Dementia care. Part 1: guidanceand the assessment process

Emma Ouldred, Catherine Bryant

AbstractThis article outlines recent guidance on dementia care and provides information ondementia, its different subtypes, the assessment process and the utility of cognitivescreening tools. As dementia progresses a person may gradually lose their ability tomake decisions for themselves. The Mental Capacity Act 2005 (MCA) is one ofthemost significant Acts to be passed in the United Kingdom, which protects peoplewith 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 dementiacare need to be aware of its clauses, as they are likely to require knowledge of iton a frequent basis. Dementia, delirium and depression are often mistaken forone another and useful ways to differentiate between the different conditions aregiven in addition to comprehensive advice about the management of people withdementia admitted to hospital with delirium.

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The report emphasizes the need for notonly a 'sea change' in how we view dementia,but also for better diagnosis, assessment andsupport for people with dementia and theircarers. It highlights the need for access todiagnosis and early intervention, and theneed for effective working across healthand social care services from acute trusts tothe community. This will only be achievedthrough coordinating the work of providersand commissioners at local levels.

The government recently announced theforthcoming production of the first evernational clementia strategy. A 12-month workprogramme 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 producedguidance that makes recommendations forthe identification, treatment and care ofpeople with dementia, and the support ofcaren. The principle of person-centred careunderpins the guidance. The main prioritiesfor 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 shouldbe informed of all care options withoutcoercion. If a person lacks capacity then theMental Capacity Act 2005 (MCA) shouldbe adhered to

• Carers: the rights and needs of carers areemphasised and their rights to a carers'assessment are also reinforced

• Coordination and integration of health andsocial care: integrated care across healthand social care agencies with the need toinvolve service users in the development,implementation and regular review ofcare plans. Guidance also recommends theassignation of a named health/social carestaff member to have overall responsibilityfor care planning

• Memory assessment services: these should bethe single point of referral for all people witha suspected diagnosis of dementia (providedby memory assessment clinics or communitymental health teams). Structural imaging{magnetic resonance imaging [MRI] orcomputed tomography |CT|) should be usedin the assessment of people with dementia

• Behavioural challengesipeople with dementiawho develop behavioural problems shouldbe offered early comprehensive assessmentand have tailored care plans

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

Cerebral cortex

Hippocampus(niemofy acquisitionl

Normal Alzheimer's

• Training: all staff working with older peoplein the health, social care and voluntarysectors bave access to dementia care training(skill cievelopnient) that is consistent withtheir roles and responsibilities

• Mental health needs in acute hospitals:acute and general hospital trusts shouldplan and provide services that address thespecific personal and social care needs andthe mental and physical health of peoplewith dementia who use acute hospitalfacilities for any reason.

DementiaDementia is a syndrome caused by disease ofthe brain, usually of a chronic or progressivenature, in which there is impairment ofmtiltiple higher cortical functions, includingmemory, thinking, orientation, comprehension,

calculation, learning capacity, language andjudgement. These cognitive symptoms canbe accompanied by non-cognitive symptoms,including changes m behaviour, emotionalcontrol and social functioning (World HealthOrganization [WHO]. 1992).

Along with the cognitive decline, peoplewith demenda can also experience behaviouraland neuropsychiatric symptoms. Cognitive andnon-cognitive symptoms will cause a declinein a persons activities of daily living. Thisdecline must be sufficient to impair activitiesof daily living (WHO, 1992).

The most common form of dementia isAlzheimer's, which accounts for 62% of allcases. Vascular dementia (VaD), either alone orco-existent with Alzheimer's, is the second mostcommon subtype of demenda (27% (Knapp etal, 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)

inn, 2UU8.Vol 17. N o .1 139

Box 2. The main features of vascular dementia

Damage to blood vessels leading to brainLack of oxygen to brain causes cell deathSymptoms may be sudden as a result of strokeProgression is often stepwise through a series of small strokesVascular dementia may overlap with Alzheimer's disease - often referred to as mixed dementiaComputerized 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 fronto-temporal dementia (FTD) (NICE, 2006).However, there are rarer and potentially treatablecauses of dementia, including hypotliyroidism,vitamin B12 and hypercalcaemia. Other lesscommon causes of dementia include Wenicke-KorsakofF's syndrome, progressive supranuclearpalsy, neurosyphilis, Huntington's disease, HIVinfection and Creutzfeldt-J:ikob disease. Furtherintormation on rarer forms of dementia can beobtained from the Alzheimer's Society website(www.alzheiniers.org.uk).

