Dementia
Welcome to the Dementia module.
This module will provide you with an interactive case study in which you will consider the presentations, diagnosis and care of a patient who has dementia.
Please review the objectives and complete the Pre-Module Test before commencing the case study. (If you are returning to the module you can skip the Pre-Test by clicking on the Continue button to go straight to the case).
Module
- Interactive Case Study
- Patient Interview
- History Taking
- Interview with Mrs Zheng
- Assessment
- Investigations
- Diagnosis
- Issues Regarding Diagnosis
- Communicating a Diagnosis
- Dr Zheng’s follow-up
- Care Plan
- Genetic testing
- Family Meeting
- Social Work Assessment
- Supportive Care
- Four years later.......
- Interviews
- Physical Assessment
- Further Investigation
- Mrs Zheng's Concern
- ACAT Assessment
- Behaviours of concern
- Conclusion
You have been asked to review Dr Henry Zheng, a retired 71 year old dentist from China, with suspected cognitive decline.
In reviewing Dr Zheng, it is important to find out about his medical history and current state of health in addition to any concerns about memory, daily functioning and social interactions.
Before you review Dr Zheng’s history through the links below, read the referral letter from his GP.
- History of Presenting Complaint
- Medical History
- Medication History
- Social History
Henry Zheng is a 71 year old retired dentist from China. His wife (Liane) has accompanied him on this visit. She reports that Dr Zheng has been increasingly forgetful over the last few months and doesn’t seem to want to do a lot of things he used to find fulfilling.
Dr Zheng has a history of minor headaches, effectively treated with paracetamol and acupuncture. In China, he was hospitalised numerous times for gastroenteritis and also for kidney stones. He had an appendectomy at age 51 and an admission for a broken elbow at age 46. He recently had a benign mole removed from his back. This was performed as an outpatient procedure 20 months ago. His medical history is otherwise unremarkable.
Dr Zheng has been well. In general, what is the dominant risk factor for dementia?
Dr Zheng is currently taking aspirin prn and a Chinese herbal blend that acts as a blood tonic.
It is important to review medication history as some medications may contribute to cognitive symptoms.
Mr and Mrs Zheng arrived in Australia 15 years ago from mainland China upon their retirement.
At this time, they spoke some conversational English, but this improved with the help of English as Second Language (ESL) programmes at their local community centre.
The Zheng’s migrated to Australia in order to live with their daughter May and her family in the country town of Narembeen.
They occasionally help out in the Chinese restaurant she runs with her husband.
Dr Zheng enjoys gardening, golf, playing mahjong, social dancing and crossword puzzles.
Family History
Dr Zheng’s mother died of tuberculosis at age 47 and his father of a stroke at age 83, but there is no strong family history of any medical condition.
In order to determine history relevant to the present complaint, you will need to ask Dr Zheng a series of questions.
In the meantime, you explain the purpose of the IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) to Mrs Zheng and give her a copy to complete while you are speaking with her husband.
Please click on the buttons below to view the conversation.
Taking a history from a person with suspected dementia
Sometimes people with early dementia are not aware of the decline in their memory or may simply attribute it to age related memory loss. It can help to speak to a close family member to obtain further information about the problems being experienced.
You should consider how it might be best to obtain information from the patient and primary carer. Depending on the circumstances, it might be best to talk to each person separately.
A separate interview may be needed if the family member is reluctant to discuss the memory issues while the patient is present. Alternatively, if the carer is rushing in to answer for the patient, continually correcting them or if they begin arguing about the person’s current state of function, conducting separate interviews would be recommended.
This depends in large on personal preference of the doctor and also on the dynamics of each situation.
In this instance, Mrs Zheng did not want to embarrass or concern her husband too much by talking about his memory decline in front of him. It will be important to speak with Mrs Zheng separately about the changes she has noticed in her husband’s function.
Please click on the questions below to obtain Mrs Zheng’s answer.
- Mrs Zheng, have you noticed that your husband has been more foregetful lately?
- How long has this been happening?
- Mrs Zheng, I would like to ask you some questions about your husbands general state of health. Has he been admitted to hospital in the past?
- Does he currently take any tablets for a medical condition?
- Does he ever complain of any troubling symptoms, such as dizzy spells or difficulty in going to the toilet?
Physical Assessment
Examine Dr Zheng to determine his current state of health. Early evaluation of suspected Alzheimer's Disease is important in order to rule out and treat reversible disorders.
Cognitive Assessment
Geriatric Assessment Tools
On their own, screening tests are not able to diagnose dementia as they test limited domains of cognition. They can be useful in identifying someone needing further investigation and are also useful if done serially to map any change in cognition over time.
