Medical care of older persons in residential aged care facilities


The Silver Book
Dementia
☰ Table of contents


Dementia is a progressive decline in general cognitive function, with normal consciousness and attention.84 There is impairment of memory, abstract thinking, judgment, verbal fluency and the ability to perform complex tasks. It is associated with behavioural and psychological changes, and impairment of social and physical functioning. Behavioural and psychological symptoms of dementia (BPSD) include psychosis, depression, agitation, aggression and disinhibition in the later stages of the illness.85

The prevalence of dementia increases with age, from about 3.4% at 70-74 years to 20% at 85-89 years, and 40% at 95 years or over. As the Australian population ages, the number of people with dementia is estimated to rise from 200 000 (1% of Australians) in 2005, to 730 000 (2.8% of the projected population) by 2050.86 Dementia is one of the most common conditions of older people who live in residential care, affecting about 30% of residents in low care and 60%in high care.

Many people with dementia will enter residential care for respite or long term care several years after onset when they require support for impairment in activities of daily living or behavioural and psychological symptoms. Dementia and BPSD can have a significant physical and emotional impact on families and carers. The process of moving to residential care can be difficult and requires understanding and support.87 Some older people may develop dementia while living in residential care. Therefore, GPs are likely to see residents with the full spectrum of mild to moderate to severe dementia.

Common types of dementia are Alzheimer disease (40-60%), vascular dementia (10-20%), and Lewy Body dementia (15-20%). Other causes are frontal lobe dementia,Parkinson disease with dementia, normal pressure hydrocephalus, post-traumatic, medications,alcohol, anoxic encephalopathy, prion diseases (eg. Cretzfeldt-Jacob disease), Huntington disease, Down syndrome and AIDS.88 Dementia may be due to a combination of causes.89

Alzheimer disease is characterised by an insidious onset of symptoms, with initial forgetfulness progressing over time to profound memory impairment with accompanying dysphasia, dyspraxia and personality change. Noncognitive symptoms may include decreased emotional expression and initiative, increased stubbornness and suspiciousness, and delusions.

Vascular dementia usually starts suddenly, with focal neurological signs and imaging evidence of cerebrovascular disease. There may be emotional lability, impaired judgment, gait disorders, with relative preservation of personality and verbal memory. It often occurs in combination with Alzheimer disease.

Lewy Body dementia is characterised by cognitive impairment that affects memory and the ability to carry out complex tasks, and fluctuates within 1 day. It is associated with at least one of the following: visual or auditory hallucinations, spontaneous motor parkinsonism, transient clouding or loss of consciousness, and repeated unexplained falls.

Frontal lobe dementia features include impaired initiation and planning, with disinhibited behaviour and mild abnormalities on cognitive testing. Apathy and memory deficit may appear later.

Residents with dementia have increased risks of other conditions, including:

  • delirium
  • depression
  • dysphagia and aspiration
  • falls, through impaired judgment, gait, visual space perception and ability to recognise and avoid hazards
  • urinary and faecal incontinence through reduced awareness and mobility
  • inadequate recognition and management of pain.



Assessment


Comprehensive assessment of residents with dementia will:

  • confirm the diagnosis, although this may have occurred at earlier stages of the illness before admission to the facility,90 or require specialist referral
  • differentiate dementia from delirium and depression, although these conditions may co-exist with dementia
  • identify the cause of dementia, which is important for treating any reversible conditions and for selecting medication
  • identify behavioural and psychological symptoms
  • determine the extent and severity of functional impairment, including activities of daily living, and decision making capacity
  • consider the impact of dementia on other geriatric syndromes and their management
  • identify the concerns of relatives and RACF staff, and their need for information and support.

Assessment methods are those outlined for the comprehensive medical assessment, with a focus on making an accurate diagnosis, identifying active problems and establishing goals of care with the resident, relatives/representative and RACF staff. (It will be helpful to do cognitive testing early in the assessment, and to talk with relatives/carers and RACF staff about their observations of functional status, BPSD and decision making capacity-see Medical assessment of the resident). The Medicare item Comprehensive Medical Assessment can be utilised on admission and for annual review of a resident with dementia (see Tools 10).

