Understand the most common diagnostic modalities used for the evaluation of dementia
Explain how a well-coordinated, interprofessional team approach can improve outcomes for patients with dementia
The word dementia describes a group of symptoms associated with an overall decline in memory and other thinking skills severe enough to reduce a person's ability to perform everyday activities.
Several definitions for dementia exist, but a commonly used framework is the one provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM). According to the DSM-5, dementia is defined as significant acquired cognitive impairment in one or more cognitive domains (eg, learning and memory, language, executive function, complex attention, perceptual-motor function, social cognition) that represents a significant decline from the previous baseline and interferes with independence in daily activities. 
Dementia is a disorder that is characterized by cognitive decline involving memory and at least 1 of the other domains, including personality, praxis, abstract thinking, language, executive functioning, complex attention, social and visuospatial skills.  In addition to the noted decline, the severity must be significant enough to interfere with daily functionality. It is often a progressive disorder, and individuals often do not have insight into their deficits.
Currently, no cure exists for any of the causes of dementia. With the improving outcomes from diseases like cancer and elongating lifespan, the incidence, and prevalence of dementia are expected to continue to increase. Currently, 47 million people in the world have dementia, and the number is expected to triple by 2050. Alzheimer's disease is the 6th leading cause of death in the United States and the 5th leading cause in the world. Dementia is a significant public health burden and significantly increases costs of care, both to the individual and society. The individual lifetime cost to care for an individual with dementia was nearly $200,000 more than an individual without dementia. In 2010, the costs of treating dementia in the United States were projected to be about $200 billion. 
The most common nursing diagnoses for patients with dementia include:
Disturbed Thought Process
Impaired Verbal Communication
Self-Care Deficit: Bathing/Hygiene
Self-Care Deficit: Dressing and Grooming
Self-Care Deficit: Toileting
Impaired Physical Mobility
Disturbed Sleep Pattern
Disturbed Sensory Perception
Several conditions cause dementia. Alzheimer's dementia (AD) is the most common cause of dementia and accounts for about 70% of cases.  Other common causes dementia of include vascular dementia, dementia of Lewy bodies (DLB), frontotemporal dementia (FTD), and Parkinson's disease dementia (PDD). Other diseases account for fewer cases of dementia, and these include Huntington's disease (HD), cortical basal degeneration (CBD), progressive supranuclear palsy (PBP), multisystem atrophy (MSA), and Creutzfeldt-Jakob disease (CJD).
AD is caused by the deposition of neurofibrillary tangles and senile plaques in the brain.  Vascular dementia occurs due to ischemic injury to the brain. Frontotemporal dementia is a disorder that is caused by various mutations leading to the deposition of tau protein and other proteins in the grey and white matter of the brain.  Lewy body dementia is caused by abnormal aggregation of the synaptic proteins in the brain.
Although there are many causes of dementia, certain risk factors have been associated with dementia and cognitive decline. Evidence shows that the greatest risk factor for late-onset dementia is age, family history, and genetic susceptibility. However, some modifiable risk factors such as uncontrolled diabetes, mid-life obesity, hypertension, hyperlipidemia, smoking, and history of traumatic brain injury have been known to also be associated with the development of dementia. 
History must be obtained from the patient and their family members. Patients may present with symptoms of change in behavior, getting lost in familiar neighborhoods, memory loss, mood changes, aggression, social withdrawal, self-neglect, cognitive difficulty, personality changes, difficulty performing tasks, forgetfulness, difficulty in communication, vulnerability to infections, loss of independence, etc., A detailed history should include past medical, family, drug, and alcohol history.
In addition to symptoms of dementia, the following atypical symptoms may be seen in the following conditions:
In patients with LBD, symptoms of well-formed visual hallucinations, delusions, sleep disturbances, and trouble processing visual information can be seen.
In patients with CJD, symptoms of muscle stiffness, twitches, muscle jerks, visual hallucinations, and double vision may be seen.
In patients with Huntington's disease, symptoms of chorea, irritability, and obsessive-compulsive behavior may be seen.
In patients with vascular dementia, symptoms of imbalance, headache, sensorimotor deficits, and speech difficulties may be seen.
In patients with FTD, behavior changes, problems with spatial orientation, and speech difficulties may be seen.
In patients with PDD, symptoms of parkinsonism characterized by muffled speech, slow movement, tremors may be seen. In addition, visual hallucinations and delusions may also be seen, especially in the late stages.
