How to Manage Dementia in General Practice

Nicholas Clarke, Farine Clarke, Denzil Edwards

• Publisher: BMJ Books
• Year: 2013
• ISBN:
  9781118352311
• Edition: 1
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

This practical guide clearly shows each stage in the management of a patient with dementia. It covers the complex issues surrounding dementia such as spouses and families, access to appropriate care, legal and ethical concerns, planning for the future and "living well" and includes the decision making process on initiating treatment and guidance on how best to access the available services.

Chapter 1

Diagnosing dementia in general practice

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Mr Tutt was a 74-year-old man who retired after a lifelong successful career marked by his strategic abilities and intellect. Not only was he the former chairman of an international company but in his youth he had won numerous prizes for his poetry and after retirement pursued an equally successful writing career.

Some 18 months before presentation Mr Tutt drove in front of a lorry at a junction. He sustained only minor injuries but his 74-year-old wife was seriously injured. Mr Tutt was cautioned for reckless driving, and became withdrawn, although his optimistic and resilient nature prevented him from becoming depressed. His wife recovered but found it increasingly difficult to manage their busy lives.

The Tutts' professional children became concerned about their father's forgetfulness and their mother's distress and took them to their GP, Dr Smythe, who decided that Mr Tutt was not depressed, but equally wasn't his ‘normal self’. In light of this and Mrs Tutt's head injury he referred the couple to an Old Age Psychiatrist.

The consultant saw them together, then separately and also interviewed the children alone. He conducted a full psychiatric history, collateral history, mental state examination, detailed clinical cognitive tests and physical examination with an emphasis on central nervous system (CNS) assessment, a CNS blood screen and MRI brain scan. Mrs Tutt had a personal previous medical and family history of depression, together with recent symptoms of early morning waking, increased tearfulness and ideas that ‘life is not worth living’. Her hospital records following the accident showed considerable parietal lobe damage with intracerebral micro-haemorrhage which had resolved, albeit with residual damage, consistent with her head striking the left hand side of the vehicle. Her MRI showed residual scarring and atrophy of the left parietal lobe but with no other abnormalities, and a clinical picture which did not suggest dementia. Mr Tutt had no signs of depression but struggled with the finer points of biographical detail, for example he was unable to name some of the grandchildren he saw regularly. There were no symptoms of post-traumatic stress disorder. The consultant concluded that Mrs Tutt had a traumatic brain injury late in life, a prolonged adjustment reaction and reactive depression due to a combination of the accident, the changes in their life and the changes in her husband. This was compounded by her vulnerability to depression. She was at risk of Alzheimer's disease purely because of her history of acquired brain injury. In contrast Mr Tutt's mild concerns were more than justified because, although he scored full marks on basic testing due to his intellect, detailed testing showed changes across a wide range of functions in different lobes of his brain. This was particularly the case for recall of newly learned information. His MRI scan showed no ischaemic lesions in the white matter but some early atrophy throughout the cerebral cortex without any lobar emphasis, which with the clinical picture was consistent with Alzheimer's disease with no vascular aetiology.

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This case of a married couple of similar age illustrates the difference between a brain injury with a static unchanging clinical picture afterwards, and the insidious creeping nature of dementia, in this case of Alzheimer's disease, which is typically dominated by memory loss and disorientation in the early stages and often later failure to identify familiar faces and places.

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Mr and Mrs Tutt were very clear that they wanted to know the diagnoses, and a separate interview with the children confirmed this was the case. The consultant conducted a series of interviews to address the diagnosis. Mr Tutt was started on memantine with a resultant rapid and striking improvement in a range of intellectual skills. His self-confidence improved and he felt his brain was ‘working better’ again. He continued teaching his 10-year-old grandson about the great poets for a further 18 months during which time he made a graceful exit from his various chairmanships. Mrs Tutt was treated with antidepressants with good effect even though she had been reluctant to take them at first. The couple remained under the care of their GP and the consultant with a view to monitoring any cognitive changes in Mrs Tutt, who also received carer support for her husband's Alzheimer's disease.

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How to undertake the assessment for dementia in general practice

The authors recognise that GPs have limited time to assess patients for dementia, particularly as symptoms and signs are not always obvious and may fluctuate between visits to the surgery. The following details outline best practice, and also give GPs the room to bring patients and relatives back to their surgery for further assessment and interviews, in order to build a full picture of the problem.

The right environment

As a first principle it is vital to create the right environment for the initial assessment. However well a GP knows the patient and family it's worth taking the history from the patient and the relatives separately. This is because if Alzheimer's is present, the patient will inevitably, albeit to a variable extent, give incomplete and error-strewn answers. Furthermore, in a joint interview the person giving the collateral history will often leave out important details and events in order to spare their loved one's feelings or out of ‘loyalty’. All too often when they are interviewed alone, they will admit a fear of verbal recriminations typified by ‘the argument in the car park’ should they report things the patient is unaware of. Relatives cite outright anger and hostility, the accusation of exaggerating the problem or ‘trying to put me in a home’ as reasons for withholding a full history when the patient is present.

The rules governing confidentiality between doctors, patients and relatives are well known and, in principle, permission to release information is required. This permission can be implicit by the patient bringing a spouse with them, or obtained through verbal or more formal written consent. A GP can receive and hold information about a patient in any form without their consent. This is useful when asking for emails and letters relating to the patient, even if the GP is not yet ‘allowed’ to talk to a spouse or relative. However, if a GP acknowledges that the patient is in their care to a third party, this does breach confidentiality if there is no evidence that this party knew about the GP's involvement.

