Art Therapy for an Individual With Late Stage Dementia a Clinical Case Description
Clinical Review Dementia: timely diagnosis and early on intervention
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3029 (Published 16 June 2015) Cite this equally: BMJ 2015;350:h3029
- Louise Robinson , full general practitioner and professor of chief intendance1,
- Eugene Tang , NIHR academic clinical fellow in general practiseone,
- John-Paul Taylor , senior clinical lecturer and honorary consultant in old age psychiatrytwo
- 1Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, United kingdom of great britain and northern ireland
- twoInstitute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- Correspondence to L Robinson a.l.robinson{at}ncl.ac.united kingdom
The bottom line
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Dementia is a major global health problem; in the absence of a cure there is increasing focus on risk reduction, timely diagnosis, and early intervention
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Primary and secondary intendance doctors play complementary roles in dementia diagnosis; differential diagnoses include cognitive impairment due to normal ageing and low
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Cost effective drug (acetylcholinesterase inhibitors) and non-drug interventions such as cognitive stimulation therapy exist that aid to filibuster cognitive deterioration and improve quality of life; information provision and practical support are also important
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Discussions near a person's wishes for future care should occur at an early phase of illness while the person has mental chapters
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Family unit carers of people with dementia are at high risk of physical and mental illness as a consequence of caring and they require equal attention and support
Dementia describes a clinical syndrome that encompasses difficulties in retentiveness, language, and behaviour that leads to impairments in activities of daily living. Alzheimer's illness is the most common subtype of dementia, followed by vascular dementia, mixed dementia, and dementia with Lewy bodies. Because the global population is apace ageing, dementia has get a concern worldwide1; the illness places considerable brunt on individuals and their families and also on health and social care provision.
Sources and selection criteria
We searched for manufactures through Medline, PubMed, and the Cochrane database of systematic reviews from January 2006 to December 2014—the period later publication of the current UK national dementia guidance9—using the search terms "dementia", "Alzheimer'due south", "carer", and "caregiver". Boosted searches were carried out for specific subsections—for case, "pharmacologic treatment" and "not-pharmacologic interventions/strategies/treatment". Where possible, we focused on systematic reviews, meta-analyses, and loftier quality randomised controlled trials. We included but articles in English language and excluded those published in not-peer reviewed journals. Recommendations in this review are derived from the virtually recent international and Britain national guidance9 on evidence based practice in dementia care and the authors' interpretation of the included testify.
By 2050 an estimated 135 million people worldwide will accept dementia. In 2010 the global cost of dementia intendance was estimated at $604bn (£396bn; €548bn) and estimated to increase to $1tr by 2030.1 Of all chronic diseases, dementia is one of the most important contributors to dependence and disability.ii 3 In the absence of a cure, a professional belief that goose egg can be washed has contributed to delays in diagnosis.4 However, increasing evidence showing that dementia may be preventable1 5 has led to an international focus on earlier diagnosis and intervention.vi This review aims to summarise current evidence and all-time practice in the diagnosis and early on intervention in dementia care.
Patient and public involvement
Patient and public interest in this clinical review has been accomplished through several processes: the inclusion of patients and the public in the groups responsible for developing the national guidelines referenced in this review; liaising with patient and public representatives from the National Plant of Health Inquiry Dementia and Neurodegenerative Diseases Research Network who contributed to systematic reviews included in this review4 9; and asking the United kingdom Alzheimer'southward Guild to comment on the final draft of the newspaper and provide up to date information resources for patients and carers.
Why is timely diagnosis important?