Patients with MSA, PSP, and CBD have symptoms of parkinsonism. In addition, MSA has symptoms of autonomic failure, PSP has symptoms of blurry vision and difficulty controlling eye movement, CBD has progressive asymmetric muscle rigidity and myoclonus.
The two most important reversible conditions that need to be ruled out in patients with dementia are hypothyroidism as well as vitamin B12 deficiency. In addition to this, the routine workup for a patient with dementia also includes a CBC as well as a basic metabolic panel to rule out metabolic causes for cognitive impairment.  Additional testing for conditions such as syphilis, Lyme disease, and human immunodeficiency virus (HIV) should be performed only when clinical suspicion warrants.
In some cases, a lumbar puncture is needed for the evaluation of certain infectious causes.
FDA-approved medications to improve cognitive functions include cholinesterase inhibitors and memantine. Cholinesterase inhibitors are donepezil, galantamine, and rivastigmine. Cholinesterase inhibitors prevent the breakdown of acetylcholine and can slow or delay the worsening of symptoms. Memantine is an NMDA agonist and decreases the activity of glutamine. Donepezil is approved for all stages of Alzheimer's disease, galantamine, and rivastigmine for mild to moderate stage and memantine for moderate to severe stage.
Behavior symptoms include irritability, anxiety, and depression. Antidepressants like SSRI, antipsychotics, and anxiolytics can help with these symptoms. In addition, non-drug approaches like supportive care, memory training, physical exercise programs, mental and social stimulation must be employed in symptom control.
Treatment of sleep symptoms must be an important consideration in patients with dementia. Medication options include amitriptyline, lorazepam, zolpidem, temazepam, quetiapine, etc., Non-drug approaches include daily exercise, light therapy, sleep routine, avoiding caffeine and alcohol, pain control, biofeedback, and multicomponent cognitive-behavioral therapy. 
Nursing management of patients with dementia should be focused on promoting safety and improving the quality of life for the patient. Nurses should evaluate all of their patients for early symptoms of dementia. They should perform a comprehensive assessment for identification and monitoring of cognitive decline on all patients with a diagnosis of dementia. They should evaluate and assess for pain and anxiety and report it as needed. Finally, they should partner with the patient's family to promote patient-centered care that encourages quality of life improvements. 
When To Seek Help
Dementia is one of the leading causes of death in the United States, however, it is underreported as a terminal condition. Nurses should seek help when a patient with dementia has dyspnea, uncontrolled agitation or pain, dysphagia, or develops a stage II or higher pressure ulcer. 
The mainstay of management of dementia is mainly symptomatic and the goals of treatment should be based on the treatment of behavioral disturbances, maintaining or enhancing quality of life, and maximizing function in activities of daily living.
Patients with dementia should undergo a careful mental status examination. There are many tools available for quantifying cognition in a patient with dementia. Tests such as the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCa) can be used to quantify a decrease in a patient's cognition and should be performed periodically by the nursing staff to assess the patient's orientation, registration, attention, recall, and language skills. These tests normally take less than 10 minutes to administer and should be used to establish a baseline and with any suspected cognitive decline.
Coordination of Care
"Dementia" is a general term that is used when a person has developed difficulties with reasoning, judgment, and memory. It may be caused by several diseases that affect the brain of which the most common cause is Alzheimer's disease. There are numerous published studies that show that interventions like care coordination as well as interprofessional communication reduce hospitalizations and decrease ED visits.
Health Teaching and Health Promotion
Being diagnosed with dementia can be stressful and overwhelming for the affected person as well as their loved ones.
It is important for people with early dementia to care for their health which means regular checkups, compliance with medicines if needed, taking a healthy diet, regularly exercising, getting good sleep, and avoiding activities that can be risky.
It is also helpful to talk to others through support groups or social workers to discuss any issues such as anxiety, frustration, anger, loneliness, or depression.
Planned or emergent hospitalizations can occur at any time during the care of a patient with dementia. Hospital visits are a source of anxiety for the patient and their family members. It is imperative for nurses to coordinate with physicians, social workers, and family members to plan ahead for discharge.
Prior to hospital discharge, the healthcare team should evaluate for long-term care needs. Recommendations should include referrals for in-home services, referrals to rehabilitation facilities, or outpatient services as warranted. The discharge plan should include a current list of all the medications that the patient is taking, a list of his allergies, copies of all legal papers to include: living will, advanced directives, power of attorney, or do not resuscitate orders, and a follow-up appointment after discharge with the patient's primary care provider. 
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Pain Assessment in Advanced Dementia (PAINAD) SCALE
Contributed by Daniel Schwerin, MD, FACEP, FAEMS, FAAEM
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