Dementia - A Resource for Health
Professionals
Mental Health Program
Recognize Possible Dementia ..................... 2Diagnosis .................................................... 2
Rule out Delirium ............................................. 3History and Physical Examination .................... 3Office-Based Psychometric Tests ...................... 4Bloodwork ........................................................ 5When to Consider Cranial Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) .................................................. 5When it is Not Dementia................................... 6When it is Dementia – Determine the Most Likely Cause ..................... 7
Disclosing the Diagnosis to Patients ........... 9Direct Early to Community Supports ........... 9Management ............................................. 10
Management Mainstays ................................. 10Alter Progression of MCI/CIND or Dementia if Possible .................................. 10Maintain Function .......................................... 10Identify Problem Behaviours .......................... 11Treat Comorbidities and Complications .......... 11Medications ................................................... 12
Manage Social Issues ................................ 14Social Issues to be Considered ...................... 14Assess Capacity ............................................. 15Assess Capacity to Drive ................................ 15Caregivers ...................................................... 16
Manage Progression.................................. 16Dementia Requires a Team Approach ......................................... 17
Family Physicians and Veterans Affairs Canada ................................. 17
More Information ...................................... 18
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Recognize Possible Dementia• Patient,friendorrelativereportsaproblem,usuallymemory.• Physiciannoticessuspiciouschangesinaknownpatient.
Initial Stepsn Pertinenthistory,accompanyingpersonsandotherhealthcareproviders.n Collateralhistoryusuallyisimportant.n Anticipateseveralvisitsforhistoryandphysicalexamination,resultsreview,
diagnosis,disclosingthediagnosisandplanningmanagement.
DiagnosisDementiaisasyndromeofdiseaseswithglobalcognitivedeclineaffectingmemoryandatleastoneothercognitiveareawithsignificanteffectsondaytodayfunctioning.
Consider dementia when, for example:
Cognitive changes: Newforgetfulness,troubleunderstandingspokenandwrittencommunication,difficultyfindingwords.
Personality changes: Newinappropriatefriendliness,socialwithdrawal,bluntingordisinterest,easyfrustration,explosivetemper.
Problem behaviours: Wandering,agitation,noisiness,restlessness,upatnight.
Changes in day-to-day Newdifficultydriving,gettinglost,unabletomakefunctioning: basicrecipes,neglectingself-care,difficulty
handlingmoney,mistakesatwork,unabletocompleteshoppingtasks.
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Thediagnosisofdementiarequiresthatallfourcriteriaarepresent:1. Deficitinshort-ormedium-termmemory,and2. Deficitinatleastoneof: a. aphasia(understandingorfindingwords); b.apraxia(complexlearnedbehaviourslikedressing); c. agnosia(recognizingfacesorobjectsandknowingtheiruse);or d.executivefunctioning(problem-solving,sequencing,multi- tasking),and3. Deficitsaresevereenoughtointerferewithsocialoroccupational functioning,and4. Declinefrompreviouslyhigherleveloffunctioning.
Rule out DeliriumAnacutemedicaldisordercausingdeliriummayrequireurgentmanagement.Considerdrugs/medication,medicalillness,toxin,headtraumaoroverstimulation.
n Acuteonsetofalteredlevelofconsciousness.n Fluctuatingalteredlevelofconsciousness(clouding).n Strikinglyshortattentionspan.n Disorganizedthoughts.n Disturbedhour-to-hoursleepandearlydisorientation.n Mixedhypoactiveandhyperactivepsychomotorsigns.
History and Physical Examination n Obtain collateral history from family, friends and other health care
providers.n Gatherevidenceforrulingindementiaanditsunderlyingdisorder.n Exploremoodtoruleoutdepressionoranxiety,whichcanmimic,maskor co-existwithdementia.
Referral Cue: Urgentoremergencyacutecarereferralwhenacutedeliriumissuspected,appropriateinvestigationsarenotreadilyavailable,patientisnotstable,ortreatablecauseisnotimmediatelyapparent.
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n Checkonhearingandvision,historyofrecentfalls/headinjury,medications,activitiesofdailyliving.
n Pulseandbloodpressure,localizingneurologicalsigns(power,tone,reflexes,cerebellarsigns),gait,tremorormovementdisorders.