In some countries the introduction of a national dementia strategy has led to greater emphasis on earlier diagnosis, although population based screening is non recommended equally dementia does non fulfil the criteria of a condition suitable for screening.7 With evidence from large longitudinal cohort studies showing that the prevalence of dementia is declining globally, in that location is now greater emphasis on prevention and gamble reduction.1 5 In England, policy has rightly or wrongly influenced the introduction of example finding in loftier risk groups—including people over 75 years of age, as age is the strongest risk gene for dementia—and those with high vascular risk, Parkinson'southward disease, and learning disabilities.eight The policy comprises proactive memory cess of people in both primary intendance and acute hospital settings who may non have symptoms; nevertheless, at that place is little evidence that such initiatives, which inevitably lead to increased referrals to specialist services, are toll constructive and whether they are distressing to patients.4 6
How can clinicians recognise dementia?
Diagnosing dementia can be difficult owing to its insidious onset, symptoms resembling "normal ageing" memory loss, and a diversity of other presenting symptoms—for case, difficulty in finding words or making decisions.ten An individual'due south ability to adjust, compensate, or even deny his or her symptoms in the early stages should too be considered. The private's family may too accept noticed difficulties in communication and personality or mood changes; family business concern is of particular importance.9 Increasing frequency of patients' visits to their full general practice, missed appointments, or defoliation over drugs may also be warning signs.8
Diagnosis of subtype is important given differences in management, illness grade, and outcomes for different dementias; awareness of early symptoms in less common dementias can assist generalists in deciding to which specialist services patients are referred (box ane). Elapsing over which symptoms have developed is also of import, with Alzheimer's disease disposed to take a more than insidious onset than vascular dementia.
Box 1 Examples of less common dementias and their early on presenting symptoms
Vascular dementia
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Wide range of signs and symptoms depending on extent, location, and severity of the cerebrovascular disease
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Symptoms tin can develop abruptly after a stroke or more insidiously with small vessel disease
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Memory loss can exist a feature merely typically is less noticeable than in Alzheimer's disease. Language, information processing, decision making, and visuospatial deficits can also be found
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Mood changes and aloofness are mutual symptoms; can co-occur with Alzheimer's disease and this is termed mixed dementia
Frontotemporal dementias
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More than common in younger age groups (50-threescore years)
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The most common clinical blazon is behavioural variant frontotemporal dementia, with changes in personality and behaviour. Disinhibition and impulsiveness tin can be features. Retentivity function is typically intact early on
Dementia with Lewy bodies
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Complex visual hallucinations are a cardinal characteristic. In the early stages they may only occur during periods of physical stress (for example, infections) or at nighttime time and may be followed by more subtle visuoperceptual symptoms—for instance, illusions
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Parkinsonism (tremor, slowed movements, postural instability, shuffling gait) is also a feature. Tremor may be less evident, but people with early on dementia with Lewy bodies may be slower in movements and more decumbent to falls
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Fluctuations or noticeable variations in cognitive function can occur and tin be difficult to dissever from delirium
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Autonomic symptoms may occur—for example, postural hypotension
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Sleep disturbances such as rapid eye movement sleep behaviour disorder (shouting out or moving while asleep) can occur many years before the onset of dementia
Parkinson's illness with dementia
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As many equally fourscore% of patients with Parkinson's develop dementia
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Symptoms are like to those of dementia with Lewy bodies, although motor Parkinson's symptoms typically predate cognitive and psychiatric symptoms past more than a year
Posterior cortical atrophy
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A less mutual course of Alzheimer's disease, which tends to affect younger people (50s and 60s)
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Visual agnosias (difficulties with recognising faces, objects, or perceiving more than 1 object at a time), apraxias (motor planning difficulties), acalculia (difficulty with calculation), and alexia (difficulty reading) are symptoms
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Memory typically preserved early on
Other uncommon to rare causes of dementia
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Alcohol related dementia, Creutzfeldt-Jakob disease, HIV related cognitive impairment, Huntington's chorea, corticobasal syndrome, motility related dementias (for case, progressive supranuclear palsy), multiple sclerosis, Niemann-Pick disease blazon C, normal pressure hydrocephalus
How is dementia diagnosed?