Alzheimer's was first used to describe severepresenile degenerative dementia in 1906 whenDr Alois Alzheimer reported the case of a 51-ycar-old woman (Augustus U) who sufferedprogressive memory impairment, psychoticdisturbances and behavioural disturbances.At post-mortem her brain showed plaques,tangles and cerebrovascular disease (Alzheimer,1907). Box I outlines the main characteristicsof Alzheimer's. Box 2 and } show the mainfeatures ofVaD and DLB, respectively.

Progression of dementiaPeople with dementia differ in the rate atwhich their abilities deteriorate and thenature of the problems they have. Theseabilities may also fluctuate on a daily basis.However, what is inevitable is that theseabilities will diminish over time. Progressionmay be fairly rapid in some people, but inothers deterioration can occur more gradually

over a number of years. CHnical features ofthe disease can be classified into three stages(see Tahk J), although not all of the featuresdescribed will be present in every person.Individuals may exhibit symptoms of morethan one stage simultaneously. It must also beremembered that not every person will movethrough each stage.

Diagnosis of dementiaAccording to NICE (2006) people who areassessed for the possibility of dementia should beasked if they wish to know the diagnosis duringthe assessment and with whom this should beshared. This is a very sensitive issue and theexperience of the diagnosis is challenging forpeople with dementia, family members, and forpractitioners.Time should be made available todiscuss the diagnosis and its implications withthe person with dementia and also with familymembers (usually only with the consent ot theperson with dementia).

Early diagnosisIn a recent survey of 500 caregivers, 62% felt anearly diagnosis of dementia was very beneficial(Taylor and Leimian, 2002).There are a numberof rea.sons this may be beneficial both to theindividual and carers (Iliffe et al, 2003):• Prompt treatment of reversible causes of

dementia, e.g. hypothyroidisui, depression• Psychiatric symptoms can be identified and

treated

• Access to education and training for personwith dementia and their family

• Able to benefit from cognitive rehabilitation/memory training

• Person with dementia and family able tocome 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 underwaywhich makes it essential for identification tobe made as early as possible

• Able to discuss safety issues and implementrisk-reduction strategies such as occupationdtherapy services, assisdve technology and socialservices assessment

• Able to consider employment issues. Anindividual with early onset dementia mightstill be working. A diagnosis of dementiadoes not necessarily mean having to giveup work but informing employers of adiagnosis in the early stages of the diseaseprocess will help to ensure the right level ofsupport is provided.

• To plan for the future and also to considerand make decisions regarding their end oflife. This might include advising people withdementia to consider setting up a lastingpower of attorney, advance decisions andwriting a will. People with dementia andtheir carers might also want details aboutlong-term care options and this informationshould be made available in written format.

Mental capacityIf a person has mental capacity (competency)they are able to make decisions for themselves.The legal definition (Office of the PublicGuardian, 2007) says that someone who lackscapacity cannot do one or more of the followingtour 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 signlanguage.

The Mental Capacity Act 2005The MCA was fully implemented in October2007. The Act applies to England and Wales.Scotland has its own legislation, the Adults withIncapacity (Scotland) Act 2000. The approachin Northern Ireland is currently governed bycommon law. This Act provides a statutoryframework to empower and protect people

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who may lack capacity to make decisionsfor themselves, e.g. people with dementia.This legislation makes it clear who can takedecisions, in which situations, and how theyshould go about this.

Main clauses of the MCALasting power of attorney (LPA): An LPAenables a person (with capacity') to nominate aspokesperson (the attorney) to make decisionsregarding cheir personal welfare, includingiieaklicare and consent to medical treatment,and also to make decisions about financialand property matters should they becomeincapable. Separate attorneys can be selectedtor making different kinds of decisions.

An LPA will only become legal once theperson has lost capacity. An LPA will need to beset up using an officia] form and be registeredwith tlie Office of the Public Guardian.

