Dementia - A Resource for Health

Professionals

Mental Health Program

Recognize Possible Dementia ..................... 2Diagnosis .................................................... 2

Rule out Delirium ............................................. 3History and Physical Examination .................... 3Office-Based Psychometric Tests ...................... 4Bloodwork ........................................................ 5When to Consider Cranial Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) .................................................. 5When it is Not Dementia................................... 6When it is Dementia – Determine the Most Likely Cause ..................... 7

Disclosing the Diagnosis to Patients ........... 9Direct Early to Community Supports ........... 9Management ............................................. 10

Management Mainstays ................................. 10Alter Progression of MCI/CIND or Dementia if Possible .................................. 10Maintain Function .......................................... 10Identify Problem Behaviours .......................... 11Treat Comorbidities and Complications .......... 11Medications ................................................... 12

Manage Social Issues ................................ 14Social Issues to be Considered ...................... 14Assess Capacity ............................................. 15Assess Capacity to Drive ................................ 15Caregivers ...................................................... 16

Manage Progression.................................. 16Dementia Requires a Team Approach ......................................... 17

Family Physicians and Veterans Affairs Canada ................................. 17

More Information ...................................... 18

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Recognize Possible Dementia• Patient,friendorrelativereportsaproblem,usuallymemory.• Physiciannoticessuspiciouschangesinaknownpatient.

Initial Stepsn Pertinenthistory,accompanyingpersonsandotherhealthcareproviders.n Collateralhistoryusuallyisimportant.n Anticipateseveralvisitsforhistoryandphysicalexamination,resultsreview,

diagnosis,disclosingthediagnosisandplanningmanagement.

DiagnosisDementiaisasyndromeofdiseaseswithglobalcognitivedeclineaffectingmemoryandatleastoneothercognitiveareawithsignificanteffectsondaytodayfunctioning.

Consider dementia when, for example:

Cognitive changes: Newforgetfulness,troubleunderstandingspokenandwrittencommunication,difficultyfindingwords.

Personality changes: Newinappropriatefriendliness,socialwithdrawal,bluntingordisinterest,easyfrustration,explosivetemper.

Problem behaviours: Wandering,agitation,noisiness,restlessness,upatnight.

Changes in day-to-day Newdifficultydriving,gettinglost,unabletomakefunctioning: basicrecipes,neglectingself-care,difficulty

handlingmoney,mistakesatwork,unabletocompleteshoppingtasks.

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Thediagnosisofdementiarequiresthatallfourcriteriaarepresent:1. Deficitinshort-ormedium-termmemory,and2. Deficitinatleastoneof: a. aphasia(understandingorfindingwords); b.apraxia(complexlearnedbehaviourslikedressing); c. agnosia(recognizingfacesorobjectsandknowingtheiruse);or d.executivefunctioning(problem-solving,sequencing,multi- tasking),and3. Deficitsaresevereenoughtointerferewithsocialoroccupational functioning,and4. Declinefrompreviouslyhigherleveloffunctioning.

Rule out DeliriumAnacutemedicaldisordercausingdeliriummayrequireurgentmanagement.Considerdrugs/medication,medicalillness,toxin,headtraumaoroverstimulation.

n Acuteonsetofalteredlevelofconsciousness.n Fluctuatingalteredlevelofconsciousness(clouding).n Strikinglyshortattentionspan.n Disorganizedthoughts.n Disturbedhour-to-hoursleepandearlydisorientation.n Mixedhypoactiveandhyperactivepsychomotorsigns.

History and Physical Examination n Obtain collateral history from family, friends and other health care

providers.n Gatherevidenceforrulingindementiaanditsunderlyingdisorder.n Exploremoodtoruleoutdepressionoranxiety,whichcanmimic,maskor co-existwithdementia.

Referral Cue: Urgentoremergencyacutecarereferralwhenacutedeliriumissuspected,appropriateinvestigationsarenotreadilyavailable,patientisnotstable,ortreatablecauseisnotimmediatelyapparent.

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n Checkonhearingandvision,historyofrecentfalls/headinjury,medications,activitiesofdailyliving.

n Pulseandbloodpressure,localizingneurologicalsigns(power,tone,reflexes,cerebellarsigns),gait,tremorormovementdisorders.

