Dementia

Differential diagnosis

  • Normal-age related memory changes
  • Mild cognitive impairment
  • Depression
  • Delirium
  • Vitamin deficiency
  • Hypothyroidism
  • Adverse drug effects
    • benzodiazepines, analgesics, anticholinergics, anti-depressants (such as tricyclics), antipsychotics (such as haloperidol), anti-convulsants (especially older preparations, such as phenytoin and phenobarbital), and corticosteroids
  • Normal pressure hydrocephalus
    • cognitive impairment, urinary incontinence, gait disorder
  • Sensory deficits
    • Vision and hearing impairment can contribute significantly to apparent cognitive decline

 

Data gathering

  • Red flags – sudden loss of memory, fall, head injury
  • others – personality, mood, speech, tremor, activities of daily living
  • Examination – Neurological, GPCOG/6 CIT

 

Clinical management

  • Investigations
    • Bloods – FBC, U+E, LFTs, TFTs, B12, folate, calcium, HbA1c, lipids, syphilis
    • Urine – dip / MSU
    • Others
      • CXR
      • ECG
      • Syphillis, HIV
  • Explanation
    • small deposits form within the brain which can damage the nerves with accompanying changes in the chemical transmitters in brain – leads to problems with short term memory, tasks, personality
  • Treatment
    • Refer – memory clinic – further assessment, MRI
    • Lifestyle – Reduce smoking, alcohol, BP, cholesterol, keep whiteboards for reminders
    • Individual care plan – keep familiar environment, consistent staffing, reduce relocations
    • Community teams e.g. social services, occupational therapy
    • Groups – physical activity, cognitive group stimulation – Alzheimer’s society
    • Medications – for moderate Alzheimer’s, low mood, aggressive behaviour, dosette box
    • Inform DVLA – can drive but yearly review
  • Follow-up / Safety net
    • PIL

NB: Consider carers needs – Carers UK, capacity

 

Dementia and aggression

  • Look for reversible causes
    • Infections – urine, chest, meningitis, viral
    • Medications – benzodiazepines, opioids, steroids, anticholinergics, anticonvulsants
    • Drugs – alochol, illict drugs
    • Metabolic causes – electrolytes, BM
    • Vitamin deficiencies – thiamine, B12
    • Endocrine – thyroid
    • Trauma – head injury
  • Investigations
    • Bloods – U+Es, LFTs, TFTs, B12, Folate
    • Urine dip
  • Management
    • Discuss with secondary care, possible options:
      • Mirtazapine 15mg ON – increase to 30mg ON after 4 weeks
      • Trazodone 25mg ON – increase in steps of 25mg up to 100mg OD (divided doses)
      • Carbamazepine 50mg – increase in steps of 50mg every 2-4 weeks up to 200mg BD
      • Risperidone 0.5mg OD – increase up to 0.5mg BD if needed (increased risk of stroke)
      • Memantine 5mg OD – increase in steps of 5mg at weekly intervals to 20mg OD
  • Refer
    • Consider Older Person Assessment Unit