Dementias ✅

Related Subjects: |Dementias |Abbreviated Mental Test Score (AMTS) |Alzheimer disease |Dementia with Lewy bodies |Frontotemporal dementia |Corticobasal degeneration |Creutzfeldt Jakob disease |Vascular Dementia |Primary progressive aphasia |Anti Dementia Drugs |AIDS Dementia Complex |Normal Pressure Hydrocephalus |Acetylcholinesterase inhibitors |Mental Capacity Act 2005 |Behavioural and Psychological Symptoms of Dementia

🧠 Dementia is a progressive syndrome caused by brain disease, with decline in cognition severe enough to interfere with daily function. It affects memory, language, attention, executive function, visuospatial ability, behaviour and independence.
🛡️ People with dementia are particularly vulnerable to abuse, neglect, financial exploitation, medication errors, falls, delirium and carer breakdown. Health and social care staff should follow local adult safeguarding and multi-agency protection policies.

📖 About Dementia

• Dementia is a clinical syndrome, not a single disease. It involves acquired decline in one or more cognitive domains with functional impact.
• Common cognitive domains affected include memory, language, attention, executive function, praxis, visuospatial skills and social cognition.
• Always distinguish dementia from delirium, which is acute, fluctuating and often reversible, and from depression, sensory impairment, medication effects and alcohol-related cognitive impairment.
• Collateral history from family/carers is essential because the patient may lack insight or may minimise functional decline.

🧬 Common Dementia Subtypes

🩺 Clinical Assessment

• History: onset, tempo, progression, cognitive domains affected, mood, sleep, hallucinations, falls, continence, driving, work and safety.
• Collateral history: essential to assess change over time, ADLs/IADLs, medication adherence, finances, wandering, nutrition and carer strain.
• Cognitive testing: use a validated tool such as 10-Cog, 6CIT, GPCOG, Mini-Cog, MoCA, MMSE or ACE-III depending on setting. MoCA/ACE-III are useful for executive and non-amnestic presentations.
• Function: assess basic ADLs and IADLs, including cooking, shopping, finances, medication, phone use, driving and personal care.
• Examination: neurological signs, parkinsonism, gait, frontal release signs, visual/hearing impairment, cardiovascular exam and evidence of systemic disease.
• Delirium screen: if acute or fluctuating confusion, use 4AT/CAM and treat delirium first if uncertain.
• Medication review: check anticholinergic burden, sedatives, opioids, benzodiazepines, antipsychotics, antihistamines, bladder antimuscarinics and polypharmacy.

🧪 Investigations

• Bloods: FBC, U&E, LFTs, TFTs, calcium, glucose/HbA1c, B12, folate; consider ESR/CRP, HIV, syphilis serology, autoimmune tests or other tests if clinically indicated.
• Structural neuroimaging: offer CT or MRI brain to exclude reversible/structural causes and to help subtype diagnosis, unless dementia and subtype are already clear.
• MRI brain: more sensitive for hippocampal atrophy, vascular disease, microbleeds, posterior cortical atrophy and frontotemporal atrophy patterns.
• CT brain: useful where MRI is unavailable/contraindicated, and to exclude tumour, subdural haematoma, hydrocephalus or major stroke burden.
• Specialist tests: FDG-PET/SPECT, DAT-SPECT, CSF biomarkers, amyloid/tau biomarkers or detailed neuropsychology may be used when diagnosis remains uncertain and results would change management.
• EEG: not routine; consider if seizures, encephalopathy or rapidly progressive dementia such as CJD is suspected.

💊 NICE Pharmacological Treatment Summary

🌱 Non-Pharmacological Management

• Offer group cognitive stimulation therapy for people with mild to moderate dementia.
• Consider group reminiscence therapy for mild to moderate dementia.
• Consider cognitive rehabilitation or occupational therapy to support function and independence.
• Promote physical activity, social engagement, hearing/vision optimisation, sleep hygiene, nutrition and hydration.
• Use environmental modification: lighting, clocks, calendars, signage, routines, medication aids and falls reduction.
• Provide carer education, respite planning and signposting to local dementia support services.

😟 Distress, Agitation, Psychosis and BPSD

• Before medication, perform a structured assessment for causes: pain, delirium, infection, constipation, urinary retention, hunger, thirst, fear, overstimulation, loneliness or inappropriate care.
• Use psychosocial and environmental interventions first.
• Offer personalised activities to promote engagement, pleasure and interest.
• Only offer antipsychotics if the person is at risk of harming themselves/others, or has agitation, hallucinations or delusions causing severe distress.
• If antipsychotics are used: discuss risks/benefits, use the lowest effective dose, for the shortest possible time, and reassess at least every 6 weeks.
• Be very cautious in DLB and Parkinson’s disease dementia because antipsychotics can worsen motor features and cause severe sensitivity reactions.
• Do not use valproate for agitation/aggression in dementia unless indicated for another condition.

⚖️ Capacity, Safeguarding and Planning

• Assess capacity for the specific decision at the specific time, in line with the Mental Capacity Act.
• Use best-interest decision-making if capacity is lacking, involving family/carers and any attorney/deputy where appropriate.
• Discuss advance care planning early: preferences, DNACPR, hospital admission, ceilings of care, advance statements and lasting power of attorney.
• Assess driving, medication safety, fire risk, nutrition, wandering, finances and vulnerability to scams or coercion.
• Follow local safeguarding procedures if abuse, neglect, self-neglect, domestic abuse or financial exploitation is suspected.

⚠️ Complications and Prognosis

• Common complications include delirium, falls, fractures, malnutrition, dehydration, aspiration pneumonia, incontinence, pressure damage, sleep disturbance and carer breakdown.
• People with dementia admitted to hospital are at higher risk of delirium, disorientation, longer stay, functional decline and mortality.
• Dementia progression is variable; early palliative care should focus on comfort, function, family support and anticipatory planning.
• From diagnosis, offer flexible needs-based palliative care because the course is often unpredictable.

🔭 Research / Emerging Treatments

• Anti-amyloid monoclonal antibodies such as lecanemab and donanemab are important emerging Alzheimer’s treatments, but they are not routine standard NHS dementia management.
• They are relevant mainly to selected early Alzheimer’s disease populations and require biomarker confirmation, MRI monitoring and careful risk assessment for amyloid-related imaging abnormalities.
• Blood biomarkers such as plasma phosphorylated tau and neurofilament light chain are under active development, but routine diagnostic pathways still rely on clinical assessment, cognitive testing, imaging and selected specialist biomarkers.
• Stem cell therapies remain experimental and should not be presented as established dementia treatment.

📚 Glossary

• ADLs: Basic self-care tasks such as washing, dressing, toileting and eating.
• IADLs: Complex daily tasks such as finances, medication, shopping, cooking and transport.
• BPSD: Behavioural and psychological symptoms of dementia, such as agitation, aggression, distress, hallucinations, delusions and sleep disturbance.
• AChE inhibitor: Acetylcholinesterase inhibitor — donepezil, rivastigmine or galantamine.

📚 References

• NICE NG97: Dementia: assessment, management and support for people living with dementia and their carers.
• NICE TA217: Donepezil, galantamine, rivastigmine and memantine for Alzheimer’s disease.