Primary Care Resources - Dementia

Dementia is associated with a progressive decline in memory and other cognitive skills severe enough to reduce a person's ability to function in which reversible and remedial factors have been excluded.

Why is it important?

  • Care is challenging and time consuming for family & health care providers (4)
  • Outcomes and prognosis is worsened in presence of dementia. Common contributor to risk of ALC (longer length in stay)
  • Family caregivers who live apart from the resident with dementia have greater burden and diminished psychological burden (3)
  • Support for the family who provide at least 80% of the care is necessary to keep relatives out of institutions (2)
  • Up to 50% of caregivers of patients with dementia develop psychiatric symptoms while caregiving (2)
  • Family caregivers think doctors do not adequately control symptoms and manage medications for dementia patients or adequately provide emotional support and social services links for caregivers (2)
  • Providing strategies for responding to behavioural changes can help family members proactively avoid crises associated with advancing disease (e.g., wandering), and delay a move to long-term care  up to 18 months (4)

Common Causes

Alzheimer's disease accounts for about 60% of cases of dementia, almost half of whom have co-existing cerebrovascular disease (mixed dementia). Vascular dementia accounts for 10-20% of dementia. Less common but important causes to consider are Lewy Body Dementia, Normal Pressure Hydrocephalus, Frontotemporal Dementia, and Dementia associated with Extrapyramidal syndromes such as Parkinson’s Disease.

Actual causes are unclear although risk factors include:

  • Family History:  5-7% occur as a result of familial AD:  a person with a direct relative (parent or sibling) with Alzheimer's disease has a 3 times greater chance of developing the disease.  15 % will get AD at age 65 or older when both parents have the disease (1)
  • All individuals with Down syndrome over 40 or develop plaques and tangles that characterize the disease (1)
  • apoE4 is the associated genetic variant: 50% all people with two apoE4 genes will develop AD at age 65 or older (1)
  • Cognitive impairment;   up to 85% of people with mild cognitive impairment in their 40-50’s develop AD within 10 years (1)
  • Vascular risk factors;  Type 2 ("Adult") diabetes is a known risk factor (1)
  • People who sustain repeated concussions can development of Alzheimer's disease (1)

Key Considerations

  • Take a careful medical history, a physical examination and explore the changes in thinking, day-to-day function and behaviour
  • Consult appropriate referrals: Geriatric Psychiatry or Psychogeriatric Social Worker, Neurologists, Geriatricians
  • Ensure Power of Attorney for Finances/Personal Care are in place and  discuss Advance Health Directives early on
  • Treatment with nonpharmacologic management should always be considered  before resorting to pharmacological strategies
  • Review driving status
  • Early referral to Alzheimer’s Society and to First Link program for provision of clear consistent information
  • There is good evidence to indicate that individualized exercise programs have an effect on functional performance in those with mild to moderate dementia (4)

References

1.  Alzheimer Society of Canada.  (2011). About Dementia.  Retrieved Feb. 2014 from: 
     http://www.alzheimer.ca/en/About-dementia

2.  Barylak, L., Irzeck, P. & Yaffe, M.  (2008).  Family physicians’ perspectives on care of dementia
     patients and family caregivers
Canadian Family Physician (CFP) Vol. 54 no. 7, 1008-15, July 2008. 
     Retrieved Feb. 2014 from: 
     http://www.cfp.ca/content/54/7/1008.full.pdf

3.  Feldman, S., Frank, C., & Schulz, M. (2011) Resources for people with dementia: The Alzheimer
     Society and beyond
.  Canadian Family Physician (CFP), Vol. 57:  December 2011. 
     Retrieved Feb. 2014 from:  
     http://www.cfp.ca/content/57/12/1387.full

4.  RNAO. (2010).  Nursing Best Practice Guideline, Caregiving Strategies for Older Adults with Delirium,
     Dementia and Depression. 
Retrieved March 2014 from:  
     http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression

Recommended Readings / Guidelines

1.  American Academy of Neurology .  DETECTION, DIAGNOSIS AND MANAGEMENT OF
     DEMENTIA
.  Retrieved March 2014 from:   
     http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf

2.  Chertkow, H., Gauthier, S., Gordon, M., Herrmann, N., Patterson, C., Rockwood, K., Rosa-Neto, P.
     & Soucy, J.P.  (2012)  Recommendations of the 4th Canadian Consensus Conference on the
     Diagnosis and Treatment of Dementia
(CCCDTD4). Can Geriatr J. Dec 2012; 15(4): 120–126. 
     Retrieved March 2014 from:
     http://www.alzheimer.ca/~/media/Files/national/For-HCP/for_hcp_recos_CCCDTD4_en.ashx

3.  Galvin, J.E. & Sadowsky, C.H. (2012)  Practical guidelines for the recognition and diagnosis of
     dementia.; NINCDS-ADRDA.  J Am Board Fam. Med. 2012 May-Jun;25(3):367-82. 
     Retrieved March 2014 from: 
     http://www.ncbi.nlm.nih.gov/pubmed/22570400

4.  Government of British Columbia.  (2012)  Dementia Guidelines.  Retrieved March 2014 from: 
     http://www2.gov.bc.ca/gov/topic.page?id=DABFEA5A7EAA45D7A22B815D830EC194

5.  National Institute for Health and Clinical Excellence.  (2006) Dementia: Supporting people with
     dementia and their carers in health and social care
. Clinical Guideline CG42 NICE Nov 2006. 
     Retrieved March 2014 from:   
     http://www.nice.org.uk/CG42

6.  Registered Nurses’ Association of Ontario.  (2004). Caregiving Strategies for Older Adults with
     Delirium, Dementia  and Depression
.  Retrieved March 2014 from: 
     http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression

7.  Registered Nurses’ Association of Ontario.  (2003).  Screening for Delirium, Dementia and
     Depression in the Older Adult
.  Retrieved March 2014 from: 
     http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult