Medical Tribune July 2008 P14-15
Diagnosis
Patients with dementia typically
present with some general
symptoms that should alert the
doctor to their condition. The major
symptom is memory deterioration,
which usually begins with difficulty
in recalling recent events. As a
result patients may misplace items,
fail to recognize people, become
disorientated to time, forget that
they have eaten and become confused
in unfamiliar surroundings.
Longer-term memory, conversely,
can often remain intact during the
early stages of the condition. Behavioral
and psychiatric symptoms
can also be suggestive of dementia,
such as agitation, aggression, hallucinations
and delusions – particularly
of people wanting to harm
them or steal from them. Sleeplessness
and nighttime wandering are
also common symptoms.
Recognizing dementia in its
early stages can be challenging
as elderly people are often quite
forgetful and these warning signs
can be dismissed as normal aging.
The condition can also be confused
with depression, as depressed patients
may also present with forgetfulness
and poor attention and
concentration. Furthermore the
diagnosis is often missed in cases
where the patient visits a doctor for
other reasons and neglects to mention
that he or she is becoming forgetful,
so it is important that physicians
remain aware of the condition
in order to recognize it early.
A full psychiatric and medical
history should be taken, and
any problems with daily functioning
and aspects of self-care such
as bathing and feeding should be
noted. A mental state examination
should be performed to look for
depressed and irritable mood, hallucinations
and delusions. It is also
important to perform a full cognitive
assessment using tests, such as
the Mini Mental State Examination
and the Elderly Cognitive Assessment
Questionnaire. These can be
time-consuming, however, and
busy general practitioners (GPs)
may prefer to use quicker tests
such as the Abbreviated Mental
Test, and then refer the patient to
a geriatrician or psychologist for
more detailed assessment. The
doctor should also take the time
to perform a complete physical examination
to rule out other medical
problems.
There are a number of tests
that general practitioners should
perform to establish whether a
patient with forgetfulness has dementia.
The initial objective is to
exclude other potential causes for
the problem, many of which may
be reversible with the appropriate
treatment. Blood testing should be
used to rule out anemia, hypoglycemia,
syphilis, and vitamin B12
and folate deficiencies. Liver, kidney
and thyroid function should
be tested, and urine analysis
should be performed to exclude
infections. Suspected cases should
also receive a chest x-ray and a
computed tomography scan, and
in some cases the radiologist will
also recommend magnetic resonance
imaging.
Once the diagnosis is established
the doctor should assess
which type of dementia is present
in the patient. The most common
forms are Alzheimer’s disease,
which is caused by the formation
of amyloid plaques and neurofibrillary
tangles, and vascular dementia,
which is caused by stroke.
Physicians can make the distinction
using specific diagnostic criteria,
such as those contained in
the International Classification of
Diseases or the Diagnostic and the
Statistical Manual of Mental Disorders.
A family history for Alzheimer’s
disease should arouse suspicion
for this diagnosis, whereas a
recent history of stroke or the presence
of multiple risk factors (such
as diabetes, hypertension, high
cholesterol and smoking) would
be clues for a diagnosis of vascular
dementia.
Practice Guidelines
Internationally-recognized
guidelines for treating patients
with dementia have been published
by the American Psychiatric
Association (APA), most
recently in October 2007. These
can be downloaded from the APA
website, along with a quick reference
guide. This document contains
a wide range of information
about all aspects of the condition
and should be relevant to doctors
in most countries.
The Ministry of Health in Singapore
published its own comprehensive
dementia guidelines in
March 2007 along with an 8-page
summary card. Dementia management
guidelines are also available
from the Academy of Medicine of
Malaysia, published in July 2003.
Treatment
Alzheimer’s disease and vascular dementia are progressive
non-reversible conditions and the
overall aim of treatment is to slow
down the functional deterioration
and to reduce the severity of associated
psychiatric symptoms.
It is important that GPs explain
these facts to the patient’s family
so that they have realistic expectations
and do not expect the patient
to make a full recovery. The family
should be educated about the
nature of dementia and its symptoms,
and should be prepared to
expect the worst.