The history

The history of the presenting complaint from the patient and relative

The aim for the GP in the first instance is to listen to what the patient describes as ‘complaints’ and establish their order and duration, even if there doesn't appear to be any illness. Commonly the patient will be brought in and declare: ‘There's nothing wrong with me’, which makes the collateral history from the spouse very important.

It is important to establish what is meant by ‘memory loss’ and the exact nature, density and consistency of the memory complaint. Loss of distant memories is more likely in Alzheimer's disease or another profound physical impairment of brain function. Memory loss in the recent past by which we mean 5 months to 15 years or more is also more indicative of Alzheimer's disease. Newly formed memory loss within 5 minutes to 15 hours is suspicious of Alzheimer's disease but could also be due to depression or poor concentration. Immediate memory loss within 15 seconds is suspicious of depression or poor concentration if in isolation, but may be present in rarer cases of Alzheimer's disease showing a striking impairment of immediate memory. For example a patient's daughter leaves her mother's room in a residential home and the patient turns to the nurse and says, ‘Is my daughter ever going to visit?’

The collateral history

Because of the nature of the disease there are several clues in the history about which the patient may be unaware but which the relative can clearly describe.

The most typical clue is a change in intellectual function which is commonly described as, ‘I have to keep repeating myself’, ‘He/She doesn't seem to pay attention’, or ‘We can't talk anymore’.

Other symptoms include ‘following’ behaviour, anxiety about being left alone and the inability to perform tasks which once were easy.

Unusual symptoms may include a flip or inversion of personality, for example when the vicar pinches the bottom of every female nurse, hallucinations or daytime impaired level of consciousness. The latter is different from a nap after lunch from which the patient is difficult to rouse, and indicates rarer dementias.

The previous psychiatric history

Generally this is irrelevant or contains no illness of significance. However, a history of recurrent depression or bipolar disease should raise the suspicion of depressive pseudodementia. Schizophrenia has its own pattern of cognitive deficits that are not progressive or generalised and dementia is not more common in these patients. Past admissions for unsuccessful suicide attempts and alcoholism, with the accompanying risk of brain damage and later dementia, should be taken into account.

Points in the previous medical history

A simple neurological general enquiry into diplopia, paraesthesia, focal weakness, fits, fainting episodes or incontinence may indicate occult intracranial pathology. Past brain injury from trauma, anoxia, prolonged hypoglycaemia or status epilepticus also increases the risk of dementia.

Physical diseases which may mimic or exacerbate dementia include hypothyroidism, pernicious anaemia with missed treatment, poorly managed diabetes mellitus, high blood pressure, ischaemic heart disease, tobacco-related diseases and excess alcohol consumption, either in the past or present.

Significant family history

Dementia does not typically run in families. However any multigenerational history of the disease occurring in up to 50% of family members, which presents under the age of 60, should raise the possibility of familial aetiology.

Sporadic history, as in ‘my mother had dementia in her eighties’ is irrelevant to the diagnosis.

However, a family history of dementia-related conditions, such as cardiovascular disease, may be relevant.

Relevant social history

The length of time a patient has lived in their house, the amount of help around and how close their immediate family are, are all of major importance not just in making the diagnosis but also in the prognosis and management. This is particularly true for the first two thirds, or 6–8 years, of the course of the illness. It is worth establishing who does the practical activities including shopping, cooking, laundry, and the bills and, if this used to be the patient, when and why that stopped.

Setting the personal history against the presenting complaint

Understanding the patient's premorbid intellect helps to put symptoms into the context of their ability. Their age at leaving school, academic performance between the ages of 11 and 15 or 18 to include exams such as the school certificate, matriculation, O and A levels and their ‘favourite’ subjects together with details of their further education are all relevant. A full career history, including national service, part-time work, promotions and awards, also informs the assessment. For women who may not have had the same educational opportunities, a useful assessment includes evidence of management skills in organisations such as the Women's Institute or quasi-professional roles in, for example, the Citizen's Advice Bureau or evidence of mathematical ability with prizes for puzzles.

A professor of engineering who can't do The Times crossword as fast as he used to is reporting an objective and subjective but significant finding. In contrast, a patient who struggles to spell a five-letter word in reverse may admit they were ‘never any good at spelling’ or ‘missed a lot of school’, which can be shorthand for illiteracy and any test should take this into account.

The temporal gradient is a useful tool to investigate likely types of dementia and brain damage from the personal history. This involves looking far back into the patient's personal memory until they remember normally. For example, ...

Table of contents

• Cover
• Title page
• Copyright page
• About the authors
• GP's Foreword by Dr Neil Arnott
• Neuroscience Foreword by Professor Paul Francis
• Acknowledgement
• Introduction
• Chapter 1: Diagnosing dementia in general practice
• Chapter 2: Complex pictures of dementia
• Chapter 3: Initiating, monitoring and adjusting dementia treatments
• Chapter 4: Emergency management of dementia
• Chapter 5: Managing families
• Chapter 6: Using the multidisciplinary team
• Chapter 7: Capacity, consent and deprivation of liberty
• Chapter 8: Choosing a residential home
• Chapter 9: Research, developments and media coverage
• Chapter 10: GP questions answered
• Recommended further reading
• Index