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Dementia

The Importance of Early Diagnosis

The very earliest identification of cognitive impairment can lead to prevention of disability, writes Dr Colm Hackett.

Recent surveys estimate the prevalence of dementia as 5% of the elderly (>65). This implies that there are 38,000 people affected by dementing illnesses in the Republic of Ireland, 60% of them with Alzheimer's disease.

The number of elderly over the age of 75 is due to increase by 20% by the year 2006 which will add greatly to the burden of dementing illnesses. These illnesses exact a very heavy emotional, physical, and financial toll on the families and carers of sufferers. Furthermore there are those who suffer from mild cognitive impairment (MCI) who do not as yet meet criteria for a diagnosis of dementia.

The majority of the demented elderly live in the community. Diagnostic and follow-up medical care is on an ad-hoc basis and is patchy across the country. Many areas of the country do not have memory clinics, assessment and treatment centres, day-care facilities, respite, long-term care units, or access to mental health services.

We as GPs are well positioned to screen our patients for early signs and symptoms and to advocate for services for them and their families. With the arrival of new therapies and worthwhile legal provisions we are better armed to tackle the problem. We perhaps have on our lists roughly equal numbers for those affected by diabetes, severe CHD, and dementia/cognitive impairment. And, yet we have the development of protocols and guidelines for diabetes care and the development of the Heartwatch Programme but nothing for dementia care. The primary care setting is ideal for screening for patients with dementia and early cognitive impairment and perhaps a template such as the Heartwatch Programme could be adapted for such on-going care.

Mild cognitive impairment (MCI)

Cognitive impairment means difficulties with ability to utilise thought processes and intellect. Tests cover memory, perception, language, and reasoning. Persons with MCI have a memory impairment beyond what is expected for normal aging. It is worth remembering that the very earliest identification of cognitive impairment may lead to prevention of disability. Therefore we need to concentrate on the early signs. There is a likely continuum between normal and abnormal function in those determined to develop dementia, particularly Alzheimer's disease.

During the phase of MCI persons are experiencing subtle cognitive deficits with largely intact cognition and activities of daily living (ADLs), frequently the presentation here is with forgetfulness. This is thought to be a forerunner state for dementia that ultimately differentiates into a variety of clinical and pathological conditions.

The clinical criteria in MCI (see Table) are largely amnestic but other cognitive domains may be involved. The judgement of the doctor here is most important in that they are saying the patient is not demented. The memory changes need to be evaluated both subjectively and objectively and a good history taken from a spouse or other carer. Those who fulfil criteria for MCI are thought to progress to dementia or probable AD at a rate of about 12% per annum. It is likely that not all of those classified as having MCI will ultimately progress to dementia but the figure may be 80%-90%. The final 10% or so will probably include 'slow learners' and those who have suffered trauma or other processes.

Note: Insert Table 1 near here.

History

Here we need to concentrate on the recall of events that have occurred in recent days or weeks and not on remote memories. We are well positioned to know which of our patients are interested in sport for example and so we can pursue a line of questioning on recent team results or player's performances. If the patient is an avid daily newspaper reader or radio listener or TV watcher we can direct our questions accordingly. If the patient tends to be vague about details we can suspect a faulty memory.

We also need to be sure that the subject is not aphasic or inattentive because if that were so the deficit may be in another area of cognition. Another useful hint is to question the patient about details of how they got to the surgery. A family member or carer may need their interview to be held separately on how the patient's memory is currently functioning relative to the recent past. Particular features that may alert us to early impairment or indeed more advanced impairment are as follow:

  • Changes in personality may be subtle.
  • Disorientation may only be unmasked by a holiday overseas or a visit to a relative's home.
  • Antisocial behaviour may occur such as shoplifting or changes in sexual behaviour.
  • A reduction in interests may occur and adoption of very rigid stereotyped routines, and sudden emotional outbursts when the patient is taxed beyond their ability.
  • Amnesia is a universal early feature, except in Frontal Lobe Dementia, but the memory loss is for recent events and distant memory is often preserved. On more detailed questioning we may find that 'recent recall' has gone.
  • Hallucinations, parkinsonism, syncope, and falls may alert us to the possibility of Lewy Body Dementia.
  • Subjective complaints about feeling that "something is not right" in the head/brain.
  • Vague neurotic symptoms.

