1. Nice guidelines 2006

2. Definition  Widespread deterioration in cerebral function without impairment of consciousness.  Occurs across a widespread of abilities  Memory – learning new materials  Analytical thought  Judgement and planning  Handling of language and spatial abilities  Social responsiveness  Conduct and feeling  Basic tasks of self care

3. Diagnosis  Clinical picture at anytime is determined by  Persons previous personality and intellectual endowment  The nature of the pathological process and the stage it has reached

4. History  Age  Family history  Progress of condition  Associations – myoclonus or seizures  Exposure to toxins – alcohol, lead drugs (barbiturates)

5. Examination  Exclude dysphasia as a cause for apparent dementia  Look for neurological signs  Find information about the patient’s social functioning which would not be normal for dementia

6. Cognitive tests  Should include tests for  Attention and concentration  Orientation  Short and long term memory  Praxis  Language  Executive function

7. Cognitive tests  MMSE  6-Item cognitive impairment test  General Practitioner assessment of cognition  7-minute screen  Take into account educational level, skills, prior level of functioning and attainment, language, sensory impairment, psychiatric illness and physical or neurological problems

8. Investigations  Fbc esr – anaemia, vasculitis  T4 TSH – hypothyroidism  Biochemical screen – hypo or hypercalcaemia  U&E’s - renal failure, dialysis dementia  Fasting blood glucose  B12 folate – vitamin deficiency dementia  Lft’s

9. Investigations  Other investigations if appropriate  MSU if suspect delirium  Syphylis serology  HIV – in a young person  Caeruloplasmin – Wilson’s disease

10. Specialist investigations  CSF – Jacob Creuztfelt disease  Brain biopsy  Imaging  MRI best if not available then CT scan  SPECT scan to differentiate Alzheimer's, vascular and fronto- temporal dementia

11. Types  Alzheimer's  Vascular dementia  Dementia with Lewy bodies  Frontotemporal dementia

12. Referral  Refer all patients with abnormal scores on cognitive testing to specialist memory clinic. This provides  More detail cognitive assessment  Imaging to exclude other disorders  Social support for patient and carer’s  Support groups  Medico-legal issues  Education about illness

13. Management  Mild to moderate dementia  Offer opportunity to participate in a structured group cognitive stimulation program  Drugs  Acetylcholinesterase inhibitors should be considered for those with moderate alzheimer’s disease mmse 10-20 points. Should be started by a specialist. They should not be used in vascular dementia or in MCI

14. Management  Non cognitive symptoms  Hallucinations  Delusions  Anxiety  Marked agitation  Aggressive behaviour  Wandering  Hoarding  Sexual disinhibition  Disruptive vocal behaviour  Apathy

15. Management  For non cognitive symptoms  Only consider medication if severe distress or risk of harm to the person or others

16. Management  Fro distressing non cognitive symptoms assess and treat  Physical health  Depression  Possible undetected pain or discomfort  Side effects of medication  Psychosocial factors  Physical environmental factors

17. Management  For co-morbid agitation consider  Aromatherapy  Multisensory stimulation  Therapeutic use of music and or dancing  Animal assisted therapy  massage

18. Management  Antipsychotics  Do not use in mild to moderate non cognitive symptoms in  Lewy body dementia as risk severe reaction  Alzheimer’s, vascular or mixed dementia’s because of increased risk of cerebrovascular adverse events and death

19. Management  Antipsychotics  Consider for severe non cognitive symptoms only if (seek advice from dementia specialist first)  Risks and benefits fully discussed  Target symptoms have been quantified and are being regularly assessed and recorded  Co-morbid conditions such as depression have been assessed  The dose is low and titrated upwards and of time limited duration

20. Management  Behaviour that challenges  Environmental, physical health and psychosocial factors that might cause it  Overcrowding  Lack of privacy  Lack of activities  Inadequate staff attention  Poor communication with patient  Conflicts between staff and carers

22. Management  Depression  CBT  Reminescence therapy  Multisensory stimulation  Animal assisted therapy  Exercise  Drugs  SSRI’s – citalopram start 10mg also helps agitation

23. Ethics and consent  Always seek valid consent, explain options, check understanding.  Use mental capacity act 2005 if person lacks capacity  Only disclose personal information without consent in exceptional circumstances  Discuss advanced statements, advanced decisions to refuse treatment, power of attorney.