Prior to the MCA any competent individualcould appoint someone else to act on her orhis behalf in relation to their financial affairs(power of attorney). However, this wouldbe invalid if that individual subsequentlybecame mentally incapable of managing theiratTairs. An enduring power ofattorney (EPA),registered witb the Court of Protection,allowed tbis power to be carried througb evenafter someone became mentally incapable.Altbough LPAs will eventually replace EPAs,people who already bold an EPA may also setup an LPA and all EPAs signed and dated byall parties before 1 October 2007 will remainvalid and can still be registered after tbis date.Advance decisions: The MCA gives peoplea statutory right to refuse treatment throughtbe use of an 'advance decision'. An advancedecision allows a person to state what formsof treatment they would or would not likesboiilii they become unable to decide fortbemselves in the future. The Alzheimer'sSociety (www.alzheimers.org.uk) supportsthe use of advance decisions as they willallow people witb dementia to be involvedin planning their future care. However, to belegally enforceable, advance decisions must bevalid (made by a person who bas capacity)and applicable (relevant to tbe medicalcircumstances). Advance decisions cannot beused to demand treatment tbat a healthcareteam deems inappropriate or against the law(e.g. eutbanasia).

Independent mental capacity advocate (IMCA):In people who lack capacity and have nobodyto support tbem with major life-cbangingdecisions, tbe MCA creates a new advocacyservice to assist vAih tbis. An IMCA will onlybe involved in specific decisions, such as tbose

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 lavatoryConfusion regarding time and placeFailure 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 offand may leave gas unlitIncreased repetitive behaviourWord-finding difficulty

3. Advanced dementia

Need for i\jil assistance with washing and dressing, eating and toiletingDouble incontinenceIncreasing physical frailty - may start to shuffle or walk unsteadily eventually becoming confinedto bed or a wheelchairIncreased risk of complications associated with prolonged immobility such as constipation.chest infection and urinary tract infectionsIncreased confusion and restlessness such as searching for dead relativeIncreased aggressive behaviourDIsinhibitionNight disturbanceUncontrolled movements - development of seizuresDifficulty eating and sometimes swallowing (dysphagia)Weight lossGradual loss of speech

From: Alzheimer's Society (2007)

relating to serious treatment provided by tbeNHS or cbanges in accommodation wbere itis provided by tbe NHS or local authority.

The MCA is underpinned by tbe principletbat every adult bas tbe right to make hisor her own decisions and must be assumedto have capacity to do so unless it isproved otherwise. A person must be givenall practicable help to make decisions, eventbougb tbey may make what might be seenas an unwise decision, it sbould not betreated as lacking capacity. In addition tbeMCA sets out to ensure tbat any decision,made under tbe Act for a person who lackscapacity, must be in their best interests andshould be the least restrictive of their basicrights and freedoms.

Practitioners sbould be aware of tbe generalclauses of the Act. All health and social care

providers have a duty to inform and trainstaff" on the MCA and further information forhealth and social care professionals, people v/ithdementia, and their carers, can be obtainedfrom tbe Department for ConstitutionalAffairs'website: www.dca.gov.uk/legal-policy/mental-capacity/publications, htm.

The assessment processDementia is a diagnosis of exclusion and itis important to eliminate the rare reversiblecauses of dementia and identify potentiallytreatable causes. Assessment of dementia,therefore, must be multidimensional andincorporate patient and carer historyassessment of cognitive function, functionalstatus, chnical screening, including physicalexamination, and routine investigations.Assessment must be an ongoing process if

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people with dementia and their carers are tohe supported and managed appropriately.

It cognitive impairment is suspected in anindividual, it is usual practice for GPs tostart the assessment process and then referpatients to a local memory assessment clinicor comniunity mental health team for fiirtherdetailed assessment. Practitioners working inprimary care, such as health visitors for olderpeople and practice nurses, are in an idealposition to recognize early signs of cognitivechange and should alert GPs of any concerns.

History and cognitive assessmentA number of different tools are available forhelping to assess cognition in people withsuspected dementia, and the following are allrecommended in the NICE (2006) dementiaguidehne. The mini-mental state examination(MMSE) (Folstein et al, 1975) is a validated,standardized assessment of cognitive capacitiesand is simple and brief enough to be used witholder people. It assesses the following areas ofcognitive fbnction:

• Orientation• Memory and attention• Language functioii• Gopying (praxis)• Following instructions.

When used with other clinical measures, theMMSE provides a reliable index of dementiaseverity and staging (Whalley and Breitner,2002). An arbitrary cut-off at 25/30 separatespossible cognitive impairment from no cognitiveimpairment. However, the MMSE assumes anability to hear reasonably well, read, write andsubtract numbers methodically, and may not besuitable for people with intellectual impairmentunrelated to dementia.

An alternative to the MMSE is the 6-itemcognitive impairment test (6-GIT) KingshillVersion 2000 (Brooke and Bullock, 1999).The 6-GIT is a six-item screening test thathas high sensitivity in mild dementia. It is alsolinguistically and culturally translatable.