Physical Examination

Apart from a general physical examination care should be afforded to the cardio-respiratory systems and a full neurological examination should be undertaken. Features of rigidity, or postural imbalance, plus or minus tremor may suggest an extrapyramidal disorder such as Parkinson's disease or early Lewy Body disorder. Visual field defects or asymmetric reflexes may suggest a vascular or mass lesion. Features of a peripheral neuropathy may suggest toxic or metabolic causes.

Investigations

This can include the Clock Drawing Test and/or Mini Mental State Examination score - the latter can have scores of 25-28 for those with MCI. A depression screen here is very useful. Neuroimaging, while not always required may be advisable for those under 60 years of age or in cases of trauma, neurological symptoms, cancer or bleeding. CT scans may rule out structural lesions such as a subdural haematoma or tumour. MRI concentrating on volumetric imaging of the hippocampus can be particularly useful.

Drug Therapy

Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) are all indicated for the treatment of mild to moderately severe Alzheimer's disease and have been shown to be effective in vascular dementia. Advantages of donepezil are once daily dosage. For 40%-50% of patients improvements may occur in overall cognition, function, and behaviour. Side effects are predominantly transient and disturbances in gastro-intestinal function.

Legal Issues

It is at the stage of MCI and very early dementia that advice should be offered to patient/carer to seek legal help in creating an Enduring Power of Attorney (EPA). An EPA is a Power of Attorney executed by a person (the Donor) who is mentally capable and which is only intended to be brought into force if the Donor becomes or is becoming mentally incapable.

In this event the solicitor appointed by the Donor should apply for the registration of the EPA so that they may act on behalf of the Donor. The EPA does not come into force until it has been registered in the offices of the Wards of Court. The patient (Donor) in creating the EPA can specify to the solicitor what the latter may do on their behalf, e.g. making care decisions. Two people must be notified that the EPA is being created and if the patient is married the spouse must be one and if the patient has children or relatives then one of them must be notified.

As GPs we may therefore be involved at two stages both in the creation of the Enduring Power and later in the registration of same when the patient is no longer capable of managing their affairs. The patient's solicitor will request medical reports at both stages.

If the patient is no longer deemed capable and does not have the provision of an Enduring Power, the only alternative to access their assets or make decisions on their behalf is to have the patient made a Ward of Court. Here two doctors' opinions are sought. This latter is a costly and more lengthy procedure.

Medical Affidavits

Affidavits, to be sworn by medical practitioners for the purpose of providing evidence as to the mental capacity or incapacity of a respondent to wardship proceedings, should contain the following information:

  • The date on which and place at which the examination of the respondent took place.
  • A description of the response of the respondent to the examination, including, where relevant, references to symptoms, demeanour, answers to mental tests, etc.
  • A diagnosis of the respondent's mental condition, where applicable.
  • Any other observations relevant to the issue of the respondent's mental capacity or incapacity.
  • The opinion and specific statement of the medical practitioner as to whether or not the respondent is of unsound mind and incapable of managing their affairs.

Living Wills

When planning the admission of patients to nursing home care it is worth recording any "living will" or "advance directive". These should be legally binding but are not. The person who has drawn up such a will should have been competent to do so at the time. A "Pathway of Care" should also be established.

In screening for MCI and symptoms of dementia GPs can help to alleviate the burden of care for sufferers and their carers. The ICGP with the Alzheimer Society hopefully may in the future set up screening and guidelines to assist in this worthwhile cause.

Dr Colm Hackett is in general practice in Newmarket-on-Fergus, Co. Clare.