Office-Based Psychometric Tests n Briefscreeningtestshelpwithassessingcognitiveimpairment.n Familiarizewithtwo:oneformildimpairment(eg,MoCA,Montreal

CognitiveAssessment)andoneformoderatetosevere(eg,MMSE,FolsteinMiniMentalStatusExamination).

n Screeningtestsmaybefalselypositiveandnegative,andarenotdiagnostic for dementia,sointerpretscreeningtestresultsinthecontextofotherclinicalinformation,includingeducation,cultureandsensorydeficits.

n Patientsandfamiliesmaymisunderstandthenon-diagnostic“screening”roleofthesetestsandbecomeupsetiftheymisinterprettheresults.

n AdministerovertimeinpatientswithMCIorCINDbecausetheyareatriskofdevelopingdementia.

n Administerovertimetomonitorprogressionofdementia.

MMSE:MiniMentalStatusExamination.n Goodsensitivity,lowerspecificity.n Affectedbyageandeducation.n Testsmanyaspectsofcognitionbutnotexecutivefunctioning.n Doesnotassessfunctionalautonomy.n Ceilingeffect:Maynotdetectmild-moderatedementiainsomecases,and

doesnotdistinguishmilddementiafromMCI.n Flooreffect:Doesnotdistinguishmoderatefromseveredementia.n Canbeusedtofollowapatientovertime.

MoCA:MontrealCognitiveAssessment.n Alsodoesnottestexecutivefunctioning,buttestssomefrontallobe

functions.n UsewhenMMSEscoreisnormalbutcognitivedysfunctionissuspected.n BetterthanMMSEinmildandearlydementia.

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n IfMoCAscoreislowbutthereisnofunctionalimpairment:ConsiderMCI(MildCognitiveImpairment).Followthepatientforpossibleprogressiontodementia.

UseofMMSEandMoCA:Memorycomplaintswithout functional problems: StartwithMoCA:

n If>26thenlikelynormal.n If20-25thenMCImorelikely.

Memorycomplaintswithfunctionalproblems:StartwithMMSE:n If<24thendementiamorelikely.n If>24thenuseMoCA;IfMoCA<26thendementiamorelikely.n Considerconfoundingeffectsofageandeducation.

Bloodwork Completebloodcount,thyroidstimulatinghormone,serumelectrolytes,creatinine/BUN,serumB12(cobalamin),liverfunctiontests,calciumandfastingglucose.

When to Consider Cranial Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)n Age<60yrs.n Rapidunexplaineddeclineincognitionorfunction,overe.g.1–2months.n Dementiapresent<2yrs.n Recentsignificantheadtrauma.

Referral Cue:Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristforconsiderationofmoredetailedneuropsychologicalcognitivetestingwhenthediagnosisisunclear.

Referral Cue: Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristifitissuspectedthatmorespecificbiomarkersmaybehelpfultodiagnosethetypeofdementia.

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n Unexplainedneurologicalsymptoms(e.g.newheadache,seizure).n Cancerhistoryespeciallytypesthatmetastasizetothebrain.n Useofanticoagulantsorhistoryofbleedingdisorder.n Urinaryincontinenceorgaitdisorderearlyinthedementiacourse(e.g.

normal-pressurehydrocephalus).n Newlocalizingneurologicalsign.n Unusualcognitivesymptoms(e.g.progressiveaphasia).n Gaitdisturbance.n Todetectcerebrovasculardiseasethatmayaffectpatientmanagement.

When it is Not Dementian Delirium: Maybeamedicalemergency.Seeabove.n Normal aging:Mayresultinmilddecreaseincognitivefunction.Simple

stablememorylosswithoutimpairmentinothercognitivedomains.Thisisthemostcommondiagnosiswheneldersreportmemoryproblems.

n Mild Cognitive Impairment (MCI),orCognitive Impairment No Dementia (CIND):Memoryorcognitiveimpairmentwithoutchangeinfunctionalability,andnoothermedicalcauseforcondition.MCIorCINDprogresstodementiainanimportantproportionofcases.Monitorabouteverysixmonths.

n Psychiatric disorders:e.g.depression,anxiety,schizophrenia.Dementia-likesymptomsandsignsdonotpersistwhenthesedisordersaretreated.

n Focal syndromes of cognitive impairment:e.g.isolatedamnesia,aphasia,apraxiaandvisuospatialimpairments.

