Dementia Care 1 Guidance Assessment

Dementia care. Part 1: guidance and the assessment process Emma Ouldred, Catherine Bryant

Abstract This article outlines recent guidance on dementia care and provides information on dementia, its different subtypes, the assessment process and the utility of cognitive screening tools. As dementia progresses a person may gradually lose their ability to make decisions for themselves. The Mental Capacity Act 2005 (MCA) is one ofthe most significant Acts to be passed in the United Kingdom, which protects people with dementia and stresses the need to advocate on behalf of this vtdnerable group. The MCA is described in detail as practitioners working in the field of dementia care need to be aware of its clauses, as they are likely to require knowledge of it on a frequent basis. Dementia, delirium and depression are often mistaken for one another and useful ways to differentiate between the different conditions are given in addition to comprehensive advice about the management of people with dementia admitted to hospital with delirium.

NEUROSCIENCE NURSING The report emphasizes the need for not only a 'sea change' in how we view dementia, but also for better diagnosis, assessment and support for people with dementia and their carers. It highlights the need for access to diagnosis and early intervention, and the need for effective working across health and social care services from acute trusts to the community. This will only be achieved through coordinating the work of providers and commissioners at local levels. The government recently announced the forthcoming production of the first ever national clementia strategy. A 12-month work programme will cover the follownig themes: • Improved awareness of dementia • Early diagnosis of dementia • Improving the quality of care for dementia (Department of Health. 2007). The National InstituteforHealthandClinical Excellence (NICE, 2()(t6) have produced guidance that makes recommendations for the identification, treatment and care of people with dementia, and the support of caren. The principle of person-centred care underpins the guidance. The main priorities for implementation include: • Non-discrimination: people should not be excluded from any services on the basis of age, diagnosis or coexisting learning disability • Valid consent: people with dementia should be informed of all care options without coercion. If a person lacks capacity then the Mental Capacity Act 2005 (MCA) should be adhered to • Carers: the rights and needs of carers are emphasised and their rights to a carers' assessment are also reinforced • Coordination and integration of health and social care: integrated care across health and social care agencies with the need to involve service users in the development, implementation and regular review of care plans. Guidance also recommends the assignation of a named health/social care staff member to have overall responsibility for care planning • Memory assessment services: these should be the single point of referral for all people with a suspected diagnosis of dementia (provided by memory assessment clinics or community mental health teams). Structural imaging {magnetic resonance imaging [MRI] or computed tomography |CT|) should be used in the assessment of people with dementia • Behavioural challengesipeople with dementia who develop behavioural problems should be offered early comprehensive assessment and have tailored care plans

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Figure 1. Comparrison of a normal healthy brain vesus the brain of a person with Alzheimer's.

Cerebral cortex

Hippocampus (niemofy acquisitionl

Normal

• Training: all staff working with older people in the health, social care and voluntary sectors bave access to dementia care training (skill cievelopnient) that is consistent with their roles and responsibilities • Mental health needs in acute hospitals: acute and general hospital trusts should plan and provide services that address the specific personal and social care needs and the mental and physical health of people with dementia who use acute hospital facilities for any reason.

Dementia Dementia is a syndrome caused by disease of the brain, usually of a chronic or progressive nature, in which there is impairment of mtiltiple higher cortical functions, including memory, thinking, orientation, comprehension,

Alzheimer's

calculation, learning capacity, language and judgement. These cognitive symptoms can be accompanied by non-cognitive symptoms, including changes m behaviour, emotional control and social functioning (World Health Organization [WHO]. 1992). Along with the cognitive decline, people with demenda can also experience behavioural and neuropsychiatric symptoms. Cognitive and non-cognitive symptoms will cause a decline in a persons activities of daily living. This decline must be sufficient to impair activities of daily living (WHO, 1992). The most common form of dementia is Alzheimer's, which accounts for 62% of all cases. Vascular dementia (VaD), either alone or co-existent with Alzheimer's, is the second most common subtype of demenda (27% (Knapp et al, 2007). Other forms of demenda include

Box I. The main characteristics of Alzheimer's disease • Depletion of acetylcholine (chemical neurotransmitter) • Characterized by a build-up of the following abnormal proteins: amyloid plaques, damaged nerve fibres and tau tangles, which are only discernible under a microscope • Medial temporal lobe (memory) is affected first, thus, primaiy signs are often forgetfulness and confusion • Gradual progression: the average length of Alzheimer s disease is between 8 and 12 years (Burke and Morgenlander, 1999) • Symptomatic relief may be gained from cholinesterase inhibitors, e.g, donepezil. galantamine and rivastigmine • Symptomatic relief may be gained from memantine (N-methyl-D-aspartate antagonist) • Computerized tomography brain scan may show mild Involutional changes and atrophy (shrinkage)

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over a number of years. CHnical features of the disease can be classified into three stages (see Tahk J), although not all of the features described will be present in every person. Individuals may exhibit symptoms of more than one stage simultaneously. It must also be remembered that not every person will move through each stage.

