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Dementia care.

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

inn, 2UU8.Vol 17. N o .1 139


• Access to education and training for person
Box 2. The main features of vascular dementia with dementia and their family
• Able to benefit from cognitive rehabilitation/
Damage to blood vessels leading to brain memory training
Lack of oxygen to brain causes cell death • Person with dementia and family able to
Symptoms may be sudden as a result of stroke come to terms with diagnosis over time
Progression is often stepwise through a series of small strokes • Early access to support networks
Vascular dementia may overlap with Alzheimer's disease - often referred to as mixed dementia • Modification and control of vascular risk
Computerized tomography scan may show areas of discrete infarcts or multiple areas oF infarction • Treatment with cholinestcrase inhibitors
Adapted from: Whalley and Breitner (200Z) • Disease modification and research into the
prevention of decline is already underway
which makes it essential for identification to
be made as early as possible
Box 3. The main features of dementia with lewy bodies • Able to discuss safety issues and implement
risk-reduction strategies such as occupationd
• Gradual degeneration and death of nerve cells therapy services, assisdve technology and social
• Spherical protein deposits found inside damaged nenye cells: Lewy bodies services assessment
• Characterized by fluctuating cognitive levels • Able to consider employment issues. An
• Parkinsonian symptoms - associated postural instability and risk of falls individual with early onset dementia might
• Poor concentration and visuai hallucinations still be working. A diagnosis of dementia
• Neuroieptic sensitivity - neuroleptics. antipsychotics and other sedating drugs should only be does not necessarily mean having to give
administered in small doses up work but informing employers of a
• Computerized tomography scan may show mild involutionai changes and cerebral atrophy diagnosis in the early stages of the disease
(shrinkage) process will help to ensure the right level of
Adapted ftom: Mynors-Wallis et al (2003) support is provided.
• To plan for the future and also to consider
dementia with Lewy bodies (DL13) and fronto- over a number of years. CHnical features of and make decisions regarding their end of
temporal dementia (FTD) (NICE, 2006). the disease can be classified into three stages life. This might include advising people with
However, there are rarer and potentially treatable (see Tahk J), although not all of the features dementia to consider setting up a lasting
causes of dementia, including hypotliyroidism, described will be present in every person. power of attorney, advance decisions and
vitamin B12 and hypercalcaemia. Other less Individuals may exhibit symptoms of more writing a will. People with dementia and
common causes of dementia include Wenicke- than one stage simultaneously. It must also be their carers might also want details about
KorsakofF's syndrome, progressive supranuclear remembered that not every person will move long-term care options and this information
palsy, neurosyphilis, Huntington's disease, HIV through each stage. should be made available in written format.
infection and Creutzfeldt-J:ikob disease. Further
intormation on rarer forms of dementia can be Diagnosis of dementia Mental capacity
obtained from the Alzheimer's Society website According to NICE (2006) people who are If a person has mental capacity (competency)
(www.alzheiniers.org.uk). assessed for the possibility of dementia should be they are able to make decisions for themselves.
Alzheimer's was first used to describe severe asked if they wish to know the diagnosis during The legal definition (Office of the Public
presenile degenerative dementia in 1906 when the assessment and with whom this should be Guardian, 2007) says that someone who lacks
Dr Alois Alzheimer reported the case of a 51- shared. This is a very sensitive issue and the capacity cannot do one or more of the following
ycar-old woman (Augustus U) who suffered experience of the diagnosis is challenging for tour thuigs:
progressive memory impairment, psychotic people with dementia, family members, and for • Understand information given to them
disturbances and behavioural disturbances. practitioners.Time should be made available to • Retain that information long enough to be
At post-mortem her brain showed plaques, discuss the diagnosis and its implications with able to make a decision
tangles and cerebrovascular disease (Alzheimer, the person with dementia and also with family • Weigh up the information available to make
1907). Box I outlines the main characteristics members (usually only with the consent ot the a decision
of Alzheimer's. Box 2 and } show the main person with dementia). • Communicate their decision by any possible
features ofVaD and DLB, respectively. means, e.g. squeezing a hand or using sign
Early diagnosis language.
Progression of dementia In a recent survey of 500 caregivers, 62% felt an
People with dementia differ in the rate at early diagnosis of dementia was very beneficial The Mental Capacity Act 2005
which their abilities deteriorate and the (Taylor and Leimian, 2002).There are a number The MCA was fully implemented in October
nature of the problems they have. These of rea.sons this may be beneficial both to the 2007. The Act applies to England and Wales.
abilities may also fluctuate on a daily basis. individual and carers (Iliffe et al, 2003): Scotland has its own legislation, the Adults with
However, what is inevitable is that these • Prompt treatment of reversible causes of Incapacity (Scotland) Act 2000. The approach
abilities will diminish over time. Progression dementia, e.g. hypothyroidisui, depression in Northern Ireland is currently governed by
may be fairly rapid in some people, but in • Psychiatric symptoms can be identified and common law. This Act provides a statutory
others deterioration can occur more gradually treated framework to empower and protect people

