Call to create awareness of dementia

Rawalpindi

The Institute of Psychiatry and WHO Collaborating Centre for Mental Health Research and Training at Benazir Bhutto Hospital in collaboration with the Department of Neurology at Shifa International Hospital, Islamabad conducted a one-day workshop on assessment and management of Dementia titled ‘Forgetful Minds’ specifically with an aim to train participants on how to manage elderly psychiatric patients.

The activity was organised as a preconference workshop for the 3rd International Scientific Conference of Rawalpindi Medical College scheduled to be held on March 24 and 25.

The workshop was a collaborative initiative between Pakistan Society of Neurology and Pakistan Psychiatric Society.

The facilitators were Professor of Neurology at Shifa International Hospital and President Pakistan Society of Neurology Professor Arsalan Ahmed and Assistant Professor of Psychiatry at RMC and Secretary Federal Chapter of Pakistan Psychiatric Society Dr Asad Tamizuddin Nizami. The co-facilitators were Senior Registrar Dr Bushra Razzaque and Registrar Dr Hania Amin at the Institute of Psychiatry at BBH.

The objective of the workshop was to teach and train the participants on how to assess an elderly psychiatric patient, how to assess and manage dementia and the behavioural and psychological symptoms of dementia.

The workshop had a massive attendance and was attended by consultant psychiatrists, post graduate trainees, psychologists, house physicians and medical students. The workshop was kept extremely interactive with a number of group works and feedback sessions.

The workshop ensued with Dr Asad introducing the subject and displaying a video clip on dementia, highlighting the plight of a person suffering from dementia.

He began his talk by giving the audience a brief overview of the content of workshop and highlighted the importance of management of dementia in a low and middle income country like Pakistan.

Dr Bushra facilitated group work activities and guided the participants about missing points in the assessments in busy clinical work of doctors’ daily practice while seeing old age patients. She highlighted various important aspects in history taking from an elderly patient, followed by assessment of an elderly patient presenting with memory difficulties and various aspects of conducting a mental state examination. A portion was delegated to neurocognitive assessment of a patient presenting with memory problems.

She particularly talked about reviewing medical records, drugs and medical co-morbidity. History should include all details about memory lapses, problems in retaining new information, details on activity of living, doing staged sequential tasks and behaviour.

Professor Arsalan started his talk by referring to the National Dementia Guidelines for management of dementia, which were distributed among all group members and are also freely available online. He talked about the lack of awareness about dementia in both the general population as well as the physicians and the lack of focus on geriatric medical education in medical schools. He then explained the differences between normal aging and dementia which often becomes difficult for the non-discerning eye.

For assessments, he urged the participants to go for neuropsychiatric evaluation for detection of coexisting depression, psychosis, agitation and other complaints. He then elaborated the need to look for medical causes of cognitive impairment and investigating for serum electrolytes, calcium, magnesium, phosphate, glucose, liver and renal function tests, TSH, B12 and folate levels.

He explained that 50 per cent of dementia patients fall under category of Alzheimer followed by18-20 per cent for vascular and 12 per cent for Fronto-temporal dementias (FTD). He emphasized the need to rule out treatable causes of dementia.

Professor Arsalan again expressed the need of thorough cognitive evaluation in assessing an elderly patient with cognitive decline. He talked about pharmacological management which is currently all based on symptomatic improvement. To date, none of the available treatments slowed down or halted the process of dementia and further research is needed for bringing newer agents which can modify the disease process.

He said patient safety should be assessed and any gap should be addressed on follow up visits for all dementia patients.

When the diagnosis of dementia is made and disclosed to the patient and family it is also important to discuss issues of advance directives and the patient should update his or her will before the patient loses his capacity to disclose his or her wishes on these matters.

Dr Asad talked about Behavioural and Psychological Symptoms of Dementia (BPSD) which are defined as symptoms of disturbed perception, thought content, mood or behaviour that frequently occur in patients with dementia. Specific behavioural symptoms include apathy, agitation, aggression (verbal and physical) wandering, verbal vocalizations and dis-inhibition.

He emphasized that BPSD are very common, some studies in nursing homes and community find that they occur in up to 97 per cent of dementia patients.

His key points regarding pharmacological management included the principle of Primum non nocere (first do no harm) and addressing the treatable medical causes for BPSD. He expressed the need to opt for Non pharmacological/psychosocial interventions as first line and very cautious use of psychotropic drugs (preferably mono therapy) if required.