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Part 1: guidance
and the assessment process
Emma Ouldred, Catherine Bryant
Abstract
This article outlines recent guidance on dementia care and provides information on
dementia, its different subtypes, the assessment process and the utility of cognitive
screening tools. As dementia progresses a person may gradually lose their ability to
make decisions for themselves. The Mental Capacity Act 2005 (MCA) is one ofthe
most significant Acts to be passed in the United Kingdom, which protects people
with dementia and stresses the need to advocate on behalf of this vtdnerable group.
The MCA is described in detail as practitioners working in the field of dementia
care need to be aware of its clauses, as they are likely to require knowledge of it
on a frequent basis. Dementia, delirium and depression are often mistaken for
one another and useful ways to differentiate between the different conditions are
given in addition to comprehensive advice about the management of people with
dementia admitted to hospital with delirium.
NEUROSCIENCE NURSING
The report emphasizes the need for not Figure 1. Comparrison of a normal healthy brain vesus the brain of a person with Alzheimer's.
only a 'sea change' in how we view dementia,
but also for better diagnosis, assessment and
support for people with dementia and their
carers. It highlights the need for access to
Cerebral cortex
diagnosis and early intervention, and the
need for effective working across health
and social care services from acute trusts to
the community. This will only be achieved
through coordinating the work of providers
and commissioners at local levels.
The government recently announced the
forthcoming production of the first ever
national clementia strategy. A 12-month work
programme will cover the follownig themes:
• Improved awareness of dementia Hippocampus
• Early diagnosis of dementia (niemofy acquisitionl
• Improving the quality of care for dementia
(Department of Health. 2007).
The National InstituteforHealthandClinical
Excellence (NICE, 2()(t6) have produced
guidance that makes recommendations for
the identification, treatment and care of
people with dementia, and the support of
Normal Alzheimer's
caren. The principle of person-centred care
underpins the guidance. The main priorities
for implementation include: • Training: all staff working with older people calculation, learning capacity, language and
• Non-discrimination: people should not be in the health, social care and voluntary judgement. These cognitive symptoms can
excluded from any services on the basis of age, sectors bave access to dementia care training be accompanied by non-cognitive symptoms,
diagnosis or coexisting learning disability (skill cievelopnient) that is consistent with including changes m behaviour, emotional
• Valid consent: people with dementia should their roles and responsibilities control and social functioning (World Health
be informed of all care options without • Mental health needs in acute hospitals: Organization [WHO]. 1992).
coercion. If a person lacks capacity then the acute and general hospital trusts should Along with the cognitive decline, people
Mental Capacity Act 2005 (MCA) should plan and provide services that address the with demenda can also experience behavioural
be adhered to specific personal and social care needs and and neuropsychiatric symptoms. Cognitive and
• Carers: the rights and needs of carers are the mental and physical health of people non-cognitive symptoms will cause a decline
emphasised and their rights to a carers' with dementia who use acute hospital in a persons activities of daily living. This
assessment are also reinforced facilities for any reason. decline must be sufficient to impair activities
• Coordination and integration of health and of daily living (WHO, 1992).