140 British Jtninial »K Nursing, 2()()8, Vol 17.No 3


NEUROSCIENCE NURSING

who may lack capacity to make decisions


for themselves, e.g. people with dementia. Table I. The three stages of dementia
This legislation makes it clear who can take
decisions, in which situations, and how they I. Early stages of dementia
should go about this. • Often this phase is only apparent in hindsight and can be misattributed to bereavement,
stress or normal ageing
• Loss of short-term memory
Main clauses of the MCA
• Loss of interest in hobbies and activities
Lasting power of attorney (LPA): An LPA • Difficulty handling money
enables a person (with capacity') to nominate a • Poor judgement
spokesperson (the attorney) to make decisions • Unwillingness to make decisions
regarding cheir personal welfare, including • Difficulty adapting to change
iieaklicare and consent to medical treatment, • Irritabiiity/distress if unable to do something
and also to make decisions about financial • Inability to manage everyday tasks
and property matters should they become • Repetitive questioning and loss of thread of conversation
incapable. Separate attorneys can be selected
tor making different kinds of decisions. 2. Moderate stages of demenda
An LPA will only become legal once the Increased need for support such as reminders to eat. wash, dress and use the lavatory
Confusion regarding time and place
person has lost capacity. An LPA will need to be
Failure to recognize people and objects (agnosia)
set up using an officia] form and be registered
Behavioural symptoms such as wandering and getting lost, and hallucinations (visual and auditory)
with tlie Office of the Public Guardian. i^si(y behaviour such as ieaving the house in night clothes, forgetting to turn the taps off
Prior to the MCA any competent individual and may leave gas unlit
could appoint someone else to act on her or Increased repetitive behaviour
his behalf in relation to their financial affairs Word-finding difficulty
(power of attorney). However, this would
be invalid if that individual subsequently 3. Advanced dementia
became mentally incapable of managing their Need for i\jil assistance with washing and dressing, eating and toileting
atTairs. An enduring power ofattorney (EPA), Double incontinence
registered witb the Court of Protection, Increasing physical frailty - may start to shuffle or walk unsteadily eventually becoming confined
allowed tbis power to be carried througb even to bed or a wheelchair
after someone became mentally incapable. Increased risk of complications associated with prolonged immobility such as constipation.
chest infection and urinary tract infections
Altbough LPAs will eventually replace EPAs,
Increased confusion and restlessness such as searching for dead relative
people who already bold an EPA may also set Increased aggressive behaviour
up an LPA and all EPAs signed and dated by DIsinhibition
all parties before 1 October 2007 will remain Night disturbance
valid and can still be registered after tbis date. Uncontrolled movements - development of seizures
Advance decisions: The MCA gives people Difficulty eating and sometimes swallowing (dysphagia)
a statutory right to refuse treatment through Weight loss
tbe use of an 'advance decision'. An advance Gradual loss of speech
decision allows a person to state what forms From: Alzheimer's Society (2007)
of treatment they would or would not like
sboiilii they become unable to decide for relating to serious treatment provided by tbe providers have a duty to inform and train
tbemselves in the future. The Alzheimer's NHS or cbanges in accommodation wbere it staff" on the MCA and further information for
Society (www.alzheimers.org.uk) supports is provided by tbe NHS or local authority. health and social care professionals, people v/ith
the use of advance decisions as they will The MCA is underpinned by tbe principle dementia, and their carers, can be obtained
allow people witb dementia to be involved tbat every adult bas tbe right to make his from tbe Department for Constitutional
in planning their future care. However, to be or her own decisions and must be assumed Affairs'website: www.dca.gov.uk/legal-policy/
legally enforceable, advance decisions must be to have capacity to do so unless it is mental-capacity/publications, htm.
valid (made by a person who bas capacity) proved otherwise. A person must be given
and applicable (relevant to tbe medical all practicable help to make decisions, even The assessment process
circumstances). Advance decisions cannot be tbougb tbey may make what might be seen Dementia is a diagnosis of exclusion and it
used to demand treatment tbat a healthcare as an unwise decision, it sbould not be is important to eliminate the rare reversible
team deems inappropriate or against the law treated as lacking capacity. In addition tbe causes of dementia and identify potentially
(e.g. eutbanasia). MCA sets out to ensure tbat any decision, treatable causes. Assessment of dementia,
Independent mental capacity advocate (IMCA): made under tbe Act for a person who lacks therefore, must be multidimensional and
In people who lack capacity and have nobody capacity, must be in their best interests and incorporate patient and carer history
to support tbem with major life-cbanging should be the least restrictive of their basic assessment of cognitive function, functional
decisions, tbe MCA creates a new advocacy rights and freedoms. status, chnical screening, including physical
service to assist vAih tbis. An IMCA will only Practitioners sbould be aware of tbe general examination, and routine investigations.
be involved in specific decisions, such as tbose clauses of the Act. All health and social care Assessment must be an ongoing process if