• Access to education and training for person with dementia and their family • Able to benefit from cognitive rehabilitation/ memory training • Person with dementia and family able to come to terms with diagnosis over time • Early access to support networks • Modification and control of vascular risk • Treatment with cholinestcrase inhibitors • Disease modification and research into the prevention of decline is already underway which makes it essential for identification to be made as early as possible • Able to discuss safety issues and implement risk-reduction strategies such as occupationd therapy services, assisdve technology and social services assessment • Able to consider employment issues. An individual with early onset dementia might still be working. A diagnosis of dementia does not necessarily mean having to give up work but informing employers of a diagnosis in the early stages of the disease process will help to ensure the right level of support is provided. • To plan for the future and also to consider and make decisions regarding their end of life. This might include advising people with dementia to consider setting up a lasting power of attorney, advance decisions and writing a will. People with dementia and their carers might also want details about long-term care options and this information should be made available in written format.

Diagnosis of dementia

Mental capacity

According to NICE (2006) people who are assessed for the possibility of dementia should be asked if they wish to know the diagnosis during the assessment and with whom this should be shared. This is a very sensitive issue and the experience of the diagnosis is challenging for people with dementia, family members, and for practitioners.Time should be made available to discuss the diagnosis and its implications with the person with dementia and also with family members (usually only with the consent ot the person with dementia).

Early diagnosis

If a person has mental capacity (competency) they are able to make decisions for themselves. The legal definition (Office of the Public Guardian, 2007) says that someone who lacks capacity cannot do one or more of the following tour thuigs: • Understand information given to them • Retain that information long enough to be able to make a decision • Weigh up the information available to make a decision • Communicate their decision by any possible means, e.g. squeezing a hand or using sign language.

In a recent survey of 500 caregivers, 62% felt an early diagnosis of dementia was very beneficial (Taylor and Leimian, 2002).There are a number of rea.sons this may be beneficial both to the individual and carers (Iliffe et al, 2003): • Prompt treatment of reversible causes of dementia, e.g. hypothyroidisui, depression • Psychiatric symptoms can be identified and treated

The Mental Capacity Act 2005 The MCA was fully implemented in October 2007. The Act applies to England and Wales. Scotland has its own legislation, the Adults with Incapacity (Scotland) Act 2000. The approach in Northern Ireland is currently governed by common law. This Act provides a statutory framework to empower and protect people

Box 2. The main features of vascular dementia Damage to blood vessels leading to brain Lack of oxygen to brain causes cell death Symptoms may be sudden as a result of stroke Progression is often stepwise through a series of small strokes Vascular dementia may overlap with Alzheimer's disease - often referred to as mixed dementia Computerized tomography scan may show areas of discrete infarcts or multiple areas oF infarction Adapted from: Whalley and Breitner (200Z)

Box 3. The main features of dementia with lewy bodies • Gradual degeneration and death of nerve cells • Spherical protein deposits found inside damaged nenye cells: Lewy bodies • Characterized by fluctuating cognitive levels • Parkinsonian symptoms - associated postural instability and risk of falls • Poor concentration and visuai hallucinations • Neuroieptic sensitivity - neuroleptics. antipsychotics and other sedating drugs should only be administered in small doses • Computerized tomography scan may show mild involutionai changes and cerebral atrophy (shrinkage) Adapted ftom: Mynors-Wallis et al (2003) dementia with Lewy bodies (DL13) and frontotemporal dementia (FTD) (NICE, 2006). However, there are rarer and potentially treatable causes of dementia, including hypotliyroidism, vitamin B12 and hypercalcaemia. Other less common causes of dementia include WenickeKorsakofF's syndrome, progressive supranuclear palsy, neurosyphilis, Huntington's disease, HIV infection and Creutzfeldt-J:ikob disease. Further intormation on rarer forms of dementia can be obtained from the Alzheimer's Society website (www.alzheiniers.org.uk). Alzheimer's was first used to describe severe presenile degenerative dementia in 1906 when Dr Alois Alzheimer reported the case of a 51ycar-old woman (Augustus U) who suffered progressive memory impairment, psychotic disturbances and behavioural disturbances. At post-mortem her brain showed plaques, tangles and cerebrovascular disease (Alzheimer, 1907). Box I outlines the main characteristics of Alzheimer's. Box 2 and } show the main features ofVaD and DLB, respectively.

