Clinical Focus dementia

Assessing the signs

of dementia
Ian Weatherhead
and Carol Courtney
discuss the
assessment of signs
of disordered
cognition, memory
and mood, which
may indicate
dementia

ementia is an umbrella term which

is used to describe organic brain
diseases characterized by problems
with thinking and memory (cognition).
It is estimated that 1 in 3 people will die
with a form of dementia, and direct costs of
dementia to the NHS and Soial Care are in
the region of 8.2 billion annually
(Department of Health (DH), 2010).

Defining dementia
The most typical symptoms of dementia
include (Alzheimers Society, 2007):

Loss of memory, e.g. forgetting the way

home from the shops, or being unable to
remember names and places
Mood changes, particularly when the
parts of the brain which control emotion
are affected by disease. People with
dementia may feel sad, angry or frightened as a result
Communication problems, e.g. a decline
in the ability to talk, read and write.
It has been estimated that there may be as
many as 200 different types of dementia. The
most common forms of dementia are:

Alzheimers disease
Vascular dementia
Mixed dementia, which has characteristics of both vascular and Alzheimers
Dementia with Lewy bodies
Fronto-temporal dementia (Picks disease).

Ian Weatherhead is lead nurse,

Admiral Nursing Direct, Dementia UK;
Carol Courtney is admiral nurse
clinical lead, North East Lincolnshire
Admiral Nursing Service, The Willows,
Barmouth Drive, Grimsby NE Lincs DN37 9EJ
Submitted for 27 May 2011; accepted for
publication following peer review 9 June 2011
Key words: Dementia, Alzheimers
disease, recognition, diagnosis,
acetylcholinesterase inhibitors
114

Dementia is not a normal part of the ageing

process, but almost all types of dementia are
progressive and incurable. With good multidisciplinary and interagency teamwork, the
symptoms can be managed and the person
with dementia and his/her carer can be helped
to maintain independence and quality of life.
Living Well with Dementia: A National
Dementia Strategy (DH, 2009) found that
greater awareness, earlier diagnosis and bettter access to treatment are required if the UK
is to effectively manage the increasing number
of people expected to be diagnosed with
dementia over the next 2030 years.

Epidemiology
There are about 750000 people diagnosed
with dementia in the UK (DH, 2010). This is
expected to double by 2050, including 11000
people from black and ethnic minority groups
(Alzheimers Society, 2007), and 16000 people with an age of onset under 65 years
(Alzheimers Society, 2011).
The incidence of dementia is similar in men
and women (Alzheimers Society, 2011).
However, more women have dementia
because their life expectancy is greater and
age is a risk factor of dementia.
In patients with dementia, comorbidity
with another illness is common, for example,
Parkinsons disease. This can make an accurate diagnosis of dementia more difficult.
For the majority of dementias, the cause is
unknown. It is likely to be multifactorial with
age, genetic susceptibility, environmental
factors, diet, and general health being
implicated.
Accurate diagnosis is important to identify
the cause of the symptoms and to exclude
depression or treatable causes of cognitive or
memory problems. A diagnosis is also
requried to enable access to a trial of
treatment with acetylcholinesterase inhibitors
where appropriate for those with Alzheimers
disease (Judd et al, 2011).
In vascular dementia it may be possible to
slow disease progression by controlling
vascular risk factors. For example, the patient
may consider stopping smoking, and treating
high blood pressure or raised cholesterol.

History-taking
The process of diagnosing dementia can be
complex. It often involves eliminating other
possible causes for cognitive changes in the
person, for example, head injury, acute infection or tumour.
For practice nurses, a key aspect in facilitating the assessment and diagnostic process is
by gaining as much history and information
about the problem, both from the patient, and
when possible from other sources, i.e. a close
relative or friend to help corroborate patient
reporting. The nature of dementia means that
patient self-reports may be inaccurate as
Practice Nursing 2012, Vol 23, No 3

Clinical Focus dementia

Table 1. Differentiating delirium from dementia

Feature

Delirium

Dementia

Acute or sub acute (days or hours)

Frequent and rapid (in hours)

Chronic (usually several years)

Slow changes (months)

Markedly reduced
Increased or decreased
Reduced in severer cases

Reduced in severe cases

Usually normal
Normal

Fleeting, poorly systematized

Common, usually visual
Usually impaired

If present, usually consistent

Infrequent, visual and verbal
Impaired in proportion to
severity

Tremor and myoclonus

Usually abnormal: increased or decreased
Usually present
Abnormalities usually present

Usually absent
Usually normal
Absent in mild cases
Normal, but postural
hypotension is common

Clinical course
Mode of onset
Fluctuations
Conscious level
Attention
Arousal
Alertness
Cognitive changes
Delusions
Hallucinations
Orientation
Motor features
Abnormal movements
Psychomotor activity
Dysgraphia
Autonomic features
From: Gelder et al, 2004.

