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.
Background: Comprehensive geriatric psychiatry liaison services are in early and evolving stages in Singapore. A description and evaluation of a geriatric psychiatry liaison programme in geriatric wards was undertaken describing programme activity and clinical outcomes in patients with neurocognitive disorders. Dementia training and staff upskilling are also discussed. Methods: This study included all referred patients by the geriatric team in Changi General Hospital over a one-year period from 15 June 2017 to 14 June 2018. As measures of good clinical practice, diagnosis of delirium and new diagnosis of dementia made during the inpatient admission following liaison consultation were included in the study. Patient-related outcomes that included length of stay (LOS), institutionalisation rates and in-hospital mortality were evaluated. Results: Dementia (53%), delirium (49%) and depression (28%) were the commonest diagnoses in this study. Dementia was newly diagnosed in 30% of cases. The median LOS in those with delirium was 19 days; 19% with a delirium diagnosis had new institutionalisation rates. In-hospital mortality in this study was 2%. Conclusions: The geriatric psychiatry liaison programme in geriatric wards in Changi General Hospital improved detection rates of delirium and new diagnoses of dementia. It also reports increased LOS and new institutionalisation rates in those with a diagnosis of delirium. Nursing staff education in neurocognitive disorders is enhanced. This article has outlined the importance of team-based care, joint specialist care and staff training in recognition of delirium and dementia in an acute hospital setting to improve outcomes for older patients.
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