social care: integrated care across health Dementia The most common form of dementia is
and social care agencies with the need to Dementia is a syndrome caused by disease of Alzheimer's, which accounts for 62% of all
involve service users in the development, the brain, usually of a chronic or progressive cases. Vascular dementia (VaD), either alone or
implementation and regular review of nature, in which there is impairment of co-existent with Alzheimer's, is the second most
care plans. Guidance also recommends the mtiltiple higher cortical functions, including common subtype of demenda (27% (Knapp et
assignation of a named health/social care memory, thinking, orientation, comprehension, al, 2007). Other forms of demenda include
staff member to have overall responsibility
for care planning
• Memory assessment services: these should be
Box I. The main characteristics of Alzheimer's disease
the single point of referral for all people with • Depletion of acetylcholine (chemical neurotransmitter)
a suspected diagnosis of dementia (provided • Characterized by a build-up of the following abnormal proteins: amyloid plaques, damaged
by memory assessment clinics or community nerve fibres and tau tangles, which are only discernible under a microscope
mental health teams). Structural imaging • Medial temporal lobe (memory) is affected first, thus, primaiy signs are often forgetfulness
{magnetic resonance imaging [MRI] or and confusion
computed tomography |CT|) should be used • Gradual progression: the average length of Alzheimer s disease is between 8 and 12 years
in the assessment of people with dementia (Burke and Morgenlander, 1999)
• Behavioural challengesipeople with dementia • Symptomatic relief may be gained from cholinesterase inhibitors, e.g, donepezil. galantamine
and rivastigmine
who develop behavioural problems should
• Symptomatic relief may be gained from memantine (N-methyl-D-aspartate antagonist)
be offered early comprehensive assessment
• Computerized tomography brain scan may show mild Involutional changes and atrophy (shrinkage)
and have tailored care plans
S
^^^^^^^^^^^^ ^^^1 Is also asked to provide some family history and to discuss
helping to assess cognition in people with
j^^^^^^^^^Hpv ^ H any worries she might have. Mr | speaks to the memory clinic
suspected dementia, and the following are all
^^^^^^^^^H • sister privately to discuss particular areas of concern such as
recommended in the NICE (2006) dementia
guidehne. The mini-mental state examination
(MMSE) (Folstein et al, 1975) is a validated,
Results
standardized assessment of cognitive capacities The memory clinic request a computerized tomography scan.
and is simple and brief enough to be used with which shows mild involutionai changes and cerebral atrophy
older people. It assesses the following areas of (see Figure I).
cognitive fbnction: Mini-mental state examination - 20/30 suggestive of
• Orientation moderate cognitive impairment
• Memory and attention Geriatric depression score: no depression
Figure 1. Computerized tomography scan
• Language functioii of a patient iHth Ahlieimer's disease.
Physical examination: no abnormal findings
• Gopying (praxis) Note the widening of the reiitricles, which Mrs I returned to the memory dinic 4 v^eeks later and a
suggest healthy hrain tissue has been diagnosis of probable Alzheimers disease was discussed with
• Following instructions. replaced hy tcrehrospinalJUiid. her and her husband.
When used with other clinical measures, the
MMSE provides a reliable index of dementia
severity and staging (Whalley and Breitner,
2002). An arbitrary cut-off at 25/30 separates Case study 2. Possible delirium
possible cognitive impairment from no cognitive
impairment. However, the MMSE assumes an Mr B is 88 years old. He lives with his wife and has moderate Alzheimer's disease. He wears a
ability to hear reasonably well, read, write and hearing aid. He is admitted to hospital late at night with a urinary tract infection. He is aggressive
and uncooperative with the nurses. He tries to pull out his intravenous cannula. He shouts out
subtract numbers methodically, and may not be
and disrupts the other patients and accuses staff of poisoning him when they try to administer his
suitable for people with intellectual impairment antibiotics. Mr B is acutely confused on a background of dementia and after 2 days of antibiotic
unrelated to dementia. therapy he Is much more settled and is discharged home. Consider what might have contributed
An alternative to the MMSE is the 6-item to his confusional state;
cognitive impairment test (6-GIT) Kingshill • His urinary infection
Version 2000 (Brooke and Bullock, 1999). • Disorientation after admission late at night, separation from his wife
The 6-GIT is a six-item screening test that • Physical discomfort (unable to verbalize this or recognize it as a problem)
has high sensitivity in mild dementia. It is also • Unfamiliar environment and people
• Sensory impairment
linguistically and culturally translatable.