The office of primary intendance
Full general practitioners are often the kickoff indicate of contact for patients who are worried that they may accept dementia. The part of master care is to exclude a potentially treatable affliction or reversible cause of the "dementia"—for example, depression, vitamin B12 deficiency, or thyroid disturbance; refer for specialist assessment, especially those with unusual symptoms (neurological, psychiatric, or behavioural changes) or those with major risk factors (for case, of import medical comorbidities, psychosocial problems, harm to self); and ensure patients who accept balmy cognitive harm (objective cerebral loss non affecting function and daily living activities) are followed up in primary care, and, if their symptoms become more severe, re-referred for specialist assessment.
Initial assessment should include a conscientious history from both the patient and the main carer, with particular emphasis on disturbance of cognitive function and activities of daily living. A physical exam should be undertaken to look for any focal neurological signs and exclude any visual or auditory problems. Baseline investigations and a brief cognitive assessment, using one of the many tools available (box ii), should also be carried out before referral to secondary care.9
Box two Investigations and brief cognitive assessment tools for dementia in primary intendance
Blood tests
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Blood tests that should be ordered are: full blood count, erythrocyte sedimentation rate, urea and electrolytes, thyroid function, vitamin B12, and folate. Midstream specimen of urine, chest radiography, and electrocardiography may also be needed where clinically appropriate
Cursory cerebral assessment tools
General practitioner assessment of cognition11
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Takes no longer than five minutes to administer and comprises two components: a six item cognitive assessment with the patient and an informant questionnaire (if the cerebral assessment score is equivocal: 5-8 inclusive). Scores >8 are deemed to represent cognitive impairment and <five intact cognition. Sensitivity 82-85%; specificity 83-86%12
6 detail cerebral harm test13
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Takes iii-4 minutes to perform and consists of half-dozen questions on orientation and memory, although the test may be susceptible to influences of language and education. Scores of 0-7 are considered normal and ≥8 suggest cognitive damage. Sensitivity 78.5-83%; specificity 77-100%12
Mini-cog assessment instrument14
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Takes two-4 minutes to complete and consists of two components, a three item retrieve and the clock drawing examination. Cognitive impairment is considered to be present if people are unable to call up any of the three items or if they recall merely one or ii items and draw an abnormal clock. Sensitivity 76-99%; specificity 89-96%12
Memory impairment screen15
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Takes effectually iv minutes to complete and is a brief iv item delayed free recall and cued think retentivity impairment examination. A score of ≤4 indicates possible dementia. Sensitivity 74-86%; specificity 96-97%12
The mini-mental state examination16 has traditionally been recommended every bit the brief cerebral cess tool of choice, although copyright restrictions are influencing its utilise in practice. The tools listed in box 2 accept been institute to be as clinically and psychometrically robust as the mini-mental land examination17; a clock drawing test may be added to the assessment if it is not already incorporated into the tool.18 The Addenbrooke's cerebral examination,19 specially the revised version, has superior diagnostic accuracy to the mini-mental country examination but takes about 25 minutes to complete and has improve accuracy in moderate to high prevalence settings.20 No one brief cognitive assessment tool is more accurate than another and all are inadequate for assessing early or subtle changes, with scores affected by factors such as educational activity. Mini-mental state examination scores are used to signal the severity of Alzheimer'due south disease: mild, scores 21-26; moderate, scores 10-20; moderately astringent, scores x-fourteen; severe, scores less than ten.
Depression masquerading equally dementia is probably the near common differential diagnosis and should always be considered; nevertheless, they can coexist and depression may precede dementia. If suspected, a trial of antidepressants may be indicated, with reassessment of the private's capabilities and cognitive function 6-8 weeks after.
The office of secondary care
Primary intendance is increasingly taking on a greater part in both the assessment and the long term care of people with dementia; one multicentre randomised controlled trial plant no evidence that specialist retention clinics were more effective than general practise services in providing post-diagnostic support.21 Secondary services have an important office in defining the dementia subtype, dealing with more complex cases, and stratifying which patients with balmy cognitive harm are at greatest risk of developing dementia and almost in need of follow-upwards.