Progression of dementia People with dementia differ in the rate at which their abilities deteriorate and the nature of the problems they have. These abilities may also fluctuate on a daily basis. However, what is inevitable is that these abilities will diminish over time. Progression may be fairly rapid in some people, but in others deterioration can occur more gradually

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NEUROSCIENCE NURSING who may lack capacity to make decisions for themselves, e.g. people with dementia. This legislation makes it clear who can take decisions, in which situations, and how they should go about this. Main clauses of the MCA Lasting power of attorney (LPA): An LPA enables a person (with capacity') to nominate a spokesperson (the attorney) to make decisions regarding cheir personal welfare, including iieaklicare and consent to medical treatment, and also to make decisions about financial and property matters should they become incapable. Separate attorneys can be selected tor making different kinds of decisions. An LPA will only become legal once the person has lost capacity. An LPA will need to be set up using an officia] form and be registered with tlie Office of the Public Guardian. Prior to the MCA any competent individual could appoint someone else to act on her or his behalf in relation to their financial affairs (power of attorney). However, this would be invalid if that individual subsequently became mentally incapable of managing their atTairs. An enduring power ofattorney (EPA), registered witb the Court of Protection, allowed tbis power to be carried througb even after someone became mentally incapable. Altbough LPAs will eventually replace EPAs, people who already bold an EPA may also set up an LPA and all EPAs signed and dated by all parties before 1 October 2007 will remain valid and can still be registered after tbis date. Advance decisions: The MCA gives people a statutory right to refuse treatment through tbe use of an 'advance decision'. An advance decision allows a person to state what forms of treatment they would or would not like sboiilii they become unable to decide for tbemselves in the future. The Alzheimer's Society (www.alzheimers.org.uk) supports the use of advance decisions as they will allow people witb dementia to be involved in planning their future care. However, to be legally enforceable, advance decisions must be valid (made by a person who bas capacity) and applicable (relevant to tbe medical circumstances). Advance decisions cannot be used to demand treatment tbat a healthcare team deems inappropriate or against the law (e.g. eutbanasia).

Table I. The three stages of dementia I. Early stages of dementia • Often this phase is only apparent in hindsight and can be misattributed to bereavement, stress or normal ageing • Loss of short-term memory • Loss of interest in hobbies and activities • Difficulty handling money • Poor judgement • Unwillingness to make decisions • Difficulty adapting to change • Irritabiiity/distress if unable to do something • Inability to manage everyday tasks • Repetitive questioning and loss of thread of conversation 2. Moderate stages of demenda Increased need for support such as reminders to eat. wash, dress and use the lavatory Confusion regarding time and place Failure to recognize people and objects (agnosia) Behavioural symptoms such as wandering and getting lost, and hallucinations (visual and auditory) i^si(y behaviour such as ieaving the house in night clothes, forgetting to turn the taps off and may leave gas unlit Increased repetitive behaviour Word-finding difficulty 3. Advanced dementia Need for i\jil assistance with washing and dressing, eating and toileting Double incontinence Increasing physical frailty - may start to shuffle or walk unsteadily eventually becoming confined to bed or a wheelchair Increased risk of complications associated with prolonged immobility such as constipation. chest infection and urinary tract infections Increased confusion and restlessness such as searching for dead relative Increased aggressive behaviour DIsinhibition Night disturbance Uncontrolled movements - development of seizures Difficulty eating and sometimes swallowing (dysphagia) Weight loss Gradual loss of speech From: Alzheimer's Society (2007)

relating to serious treatment provided by tbe NHS or cbanges in accommodation wbere it is provided by tbe NHS or local authority. The MCA is underpinned by tbe principle tbat every adult bas tbe right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise. A person must be given all practicable help to make decisions, even tbougb tbey may make what might be seen as an unwise decision, it sbould not be treated as lacking capacity. In addition tbe MCA sets out to ensure tbat any decision, Independent mental capacity advocate (IMCA): made under tbe Act for a person who lacks In people who lack capacity and have nobody capacity, must be in their best interests and to support tbem with major life-cbanging should be the least restrictive of their basic decisions, tbe MCA creates a new advocacy rights and freedoms. service to assist vAih tbis. An IMCA will only Practitioners sbould be aware of tbe general be involved in specific decisions, such as tbose clauses of the Act. All health and social care

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providers have a duty to inform and train staff" on the MCA and further information for health and social care professionals, people v/ith dementia, and their carers, can be obtained from tbe Department for Constitutional Affairs'website: www.dca.gov.uk/legal-policy/ mental-capacity/publications, htm.

