementia (15%)
Others (5%) frontotemporal, focal, PD,
intracranial lesions
Explain Alzheimer’s disease to a
patient/carer.
Alzheimer’s disease
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Chronic progressive neurodegenerative
disorder - 3 groups of symptoms
Cognitive: memory, language, executive
function
Psychiatric/behavioural (non-cognitive):
depression,hallucinations,delusions,agitation
Problems with ADLs - instrumental/basic
Insidious onset
Mild cognitive impairment
(MCI)
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Subjective Sx (memory), ADLs OK
Observable several yrs before dementia
Not different from normal ageing
Not detectable in clinical encounter
May not progress, no test to identify
15 times more likely to develop dementia
Transition: detectable decline - 2 to 5 yrs
Prevention
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No cause identified
Some genetic influence, Down’s syndrome
‘Brain healthy’ - seven signposts
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Keep brain active
Healthy diet
Physical activity
CV risk factors
Social activities
Don’t smoke, moderate alcohol
Avoid head injury
Treatment
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Acetylcholinesterase inhibitors
Moderate disease (MMSE 10-20)
Donepezil, galantamine, rivastigmine
Review every 6/12
Contine if score >10 and ‘worthwhile
effect’
Other causes
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Vascular dementia - days
Depression - weeks
Lewy body dementia
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PD type motor features
Visual hallucinations
Fluctuation in symptoms
Night time confusion
Adverse reactions to antipsychotics
Support
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Holistic approach, patient and family
Information: alzheimers.org.uk, local support
services
Financial, legal and advocacy advice
Medico-legal issues - driving
? Vulnerable adult
Respite care
Aim: maximise independent activity
Non-cognitive symptoms
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Examination - infection,pain
Depression?
Adverse drug effects
Environmental factors
Care plan approach - aromatherapy,
music, pets, massage
Carer input is critical
Pharmacological interventions
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First choice if severe distress/potential of
harm
Otherwise second line only
Lowest effective dose
Oral before parenteral
Effect on relationship with patient/carers
Consider CV risk,sedation and risk of
falls,cognitive decline
Medication options
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Mild agitation:
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Severe agitation/psychosis:
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Citalopram, sertraline
Severe behavioural problems:
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Quetiapine, risperidone,olanzapine
Depressive symptoms:
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Trazodone, lorazepam, citalopram, valproate
Haloperidol, small dose(0.5-4mg), time limited
Acute severe: lorazepam/haloperidol IM
End of life care
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Normal palliative approach
Advance statements
Encourage to eat and drink for as long
as possible
Do not use tube feeding
CPR is unlikely to succeed
Capacity
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Ability to:
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Understand
Retain
Weigh up
Communicate decision
Decision specific and vary over time
May need a specialist opinion for big
decisions
Lasting power of attorney, court of protection,
living wills
Mental capacity Act 2005
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Assume to have capacity unless proved
otherwise
Must have all available support before
concluding lack of capacity
Retain the right to make eccentric/unwise
decisions
If no capacity - decisions in the best interests
with minimum restrictions to rights and basic
freedoms
Tips
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Consider dementia if memory problems
Days, weeks, months/years
Occasional lapses of memory are common review if in doubt
Suspect if they turn to spouse to answer a
simple question
If suspicious - informant Hx
Low threshold for referral
References
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Dementia: Burns,Iliffe
BMJ.2009;338:b75
Alzheimer’s disease: Burns,Iliffe
BMJ.2009;338:b158
NICE guidelines on dementia (2006):
nice.org.uk
Alzheimer’s society: alzheimers.org.uk