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Dementia - Coggle Diagram
Dementia
Differential diagnosis
Vitamin deficiency
Hypothyroidism
Delirium
Depression
Adverse drug effects
Mild cognitive impairment
Normal pressure hydrocephalus
Normal age related memory changes
Sensory deficits
Risk factors
Learning disability
Genetics
Mild cognitive impairment
Cardiovascular disease
Age
Cerebrovascular disease
Parkinson's disease
Modifiable risk factors include - lower educational attainment, hypertension, hearing impairment, smoking, obesity, depression, physical activity, diabetes, low social engagement and support, alcohol consumption, traumatic brain injury and air pollution.
Management: Follow up confirmed dementia
Offer early and ongoing support for those living with dementia for benefits of planning ahead, POA, advance statement, decision to refuse treatment, and their preferences for place of care/death.
Monitor physical and mental health.
Ask for consent to information sharing.
Monitor response to, and adverse effects from, dementia treatments and the progression of dementia.
Offer the person and their family members or carers (as appropriate) oral and written information explaining - the subtype, health and social care teams involved with care, DVLA information, legal rights and responsibilities, right to reasonable adjustments if they are working/looking and groups that can provide support.
Review medication — reduce polypharmacy (if appropriate to do so), minimize use of drugs that impair cognition (such as anticholinergics), review use of antipsychotics (if appropriate), stop unnecessary medicines.
Provide people living with dementia and their family members or carers (as appropriate) with information that is relevant to their circumstances and the stage of their condition (if this has not already been done in secondary care).
Refer or seek advice from a specialist (such as an elderly care psychiatrist, challenging behaviour team, or elderly care physician) if: do not respond to initial treatment, safeguarding concerns, legal issues, Detention under the Mental Health Act (1983) is being considered or dose adjustments required.
Management: Suspected dementia
For people with mild cognitive impairment (depending on local pathways and protocols): discuss the diagnosis, arrange follow up visits to monitor, suggest healthy brain activities.
Refer people with suspected rapidly progressive dementia to a neurological service with access to tests (including cerebrospinal fluid examination) for Creutzfeldt–Jakob disease and similar conditions.
Refer people with learning disabilities with suspected dementia to a psychiatrist with expertise in assessing and treating mental health problems in people with learning disabilities.
Discuss the Driver and Vehicle Licensing Agency (DVLA) regulations on driving and cognitive impairment.
Refer to a specialist dementia diagnostic service such as the memory clinic
Treat any identified, modifiable risk factors for cognitive impairment (such as excess alcohol consumption, diabetes mellitus, cardiovascular risk factors) where possible.
Consider admission for those who are severely disturbed, and admission required to ensure health/safety of the person or others, or primary care assessment is not appropriate.
Management: End stage dementia
When providing care: ensure personalization, avoid overly aggressive, burdensome, or futile treatment, ensure continuity and coordination of care, provide psychosocial and spiritual support, recognize and discuss the terminal stage with family/carers, offer support to carers.
Concerns with: eating and drinking, distress or changes in behaviour, constipation, nausea, loss of appetite, withholding/withdrawal of treatment, resuscitation should be planned and managed appropriately.
For people living with dementia who are approaching the end of life, use an anticipatory healthcare planning process.
Seek advice from Palliative Care specialist if required.
Plan ahead where possible for advance decisions, lasting POA, preferred place of care/death, make a will.
End of life care in dementia shares many of the same principles as palliative care and focuses on improving quality of life, maintaining function, and maximizing comfort of the person with dementia.
Clinical features
Behavioural and psychological symptoms: psychosis, agitation and emotional lability, depression and anxiety, withdrawal or apathy, disinhibition, motor disturbance, sleep cycle disturbance or insomnia, and tendency to repeat phrases or questions.
Cognitive symptoms: Memory loss, Problems with reasoning and communication, difficulty in making decisions, dysphagia, difficulty in carrying out coordinated movements, disorientation and unawareness of the time and place, impairment of executive function.
Difficulties with activities of daily living
Also specific symptoms for individual types of dementia.
Assessment
Arrange blood to exclude reversible causes - FBC, ESR, CPR, U&E, Calcium, HbA1c, LFTs, TFTs, Serum B12 and folate. If appropriate - microscopy and culture, chest x-ray, ECG, syphilis serology, HIV testing.
If suspected examine for: focal neurological signs - coordination and gait abnormalities, sensory findings, motor symptoms. Visual or auditory problems. Cardiovascular signs. Other possible causes of symptoms.
Assess cognition using validated assessment tool.
Ask about onset of symptoms, deterioration, impact on activities of daily life, cognitive, behavioural and psychological symptoms, comorbidities, risk factors, medication history, family history, alcohol or drug use, and any concerns they have.
Definition: Dementia is a progressive, irreversible clinical syndrome with a range of cognitive and behavioural symptoms including memory loss, problems with reasoning and communication, change in personality, and reduction in the person's ability to carry out daily activities.