Referral Cue:Dementiaclinic,geriatrician,neurologist,internist,orgeriatricpsychiatristwhenoptimumapproachtoworkupisnotclear.

Referral Cue:Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristwhenthediagnosisisunclear.

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When it is Dementia – Determine the Most Likely CauseConsiderareversibleconditionbeforeoneofthechroniccausesofdementia.

Alzheimer’s Disease (AD)n Insidiousonset,gradualdeclinewithplateausover7–10yrs;withn Continuinggradualmemorydecline,particularlyshort-term;andatleastone

othercognitivedomainimpairmentnotexplainedbyotherdisorders.n Mostcommondementingprocess.n Manyaffectedbydepressionandweightloss.

MorelikelyAlzheimer’sn Alteredbehavioursn Familyhistory

LesslikelyAlzheimer’sn Earlygaitinvolvementn Focalneurologicaldeficitsn Suddenonset

Vascular Dementia (VaD)n Abruptonset.n Stepwiseorinsidiousdecline.n Associatedwithcerebrovasculardisease.n Impairedexecutivefunction.n Gaitdisorder.n Emotionallability.n Diagnosisrequiresintegratedclinicalandinvestigationapproach(history,

vascularriskfactors,physicalexam,clinicalcourse,neuroimaging,patternofcognitiveimpairment).

n Purevasculardementiaisuncommonandpossiblyrare.n Focalneurologicaldeficitsoccurearly,suchasmovementdisorderssimilarto

Parkinson’s.

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Dementia due to multiple etiologies n Alzheimer’sDiseaseandVascularDementiaoftenoccurtogether,more

commonlythanpurevasculardementia.n Otherdementiasmayoccurtogether.

Dementia with Lewy body-related neurodegeneration (DLB) n Progressive,markedlyfluctuatingcognitivedecline.n Hallucinations.n Parkinsonismmaybepresent,typicallygaitandbalanceproblemsand

repeatedfallsaremorecommonthantremor,andthedementiaoccursearlywiththeParkinsoniansigns.

n ParkinsonDiseaseDementiatendstooccurinsettingofwellestablishedParkinson’sDisease.

n Hypersensitivitytoneurolepticmedication.n Thirdmostcommon.n MayoccurwithAlzheimer’sDisease.

Frontotemporal Dementia (FTD)n Rarergroupofdementiasthanothertypes,includesPickComplexDisease.n Youngerage.n FeaturesvarywiththetypeofFTD.n Insidiousonsetandslowprogressionofearlybehaviouralchangessuchas:

lossofsocialawarenessanddisinhibition;emotionalblunting,mentalrigidity,distractibility,lossofinsight;declininghygiene.

n Prominentlanguagechangesincludinghyperoralityandperseverance.

Other causes of dementia:n Substanceabuse.n Normalpressurehydrocephalus:earlygaitapraxiaorurinaryincontinence.n Creutzfeld-JakobDisease:considerinrapidlyprogressivedementia.n Otherdisorders:traumaticbraininjury,endocrine,nutritional,infectious

(e.g.HIV,neurosyphilis,cryptococcosis),autoimmune,renalorhepaticdysfunction,metabolic,neurological(e.g.multiplesclerosis,Parkinson’s,Huntington’s),andotherstructuralbrainlesions.

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Disclosing the Diagnosis to Patientsn Ethicistsrecommendinformingpatientswithdementiaabouttheirdiagnosis.n Perhapsstartwith,“Whatdoyouthinkiscausingallthis?”n IfthediagnosisisMCI/CIND,differentiatefromdementiaforthepatientand

family,butexplainriskofprogression.n Useprogressivedisclosureastheclinicalpicturebecomesclearer.n Theremaybeover-ridingconsiderationsinsomecases,includingworsening

depression,suicideriskandanxietyoverdiagnosticuncertainty.n Disclosureallowspatientandfamilytoplanandconsiderappropriate

treatments.

Direct Early to Community Supports

Ifacurrentlistofcommunitysupportsisnotavailable,considerreferraltoanagencythathasone.

Referral Cue: Dementiaclinic,geriatrician,neurologist,internistorpsychiatristwhenthediagnosisofthedementingdisorderisnotclear,anunusualdementiaissuspected,orwhenthepatientorfamilyrequestsasecondopinion.Atypicalandnonspecificpresentationsofalldementingdisordersarenotuncommon.

Referral Cue: Mostpatientswithdementiawhoconsentshouldbedirectedearlytocommunitysupports:AlzheimerSociety,supportgroups,regionalsocialservices,communitysupportservices,credibleInternetinformationsourcesandcaregiversoftheirchoice.

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Management

Management Mainstaysn Teamapproachandsharedcasemanagementimportant.n Validate,educateandsupportpatientandcaregivers.n Treatmentmayimprovequalityoflife.n Promoteahealthylifestyle:diet,physicalactivity,cognitiveactivity,workor

hobbies,sociallife.n Identifyandtreatproblembehavioursandcomplications.n Anticipatedecline:Stagethepatient’sdementiatoidentifystage-related

interventions.

Alter Progression of MCI/CIND or Dementia if Possiblen Lowertheriskfactorsforvasculardisease,inparticularbloodpressure(treat

ifsystolicpressure>160mmHg,aimforsystolicpressure<140mm).n AvoidNSAID,estrogen,GinkgobilobaandVitaminEinMCI.n ThereisinsufficientevidencetorecommendcholinesteraseinhibitorsinMCI.

Maintain Functionn Arrangeanindividualizedexerciseprogramforpatientswithmildtomoderate

dementia.n Behaviourmodification.n Scheduledroutines,e.g.scheduledtoiletingandpromptedvoiding.n Gradedassistance,positivereinforcement.n Structuredenvironment.n Anticipateonsetofdeliriuminnewenvironments(travel,hospitalization).

Referral Cue:Considerearlythevaluetopatientandcaregiversofspecializednursing,occupationaltherapy,physicaltherapy,psychology,socialwork,dayprograms,respiteandsupportsfortheclient’suniqueculturalneeds.

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Identify Problem Behavioursn Withdrawal,apathy,negativism.n Physicalaggressiveness.n Verbalaggressiveness.n Suspiciousness.n Delusionsandhallucinations.n Wanderingwithagitation/aggression.n Sexuallyinappropriatebehaviourwithagitation/aggression.n Anxiousness,restlessness.n Sadness,crying,anorexia.n Benignaimlesswandering.n Inappropriateurination/defecation.n Inappropriatedressing/undressing.n Vocallyrepetitiousbehaviour.n Hidingandhoarding.n Eatinginedibleobjects.n Inappropriateisolation.n Pushingaroundwheelchairs.n Tuggingandremovingrestraints(avoidrestraints).

Treat Problem Behavioursn Manageoneproblematatime.n Ruleoutmedicationsideeffects,occultmedicaldisorder,environmental

triggers.n Findandcontrolpain.n Considerpsychiatricdiagnosis.n Reassessmedicationifsafetyofpatientorothersatrisk.n Minimizepolypharmacy.Ifmusttryamedication,startlow,titrategradually,

watchforsideeffects,andtaperoffafter3monthstoseeifremainsstable.n Registerina“safereturnprogram”ifriskofwandering.n Lookforunintentionalbehaviourrewardingthatcanbeeliminated.n Modifyenvironment(e.g.music,people,pets,wallcolour,activity).n Encouragewalkingandotherlightexercise.n Removeabilitytoengageinconflictanddangerousbehaviours.n Eliminateprovokingfactors(e.g.,urinarytractinfection,certainstaff

interactions,unwantedroutineevents).

