Dementia

Dementia: assessment, management and support for people living with dementia and their carers. NICE guideline [NG97] Published date: June 2018

Definition

Dementia is a clinical syndrome of deterioration in mental function which:

  1. Affects more than one cognitive domain (for example memory, language, orientation, or judgement)

  2. Affects social behaviour (behavioural and psychological symptoms of dementia (BPSD) such as emotional control, agitation, insomnia or motivation).

  3. Interferes with activities of daily living (ADLs).

Common subtypes of dementia

  • Alzheimer's disease (50–75%) which often co-exists with vascular dementia

  • Vascular dementia (up to 20%)

  • Dementia with Lewy bodies DLB (10–15%)

  • Frontotemporal dementia (2%)

Other types

Early onset dementia: dementia that develops before 65 years of age.

Mild cognitive impairment: cognitive impairment that does not fulfil the diagnostic criteria for dementia.
For example, only one cognitive domain is affected, or ADLs are not significantly affected.

Prevalence

1 in 14 in people over 65 years old have dementia
1 in 3 people with established dementia remain unrecognised

Preventive strategies

Modification of specific risk factors (in particular, cardiovascular risk factors such as smoking, diabetes and lack of physical activity) can delay or prevent the onset of dementia.

Early diagnosis of dementia is important for treatment of reversible causes, initiation of pharmacological and rehabilitative therapies, and advance planning while a person still has mental capacity.

Clinical presentation

 

Cognitive
impairment

memory problems
dysphasia and dyspraxia
disorientation to time and place
impairment of executive function (planning and problem solving)

 

Behavioural and psychological symptoms of dementia (BPSD)

delusions
hallucinations
agitation
emotional lability
depression
anxiety
apathy
social or sexual disinhibition
motor disturbance (wandering or repetitive activity)
sleep disruption

Impaired activities of daily living (ADLs)

eating
personal hygiene
grooming and dressing
making mistakes at work



 

Characteristics of dementia subtypes

Alzheimer's
Slow progressive decline in cognition and ability to function.
Early impairment of episodic memory — this may include memory loss for recent events, repeated questioning, and difficulty learning new information

Vascular dementia
Stepwise increases in the severity of symptoms — subcortical ischaemic vascular dementia may present insidiously with gait and attention problems and changes in personality.
Focal neurological signs (such as hemiparesis or visual field defects) may be present.

Dementia with Lewy bodies DLB
Fluctuation in awareness: periods of being alert and coherent alternate with periods of being confused usually over a period of days to weeks.
Repeated falls, syncope or transient loss of consciousness
Parkinsonian motor features (such as shuffling gait, rigidity, slow movement [bradykinesia], and loss of spontaneous movement) and autonomic dysfunction (such as postural hypotension, difficulty in swallowing, and incontinence or constipation)
Delusions and hallucinations

Frontotemporal dementia
Personality change and behavioural disturbance (such as apathy or social/sexual disinhibition) may develop insidiously.
Other cognitive functions (such as memory and perception) may be relatively preserved.

Parkinson's dementia
Cognitive impairment that leads to dementia typically begins 10 to 15 years after motor symptoms have appeared.
Parkinson's disease dementia may affect multiple cognitive domains including attention, memory, and visuospatial, constructional, and executive functions.
Executive dysfunction typically occurs earlier
Psychiatric symptoms (e.g. hallucinations, delusions) appear to be less frequent and/or less severe than in Lewy body dementia.

By convention:

  • People who develop cognitive symptoms and motor features of Parkinson's disease within 1 year are classed as having dementia with Lewy bodies DLB.

  • People with Parkinson's disease who develop dementia after more than 12 months are classed as having Parkinson's disease dementia.

 

Assessment

All people with suspected dementia or mild cognitive impairment should be referred to a memory assessment service for specialist assessment and management

Do not rule out dementia solely because the person has a normal score on a cognitive instrument

  1. History (cognitive, behavioural, and psychological symptoms and the impact symptoms have on their daily life ADLs) from patient and collateral family member/carer

  2. Validated cognitive assessment tool. Shorter cognitive testing, such as the 10-point cognitive screener (10-CS) and 6-item cognitive impairment test (6CIT), are recommended rather than longer tests such as the MOCA or MMSE. The tests have limited diagnostic accuracy, so a normal score does not preclude the presence of dementia.

