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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

5.5 Dementia

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

With people aged >65 years, clinicians should be alert to the symptoms and signs of dementia. These may be detected opportunistically and assessed using questions addressed to the person and/or their carer (C). Depression and dementia may co-exist. When a person has dementia, adequate support is required for the person, carer and family. Counselling and education are important. Management priorities will vary from patient to patient, but there may be a need to consider medical management of dementia, behaviour and comorbidity, legal and financial planning, current work situation, driving, and advance care planning.59

Table 5.5.1. Dementia: Identifying risks
Who is at risk?What should be done?How often?
Average risk
  • Those without symptoms 60, 61
 No evidence of benefit from screening (II, C) N/A
Moderate risk62–64
  • Those with symptoms (refer to Table 5.5.2)
  • A family history of Alzheimer’s disease
  • People with history of repeated head trauma 65
  • People with Down syndrome
  • Those with elevated cardiovascular risk (eg heart disease, stroke, hypertension, obesity, diabetes, elevated homocysteine, elevated cholesterol, smoking, sedentary lifestyle)66–69
  • Those with depression or a history of depression
  • People with low levels of education
  • Aboriginal and Torres Strait Islander peoples 70–74 (Note that culturally safe practices should be adopted with this community)
 Case finding and early intervention (III, C) N/A
Table 5.5.2. Dementia: Preventive interventions
InterventionTechnique
Case finding and confirmation
  • Ask ‘How is your memory?’ and obtain information about dementia and other cognitive problems from others who know the person (eg repeating questions, forgetting conversations, double buying, unpaid bills, social withdrawal) 75–77
  • Other symptoms may include a decline in thinking, planning and organising, and reduced emotional control or change in social behaviour affecting daily activities. Not everyone with dementia has memory problems as an initial symptom (C). Other clues are missed appointments (receptionist often knows), change in compliance with medications, and observable deterioration in grooming or dressing. Falls may also be an indication of cognitive impairment
  • Over several consultations, obtain the history from the person and family/carer, and perform a comprehensive physical examination. Undertake cognitive assessment using: A suite of recommended rating tools is available here
  • Assess functional status.80,81 The Instrumental activities of daily living assessment tool may be used. All screening instruments used to assess dementia in general practice have high rates of overdiagnosis (false positives) and underdiagnosis (false negatives), so the full clinical presentation needs to be taken into account. Reassessment after 6–12 months may be helpful
Assessment should include relevant blood tests and imaging to a exclude space-occupying lesion or other brain disorder

Relevant tests are recommended in the Clinical practice guidelines for dementia in Australia.
Early intervention and prevention Evidence is growing that attention to cardiovascular disease (CVD) risk factors may improve cognitive function and/or reduce dementia risk. There is sufficient evidence now for clinicians to recommend the following strategies for early intervention and prevention of dementia:68, 69, 82–87, 88
  • increased physical activity (eg 150 minutes per week of moderate-intensity walking or equivalent)
  • social engagement (increased number of social activities per week)89, 90
  • cognitive training and rehabilitation 91, 92
  • diet – the Mediterranean and the Dietary Approaches to Stop Hypertension (DASH) diets have been shown to be protective against cognitive decline 67
  • smoking cessation 66, 68
  • management of vascular risk factors (refer to Chapter 8. Prevention of vascular and metabolic disease
  • use of the risk assessment tool developed by the Collaborative Research Centre, which is based on dementia prevention, and takes about 15 minutes to fill out and provides a good overview for all the possible risks for dementia, for discussion with the GP is available here
Refer to Chapter 7. Prevention of chronic disease, Chapter 8. Prevention of vascular and metabolic disease, and Chapter 10. Psychosocial
CVD, cardiovascular disease; DASH, Dietary Aproaches to Stop Hypertension; KICA, Kimberley Indigenous Cognitive Assessment; MMSE, Mini-Mental State Examination; SMMSE, Standardised Mini-Mental State Examination

