Dementia

Question 1

A 73 year old woman, who lives alone, has become increasingly forgetful and vague. Her son is worried that she is unsafe. How would you manage this situation?

Answer 1

Impression
Given the patients age and sx of forgetfulness and vagueness, this most likely represents a form of dementia, most commonly alzheimers disease. Important to consider the type of dementia this woman is suffering from and factor this into the counselling and ultimate management of the patient.

Dementia subtypes

• FTD
• vascular dementia (step-wise)
• Lew-body dementia
• Alzheimers disease (most common)

Causes of dementia (VANISHED)

• V: vascular, vitamins
• A: alzheimers
• N: normal pressure hydrocephalus, neoplasia
• I: Infective: HIV/AIDs,
• S: - sub-dural Hb, substance abuse
• H: Hormones; hyperparathyroidism, hypothyroidism
• E: electrolytes
• D: Depression/delirium

Management goals
- Further collateral Hx/Ex/Ix and assess mother to gauge extent and degree of dementia, rule out reversible causes

Question 2

Dementia Counselling - History

Answer 2

History
Would want to take a further history to better understand the patients situation
- Hx: time course, personality/behavioural changes (FTD), type of memory loss, progression, associated motor features (Lew-body),
- RISKS: age, fam hx, medications, vascular risk factors, social isolation, low SES and educational attainment.
- PMHx: CVD history (Stroke, heart attacks)
- ADLs, impact on function, current functionality, any current care packages, escalated living

Question 3

Dementia counselling - Examination

Answer 3

Examination
- Cognitive testing to quantify degree of impairment;
   o MOCA
   o MMSE
   o RUDAS (if NESB/CALD)
- cardio examination
- neurological examination
- MSE
- ECOG status

Question 4

Dementia counselling - Investigations

Answer 4

Investigations
Rule out organic causes of dementia;
- Beside: urine tox screen, ECG
- Bloods: B12/folate level, PTH, TFT, CMP, fit D, other baselines (FBC, UEC, LFT, CRP)
- Imaging: MRI Brain

Question 5

Dementia counselling - Management

Answer 5

Management
Setting/safety considerations
- inpatient vs outpatient mx

• Biological
  o Acetylcholinesterase inhibitors: Donepezil, Rivastigmine: only holds of progression of disease for 6 months then not effective (only in alzheimers
  o Memantine (NMDA receptor) for severe AD
  o Meds for Parkinsons if assoc. with Lewy body dementia
  o meds for CVD risk factor optimisation (SABA)
  o geriatrics referral
• Psychological
  o patient and family education: what disease is, likely course, prognosis, how it will continue to affect life, reassurance, how it will be manageed
  o memory training
  o structured group cognitive training
• Social
  o exercise groups
  o ACAT referral for home assessment, aged care services package (cleaning, cooking, gardening, etc)
  o Future planning: ACD, power of attorney, enduring guardian, etc.