3. ASSESSMENT & DIAGNOSIS
Insufficient evidence to recommend routine cognitive
screening for asymptomatic community-dwelling elderly.
Targeted evaluation on cognitive and non-cognitive
assessment for dementia
▪ History
▪ Physical examination
▪ Blood test and imaging
▪ Diagnostic criteria
Exclude dementia mimicking conditions
Use of rating scales to assess non-cognitive domains
10. Evaluation of Dementia
Clinical assessment
➢ Physical examination
Overall well being – hydration, lethargy, septic looking
(Delirium)
Signs of hypothyroidism
Signs of anemia
Vision
Hearing
Focal neurological deficits
Parkinsonism features
Other involuntary movements
12. Evaluation of Dementia
Clinical assessment
➢ Cognitive assessment
= MMSE, MoCA
35. Tsoi KK, Chan JY, Hirai HW, et al. Cognitive Tests to Detect Dementia: A Systematic Review and Metaanalysis. JAMA internal medicine. 2015;175(9):1450-8
37. Davis DH, Creavin ST, Yip JL, et al. Montreal Cognitive Assessment for the diagnosis of Alzheimer’s disease and other dementias. The Cochrane database of systematic reviews.
2015;2015(10):Cd010775.
Cognitive
assessment
tools
Accuracy Validation in
local languages
Sensitivity
(95% CI)
Specifciity
(95% CI)
MMSE
*35, level I
Cut-off points
23-24
Yes:Malay,
Mandarin
0.81(0.78 - 0.84) 0.89(0.87 – 0.91)
MoCA
*37, level III
Cut-off points
18-26
Yes:Malay,
Mandarin
Range 0.77 – 1.00 Range 0.51 – 0.87
13. Evaluation of Dementia
Clinical assessment
➢ Non-cognitive assessment
= NPI
Two systematic reviews on the Neuropsychiatric Inventory
(NPI) showed that:
able to identify behavioural and psychological symptoms in
persons with Alzheimer’s dementia. *43
the items on irritability, agitation, anxiety, apathy, sleep
disturbances and delusion exerted the most impact on
caregiver for PWD. *44
43. Canevelli M, Adali N, Voisin T, et al. Behavioral and psychological subsyndromes in Alzheimer’s disease using the Neuropsychiatric Inventory.
International journal of geriatric psychiatry. 2013;28(8):795-803.
44. Terum TM, Andersen JR, Rongve A, et al. The relationship of specific items on the Neuropsychiatric Inventory to caregiver burden in dementia: a
systematic review. International journal of geriatric psychiatry. 2017;32(7):703-17.
14. Evaluation of Dementia
Clinical assessment
➢ Non-cognitive assessment
= NPI
The NPI was utilised
- to assess the presence and severity of behavioural and
psychological symptoms in PWD
- proven good psychometric properties, sensitivity to
pharmacological and non-pharmacological interventions
- applicability to various institutional, outpatient and
community settings. *45
45. Jeon YH, Sansoni J, Low LF, et al. Recommended measures for the assessment of behavioral disturbances associated with dementia. The
American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2011;19(5):403-15.
15.
16. Evaluation of Dementia
Clinical assessment
➢ Non-cognitive assessment
In another systematic review on caregiver burden, the Zarit
Burden Interview scale(ZBI, 22-item version) had: *49
• strong psychometric properties [reliability (Cronbach’s alpha
ranging from 0.70 to 0.93) and validity]
• had been used for caregivers in the care of PWD.
49. Whalen KJ, Buchholz SW. The reliability, validity and feasibility of tools used to screen for caregiver burden: a systematic review. JBI library of
systematic reviews. 2009;7(32):1373-430.
17.
18. Evaluation of Dementia
Clinical assessment
➢ Non-cognitive assessment
Other non-cognitive assessment
A cut-off score ≤5 and ≤7 for Cornell Scale for Depression
in Dementia (CSDD) and Montgomery-Asberg Depression
Rating Scale (MADRS) respectively give a 100% sensitivity
in the screening of depression in nursing home residents with
dementia when the source of information is from the
professional caregivers. *47
Geriatric Depression Scale (GDS) is also an effective
screening tool for depression in the older people. *10
47. Leontjevas R, Gerritsen DL, Vernooij-Dassen MJ, et al. Comparative validation of proxy-based Montgomery-Åsberg depression rating scale and cornell scale for depression in dementia
in nursing home residents with dementia. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2012;20(11):985-93. 10.
Ministry of Health Malaysia. Management of Dementia (Second Edition). Putrajaya: Ministry of Health Malaysia; 2009.