 

Cognitive testing


Cognitive testing is useful to assess and document severity of cognitive impairment and to measure changes in cognitive function over time. It can help differentiate between dementia, delirium and depression. Many tests are available and suitable for cognitive assessment. Currently, the Mini-Mental State Examination (MMSE)91 and clock drawing test are the most widely used and recommended. The Abbreviated Mental Test Score (AMTS)92 is a quicker measure of cognitive impairment that correlates well with the MMSE and has been tested on an Australian sample of patients93 (see Tools 4).

Versions of the MMSE are available in Medical Director software and in several publications.94,95 Patients with Alzheimer disease are likely to score at least 21 on the MMSE for mild disease, 10-20 for moderate disease, and 9 or less for severe disease.96 The MMSE score may be normal for people with early cognitive impairment.

The clock drawing test is useful in combination with the MMSE. It may demonstrate changes in the early stages of dementia, reflecting deficits in planning, spatial perception and cognition.97 The technique involves giving the patient a sheet of paper and asking them to draw a clock face (big enough to ensure there is a need to plan the number spacing), draw the numbers in correct position, and draw hands to show the time of'ten past 11'. There are several methods used to score the test, eg. one point for drawing a closed circle, one point for drawing 12 numbers, one point for positioning numbers correctly, and one point for placing clock hands at a designated time.98

 

Differentiation of dementia from delirium and depression


Table 6 compares the clinical features of dementia with delirium and depression.99 However, features may co-exist, as residents with dementia are at increased risk of delirium and depression. It is important to identify delirium and arrange urgent investigation and treatment for physicaland medication related causes (see Delirium). Obtaining a history of depressive symptoms, and using depression assessment scales and cognitive testing, can assist in the diagnosis of depression (see Depression). Depression occurring in people with dementia needs to be distinguished from depressive pseudodementia, an uncommon condition of depression presenting as a dementia-like illness.

 

Table 6. A comparison of the clinical features of delirium.dementia and depression 100

Feature

Delirium

Dementia

Depression

Onset

Acute/sub-acute depends on cause, often twilight

Chronic, generally insidious, depends on cause

Coincides with life changes, often abrupt

Course

Short, diurnal fluctuations in symptoms; worse at night in the dark and on awakening

Long, no diurnal effects, symptoms progressive yet relatively stable over time

Diurnal effects, typically worse in the morning; situational fluctuations but less than acute confusion

Progression

abrupt

slow but even

Variable, rapid-slow but uneven

Duration

Hours to less than 1 month, seldom longer

Months to years

At least 2 weeks, but can be several months to years

Awareness

Reduced

Clear

Clear

Alertness

Fluctuates; lethargic or hypervigilant

Generally normal

Normal

Attention

Impaired, fluctuates

Generally normal

Minimal impairment but is distractible

Orientation

Fluctuates in severity, generally impaired

May be impaired

Selective disorientation

Memory

Recent and immediate impaired

Recent and remote impaired

Selective or patchy impairment,'islands' of intact memory

Thinking

Disorganised, distorted, fragmented, slow or accelerated, incoherent

Difficulty with abstraction, thoughts impoverished, marked poor judgment, words difficult to find

Intact but with themes of hopelessness, helplessness or self deprecation

Perception

Distorted; illusions, delusions and hallucinations, difficulty distinguishing between reality and misperceptions

Misperceptions often absent

Intact; delusions and hallucinations absent except in severe cases

Stability

Variable hour to hour

Fairly stable

Some variability

Emotions

Irritable, aggressive, fearful

Apathetic, labile, irritable

Flat, unresponsive or sad; may be irritable

Sleep

Nocturnal confusion

Often disturbed; nocturnal wandering and confusion

Early morning awakening

Other Features

Other physical disease may not be obvious

 

Past history of mood disorder

 

A detailed history obtained from the resident and relatives/carers will help evaluate101:

  • cognitive impairment and decline from a former level of functioning: memory, problem solving, language, getting lost, using appliances, failure to recognise people or objects
  • behavioural and psychological symptoms: depression, withdrawal, aggression, agitation, false beliefs, hallucinations, sleep disturbance, loss of social graces, obsessive-compulsiveness
  • risk assessment: falls, wandering, nutrition, medication, abuse
  • alcohol intake
  • family history
  • capacity to consent to medical treatment, appoint a representative and make an advance care plan.

