DEMENTIA CARE.

[gmohan]

Principles of care
Community-based care
Support people with dementia in the community as far as possible. If considering psychiatric inpatient admission seek guidance from local institution.

Diversity and equality
Always treat people with dementia and their carers with respect.
Ensure people with dementia are not excluded from services because of their diagnosis, age (whether regarded as too old or too young), or any learning disability.:

Ensure that people suspected of having dementia because of cognitive and functional deterioration, but who do not have sufficient memory impairment for diagnosis, are not denied access to support services.

Needs and preferences of people with dementia
Identify specific needs, including those arising from:
diversity (such as sex, ethnicity, age, religion and personal care)
ill health, physical and learning disabilities, sensory impairment, communication difficulties, problems with nutrition and poor oral health.
Identify and wherever possible accommodate preferences (such as diet, sexuality and religion), particularly in residential care.
Record and address needs and preferences in the care plan.

Younger people with dementia
Specialist multidisciplinary services, allied to existing dementia services, should be developed for the assessment, diagnosis and care of younger people with dementia.

People with learning disabilities
Health and social care staff working with people with learning disabilities and other younger people at risk of dementia should be trained in dementia awareness.
People with learning disabilities and those supporting them should have access to specialist advice and support for dementia.

Ethics and consent
Always seek valid consent from people with dementia.
Explain options and check that the person understands, has not been coerced and continues to consent over time.
Use the Mental Capacity Act 2005 in UK, if the person lacks capacity..Seek relevant guidance locally.
Encourage the use of advocacy services and voluntary support. These services should be available to people with dementia and carers separately if required.

Allow people with dementia to convey information in confidence.
Discuss with the person any need to share information with colleagues or other agencies.
Only disclose confidential material without consent in exceptional circumstances.
As the dementia worsens, any decisions about sharing information should be made in the context of the Mental Capacity Act of the country.

Discuss with the person with dementia, while he or she still has capacity, and his or her carer the use of:
• advance statements (stating what is to be done if the person loses the capacity to communicate or make decisions)
• advance decisions to refuse treatment
• Lasting Power of Attorney
• a Preferred Place of Care Plan.

Other principles of care

Impact of dementia on relationships
Assess the impact of dementia on personal (including sexual) relationships at the time of diagnosis and when indicated subsequently. Provide information about local support services if required.
Because people with dementia are vulnerable to abuse and neglect, health and social care staff should have access to information and training about adult protection and abide by the local multi-agency policy.

DRUGS FOR DEMENTIA.
Drug treatment is only a part in the comprehensive management plan tailored to each individual and their specific circumstances.

Acetylcholinesterase inhibiting drugs are used in the treatment of Alzheimer's disease, specifically for mild to moderate disease.

Rivastigmine is also licensed for mild to moderate dementia associated with Parkinson's disease. The evidence to support the use of these drugs relates to their cognitive enhancement.

Treatment with drugs for dementia should be initiated and supervised only by a specialist experienced in the management of dementia.

Benefit is assessed by repeating the cognitive assessment at around 3 months. Such assessment cannot demonstrate how the disease may have progressed in the absence of treatment but it can give a good guide to response.

Up to half the patients given these drugs will show a slower rate of cognitive decline.
Drugs for dementia should be discontinued in those thought not to be responding.
Many specialists repeat the cognitive assessment 4 to 6 weeks after discontinuation to assess deterioration; if significant deterioration occurs during this short period, consideration should be given to restarting therapy.

Donepezil is a reversible inhibitor of acetylcholinesterase.
Galantamine is a reversible inhibitor of acetylcholinesterase and it also has nicotinic receptor agonist properties.
Rivastigmine is a reversible non-competitive inhibitor of acetylcholinesterases; it is also licensed for treating mild to moderate dementia in Parkinson's disease.

Acetylcholinesterase inhibitors can cause unwanted dose-related cholinergic effects and should be started at a low dose and the dose increased according to response and tolerability.

Memantine is a glutamate receptor antagonist; it is licensed for treating moderate to severe Alzheimer's disease.
Memantine can be used for moderate Alzheimer's disease in patients who are unable to take acetylcholinesterase inhibitors, and for patients with severe disease; combination treatment with memantine and an acetylcholinesterase inhibitor is not recommended. Treatment should only be prescribed under the following conditions:

Special Notes.

Alzheimer's disease must be diagnosed and treatment initiated by a specialist; treatment can be continued by general practitioners under a shared-care protocol;
the carers' views of the condition should be sought before and during treatment;
treatment should continue only if it is considered to have a worthwhile effect on cognitive, global, functional, or behavioural symptoms.
Healthcare professionals should not rely solely on assessment scales to determine the severity of Alzheimer's disease when the patient has learning or other disabilities, or other communication difficulties.

G Mohan.

Do request more info on any of the drugs mentioned .

[Badri]

Mohan,

Can you rewrite this article for patients and doctors living and practising in India. Many of these topics are being posted to guide and help the doctors in India. I have had many enquires from people in Madras where they are struggling to cope with patients with dementia.

Many thanks.