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Treat Comorbidities and Complicationsn Considerconditionsthatmayworsendementia,particularlyhypertension,

diabetes,depression.n Whenpatientswithdementiaexperiencesymptomsfromcomorbidconditions,

changesinbehaviourmaybetheonlysignaltheycanprovide.n Screenfortheseoftentreatableconditions:

• Moodproblems,particularlydepressionandanxiety.• Medicationeffects.• Relationshipproblems.• Nutritionaldeficiencies.• Medicationsideeffects.• Neurologicaldeficits(motor,sensory).• Physicalconditionsthatmaybemaskedbytheperson’sdementia,eg

urinarytractinfections,constipation,skinlesions,painfulmusculoskeletaldisorders,heartdisease,andmanymore.

n Caregiverswillneedtosupervisemanagementofchronicconditions.

MedicationsPrinciplesn Prescribeaftertryingnon-pharmacologicinterventions.n Ensurepatient’sprescriptionfundingagencysupportsprescribedmedication.n Verifymedicationsbeingconsumedandidentifycomplianceissues.n Startmedicationsinlowdoses,increasedosesslowlyandallowseveralweeks

beforedecidingwhetherthereisaneffectatagivendose.

Referral Cue:Dementiaclinic,geriatrician,psychiatrist,orhomecarenursingwhenbehaviouralproblemsarepresentandnotreadilymanaged.

Referral Cue:Dementiaclinic,geriatrician,neurologist,internistorgeriatricpsychiatristwhencomorbiditiesaredifficulttodistinguishortreat.Refertomentalhealthservicesforassistancewithpsychiatriccomorbidities.

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n Considercontraindicationsandmonitorforsideeffects.n Documentresponsetomedicationtrials.

Treatmentn ReviewHoganetal.Diagnosis and treatment of dementia: 5.

Nonpharmacologic and pharmacologic therapy for mild to moderate dementia.CMAJ.2008b;179(10):1019-26,availableinfulltextatwww.cmaj.ca.

n TreatdocumentedVitaminB12(cobalamin)andfolatedeficiencies.n Depression:

• Treatdepressionbeforestartingamemory/cognitiveenhancer.• Considerantidepressantifdepressionsymptomsarepresent,non-

pharmacologicmeasuresareineffective,anddepressionissignificant.• Startwithaselectiveserotoninreuptakeinhibitortominimize

anticholinergicsideeffects,whichmayworsencognitivedeficits.• Continuetrialfor2–3months.

n Memoryandcognitiveimpairmentindementia:• Cholinesteraseinhibitorsaremodestlyeffectiveformildtomoderate

Alzheimer’sDisease;considercontraindicationsandprecautions.• Recallstartingdoses,titrationregimens,contraindications,precautions

andadverseeffectsofmedications.• Trial3-6monthsandfollowforeffectsoncognitionandfunctionusing

briefassessmenttoolsandindividualizedproblemtargets,andforsideeffects.

n Aggression,agitation,psychosisorvisualhallucinationsindementia:Reviewguidelinesforlimiteduseoflowdoseantipsychoticsandalternatives.

n Insomnia:• Ruleoutcontributingfactors.• Usenon-pharmacologicapproachesfirst.• Ifrequired,considerlimitedshortcoursesandlowestdosesofshort—to

intermediate—actingbenzodiazepines.

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Avoid or Cautionn Considerpossibilitythatnewproblemsaremedicationsideeffects.n Avoidmedicationswithanticholinergiceffects.n Useantipsychoticmedicationwithcaution,balancingpotentialbenefitwith

risksofmortalityandcerebrovascularincidents.n AvoidneurolepticsinDementiawithLewyBodies(DLB):riskofworsening

andmortality.n Notrecommendedfordementia:highdosevitaminE(>400IU/day);vitamin

B1,B6,B12orfolicacidifnotdeficient;anti-inflammatoryfordementiasymptoms;HMG-CAreductaseenzymeinhibitor;hormonereplacementtherapyforcognitiveimpairment.

Manage Social Issues

Social Issues to be ConsideredFinancialmanagement: Assesscapacity(seebelow),provideassistanceand

prepareforpowerofattorney.Driving: Assesscapacity,monitorandprepareforlossofdriving.Homecare: Assessforneedforyardandhousemaintenance,

housekeepingandmealpreparation.Respite: Prepareforcaregiverrest.Placement: Prepareforlossofabilitytoliveindependently.Endoflifeissues: Willandresuscitationorders.

