Medical Care for the Dementia Patient

Medical care for patients with dementia differs from the management of cognitively intact elders. Dementia patients cannot explain their symptoms, cannot remember instructions, often resist therapy, and these patients may have select physiological differences from non-brain damaged individuals. The type of physical problems and obstacles to medical care will depend on the type of dementia. When dementia is viewed as a progressive disease with terminal outcomes, it becomes clear that dementia patients need a broad range of healthcare interventions including basic medical care, health prevention, dental care, nutritional management and end-of-life management. This chapter discusses basic healthcare management issues for the dementia patient. These considerations apply to the four common conditions -Alzheimer’s disease, vascular dementia, diffuse Lewy body disease and alcoholic dementia. The average life expectancy of Alzheimer’s patients is approximately 8 years. Although the disease can be divided into multiple stages (e.g., 3 to 7), a simpler concept is early, middle and late. Patients with early phases of dementia have healthcare needs that reflect other elders who are cognitively intact. Patients in the middle stage have the additional complication of multiple ADL impairments, significant behavioral or psychiatric complications and caregiver fatigue. End-stage patients frequently reside in nursing homes where they require careful attention to end of life issues. The Folstein mini-mental status exam is a short, cost-effective cognitive screen that can estimate the severity of dementia. The mini-mental scores range from 0 to 30 with normal above 26. Alzheimer patients lose two points per year. Mild dementia patients score 20 to 26, moderate score 10 to 20, and severe score below 10. The mini-mental can help assess medical decision-making competency, as patients with scores below 15 are usually unable to give informed consent. The clinician must contend with both cognitive and psychiatric complications of dementia. Depression (25%) and psychosis (25%) are common in dementia. Medications to enhance cognition or lessen psychiatric morbidity have significant physical health side effects as well as mental health benefits. Studies show that primary care physicians find dementia patients difficult and unrewarding to manage. Management of dementia requires a biopsychosocial approach that includes both the patient and the caregiver. The clinician must tend to the neuropsychiatric morbidity from the dementia, the psychological complications and the social support needs of the patient. Caregivers have a higher rate of physical morbidity and psychotropic medication usage. This article outlines a practical approach to the management of medical problems of patients with dementia.