The assessment process Dementia is a diagnosis of exclusion and it is important to eliminate the rare reversible causes of dementia and identify potentially treatable causes. Assessment of dementia, therefore, must be multidimensional and incorporate patient and carer history assessment of cognitive function, functional status, chnical screening, including physical examination, and routine investigations. Assessment must be an ongoing process if

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people with dementia and their carers are to he supported and managed appropriately. It cognitive impairment is suspected in an individual, it is usual practice for GPs to start the assessment process and then refer patients to a local memory assessment clinic or comniunity mental health team for fiirther detailed assessment. Practitioners working in primary care, such as health visitors for older people and practice nurses, are in an ideal position to recognize early signs of cognitive change and should alert GPs of any concerns. History and cognitive assessment A number of different tools are available for helping to assess cognition in people with suspected dementia, and the following are all recommended in the NICE (2006) dementia guidehne. The mini-mental state examination (MMSE) (Folstein et al, 1975) is a validated, standardized assessment of cognitive capacities and is simple and brief enough to be used with older people. It assesses the following areas of cognitive fbnction: • • • • •

Orientation Memory and attention Language functioii Gopying (praxis) Following instructions. When used with other clinical measures, the MMSE provides a reliable index of dementia severity and staging (Whalley and Breitner, 2002). An arbitrary cut-off at 25/30 separates possible cognitive impairment from no cognitive impairment. However, the MMSE assumes an ability to hear reasonably well, read, write and subtract numbers methodically, and may not be suitable for people with intellectual impairment unrelated to dementia. An alternative to the MMSE is the 6-item cognitive impairment test (6-GIT) Kingshill Version 2000 (Brooke and Bullock, 1999). The 6-GIT is a six-item screening test that has high sensitivity in mild dementia. It is also linguistically and culturally translatable. The dementia questionnaire for mentally retarded persons (DMR) (Evenhuis et al, 1990) is a validated informant-based questioruiaire with eight subscales (short-term memory, long-term memory,spatial and temporal orientation,speech, practical skills, mood, activity and interests, and behavioural disturbances), which is specifically designed for screening for dementia in people with pre-existing intellectual impairment. The informant questionnaire on cognitive decline in the elderly Tliis is a short questionnaire (comprising 16 questions) that is filled in by somebody who

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Case study 1. Possible dementia Mrs I is a 73-year-old retired nurse, living with her husband. Mrs | has always been very particular about paying the bills, remembering hospital appointments and birthdays but over the past year or so she has become more forgetfijl and on several occasions she has not remembered to pay the bills. She used to enjoy playing bridge but has refused to attend recently. She used to enjoy applying make-up and buying new clothes but has recently lost the motivation to do this and has started to look a little unkempt. Mr j suffers ill health himself and has begun to worry about his wife's gradually fading memory and subtle changes in her personality, such as verbal aggression and secretiveness. Mrs j agrees to see her GP, but really doesn't know what all the fuss Is about, as she doesn't think she has got a problem. Dr H performs some routine blood tests and a G-item cognitive impairment test (6-CIT). She scored 12/28 on 6-CIT suggestive of cognitive impairment. All blood test results were within normal limits. Mrs J is referred to the local memory clinic. At the clinic Mr and Mrs J are asked to provide detailed information regarding her previous level of functioning, past medical ^^^^^^_^ .^^^_ ^^^^^^^^^^^^ ^^^1 j^^^^^^^^^Hpv ^ H ^^^^^^^^^H •

S

Figure 1. Computerized tomography scan of a patient iHth Ahlieimer's disease. Note the widening of the reiitricles, which suggest healthy hrain tissue has been replaced hy tcrehrospinalJUiid.

history, current problems and past psychiatric history. Mrs j Is also asked to provide some family history and to discuss any worries she might have. Mr | speaks to the memory clinic sister privately to discuss particular areas of concern such as

Results The memory clinic request a computerized tomography scan. which shows mild involutionai changes and cerebral atrophy (see Figure I). Mini-mental state examination - 20/30 suggestive of moderate cognitive impairment Geriatric depression score: no depression Physical examination: no abnormal findings Mrs I returned to the memory dinic 4 v^eeks later and a diagnosis of probable Alzheimers disease was discussed with her and her husband.