Referral Cue:Dementiaclinic,neurologist,geriatrician,orgeriatricpsychiatristtochoosemedicationsandassessresponsetomedicationwhenunclear.

Referral Cue: Placementagencytoplanforrespiteandlong-termadmission.

Referral Cue:Lawyertoassistwithpowerofattorney,willsandotherfuturelegalmatters.Legalissuesvarysignificantlybetweenprovinces.

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Assess Capacity Familyphysiciansmaybeexpectedtodeterminethecapacityofapersonwithdementiatomanagetheirfinances,driveacarorliveindependently.

Capacityistheabilityto…n understandinformationnecessaryforadecision.n understandrisksandbenefitsassociatedwithdecision.n useownvaluesystemtomakeappropriatedecision.

Assesscapacityto…1. consenttocare.2. managefinancesandawill.3. livealone:

• Abletounderstandtheyarebeingaskedtodescribewhattheyneedtoliveathomesafely.

• Abletounderstandtheriskandbenefitsofacceptingorrejectingrequiredassistance.

• Abletodecidehowtheywanttoliveandtheconsequencesoftheirdecisions.

Assess Capacity to Driven Askpatientandfamilyaboutdrivingcapabilityandhistoryofaccidentsand

near-misses.n Milddementia:Assessindividually.Warnthatlossofdrivingisinevitable.

Reassessatleastevery6–12months.n Drivingcontraindicatedifunabletoperformmultipleindependentactivities

ofdailyliving(e.g.medications,banking,shopping),oranybasicactivityofdailyliving(e.g.hygiene,dressing).

n Seethe“DrivingandDementiaToolkit”intheCanadianMedicalAssociation’sDeterminingMedicalFitnesstoOperateMotorVehicles.

Referral Cue: Dementiaclinic,geriatrician,neurologist,orgeriatricpsychiatristwhencapacitytolivealoneormanagefinancesisunclear.

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n Drivingcompetencymaybedifficulttodetermineinanofficesettingwhendementiaisnotsevere.

Caregiversn Caregiversareanessentialsourceofinformationforphysiciansandother

membersofthehealthcareteam.n Caregiversneedspecialattention:

• Provideopportunitiestoaskquestionsandexpressneeds.• Assessforstressandexhaustion.• Referforeducationandsupportasrequired.• Caregiversupportmaydelayinstitutionalization.

Manage Progressionn Anticipatetheprogressionthatcharacterizesdementia.n Followpatientregularly,establishscheduleofvisits.n RegularlydocumentprogressiveneedsusingtheFAST-ACTtoolorasimilar

measureoffunctionalstatus.n Obtaincollateralinformationfromfamilyandcaregivers.n Planaheadtothenextphaseofdisabilityandlossofindependence.n Preparefamily.

Referral Cue:Specializedhealthprofessional-baseddrivingassessmentwhencapacitytodriveisnotclear.

Referral Cue:Caregivers’ownphysicianormentalhealthreferralifhealthisaffected.

Referral Cue:Supportorganizationstoallowpatientsandcaregiverstofindsolutionstoproblems.Caregiverswillneedincreasingassistanceandtrainingasdementiaprogresses.

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n Preparemanagementoptions.n Inseveredementia(totaldependenceoncaregiver),reassessevery3months:

MMSE,medicalstatus,behaviours,nutrition,safetyandcaregiverhealth.

Dementia Requires a Team ApproachDementiaisachallengeforpatient,families,caregiversanddoctors.Donotgoitalone—bepartofateam.

Family Physicians and Veterans Affairs CanadaEligibleclientsofVeteransAffairsCanadamayincludestill-servingandformermembersoftheRegularandReserveCanadianForces,RoyalCanadianMountedPolice,certaincivilianswhoareentitledtobenefitsbecauseoftheirwartimeservice,andfamilymemberswhoaresurvivorsanddependentsofmilitaryandcivilianpersonnel.Clientsmayhaveaccesstocasemanagement,disabilitycompensationortreatmentbenefits,dependingontheireligibility.

