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Dementia: an essential guide

In the final part of our series on mental health in primary care, GP and former psychiatrist Dr Mark Morris discusses dementia

In the final part of our series on mental health in primary care, GP and former psychiatrist Dr Mark Morris discusses dementia

Dementia is a set of symptoms showing evidence of a decline in memory and thinking sufficient to impair day-to-day function for six months or more. This may be accompanied by a decline in emotional control, social behaviour, motivation and/or higher cortical functions. The onset of dementia may be from age 45, but is not usually before 65.

Types of dementia

Alzheimer's disease

There tends to be a gradual, non-step-wise decline. It is associated with a reduction in the quantity of brain cells that are involved in the release of acetylcholine. Anticholinesterase medication may help.

Vascular dementia

There is usually a step-wise decline in a patient who typically has cardiovascular risk factors. Emotional lability, especially at night, may be a feature. Antiplatelet therapy and tackling cardiovascular risk factors may prevent further decline.

Lewy body disease

There is often a fluctuating course. Other features include visual hallucinations and parkinsonian symptoms and signs.

Rare reversible causes of dementia

These include:

• thyroid disease

• parathyroid disease

• normal pressure hydrocephalus

• syphilis

• brain tumour

• renal failure

• vitamin B12 or folic acid deficiency

• severe anaemia

• anticonvulsant toxicity.

Useful questions in the assessment

• Have you noticed any change in personality?

• Have you noticed any increased forgetfulness?

• Have any activities been given up? Why?

• Has there been any confusion or muddling at night?

• Have there been any problems recognising people?

• Have there been any difficulties with speech?

• Have the changes been gradual or has there been sudden worsening?

Screening tools

Mini mental state examination

The patient's verbal fluency, age, education, and social group can all influence the test score. It only takes about 10 minutes, but is limited because it will not detect subtle memory losses, particularly in well-educated patients. Interpret the scores as follows:

• over 26 – diagnosis of dementia unlikely

• 21-26 – may indicate mild dementia

• 10-20 – may indicate moderate dementia

• under 10 – usually indicates severe dementia.

When a cut-off of 24 points is used, the mini mental state examination has a sensitivity of 87% and a specificity of 82% in white populations.

Clock drawing test

The patient is asked to draw a clock and then write in the numbers 1 to 12. An inability to complete the test has a diagnostic sensitivity of 87% and specificity of 93% for Alzheimer's disease. If the patient's ability to draw the hands of the clock at 11:20 is included, the sensitivity and specificity are increased further.

Referral

If dementia is suspected, early referral is important. Not only does this allow identification of the supportive and social care needs of both carer and patient, it will also prompt assessment for the suitability of medications – particularly the acetylcholinesterase inhibitors.

Treatment

Non-pharmacological approaches to dementia care

Behavioural therapy: A patient with dementia may exhibit problematic behaviours such as physical aggression, wandering, verbal outbursts, resistance to bathing or other care needs, and restless motor activity like pacing or rocking.

It is important to attempt identification of antecedents, behaviours and consequences (ABC) – for example, by the carer keeping a diary or chart.

Environmental triggers might include disruptions in routine, time change (such as with daylight savings time or travel across time zones), changes in the care-giving environment, new carers, a life stress, over- or under-stimulation, and the disruptive behaviour of other patients.

To modify the behaviour, aim to change the context in which the behaviour takes place and use reinforcement strategies and schedules that reduce the behaviour. For elderly patients the antecedents or triggers may be ‘internal' – a physical change such as constipation, pain, infection and medication side-effects can alter behaviour.

Reality orientation: This reminds patients of facts about themselves and their environment. It can be used both with individuals and groups. In either case, people with memory loss are oriented to their environment using a range of materials and activities. This approach has been favourably reviewed, though there have been concerns that reminding people of their deterioration could have a negative impact on self-esteem and mood.

Reminiscence therapy: This involves helping the patient relive past experiences, especially those that might be positive and personally significant – such as family holidays and weddings. This therapy can be used with groups or individuals. It may not improve cognitive measures, but there may be improvements in behaviour, wellbeing, social interaction, self-care and motivation.

Music therapy: Several studies have reported benefits from musical activity (such as singing or playing an instrument) or merely listening to songs or music.

Exercise: Daytime exercise has been shown to help reduce daytime agitation and night-time restlessness.

Aromatherapy: The two essential oils used most often in aromatherapy for dementia are extracted from lavender and Melissa balm. Recent controlled trials have shown significant reductions in agitation.

Pharmacological approaches to dementia care

Medication should only be used to control behaviour as a first-line therapy if there is severe distress or risk of harm to the patient or others. In all other cases, an assessment of ABC should take place as outlined above and behavioural management strategies should be employed.

Antipsychotics: There is a possible increased risk of cerebrovascular adverse events with the use of antipsychotics. In 2004, the UK Committee on Safety of Medicines advised that ‘risperidone and olanzapine should not be used for the treatment of behavioural symptoms of dementia'. Patients with Lewy body dementia are at increased risk of extrapyramidal side-effects from antipsychotics. These medications may accelerate cognitive decline.

Benzodiazepines: These may help with restlessness and agitation in the short term. But there are a number of disadvantages, including sedation, worsening memory, dizziness and dependency. Review of cognitive function and effectiveness of medication at alleviating the target problems should take place regularly.

Cholinesterase inhibitors: This treatment boosts the transmission of acetylcholine in the brain. A typical improvement is a one- to two-point rise in the score on the mini mental state examination over a period of six months. This compares with an average decline of five to six points over six months in patients not on these drugs. But it is the improvement in social functioning and quality of life that seems more important.

Dr Mark Morris is a GP in Falmouth, Cornwall

This is an extract from Mental Health for Primary Care; a practical guide for non-specialists' Pulse readers can buy it at the special price of £19.95 + P&P (usual price £24.95 + P&P). To claim, visit Radcliffe Publishing's website at www.radcliffe-oxford.com and enter the discount code MHPC9 at the checkout (code is case-sensitive). Alternatively, order via 01235 528820 quoting the same code. Offer ends 22 May 2009.

A patient's fluency and education level can influence screening test scores Dementia

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