Pharmacological treatment can
be employed in order to slow the
rate of cognitive decline in dementia
patients. The use of an acetylcholinesterase
inhibitor should
be considered for this purpose in
most patients. Donepezil, rivastigmine
and galantamine are all effective
drugs from this class. Memantine,
an N-methyl D-aspartate
antagonist, can also be used – either
alone or in conjunction with
an acetylcholinesterase inhibitor.
Other pharmacological agents
such as anti-inflammatories, prednisolone
and estrogen are not recommended
for preventing cognitive
decline in dementia patients.
Drug therapy can also be used
to target the specific symptoms
that may accompany dementia
such as depression, hallucinations
and psychosis. The use of these
drugs should be decided on a caseby-
case basis.
Doctors must also give careful
consideration to the non-pharmacological
aspects of dementia
management, and should try to
improve the quality of life for
both patients and their families
wherever possible. Depression,
psychiatric symptoms and sleep
disorders can all be distressing for
the family and should be taken
into consideration. GPs should
look out for carer stress and burnout,
which can lead to frustration
and sometimes elder abuse. They
should try to assess stress levels
by asking indirectly, but this can
be challenging as carers are unlikely
to volunteer such information
readily and may be sensitive
to questioning.
Dementia patients may benefit
from being referred to a day center
in order to keep them occupied.
This may also help the patient to
sleep better at night and reduce
carer stress levels.
In patients with VaD it is important
to prevent further strokes,
and risk factors such as hypertension
and diabetes should be addressed.
These patients should also
be given aspirin to reduce the risk
of recurrence.
Disease management tools
GPs who wish to further their
understanding of dementia can
often sign up for specialist training.
Programs such as these can
increase doctors’ knowledge of
the available resources and treatment
options and help them to
feel more confident about handling
their patients.
The Institute of Mental Health
(IMH) in Singapore, for example,
has a partnership program with
GPs – offering training comprised
of lectures and workshops. Upon
completion of training the GPs
can sign up for the IMH-GP partnership
program, where they can
participate in the management of
psychiatric and dementia patients
in their own clinics.
Conclusion
Dementia is distinct from normal
aging and needs to be carefully
distinguished from other causes
of forgetfulness. Early detection
is beneficial so that the patient
can be managed appropriately in
order to delay the progression of
symptoms and prevent further
complications.
Diagnosis
Patients with dementia typically
present with some general
symptoms that should alert the
doctor to their condition. The major
symptom is memory deterioration,
which usually begins with difficulty
in recalling recent events. As a
result patients may misplace items,
fail to recognize people, become
disorientated to time, forget that
they have eaten and become confused
in unfamiliar surroundings.
Longer-term memory, conversely,
can often remain intact during the
early stages of the condition. Behavioral
and psychiatric symptoms
can also be suggestive of dementia,
such as agitation, aggression, hallucinations
and delusions – particularly
of people wanting to harm
them or steal from them. Sleeplessness
and nighttime wandering are
also common symptoms.
Recognizing dementia in its
early stages can be challenging
as elderly people are often quite
forgetful and these warning signs
can be dismissed as normal aging.
The condition can also be confused
with depression, as depressed patients
may also present with forgetfulness
and poor attention and
concentration. Furthermore the
diagnosis is often missed in cases
where the patient visits a doctor for
other reasons and neglects to mention
that he or she is becoming forgetful,
so it is important that physicians
remain aware of the condition
in order to recognize it early.
A full psychiatric and medical
history should be taken, and
any problems with daily functioning
and aspects of self-care such
as bathing and feeding should be
noted. A mental state examination
should be performed to look for
depressed and irritable mood, hallucinations
and delusions. It is also
important to perform a full cognitive
assessment using tests, such as
the Mini Mental State Examination
and the Elderly Cognitive Assessment
Questionnaire. These can be
time-consuming, however, and
busy general practitioners (GPs)
may prefer to use quicker tests
such as the Abbreviated Mental
Test, and then refer the patient to
a geriatrician or psychologist for
more detailed assessment. The
doctor should also take the time
to perform a complete physical examination
to rule out other medical
problems.
There are a number of tests
that general practitioners should
perform to establish whether a
patient with forgetfulness has dementia.