The dementia questionnaire for mentallyretarded persons (DMR) (Evenhuis et al, 1990) isa validated informant-based questioruiaire witheight subscales (short-term memory, long-termmemory,spatial and temporal orientation,speech,practical skills, mood, activity and interests, andbehavioural disturbances), which is specificallydesigned for screening for dementia in peoplewith pre-existing intellectual impairment.

The informant questionnaireon cognitive decline in the elderlyTliis is a short questionnaire (comprising 16questions) that is filled in by somebody who

Case study 1. Possible dementia

Mrs I is a 73-year-old retired nurse, living with her husband. Mrs | has always been very particularabout paying the bills, remembering hospital appointments and birthdays but over the past year orso she has become more forgetfijl and on several occasions she has not remembered to pay thebills. She used to enjoy playing bridge but has refused to attend recently. She used to enjoy applyingmake-up and buying new clothes but has recently lost the motivation to do this and has started tolook a little unkempt. Mr j suffers ill health himself and has begun to worry about his wife's graduallyfading 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 thinkshe has got a problem. Dr H performs some routine blood tests and a G-item cognitive impairmenttest (6-CIT). She scored 12/28 on 6-CIT suggestive of cognitive impairment. All blood test resultswere within normal limits. Mrs J is referred to the local memory clinic. At the clinic Mr and Mrs Jare asked to provide detailed information regarding her previous level of functioning, past medical

S^ ^ ^ ^ ^ ^ _ ^ . ^ ^ ^ _ history, current problems and past psychiatric history. Mrs j

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ 1 Is also asked to provide some family history and to discussj ^ ^ ^ ^ ^ ^ ^ ^ ^ H p v ^ H any worries she might have. Mr | speaks to the memory clinic^ ^ ^ ^ ^ ^ ^ ^ ^ H • sister privately to discuss particular areas of concern such as

Figure 1. Computerized tomography scanof a patient iHth Ahlieimer's disease.Note the widening of the reiitricles, whichsuggest healthy hrain tissue has beenreplaced hy tcrehrospinalJUiid.

ResultsThe 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 ofmoderate cognitive impairmentGeriatric depression score: no depressionPhysical examination: no abnormal findingsMrs I returned to the memory dinic 4 v^eeks later and adiagnosis of probable Alzheimers disease was discussed withher 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 ahearing aid. He is admitted to hospital late at night with a urinary tract infection. He is aggressiveand uncooperative with the nurses. He tries to pull out his intravenous cannula. He shouts outand disrupts the other patients and accuses staff of poisoning him when they try to administer hisantibiotics. Mr B is acutely confused on a background of dementia and after 2 days of antibiotictherapy he Is much more settled and is discharged home. Consider what might have contributedto 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 tocognitive testing and identifies the presenceof dementia prior to the current presentationQorm, 1994). It asks respondents to considerchanges to a person's memory or intelligence atthe present time compared with 10 years ago.

Functional assessmentFunctional impairment should be assessedalongside cognitive impairment. It is importantto establish how someone's memory affects hisor her daily life and also to find out whetherthis represents a change fix)m a person's previous

level of functioning. A reliable indicator ofdementia is a carer's account of deterioration infour 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 behelpful. The Bristol Activities of Daily LivingScale (Bucks et al, 1996) was developed with toinvestigate issues that carers rated as importantin the daily living skills shown by people withdementia and measures 20 daily living skills.

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It is important to gain information that anindividuals present state represents a declinefrom prior levels of ability. The natural historyof the illness, such as onset, severity andduration, are reported. Inforniation gleanedabout psychiatric history, past medical historyand drug history can inform the diagnosticprocess in addition to establishing any t'aniilyhistory of mental illness. It is quite common forpeople with suspected cognitive impairment tolack insight into their problems so it might betactful and more productive to hold separateconsultations with an individual and relative/carer to ensure an accurate history is given.Use of a questionnaire, such as the informationquestiormaire on cognitive decline Qorm, 1994),may be helpflii.

Physical examinationThere should be a thorough systems reviewto exclude potentially treatable or reversiblecauses for the memory difficulties, even thoughthese are rare, such as B12 folate and thianiinedeficiency. Examination will also look forcomorbid physical disease, risk factors forvascular disease, such as hypertension, and signsof neurological disease. It is also important to

remember that people with dementia are morelikely 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 formedial temporal lobe and hippocanipalatrophy suggestive of Alzheimer's

• Screening for syphilis or HIV should only bedone if the clinical picture suggests testing.