The ideal screening test would be both sensitive (high rate of true positive) and specific (high rate of true negatives results). However this is not as straight forward as it sounds, because positive predictive value of tests is also influenced by the prevalence of the disease condition! Keep in mind too that “cut offs” are based on population norms or empiric studies and thus can not be considered in isolation.
Please click on the tabs below to reveal more information about each of the commonly used screening tools.
- Folstein’s Mini-Mental Status Examination (MMSE)
- Clock Draw and GPCOG
- Geriatric Depression Scale
- IQCODE
- Frontal Assessment Battery
- Alzheimer’s Disease Assessment Scale cognitive sub-scale (ADAS-Cog)
- Abbreviated Mental Test Score (AMTS)
- RUDAS
The Mini Mental State Examination
The MMSE is the most common test for screening for cognitive impairment. It tests multiple cognitive domains including orientation in time and place, attention, calculation, short term memory, language and copying. It helps to quantify the patient’s degree of impairment, and may be followed over time to track the progression of impairment. It is however, poor at detecting very mild dementia and does not test frontal/executive function and visuospatial function well, making it less valuable in non-Alzheimer’s type dementias. A score of 24/30 or below is suggestive of cognitive impairment, although a ‘normal’ MMSE does not rule out the possibility of cognitive impairment, especially in younger or well-educated patients. This test usually takes around 10 minutes to complete.
The Clock Drawing Test
This is a screen for visuospatial, constructional praxis and frontal executive impairment that takes 1 or 2 minutes to complete. It is a simple bedside test that is independent of bias due to intellect, language or cultural factors. The clock drawing test does not detect early cognitive changes or discriminate between types of dementia raising questions about its suitability to be used in isolation.
There are a number of alternative ways of administering and scoring the CDT, such as those described by, Shulman (1993), Sunderland (1989) and Wolf-Klein (1989). Of these, the Shulman method has been found to be the most sensitive and specific screening test for mild-moderate dementia when used in conjunction with MMSE.
In the Shulman method, subjects are asked to add the numbers of a clock-face on to a pre-drawn circle and to mark in the hands to resemble a specified time. Results are scored as follows:
- a perfect clock
- mild visuospatial errors
- errors in denoting the specified time
- moderate visuospatial disorganisation
- severe visuospatial disorganisation
- no reasonable representation of a clock
It is a good idea to read the following article to familiarise yourself with each the commonly used CDT methods, as they are frequently used by doctors, allied health professionals and ACAT nurses.
Brodarty H and Moore C. 1997. The Clock Drawing Test For Dementia Of The Alzheimer’s Type: A Comparison Of Three Scoring Methods In A Memory Disorders Clinic. International Journal of Geriatric Psychiatry, 12: 619-627.
GPCOG
This brief validated screen (specifically for Primary Care) incorporates the Clock Drawing task. The test is available online.
Geriatric Depression Scale
The Geriatric Depression Scale is commonly used to screen mood disorder which may impact on performance of other cognitive assessments. A score of 5 or more is suggestive of an underlying mood disorder and further clinical assessment is recommended.
There has been some concern about its accuracy in detecting minor depression. It is suitable for use with people with a Mini-Mental Status score of more than 14. It takes 5-10 minutes to complete.
The Geriatric Depression Scale is available in many languages.
Most screening tests for dementia involve a brief list of questions to directly assess cognitive functioning, such as the MMSE. A disadvantage of such tests is that they are affected by the person’s level of education, familiarity with the dominant language and culture in their country, and level of intelligence before the onset of dementia. Because of this, cognitive screening tests can falsely indicate dementia in people with lower education, culturally and linguistically diverse backgrounds, and lower intelligence. The IQCODE attempts to overcome this problem by assessing change from earlier in life, rather than the person’s current level of functioning. It does this by making use of the informant’s knowledge of both the person’s earlier and current cognitive functioning. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a questionnaire that can be filled out by a relative or carer (the informant) of an older person to determine whether that person has declined in cognitive functioning. The IQCODE is often used as a screening test for dementia.
IQCODE is especially useful in cases where, for different reasons, a meaningful formal cognitive assessment cannot be performed. It also gives the relative an opportunity to say what they feel. IQCODE has been found to have similar specificity and sensitivity to the MMSE.
To score the IQCODE, add up the score for each question and divide by the number of questions (for the short IQCODE, divide by 16). A cut-off point of 3.31/3.38 achieves a balance of sensitivity and specificity.
