As an FY1 in hospital, you will come across lots of patients with dementia. They often have multiple problems requiring longer hospital stays, higher morbidity & mortality.

Dementia is a syndrome describing chronic and progressive failure of higher cognitive functions (e.g. memory, planning, emotional control), affecting daily functioning.

Types and presentation
Knowing the subtype & severity of dementia can help guide management and prognosis. Each subtype has its own risk factors, but age, genetics and gender play a large part.

Type Features
Alzheimer’s disease (AD) Most common type but often overlaps with vascular dementia
Insidious onset and gradual decline of cognitive functions
Vascular dementia A step-wise decline of cognitive decline (rather than gradual)
Sometimes has neurological features
Lewy body dementia Memory may be preserved initially
Hallmark features: visual hallucinations, attention issues and fluctuating confusion/cognition
Parkinsonism develops after dementia
Parkinson’s disease dementia Dementia develops after PD
Alcohol-related brain damage Cerebellar features
Focal dementias Frontal lobe dementia (previously Pick’s disease)
Primary progressive aphasia
Semantic dementia

Diagnosis
Diagnosis is carried out by specialists through obtaining a history, cognitive tests & imaging usually during an outpatient memory clinic. This is so the acute medical issues have been corrected in case they're contributing to the confusion.

Assessment
Your role as a junior doctor is to identify whether this is acute confusion (e.g. due to delirium, stroke, head injury) and whether there is chronic cognitive decline. In hospital, there is usually an element of acute confusion - the 4AT can help identify the fluctuating course, changes in alertness/attention that point towards delirium.
  • Proceed with the investigations & management steps for delirium
  • Identify chronicity by discussing with patients & relatives focussing on impact on daily life, timeframe & progression, evidence of psychosis/depression, alcohol use & safety issues (driving, violence, vulnerability & self-care). The IQCODE lists useful questions to ask next of kin.
  • If the patient is at their baseline cognition, consider cognitive screening tools (e.g. ACE, MMSE, MOCA) which can also help to monitor for progression.
MDT Approach

Team Things to consider
Medical Medication
Capacity
Fluid, food & stool charts
Consider frailty
DNACPR form
Communication with family re: prognosis & expectations
Physiotherapy Mobility & falls
Occupational Therapy Fall detection devices
Safety when carrying out ADLs
Accessibility of home
Speech & Language Swallow, risk of aspiration
Tissue Viability Bedsores
Palliative Care Communication with family
Dealing with symptoms
Social Worker Discharge Planning

Capacity
Do they have capacity to make decisions? If not, you may need to make decisions for them in their best interests but you should discuss this with your seniors. Review if patients a Power of Attorney in place or advanced directives.

England & Wales
The Mental Capacity Act may help identify those lacking capacity to support, for example, administration of medication in their best interest. Additionally, a Deprivation of Liberty Safeguards (DoLS) is used if restrictions to restrict a patient's liberties e.g. prevent them from leaving, mittens to stop them pulling lines or sedation. The completed form needs to be sent to a supervisory body for approval.

Scotland
An Adults With Incapacity (AWI) form is used in Scotland. It allows you to provide physical medical care in the best interest of a patient, when they do not have the capacity to make specific decisions. An AWI must be put in place by an FY2 or higher grade and countersigned by a consultant.

Communication
With the patient
Patients may bring a "this is me" passport. It includes information on how to communicate with them & what to do when they're distressed.

Don't avoid questions because the patient is confused. This can be isolating. Frequent re-orientation, lighting & ensuring food/drink is easily accessible can also help promote independence.

Use simple, clear words when communicating. Baby-talking is condescending & can impede communication.

With family
Delirium & dementia can be a difficult diagnosis for patients and families. It may be a huge shock for the family & they often have many questions. See the resources section below for things they can be signposted to. Do ask the family to bring in clocks, photos, visual/hearing aids to provide good supportive care. It is helpful to take a collateral & appreciate the concerns/expectations of the family.

It is also helpful to discuss discharge planning with them.

DNACPR forms
Discussing ceilings of care can be useful. Patients may not wish to be resuscitated or may not understand what it entails.

Medication
You are not expected to initiate or alter these yourself but in addition to adding more medication, consider which you may be able to stop. Polypharmacy is discussed more here.
  • Disease altering drugs: acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) & memantine can help in mild to moderate Alzheimers dementia
  • Psychiatric: 
    • Depression: sertraline, mirtazapine, trazadone
    • Agitation: medication is used as a last resort, but lorazepam tends to be first-line
    • Distress/Psychosis: risperidone or quetiapine may be used
Useful resources
Written by Isabel Eldergill-Storm (FY3)