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AGED CARE: Module 2, Dementia

Objectives

Behavioural & Psychological Symptoms of Dementia (list, provide examples)
Approaches to dealing w/ BPSD
Other symptoms that complicate dementia - eg, inability to mx meds, personality
change, mood change, impaired cognition, impaired ability to perform tasks, impaired
judgement
Approaches to dealing w/ symptoms that complicate dementia
Limited evidence of benefit for pharmacotherapy in dementia

Dementia Notes

Dementia Diagnosis
Diagnosis
No diagnostic test
Establish symptoms
Exclude other causes (incl. depression, delirium, deficiency)
Evaluate impact of cognitive deficits on patient, family
Diagnostic criteria
Impairment of memory
At least one other cognitive domain
language
apraxia
agnosia
executive functioning
Deterioration from previous level of function having a significant impact on daily
life
Findings dont occur exclusively in the setting of delirium or other neuro or psych
disorders

Cognitive symptoms of dementia
Memory loss (e.g, personal info & events, medical hx, medications, current affairs),
appointments forgotten, items misplaced
Impaired language skills (e.g, struggling to find right words to use; overreliance on
common social phrases)
Difficulty recognising people or things
Difficulty performing tasks (navigating, driving, sports, manual activities)

Some characteristics of different forms of dementia

Alzheimers
Hippocampus affected first, where new memory links are made
Over time, neurodegeneration spreads to involve rest of temporal lobe (causing
deficits in older/established memories, factual knowledge, language abilities)
Vascular
Occlusion of small & large cerebral vessels
Decline in mental/physical function; motor symptoms may be present
May be large stroke, or widespread multiple small vessel occlusions (lacunes or
white matter lesions) causing subcortical dysfunction
May be gradual or stepwise
LBD
Motor signs appear early and progress
Parkinsonian features may predominate
Cognitive changes are characterised by fluctuating cognitive ability, esp.
attention and alertness (over hours or days), visuospatial difficulties and detailed
visual hallucinations
Pts sensitive to AEs of neuroleptics (eg haloperidol)
Parkinsons
Same ssx as LBD - early, progressive motor sx; fluctuating cognitive ability (esp
attention & alertness); visuospatial difficulty / visual hallucinations
Develops more than 12 months after Parkinsonian sx
If Parkinsons, RR of Dementia 6
Cholinesterase inhibitors may be helpful, improve hallucinations
L-dopa doesnt improve cognitive dysfunction
Natural hx of dementia
Great individual variation in progression; difficult to give prognosis
AD LE ~7-10 years, range from 3-20
AD progressive
Moderate stage increasing support to function, + behav/personality changes
Advanced stage cant perform ADLs, loss of mobility, death
RESIDENTIAL CARE: mutlifactorial considerations, including whether
behavioural sx and avail/willingness of others to provide care

1. Examples of BPSD (ie, non-cognitive dementia sx)

Symptoms of disturbed perception, thought content, mood or behaviour that frequently occur in
patients with dementia (Finkel & Burns, 1999)

Behavioural symptoms
Usually identified on the basis of observation of the patient, including:
physical aggression
screaming
restlessness/pacing
agitation
wandering
culturally inappropriate behaviors
sexual disinhibition
hoarding
swearing
shadowing
insomnia

Psychological symptoms
Best assessed from history from patient + collateral. Symptoms include:
Anxiety
Depression
Hallucinations
Delusions
Withdrawal/apathy

Evidence suggests that if untreated, BPSD may contribute to:
Premature institutionalisation
Increased cost of management
Decreased QOL for carer and patient
Significant carer burden
Increased stress to staff in residential care facilities
Increased patient disability

Causes of BPSD
Biological - extrinsic
Frontal pathology (behavioural disturbance, disinhibition, depression)
Basal ganglia lesions (delusions)
Temporal lobe pathology (delusions, hallucinations)
Locus coeruleus (psychosis, depression)
Chemical changes - serotonin, NA, DA
Genes - serotonin, dopamine receptors
Family history of psychiatric disorder
Biological - intrinsic
Acute medical illness
Medication
Pain syndromes
Constipation
Sensory impairments
Fatigue
Fears
Basic needs (hunger, thirst...)
Psychiatric syndromes
Environmental
Overstimulation
Understimulation (boredom)
Overcrowding
Size of home
Inconsistent routine
Provocation by others
Physical restraints

2. Possible approaches to dealing with BPSD

- Difficult to treat; often most distressing sx
- No single strategy - tailor combination of strategies to individual

Pharmacological approaches limited by AEs, not 1st-line
Evidence of benefit for pharmacotherapy in dementia
No curative therapy
Specific therapies of modest, temporary benefit
Physical & psychological supports important for pts, family and carers
Maintain fitness, nutrition, general health status
Manage conditions which can increase confusion or care burden (eg,
depression, pain, incontinence, infection, drug AEs)
Start low and go slow
Correct reversible factors; environmental & psychological mx 1st-line
Cholinesterase inhibitors
Modest benefit in mild-moderate dementia
Sx of apathy & hallucinations have better response
Rivastigmine
NMDA antagonists - eg, Memantine
Antipsychotics best avoided, but haloperidol or risperidone is occasionally used
(beware of dosing, esp in LBD)
Antidepressants
Evidence for citalopram, moclobemide, sertraline, noritriptyline
Anticonvulsants for agitation/aggression
carbamazepine/tegretol; sodium valproate/epilum
Antipsychotics for agitation/aggression/psychosis
haloperidol - low dose, start 0.25-0.5mg, consider EPS; risperidone;
olanzapine; quetiapine
Issues with atypicals: cost; CVA, increased mortality



