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Hot topics - dementia

Dr Satpal Shekhawat digests a key topic that could be tested in the MRCGP

Dr Satpal Shekhawat digests a key topic that could be tested in the MRCGP

Dementia is an acquired global impairment of intellect, memory and personality, but without impairment of consciousness. Dementia is a significant and increasing burden to our health system. It currently affects about 700,000 people in the UK and costs around £17 billion a year. Only a minority of services are run by elderly care physicians. Memory clinics play a vital role in diagnosing and managing early dementia and provide support to patients and their carers.

Dementia affects about 10% of those aged over 65 years and 20% of those over 80.

Diagnosis

Make a diagnosis of dementia only after a comprehensive assessment, including:

• history taking

• medication review ( identify any drugs affecting cognitive function)

• cognitive and mental state examination

• physical examination

Cognitive assessment

• Attention and concentration

• Effect on short and long-term memory

• Orientation in time, place and person

• Cognitive testing using standardised instruments such as mini mental state examination (MMSE) and six-item cognitive impairment (6-CIT)

While using scoring systems, always consider other factors such as education level, language skills, sensory impairment and physical conditions. Always conduct a basic dementia screen which includes

• FBC, U&E, LFT, B12 and folate levels, renal and thyroid functions, calcium and glucose levels

• midstream urine sample

• chest X-ray and ECG

• tests for syphilis and HIV if a clinical picture dictates along with CSF analysis.

Specialist assessment services

Memory assessment services, provided by a memory assessment clinic or community mental health teams, should be the single point of referral for people with possible dementia.

Types of dementia

There are various causes, classified under various groups.

Degenerative and vascular causes comprise the majority of UK dementia cases.

Brain imaging plays a vital role in establishing dementia subtypes in our population. CT scan or MRI, depending on availability, are commonly used to determine vascular causes for dementia. Use perfusion hexamethylpropyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT) to help differentiate Alzheimer's disease, vascular dementia and frontotemporal dementia.

Treatment

Treatment can be broadly divided into the following categories.

Pharmacological therapies

Cholinesterase inhibitors (tacrine, donepezil, tartrate, galantimine) improve cognitive outcomes in those with mild to moderate Alzheimer's disease. Only consider cholinesterase inhibitors for patients with MMSE scores of 10 to 20 points. These should be started by a specialist in dementia care.

Antidepressants are useful in patients who are depressed.

Antipsychotic medication is useful for those with agitation or psychosis.

No benefit has been seen for cholinesterase precursors (lecithin, xanomeline).

Continually reassess dementia patients after they have been started on treatment. There are various tools available to assess the benefits of pharmacological therapies, such as

• improvement in MMSE scores

• relatives stress scale

• Bristol activities of daily living scale.

Non-pharmacological therapies

• Education of caregivers delays the time to the patient's institutionalisation

• Scheduled toileting reduces urinary incontinence

• Graded help and practising skills, together with positive reinforcement, improved independence.

NICE guidelines recommend adopting a palliative care approach from diagnosis until death to support the quality of life for people with dementia and to enable them to die with dignity in a place of their choosing.

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