The initial objective is to
exclude other potential causes for
the problem, many of which may
be reversible with the appropriate
treatment. Blood testing should be
used to rule out anemia, hypoglycemia,
syphilis, and vitamin B12
and folate deficiencies. Liver, kidney
and thyroid function should
be tested, and urine analysis
should be performed to exclude
infections. Suspected cases should
also receive a chest x-ray and a
computed tomography scan, and
in some cases the radiologist will
also recommend magnetic resonance
imaging.
Once the diagnosis is established
the doctor should assess
which type of dementia is present
in the patient. The most common
forms are Alzheimer’s disease,
which is caused by the formation
of amyloid plaques and neurofibrillary
tangles, and vascular dementia,
which is caused by stroke.
Physicians can make the distinction
using specific diagnostic criteria,
such as those contained in
the International Classification of
Diseases or the Diagnostic and the
Statistical Manual of Mental Disorders.
A family history for Alzheimer’s
disease should arouse suspicion
for this diagnosis, whereas a
recent history of stroke or the presence
of multiple risk factors (such
as diabetes, hypertension, high
cholesterol and smoking) would
be clues for a diagnosis of vascular
dementia.
Practice Guidelines
Internationally-recognized
guidelines for treating patients
with dementia have been published
by the American Psychiatric
Association (APA), most
recently in October 2007. These
can be downloaded from the APA
website, along with a quick reference
guide. This document contains
a wide range of information
about all aspects of the condition
and should be relevant to doctors
in most countries.
The Ministry of Health in Singapore
published its own comprehensive
dementia guidelines in
March 2007 along with an 8-page
summary card. Dementia management
guidelines are also available
from the Academy of Medicine of
Malaysia, published in July 2003.
Treatment
Alzheimer’s disease and vascular dementia are progressive
non-reversible conditions and the
overall aim of treatment is to slow
down the functional deterioration
and to reduce the severity of associated
psychiatric symptoms.
It is important that GPs explain
these facts to the patient’s family
so that they have realistic expectations
and do not expect the patient
to make a full recovery. The family
should be educated about the
nature of dementia and its symptoms,
and should be prepared to
expect the worst.
Pharmacological treatment can
be employed in order to slow the
rate of cognitive decline in dementia
patients. The use of an acetylcholinesterase
inhibitor should
be considered for this purpose in
most patients. Donepezil, rivastigmine
and galantamine are all effective
drugs from this class. Memantine,
an N-methyl D-aspartate
antagonist, can also be used – either
alone or in conjunction with
an acetylcholinesterase inhibitor.
Other pharmacological agents
such as anti-inflammatories, prednisolone
and estrogen are not recommended
for preventing cognitive
decline in dementia patients.
Drug therapy can also be used
to target the specific symptoms
that may accompany dementia
such as depression, hallucinations
and psychosis. The use of these
drugs should be decided on a caseby-
case basis.
Doctors must also give careful
consideration to the non-pharmacological
aspects of dementia
management, and should try to
improve the quality of life for
both patients and their families
wherever possible. Depression,
psychiatric symptoms and sleep
disorders can all be distressing for
the family and should be taken
into consideration. GPs should
look out for carer stress and burnout,
which can lead to frustration
and sometimes elder abuse. They
should try to assess stress levels
by asking indirectly, but this can
be challenging as carers are unlikely
to volunteer such information
readily and may be sensitive
to questioning.
Dementia patients may benefit
from being referred to a day center
in order to keep them occupied.
This may also help the patient to
sleep better at night and reduce
carer stress levels.
In patients with VaD it is important
to prevent further strokes,
and risk factors such as hypertension
and diabetes should be addressed.
These patients should also
be given aspirin to reduce the risk
of recurrence.
Disease management tools
GPs who wish to further their
understanding of dementia can
often sign up for specialist training.
Programs such as these can
increase doctors’ knowledge of
the available resources and treatment
options and help them to
feel more confident about handling
their patients.
The Institute of Mental Health
(IMH) in Singapore, for example,
has a partnership program with
GPs – offering training comprised
of lectures and workshops. Upon
completion of training the GPs
can sign up for the IMH-GP partnership
program, where they can
participate in the management of
psychiatric and dementia patients
in their own clinics.
Conclusion
Dementia is distinct from normal
aging and needs to be carefully
distinguished from other causes
of forgetfulness. Early detection
is beneficial so that the patient
can be managed appropriately in
order to delay the progression of
symptoms and prevent further
complications.
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