Table 2. Possible
causes for changes
in behaviour
Confusion
Not understanding instructions
Poor communication
Environment
Receptive/expressive dysphasia
Depression
Physical changes e.g. pain,
infection, constipation
Illness progression

116

insight is frequently impaired, or denial is

used as a self-protective mechanism.
A detailed history of the presenting problem, onset, any changes in behaviour, general
concerns, and past medical and psychiatric
history all help to create a clearer picture.
This takes time, and is often a reason why
things can be overlooked initially. The
patients thinking may be slower and it may
be harder to find the words. Limited time to
see a practice nurse or GP may mean that an
opportunity to explore signs or questions in
depth is missed.
Many people are fearful that they may
have dementia. It is a sensitive topic requiring
careful and skilled discussion with the family.
Many people report being told during their
first contact with a nurse or GP that dementia
is a part of getting old and nothing can be
done. This is inaccurate and dismissive. This
view must be challenged and corrected, as
dementia is not a normal part of ageing, but
a serious, progressive brain disease requiring
increasing levels of support which will eventually remove the persons ability to live
independently.
However, it is also important to remain
optimistic and affirm that there may be other
reasons for cognitive and memory changes
which require full investigation, as not all
cognitive changes mean dementia.
A sound basic knowledge of what is and
what isnt dementia can be very helpful so
that a referral to a specialist team and services can be made.

Recognizing the signs of dementia

Often, dementia and delirium are confused
and misdiagnosed. It is important to consider
the principle differences between the two
conditions (Table 1).
Families and carers will often describe
behavioural changes, which can be difficult
for them to understand or manage. An awareness of potential reasons for these can be a
benefit to help the carer manage (Table 2).
If the onset is sudden, it is unlikely to be
dementia and physical screening should be
undertaken. Depression in the elderly can
mimic dementia in its effects on memory and
slowed thinking; this should also be considered.
Alzheimers disease usually has a gradual
onset, often over several years, with a steady
deterioration in functioning and abilities.
Vascular dementia often presents distinctively with a stepwise progression; as vascular accidents occur, there is a drop in abilities
before levelling out until another incident.
However, it is important to be aware that it
could be a first vascular accident that the
patient is presenting with; if so, it requires
immediate medical investigation.
Some of the early symptoms of possible
dementia commonly seen include word finding difficulty, forgetfulness, for example,
missing appointments, misplacing items, losing house or car keys. Agitation, anxiety and
fear may also be evident, understandably so,
as the person may retain enough insight to
notice things are not right, but not sufficiently to make sense of it. Forgetting names of
people, places, and getting lost in familiar
surroundings are among other common characteristics (Table3).
A clinical assessment of dementia includes
formal cognitive testing using a validated
instrument such as the Mini Mental State
Examination (MMSE) (Folstein et al, 1975),
the 6-item Cognitive Impairment Test (6-CIT)
(Brooke and Bullock, 1999), the General
Practitioner Assessment of Cognition
(GPCOG) (www.gpcog.com.au) or the
7-Minute Screen (Ijuin et al, 2008).
Full blood count, blood screening (especially sodium, calcium, and glucose concentrations), and liver, renal and thyroid function
tests are of value for the diagnosis of suspected disease. They are useful as routine tests
in evaluating patients for dementia. A careful
history and physical examination, accompanied by complete blood cell count, chemistry
battery, and a thyroid function test can be
effective in diagnosing treatable illnesses causPractice Nursing 2012, Vol 23, No 3

ing cognitive impairment (Larson et al, 1986).

This is also supported by the Quality and
Outcomes Framework (QOF) indicator for
dementia which was introduced in 2011/12
for general practices. Practice nurses should
familiarize themselves with the QOF when
developing a register of people with dementia
in their practice (National Institute for Health
and Clinical Excellence (NICE), 2011).