What are the roles of imaging and other investigations?
Imaging, in particular structural scanning (computed tomography or magnetic resonance imaging), is recommended as part of the investigations of people with suspected dementia in UK,9 European,22 and US guidelines.23 Imaging is now also embedded in several modern diagnostic criteria for different dementias, including Alzheimer's disease and dementia with Lewy bodies.24 25 26 In modern dementia imaging there is at present less focus on "excluding" reversible causes of dementia (for example, tumours) and more than on determination of subtype. Structural imaging, particularly magnetic resonance imaging, tin also help clarify whether a vascular disease is contributing to the cognitive impairment and thus whether strict adherence to handling guidance for vascular risks is warranted.
In the United Kingdom, functional neuroimaging, including hexamethylpropyleneamine oxime (HMPAO) unmarried photon emission computed tomography (SPECT) and [18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), is available but unremarkably used as a second line approach to aid with subtype diagnoses, specially where the diagnosis is in doubt. Dopaminergic iodine-123-radiolabelled 2β-carbomethoxy-3β-(4-iodophenyl)-N-(three-fluoropropyl) nortropane (FP-CIT) SPECT imaging is licensed in Europe and in a number of other countries for the diagnosis of dementia with Lewy bodies and may also be helpful where the clinical diagnosis of dementia with Lewy bodies is non clear.27
What new investigations are emerging in the diagnosis of dementia?
Cerebrospinal fluid sampling is used to exclude inflammatory, infective, and malignancy related causes of dementia and is typically recommended in individuals with rapid cognitive decline, unusual or neurological presentations, or cognitive impairment at less than 55 years of historic period.28 More recently there has been a focus on developing cerebrospinal fluid based markers, such as β amyloid and tau, for changes in Alzheimer'south disease that can predate the onset of the dementia, the then called prodromal phase of Alzheimer's affliction. Although such markers have been incorporated into contempo diagnostic criteria for Alzheimer'due south disease,25 26 whether they are effective at predicting those who volition develop dementia29 and, more importantly, practically acceptable, makes their widespread clinical use challenging at present.
Information technology is at present possible to straight image amyloid in the brain using several positron emission tomography radiotracers, and this imaging technique may have a futurity office clinically in predicting which people with mild cognitive impairment will develop Alzheimer's disease. However there is still major heterogeneity in how these scans are interpreted. For example, a recent meta-analysis found that although amyloid imaging has loftier sensitivity (83-100%) in detecting people with mild cognitive impairment who convert to Alzheimer's affliction related dementia, diagnostic specificities varied considerably betwixt studies (46-88%).30
What constitutes best practice in early intervention?
Discussing the diagnosis: saying the "D" word
Wellness professionals tin be reluctant to speak openly and honestly with patients and their families about dementia, with some refraining from using the "D" word.28 Although initially discussing the diagnosis may be deplorable, evidence suggests most people prefer to know if they have dementia in club to admission appropriate support and treatment and to plan for the time to come.4 31
What options are available afterward diagnosis?