Physical examination can help diagnose:102

  • specific conditions which may cause dementia, eg. stroke, cerebrovascular disease, Parkinson disease, hypothyroidism, alcoholism. Look for focal neurological signs, poor/abnormal gaze, tremor or abnormal gait
  • underlying chronic conditions which may aggravate dementia, eg. hypertension, cardiac failure, renal failure, diabetes, asthma
  • conditions which may cause delirium, eg. respiratory or urinary tract infection (UTI).

Investigations are usually undertaken to identify reversible causes of dementia and may include:

  • haemoglobin, white cell count, erythrocyte sedimentation rate, serum B12 and folate levels
  • serum electrolytes and renal function, serum calcium and phosphate
  • liver function, thyroid function, blood sugar
  • urine micro and culture
  • chest X-ray (if delirium)
  • brain scan
  • syphilis serology and HIV antibodies if indicated.

 

Management


General practitioners are well placed to provide care to patients with dementia from the early stages at home through to later stages at a RACF.103 Most residents with dementia are managed by their GP and RACF staff. Complex cases, or early cases where the differential diagnoses are unclear, may require specialist advice or support, eg. through cognitive, memory and dementia services, ACATs, psychogeriatric services, or palliative care services. Some people with severe dementia may require admission to a psychogeriatric unit. Involvement of the resident's relatives and carers can ameliorate feelings of loss and captivity, increase satisfaction with care, and improve clinical outcomes.104,105

A general approach to management of dementia by GPs involves:106

  • establishing partnerships with the resident, family, RACF staff and relevant local specialist services
  • regularly reviewing the physical and mental health of the resident, including the use of medication
  • treating reversible causes and co-existing conditions
  • requesting RACF staff to monitor symptoms and behaviours that cause concern, preferably using established scales
  • discussing with RACF staff the psychological and social strategies for the management of BPSD
  • understanding the resident and family perspective, so that the transition through stages of care can be sensitively managed.

Consultations with residents and their relatives/carers will enable GPs to provide information and address expectations and concerns. In the early stages of dementia, discussion may cover the condition, advance care planning, appointing a representative, and ways to maintain function. While remaining frank and open about what to expect, GPs may also be positive about the development of new treatments. Information and support for residents, their relatives/carers and health professionals is available from Alzheimer's Australia (see Contacts).

It is important that other geriatric syndromes are recognised and managed appropriately as often residents with dementia may not report specific problems during routine care. The residential care setting provides opportunities for carefully targeted prevention and intervention programs for care of common conditions in people with dementia,107,108,109 including routine assessment of swallowing difficulties, monitoring nonverbal pain behaviours, prompting patients to visit the toilet on a regular basis, and reducing falls risk by minimising environmental hazards. Once reversible causes have been treated and coexisting conditions managed, the major mode of dementia management is with nonpharmacological interventions. These can be targeted to specific symptoms including cognitive impairment, apathy, depression, psychotic symptoms,and aggression.

 

Management of behavioural and psychological symptoms of dementia


Psychological and behavioural symptoms are an integral manifestation of dementia. Depression is common in the early stages. Behavioural manifestations are common in the intermediate stages of Alzheimer disease and at various stages in other types of dementia.110

Brodaty et al developed a service delivery model for managing people with behavioural and psychological symptoms of dementia.111 The model divides people with BPSD into seven tiers in ascending order of symptom severity and decreasing levels of prevalence. Recommended treatment is cumulative through the tiers, with increasing interventions as symptoms become more serious.