Jorm, A. F. (1994). A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and cross-validation. Psychological Medicine, 24, 145-153
The Frontal Assessment Battery is a brief tool that can be used at the bedside or in a clinic setting to assist in discriminating between dementias with a frontal dysexecutive phenotype and Dementia of Alzheimer’s Type (DAT). The FAB has validity in distinguishing Fronto-temporal type dementia from DAT in mildly demented patients (MMSE > 24). Total score is from a maximum of 18, higher scores indicating better performance.
Slachevsky: Frontal Assessment Battery and Differential Diagnosis of Frontotemporal Dementia and Alzheimer Disease. Arch Neurol. 2004;61:1104-1107
Alzheimer’s Disease Assessment Scale – Cognitive (ADAS-Cog)
The Alzheimer’s Disease Assessment Scale (ADAS) of which one section is the ADAS Cog, evaluates cognitive functions affected in Alzheimer’s disease including memory, language and praxis. This 11-part test is more thorough than the MMSE and can be used for people with mild symptoms. It is a commonly used for brief examination of memory and language skills and is often used as a measure in clinical drug trials. It takes around 30 minutes and can be conducted by several members from the multidisciplinary team (such as a doctor, nurse, OT or psychologist)
AMTS
This brief 10 item screen takes about 3 minutes to administer, It includes components requiring intact short and long term memory attention and orientation.
One point is allocated for each correct response. A score of <8/10 is suggestive of significant cognitive deficit, although further and more formal tests are necessary to confirm the diagnosis. Results areaffected by language and cultural background. Its advantage is its brevity.
Hodkinson, HM (1972). "Evaluation of a mental test score for assessment of mental impairment in the elderly.".Age and Ageing 1 (4): 233-8. https://ageing.oxfordjournals.org/cgi/reprint/1/4/233.
RUDAS
Australia is culturally diverse, with many people who have non-English speaking backgrounds (NESB). Unfortunately this can make the MMSE difficult to use as many of the concepts do not translate easily. A new tool was developed and validated in the multicultural population of South West Sydney: the Rowland Universal Dementia Assessment Scale – (RUDAS). The score is affected by age but it is not affected by educational level or preferred language. (Storey, Rowland, Conforti, and Dickson 2006). This test is most applicable to people with limited ability to speak or understand spoken English and, unlike the other tests, it remains reliable when administered through an interpreter.
This tool is commonly used by allied health staff and ACAT nurses.
Cognitive Assessment Results
Click to review the results of Dr Zheng's assessments....
- Folstein’s Mini-Mental Status Examination (MMSE)
- Clock Drawing Test
- Geriatric Depression Scale
- IQCODE
Dr Zheng’s MMSE score was 22/30.
To view Dr Zheng's MMSE, click here
He was able to correctly identify the year, season, day of the week and month, but could not name the present date. He was able to name three objects immediately after they were shown, but was able to recall only one. He spelled ‘world’ backwards correctly for three letters, but missed the last two. He could write a simple sentence and correctly copied the intersecting pentagons.
Dr Zheng is asked to draw a clock with all the numbers on it and then “make the clock say 25 past 4.”
Score the clock based on the following six-point scoring system:
One approach to scoring the clock is to draw a line between whatever the top indicator is on the clock through the centre, and then perpendicular to that line to create four quadrants. A perfect clock drawing would have normal contouring, properly sequenced numbers, correct hand placement and three numbers in each quadrant.
Even though Dr Zheng’s mood appears normal, to be sure you perform a geriatric depression scale, as depression often accompanies and can sometimes be mistaken for dementia.
Please click here to see Dr Zheng’s GDS.
He scores 2/15 indicating he is unlikely to be currently troubled by depressive symptoms.
Using the scoring method already outlined, work out Dr Zheng’s IQCODE score. You can access the completed form via the link below.
Click here to review Mrs Zheng's completed IQCODE form and then return to this page to answer the question below.
Combining MMSE and GDS
Quite a few studies advocate the combination of MMSE and IQCODE to give better diagnostic sensitivity and specificity.
Dr Zheng’s IQCODE and MMSE scores have been plotted on the chart below. It is evident that he falls within the "ill" range.
These results indicate that Dr Zheng is likely to have a cognitive impairment
Consider the investigations that might be useful in the investigation of Dr Zheng’s cognitive decline. The aim is to eliminate other possible causes of cognitive impairment and determine the most likely cause of his memory problem.
Please click on each of the following to obtain test results and rationale for ordering.
- Blood Screening
- Computed Tomography (CT)
- Magnetic Resonance Imaging (MRI)
Based on Dr Zheng’s history, physical examination and investigations, answer the following questions?
