Community Care Resources - Dementia

Dementia is associated with a progressive decline in memory and other cognitive skills severe enough to reduce a person's ability to function in which reversible and remedial factors have been excluded.

Why is it important?

  • 14. 9 % of Canadians 65yr. and older have cognitive impairment including dementia. Numbers will probably double by 2031.(1)
  • Direct (medical) and indirect (lost earnings) costs amount to $33 billion annually. Estimated that those numbers will increase 9 fold by 2040 (1)
  • Poorer health outcomes and prognosis in the presence of dementia. Common contributor to extended LOS (length in stay)  in hospital and risk of ALC ( Alternate Level of Care) status
  • High caregiver burden: physical, emotional and psychological burden.(3) Up to 50% of caregivers of patients with dementia develop psychiatric symptoms while caregiving (2)
  • A quarter of all family caregivers are seniors themselves; a third of them (more than 200,000) are older than 75 (1)
  • Support for the family who provide at least 80% of the care is necessary to keep relatives out of institutions (2)
  • Family caregivers think doctors do not adequately control symptoms and manage medications for dementia patients or adequately provide emotional support and social services links for caregivers (2)
  • Providing strategies for responding to behavioural changes can help family members and caregivers proactively avoid crises associated with advancing disease (e.g., wandering), and delay a move to long-term care  up to 18 months (4)
  • Care may be challenging and time consuming for family & health care providers (4)

Common Causes

Alzheimer's disease accounts for about 60% of cases of dementia, almost half of whom have co-existing cerebrovascular disease (mixed dementia). Vascular dementia accounts for 10-20% of dementia. Less common but important causes to consider are Lewy Body Dementia, Normal Pressure Hydrocephalus, Frontotemporal Dementia, and dementia associated with extrapyramidal syndromes such as Parkinson’s Disease or Creutzfeldt-Jakob disease (CJD) (1)

Actual causes are unclear although risk factors include:

  • Family History:
    • 5-7% occur as a result of familial AD ( Alzheimer’s Disease):  a person with a direct relative (parent or sibling) with Alzheimer's disease has a 3 times greater chance of developing the disease
    • 15 % will get AD at age 65 or older when both parents have the disease (1)
  • All individuals with Downs syndrome over 40 or who develop plaques and tangles that characterize the disease (1)
  • ApoE4 is the associated genetic variant: 50% all people with two apoE4 genes will develop AD at age 65 or older (1)
  • Cognitive impairment;   up to 85% of people with mild cognitive impairment in their 40-50’s develop AD within 10 years (1)
  • Vascular risk factors; Type 2 diabetes is a known risk factor (1)
  • People who sustain repeated concussions can develop Alzheimer’s disease (1)

Key Considerations

  • Early diagnosis and interventions are important factors: Take a careful history and explore the changes in thinking, day-to-day function and behavior. Engage the family/caregiver. Confirm driving status
  • Consult appropriate referrals: Geriatric Psychiatry or Psychogeriatric Social Worker, Neurologists, Geriatricians
  • Ensure Power of Attorney for Finances and Personal Care are in place. Discuss Advance Health Directives early in care
  • Treatment with nonpharmacological management should always be considered before resorting to pharmacological strategies
  • Enhance skills and education of the dementia workforce and caregivers
  • Early referral to Alzheimer’s Society and to First Link program for provision of clear consistent information
  • Good evidence to indicate that individualized exercise programs have a positive effect on functional performance in individuals with mild to moderate dementia (4)

References

1.   Alzheimer Society of Canada.  (2011). About Dementia.  Retrieved Feb. 2014 from: 
      http://www.alzheimer.ca/en/About-dementia

2.  Barylak, L., Irzeck, P. & Yaffe, M.  (2008).  Family physicians’ perspectives on care of dementia patients and family
     caregivers
.  Canadian Family Physician (CFP) Vol.  54 no. 7, 1008-15, July 2008.  Retrieved Feb. 2014 from: 
     http://www.cfp.ca/content/54/7/1008.full.pdf

3.  Feldman, S., Frank, C., & Schulz, M. (2011) Resources for people with dementia: The Alzheimer Society and
     beyond
.  Canadian Family Physician (CFP), Vol. 57:  December 2011.  Retrieved Feb. 2014 from:  
     http://www.cfp.ca/content/57/12/1387.full

4.  RNAO. (2010).  Nursing Best Practice Guideline, Caregiving Strategies for Older Adults with Delirium, Dementia and
     Depression
.  Retrieved March 2014 from: 
     http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression

Recommended Readings / Guidelines

1.   American Academy of Neurology.  DETECTION, DIAGNOSIS AND MANAGEMENT OF DEMENTIA
      Retrieved March 2014 from:   
      http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf

2.   Chertkow, H., Gauthier, S., Gordon, M., Herrmann, N., Patterson, C., Rockwood, K., Rosa-Neto, P. &  
      Soucy, J.P. (2012)  Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and
      Treatment of Dementia
(CCCDTD4). Can Geriatr J. Dec 2012; 15(4): 120–126.  Retrieved March 2014 from:
      http://www.alzheimer.ca/~/media/Files/national/For-HCP/for_hcp_recos_CCCDTD4_en.ashx

3.   Galvin, J.E. & Sadowsky, C.H. (2012)  Practical guidelines for the recognition and diagnosis of dementia.;
      NINCDS-ADRDA.  J Am Board Fam. Med. 2012 May-Jun;25(3):367-82.  Retrieved March 2014 from: 
      http://www.ncbi.nlm.nih.gov/pubmed/22570400

4.   Government of British Columbia.  (2012)  Dementia Guidelines.  Retrieved March 2014 from: 
      http://www2.gov.bc.ca/gov/topic.page?id=DABFEA5A7EAA45D7A22B815D830EC194

5.   National Institute for Health and Clinical Excellence.  (2006) Dementia: Supporting people with dementia and
      their carers in health and social care
. Clinical Guideline CG42 NICE Nov 2006.  Retrieved March 2014 from:   
      http://www.nice.org.uk/CG42

6.   Registered Nurses’ Association of Ontario.  (2004). Caregiving Strategies for Older Adults with Delirium,
      Dementia and Depression
.  Retrieved March 2014 from: 
      http://rnao.ca/bpg/guidelines/caregiving-strategies-older-adults-delirium-dementia-and-depression

7.   Registered Nurses’ Association of Ontario.  (2003).  Screening for Delirium, Dementia and Depression in the
      Older Adult
.  Retrieved March 2014 from: 
      http://rnao.ca/bpg/guidelines/screening-delirium-dementia-and-depression-older-adult