Dementia Masterclass for Gps: Types of Dementia, Key Features, Prognostic Issues and When

Dementia Masterclass for GPs: Types of Dementia, key features, prognostic issues and when to re-refer.

Case 1: Mrs. D

Mrs. D is an 80 year old lady with a diagnosis of Alzheimer’s Dementia. She was initially referred to memory services with a subjective insidious short term memory loss, and feeling ‘lost’ at the local shops. She has been reviewed by the memory team and has been started on Donepezil 10mg OD, which is well tolerated.

Although she lives alone, her daughter Ann is very supportive, and sees her daily. Her granddaughter takes her shopping, and she manages well in her bungalow.

A year down the line, Ann calls the surgery to report concern about her mother’s self care, and reports of wandering. On review, Mrs. D has lost weight, she appears much more forgetful, and is suspicious of her family. It transpires that she thinks that there are people in her home overnight, and therefore she leaves the house as she feels scared.

She accepts a referral to social services, and with carers attending once in the morning, her hygiene and self-care improve. She accepts anti-psychotic medication, which appears to help with anxiety, feeling suspicious of her family, and thoughts of people being in the house overnight. She has only wandered once since the introduction of this medication, although this was thought to be in the context of a urinary tract infection. Her appetite improves.

One year later, things have been stable at home, with an increase in carer support and continuing with a low dose of an antipsychotic medication. Unfortunately, Mrs. D has fallen and broken her right arm.

On admission to hospital, she is referred to the Old Age Liaison (LILY) team, as she appears more distressed than before admission, she is very confused and disoriented and her daughter feels that she will not manage at home alone.A best interest meeting is planned, and the Old Age Psychiatry team are invited to review Mrs. D and attend this meeting.

She is discharged to 24 hour residential care. Her mental state has improved since discharge to her new address. She remains confused and disoriented at times (with an MMSE of 8/30) although she does not appear to be distressed, or psychotic.

Questions: When to re-refer this lady? Considerations for community follow-up?

Case 2: Mr. A

Mr. A is a 72 year old man with a diagnosis of vascular dementia, following a CVA in 2010. Since this time, he has lived at home with his wife, who has medical problems, and their son living locally, attending the home most days. Mr. A has difficulties with his short term memory, forgetting things such as whether he has had breakfast, and frustration as a consequence of this. He has a number of cardiac problems and peripheral vascular disease. He has always been a ‘big man’ although he has become much more frail. He has been a heavy smoker and alcohol drinker, although he has stopped both since this CVA.

He has always been a ‘difficult man’ according to his family, although his cognitive impairment post-stroke appears to have made him quite low in mood, and very easily upset by things. His wife says that he is ‘all over the place’ at home, and can go from laughter to tears within minutes. She finds him to be unpredictable.

Mrs. A presents to you saying that her husband’s mobility is deteriorating, impacting his mood. He appears to be low, angry, and aggressive. It is difficult to ascertain exactly what is going on at home.

Mr. A is referred to the local Old Age Psychiatry team, and Social Services. The couple are allocated a social worker, who liaises with the local Old Age Psychiatry team. Re-ablement is introduced. Social services report that Mrs. A has been struggling with this man’s care for some months, especially as he has become less mobile, and having difficulty on the stairs. Carers attend the home twice a day, to attend to personal care, medications, food preparation and assist mobility.

An occupational therapy assessment demonstrates that the home is not adequately modified to suit the needs of the couple. Modifications are made to the home. A physiotherapy referral is made. The OT is worried about Mr. A’s mental state and requests a medical and CPN review. Sertraline 50mg once a day is prescribed by the team’s ST Doctor, and a CPN is involved to review response to this in the community. Mr. A’s mood seems to improve slightly- he appears led frustrated with his predicament, his mobility improves, with the introduction of aids and home modifications. Mrs. A is sign-posted to a local carers group, which she attends weekly, which she is says is great help for her health.

Case 3: Mr. B

(Taken from the Journal of the American Board of Family Practitioners, Lewy Body Dementia: A case Report, Khotianov, Singh and Singh 2002).