More information about the differential diagnosis of dementia
Dementia Subtypes
Alzheimer’s disease is the most common CAUSE of dementia. Although some people mix the terms up, Alzheimer’s disease is only one sub-type of dementia. It has characteristic neuropathology (plaques and tangles seen on post mortem brain samples using a microscope). Vascular dementia or a combination of vascular dementia and Alzheimer’s disease is also very common. Lewy body disease is the next most common cause of dementia, followed by frontotemporal dementia. Use the exercise below to find out which features suggest the various dementia sub-type.
Choose the following symptoms to the relevant dementia sub-type.
Dr Zheng's Diagnosis
Personal and Cultural Issues Regarding Diagnosis
Dementia is a progressive, incurable disease which is uniformly fatal. Many people say they would rather die than “lose their marbles”. In this respect dementia can be perceived as worse than many purely physical illnesses, which are not perceived as threatening the essence of an individual’s personhood. Dementia can thus be a devastating and difficult diagnosis to communicate.
This is not always the case though. Some people minimise the symptoms of dementia, regarding them as normal “forgetfulness” related to ageing, even when it becomes clear to health care workers that the problems are in fact not part of normal ageing.
Thus there are some personal and cultural issues that you may need to consider in communicating this diagnosis to Dr Zheng.
It is possible that his family might not wish Dr Zheng to know about the diagnosis. It is also possible that Dr Zheng may not wish to know either! Some people believe that a person is entitled to be protected when they are ill. They believe that discussing the reality of the disease may make the patient suffer more than they are already suffering as a result of illness. The more severe the illness, the greater the need for protection. This belief is cited as common in Chinese culture. In contrast, Western traditions usually indicate honesty in communicating a diagnosis. You can see that (well meaning) honesty could be perceived as unkind by some patients and their families. These issues can be even more relevant in the late stages of dementia. Some people feel that to tell someone he or she is dying is not only rude but dangerous. They fear that openly acknowledging the possibility of imminent death is courting bad luck and will make the person despair and die sooner.
Muller JH, Desmond B: Ethical dilemmas in a cross-cultural context-A Chinese example, In Cross-cultural Medicine-A Decade Later [Special Issue]. West J Med 1992 Sep; 157:323-327)
Dr Zheng’s case
Dr Zheng’s, and his family’s, feelings about discussing illness could potentially create a difficult situation. There could be a mismatch between the health care worker’s, patient’s and family’s, attitudes to discussing the diagnosis and its impact on future care planning and support needs
The Zheng’s, especially May, have been living in Australia for some time, where full disclosure of diagnosis and its implications is generally the norm. However, it is important not to assume that the Zhengs all necessarily hold the same views.
How would you approach this dilemma? Click on each statement to obtain feedback.
- Speak first with Dr Zheng’s wife and daughter before communicating his diagnosis, to discuss their thoughts and wishes
- Go ahead and tell Dr Zheng that he has Alzheimer’s Disease. It is the way things are done in Australia and it is important to avoid possible litigation
- Ask Dr Zheng if he would like to know the results of his tests and whether he would like his family present at that time
Could be appropriate, depending on the situation. Raises ethical issues relating to patient confidentiality.
This could potentially be culturally rude, and might risk alienating a family who have approached you for help.
This would be the ideal scenario in this case, as Dr Zheng appears likely to retain the ability to form and express an opinion regarding sharing information with his family. If he or his family do not wish for him to know the diagnosis or disease implications, this preference should be taken into account.
Cultural Perspectives
There are many cultural perspectives that you may need to consider in relation to dementia when dealing with different ethnic groups. In this case study, a gentleman from China is used as an illustrative case. However, similar scenarios can easily be applied to people from other ethnic and cultural groups.
Some issues that you may need to consider include:
- In some parts of the community, dementia is stigmatised as a form of mental illness. Alternatively, as in Dr Zheng’s case, forgetfulness and memory loss are attributed to be a normal part of ageing.
- Dementia is often not openly discussed in the some cultures, raising concerns about access to support services and social isolation.
- Many ethnic communities place high value on older people. Children are generally expected to care for their parents as they grow older.
For further information on cultural perspectives on dementia, see;
Perceptions of dementia in ethnic communities. Alzheimer’s Australia 2008
Communicating a difficult diagnosis can be distressing for both the health professional and the patient.
Ways to help minimise the distress for the patient include:
- Allow adequate time and ensure privacy
- Let the patient decide how much they want to know
- Tell the patient and carer separately if they wish
- Encourage expressions of feelings
- Break the news in stages over several consultations
- Assess patients’ understanding frequently
- Be aware that both patients and carers may suffer negative thoughts or anxiety after hearing the diagnosis
When communicating with people (particularly those with cognitive impairment), you should work to instil feelings of trust, confidence and respect and ensure that the patient and family have understood what has been said.