Case study 2. Possible delirium Mr B is 88 years old. He lives with his wife and has moderate Alzheimer's disease. He wears a hearing aid. He is admitted to hospital late at night with a urinary tract infection. He is aggressive and uncooperative with the nurses. He tries to pull out his intravenous cannula. He shouts out and disrupts the other patients and accuses staff of poisoning him when they try to administer his antibiotics. Mr B is acutely confused on a background of dementia and after 2 days of antibiotic therapy he Is much more settled and is discharged home. Consider what might have contributed to his confusional state; • His urinary infection • Disorientation after admission late at night, separation from his wife • Physical discomfort (unable to verbalize this or recognize it as a problem) • Unfamiliar environment and people • Sensory impairment knows the patient and is a usetlil adjunct to cognitive testing and identifies the presence of dementia prior to the current presentation Qorm, 1994). It asks respondents to consider changes to a person's memory or intelligence at the present time compared with 10 years ago. Functional assessment Functional impairment should be assessed alongside cognitive impairment. It is important to establish how someone's memory affects his or her daily life and also to find out whether this represents a change fix)m a person's previous

level of functioning. A reliable indicator of dementia is a carer's account of deterioration in four specific activities of daily living: • Managing medication • Using the telephone • Coping with a budget • Using transport (Whalley and Breitner, 2002). Use of 6.mctional assessment tools can also be helpful. The Bristol Activities of Daily Living Scale (Bucks et al, 1996) was developed with to investigate issues that carers rated as important in the daily living skills shown by people with dementia and measures 20 daily living skills.

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NEUROSCIENCE NURSING It is important to gain information that an individuals present state represents a decline from prior levels of ability. The natural history of the illness, such as onset, severity and duration, are reported. Inforniation gleaned about psychiatric history, past medical history and drug history can inform the diagnostic process in addition to establishing any t'aniily history of mental illness. It is quite common for people with suspected cognitive impairment to lack insight into their problems so it might be tactful and more productive to hold separate consultations with an individual and relative/ carer to ensure an accurate history is given. Use of a questionnaire, such as the information questiormaire on cognitive decline Qorm, 1994), may be helpflii. Physical examination There should be a thorough systems review to exclude potentially treatable or reversible causes for the memory difficulties, even though these are rare, such as B12 folate and thianiine deficiency. Examination will also look for comorbid physical disease, risk factors for vascular disease, such as hypertension, and signs of neurological disease. It is also important to

remember that people with dementia are more likely to under report their symptoms. Typical investigations should include: • Full blood count • Vitamin B12 and folate levels • Thyroid function tests • Urea and electrolytes • Liver function tests • Blood glucose • Calcium levels • CT head scan/MRl scan - this enables the exclusion ofothcrdisordersthat cause dementia, such as brain tumour and hydrocephalus. Neuroimaging is also helpflil to look for medial temporal lobe and hippocanipal atrophy suggestive of Alzheimer's • Screening for syphilis or HIV should only be done if the clinical picture suggests testing.

Box 4. Risk factors for delirium

Depression

• Dementia • Fractures and anaesthesia • Environmental factors such as admission to iCU. resident of a nursing home, changed environment, sieep deprivation • Severe iiiness and muitipie medical problems especiaiiy infection • liiicit drug/aicohol use • Advancing age • Prescribed medication especiaiiy sedative drugs and those with anticholinergic activity such as oxybutynin and atropine • Sensory impairment • Pain • Metabolic disturbances ' Infection Source: British Geriatrics Society and itoyal Coiiege of Physicians (2006)

Depressive disorders may coexist with dementia; the prevalence of depression is 1020% of people with dementia (Mynors-Wallis, 2003). The symptoms of early stage dementia can mimic depression; this is often referred to as depressive pseudodementia. Symptoms of depression include:

Emotional deterioration Memory loss Disturbed sleep pattern Weight loss Motor retardation Reduced appetite.