Office-Based Psychometric Tests n Briefscreeningtestshelpwithassessingcognitiveimpairment.n Familiarizewithtwo:oneformildimpairment(eg,MoCA,Montreal
CognitiveAssessment)andoneformoderatetosevere(eg,MMSE,FolsteinMiniMentalStatusExamination).
n Screeningtestsmaybefalselypositiveandnegative,andarenotdiagnostic for dementia,sointerpretscreeningtestresultsinthecontextofotherclinicalinformation,includingeducation,cultureandsensorydeficits.
n Patientsandfamiliesmaymisunderstandthenon-diagnostic“screening”roleofthesetestsandbecomeupsetiftheymisinterprettheresults.
n AdministerovertimeinpatientswithMCIorCINDbecausetheyareatriskofdevelopingdementia.
n Administerovertimetomonitorprogressionofdementia.
MMSE:MiniMentalStatusExamination.n Goodsensitivity,lowerspecificity.n Affectedbyageandeducation.n Testsmanyaspectsofcognitionbutnotexecutivefunctioning.n Doesnotassessfunctionalautonomy.n Ceilingeffect:Maynotdetectmild-moderatedementiainsomecases,and
doesnotdistinguishmilddementiafromMCI.n Flooreffect:Doesnotdistinguishmoderatefromseveredementia.n Canbeusedtofollowapatientovertime.
MoCA:MontrealCognitiveAssessment.n Alsodoesnottestexecutivefunctioning,buttestssomefrontallobe
functions.n UsewhenMMSEscoreisnormalbutcognitivedysfunctionissuspected.n BetterthanMMSEinmildandearlydementia.
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n IfMoCAscoreislowbutthereisnofunctionalimpairment:ConsiderMCI(MildCognitiveImpairment).Followthepatientforpossibleprogressiontodementia.
UseofMMSEandMoCA:Memorycomplaintswithout functional problems: StartwithMoCA:
n If>26thenlikelynormal.n If20-25thenMCImorelikely.
Memorycomplaintswithfunctionalproblems:StartwithMMSE:n If<24thendementiamorelikely.n If>24thenuseMoCA;IfMoCA<26thendementiamorelikely.n Considerconfoundingeffectsofageandeducation.
Bloodwork Completebloodcount,thyroidstimulatinghormone,serumelectrolytes,creatinine/BUN,serumB12(cobalamin),liverfunctiontests,calciumandfastingglucose.
When to Consider Cranial Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)n Age<60yrs.n Rapidunexplaineddeclineincognitionorfunction,overe.g.1–2months.n Dementiapresent<2yrs.n Recentsignificantheadtrauma.
Referral Cue:Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristforconsiderationofmoredetailedneuropsychologicalcognitivetestingwhenthediagnosisisunclear.
Referral Cue: Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristifitissuspectedthatmorespecificbiomarkersmaybehelpfultodiagnosethetypeofdementia.
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n Unexplainedneurologicalsymptoms(e.g.newheadache,seizure).n Cancerhistoryespeciallytypesthatmetastasizetothebrain.n Useofanticoagulantsorhistoryofbleedingdisorder.n Urinaryincontinenceorgaitdisorderearlyinthedementiacourse(e.g.
normal-pressurehydrocephalus).n Newlocalizingneurologicalsign.n Unusualcognitivesymptoms(e.g.progressiveaphasia).n Gaitdisturbance.n Todetectcerebrovasculardiseasethatmayaffectpatientmanagement.
When it is Not Dementian Delirium: Maybeamedicalemergency.Seeabove.n Normal aging:Mayresultinmilddecreaseincognitivefunction.Simple
stablememorylosswithoutimpairmentinothercognitivedomains.Thisisthemostcommondiagnosiswheneldersreportmemoryproblems.
n Mild Cognitive Impairment (MCI),orCognitive Impairment No Dementia (CIND):Memoryorcognitiveimpairmentwithoutchangeinfunctionalability,andnoothermedicalcauseforcondition.MCIorCINDprogresstodementiainanimportantproportionofcases.Monitorabouteverysixmonths.
n Psychiatric disorders:e.g.depression,anxiety,schizophrenia.Dementia-likesymptomsandsignsdonotpersistwhenthesedisordersaretreated.
n Focal syndromes of cognitive impairment:e.g.isolatedamnesia,aphasia,apraxiaandvisuospatialimpairments.