‘A79-year-old man was brought to the emergency department of a hospital in November 2000 after having been found by the police wandering on the street. The patient reported no complaints with the exception of visual hallucinations, which were of a nonthreatening nature (eg. the patient had seen objects in the room). At this point the patient was confused and unable to provide a detailed history; therefore, the admitting physician relied on the patient’s wife and daughter for most of the information.

Eight years earlier, the patient had Parkinson’s disease diagnosed. He was examined by a neurologist

and was started on a combination Carbidopa/Levodopa medication. The dosage was titrated up to

50 mg of Carbidopa and 200 mg of Levodopa four times a day. Although the prescribing physician

noted no improvement in his parkinsonian symptoms, the medication was continued. Less than a year later, the patient developed memory problems,and Alzheimer’s disease was diagnosed. During thenext 5 years, the patient’s condition remained stable,and he continued to work as an attorney.

Two years before the November 2000 emergencydepartment visit, the patient began experiencing

frequent visual hallucinations, thought bythe neurologist to be related to the anti-parkinsonian

medication. The neurologist prescribed Quetiapine (125 mg OM + 100 mg ON) in an attempt to control these hallucinations.Despite this treatment, these symptomscontinued to occur intermittently. He was taking this at time of emergency presentation, with anti-parkinsonian medications. He was taking no other medications.’

In A+E, the patient was a well-nourished,well-hydrated elderly white man in no apparentdistress. He was disoriented to place andtime. He had an obvious tremor in both hands andfeet. Hisgait was unsteady. There were no other neurologicalfindings. His score on Mini-MentalState Examination was 20/30.’CT brain showed only age-related cerebral atrophy. No other laboratory tests revealed any abnormalities. A diagnosis of Lewy Body Dementia was made, Rivastigmine at nightwas prescribed, Quetiapine and anti-parkinsonian medications were stopped and the patient was discharged.

Thinking about this patient in the community: Following discharge from the hospital, the patient was reviewed at home by the Old Age Psychiatry team, although his parkinsonian symptoms hadn’t worsened in the absence of medication, they persisted. The patient reported visual hallucinations, especially at night. There had been a positive improvement in his mental state. His MMSE score improved to 27/30. Because the patient’s parkinsonism and hallucinationspersisted, the anti-parkinsonian medications and Quetiapine were both subsequently restarted atlower doses, with support from the Old Age Psychiatry and Neurology teams locally.

Furth

Case 4: Mrs. Z

Mrs. Z is 60 years of age. At time of initial review, she lives at home with her husband, her daughter and her young family, including her husband and 2 children.

Her daughter Sheena brings her Mum to your practice reporting that she has been behaving ‘oddly’. She has always been a quiet and mild mannered lady, but she has become quite loud, very impulsive, more irritable, and unpredictable. She was an active and motivated person, but spends most of her time at home now, saying that she ‘can’t be bothered’ with doing things. She does not appear particularly depressed, but you notice a change in this lady.

She usually looks after her grandchildren whilst her daughter works, but Sheena says that she will not allow her children to be alone with them as she worries about her impulsivity, and potential neglect. The home situation has become very tense, and Sheena is looking to move her family.

Referral to services: Mrs. Z is referred to local Memory services, who request an MRI brain which demonstrates frontal lobe pathology profusely. She is diagnosed with Fronto-Temporal Dementia. With consideration of the home situation, Admiral Nurses and a team Community Psychiatric Nurse from the Young Onset Dementia Team are introduced.

Sheena moves out of the family home with her young family, and her parents are home alone. Mr. Z is frail, and it is difficult for the couple to stay in their large home. Sheena finds a local supported accommodation scheme where her parents can live together. With Social Services support, the move is made.

The Young Onset Team (YODS) remain involved in Mrs. Z’s care and support the family also. Things remain stable at home, and the relationship between Mrs. Z and Sheena has improved. She is reviewed on a 6 monthly basis by Old age Psychiatry.