Diagnosis and Management of Dementia in Long-Term Care

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Author(s): 

Consuelo H. Wilkins, MD, CMD, Kyle C. Moylan, MD, and David B. Carr, MD, CMD

Author Affiliations: Dr. Wilkins is Assistant Professor of Medicine and Psychiatry and Dr. Carr is Associate Professor of Medicine and Neurology, Division of Geriatrics and Nutritional Science, Washington University School of Medicine, St. Louis, MO; and Dr. Moylan is Assistant Professor of Medicine, University of Missouri-Columbia.

Introduction

With as many as 12% of individuals over age 65 years and half of all individuals over age 85 years affected by dementia of the Alzheimer’s type,1 the economic and social impact of this disease is tremendous.2 Due to worsening cognitive function, concurrent physical declines, and changes in behavior, persons with Alzheimer’s disease (AD) and other dementias often require management in a long-term care (LTC) setting. It is estimated that 60-80% of elderly nursing home (NH) residents have dementia.3 Since increasing age is associated with both dementia and NH admissions, the number of persons with dementia residing in this setting is expected to increase.4 Additionally, the average length of stay for NH residents is increasing, with more than one-third residing there for three years or longer.4 Although many older adults are admitted to NHs after the diagnosis of AD, the longer duration of stay may result in more individuals developing and being diagnosed with dementia after their admission to a skilled nursing facility.

AD in the Nursing Home

The diagnostic criteria for AD require a history of a gradual onset and progressive decline in memory with at least one other cognitive domain affected.5 The cognitive impairment must also negatively impact the ability to perform activities at the previous level of function. Establishing a diagnosis of AD in persons recently admitted to a NH can be challenging, especially if the individual was not previously known by the clinician. An important component of the initial assessment is an interview, in person or by phone, with a family member or friend who can provide details of the cognitive and physical function of the individual prior to admission. A list of pertinent questions that will assist in the diagnosis of dementia is included in Table I.

Non-Alzheimer’s Causes of Cognitive Impairment

Admission to a NH is often prompted by an increased need for assistance with activities of daily living (ADLs) or by behavioral changes. Since dementia can be associated with both, it is important to consider AD and other causes of cognitive impairment in the differential diagnosis. Hallucinations and delusions may occur in moderate and severe AD; however, if persons with mild memory loss have hallucinations or delusions, dementia with Lewy bodies (DLB) must be considered. DLB is characterized by cognitive impairment, prominent hallucinations, parkinsonism, and fluctuations in attention and alertness. Unexplained falls, delusions, syncope, and sensitivity to neuroleptics can support the diagnosis of DLB. The latter issue is important when determining appropriate drug treatment for psychosis, and there are data to suggest that these persons may be more responsive to cholinesterase inhibitors. Frontotemporal dementia is less common, but should be considered if early loss of personal and social awareness, hyperorality, and pronounced language dysfunction are observed, especially in persons under 70 years of age.

Cerebrovascular disease may be the primary etiology of dementia or may coexist with other dementing illnesses. Vascular dementia due to cerebral infarcts is the most common clinical diagnosis and is characterized by an acute cognitive decline temporally related to an acute cerebrovascular event. The history of an acute-onset or stepwise decline in cognition, and evidence of cerebral infarct by neuroimaging, are generally sufficient for the diagnosis of vascular dementia.

References: 


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