Dementia in older people

Dementia is not one specific disease; it is an umbrella term to describe a set of symptoms caused by a number of neurological diseases that affect the brain and a person’s ability to think, remember, understand, make judgments, communicate, socially interact and perform everyday tasks.

The type of symptoms and how they develop vary depending on the form of dementia a person has and the areas of the brain that are damaged.

Dementia usually has a gradual onset and is progressive and irreversible.

Symptoms and signs

Most people are aware that dementia affects a person’s memory; in particular their short-term memory. It can also impact a person’s thinking, behaviour, movement and ability to do everyday tasks.

Symptoms and signs of dementia can include:

• loss of insight, difficulty learning and following instructions
• difficulty with language and comprehension
• problems with calculation, judgment and reasoning
• difficulty with decision making and concentration
• lack of motivation, including apathy and withdrawal
• change in their personality and social behaviour
• problems with orientation to time and place
• difficulty sequencing tasks, such as coordinating getting dressed
• poor hygiene and dental care.

Behavioural and psychological symptoms of dementia (BPSD)

Changes in behaviour, such as wandering, pacing, agitation, depression, aggression, social inappropriateness, repetitive behaviour, sleep disturbances and hallucinations, are common in people with dementia - affecting up to 90 per cent of people with dementia.

Severity

The severity of dementia is commonly referred to as mild, moderate or severe:

• Mild – at the early stage, deficits are noted in a number of areas but the person can function with minimal assistance.
• Moderate – deficits become more obvious and greater levels of assistance are needed to help the person function.
• Severe – the person is almost totally dependent on the care and supervision of others¹.

Types

There are many types of dementia. Alzheimer’s disease is the most common (50–70 per cent of all dementia cases worldwide); vascular dementia accounts for 20–30 per cent of cases, frontotemporal dementia accounts for 5–10 per cent of cases, and Dementia with Lewy bodies (DLB) accounts for 5 per cent of cases. Other types of dementia include younger onset dementia, alcohol-related dementia (Korsakoff’s Syndrome) and dementia in other diseases (such as Parkinson Disease, Huntington’s Disease, AIDS and Down syndrome). Mixed dementia may be more widespread with Alzheimer/vascular dementia accounting for 25 per cent of dementia cases and Alzheimer/DLB accounting for 15 per cent, particularly with increasing age.

Dementia and ageing

Older people with dementia are admitted to hospital each year at twice the rate of older people without dementia. They have longer lengths of stay, are at risk of falls, gait and balance impairments, inattention, hypotension, eating and hydration problems, sleep problems, pneumonia, untreated pain, delirium, urinary tract infections, sepsis, pressure injuries, fractures, functional decline and even death.^{2,3 4} The longer a person stays in hospital, the worse their outcomes.⁵

For people with dementia, the hospital environment, routines and interactions with multiple people can be overwhelming, and can increase their confusion and trigger changes in their behaviour and emotions. It is important that we address these behaviours and do not label patients with dementia as ‘difficult’.

Carers and family members often find hospital environments overwhelming. It is important to include them in your assessment and be alert for signs of for carer stress and carer fatigue. Involve carers and family members when developing a person-centred care plan. If the person does not have family or carers, seek information from other sources, such as their GP and service providers.

All people aged 65 and over should be screened for evidence of cognitive impairment on admission to hospital. Screening identifies the existence and extent of cognitive impairment and provides a baseline to help identify any decline or fluctuation in cognition that may be attributed to treatable causes, such as delirium or depression. This process is known as differential diagnosis.

Identifying dementia - screening and assessment

Use a validated screening tool

There is a range of validated tools suitable for screening older patients for dementia. These include tools designed for hospital settings, for people from culturally and linguistically diverse backgrounds, for Indigenous people and for family members and carers. For descriptions of tools, see Cognition screening tools.

Most people are aware that dementia will affect a person’s memory, in particular their short-term memory. It can also impact a person’s thinking, behaviour, movement and the ability to do everyday tasks. You may include the older patient is experiencing things including:

• difficulty following conversation and instructions and learning new tasks (such as post-surgery precautions)
• problems with orientation to time and place
• difficulty navigating an unfamiliar environment, such as filling in a menu, eating off a meal tray,
• unable to recall your previous conversation or whether they have eaten their meal and are drinking water regularly and taking medications
• difficulty sequencing tasks, such as coordinating getting dressed, getting our of a hospital bed
• problems managing hygiene and dental care.

Behavioural and psychological symptoms of dementia (BPSD)

Changes in behaviour, such as wandering, pacing, agitation, depression, aggression, social inappropriateness, repetitive behaviour, sleep disturbances and hallucinations, are common in people with dementia. These behavioural and psychological symptoms of dementia (BPSD) can be stressful to the individual, their family and carers, staff, other patients and visitors. BPSD affect up to 90 per cent of people with dementia.

Determining diagnosis

There is no definitive test for dementia; we use findings from a variety of sources and tests, often conducted over many months, to build a case for diagnosis.

Some investigations may commence during the patient’s hospital stay (to eliminate treatable causes), however, most generally occur post discharge. A referral for post discharge follow-up, either through a geriatrician or referral to a Cognitive, Dementia and Memory Service (CDAMS), is essential because there are benefits to early diagnosis of dementia.

When a patient is suspected of having dementia, we can undertake a range of medical investigations, such as^1,2:

• a medical history; including a review of all medications
• physical examinations and laboratory tests to rule out other conditions such as vitamin deficiency, infection, metabolic disorders and drug side effects. Pathology tests include full blood examination, urea and electrolytes, liver function tests, thyroid function tests, vitamin B12, folate, calcium and random glucose. Additional tests may be required depending on clinical indications
• cognitive testing, which may include referring to a neuropsychologist for further tests. Neurological tests examine different areas of function in greater detail, such as memory, language, reasoning, calculation and ability to concentrate. They help distinguish between different patterns of decline and help identify the individual’s particular type of dementia
• brain imaging: computerised tomography (CT) scans, magnetic resonance imaging (MRI) or positron emission tomography (PET)/single-photon emission computerised tomography (SPECT) help rule out other conditions, such as brain tumours, blood clots, or hydrocephalus, and detect patterns of brain tissue loss that help determine the form of dementia
• collateral information from those who know the older person, such as their family and carers, their GP and regular service providers.

Assessing behavioural and psychological symptoms in hospital

As clinicians, the primary goal of assessing BPSD is to understand how the person’s cognitive impairment impacts their day-to-day function and behaviour. We can then reduce the risk of adverse events in hospital and make suitable plans for discharge.

By closely observing a patient’s symptoms, we can determine which BPSD are present, identify triggers for the behaviour and implement a person-centred response to minimise the risk of functional decline during admission.

We should clearly and fully document the patient’s behaviour and the circumstances that lead to the behaviour.

A cycle of evaluation that includes acceptance, assessment, action and reassessment is recommended³. This involves:

• accepting the person and their history and the involvement and expertise of different health professionals and families and carers
• assessing the physical and psychosocial care needs of the patient
• developing and implementing an action care plan
• reassessing the person and outcomes and refining the care plan.

The ABC (Antecedent-Behaviour-Consequence) approach is another model of understanding and supporting patients and staff when behaviour change³ occurs.