Referral Cue:Dementiaclinic,geriatrician,neurologist,internist,orgeriatricpsychiatristwhenoptimumapproachtoworkupisnotclear.
Referral Cue:Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristwhenthediagnosisisunclear.
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When it is Dementia – Determine the Most Likely CauseConsiderareversibleconditionbeforeoneofthechroniccausesofdementia.
Alzheimer’s Disease (AD)n Insidiousonset,gradualdeclinewithplateausover7–10yrs;withn Continuinggradualmemorydecline,particularlyshort-term;andatleastone
othercognitivedomainimpairmentnotexplainedbyotherdisorders.n Mostcommondementingprocess.n Manyaffectedbydepressionandweightloss.
MorelikelyAlzheimer’sn Alteredbehavioursn Familyhistory
LesslikelyAlzheimer’sn Earlygaitinvolvementn Focalneurologicaldeficitsn Suddenonset
Vascular Dementia (VaD)n Abruptonset.n Stepwiseorinsidiousdecline.n Associatedwithcerebrovasculardisease.n Impairedexecutivefunction.n Gaitdisorder.n Emotionallability.n Diagnosisrequiresintegratedclinicalandinvestigationapproach(history,
vascularriskfactors,physicalexam,clinicalcourse,neuroimaging,patternofcognitiveimpairment).
n Purevasculardementiaisuncommonandpossiblyrare.n Focalneurologicaldeficitsoccurearly,suchasmovementdisorderssimilarto
Parkinson’s.
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Dementia due to multiple etiologies n Alzheimer’sDiseaseandVascularDementiaoftenoccurtogether,more
commonlythanpurevasculardementia.n Otherdementiasmayoccurtogether.
Dementia with Lewy body-related neurodegeneration (DLB) n Progressive,markedlyfluctuatingcognitivedecline.n Hallucinations.n Parkinsonismmaybepresent,typicallygaitandbalanceproblemsand
repeatedfallsaremorecommonthantremor,andthedementiaoccursearlywiththeParkinsoniansigns.
n ParkinsonDiseaseDementiatendstooccurinsettingofwellestablishedParkinson’sDisease.
n Hypersensitivitytoneurolepticmedication.n Thirdmostcommon.n MayoccurwithAlzheimer’sDisease.
Frontotemporal Dementia (FTD)n Rarergroupofdementiasthanothertypes,includesPickComplexDisease.n Youngerage.n FeaturesvarywiththetypeofFTD.n Insidiousonsetandslowprogressionofearlybehaviouralchangessuchas:
lossofsocialawarenessanddisinhibition;emotionalblunting,mentalrigidity,distractibility,lossofinsight;declininghygiene.
n Prominentlanguagechangesincludinghyperoralityandperseverance.
Other causes of dementia:n Substanceabuse.n Normalpressurehydrocephalus:earlygaitapraxiaorurinaryincontinence.n Creutzfeld-JakobDisease:considerinrapidlyprogressivedementia.n Otherdisorders:traumaticbraininjury,endocrine,nutritional,infectious
(e.g.HIV,neurosyphilis,cryptococcosis),autoimmune,renalorhepaticdysfunction,metabolic,neurological(e.g.multiplesclerosis,Parkinson’s,Huntington’s),andotherstructuralbrainlesions.
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Disclosing the Diagnosis to Patientsn Ethicistsrecommendinformingpatientswithdementiaabouttheirdiagnosis.n Perhapsstartwith,“Whatdoyouthinkiscausingallthis?”n IfthediagnosisisMCI/CIND,differentiatefromdementiaforthepatientand
family,butexplainriskofprogression.n Useprogressivedisclosureastheclinicalpicturebecomesclearer.n Theremaybeover-ridingconsiderationsinsomecases,includingworsening
depression,suicideriskandanxietyoverdiagnosticuncertainty.n Disclosureallowspatientandfamilytoplanandconsiderappropriate
treatments.
