There are more than 40,000 dementia sufferers in Ireland, with 11 new cases diagnosed on a daily basis, writes Joanne Flood
The increased longevity of the world’s population or the greying of society should be celebrated as one of the greatest success stories of modern times. However, old age itself carries increased potential for many age-related chronic illnesses of which dementia one of the most feared.
Dementia in the Irish context
There are more than 40,000 dementia sufferers in Ireland, and
with 11 new cases diagnosed on a daily basis, it is estimated that
there will be 71,000 active cases by 2026.1 It is also estimated
that 76% of the care of people with dementia (PWD) is by family
members in the community or primary care. There are 50,000
family members looking after a loved one with dementia. When
residential or nursing home care is examined, statistics have differed
dramatically over the years. In 2007, the number of those in
long-term care calculated to have dementia was 60-70%.2 This is
a significant figure, although a more recent small study carried
out by TCD researchers3 following mini mental (Folstein) testing
in four nursing homes in south county Dublin found significant
cognitive impairment in 89% of all residents assessed.
Primary care From a primary care perspective, at the first national memory clinics conference in 2011, held in the Guinness Store House in Dublin, one memory clinic showed some very interesting findings in relation to individuals who were referred to the clinic for dementia.4 Of the 58 PWD who were seen over an 18-month period: five had depression, five had low B12/folate levels, and two were suffering from anxiety. This alone shows the importance of fully assessing anyone who may complain of memory problems as, in line with a delirium, there can be many causes of memory loss and confusion particularly in older people.
According to Prof Banarjee, the consultant psychiatrist who led the UK dementia management strategy, only one-third of PWD get a formal diagnosis, and when it happens it is often late into the illness – too late to enable choice, at a time of crisis, and too late to prevent harm and further crises. Prof Banarjee states that the cost of dementia in the UK is more than diabetes, cancer and heart disease put together. To date, the cost of dementia is not as fully researched in Ireland, but in 2006 it was estimated at €400 million with less than 10% attributed to community care.5
Testing domains
When someone presents with memory loss, confusion or a
change in behaviour or mood it is wise to assess for mood disorder,
rule out delirium and to conduct a dementia work up.
Collateral history from a next of kin is vital, and if there is no next
of kin, engaging with any others who have had access to the
patient will be needed. The onset of the presenting complaint will
help differentiate a delirium from dementia – although it may be
the case that a delirium can superimpose a dementia. This is particularly
significant in the acute hospital setting.
Delirium screening should look at ruling out any infective or medical cause of confusion and/or agitation. A full blood work up is needed with a particular focus on an infective screen, thyroid function, and if the patients is on any SSRIs, low sodium levels. Simple but very common causes of delirium in the elderly can be constipation, urinary tract infections and pain.
General testing
General testing domains in dementia are cognition, function,
behaviour, and carer strain. Cognitive function includes performing
a mini mental exam on the person, being mindful of their
level of education with regards to the spelling of world and
serial sevens. Usually, any score under 24 needs further investigation
to uncover the underlying cause. The Geriatric Depression
Scale should always be used with the mini mental exam because
depression in the elderly can masquerade as dementia, causing
them to score low on the mini mental exam.
Functional assessment can be carried out using different tools to assess their ADL independent abilities. Meanwhile, behavioural assessment can be very tricky: If a family member or relative has brought the person to your attention for behavioural issues, the illness may have progressed and a crisis, such as an aggressive or paranoid event, may have occurred. Behavioural and psychological symptoms of dementia (BPSD) are discussed below.
Carer strain is a very important element in the primary care of someone with dementia. The carer’s support, knowledge and coping mechanisms for managing someone with dementia will dictate when the PWD enters long-term care. Working with family members and carers and arming them with the relevant skills and knowledge is required from very early on in the process.
Behavioural and psychological symptoms of dementia (BPSD)
In 1995, the International Psychogeriatric Association (IPA)
organised an international consensus conference on dementia
and the associated behavioural issues.6 BPSD are categorised
into two domains: behavioural and psychological. Behavioural
symptoms include restlessness, physical aggression, screaming,
agitation, wandering, sexual disinhibition, hoarding, cursing and
shadowing. Psychological symptoms include anxiety, depression,
hallucinations and delusions.
Understanding agitation
Some of the most common behavioural issues are that of agitation,
wandering and aggression. In order to be able to assess,
manage and treat agitation, it is of the utmost importance to
investigate exactly what type of agitation is occurring and its
description in detail. Agitation is further categorise agitation (see
Table 1),7 so that when someone presents with BPSD and delirium has been ruled out from assessment, the exact type of agitation
can be identified.
| Categorising agitation | ||
| Category | Characteristics | Assessment |
| Physical aggressive behaviour | Slapping, kicking, hitting, punching, pinching, scraping |
|
| Verbal aggressive behaviour | Abusive words or screaming at another person |
|
| Physical nonaggressive behaviour | Wandering, active, rummaging, restless behaviour without aggression |
|
| Verbal agitated behaviour | Repeated vocal demands for attention, repetitive questions or statements that are not abusive |
|
Wandering
Wandering can also be further categorised to help identify
what is happening.
Exit-seeking behaviour
This is the most problematic behaviour and involves many
predisposing and precipitating factors, most often, a combination
of loss of short-term memory and sundowning behaviour.
The short-term memory of someone with dementia often means
they don’t have any memory of their house, which is usually the
home they have lived in for most of their adult life – instead
their long-term memories only allows them to recall the family
home where they grew up. In the acute general hospital setting,
wandering can pose a significant risk to PWD and is often placed
on a ‘special’ or 1:1 for observation. Usually medication used at
appropriate times in the afternoon and evening can help with
this, as well as using reminiscence to help them feel in control
and comforted.
Self-stimulation
This can often be mistaken for exit-seeking behaviour as self
stimulators are people who were active their entire life and remain
active into their dementia. Usually care approaches involve as previously
mentioned using their long-term memories and finding
out what it was they enjoyed or worked at when younger.
Sundowning
There is generally an increase in restlessness and wandering,
confusion and irritability in PWD as the day progresses.8 It is
important to recognise when this is happening and appropriate
psychosocial interventions and medication can help.
Aggression
Only 2% of aggressive events happen without an antecedent in
dementia.9 It is mostly the result of our interaction with PWD, their
environment and the type of dementia they have. Aggression is
most commonly caused when we are trying to get the PWD to do
something (eg. get up, get dressed, eat, take medication). Aggression
can also be the result of a delirium.
BPSD assessment of the PWD10
Behavioural observation sheets
Behavioural observation sheets allow us to obtain a more
detailed picture of the BPSD occurring, and at the times of the
day it’s at its worst. Three days of using these can help identify
patterns of behaviour, including: possible antecedents; times of
the day; and sundowning behaviour. It can also provide an overall
picture of the person’s daily routine, including: eating patterns;
activity periods; daytime sleeping; and sleep hygiene at night.
Joanne Flood is a clinical nurse manager 3 in Highfield Hospital in Dublin
References available on request from nursing@medmedia.ie (Quote: Flood, J Providing practical care for people with dementia. WIN 2013; 21 (1): 37-38)
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Continuing education - Brain disease - Providing practical care for people with dementia |