The dementia questionnaire for mentally
retarded persons (DMR) (Evenhuis et al, 1990) is knows the patient and is a usetlil adjunct to level of functioning. A reliable indicator of
a validated informant-based questioruiaire with cognitive testing and identifies the presence dementia is a carer's account of deterioration in
eight subscales (short-term memory, long-term of dementia prior to the current presentation four specific activities of daily living:
memory,spatial and temporal orientation,speech, Qorm, 1994). It asks respondents to consider • Managing medication
practical skills, mood, activity and interests, and changes to a person's memory or intelligence at • Using the telephone
behavioural disturbances), which is specifically the present time compared with 10 years ago. • Coping with a budget
designed for screening for dementia in people • Using transport (Whalley and Breitner, 2002).
with pre-existing intellectual impairment. Functional assessment Use of 6.mctional assessment tools can also be
Functional impairment should be assessed helpful. The Bristol Activities of Daily Living
The informant questionnaire alongside cognitive impairment. It is important Scale (Bucks et al, 1996) was developed with to
on cognitive decline in the elderly to establish how someone's memory affects his investigate issues that carers rated as important
Tliis is a short questionnaire (comprising 16 or her daily life and also to find out whether in the daily living skills shown by people with
questions) that is filled in by somebody who this represents a change fix)m a person's previous dementia and measures 20 daily living skills.
It is important to gain information that an remember that people with dementia are more
individuals present state represents a decline likely to under report their symptoms. Box 4. Risk factors for delirium
from prior levels of ability. The natural history Typical investigations should include:
of the illness, such as onset, severity and • Full blood count • Dementia
duration, are reported. Inforniation gleaned • Vitamin B12 and folate levels • Fractures and anaesthesia
about psychiatric history, past medical history • Thyroid function tests • Environmental factors such as admission
and drug history can inform the diagnostic • Urea and electrolytes to iCU. resident of a nursing home, changed
process in addition to establishing any t'aniily • Liver function tests environment, sieep deprivation
history of mental illness. It is quite common for • Severe iiiness and muitipie medical
• Blood glucose
people with suspected cognitive impairment to problems especiaiiy infection
• Calcium levels
• liiicit drug/aicohol use
lack insight into their problems so it might be • CT head scan/MRl scan - this enables the • Advancing age
tactful and more productive to hold separate exclusion ofothcrdisordersthat cause dementia, • Prescribed medication especiaiiy sedative
consultations with an individual and relative/ such as brain tumour and hydrocephalus. drugs and those with anticholinergic activity
carer to ensure an accurate history is given. Neuroimaging is also helpflil to look for such as oxybutynin and atropine
Use of a questionnaire, such as the information medial temporal lobe and hippocanipal • Sensory impairment
questiormaire on cognitive decline Qorm, 1994), atrophy suggestive of Alzheimer's • Pain
may be helpflii. • Screening for syphilis or HIV should only be • Metabolic disturbances
done if the clinical picture suggests testing. ' Infection
Physical examination Source: British Geriatrics Society and itoyal
There should be a thorough systems review Depression Coiiege of Physicians (2006)
to exclude potentially treatable or reversible Depressive disorders may coexist with
causes for the memory difficulties, even though dementia; the prevalence of depression is 10- Emotional deterioration
these are rare, such as B12 folate and thianiine 20% of people with dementia (Mynors-Wallis, Memory loss
deficiency. Examination will also look for 2003). The symptoms of early stage dementia Disturbed sleep pattern
comorbid physical disease, risk factors for can mimic depression; this is often referred to Weight loss
vascular disease, such as hypertension, and signs as depressive pseudodementia. Symptoms of Motor retardation
of neurological disease. It is also important to depression include: Reduced appetite.
i X-p;irtnK'ncofHfalth (2007) GovcrnjTiciit project to prtitkice O'Rionlan et al (19VI)) The efiect of mild to moderate Working Gmup for the Factilty of Old Age Psycliiatry.