of Nursing. 2(MI«.Vol !7. N o 3 141


people with dementia and their carers are to
he supported and managed appropriately. Case study 1. Possible dementia
It cognitive impairment is suspected in an
individual, it is usual practice for GPs to Mrs I is a 73-year-old retired nurse, living with her husband. Mrs | has always been very particular
start the assessment process and then refer about paying the bills, remembering hospital appointments and birthdays but over the past year or
so she has become more forgetfijl and on several occasions she has not remembered to pay the
patients to a local memory assessment clinic
bills. She used to enjoy playing bridge but has refused to attend recently. She used to enjoy applying
or comniunity mental health team for fiirther
make-up and buying new clothes but has recently lost the motivation to do this and has started to
detailed assessment. Practitioners working in look a little unkempt. Mr j suffers ill health himself and has begun to worry about his wife's gradually
primary care, such as health visitors for older fading memory and subtle changes in her personality, such as verbal aggression and secretiveness.
people and practice nurses, are in an ideal Mrs j agrees to see her GP, but really doesn't know what all the fuss Is about, as she doesn't think
position to recognize early signs of cognitive she has got a problem. Dr H performs some routine blood tests and a G-item cognitive impairment
change and should alert GPs of any concerns. test (6-CIT). She scored 12/28 on 6-CIT suggestive of cognitive impairment. All blood test results
were within normal limits. Mrs J is referred to the local memory clinic. At the clinic Mr and Mrs J
are asked to provide detailed information regarding her previous level of functioning, past medical
History and cognitive assessment
A number of different tools are available for ^^^^^^_^ .^^^_ history, current problems and past psychiatric history. Mrs j

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.

142 British Jmirnjl iii" Nursing. 2IK)8.Vol 17. No 3


NEUROSCIENCE NURSING

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.

Table 2. Distinguishing features of depression , dementia and delirium


Depression Dementia Delirium
History Onset and decline often Vague Insidious onset, symptoms Sudden onset over iiouts and days
rapid with identifiabie progress siowiy with fluctuations
trigger factor or iife event
sucb as bereavement
Symptoms Obvious at an early stage Might go unnoticed for years Obvious if hyperactive delirium
but may be harder to recognize
if 'quief delin'um (e.g. apathy)
Subjective complaints Lacit of insight. Attempts to hide Disorientated to time, piace
of memory loss problems or be unaware and person
Often disorientated to time, piace Short-term memory impaired
and person. Processing of external Processing of external and internai
and internal information impaired information impaired
Symptoms often worse Confusion worse in the evening Confusion worse at night
in the morning (sundowning)
Consciousness Normal Normai Clouding consciousness {impaired
attention}
Mental state Distressed/unhappy Possibie iabite mood Emotionai iabiiity. anxiety, fear,
depression, aggression
Variabiiity in cognitive performance Consistent cognitive performance Variability in cognitive performance
(aithough not as consistent in
peopie with Lev*,^ body dementia
Delusions/ Rare Delusions common. Hailucinations Common
hallucinations rare in eariy stage dementia
Psychomotor May get psychomotor retardation Psychomotor disturbance Psychomotor disturbance -
disturbance If depression is severe evident in later stages purposeless, apathetic or
hyperactive

Adapted from: Brown and Hillam {2004)

