Dementia

Dementia

Risk Factors

• Vascular risk factors (diabetes, hypertension, hypercholesterolaemia, smoking, previous stroke)

• Family history of dementia

• Depression

• Traumatic brain injury

• Excess alcohol

• Sedentary lifestyle

• Social isolation

• Hearing impairment (recently recognised as a modifiable risk factor)

Types (Most to Least Common)

Diagnosis

• Cognitive Testing: GPCOG, RUDAS

• Exclude Reversible Causes: Depression, psychotropic medications (e.g. TCAs, benzodiazepines, beta-blockers), metabolic or infectious causes

• Functional Assessment: Must show impact on daily life

• Avoid MMSE in Lewy Body Dementia/Parkinson’s disease (less reliable)

  MMSE Scoring (for broad reference):

  • 20–24 = Mild impairment

  • 13–20 = Moderate impairment

  • <12 = Severe impairment

Symptoms

• Impaired memory, concentration, perception, judgement, language

Differentials

• Dementia subtypes (Alzheimer’s, Lewy Body, Frontotemporal, Vascular)

• Delirium (acute onset)

• Depression or anxiety

• Elder abuse or neglect

• Hearing impairment

• Drug/alcohol misuse

• Intracranial causes: Tumour, chronic subdural haematoma, normal pressure hydrocephalus (NPH), stroke

• Metabolic: B12/folate/iron deficiency, hypercalcaemia, hyponatraemia, hypothyroidism

• Infections: HIV, syphilis

• Mild cognitive impairment (MCI)

History

• Differentiate dementia vs delirium vs depression

• Check onset (acute, fluctuating, or gradual)

• Ask about family history, hallucinations, personality/behaviour changes

• Look for fluctuating symptoms (e.g. sundowning in delirium/dementia)

• Sleep disturbances: Depression often worse in the morning, insomnia or early waking

• Review for reversible factors: Alcohol use, falls, headaches, diet, possible infection

Investigations

• Delirium Workup: FBC, UEC, LFTs, BGL, ECG (check for arrhythmias/contraindications to cholinesterase inhibitors), urine MCS. If indicated, CT brain, CXR, troponin, blood cultures.

• Dementia Reversible Causes: B12, folate, TFTs, CMP, iron studies, HIV/syphilis serology.

  Note:

  • Normal pressure hydrocephalus (NPH): “Wacky, wobbly, wet” (dementia, wide-based gait, urinary incontinence).

  • Chronic subdural haematoma: ~50% without clear trauma history, check anticoagulation status.

  • Advanced care planning (AHD) terminology: enduring power of attorney/guardian.

Management

• Non-Pharmacological

  • Home aged care assessment for support services

  • Advance care planning (AHD), will creation

  • Dementia Australia referral for patient/carer support

  • Assess driving safety (occupational therapist driver assessment if needed)

  • Carer support, encourage social engagement

  • Education on the progressive nature of dementia

  • Use blister packs/medication review to ensure adherence

  • Cognitive training (e.g. crosswords, though evidence is limited)

  • Regular aerobic exercise for general health (cognitive benefit uncertain)

  • If delirium risk or MCI, follow up closely to monitor cognitive changes

  • Hearing assessment and aids if indicated

Notes

• Delirium superimposed on dementia can worsen outcomes; early identification is crucial.

• If suspected post-stroke or vascular dementia, optimise vascular risk factor management (BP, lipids, glucose).

• Anticholinergics and sedatives can exacerbate confusion; review medications carefully.

• Hearing impairment can significantly impact cognitive function; correct if possible.