Table 2. Distinguishing features of depression , dementia and delirium Depression

Dementia

Delirium

History

Onset and decline often rapid with identifiabie trigger factor or iife event sucb as bereavement

Vague Insidious onset, symptoms progress siowiy

Sudden onset over iiouts and days with fluctuations

Symptoms

Obvious at an early stage

Might go unnoticed for years

Subjective complaints of memory loss

Symptoms often worse in the morning

Lacit of insight. Attempts to hide problems or be unaware Often disorientated to time, piace and person. Processing of external and internal information impaired Confusion worse in the evening (sundowning)

Obvious if hyperactive delirium but may be harder to recognize if 'quief delin'um (e.g. apathy) Disorientated to time, piace and person Short-term memory impaired Processing of external and internai information impaired Confusion worse at night

Consciousness

Normal

Normai

Clouding consciousness {impaired attention}

Mental state

Distressed/unhappy

Possibie iabite mood

Variabiiity in cognitive performance

Consistent cognitive performance (aithough not as consistent in peopie with Lev*,^ body dementia

Emotionai iabiiity. anxiety, fear, depression, aggression Variability in cognitive performance

Delusions/ hallucinations

Rare

Delusions common. Hailucinations rare in eariy stage dementia

Common

Psychomotor disturbance

May get psychomotor retardation If depression is severe

Psychomotor disturbance evident in later stages

Psychomotor disturbance purposeless, apathetic or hyperactive Adapted from: Brown and Hillam {2004)

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seriously unwell. It has been estimated that the prevalence of delirium is as high as 60% in hospitahzed older people on medical and surgical wards (Fick and Foreman, 2000). DeUriuni is associated with increased length of hospital stay and mortality in addition to increased rates of institutionalizarion and higher rates of comphcations such as falls.The symptoms ofdcmentia,depression and dehriuin can often overlap, and the conditions can also coexist, making recognition of dehrium very difficult (7tifa/L'2).There are a number of risk factors for delirium. Dementia is the most powerful of these factors {Box 4).

is highly agitated or hallucinating (British Geriatrics Society and Royal College of Physicians, 2006).

Management of delirium The key strategies to therapy in delirium should be treatment of the underlying cause, management of confusion and prevention of complications. Once dehrium has been diagnosed, management should be directed at identifying and trearing the underlying cause. This should focus on withdrawal of incriminating drugs, correcting biochemical derangements and treatment of any underlying infection. Parenteral thiamine should be given when alcohol abuse or under-nutrition is suspected (British Geriatrics Society and Screening for depression There are validated depression assessment Royal College of Physicians, 2006). scales for use in older people with demenda. There is evidence to suggest that some The Geriatric Depression Scale can be used cases of delirium can be prevented in a for people with mild and moderate dementia, significant number of people through the and is quick and simple to administer recognition of high-risk individuals and the (O'Riordan et al, 1990). implementation of preventative interventions. The Yale delirium prevention trial (Inouye et The Cornell Scale for depression in dementia is a l9-item instrument specifically al, 1999) demonstrated the efTectiveiiess of designed for the raring of symptoms of intervention protocols targeted against six depression in people with demenria. Items risk factors: were constructed so that they can be rated • Orientation and therapeutic activities for primarily on the basis of observarion, and thus cognitive impairment it is a useful assessment tool for people with • Early mobihzation more advanced dementia and for those with • Non-pharmacological approaches to minimize language problems (AJexopoulos et al, 1988). the use of psychoactive drugs • Interventions to prevent sleep deprivation • Correction of sensory deficits (vision and Delirium/acute confuslonal state hearing) People with dementia may also present as • Early intervention for volume depletion. acutely conflised at times. Individuals with Non-pharmacological strategies should dementia are five times more likely to develop delirium (Royal College of Psychiatrists, 2005). always be used in the management of Delirium is a severe and common syndrome in delirium {Box 5). In particular the use of which there is an acute decline in cognitive any kind of physical restraint should be function and behaviour. 'The essential feature avoided. The use of sedation in delirium of a delirium is a disturbance in consciousness should be kept to a minimum. All sedative that is accompanied by a change in cognition drugs can cause delirium, especially those that cannot be better accounted for by a pre- with anticholinergic effects. They should existing or evolving dementia' (American only be used in individuals to allow essential Psychiatric Association, 1994). investigations or treatment, to prevent a Delirium is under-detected, under-treated person endangering themselves or others, and may be an indicator that a parient is or to relieve distress in an individual who

Part one of this series on demenria has considered the main forms of dementia and their characterisdcs. It has examined the assessment process and also tlie differences between dementia, delirium and depression. The medico-legal background to die issue of iTiental capacity has been reviewed as legislarion in England and Wiles has changed recently. Part two builds on the demenria knowledge gained in this arricle and describes n o n pharmacological interventions to manage demenria in addition to a discussion of the drugs available to treat dementia. T h e contribution carers make to dementia care and the importance of supporring carers in this difficult role is also covered. For further informarion on caring for patients with demenria please visit the Carers UK website (care www. carersuk.org) or the Alzheimer's Society website (www.alzheimcrs.org.uk), which provide advice on all aspects of dementia care, and carers' rights and welfare benefits. iQH