Direct Early to Community Supports
Ifacurrentlistofcommunitysupportsisnotavailable,considerreferraltoanagencythathasone.
Referral Cue: Dementiaclinic,geriatrician,neurologist,internistorpsychiatristwhenthediagnosisofthedementingdisorderisnotclear,anunusualdementiaissuspected,orwhenthepatientorfamilyrequestsasecondopinion.Atypicalandnonspecificpresentationsofalldementingdisordersarenotuncommon.
Referral Cue: Mostpatientswithdementiawhoconsentshouldbedirectedearlytocommunitysupports:AlzheimerSociety,supportgroups,regionalsocialservices,communitysupportservices,credibleInternetinformationsourcesandcaregiversoftheirchoice.
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Management
Management Mainstaysn Teamapproachandsharedcasemanagementimportant.n Validate,educateandsupportpatientandcaregivers.n Treatmentmayimprovequalityoflife.n Promoteahealthylifestyle:diet,physicalactivity,cognitiveactivity,workor
hobbies,sociallife.n Identifyandtreatproblembehavioursandcomplications.n Anticipatedecline:Stagethepatient’sdementiatoidentifystage-related
interventions.
Alter Progression of MCI/CIND or Dementia if Possiblen Lowertheriskfactorsforvasculardisease,inparticularbloodpressure(treat
ifsystolicpressure>160mmHg,aimforsystolicpressure<140mm).n AvoidNSAID,estrogen,GinkgobilobaandVitaminEinMCI.n ThereisinsufficientevidencetorecommendcholinesteraseinhibitorsinMCI.
Maintain Functionn Arrangeanindividualizedexerciseprogramforpatientswithmildtomoderate
dementia.n Behaviourmodification.n Scheduledroutines,e.g.scheduledtoiletingandpromptedvoiding.n Gradedassistance,positivereinforcement.n Structuredenvironment.n Anticipateonsetofdeliriuminnewenvironments(travel,hospitalization).
Referral Cue:Considerearlythevaluetopatientandcaregiversofspecializednursing,occupationaltherapy,physicaltherapy,psychology,socialwork,dayprograms,respiteandsupportsfortheclient’suniqueculturalneeds.
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Identify Problem Behavioursn Withdrawal,apathy,negativism.n Physicalaggressiveness.n Verbalaggressiveness.n Suspiciousness.n Delusionsandhallucinations.n Wanderingwithagitation/aggression.n Sexuallyinappropriatebehaviourwithagitation/aggression.n Anxiousness,restlessness.n Sadness,crying,anorexia.n Benignaimlesswandering.n Inappropriateurination/defecation.n Inappropriatedressing/undressing.n Vocallyrepetitiousbehaviour.n Hidingandhoarding.n Eatinginedibleobjects.n Inappropriateisolation.n Pushingaroundwheelchairs.n Tuggingandremovingrestraints(avoidrestraints).
Treat Problem Behavioursn Manageoneproblematatime.n Ruleoutmedicationsideeffects,occultmedicaldisorder,environmental
triggers.n Findandcontrolpain.n Considerpsychiatricdiagnosis.n Reassessmedicationifsafetyofpatientorothersatrisk.n Minimizepolypharmacy.Ifmusttryamedication,startlow,titrategradually,
watchforsideeffects,andtaperoffafter3monthstoseeifremainsstable.n Registerina“safereturnprogram”ifriskofwandering.n Lookforunintentionalbehaviourrewardingthatcanbeeliminated.n Modifyenvironment(e.g.music,people,pets,wallcolour,activity).n Encouragewalkingandotherlightexercise.n Removeabilitytoengageinconflictanddangerousbehaviours.n Eliminateprovokingfactors(e.g.,urinarytractinfection,certainstaff
interactions,unwantedroutineevents).