DepressionDepressive disorders may coexist withdementia; the prevalence of depression is 10-20% of people with dementia (Mynors-Wallis,2003). The symptoms of early stage dementiacan mimic depression; this is often referred toas depressive pseudodementia. Symptoms ofdepression include:

Box 4. Risk factors for delirium

• Dementia• Fractures and anaesthesia• Environmental factors such as admission

to iCU. resident of a nursing home, changedenvironment, sieep deprivation

• Severe iiiness and muitipie medicalproblems especiaiiy infection

• liiicit drug/aicohol use• Advancing age• Prescribed medication especiaiiy sedative

drugs and those with anticholinergic activitysuch as oxybutynin and atropine

• Sensory impairment• Pain• Metabolic disturbances' Infection

Source: British Geriatrics Society and itoyalCoiiege of Physicians (2006)

Emotional deteriorationMemory lossDisturbed sleep patternWeight lossMotor retardationReduced appetite.

Table 2. Distinguishing features of depression

History

Symptoms

Consciousness

Mental state

Delusions/hallucinations

Psychomotordisturbance

Depression

Onset and decline oftenrapid with identifiabietrigger factor or iife eventsucb as bereavement

Obvious at an early stage

Subjective complaintsof memory loss

Symptoms often worsein the morning

Normal

Distressed/unhappy

Variabiiity in cognitive performance

Rare

May get psychomotor retardationIf depression is severe

, dementia and delirium

Dementia

Vague Insidious onset, symptomsprogress siowiy

Might go unnoticed for years

Lacit of insight. Attempts to hideproblems or be unawareOften disorientated to time, piaceand person. Processing of externaland internal information impairedConfusion worse in the evening(sundowning)

Normai

Possibie iabite mood

Consistent cognitive performance(aithough not as consistent inpeopie with Lev*, body dementia

Delusions common. Hailucinationsrare in eariy stage dementia

Psychomotor disturbanceevident in later stages

Delirium

Sudden onset over iiouts and dayswith fluctuations

Obvious if hyperactive deliriumbut may be harder to recognizeif 'quief delin'um (e.g. apathy)Disorientated to time, piaceand personShort-term memory impairedProcessing of external and internaiinformation impairedConfusion worse at night

Clouding consciousness {impairedattention}

Emotionai iabiiity. anxiety, fear,depression, aggressionVariability in cognitive performance

Common

Psychomotor disturbance -purposeless, apathetic orhyperactive

Adapted from: Brown and Hillam {2004)

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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

alarmsSource: British Geriatrics Society and Royal

College of Physicians (2006)

Screening for depressionThere are validated depression assessmentscales for use in older people with demenda.The Geriatric Depression Scale can be usedfor people with mild and moderate dementia,and is quick and simple to administer(O'Riordan et al, 1990).

The Cornell Scale for depression indementia is a l9-item instrument specificallydesigned for the raring of symptoms ofdepression in people with demenria. Itemswere constructed so that they can be ratedprimarily on the basis of observarion, and thusit is a useful assessment tool for people withmore advanced dementia and for those withlanguage problems (AJexopoulos et al, 1988).

Delirium/acute confuslonal statePeople with dementia may also present asacutely conflised at times. Individuals withdementia are five times more likely to developdelirium (Royal College of Psychiatrists, 2005).Delirium is a severe and common syndrome inwhich there is an acute decline in cognitivefunction and behaviour. 'The essential featureof a delirium is a disturbance in consciousnessthat is accompanied by a change in cognitionthat cannot be better accounted for by a pre-existing or evolving dementia' (AmericanPsychiatric Association, 1994).

Delirium is under-detected, under-treatedand may be an indicator that a parient is

seriously unwell. It has been estimated thatthe prevalence of delirium is as high as 60%in hospitahzed older people on medical andsurgical wards (Fick and Foreman, 2000).

DeUriuni is associated with increased lengthof hospital stay and mortality in additionto increased rates of institutionalizarion andhigher rates of comphcations such as falls.Thesymptoms ofdcmentia,depression and dehriuincan often overlap, and the conditions can alsocoexist, making recognition of dehrium verydifficult (7tifa/L'2).There are a number of riskfactors for delirium. Dementia is the mostpowerful of these factors {Box 4).

