Case 4 - Dementia

Question 1

What is dementia?

Answer 1

Dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing. It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected. The impairment in cognitive function is commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation.

Question 2

What can cause dementia?

Answer 2

Dementia results from a variety of diseases and injuries that primarily or secondarily affect the brain, such as Alzheimer’s disease or stroke.

Question 3

What symptoms characterise early stage dementia?

Answer 3

Early stage: the early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include:

1) Forgetfulness
2) Losing track of the time
3) Becoming lost in familiar places

Question 4

What symptoms characterise middle stage dementia?

Answer 4

Middle stage: as dementia progresses to the middle stage, the signs and symptoms become clearer and more restricting. These include:

1) Becoming forgetful of recent events and people’s names
2) Becoming lost at home
3) Having increasing difficulty with communication
4) Needing help with personal care
5) Experiencing behaviour changes, including wandering and repeated questioning

Question 5

What symptoms characterise late stage dementia?

Answer 5

Late stage: the late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include:

1) Becoming unaware of the time and place
2) Having difficulty recognizing relatives and friends
3) Having an increasing need for assisted self-care
4) Having difficulty walking
5) Experiencing behaviour changes that may escalate and include aggression (NICE suggests using ‘anti-psychotic’ drugs sparingly and only fit a short time)

Question 6

What are the different forms of dementia?

Answer 6

There are many different forms of dementia and the boundaries between them are indistinct, so mixed forms often co-exist.

1) Alzheimer’s disease is the most common form (contributes to 60–70% of cases)
2) Vascular dementia
3) Dementia with Lewy bodies (abnormal aggregates of protein that develop inside nerve cells)
4) A group of diseases that contribute to frontotemporal dementia (degeneration of the frontal lobe of the brain)

Question 7

How many people worldwide suffer from dementia?

Answer 7

Worldwide, around 50 million people have dementia, with nearly 60% living in low- and middle-income countries. Every year, there are nearly 10 million new cases.

Question 8

What is the proportion of the population over 60 with dementia?

Answer 8

The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5-8%.

Question 9

How are dementia numbers projected to change in the future?

Answer 9

The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050. Much of this increase is attributable to the rising numbers of people with dementia living in low- and middle-income countries.

Question 10

Can dementia be treated?

Answer 10

There is no treatment currently available to cure dementia or to alter its progressive course. Numerous new treatments are being investigated in various stages of clinical trials.

Question 11

What dementia support exists?

Answer 11

A lot can be offered to support and improve the lives of people with dementia and their carers and families. The principal goals for dementia care are:

1) Early diagnosis in order to promote early and optimal management
2) Optimising physical health, cognition, activity and well-being
3) Identifying and treating accompanying physical illness
4) Detecting and treating challenging behavioural and psychological symptoms
5) Providing information and long-term support to carers.

Question 12

What are the risk factors of dementia?

Answer 12

1) Age is the strongest known risk factor for dementia, but young onset dementia (the onset of symptoms before the age of 65 years) accounts for up to 9% of cases.
2) Lack of regular exercise (0.5-1 hour, 3-5 times a week)
4) Smoking and harmful use of alcohol
5) Obesity and an unhealthy diet
6) Poorly maintained blood pressure (blood pressure medication has been shown to decrease cognitive decline), cholesterol and blood sugar levels
7) Mental health issues such as depression and social isolation (anti-depressants and social support could be useful)
8) Low educational attainment and cognitive inactivity

Question 13

What is mild cognitive impairment (MCI)?

Answer 13

Mild cognitive impairment (MCI) is a condition causing minor problems with cognition - mental abilities such as memory or thinking. In MCI these difficulties are worse than would normally be expected for a healthy person of their age. However, the symptoms are not severe enough to interfere significantly with daily life, and so are not defined as dementia.

Question 14

What proportion of the population over 65 suffer from mild cognitive impairment?

