‘ a progressive and largely irreversible clinical syndrome that is characterized by global deterioration in intellectual function, behavior and personality in the presence of normal consciousness and perception’ (in an acute confusional state the level of consciousness is impaired)
It is clinically diagnosed and is characterised by a triad of changes.. Memory loss, loss of another aspect of cognition, and impairment of every day life.
If impairment of consciousness is present together with general intellectual impairment, then the condition is defined as delirium or confusional state - acute or sub-acute.
The period from first symptoms to presentation to the GP is currently somewhere between 12 and 18 months, (and again there is a similar time lag from that point of recognition to time of formal diagnosis)
Many patients have preserved positive personality traits and personal attributes but the following features may become evident as the disease progresses:
changes in personality,
difficulty in carrying out daily activities,
psychiatric symptoms - apathy, depression or psychosis
unusual behavior - aggression, sleep disturbance or disinhibited sexual behavior
Most patients with dementia lose insight into their condition at a nearly stage and fail to report lapses in memory and behaviour
Mrs D is a 75 year old widow with previously infrequent attendance at the surgery until the death of her husband 2 months ago. Her son lives a few doors down . Despite missing her husband she denies having any problems coping without him, but presents with vague symptoms often muddling up her appointment days and times. Her son calls the surgery concerned about the state of the house and his mother’s hygiene. She has been going to the shops as usual, but is stock-piling tins that she never seems to open, and there is no fresh food in the house. He is going to take her to live with him for the time being but wants you to investigate.
The differential diagnosis could be Dementia, but also a bereavement reaction, depression, or delirium secondary to a medical condition.
Old age is often associated with bereavement, social isolation, physical and mental disability, and all these factors could be having an impact. Mrs D was able to cope while her husband was alive, possibly because he carried out many of the essential tasks. With a pt who presents with a multitude of physical problems the initial focus is on excluding any physical cause while considering grief reaction, depression, or dementia. It is also worth bearing in mind these can all present together, eg dementia is a risk factor for depression!
Diagnosis of dementia should be made only after through assessment which should include history, cognitive and mental state examination, physical examination, appropriate investigations and a review of medication which might affect cognitive function.
Cholinesterase inhibitors (donepazil rivastigmine, and galantamine) correct low acetylcholine levels in Alzheimer's disease, resulting in a small but worthwhile improvement in memory energy and mood.
NICE recommended as an option in the management of patients with Alzheimer’s disease of moderate severity only (that is those with a MMSE score of 10-20 points)
These should be started and reviewed (every 6 months) by secondary care though shared care can allow GP to monitor tolerability and side effects
Common side effects include nausea, diarrhoea, vivid dreams and leg cramps. Bradychardia is almost invariable.
The drug should only be continued while the patient’s MMSE score remains at or above 10 points and their global, functional and behavioral condition remains at a level where the drug is considered to be having a worthwhile effect.
The percentage of patients diagnosed with dementia whose care has been reviewed in the preceding 15months. This should include an assesment of support needs of the patient and their carer and a review of co-ordination arrangements with secondary care.