  • Tier 1: For no dementia, management is universal prevention, although specific strategies to prevent dementia remain unproven
  • Tier 2: For dementia with no BPSD (40% prevalence), management is by selected prevention through preventive or delaying interventions (not widely researched)
  • Tier 3: For dementia with mild BPSD (prevalence 30%), eg. night time disturbance, wandering, mild depression, apathy, repetitive questioning, and shadowing, management is by primary care workers
  • Tier 4: For dementia with moderate BPSD (prevalence 20%), eg. major depression, verbal aggression, psychosis, sexual disinhibition, and wandering, management is by primary care workers with specialist consultation as required
  • Tier 5: For dementia with severe BPSD (prevalence 10%), eg. severe depression, psychosis, screaming, and severe agitation, management is in dementia specific high level residential care, or by case management under a specialist team
  • Tier 6: For dementia with very severe BPSD (prevalence<1%), eg. physical aggression, severe depression, and suicidal tendencies, management is in a psychogeriatric or neurobehavioural unit
  • Tier 7: For dementia with extreme BPSD (rare), eg. physical violence, management is in an intensive specialist care unit.

General practitioners and RACF staff can minimise and manage BPSD effectively by getting to know residents with dementia and how to approach them, and by recognising the factors that aggravate their behavioural and psychological symptoms. Careful analysis of the cause of behaviour (Table 7), behavioural management strategies and good environmental design may reduce BPSD.

 

Table 7. Factors that may contribute to behavioural disturbances in dementia 112

Patient

Interaction

Environment

  • Cultural background, values,language
  • Social history
  • Impact of changes to family or work roles
  • Personality traits
  • Tiredness, sleeping problems
  • Hunger, thirst
  • Feelings of frustration,sadness, anger, grief
  • Pain, discomfort
  • Hearing impairment
  • Visual impairment
  • Infections, new illness
  • Physical movement problems
  • Incontinence
  • Constipation
  • Poor dental health
  • Blood pressure (high or low)
  • Pre-existing illness
  • Medication adverse effects,interactions
  • Progression of dementia
  • Poor communication (speaking too fast, slurring words, mumbling)
  • Language too complex or condescending
  • Not enough information and prompting given
  • Poor eye contact
  • Hostile or defensive tone in voice or body language
  • Inappropriate or misunderstood verbal or nonverbal cues
  • Personal space invaded
  • Task or activity too complex or demeaning
  • Changes to routines or activities
  • Social isolation or too much socialisation
  • Minimal or overwhelming levels of activity
  • Unfamiliar people
  • Cultural and religious influences not considered
  • Preferred language not used
  • Feelings of resident not acknowledged
  • Unfamiliar surroundings
  • Too much or competing noise
  • Clutter and obstructions
  • Visual distraction (patterned carpet)
  • Poor lighting (glare, shadows)
  • Decor and fittings confusing
  • Lack of visual prompts (eg. not obvious where toilet is located)
  • Visual prompts that cue unwanted behaviour (eg. coats or hats hung by the door)
  • Unsafe environment
  • Uncomfortable temperature(hot/cold)
  • Lack of personal belongings
  • Culturally inappropriate environment
  • Lack of privacy and personal space
  • Environment not sensitive to perceptual changes of dementia


Changes to the resident's environment, routines and tasks may help to reduce distress in day-today activities. (See the Alzheimer's Association website) for help sheets on daily care (hygiene, dressing, safety), behavioural issues (sundowning, wandering, aggression, agitation), and changes that can be made to the resident's environment.

Behavioural interventions may include:113

  • education: explanation for residents and relatives/carers, and training of RACF staff
  • sensory stimulation: orientation cues, diversional activities, music, massage, pets
  • cognitive: reminders and repetition of information
  • self care skills: dressing, eating, toileting
  • physical activity: simple exercise routines, eg. walking, gentle exercise groups
  • social interaction: regular social activity, groups, and visitors
  • behavioural therapies.

Behavioural therapies (eg. re-orientation, reminiscence, music therapy) may be useful for some people with behavioural disturbance, however clinical trials are small and few.114 Residential aged care staff have access to training and several psychosocial approaches to care such as'reality orientation','validation therapy'and other nonmedication therapies for BPSD.115 Delirium should be suspected and the cause treated if a resident with dementia becomes acutely disturbed (see Delirium).

Restraint may be used in a RACF in situations where a patient's behaviour or activity may result in loss of dignity, personal harm, damage to property, or severe disruption to others. However it should be as a last resort and not a substitute for adequate education or resources in the facility. Restraint is,any aversive practice, device or action that interferes with a resident's ability to make a decision or which restricts their free movement'.116 Most RACFs have a restraint policy which complies with The Aged Care Act 1997, as well as the requirements of the Aged Care Standards and Accreditation Agency, state and territory legislative processes, and professional and ethical requirements.

