Managing challenging behaviours in dementia.

Dementia is a condition marked by the progressive and irreversible clinical syndrome of cognitive decline that is eventually severe enough to interfere with daily living. Management of dementia is often complex and requires a multidisciplinary approach. This article discusses the behavioural and psychological symptoms of dementia (BPSD), such as agitation, insomnia, restlessness, hallucinations, anxiety and depressed mood, for which patients and their caregivers commonly seek medical advice from their primary care clinician. These symptoms can cause significant distress to patients, their families and caregivers, and may even lead to the patient being prematurely institutionalised. Management consists of assessment of BPSD and supporting the needs of the family, especially those of the caregiver, and can be both non-pharmacological and pharmacological.

Dementia management: a brief overview for primary care clinicians.

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.

Approach to the forgetful patient.

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.