Drug interventions
Clinically and cost effective drugs for dementia are available; the accent is to improve or maintain role after neuronal harm rather than to alter the underlying pathogenesis leading to the dementia syndrome. Two classes of drugs are currently recommended for symptomatic (Alzheimer'south disease and mixed) dementia6 32: acetylcholinesterase inhibitors donepezil, galantamine, and rivastigmine, and Due north-methyl-D-aspartic acid receptor antagonists such as memantine. Now, acetylcholinesterase inhibitors are the but recommended options to manage balmy to moderate Alzheimer's disease and there is no evidence that one is more efficacious than another33; notwithstanding, a large randomised controlled trial has recently shown that continued treatment with donepezil is associated with cognitive benefits in moderate to severe dementia.34 Memantine has been approved for people with moderate to severe Alzheimer'due south disease or those with intolerance to acetylcholinesterase inhibitors; information technology has also been used in mild Alzheimer's affliction but the evidence for this is currently lacking despite its frequent off-label utilize.35
Non-drug approaches
The testify base is steadily increasing for non-drug interventions in dementia intendance, although further research in many areas is however needed.6 In a big systematic review evaluating both drug and non-drug interventions in dementia intendance, cognitive stimulation therapy was constitute to be every bit clinically and cost effective as the acetylcholinesterase inhibitors36; reminiscence therapy is also recommended in national guidelines.9 Withal, the testify base for innovative service provision such as instance management, whereby a instance manager, usually a nurse or social worker acts equally the main care coordinator between central stakeholders, including primary and secondary care, is mixed.vi 36 Although the bear witness base of operations for cost effectiveness is depression,37 especially developed assistive applied science—whatever device or system that allows an private to perform tasks that they would otherwise be unable to do, or increases the ease and safety with which the task can be performed—to aid people with dementia is bachelor and can be useful in relieving carer anxiety and helping people with dementia to remain living at home (world wide web.atdementia.org.united kingdom/).
Information provision
People with dementia and their families require emotional and practical support to aid them alive as good a quality of life as they can; the family unit dr. is in a primal position to provide ongoing support and communication once the diagnosis is confirmed.4 six Voluntary organisations such as Alzheimer'due south International provide a wide range of information resources and practical back up for people living with all types of dementia (www.alz.co.uk/). Signposting to local sources of support as well as social services and respite care are integral to the consultation. Listening to an individual patient'southward difficulties and concerns and providing simple cognitive and emotional strategies in the principal care consultation are beneficial to both patients and their families.
Discussing the future
One important expanse to be discussed in the earlier stages of dementia, while people withal accept mental capacity, is personal wishes for hereafter care and too who should make decisions when the patients are no longer able to do and then. In dementia, such discussions—termed advance intendance planning—have been shown to reduce inappropriate hospital admissions towards the stop of life, simply the bear witness base of operations is weak.38 39 Discussions almost advance care planning crave both sensitivity and honesty; general practitioners or infirmary specialists are well placed to undertake these discussions if they have an established human relationship with the patient. After such conversations, patients tin can formally tape their wishes in several means, including the completion of an advance directive, or "living will" as information technology was previously known (box 3).
Box 3 Outcomes of advance care planning discussions: international and national terminology
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Statement of wishes and preferences—this documents an individual'due south wishes for future care and is non legally binding; in the UK this is known as an advance argument
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An advance directive for refusal of treatment (or "living will")—this is a statement of an individual's refusal to receive specific medical treatment in a predefined future state of affairs. It is legally binding and comes into effect when a person loses mental capacity. In the United kingdom of great britain and northern ireland, this is known every bit an advance decision to reject treatment
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A proxy determination maker or power of attorney—This is a legally binding certificate whereby an individual ("donor") nominates another ("attorney") to make decisions on his or her behalf should he or she lose capacity. In England, following the Mental Capacity Act, this is now known every bit a lasting power of chaser and there are ii separate aspects to lasting ability of attorney, one for an individual's health and welfare and a second for property and financial affairs
Primary care doctors may detect it difficult to assess the mental capacity of an individual with dementia; mental capacity may fluctuate with time and likewise with acute affliction. In England, the introduction of the Mental Capacity Act in 2005 provided much needed guidance for wellness and social care professionals on how to undertake an assessment of capacity and to make decisions in the best interests of adults who lack the mental capacity to practise so for themselves (box 4).
Box iv Assessment of mental capacity (as derived from UK Mental Chapters Deed 2005)
Two stage exam for determining whether an private has mental capacity to brand a specific decision
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ane. Does the patient have an impairment or disturbance of office of the encephalon?