 

Medication management


Medication can enhance cognitive function and delay progression of dementia, treat depression, and improve behavioural and psychological symptoms.117 For any treatment, the impact on quality of life is a key consideration, including potential benefits and risks.

Acetylcholinesterase inhibitors can have a positive effect on cognitive impairment, apathy, psychotic symptoms and aggression.118 However, while these medications improve the quality of life of some people with mild to moderate Alzheimer disease, clinical trials have found that, on average, improvements are modest in cognitive function and delay of functional decline. Guidelines suggest that patients who do not stabilise or improve in the first 6 months of anticholinesterase therapy are unlikely to have any subsequent benefit. Therefore patients should be reviewed regularly to assess the value of ongoing treatment. A meta-analysis reported similar effect sizes for donepezil, rivastigmine and galantamine, however crossover studies suggest a trial of a second agent in nonresponders is reasonable. Adverse effects such as nausea, vomiting, diarrhoea and dizziness are dose related.119 See the Pharmaceutical Benefits Scheme Handbook for current prescribing guidelines for cholinestererase inhibitors.

Psychotropic medication may be effective for specific indications such as depression, anxiety, psychotic symptoms (hallucinations and delusions), motor activity and aggression. Starting doses should be low and increased slowly with careful monitoring for adverse effects, especially sedation, postural hypotension and parkinsonism.120 Respiridone has been approved by the Pharmaceutical Benefits Scheme for management of BPSD.

Antidepressants are helpful in managing depressive symptoms and aggression in residents with dementia.121 Nontricyclic antidepressants may be indicated, depending on symptoms and their severity, including sleep disorder, anxiety, and obsessive-compulsive features.122 Tricyclic antidepressants with anticholinergic adverse effects have the potential to exaggerate cognitive impairment due to central acetylcholine deficiency in Alzheimer disease and should be avoided.123

Benzodiazepines may exacerbate cognitive impairment in dementia, and increase the risk of falls and associated injury. Oxazepine is recommended for severe anxiety, and agitation.124 Medication for the management of distressing BPSD may be considered in addition to nonmedication interventions. Psychotropic medication can be effective, particularly for behaviours and distress that have been precipitated by hallucinations and delusions.125 However, there is limited evidence of efficacy for medications for restraint and significant risk of adverse effects.126

Antipsychotic agents may be required to manage distressing psychotic symptoms, aggression and behavioural disturbance. Conventional antipsychotic agents such as haloperidol are not recommended due to lack of evidence of effectiveness, common extrapyramidal side effects, and sedative anticholinergic side effects.127 They should not be used in patients with suspected Lewy Body dementia or Parkinson disease.128 Respiridone, an atypical neuroleptic agent, is effective for reducing psychotic features and aggression. Although it has fewer serious adverse effects and is better tolerated than conventional antipsychotic medications, it may sometimes cause extrapyramidal side effects, drowsiness, hypotension, hyperglycaemia and increased risk of cerebrovascular accidents.129,130,131 Ask RACF staff to monitor and report signs of possible adverse effects such as abnormal movements of the face, trunk and limbs; dizziness or fainting on standing; sudden weakness or numbness in the face, arms or legs; speech or vision problems; or worsening diabetic control.132

Lewy Body dementia is a contraindication to the use of major tranquilliser-neuroleptic agents including the newer atypical antipsychotics.133

Anti-epileptic agents in low doses may be effective in reducing behaviours characterised by motor overactivity and aggression.134

Behavioural disturbances may be short term, therefore the need for medication should be reviewed within 6 months and the dose diminished and discontinued where possible.

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  230. Ibid.
  231. Reuban DB, Herr KA, Pacala JT, et al, op. cit.
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  234. Ibid.
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  240. Ibid.
  241. National Health and Medical Research Council, op. cit.
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  244. Australian Medicines Handbook, op. cit.
  245. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary Tract Infections, op. cit.
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  247. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
  248. Ibid.
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  250. Ruth D, Wong R, Haesler E. General practice in residential aged care: clinical information sheet: Urinary tract infections, op. cit.
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