Dementia: A Practical Guide for Junior Doctors

Introduction

Dementia is a common but complex condition that involves a progressive decline in cognitive function, affecting memory, thinking, and the ability to perform everyday activities. For junior doctors, recognizing and managing dementia in the emergency setting can be challenging but crucial. This guide will help you navigate the essential aspects of history-taking, examination, investigations, and management, drawing on the best practices and guidelines available.

History Taking: The Key Questions

Taking a thorough history is the cornerstone of diagnosing dementia. Your questions should aim to uncover the extent of cognitive decline and its impact on daily life. Here's how to structure your history:

Cognitive Decline:

• Memory Issues: "Can you tell me about any problems you've had with your memory, especially with recent events?"

• Language Difficulties: "Have you noticed any trouble finding the right words or understanding what others are saying?"

• Disorientation: "Have there been moments when you've felt lost or confused about where you are or what time it is?"

• Judgment and Decision-Making: "Have you made any decisions recently that were out of character or led to problems?"

Functional Decline:

·       Activities of Daily Living (ADLs): "Have you found it harder to manage tasks like cooking, shopping, or managing your finances?"

·       Personal Care: "Have there been changes in how well you're able to take care of yourself, such as dressing or bathing?"

Behavioral and Psychological Symptoms:

·       Mood and Personality Changes: "Have you felt more anxious, depressed, or irritable than usual? Have others noticed any changes in your personality?"

·       Hallucinations or Delusions: "Have you seen or heard things that others don't, or held beliefs that seem unusual to others?"

Medical History:

·       Previous Conditions: "Do you have a history of strokes, head injuries, or other neurological issues?"

·       Medications: "What medications are you currently taking? Have any been started or stopped recently?"

·       Family History: "Is there a family history of dementia or other cognitive disorders?"

Social and Occupational History:

·       Living Situation: "Who do you live with, and how do they help you with your daily activities?"

·       Support System: "Do you have a support network of family or friends? How do they assist you?"

·       Occupation and Retirement: "When did you retire, and what kind of work did you do?"

Substance Use:

·       Alcohol and Drug Use: "How much alcohol do you drink, and do you use any recreational drugs?"

Examination: What to Look For

A focused examination helps to identify signs of dementia and rule out other potential causes of cognitive decline. Here’s what to include:

Cognitive Examination:

·       Mini-Mental State Examination (MMSE): A quick screening tool to assess cognitive function, including orientation, memory, attention, and language.

·       Montreal Cognitive Assessment (MoCA): A more sensitive tool, especially for detecting mild cognitive impairment.

·       Clock Drawing Test: Assesses executive function and visuospatial abilities, often affected in dementia.

Neurological Examination:

·       Cranial Nerves: Check for abnormalities that might suggest an alternative diagnosis, such as a stroke or brain tumor.

·       Motor Function: Look for signs of rigidity, bradykinesia, or tremor, which could suggest Parkinson’s disease or Lewy body dementia.

·       Gait and Balance: Assess for a shuffling gait or balance issues, common in vascular dementia and Parkinson’s disease.

·       Reflexes: Hyperreflexia or a positive Babinski sign could indicate upper motor neuron involvement.

General Physical Examination:

·       Cardiovascular Examination: Assess for hypertension, arrhythmias, or signs of heart failure, which could contribute to vascular dementia.

·       Respiratory Examination: Check for signs of COPD, as chronic hypoxia can exacerbate cognitive decline.

·       Nutritional Assessment: Look for signs of malnutrition, which can impact cognitive function.

Investigations: What to Order

To confirm the diagnosis and rule out reversible causes, you'll need to order several investigations:

Blood Tests:

·       Full Blood Count (FBC): To rule out anemia or infection.

·       Thyroid Function Tests: Hypothyroidism can mimic dementia.

·       Vitamin B12 and Folate Levels: Deficiencies can cause cognitive impairment.

·       Liver and Kidney Function Tests: To assess for metabolic causes of cognitive decline.

·       Glucose Levels: To check for diabetes or hypoglycemia, which can affect cognition.

Imaging:

·       CT or MRI Brain: To identify structural abnormalities like strokes, tumors, or atrophy. MRI is preferred for its greater sensitivity.

·       PET scan: In specific cases, to detect amyloid plaques or differentiate between dementia types.

Other Tests:

·       ECG: To detect arrhythmias that could contribute to vascular dementia.

·       Lumbar Puncture: In atypical cases, to analyze cerebrospinal fluid for markers of Alzheimer’s disease or infections.

·       Neuropsychological Testing: To provide a detailed assessment of cognitive deficits.

Management Plan: How to Proceed

Managing dementia involves both medical treatment and supportive care. Here’s how to approach it:

Pharmacological Management:

·       Acetylcholinesterase Inhibitors (e.g., Donepezil, Rivastigmine): Used in mild to moderate Alzheimer’s to slow cognitive decline.

·       NMDA Receptor Antagonists (e.g., Memantine): For moderate to severe Alzheimer’s disease.

·       Antipsychotics (e.g., Risperidone): For severe agitation or psychosis, though these should be used with caution due to potential side effects.

·       Antidepressants (e.g., SSRIs): For managing depression, which is common in dementia patients.

Non-Pharmacological Interventions:

·       Cognitive Stimulation Therapy: Regular group activities that stimulate cognitive function.

·       Occupational Therapy: To help patients maintain their independence in daily activities.

·       Support for Caregivers: Providing education, resources, and respite care options for families.

Addressing Modifiable Risk Factors:

·       Blood Pressure Control: Managing hypertension to reduce the risk of vascular dementia.

·       Diabetes Management: Optimizing blood glucose levels to prevent cognitive decline.

·       Lifestyle Modifications: Encouraging smoking cessation and alcohol reduction to improve overall health.

Future Planning:

·       Advanced Care Planning: Discuss the patient’s wishes for end-of-life care, including advanced directives.

·       Driving: Evaluate and advise on the patient’s ability to drive, considering the legal requirements.

·       Regular Follow-Up: Schedule regular assessments to monitor disease progression and adjust the management plan accordingly.