Importance of diagnosis
A diagnosis of dementia can be beneficial and
essential for a number of reasons. Diagnosis
can enable access to potential treatments, as
well as leading to other benefits, for example,
entitlement to certain financial benefits, attendance allowance, disability living allowance (if
under 65), and council tax reduction eligibility.
More importantly, it enables
the person with dementia and
his/her family access to specialist teams and support services.
These services can provide education, information and advice
about all aspects of dementia.
Referral to the older adults
mental health team, social services, and the local Admiral nurses (specialist mental health nurses) can all be valuable in engaging and supporting the family.
Carer burden, stress, grief
and depression when looking
after a loved one with dementia
are often overlooked. It is
important for the practice
nurse to see the whole family,
not just the person suspected of
having dementia.
Early on it can be helpful to
discuss the purpose of possible
diagnostic investigations, what
they entail and how results will
be given. This is usually by the
specialist older adults mental
health team or the neurologist.
These may include brain scans,
blood tests, or psychometric
testing.
Although it will usually be
the specialist team that requests
these tests, some preparation
work by the practice nurse can
allay many fears and anxieties.
This is an important time to
establish a relationship with
the patient and his/her carer,
Practice Nursing 2012, Vol 23, No 3

understanding the main problems from their

perspectives, and liaising with other health
and social care providers. Following diagnosis, it may be appropriate to follow up on the
consultants discussions on diagnosis and
prognosis to check understanding, give advice
on the next steps and continue liaison with
local services (Judd et al, 2011).
In many cases, the practice nurse or the
surgery may be the first point of call for
families with concerns.
Sharing information and confidentiality
can be difficult. An awareness of the following can help inform the practice nurse on
some legal aspects in dementia care:

Table 3. Areas of
cognition affected
by dementia
Memory
Thinking
Orientation
Comprehension
Calculation
Learning capability
Language
Judgment
Emotional control
Changes to social behaviour
Motivation

Data Protection Act 1998: Many carers

and relatives often complain at feeling

117

Clinical Focus dementia

Key Points
Assessment and diagnosis
of dementia is vital for
access to appropriate
services
Dementia is progressive
and irreversible
Acetylcholinesterase
inhibitors can help slow
the rate of progression
for some
Practice nurses can help
reduce risk factors with
effective health
monitoring and
management
Hypertension, raised
cholesterol, diabetes and
smoking all increase risk
of vascular dementia

Useful resources
Admiral Nurse DIRECT
0845 257 9406
www.dementiauk.org
direct@dementiauk.org
Alzheimers Society
0845 300 0336
www.alzheimers.org.uk
Carers UK
0808 808 7777
www.carersuk.org

excluded from a loved ones diagnosis,

with the Act often being quoted to protect the individual. However, it may be
argued that if the patient lacks insight or
awareness into his/her illness, it may be
in the patients best interests to have this
information shared with loved ones caring for him/her
Mental Capacity Act 2005: This Act enables and supports individuals to make
decisions for themselves where possible,
but also enables others to make decisions
for someone who lacks capacity to make
a specific decision, acting in his/her best
interests
Advance decisions: This allows a person
to state what forms of treatment he/she
would or would not like if he/she
becomes unable to decide in the future.
If this knowledge is discussed with the
patient and, where appropriate, close family
members, early in the process, it can help to
involve the entire family unit in future care,
considerations and communications.
Later in the illness, input will focus largely on
symptom management. Dementia may impair a
persons ability to take responsibility for actions
and affect judgment over time. The family will
require guidance on how to manage this.
A key focus for the practice nurse will be
to know what resources are available locally
so the family is aware of ongoing help. For
example, Admiral nurses, can provide indepth psychological interventions and support. Dementia advisers can help support the
family when engaging with other local specialist services in a clear pathway, and local
Alzheimers Society branches may provide
individual or group support and advice.

Risk factors for vascular dementia

The management of risk factors in vascular
dementia are within the remit of the practice
nurses. They can impact significantly on
minimizing risk and the potential prevention
of developing dementia. Effective management of cholesterol, blood pressure, diabetes,
and smoking cessation can all play a significant part in reducing risk and improving a
healthier lifestyle.

Conclusions
Providing good quality care to the
patient and his/her carer can be a challenge.
Early recognition and diagnosis is vital in
gaining access to care, potential treatments,
118

and specialist help.

Dignity and respect should be paramount
throughout. Practice nurses can provide
much help and support throughout the course
of dementia; from diagnosis, through to
bereavement and beyond. People with dementia and their carers deserve the highest standard of care and support, informed by technical expertise and delivered within a relationship and person-centred context. Practice
nurses must rise to the challenge of dementia
and develop the skills they have in order to
face the growing demand for care and treatment that lies ahead.
Conflict of interest: none

References

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