British Journal i>f Nursuii:, 2(l08.Vol 17. No 3


143
seriously unwell. It has been estimated that is highly agitated or hallucinating (British
Box 5. Management of delirium the prevalence of delirium is as high as 60% Geriatrics Society and Royal College of
in hospitahzed older people on medical and Physicians, 2006).
• Appropriate lighting levels
surgical wards (Fick and Foreman, 2000).
• Consider single room/small bay/close
to nursing station DeUriuni is associated with increased length Conclusion
• Provide repeated visible and verbal clues of hospital stay and mortality in addition Dementia is a common condition in older
to orientation for exampie clocks/calendars to increased rates of institutionalizarion and people and will be encountered by practitioners
• Provide reassurance/explanation in short higher rates of comphcations such as falls.The working across primary and secondary care.The
sentences symptoms ofdcmentia,depression and dehriuin N A O (21)07) has recently higlilighted the need
• Ensure continuity of care, e.g. one nurse can often overlap, and the conditions can also for improved care of people with dementia
to establish a rapport coexist, making recognition of dehrium very and there is currently a Department of Health
• Ensure glasses/hearing aids are worn difficult (7tifa/L'2).There are a number of risk dementia strategy progranunc in development
and working factors for delirium. Dementia is the most that will hopefliUy drive forward improvement
• Avoid inter- and intra-ward moves powerful of these factors {Box 4). ill quality of care for people with dementia and
• Avoid catheters support for their famiHes and carers.
• Encourage early mobilization
• Ensure adequate pain control-regular pain Management of delirium Part one of this series on demenria has
relief is preferential to 'as required' The key strategies to therapy in delirium considered the main forms of dementia and
• Establish regular sleep pattern - maintain should be treatment of the underlying cause, their characterisdcs. It has examined the
and restore pattern. Avoid naps. management of confusion and prevention assessment process and also tlie differences
• Ensure good diet and fluid intake of complications. Once dehrium has been between dementia, delirium and depression.
• Avoid constipation diagnosed, management should be directed The medico-legal background to die issue of
• Avoid sedation at identifying and trearing the underlying iTiental capacity has been reviewed as legislarion
• Eiiminate unexpected noises, e.g. pump cause. This should focus on withdrawal of in England and Wiles has changed recently.
alarms incriminating drugs, correcting biochemical Part two builds on the demenria knowledge
Source: British Geriatrics Society and Royal
derangements and treatment of any underlying gained in this arricle and describes n o n -
College of Physicians (2006)
infection. Parenteral thiamine should be given pharmacological interventions to manage
when alcohol abuse or under-nutrition is demenria in addition to a discussion of the
Screening for depression suspected (British Geriatrics Society and drugs available to treat dementia. T h e
There are validated depression assessment Royal College of Physicians, 2006). contribution carers make to dementia care and
scales for use in older people with demenda. There is evidence to suggest that some the importance of supporring carers in this
The Geriatric Depression Scale can be used cases of delirium can be prevented in a difficult role is also covered. For further
for people with mild and moderate dementia, significant number of people through the informarion on caring for patients with demenria
and is quick and simple to administer recognition of high-risk individuals and the please visit the Carers UK website (care www.
(O'Riordan et al, 1990). implementation of preventative interventions. carersuk.org) or the Alzheimer's Society website
The Cornell Scale for depression in The Yale delirium prevention trial (Inouye et (www.alzheimcrs.org.uk), which provide advice
dementia is a l9-item instrument specifically al, 1999) demonstrated the efTectiveiiess of on all aspects of dementia care, and carers' rights
designed for the raring of symptoms of intervention protocols targeted against six and welfare benefits. iQH
depression in people with demenria. Items risk factors:
were constructed so that they can be rated • Orientation and therapeutic activities for 7Iic milliors woulil iihe to ihanl^ IMtfeisorJackson and Mrs Alison
Austin for tlieir help in proofreading this work.
primarily on the basis of observarion, and thus cognitive impairment
it is a useful assessment tool for people with Alexiipoulos C'rS. Abrains WC. Yoiiii^ R C , Shanioian CA
• Early mobihzation (l'JS8) C'orneli scale for cicpressioii in dciiiciitia. Biot
more advanced dementia and for those with • Non-pharmacological approaches to minimize Psydmilry 23{7,y.27}'H4
Alzheimer A (1907) Uber eitie eigenartige Erkniiikiing der
language problems (AJexopoulos et al, 1988). the use of psychoactive drugs Himriiide. Atli; Zeiisflir I'sychialr 64: 14f>-4«
• Interventions to prevent sleep deprivation Alzheimer's Sociecy (2III17) hiforniaiioti Stieerllw l^^esiioii
(i//>""'/((iVf. Alzheimer's Soctet)'. London
Delirium/acute confuslonal state • Correction of sensory deficits (vision and American Psychiatric Assticiacion (I'J'M) D(Vjiijw.>(rV dud
People with dementia may also present as hearing) Staiistical Manual of Mental [Disorders (I5SM-1V). 4th edn.
APA, Washington
acutely conflised at times. Individuals with • Early intervention for volume depletion. Brooke H Bullocit l l (1 ^ 9 ) Valitbtion of a 6-item cognitive
dementia are five times more likely to develop Non-pharmacological strategies should impaimietit test with a view to primary care usage. Int J
Gcrintr Psychiatry 14( 11) ')36-4()
delirium (Royal College of Psychiatrists, 2005). always be used in the management of Brown J, Hillim J (2004) Deii>entia:Yciur Quesrion.-: Amu'ered.
Delirium is a severe and common syndrome in delirium {Box 5). In particular the use of Churchill Livingstniie, C'hina
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