Box 5. Management of delirium • Appropriate lighting levels • Consider single room/small bay/close to nursing station • Provide repeated visible and verbal clues to orientation for exampie clocks/calendars • Provide reassurance/explanation in short sentences • Ensure continuity of care, e.g. one nurse to establish a rapport • Ensure glasses/hearing aids are worn and working • Avoid inter- and intra-ward moves • Avoid catheters • Encourage early mobilization • Ensure adequate pain control-regular pain relief is preferential to 'as required' • Establish regular sleep pattern - maintain and restore pattern. Avoid naps. • Ensure good diet and fluid intake • Avoid constipation • Avoid sedation • Eiiminate unexpected noises, e.g. pump alarms Source: British Geriatrics Society and Royal College of Physicians (2006)

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Conclusion Dementia is a common condition in older people and will be encountered by practitioners working across primary and secondary care.The N A O (21)07) has recently higlilighted the need for improved care of people with dementia and there is currently a Department of Health dementia strategy progranunc in development that will hopefliUy drive forward improvement ill quality of care for people with dementia and support for their famiHes and carers.

7Iic milliors woulil iihe to ihanl^ IMtfeisorJackson and Mrs Alison Austin for tlieir help in proofreading this work. Alexiipoulos C'rS. Abrains WC. Yoiiii^ R C , Shanioian CA (l'JS8) C'orneli scale for cicpressioii in dciiiciitia. Biot Psydmilry 23{7,y.27}'H4 Alzheimer A (1907) Uber eitie eigenartige Erkniiikiing der Himriiide. Atli; Zeiisflir I'sychialr 64: 14f>-4« Alzheimer's Sociecy (2III17) hiforniaiioti Stieerllw l^^esiioii (i//>""'/((iVf. Alzheimer's Soctet)'. London American Psychiatric Assticiacion (I'J'M) D(Vjiijw.>(rV dud Staiistical Manual of Mental [Disorders (I5SM-1V). 4th edn. APA, Washington Brooke H Bullocit l l (1 ^ 9 ) Valitbtion of a 6-item cognitive impaimietit test with a view to primary care usage. Int J Gcrintr Psychiatry 14( 11) ')36-4() Brown J, Hillim J (2004) Deii>entia:Yciur Quesrion.-: Amu'ered. Churchill Livingstniie, C'hina Bucks RS, A_shworth I.)L. Wilco>.k CJK. Siegfried (19%) Assess [li en t ot activities of daily living in dementia: development of the Bristol Activities of Daily Living Scale, .VHyniii; 25(2): ll.V-20 Burke J l \ , Morgenlander J C (1999) Update on Alzheimer s disease: proiiiLsing advances m detection and treatiiient. Postgrad Med 106(5): 85-96 British Geriatrics Society and Royal College of Physicians (2006) Guidelines tor the Prevention, Diagnosis and Management of Delirinni in Older i'eople. Concise Guidance to Good Practice Series, N o (>. Koyal tr.ollegc of Physidaiw, London. Available at: http://ww\v.bgs. org.uk/Publications/Clinical Guidelines/cliiiical_l-2_ ftiUdeHrium.htra (last accessed 1 February 2008)

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NEUROSCIENCE NURSING i X-p;irtnK'ncofHfalth (2007) GovcrnjTiciit project to prtitkice the first over national dementia strategy-; work programme. D H . Limdon. .ivaiiabic ac; httji://wwwdh.gov.uk/en/ Policyandguidanci'/HealrhaiidsociaicaretopiLs/Older p(;oplesservices/DHJI77211 {kst accessed I February 2(H)8) Evenhuis H M {ly'Xl) The tiatiiml history of demenda in Down's syndmnif. Arch Nnm'l 47(3): 26.1-7 Flt:k D. Foreman M (2(H)*)) Consequences of not recognizing dcliriinii supcr-itnposed on dementia in hospitalized elderly individuals, j (.kwfiw/ Niirs 26(1); 3l>-4n FoLsteiii MF. Folstein SE. MfHiit;ii I'R (!975)'Mini-meiicai state". A pracrical method for grading the cognitive impairment of parionts tor the dinjciaii.J Psychiatr Res 12(3): 18<^-9K Harvey \K}, Ske Iron-Robinson M, Rossor MN (2(H)3) The pre\-alcnce and causes of dementia in people under the age of ft.S yi"ars._/ Nmrul Neiin>siitx Psychiatry 74(4): 12U(i-y Inouye SK. Bc^rdus ST, Charpenticr PA ec al (iyy'>) A muitieoiiiponenc intervention to prevent dehrium in hospitalized older patieim. N Eti^lJ Mai 340(9): 6f.'>-7(i lanicki M. Dalton AJ (2()0()) PrevaJem-e of dementia anii impact on intdlectual disability services. Mciii Rriord 38(3): 276-88 Jorm AF (I W4) A short form ofthe liiforni.int Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and ci\iss-valii.lnion. Psychol Med 24(1):

