Dementia Care: A Practical Manual

437 Pages·2008·1.471 MB·English

by  Jonathan Waite, Rowan Harwood, Ian Morton, David Connelly

OXFORD MEDICAL PUBLICATIONS
Dementia care
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Dementia care:
a practical
manual
Jonathan Waite
Consultant in the Psychiatry of Old Age,
Nottinghamshire Healthcare NHS Trust, UK
Rowan H. Harwood
Consultant Physician and Geriatrician,
Nottingham University Hospitals, UK
Ian R. Morton
Manager, Broxtowe Specialist Dementia Care Team,
Nottingham, UK
David J. Connelly
Consultant Clinical Psychologist,
Integrated Community Mental Health Team for Older People,
Bramwell Centre, Nottingham, UK
1
1
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v
Contents
Preface vii
Abbreviations ix
1 What is dementia? 1
2 Assessment 23
3 Delirium 49
4 Care 75
5 Dementia in the community 107
6 Treatment 137
7 Care homes for people with dementia 171
8 Dementia and delirium in hospitals 185
9 ‘Physical’ problems in dementia 217
10 Palliative care in dementia 263
11 Legal aspects of dementia care 283
12 Making decisions 303
13 Measurement and rating scales 315
14 Issues with particular groups of people 337
15 Rarer causes of dementia 351
16 Biological aspects of dementia 365
17 Prevention 377
18 Outcome in dementia 399
Index 409
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vii
Preface
Cognitive disorders are one of the great challenges of our age.
They are common. Each of us expecting to reach our 80th year has
a one in fi ve chance of becoming demented. Manifestations emerge from a
spectrum of normal variation in the population, from ability to remember,
to behaviour and personality traits. They raise diffi cult questions about
independence and autonomy, coping and caring. They run counter to the
expectations of our culture, for strength and wisdom amongst adults. This
leads to unfortunate references to ‘second childhood’ and a whole ‘malig-
nant social psychology’ of how we treat people with dementia, which
exacerbates the very problems that lead to the term being used in the
fi rst place. Families and health and social care organizations struggle to
cope with people who push at the boundaries of expectation and care
provision, leading to frustration, stress, and despair.
Many cognitive disorders are incurable, progressive, and disabling. There
is no denying that in some cases dementia can be a miserable condition.
But, as with many diffi cult problems, there is a good way and a bad way of
managing it. The good way spots reversible elements and treats them (and
in some cases provides an alternative, and sometimes curable, diagnosis).
The good way minimizes problems, maximizes function, increases choices,
gives information, and supports carers. The bad way leads to unnecessary
distress and disability, dissatisfi ed carers and professionals, excessive insti-
tutionalization, prolonged hospital stays, and cost.
These are problems that no adult health or social care professional can
avoid. They are everyone’s problem. The good news is that there is an
expertise that makes a difference.
Do not expect every piece of advice in this book to be backed up by
evidence from a randomized, controlled trial. Elderly people, psychiatric
disorders, and dementia and delirium have been particularly poorly served
by trials. Where there is evidence we need to be aware of it and take
account of it. A lot of what we say derives from the accumulated wisdom
of people who have refl ected intelligently on successful (and sometimes
unsuccessful) services. But we believe that what is in this book is worth
knowing. Above all it is intended as useful practical advice.
There is now great concern about the harm that sedative drugs can do
to people with dementia. Many people would like to see them banned
completely, but there is little in the way of effective alternatives in urgent
situations. We have tried to indicate how to avoid such crises arising and
how to deal with long-term problems, but we have also included guidance
on the safe and appropriate use of medication.
The wisdom is multidisciplinary. Whilst doctors have a particular role
in making diagnoses and conveying explanations to others, many valuable
strands of thought and experience come from nursing and psychology, as
well as many other disciplines. We thank Lyndsey Beck, Louise Bevan, Phil
Blatherwick, Hilary Cobb, Peter Connelly, Adam Gordon, Kate Gordon,
Dawn Newman, Stephanie Page, Mary Read, Lisa Stanton, Pat Sumner,
Mary Watson, and Lauren Wintrip, who have advised us on some of these,
viii PREFACE
but of course we take responsibility for the fi nal product and any errors
that remain. Special thanks are due to Dorothee Auer and Jim Lowe for
images of dementia.
You can read this book from cover to cover, but will probably fi nd it
more useful to use as a reference guide on specifi c issues and topics as
they arise.
ix
Abbreviations
6-CIT 6 item Cognitive Impairment Test
A&E Accident and Emergency
AB Amyloid beta protein
ABC Antecedents, Behaviours, Consequences
ACE Angiotensin converting enzyme
AChEI acetylcholinesterase inhibitor
AD Alzheimer’s disease
AF Atrial fi brillation
ADAS-Cog Cognitive subscale of the Alzheimer’ Disease Assessment
Schedule
ADH Anti-diuretic hormone
ADL Activities of daily living
AIDS Acquired immune defi ciency syndrome
AMHP Approved Mental Health Professional
AMT Abbreviated mental test
ANH Artifi cial nutrition and hydration
APP Amyloid precursor protein
AWI Adults with Incapacity (Scotland) Act
bd twice daily
BMA British Medical Association
BME Black and minority ethnic
BNF British National Formulary
BPSD Behavioural and psychological symptoms in dementia
BPVS British Picture Vocabulary Test
C Celsius
CBD Cortico-basal degeneration
CBT Cognitive behavioural therapy
CEA Carcino-embryonic antigen
CI Confi dence interval
CJD Creutzfeldt-Jakob disease
CK Creatine kinase
CMHT Community mental health team
COMT Catechol-o-methyl transferase
COPD Chronic obstructive pulmonary disease
CPN Community psychiatric nurse
CPR Cardio-pulmonary resuscitation
CRP C-reactive protein