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Treat Comorbidities and Complicationsn Considerconditionsthatmayworsendementia,particularlyhypertension,
diabetes,depression.n Whenpatientswithdementiaexperiencesymptomsfromcomorbidconditions,
changesinbehaviourmaybetheonlysignaltheycanprovide.n Screenfortheseoftentreatableconditions:
• Moodproblems,particularlydepressionandanxiety.• Medicationeffects.• Relationshipproblems.• Nutritionaldeficiencies.• Medicationsideeffects.• Neurologicaldeficits(motor,sensory).• Physicalconditionsthatmaybemaskedbytheperson’sdementia,eg
urinarytractinfections,constipation,skinlesions,painfulmusculoskeletaldisorders,heartdisease,andmanymore.
n Caregiverswillneedtosupervisemanagementofchronicconditions.
MedicationsPrinciplesn Prescribeaftertryingnon-pharmacologicinterventions.n Ensurepatient’sprescriptionfundingagencysupportsprescribedmedication.n Verifymedicationsbeingconsumedandidentifycomplianceissues.n Startmedicationsinlowdoses,increasedosesslowlyandallowseveralweeks
beforedecidingwhetherthereisaneffectatagivendose.
Referral Cue:Dementiaclinic,geriatrician,psychiatrist,orhomecarenursingwhenbehaviouralproblemsarepresentandnotreadilymanaged.
Referral Cue:Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristwhencomorbiditiesaredifficulttodistinguishortreat.Refertomentalhealthservicesforassistancewithpsychiatriccomorbidities.
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n Considercontraindicationsandmonitorforsideeffects.n Documentresponsetomedicationtrials.
Treatmentn ReviewHoganetal.Diagnosis and treatment of dementia: 5.
Nonpharmacologic and pharmacologic therapy for mild to moderate dementia.CMAJ.2008b;179(10):1019-26,availableinfulltextatwww.cmaj.ca.
n TreatdocumentedVitaminB12(cobalamin)andfolatedeficiencies.n Depression:
• Treatdepressionbeforestartingamemory/cognitiveenhancer.• Considerantidepressantifdepressionsymptomsarepresent,non-
pharmacologicmeasuresareineffective,anddepressionissignificant.• Startwithaselectiveserotoninreuptakeinhibitortominimize
anticholinergicsideeffects,whichmayworsencognitivedeficits.• Continuetrialfor2–3months.
n Memoryandcognitiveimpairmentindementia:• Cholinesteraseinhibitorsaremodestlyeffectiveformildtomoderate
Alzheimer’sDisease;considercontraindicationsandprecautions.• Recallstartingdoses,titrationregimens,contraindications,precautions
andadverseeffectsofmedications.• Trial3-6monthsandfollowforeffectsoncognitionandfunctionusing
briefassessmenttoolsandindividualizedproblemtargets,andforsideeffects.
n Aggression,agitation,psychosisorvisualhallucinationsindementia:Reviewguidelinesforlimiteduseoflowdoseantipsychoticsandalternatives.
n Insomnia:• Ruleoutcontributingfactors.• Usenon-pharmacologicapproachesfirst.• Ifrequired,considerlimitedshortcoursesandlowestdosesofshort—to
intermediate—actingbenzodiazepines.
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Avoid or Cautionn Considerpossibilitythatnewproblemsaremedicationsideeffects.n Avoidmedicationswithanticholinergiceffects.n Useantipsychoticmedicationwithcaution,balancingpotentialbenefitwith
risksofmortalityandcerebrovascularincidents.n AvoidneurolepticsinDementiawithLewyBodies(DLB):riskofworsening
andmortality.n Notrecommendedfordementia:highdosevitaminE(>400IU/day);vitamin
B1,B6,B12orfolicacidifnotdeficient;anti-inflammatoryfordementiasymptoms;HMG-CAreductaseenzymeinhibitor;hormonereplacementtherapyforcognitiveimpairment.
Manage Social Issues
Social Issues to be ConsideredFinancialmanagement: Assesscapacity(seebelow),provideassistanceand
prepareforpowerofattorney.Driving: Assesscapacity,monitorandprepareforlossofdriving.Homecare: Assessforneedforyardandhousemaintenance,
housekeepingandmealpreparation.Respite: Prepareforcaregiverrest.Placement: Prepareforlossofabilitytoliveindependently.Endoflifeissues: Willandresuscitationorders.