20. Evaluation of Dementia
Brain imaging
Structural neuroimaging (CT / MRI)
➢ Usually offered in the assessment of people with suspected
dementia, to exclude potentially reversible causes of cognitive
decline, or cerebral pathologies. *42, 50
➢ May assist in subtype diagnosis. *42, 50
➢ MRI is recommended if dementia subtype is uncertain, and
vascular dementia is suspected. *42
➢ CT can be used if MRI is unavailable or contraindicated. It
is more readily available and better tolerated.
42. National Institute for Health and Care Excellence (NICE). Dementia: assessment, management and support for people living with dementia and
their carers. London: NICE; 2018.
50. Guideline Adaptation Committee. Clinical Practice Guidelines and Principles of Care for People with Dementia. Sydney: Guideline Adaptation
Committee; 2016.
21. Take Home Messages
The diagnosis of dementia should be based on detailed
history & physical examination, & supported by
cognitive, functional & behavioural evaluation.
24. Goals of Therapy
Positive effect on cognition and quality of life
Management of challenging behaviours
Management of psychological symptoms in the context of dementia
BPSD
25. TREATMENT
NON-PHARMACOLOGICAL INTERVENTION
Positive effect on cognition and quality of life
OBJECTIVE:
To maintain the PWD independence for as long as possible by taking part
actively in their own day to day activity.
Based on evidence-based study & NICE recommendations, activities that
promote positive effect on cognition (cognitive maintenance) and quality
of life:
➢ physical activity
➢ cognitive stimulation therapy ; cognitive stimulation, cognitive training
& cognitive rehabilitation
➢ reminiscence therapy
➢ spirituality and religious activity
26. Behavioural and Psychological Symptoms of Dementia (BPSD)
NICE recommends structured assessment exploring & addressing
possible reasons for distress including clinical / environmental causes:
Physical problem; ex: pain, delirium
Inappropriate care
Psychosocial Interventions to reduce anxiety & depression:
Cognitive behavioural therapy
Counselling session
Psychoeducation
Outreach support to patients & carers
27.
28. No new drug licensed since CPG Dementia 2nd ED. 2009
Acetylcholinesterase Inhibitors (AChEI) (donepezil, galantamine and
rivastigmine)
N-methyl-D-aspartate (NMDA) receptor antagonist (memantine)
29. Not curative
Managing symptoms – cognitive, non-cognitive, behavioural
Improve independence
Preserve function
3T approach
specific Target symptoms
start low & Titrate upwards
Time limited
30. Alzheimer’s Disease
Donepezil should be offered of all severity
Rivastigmine is an option in mild to moderate AD
Memantine may be considered in moderate to severe AD as
monotherapy / in combination with acetylcholinesterase inhibitors
NICE recommends memantine monotherapy as an option in
Moderate AD where there is intolerance / contraindications to AChEI
Severe AD
31. Vascular dementia
Patients with vascular dementia with concurrent vascular risk factors
should be treated with recommended drugs for the management of the
medical problems
Acetylcholinesterase inhibitors / memantine may be considered
32. Disease Dementia)
Rivastigmine / donepezil may be considered for dementia with Lewy
body & Parkinson’s disease dementia
Memantine
Cochrane systematic review found very low certainty evidence that
monotherapy memantine had no difference of improvement in
cognition compared with placebo (based on MMSE).
34. Behavioural & Psychological Symptoms
Antipsychotics may be considered for behavioural &
psychological symptoms in PWD where there’s a risk
of harming themselves / others
NICE recommends on AP in PWD
Lowest effective dose should be used & for the shortest possible duration
Reassess regularly & wean off if it’s not needed
Antidepressants
May be considered for PWD who have agitation
May be prescribed for PWD with pre-existing severe mental health problem
There’s insufficient evidence to support the use of
35. Take Home Messages
Nonpharmacological interventions should be the mainstay of the
treatment for cognition and behavioral and psychological symptoms
(BPSD) in the context of Dementia, throughout all stages.
Psychosocial interventions need to be tailored to individual needs.
For those who require regular medication, the ‘3T’ approach is a good
practice:
Treatments should have a specific Target symptoms
Starting dose should be low & Titrated upwards
Treatments should be Time limited
36. = penjenamaan semula Program “ National Integrated Care for Dementia (ICD) in
Geriatric Mental Health Services”
Visi:
Making ICD in older persons the leading service intervention in caring for persons
with dementia in Malaysia
37. Modul ICD:
- Penilaian tahap demensia : MMSE/MoCA/GDS/FAST
- Penilaian tahap gejala tingkahlaku : NPI
- Merangka jadual bermanfaat (design activity)
- Psikoedukasi : modul psikoedukasi
- Stimulasi kognitif : modul CST
38. Indikator setiap 6 bulan (KPI):
PERKARA KPI
6 MONTHLY ASSESSMENT
(MMSE, BADL, IADL, NPI)
80%
PSYCHOEDUCATION 80%
RUJUKAN KEPADA OT
(CST, DESIGN ACTIVITY)
60%