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2. Regarding a specific decision, can the patient:
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sympathize the determination to be made?
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retain sufficient information to brand an informed decision?
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use information appropriately?
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communicate their conclusion?
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Practical tips for assessment of chapters:
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Information may need to be provided in different forms
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General practitioners may need to assess patients on several occasions—that is, if morning is the best time for them
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Record information and the ii stages described above accurately in patient notes
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Refer to experts (erstwhile age psychiatry) if in doubt
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Caring for family unit carers
In the UK, ii thirds of people with dementia alive independently in the community, with near of their care and support provided past family and friends. Such informal carers are more likely to experience depressed mood, to report a higher intendance "burden," and to have worse physical health than carers of people with other long term conditions.40 They may grieve as their family member loses functional and cognitive abilities, and every bit companionship, affection, and intimacy are affected; this is termed a living bereavement. Still the satisfaction carers experience from caring, the support they receive and their ability to seek assistance when needed influence how they cope. Supporting informal carers, monitoring their health and wellbeing, and providing or referring them for additional applied and psychological support is some other crucial role for full general practitioners and community care services.41
Tips for non-specialists
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Occasional memory lapses are common equally people go older, particularly in the presence of stress, depression, and acute physical illness; review the patient subsequently appropriate treatment has been given or a reasonable length of time has elapsed
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If you doubtable dementia, have a history from both the patient and the main family carer; the latter'south suspicions are often right
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Be aware that sure groups of people are at greater risk of developing dementia—for example, those who have had a stroke and those with Parkinson's illness
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Early identification of modifiable take chances factors for dementia may reduce the numbers of people developing dementia in afterward life
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Effective and useful treatments exist for people with dementia; have a low threshold for referring someone with suspicious symptoms for a specialist retentivity assessment
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Assess both the physical and the mental health of the primary family carer; supporting informal carers is an important part of dementia care
Boosted educational resources
Resource for patients and carers
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Social Care Institute for Excellence. Dementia gateway (world wide web/scie/org.britain/dementia)—spider web based information and eastward-learning resources written by experts mainly for professional person carers and supporters
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Alzheimer'due south Society. The dementia guide: living well after diagnosis (www.alzheimers.org.uk/dementiaguide or asking copies at publications@alzheimers.org.uk)—comprehensive applied information for people with dementia and families with a recent diagnosis. Includes a complimentary booklet, video instance studies, and downloadable translations
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Lewy torso Society (http://lewybody.org/aboutdlb)—website of the only charity in Europe exclusively concerned with dementia with Lewy bodies
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FTD Talk (world wide web.ftd.org)—accessible updates and web information for people with frontotemporal dementia from researchers
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Alzheimer'southward Disease International. Assistance for caregivers (world wide web.alz.co.uk/ADI-publications)—a downloadable booklet produced in collaboration with the World Wellness Organisation: practical tips on caring for someone with dementia
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Carers UK Factsheets (http://carersuk.org)—practical information for carers most topics such as benefits and getting help and support
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at dementia (www.atdementia.org.u.k.)—a website providing information on assistive technology for people with dementia
Notes
Cite this equally: BMJ 2015;350:h3029
Footnotes
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We give thanks Tim Beanland, cognition services manager at the Alzheimer'south Gild, London for advice. LR is supported by a National Found for Wellness Research professorship (NIHR-RP-011-043).
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Contributors: LR drafted the outline and overview of the article; all authors contributed equally to the content. LR is the guarantor of the paper.
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Competing interests: We have read and understood the BMJ policy on annunciation of interests and declare the following interests: none.
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Provenance and peer review: Commissioned; externally peer reviewed.
This is an Open Access commodity distributed in accord with the terms of the Artistic Commons Attribution (CC Past iv.0) license, which permits others to distribute, remix, adapt and build upon this piece of work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.
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Source: https://www.bmj.com/content/350/bmj.h3029