  3. Collateral history: consider using a structured instrument such as the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or the Functional Activities Questionnaire (FAQ).

  4. Conduct a physical examination and mental state examination (to exclude depression)

  5. Undertake blood and urine and structural imaging (CT or MRI head) tests to exclude reversible causes of cognitive decline and to assist with subtype diagnosis:

    • Full blood count.

    • Erythrocyte sedimentation rate (ESR).

    • Urea and electrolytes.

    • Calcium.

    • HbA1c.

    • Liver function tests.

    • Thyroid function tests.

    • Serum B12 and folate levels.

    If clinically indicated:

    • A midstream urine, for example when delirium is a possibility.

    • Chest X-ray, electrocardiogram (ECG), syphilis serology, and HIV testing.

Reversible causes of cognitive decline

  • Delirium vs. Delirium superimposed on Dementia
    use The long Confusion Assessment Method (CAM) or The Observational Scale of Level of Arousal (OSLA)]

  • Depression

  • Sensory impairment (such as sight or hearing loss)

  • Cognitive impairment from drugs that have increased anticholinergic burden

Management

  1. People living with dementia should be provided with a single health or social care professional to coordinate their care

  2. Provision of information
    Treatment and prognosis of dementia
    External sources of support (for the patient and their family/carer).

  3. Mental capacity assessment
    Where possible, enabling people with dementia to give informed consent

  4. Assessment of individual with dementia:

    a) Physical health
    Modifying cardiovascular and cerebrovascular risk factors
    Drug treatment for cognitive symptoms of dementia (see below)
    Check for anticholinergic cognitive burden scale

    Drugs with antimuscarinic effects include some antidepressants (e.g. amitriptyline hydrochloride, paroxetine), antihistamines (e.g. chlorphenamine maleate, promethazine hydrochloride), antipsychotics (e.g. olanzapine, quetiapine), and urinary antispasmodics (e.g. solifenacin succinate, tolterodine tartrate).

    b) Mental and psychological health
    Treatment of BPSD (such as pain, depression, sleep disturbance), with non-pharmacological and/or pharmacological (may need antidepressants or antipsychotics) interventions.

    For people with mild to moderate dementia, offer group cognitive stimulation therapy (but do not offer cognitive training)

    Do not offer melatonin to manage insomnia in people living with Alzheimer’s disease.

    c) Functional disability

    d) Social care needs

  5. Assessment of carer needs
    Inform carers of people living with dementia that they are entitled to a formal needs assessment and assessment for respite and should be offered access to psychoeducation and skills training

  6. Advance care planning: structured follow up and appropriate end-of-life care.

Drug treatment for cognitive symptoms of dementia

Once a decision has been made by an appropriate specialist to start a cholinesterase inhibitor (donepezil, galantamine and rivastigmine) or memantine (a N-methyl-D-aspartic acid receptor antagonist), the first prescription may be made in primary care.

Pharmacological management of Alzheimer’s disease

mild Alzheimer’s disease: cholinesterase inhibitor (donepezil hydrochloride, galantamine, or rivastigmine)
moderate Alzheimer’s disease: cholinesterase inhibitor +/- memantine
severe Alzheimer’s disease: cholinesterase inhibitor AND memantine (memantine is the drug of choice for severe Alzheimer’s disease)

Dementia with Lewy bodies LB

Mild to moderate dementia with LB: first-line donepezil or rivastigmine, second-line galantamine
Severe Dementia with LB: Donepezil or rivastigmine
Consider memantine for people with dementia with Lewy bodies if cholinesterase inhibitors are not tolerated or are contraindicated

Other dementia subtypes

Co-morbid vascular dementia WITH Alzheimer’s disease, Parkinson’s disease dementia, or dementia with Lewy bodies: recommend cholinesterase inhibitors or memantine for people

Frontotemporal dementia or cognitive impairment caused by multiple sclerosis:
DO NOT offer cholinesterase inhibitors or memantine

Check for Anticholinergic Cognitive Burden Scale

High anticholinergic burden can lead to cognitive impairment: validated tools, such as the Anticholinergic Cognitive Burden Scale can be used to minimise this adverse effect.

Group 1 Driving and cognitive impairment

Mild cognitive impairment (not mild dementia): continue to drive

Dementia, any severity: driver must inform DVLA, 2016; may require a formal medical assessment for fitness to drive.

Dr Rajesh VarmaDementia