VeteransAffairsCanadadistrictofficeinterdisciplinaryclientserviceteamswelcomefamilyphysicians’participationinclientservices.Dependingoneligibility,VeteransAffairsCanadaclientswithdementiamayhaveaccesstocasemanagementandvariousassessmentortreatmentservicesthatmayincludenursingandoccupationaltherapyassessments,medications,medicaldevices,homeadaptations,mobilityassistivedevices,homecareservicesandlong-termcareassistance.Treatmentbenefitsmaysupplementbutdonotreplacethoseprovidedbyprovincialagencies.

Referral Cue: Dementiaclinic,geriatrician,neurologist,orgeriatricpsychiatristwhenprogression,changeindiagnosisorresponsetotreatmentisunclear.

Referral Cue: Supportorganizationstoallowpatientsandcaregiverstoanticipatefutureproblemsandplanforsolutions.

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Communicating About Your Patient/Our ClientInorderforVeteransAffairsCanadatoconsideraclient’srequestforvariousservicesandbenefits,aclientmaybeaskedtosubmitaprovider’swrittenprescriptionorreport.PleasecompleteVeteransAffairsCanadaformscarefully,sincewrittenreportsareimportantwhenclientrequestsareassessed.Providersareencouragedtoincludeadditionalinformation,astheyseefit.ThereareseveralwaysahealthprofessionalmaycontactaVeteransAffairsCanadainterdisciplinaryclientservicesteamregardingapatientwhoisaVACclient:

n CalltheNationalContactCenterat1-866-522-2122(English)or1-866-522–2022(French).IfyourpatientorclientisaVeteransAffairsCanadaclient,ithelpstoprovidetheirVACClientNumber,carriedontheirVACclientcard.

n SendareferrallettertotheVeteransAffairsCanadaInterdisciplinaryClientServicesTeaminthelocalDistrictOffice.Thereferrallettershouldcontaintheseelements:• Reasonforthereferral,includingtypesofassessmentorservices.• IndicationthattheVeteranhasgivenconsentforthereferral.• Descriptionoftheproblem.• Pastmedicalhistoryandmedications.• Currenttreatmentplansandnamesofotherhealthcareproviders.

n ParticipateinVeteransAffairsCanadaDistrictOfficeInterdisciplinaryClientServicesTeamcasemanagement.

More InformationOffice screening tools:• MiniMentalStatusExamination(MMSE):www.parinc.comandsearchforMMSE.

• MontrealCognitiveAssessment(MoCA):www.mocatest.org• FAST-ACT:MacDonaldConnollyD,PedlarD,MacKnightC,LewisC,

Referral Cue: VeteransAffairsCanadawhenpatientswithmilitaryorRCMPserviceortheirfamiliesmaybeeligiblefortreatmentservices.

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FisherJ.GuidelinesforStage-BasedSupportsinAlzheimer’sCare:TheFAST-ACT.JGerontNurs2000;November:34–45.

Electronic copy of this Dementia Resource:• AnelectronicversionofthisVACDementiaResourceandapaperdescribinghowitwasdevelopedareavailableontheVACWebsiteat

www.vac-acc.gc.ca.

Detailed guidelines from the 3rd Canadian Consensus Conference on Diagnosis and Treatment of Dementia:

n Visitwww.cccdtd.caandclickon“FullRecommendations”foralistofall142recommendations,and“Articles”forthefulltextoftheOctober2007issueofAlzheimer’s & Dementia.

n Visitwww.cmaj.ca/andsearchon“dementia”tofindtheseriesofpapersthatbeganin2008.

Not a GuidelineThisDementiaResourceisofferedtofamilyphysiciansandotherhealthprofessionalswhowilldecideindividuallywhetheritisusefulincaringforpatientswithdementia,theirfamiliesandcaregivers.Thetoolisnotaclinicalpracticeguideline,doesnotdefinestandardofcare,doesnotreplaceclinicaljudgmentandisnottheonlywaytoapproachthediagnosisandmanagementofdementia.

© Her Majesty the Queen in Right of Canada, represented by the Minister of Veterans Affairs, 2009. Catalogue No.: V32-217/2009E ISBN: 978-1-100-13317-1 Printed in Canada

NationalMentalHealthProgramVeteransAffairsCanadaCharlottetownPECanadamentalhealth_santementale@vac-acc.gc.ca