Non-pharmacological mx
ONGOING assessment
physical health
psychological health
cognition
behaviour
function
unmet needs
mobility and falls risk
social needs
carer needs
capacity of d/c supports to meet needs
Establish & maintain rapport w/ patient
Communicate respectfully
Safe environment
Respect privacy
Home-like environment, with colours & furnishings & architecture
Exclude other causes (pain, delirium, depression, etc)
Identify triggers
Multidisciplinary approach
Person
Relatives/carers
Medical officer
Psychologist
Dietitian
Nurses
Social worker
Physio
OT
Carer education
Other interventions (music, exercise, pet therapy, care training, memory aids,
social activities, respite)
Avoid conflict (try to distract/offer pleasant alternative); avoid physical restraint
Start d/c planning early w/ patient, carer, community supports

3. List & provide egs of other sx that complicate dementia
Symptoms by cognitive domains
Memory
Forgetting appointments/social commitments
Forgetting relatives names
Losing items/becoming lost
Frontal executive
Difficulty adapting to new situations / learning new skills
Difficulty with dressing, toileting
Language
Repeating conversations
Spatial
Apraxia
Subcortical
Attention
Mental flexibility
Difficulty managing medication regimen
Personality change (thus impacting upon interpersonal rships)
Mood change
Impaired judgement / potential disinhibition - risky behaviour (driving, crossing road
unalert, being taken advantage of)
Delusions in relation to family or carer may complicate mx
Carer burden
Other factors may complicate assessment of sx, especially in acute setting or where
poor patient information available, so may want to:
Assess any possible causes of distress / delirium
Review meds (esp. anticholinergics, benzos)
Consider enviro factors (noise, lighting, conflict)
Consider pysch causes (anxiety/depression)
Deficiency (B12, Folate); substances (incl. ETOH)
Assess vascular RFs
Neuro disorders (stroke, PD, MS, etc)
Neuro trauma

4. Describe possible approaches to dealing with sx that complicate dementia
Interdisciplinary approach
Impaired cognition
Regular, appropriate levels of stimulation
Social groups and outings
Carer/family education
Music, exercise, pet therapy, care training, memory aids, social activities, respite
Impaired ability to do tasks
Home services
Home modifications
Care training & respite
Aged care facilities
Impaired judgement
Coordinate alternate forms of transport to driving
Monitoring by family/carer/friends
Consider symptomatic pharmacological mx where non-pharmacological management
fails

5. Evidence of benefit for pharmacotherapy in dementia

Cognitive enhancers
Cholinesterase inhibitors in patients with dementia produce, on average, small
improvements in measures of cognition and ADLs
Not all patients benefit
Impact on long-term outcomes, disability and institutionalisation = unclear
Most studies have been in AD patients; but there is some evidence of benefit for patients
with VaD, mixed dementia, LBD, and dementia in PD
Can consider treatment trial with a cholinesterase inhibitor for patients with mild to
moderate dementia (MMSE 10 to 26) (Grade 2A). The choice between donepezil,
rivastigmine and galantamine = based upon cost, patient tolerance, and physician
experience (efficacy appears to be similar)
Can also consider memantine
In patients with moderate to advanced dementia (MMSE <17), can consider
adding memantine (10 mg twice daily) to a cholinesterase inhibitor, or using
memantine alone in patients who do not tolerate or benefit from a cholinesterase
inhibitor (Grade 2B)
In patients with severe dementia (MMSE <10), we suggest continuing
memantine, given the possibility that memantine may be disease-modifying
(Grade 2C). However, in some patients with advanced dementia it may make
sense to discontinue administration of medications to maximise quality of life and
patient comfort.

Behavioural symptoms
When neuropsychiatric symptoms, first step = rule out & treat medical cause or
superimposed delirium
Environmental, behavioral, and other nonpharmacologic therapies can be effective in
this population and, when appropriate, are preferred over medications, which have a
high rate of adverse effects.
Cholinesterase inhibitors do not produce clinically significant improvement in
neuropsychiatric symptoms in patients with dementia
Antipsychotic agents have limited efficacy and are associated with increased mortality in
patients with dementia.
Can consider use of low doses of olanzapine or quetiapine in patients with
severe, disabling symptoms after informing families of the mortality risk (Grade
2B). Short term use when possible, with regular reassessments of risks and
benefits, is advised.
LBD patients = at especially high risk of severe side effects with neuroleptic medications
SSRI trial suggested for the treatment of depression in AD (Grade 2C).
Citalopram often used because of its possible additional benefits for
neuropsychiatric symptoms
Sertraline = a well studied alternative to citalopram
TCAs should be avoided because of side effects and drug interactions
Agitation may be due to unrecognised depression and respond to an SSRI.
Benzodiazapines reserved for acute stressful episodes, due to risk of side effects with
long-term use (Grade 2C).