Anthea Hardcastle presents with her 75-year-old mother Constance. She is concerned that her mother is 'losing it'. This is the second time in the last 2 weeks that she has arrived at her mother's place to find bathwater overflowing into the hallway. The carpet is now ruined and her mother cannot remember turning the taps on.
Constance appears well, but she does not seem to think she has any problems. She acknowledges her memory is "not as good as it used to be", but thinks this is normal for anyone getting older. Constance feels her daughter is worrying over nothing.
Anthea is concerned that her mother has dementia.
It is important to recognise the features of 'normal ageing' and the spectrum that ranges from mild cognitive impairment (CI) to dementia. Age-related mild CI (or age-associated memory impairment or age-related cognitive decline) refers to a syndrome that may predate the development of dementia. It describes a syndrome of objective memory impairment that does not significantly affect activities of daily living.
The first step in evaluating a patient with memory complaints is deciding whether or not there is a cognitive impairment and if this impacts on their function. It is also important to differentiate between the '4 D's' of cognitive decline: Depression, delirium, dementia and normal age-related decline. The clinical examination must be focused on excluding a delirium or depression as a cause of the cognitive decline. The history is the most important part of assessing a patient for dementia.
Assess the degree of cognitive impairment:
Functional Assessment: the impact of cognitive impairment (collaborative history may be important here); managing finances; how do they manage their day (remember appointments, cooking, clothes washing, take medications, any problems with behaviour, dressing, showering).
Objective evaluation: Screening tests (Typical early changes of dementia include recall and orientation difficulties):
Further investigations should focus on excluding reversible causes of cognitive impairment and identifying the type of dementia.
Investigations should include:
Non-pharmacological strategies
Improve cognition:
Preserve function and maintain safety:
Manage difficult behaviour:
Pharmacological
Before starting cholinesterase inhibitors (ChI) or memantine, review current medications to identify drugs that may exacerbate the patient's clinical condition or that could interact with ChIs.
Other management strategies:
Prognosis and treatment efficacy:
The rapidity of progression is generally unpredictable. However, in broad terms, the time of diagnosis to death in Alzheimer's is about 10 years; Lewy body dementia is more rapid, and frontotemporal dementia is more rapid again.
The benefit of treatment with ChI's varies according to the type of dementia. Treatment of people with mild and moderate Alzheimer's disease for 6 months improves cognition scores an average of 2-3 points compared with placebo. There is insufficient evidence for the use of ChI's inhibitors in Lewy body dementia so there is no PBS use for this. In patients with vascular dementia the most important management step is to control the vascular risk factors and, if safe, use aspirin. There is no support for the use of cholinesterase inhibitors in frontotemporal dementia.
As a dementia advances, families will require access and referral to community or dementia specific aged care packages for assistance with personal care, meals, medication monitoring and domestic cleaning. Families may also need to consider respite or full-time placement for the person with dementia.
Services available to help relatives of patient with Dementia:
Options available to Constance:
The Aged Care Assessment Team (ACAT) plays a crucial role in: