Diagnosis and management of dementia in older people!
Dementia is a leading cause of morbidity and death in the UK. Diagnostic criteria exist for the different aetiologies and subtypes. Alzheimer's disease is the most common type and there is evidence of benefit from acetylcholinesterase inhibitors for some people living with Alzheimer's disease. Care for people living with dementia in hospital and in the community needs improvement. Non-pharmacological means of managing distress people living with dementia should be prioritized over the use of antipsychotic and sedative medications, and greater focus on symptom management towards the end of life is required. This article discusses key features for diagnosing common subtypes of dementia, along with the non-pharmacological and pharmacological approaches to management.
For a diagnosis of dementia, a 6-month history of progressive decline in two or more cognitive domains is required. Every attempt should be made to identify the subtype of dementia as this can have implications for treatment and prognosis.
Where possible use non-pharmacological measures to assess and manage distress and unmet needs.
Taking measures to minimize the risk of delirium, along with identifying and treating delirium superimposed on dementia during hospital admissions is important for improving care and outcomes for people living with dementia.
Assess for symptoms including pain, breathlessness and delirium at the end of life. Ensure early specialist involvement, including specialist palliative care, for people dying from dementia.
Dementia is a clinical syndrome of impairment in multiple cognitive domains (e.g. memory, language, executive function which includes self-regulation, task planning and execution) affecting activities of daily living and everyday function that is progressive in nature and not the result of reversible causes. It is insufficient simply to diagnose ‘dementia’. Assessment tools and clinical criteria can help to diagnose the subtype of dementia where possible. This can then provide information about potential disease trajectory and prognosis.
Depression and anxiety are common in dementia but can be difficult to treat with antidepressants. Antipsychotics should only be initiated in people with dementia after specialist mental health review.
Supporting people living with dementia during hospital
Dementia affects 1 in 4 people admitted to hospital and up to 15% of hospital inpatients may have unrecognized dementia.3 Presentation is often with frailty syndromes including falls, immobility and delirium, and there is poorer outcome than in people without cognitive impairment admitted to hospital.3 Recognition of delirium and delirium superimposed on dementia is equally poor, as is the differentiation of delirium from dementia, there have been instances of families told by non-specialists that their loved ones have dementia when they have instead had an unrecognized and untreated delirium. The 4AT and Confusion Assessment Method (CAM) are validated to identify delirium superimposed on dementia and should be routinely used during hospital admission to facilitate screening for and diagnosis of delirium. This should prompt an assessment and management of potential causes and the implementation of a management plan for the delirium that includes but is not limited to orientation, hydration, management of sensory impairments, medication review and patient and family education.
Hospital admission can be a distressing time for people living with dementia, their carers and relatives. Communication difficulties and failure to recognize and address an unmet need such as fear, hunger, boredom or need for the toilet can result in distressed behaviour, for example pacing around or declining interventions such as a cannula. In turn, this can result in pharmacological treatment with antipsychotics or benzodiazepines without identifying or addressing the underlying cause for distress, often causing adverse effects.5 Where safe to do so, non-pharmacological means of identifying the causes and managing distress should be trialled before medication is started, using an ABC (Antecedents, Behaviours, Consequences) approach.
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