Referral Cue:Dementiaclinic,neurologist,geriatrician,orgeriatricpsychiatristtochoosemedicationsandassessresponsetomedicationwhenunclear.
Referral Cue: Placementagencytoplanforrespiteandlong-termadmission.
Referral Cue:Lawyertoassistwithpowerofattorney,willsandotherfuturelegalmatters.Legalissuesvarysignificantlybetweenprovinces.
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Assess Capacity Familyphysiciansmaybeexpectedtodeterminethecapacityofapersonwithdementiatomanagetheirfinances,driveacarorliveindependently.
Capacityistheabilityto…n understandinformationnecessaryforadecision.n understandrisksandbenefitsassociatedwithdecision.n useownvaluesystemtomakeappropriatedecision.
Assesscapacityto…1. consenttocare.2. managefinancesandawill.3. livealone:
• Abletounderstandtheyarebeingaskedtodescribewhattheyneedtoliveathomesafely.
• Abletounderstandtheriskandbenefitsofacceptingorrejectingrequiredassistance.
• Abletodecidehowtheywanttoliveandtheconsequencesoftheirdecisions.
Assess Capacity to Driven Askpatientandfamilyaboutdrivingcapabilityandhistoryofaccidentsand
near-misses.n Milddementia:Assessindividually.Warnthatlossofdrivingisinevitable.
Reassessatleastevery6–12months.n Drivingcontraindicatedifunabletoperformmultipleindependentactivities
ofdailyliving(e.g.medications,banking,shopping),oranybasicactivityofdailyliving(e.g.hygiene,dressing).
n Seethe“DrivingandDementiaToolkit”intheCanadianMedicalAssociation’sDeterminingMedicalFitnesstoOperateMotorVehicles.
Referral Cue: Dementiaclinic,geriatrician,neurologist,orgeriatricpsychiatristwhencapacitytolivealoneormanagefinancesisunclear.
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n Drivingcompetencymaybedifficulttodetermineinanofficesettingwhendementiaisnotsevere.
Caregiversn Caregiversareanessentialsourceofinformationforphysiciansandother
membersofthehealthcareteam.n Caregiversneedspecialattention:
• Provideopportunitiestoaskquestionsandexpressneeds.• Assessforstressandexhaustion.• Referforeducationandsupportasrequired.• Caregiversupportmaydelayinstitutionalization.
Manage Progressionn Anticipatetheprogressionthatcharacterizesdementia.n Followpatientregularly,establishscheduleofvisits.n RegularlydocumentprogressiveneedsusingtheFAST-ACTtoolorasimilar
measureoffunctionalstatus.n Obtaincollateralinformationfromfamilyandcaregivers.n Planaheadtothenextphaseofdisabilityandlossofindependence.n Preparefamily.
Referral Cue:Specializedhealthprofessional-baseddrivingassessmentwhencapacitytodriveisnotclear.
Referral Cue:Caregivers’ownphysicianormentalhealthreferralifhealthisaffected.
Referral Cue:Supportorganizationstoallowpatientsandcaregiverstofindsolutionstoproblems.Caregiverswillneedincreasingassistanceandtrainingasdementiaprogresses.
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n Preparemanagementoptions.n Inseveredementia(totaldependenceoncaregiver),reassessevery3months:
MMSE,medicalstatus,behaviours,nutrition,safetyandcaregiverhealth.
Dementia Requires a Team ApproachDementiaisachallengeforpatient,families,caregiversanddoctors.Donotgoitalone—bepartofateam.
Family Physicians and Veterans Affairs CanadaEligibleclientsofVeteransAffairsCanadamayincludestill-servingandformermembersoftheRegularandReserveCanadianForces,RoyalCanadianMountedPolice,certaincivilianswhoareentitledtobenefitsbecauseoftheirwartimeservice,andfamilymemberswhoaresurvivorsanddependentsofmilitaryandcivilianpersonnel.Clientsmayhaveaccesstocasemanagement,disabilitycompensationortreatmentbenefits,dependingontheireligibility.