Management of deliriumThe key strategies to therapy in deliriumshould be treatment of the underlying cause,management of confusion and preventionof complications. Once dehrium has beendiagnosed, management should be directedat identifying and trearing the underlyingcause. This should focus on withdrawal ofincriminating drugs, correcting biochemicalderangements and treatment of any underlyinginfection. Parenteral thiamine should be givenwhen alcohol abuse or under-nutrition issuspected (British Geriatrics Society andRoyal College of Physicians, 2006).

There is evidence to suggest that somecases of delirium can be prevented in asignificant number of people through therecognition of high-risk individuals and theimplementation of preventative interventions.The Yale delirium prevention trial (Inouye etal, 1999) demonstrated the efTectiveiiess ofintervention protocols targeted against sixrisk factors:• Orientation and therapeutic activities for

cognitive impairment• Early mobihzation• Non-pharmacological approaches to minimize

the use of psychoactive drugs• Interventions to prevent sleep deprivation• Correction of sensory deficits (vision and

hearing)• Early intervention for volume depletion.

Non-pharmacological strategies shouldalways be used in the management ofdelirium {Box 5). In particular the use ofany kind of physical restraint should beavoided. The use of sedation in deliriumshould be kept to a minimum. All sedativedrugs can cause delirium, especially thosewith anticholinergic effects. They shouldonly be used in individuals to allow essentialinvestigations or treatment, to prevent aperson endangering themselves or others,or to relieve distress in an individual who

is highly agitated or hallucinating (BritishGeriatrics Society and Royal College ofPhysicians, 2006).

ConclusionDementia is a common condition in olderpeople and will be encountered by practitionersworking across primary and secondary care.TheN A O (21)07) has recently higlilighted the needfor improved care of people with dementiaand there is currently a Department of Healthdementia strategy progranunc in developmentthat will hopefliUy drive forward improvementill quality of care for people with dementia andsupport for their famiHes and carers.

Part one of this series on demenria hasconsidered the main forms of dementia andtheir characterisdcs. It has examined theassessment process and also tlie differencesbetween dementia, delirium and depression.The medico-legal background to die issue ofiTiental capacity has been reviewed as legislarionin England and Wiles has changed recently.

Part two builds on the demenria knowledgegained in this arricle and describes non-pharmacological interventions to managedemenria in addition to a discussion of thedrugs available to treat dementia. Thecontribution carers make to dementia care andthe importance of supporring carers in thisdifficult role is also covered. For furtherinformarion on caring for patients with demenriaplease visit the Carers UK website (care www.carersuk.org) or the Alzheimer's Society website(www.alzheimcrs.org.uk), which provide adviceon all aspects of dementia care, and carers' rightsand welfare benefits. iQH

7Iic milliors woulil iihe to ihanl^ IMtfeisorJackson and Mrs AlisonAustin for tlieir help in proofreading this work.

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British Geriatrics Society and Royal College of Physicians(2006) Guidelines tor the Prevention, Diagnosis andManagement of Delirinni in Older i'eople. ConciseGuidance to Good Practice Series, No (>. Koyal tr.ollegcof Physidaiw, London. Available at: http://ww\v.bgs.org.uk/Publications/Clinical Guidelines/cliiiical_l-2_ftiUdeHrium.htra (last accessed 1 February 2008)

144 British Journal of Nursing. 2008.Vol 17. No 3

NEUROSCIENCE NURSING

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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 withdementia over the past five years.

• Alzheimer s is the commonest form of dementia and is characterized by a gradualdeterioration in cognition and activities of daiiy iiving,

• The Mental Gipacity Act (2005) provides a statutory framework to empower and protectpeople who lack capacity to make decisions for themselves.

• Dementia, deiirium and depression are often mistaken for each other: practitioners shouldbe aware of the similarities and differences between these conditions.

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Portfolios in theNursing ProfessionUse in Assessment and ProfessionalDevelopmentEdited by Kay Norman234 X 156 mm; p/back; 138 pages; publication January 2008; £22.99;ISBN-W: 1-85642-342-5 ISBN-13: 978-1-85642-342-7This book is an essentiai resource for aii nursing and healthcare staffwho are undertaking higher education courses and who require apractical and understandabie text on portfolio deveiopment relatingto assessment. This booi< introduces the concept of portfoliodevelopment in the assessment of learning and competence, andprovides a practical guide tostudent-centred learning. This isalso useful for practising nursesand healthcare staff who wish tokeep a continuous professionaldevelopment record.

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About the EditorKay Norman MSc PGDE BSc(Hons) RGN is Principal Lecturer,Faculty of Health, StaffordshireUniversity

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