l45!;3 Knapp M. Prince M. Albaiiese E et al (2()07) Dementia UK, Aizheimer's Scciet>'. London Mynoi-s-Wallis L, Moon- M, Magiiire J, Hollingberry T (2(HI3) Shan^d Carv in Mental Health. Oxford UniversitA' Press, Oxford National Audit Office (20117) linprot'irix Sen'ices mid .Support pf l\opk with lii-mi'iitia. TSO, London National Institute lor He.iltli and C^linical Excellence (20(lfi) Siipponinx l'eiy[>k wilh Dcmailin aiiii ihcir CJ^ircn in Hidlh iitut Social Care. NICE, London

O'Rionlan et al (19VI)) The efiect of mild to moderate Working Gmup for the Factilty of Old Age Psycliiatry. dementia on the Geriatric Depression Scale and on the Koyal College of Psychiatrists, London. Available at: General Health Questionnaire. 4?f4^tnHi; 19(1): 57-61 http://www.rcpsych.ac.uk/PDF/WhoCaresWins.pdf Office ofthe I'liblic tniardlMi (2IK)7) Making Dedsioiis.4houi (last accessed 1 February 2tMJ8) Your Health, IVelfan' ur Finmicc... lilio Decides inwn You Taylor H. Leitiiian R (20(12) Failure to seek medical advice Can't? Viere'i a Neir Law tliat Can Help. Office of the for early syinptonts of Alzheimer's disease a-sults in Public Giiartiian, London. Available at: littp://www.dea. delayed diagnosis and treatment whieh is often regretted gov.uk/1egul-pollcy /11 len t.il-capacitj-/mL a-1 eaf!et-eiiglish. later on. Health Care News 2(4): 1-3 pdf (last accessed l' fcbriiary 2(N1«) Whallej' L, Breitner (2(Kl2) Demmtia: Fast Facts. Health Press Ro\'al CoUege of Psychiatrists (21)05) Ww Cans Wilts: liiternatitinal.Wa'iiiington ImproiHng the Outcome.': for Older People Admitted lo ihc World Healdi Org^mization (1992) 'Ihe ICD- W ClassiUcatwn General Hospital. Guidelines for rhe Ddvlofwietu of Lsaisori ql Menial and Beliai'ioiiral Disorders: Clinical Descriptiom anil .Mciual Health Services for Older Pt'oplf. Report of a DivtiiGrii(/f/iHo. W H O , Geneva

KEY POINTS • Dementia has a major impact on the individual, their families and their carers. • Substantial guidance on best practice has been produced for the care of people with dementia over the past five years. • Alzheimer s is the commonest form of dementia and is characterized by a gradual deterioration in cognition and activities of daiiy iiving, • The Mental Gipacity Act (2005) provides a statutory framework to empower and protect people who lack capacity to make decisions for themselves. • Dementia, deiirium and depression are often mistaken for each other: practitioners should be aware of the similarities and differences between these conditions.

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Use in Assessment and Professional Development Edited by Kay Norman 234 X 156 mm; p/back; 138 pages; publication January 2008; £22.99; ISBN-W: 1-85642-342-5 ISBN-13: 978-1-85642-342-7 This book is an essentiai resource for aii nursing and healthcare staff who are undertaking higher education courses and who require a practical and understandabie text on portfolio deveiopment relating to assessment. This booi< introduces the concept of portfolio development in the assessment of learning and competence, and provides a practical guide to student-centred learning. This is also useful for practising nurses and healthcare staff who wish to keep a continuous professional development record. This text also offers an overview of assessment in relation to portfolio development and discusses possible strategies that may be utilised in order to achieve learning outcomes. About the Editor Kay Norman MSc PGDE BSc (Hons) RGN is Principal Lecturer, Faculty of Health, Staffordshire University

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