Answer 14

It is estimated that between 5 and 20% of people aged over 65 have MCI. It is not a type of dementia, but a person with MCI is more likely to go on to develop dementia. There is a lot that someone can do to help reduce their chances of MCI progressing to dementia.

Question 15

What are the symptoms of mild cognitive impairment?

Answer 15

A person with MCI has mild problems with one or more of the following:

1) Memory: forgetting recent events or repeating the same question
2) reasoning, planning or problem-solving: struggling with thinking things through
3) Attention: being very easily distracted
4) Language: taking much longer than usual to find the right word for something
5) Visual depth perception: struggling to interpret an object in three dimensions, judge distances or navigate stairs

Question 16

How can MCI be tested?

Answer 16

Tests of mental abilities can be taken, and problems would be shown by a low test score or by falling test scores over time. This decline in mental abilities is often caused by an underlying illness.

Question 17

What are the 3 forms of cognitive intervention?

Answer 17

1) Cognitive stimulation: comprises involvement in group activities that are designed to cognitive and social function in a nonspecific manner.
2) Cognitive training: this is the most widely used intervention as it is a more specific approach, which teaches theoretically supported strategies and skills to optimise specific cognitive functions.
3) Cognitive rehabilitation: involves and individualised approach using tailored programs centred on specific activities in daily life. Personally relevant goals are identified, and the therapist, patient and family work together to achieve these goals (e.g. joining a social group).

Question 18

What other therapies have been found useful in combatting cognitive decline?

Answer 18

1) Reminiscence therapy: encouraging patients to think or talk about significant events that occurred in the past.
2) Art and dance therapies: cognitively stimulating activities that improve well being.
3) Music therapy: used to improve apathy, depression, irritability, agitation and anxiety, euphoria, hallucinations and inhibition.

Question 19

Define multidisciplinary team (MDT)

Answer 19

This refers to a combination of professionals from a variety of clinical backgrounds and with specific expertise, that work together to optimise a patient’s care. Multidisciplinary team meetings (MDM) refers to a meeting between the different specialities to plan the best care for a patient.

Question 20

Outline the MDT composition for a patient suffering from dementia

Answer 20

Core: consultant in old-age psychiatry, several specialist nurses (CPNs and/or Community Matrons), advanced Practice Nurse, dementia social worker, carer
Additional team: GPS, social workers, OTs, physiotherapist, voluntary services

Question 21

How does Alzheimer’s develop?

Answer 21

Alzheimer’s often develops slowly over several years, so symptoms are not always obvious at first. A loss of interest and enjoyment in day-to-day activities can often be one of the first changes, but this can be subtle and may be mistaken for other conditions such as depression. In the early stages of the disease, it can also be difficult to distinguish memory problems associated with Alzheimer’s from mild forgetfulness that can be seen in normal ageing.

Question 22

What are the typical early symptoms of Alzheimer’s?

Answer 22

1) Memory problems (e.g. forgetting recent events, names and faces).
2) Becoming increasingly repetitive (e.g. repeating questions after a very short interval or repeating behaviours and routines).
3) Regularly misplacing items or putting them in odd places.
4) Confusion about the date or time of day.
5) Uncertainty of whereabouts or getting lost, particularly in unfamiliar places.
6) Problems communicating or finding the right words.
7) Becoming low in mood, anxious or irritable. Also, losing self-confidence or showing less interest in what’s happening around them.

Question 23

What are the symptoms associated with Alzheimer’s progression?

Answer 23

1) Memory and thinking skills, remembering thinking and making decisions worsens.
2) Communication and language become more difficult.
3) Difficulty recognising household objects or familiar faces.
4) Carrying out day-to-day tasks becomes harder (e.g. using a TV remote control, phone or kitchen appliance). May also have difficulty locating objects in front of them.
5) Changes in sleep patterns often occur.
6) Becoming sad, depressed or frustrated about the challenges they face. Experience anxieties seeking extra reassurance or become fearful or suspicious.
7) Problems walking, being unsteady on their feet, finding swallowing food more difficult or having seizures.
8) Experiencing hallucinations or delusions.
9) Requiring more help with daily activities like dressing, eating and using the toilet.