References

  1. The Royal Australian College of General Practitioners, NSW Health. Care of patients with dementia in general practice: Guidelines. Sydney: Department of Health, 2003.
  2. Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: A summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2003;138(1):927–37.
  3. National Collaborating Centre for Mental Health. Dementia: A NICE-SCIE Guideline on supporting people with dementia and their carers in health and social care. London: National Institute for Health and Care Excellence, 2007.
  4. Gao S, Hendrie HC, Hall KS, Hui S. The relationship between age, sex and the incidence of dementia and Alzheimer disease: A metaanalysis. Arch Gen Psychiatry 1998;55(9):809–15.
  5. Lenoir H, Dufouil C, Auriacombe S, et al. Depression history, depressive symptoms, and incident dementia: The 3C Study. J Alzheimers Dis 2011;26(1):27–38.
  6. Fleminger S, Oliver DL, Lovestone S, Rabe-Hesketh S, Giora A. Head injury as a risk factor for Alzheimer’s disease: The evidence ten years on; a partial replication. J Neurol Neurosurg Psychiatry 2003;74(7):857–62.
  7. Anstey KJ, Eramudugolla R, Hosking DE, Lautenschlager NT, Dixon RA. Bridging the translation gap: From dementia risk assessment to advice on risk reduction. J Prev Alzheimers Dis 2015;2(3):189–98.
  8. Anstey KJ, von Sanden C, Salim A, O’Kearney R. Smoking as a risk factor for dementia and cognitive decline: A meta-analysis of prospective studies. Am J Epidemiol 2007;166(4):367–78.
  9. Alzheimer’s Disease International. World Alzheimer report 2014. Dementia and risk reduction. An analysis of protective and modifiable risk factors. London: Alzheimer’s Disease International, 2014.
  10. Beydoun MA, Beydoun HA, Gamaldo AA, Teel A, Zonderman AB, Wang Y. Epidemiologic studies of modifiable factors associated with cognition and dementia: Systematic review and meta-analysis. BMC Public Health 2014;14:643.
  11. Flicker L, Holdsworth K. Aboriginal and Torres Strait Islander people and dementia: A review of the research. A report for Alzheimer’s Australia. North Ryde, NSW: Alzheimer’s Australia, 2014.
  12. Smith K, Flicker L, Shadforth G, et al. ‘Gotta be sit down and worked out together’: Views of Aboriginal caregivers and service providers on ways to improve dementia care for Aboriginal Australians. Rural Remote Health. 2011;11:1650: Available at www.rrh.org.au/articles/subviewnew.asp?ArticleID=1650 [Accessed 26 January 2016].
  13. Brodaty H, Pond D, Kemp NM, Luscombe GS, Harding L. The GPCOG: A new screening test for dementia designed for general practice. J Am Geriatr Soc 2002;50(3):530–34.
  14. Dementia Collaborative Research Centre – Assessment and Better Care 2011. 14 Essentials for good dementia care in general practice. Sydney: University of New South Wales, 2011.
  15. Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care: Sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry 2001;16(10):935–40.
  16. Storey J, Rowland JTJ, Conforti DA, Dickson HG. The Rowland Universal Dementia Assessment Scale (RUDAS): A multicultural cognitive assessment scale. Int Psychogeriatr 2004;16(1):13–31.
  17. Laver K, Cumming RG, Dyer SM, et al. Clinical practice guidelines for dementia in Australia. Med J Aust 2016;204(5):191–93.
  18. Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Sydney: Guideline Adaptation Committee, 2016.
  19. Farooki A. Central obesity and increased risk of dementia more than three decades later. Neurology 2009;72(11):1030–31.
  20. White L, Launer L. Relevance of cardiovascular risk factors and schemic cerebrovascular disease to the pathogenesis of Alzheimer disease: A review of accrued findings from the Honolulu-Asia Aging Study. Alzheimer Dis Assoc Disord 2006;20(3 Suppl 2):S79–83.
  21. Mortimer JA, Ding D, Borenstein AR, et al. Changes in brain volume and cognition in a randomized trial of exercise and social interaction in a community-based sample of non-demented Chinese elders. J Alzheimers Dis 2012;30(4):757–66.
  22. Sitzer DI, Twamley EW, Jeste DV. Cognitive training in Alzheimer’s disease: A meta-analysis of the literature. Acta Psychiatr Scand 2006;114(2):75–90.
  23. Lampit A, Hallock H, Moss R, et al. Dose-response relationship between computerized cognitive training and global cognition in older adults. J Nutrit Health Aging 2013;17(9):803–04.
  24. Lourida I, Soni M, Thompson-Coon J, et al. Mediterranean diet, cognitive function, and dementia: A systematic review. Epidemiology 2013;24(4):479–89.
  25. Tangney CC, Li H, Wang Y, et al. Relation of DASH- and Mediterranean-like dietary patterns to cognitive decline in older persons. Neurology 2014;83(16):1410–6.
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