the first over national dementia strategy-; work programme. dementia on the Geriatric Depression Scale and on the Koyal College of Psychiatrists, London. Available at:
D H . Limdon. .ivaiiabic ac; httji://wwwdh.gov.uk/en/ General Health Questionnaire. 4?f4^tnHi; 19(1): 57-61 http://www.rcpsych.ac.uk/PDF/WhoCaresWins.pdf
Policyandguidanci'/HealrhaiidsociaicaretopiLs/Older Office ofthe I'liblic tniardlMi (2IK)7) Making Dedsioiis.4houi (last accessed 1 February 2tMJ8)
p(;oplesservices/DHJI77211 {kst accessed I February Your Health, IVelfan' ur Finmicc... lilio Decides inwn You Taylor H. Leitiiian R (20(12) Failure to seek medical advice
2(H)8) Can't? Viere'i a Neir Law tliat Can Help. Office of the for early syinptonts of Alzheimer's disease a-sults in
Evenhuis H M {ly'Xl) The tiatiiml history of demenda in Public Giiartiian, London. Available at: littp://www.dea. delayed diagnosis and treatment whieh is often regretted
Down's syndmnif. Arch Nnm'l 47(3): 26.1-7 gov.uk/1egul-pollcy /11 len t.il-capacitj-/mL a-1 eaf!et-eiiglish. later on. Health Care News 2(4): 1-3
Flt:k D. Foreman M (2(H)*)) Consequences of not recognizing pdf (last accessed l' fcbriiary 2(N1«) Whallej' L, Breitner (2(Kl2) Demmtia: Fast Facts. Health Press
dcliriinii supcr-itnposed on dementia in hospitalized Ro\'al CoUege of Psychiatrists (21)05) Ww Cans Wilts: liiternatitinal.Wa'iiiington
elderly individuals, j (.kwfiw/ Niirs 26(1); 3l>-4n ImproiHng the Outcome.': for Older People Admitted lo ihc World Healdi Org^mization (1992) 'Ihe ICD- W ClassiUcatwn
FoLsteiii MF. Folstein SE. MfHiit;ii I'R (!975)'Mini-meiicai General Hospital. Guidelines for rhe Ddvlofwietu of Lsaisori ql Menial and Beliai'ioiiral Disorders: Clinical Descriptiom anil
state". A pracrical method for grading the cognitive .Mciual Health Services for Older Pt'oplf. Report of a Divtii- Grii(/f/iHo. W H O , Geneva
impairment of parionts tor the dinjciaii.J Psychiatr Res
12(3): 18<^-9K
Harvey \K}, Ske Iron-Robinson M, Rossor MN (2(H)3)
The pre\-alcnce and causes of dementia in people under
the age of ft.S yi"ars._/ Nmrul Neiin>siitx Psychiatry 74(4): KEY POINTS
12U(i-y
Inouye SK. Bc^rdus ST, Charpenticr PA ec al (iyy'>) A
muitieoiiiponenc intervention to prevent dehrium in • Dementia has a major impact on the individual, their families and their carers.
hospitalized older patieim. N Eti^lJ Mai 340(9): 6f.'>-7(i
lanicki M. Dalton AJ (2()0()) PrevaJem-e of dementia anii • Substantial guidance on best practice has been produced for the care of people with
impact on intdlectual disability services. Mciii Rriord
38(3): 276-88 dementia over the past five years.
Jorm AF (I W4) A short form ofthe liiforni.int Questionnaire
on Cognitive Decline in the Elderly (IQCODE): • Alzheimer s is the commonest form of dementia and is characterized by a gradual
development and ci\iss-valii.lnion. Psychol Med 24(1):
l45!;3 deterioration in cognition and activities of daiiy iiving,
Knapp M. Prince M. Albaiiese E et al (2()07) Dementia UK,
Aizheimer's Scciet>'. London • The Mental Gipacity Act (2005) provides a statutory framework to empower and protect
Mynoi-s-Wallis L, Moon- M, Magiiire J, Hollingberry T
(2(HI3) Shan^d Carv in Mental Health. Oxford UniversitA' people who lack capacity to make decisions for themselves.
Press, Oxford
National Audit Office (20117) linprot'irix Sen'ices mid .Support • Dementia, deiirium and depression are often mistaken for each other: practitioners should
pf l\opk with lii-mi'iitia. TSO, London
National Institute lor He.iltli and C^linical Excellence (20(lfi) be aware of the similarities and differences between these conditions.
Siipponinx l'eiy[>k wilh Dcmailin aiiii ihcir CJ^ircn in Hidlh
iitut Social Care. NICE, London
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