VeteransAffairsCanadadistrictofficeinterdisciplinaryclientserviceteamswelcomefamilyphysicians’participationinclientservices.Dependingoneligibility,VeteransAffairsCanadaclientswithdementiamayhaveaccesstocasemanagementandvariousassessmentortreatmentservicesthatmayincludenursingandoccupationaltherapyassessments,medications,medicaldevices,homeadaptations,mobilityassistivedevices,homecareservicesandlong-termcareassistance.Treatmentbenefitsmaysupplementbutdonotreplacethoseprovidedbyprovincialagencies.
Referral Cue: Dementiaclinic,geriatrician,neurologist,orgeriatricpsychiatristwhenprogression,changeindiagnosisorresponsetotreatmentisunclear.
Referral Cue: Supportorganizationstoallowpatientsandcaregiverstoanticipatefutureproblemsandplanforsolutions.
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Communicating About Your Patient/Our ClientInorderforVeteransAffairsCanadatoconsideraclient’srequestforvariousservicesandbenefits,aclientmaybeaskedtosubmitaprovider’swrittenprescriptionorreport.PleasecompleteVeteransAffairsCanadaformscarefully,sincewrittenreportsareimportantwhenclientrequestsareassessed.Providersareencouragedtoincludeadditionalinformation,astheyseefit.ThereareseveralwaysahealthprofessionalmaycontactaVeteransAffairsCanadainterdisciplinaryclientservicesteamregardingapatientwhoisaVACclient:
n CalltheNationalContactCenterat1-866-522-2122(English)or1-866-522–2022(French).IfyourpatientorclientisaVeteransAffairsCanadaclient,ithelpstoprovidetheirVACClientNumber,carriedontheirVACclientcard.
n SendareferrallettertotheVeteransAffairsCanadaInterdisciplinaryClientServicesTeaminthelocalDistrictOffice.Thereferrallettershouldcontaintheseelements:• Reasonforthereferral,includingtypesofassessmentorservices.• IndicationthattheVeteranhasgivenconsentforthereferral.• Descriptionoftheproblem.• Pastmedicalhistoryandmedications.• Currenttreatmentplansandnamesofotherhealthcareproviders.
n ParticipateinVeteransAffairsCanadaDistrictOfficeInterdisciplinaryClientServicesTeamcasemanagement.
More InformationOffice screening tools:• MiniMentalStatusExamination(MMSE):www.parinc.comandsearchforMMSE.
• MontrealCognitiveAssessment(MoCA):www.mocatest.org• FAST-ACT:MacDonaldConnollyD,PedlarD,MacKnightC,LewisC,
Referral Cue: VeteransAffairsCanadawhenpatientswithmilitaryorRCMPserviceortheirfamiliesmaybeeligiblefortreatmentservices.
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FisherJ.GuidelinesforStage-BasedSupportsinAlzheimer’sCare:TheFAST-ACT.JGerontNurs2000;November:34–45.
Electronic copy of this Dementia Resource:• AnelectronicversionofthisVACDementiaResourceandapaperdescribinghowitwasdevelopedareavailableontheVACWebsiteat
www.vac-acc.gc.ca.
Detailed guidelines from the 3rd Canadian Consensus Conference on Diagnosis and Treatment of Dementia:
n Visitwww.cccdtd.caandclickon“FullRecommendations”foralistofall142recommendations,and“Articles”forthefulltextoftheOctober2007issueofAlzheimer’s & Dementia.
n Visitwww.cmaj.ca/andsearchon“dementia”tofindtheseriesofpapersthatbeganin2008.
Not a GuidelineThisDementiaResourceisofferedtofamilyphysiciansandotherhealthprofessionalswhowilldecideindividuallywhetheritisusefulincaringforpatientswithdementia,theirfamiliesandcaregivers.Thetoolisnotaclinicalpracticeguideline,doesnotdefinestandardofcare,doesnotreplaceclinicaljudgmentandisnottheonlywaytoapproachthediagnosisandmanagementofdementia.
© Her Majesty the Queen in Right of Canada, represented by the Minister of Veterans Affairs, 2009. Catalogue No.: V32-217/2009E ISBN: 978-1-100-13317-1 Printed in Canada
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