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Managing multi-infarct dementia

Case

history

Robert is a 65-year-old

retired postal worker. He is accompanied by his daughter. She is worried that her father's memory is getting worse. He often leaves the house without his keys and then cannot remember why he went out in the first place. Up until recently he was a very outgoing, confident man. But something happened to him six months ago and he has become much more passive. Robert thinks his daughter is worrying too much and would rather be back at the pub having 'a drink and a smoke'. Dr Tanvir Jamil discusses.

A patient with no insight and a worried relative ­ dementia right?

Right. It sounds like Robert may have had a small infarct six months ago. With his history the diagnosis is most likely to be multi-infarct dementia (MID). Sixty-five is the typical age of presentation.

MID is a disorder involving deterioration in mental function caused by changes or damage to the brain tissues as a result of multiple blood clots throughout the brain. Risk factors include hypertension, smoking, male gender and atherosclerosis (eg PVD, CHD, cerebrovascular disease, obesity and diabetes).

It affects four out of 10,000 people (about 15 per cent of all dementias). Onset is occasionally abrupt followed by a characteristic downward course with intermittent periods of rapid deterioration ('step-wise' decline).

This distinguishes MID from the slow steady decline of Alzheimer's. Death may occur from stroke, heart disease or pneumonia, or other infection.

Are there any other signs I should look out for?

Sometimes at the very early stages when patients are still aware of mental deterioration, they may present with anxiety and depression. Other symptoms that may develop include memory loss; difficulties with attention, judgment and behaviour; confusion, disorientation; hallucination, delusion; unco-ordinated movements; aphasia; personality changes; social withdrawal; inability to interact in social or personal situations; inability to maintain employment; decreased ability to function independently; decreased interest in daily living activities; lack of spontaneity; loss of movement (weakness) or sensory loss; and urinary incontinence.

Is an examination worthwhile?

Neurological examination may reveal multiple, focal neurological deficits and abnormal reflexes. Signs of cerebellar dysfunction

(eg loss of co-ordination) may also be

picked up. Diagnosis, however, is usually based on the history (especially from a spouse, friends or relatives) and a mental state examination.

Will any investigations change the management plan?

Investigations are essential to rule out other treatable causes:

·full blood count, B12 and folate ­ a macrocytosis suggests alcoholism or B12 or folate deficiency; ESR (malignancy)

·U&Es, LFTs, Plasma Ca (renal or hepatic failure, alcoholism, malignancy, other causes of a low serum calcium) TFTs (hypothyroidism). Blood glucose (diabetes)

·Serology ­ for syphilis

·ECG ­ ischaemic changes, LVH

·Radiology ­ CXR (malignancy)

What's my role as his GP?

·Have a low index of suspicious for depression and treat if appropriate.

·Review medications that may cause confusion, eg anticholinergics, analgesics, cimetidine, CNS depressants.

·Address risk factors, eg hypertension, diabetes.

·Lifestyle advice ­ stop smoking, exercise, diet.

·Encourage use of memory aids, eg calendars and diaries.

·Be certain that sensory function is optimal ­ if not, refer for hearing aids, glasses or cataract surgery.

·Advice on driving ­ the patient should inform the DVLA. They will not automatically lose their licence but it will be reviewed annually. Advise patients to stop driving if they lose visuospatial awareness or their short-term memory deteriorates so much that they may forget where they are going or how to come back.

·Treat intercurrent illness ­ infections

(eg UTIs, LRTIs) tend to cause rapid worsening of confusion, sometimes an acute or chronic confusional state. Antibiotic treatment has dramatic results. Other illnesses, malignancy, osteoporosis, cardiovascular and cerebrovascular disease are frequently seen, as would be expected in a population of this age group.

·Support for carers ­ if the carer is the spouse they are also likely to be elderly and possibly in poor physical health. GPs and the primary health care team should look at those aspects of dementia that wear carers down such as restlessness, aggression, disturbed nights and incontinence.

·Advice on enduring power of attorney ­ created by an Act of Parliament (1985). The power is not invoked until the patient becomes incapable.

·Referral to social services for home help, day care and various benefits including attendance allowance.

·Watch for 'elder abuse' ­ physical (including sexual), psychological or financial. Any suspicions should be brought to the attention of the local social service department to investigate. Some abuse is the result of an overstressed carer, and extra support into the home or respite arrangements may help.

·Referral for respite care or residential care.

·Bereavement counselling ­ contact with the bereaved carer must be continued, both through the initial grieving and then to ensure social contacts with others are in place. Support groups can play a important part at this stage.

What role does the specialist play?

The specialist will help to rule out other treatable causes but is often referred to because you need a CT scan (or MRI) and cannot arrange it yourself! These scans can clearly identify significant pathology in MID with patients showing cortical and/or deep infarcts. MRI is more sensitive to lesions in the brain than CT, but this is not necessarily an advantage in the diagnosis of MID. A scan would also exclude hydrocephalus, tumours, subdural haematoma and CNS cysticercosis.

Scans are usually not required in much older patients in whom the diagnosis is obvious or who have such severe dementia that a scan would be impossible to perform.

The specialist may also become actively involved in prescribing blood-thinning agents (eg aspirin, ticlopidine, warfarin), arranging carotid endarterectomy if indicated and medication to control aggressive or agitation, eg antipsychotics, ?-blockers, SSRIs, lithium and tricyclics.

What about community psychiatric nurses (CPNs)?

I've left this until last but referral to a CPN should be the first thing you think about after making a diagnosis of dementia. A good CPN can help direct everything from investigations required to social services referral; from monitoring, support and counselling to helping with practical, financial and emotional difficulties.

Contacts

·Alzheimer's Disease Society, Gordon House, 10 Greencoat Place,

London SW1P 1PH. Tel: 0845 300 0336

·Age Concern, Astral House, 1268 London Road, Norbury,

London SW16 4ER. Tel: 020 8679 8000

Tanvir Jamil is a GP in Burnham, Bucks

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