Dementia is a condition marked by the progressive and irreversible clinical syndrome of cognitive decline, which is eventually severe enough to interfere with daily living. Management of dementia is often complex and requires a multidisciplinary approach. This is the last article in our dementia series, after our previous two articles, 'Approach to the forgetful patient' (1) and 'Dementia management: a brief overview for primary care clinicians' (2) that discussed making the diagnosis and management of dementia. In this article, we discussed the behavioural and psychological symptoms of dementia (BPSD), such as agitation, insomnia, restlessness, hallucinations, anxiety and depressed mood. These can cause significant distress to families and caregivers, and may even lead to premature institutionalisation of the patient. Management consists of assessment of BPSD and supporting the needs of the family or caregiver.

With the increasing life expectancy and ageing population in Singapore, we are likely to see more patients with dementia seeking help from their primary care clinicians. Acetylcholinesterase inhibitors and N-Methyl-D-aspartate receptor antagonists for dementia management can be costly given their modest efficacy, and it is important to discuss the risks and benefits with patients before a shared decision is made. Non-pharmacological management such as regular structured routine, good sleep hygiene, reminiscence and other activities are also useful in improving the well-being of dementia patients. Caregivers and family members can be advised on what to watch out for to keep patients safe at home and outdoors, as dementia patients have poor safety awareness. The primary care clinician can manage depression, if present, and refer the patient to memory clinics or appropriate specialist clinics for further assessment when indicated.

Singapore has an ageing population with a projected 53,000 people aged ≥ 60 years living with dementia by 2020. Primary care doctors have the opportunity to initiate early work-up for reversible causes of cognitive dysfunction, allowing identification of comorbidities and discussion of medical therapy options. Early diagnosis confers the sick role on the patient, which allays frustration and explains events and behaviour that may have strained relationships with family and friends. The patient can be encouraged to plan for future health and personal care options with a Lasting Power of Attorney and/or Advance Care Planning. Objective cognitive tests (e.g. abbreviated mental test and Mini-Mental State Examination) and brain imaging are adjuncts that help in formulating the diagnosis. Referral to a hospital memory clinic activates a multidisciplinary team approach to dementia, including clinical consultation, dementia counselling, physiotherapy sessions on gait/fall prevention, occupational therapy sessions on cognitive stimulation and caregiver training.

Objective Anticholinergic burden refers to the cumulative effects of taking multiple medications with anticholinergic effects. This study was carried out in a public hospital in Singapore, aimed to improve and achieve a 100% comprehensive identification and review of measured, anticholinergic burden in a geriatric psychiatry liaison service to geriatric wards. We evaluated changes in pre-to post-assessment anticholinergic burden scores and trainee feedback. Method Plan Do Study Act methodology was employed, and Anticholinergic Effect on Cognition scale (AEC) was implemented as the study intervention. A survey instrument evaluated trainee feedback. Results There was no measured anticholinergic burden in a baseline of 170 assessments. 75 liaison psychiatry assessments were conducted between June and November 2021 in two cycles. 94.7% of pre-assessments (at the time of assessment) and 71.1% of post-assessments (following assessment) had a record of AEC scores in clinical documentation in cycle one, improving in the second cycle to 100%, 94.6%, respectively. A high post-assessment AEC score of 3 and over reduced from 15.8% in cycle one to 5.4% in cycle two. The trainee feedback suggested an enriching educational experience. Conclusions Using the AEC scale, the findings support the feasibility of comprehensive identification and review of measured anticholinergic burden in older people with neurocognitive disorders.