Question 24

How does vascular dementia develop?

Answer 24

The symptoms of vascular dementia get worse over time. This can take several years, but the speed of change can vary over time and from person to person. There may be a sudden change after an event such as a stroke.

Question 25

What are the symptoms of vascular dementia?

Answer 25

These may include memory loss, disorientation and problems with communication. There can also be more specific symptoms and these will differ depending on the area of the brain affected. These symptoms may include:

1) Slower thinking - taking more time to process information and to form thoughts and sentences.
2) Personality changes – becoming low in mood, more emotional or lose interest in what’s happening around them.
3) Movement problems - difficulty walking or changes in the way a person walks.
4) Stability – unsteadiness and falls.

Question 26

How does vascular dementia affect daily life?

Answer 26

In the later stages, the condition affects more aspects of everyday life. People may need help with activities such as eating, dressing and using the toilet.

Question 27

How does dementia with Lewy bodies progress?

Answer 27

DLB is a progressive condition which means symptoms get worse over time. The diseases can progress slowly over several years, but the speed of change and type of symptoms can vary from person to person.

Question 28

What are the symptoms of dementia with Lewy bodies?

Answer 28

1) :Changes in alertness and attention, and periods of confusion, that may be unpredictable and change from hour-to-hour or day-to-day.
2) Movement problems - Parkinson’s-type symptoms such as slower movements, stiffness in the arms and legs, and shaking or trembling.
3) Unsteadiness and falls.
4) Visual hallucinations that often happen repeatedly and are realistic and well-formed.
5) Sleep disturbances - Vivid dreams, shouting out or moving while sleeping which can disrupt sleep, and may cause injury.
6) Problems detecting smells.

Question 29

How does dementia with Lewy bodies affect daily life?

Answer 29

As the disease progresses, people will need more help eating, moving, dressing and using the toilet.

Question 30

How does frontotemporal dementia progress?

Answer 30

Symptoms get worse over time, gradually leading to more widespread problems with day-to-day function. Some people may develop movement problems similar to those seen in Parkinson’s disease. The speed of change can vary widely.

Question 31

What are the symptoms of frontotemporal dementia?

Answer 31

1) Changes in emotions - this may include a change in how people express their feelings towards others or a lack of understanding of other people’s feelings.
2) Lack of interest - becoming withdrawn or losing interest in looking after themselves, such as failing to maintain a normal level of personal hygiene.
3) Inappropriate behaviour - this might include making inappropriate jokes or showing a lack of tact. Humour or sexual behaviour may change. Becoming impulsive or easily distracted.
4) Obsessions – Developing unusual beliefs, interests or obsessions.
5) Diet - changes in food preference such as eating more sweet things, over-eating or over-drinking.
6) Awareness - not recognising changes in their personality or behaviour.
7) Decision making - difficulty making simple plans and decisions.
8) Language - decline in language abilities: difficulty speaking or understanding the meaning of words or repeating words and phrases or forget what words mean.
9) Recognition - difficulty recognising people or knowing what objects are for.
10) Memory - day-to-day memory may be relatively unaffected in the early stages, but problems with attention and concentration could give the impression of memory problems.
11) Movement problems - 1/8 people with behavioural variant FTD also develop movement problems of motor neurone disease. This can include stiff or twitching muscles, muscle weakness and difficulty swallowing.

Question 32

How does frontotemporal dementia affect daily life as it progresses?

Answer 32

Over time, people with FTD can find it harder to swallow, eat, communicate and move, and may have difficulties with bladder or bowel control. They will require more support to look after themselves. The average survival time after symptoms start is about eight years, but some people live with the condition for much longer than this.