Guidelines for communicating a diagnosis of dementia
Communicating Dr Zheng's Diagnosis
Dr Zheng and his family both agree that it is important for him to learn about his diagnosis. All are present at the time of communicating the diagnosis.
Think about the following approaches to beginning the discussion regarding Dr Zheng’s diagnosis.
Click on each to receive feedback.
- We have received the results back from your assessment Dr Zheng. Your tests indicate that you have cognitive impairment conistent with Alzheimers disease.
- Your test show no physical illness. The mostly likely diagnosis is Alzheimers disease, the most common cause of dementia.
- We have conducted a number of tests. Unfortunately, these tests do suggest that there are problems with your thinking and memory.
- Unfortunately, I can find nothing treatable. I think that you may have dementia, I do not want you to lose heart as a lot of help and support is available.
- Dr Zheng we need to discuss your test results. First I would like to find out what you and your family think could be the cause of your memory problems.
As a general point it is often a good idea to
- Offer time to talk with family before a second discussion. Sometimes the second discussion will be with another health care worker, in this case perhaps the referring GP. The GP may appreciate an opportunity to discuss Mr Zheng’s care before he presents.
- Refer to Alzheimer’s Australia. Courses and help sheets are also available (Such as those regarding Alzheimer’s Disease and information for family and friends).
- Check if the patient or family have any questions
Dr Zheng has presented for his follow up appointment.
You ask him how he has been since you met to discuss his diagnosis. You emphasise that you are happy to answer any questions he has.
Click on Dr Zheng's questions to see how you might respond.
- I am OK. The diagnosis was a shock. But we know what is happening now. I read that Alzheimer’s disease is progressive. I am wondering how fast things will get worse?
- What other things might happen to me?
- How do we treat it?
- What are these treatments?
- Are there other options?
- Is there anything else I can do?
- Will I die from this disease?
- How long have I got?
You have given Dr Zheng and his family a lot of information, some of which may be distressing. Ensure that they have understood the implications of the diagnosis. Respectfully ask if they have any other questions at this point? Are they happy to continue the consult or would they like to re-visit later in the week?
The Zheng’s would like to continue the current visit. They are coping with the information and would like to return home to Narembeen as soon as possible.
Click on the question below to see how Dr Zheng feels about medication for his dementia.
- What I would like to discuss with you is what will happen next. Dr Zheng, would you like to consider the medication treatment we’ve talked about?
Dr Zheng’s daughter is concerned about the implications of her father’s diagnosis and has made an appointment to see you. Please click on May’s questions to view appropriate responses.
- Somebody from work told me that Alzheimers disease is genetic. Does that mean that me or my children will get it too?
- We have no relatives with dementia that I know of. My grandparents, aunts and uncles have not had this problem. What does this mean?
- Is there anything we can do to prevent getting it?
More Information about Familial Alzheimer's Disease
Dr Zheng’s GP from Narembeen has arranged a meeting with the Zheng’s. Also present are the local Occupational Therapist, Social Worker and Community Health Nurse from Narembeen District Hospital. It is now about three months since their return to Narambeen
Important aspects to discuss in the family meeting include:
- How have they coped since returning to Narembeen
- The prognosis of dementia and planning for future events
- Capacity for Decision Making
- Advance care plans and other legal considerations
- Support services available, including emotional, financial and respite care services and how to access them
- Elder Abuse
Some families feel like they “fall through the cracks”. Others will feel stigmatised. Others are stoic and adopt a philosophical attitude. You can only find out by asking!
Because dementia is a progressive disease, and the quality of care and quality of life for the patient depends in large part on the ability of the caregivers to arrange and participate in the care of the patient, it is important to provide information about the prognosis, and to begin planning for Dr Zheng’s future care. Information delivered at the time of diagnosis may not have been well retained, and may need reinforcement.
You should ensure that Dr Zheng and his family understand the diagnosis and the prognosis. To facilitate this, you might ask, “tell me about your understanding of your/your husband’s/your father’s medical problem…”.
An understanding of what to expect in the future will help the family, in conjunction with the multi-disciplinary team, in planning for future care and making decisions about who will provide that care and what help or assistance may be required.
Determining decision making capacity is an important component of planning the care of a person with dementia. Dr Zheng has been diagnosed early, so it is likely that he will be capable to finalise a legal will, organise the management of financial affairs, provide consent or non-consent for medical treatment and participate in discussions to formulate an advanced care plan.
If there are concerns about capacity, patients can be referred to local geriatric or pyschogeriatric services for further assessment.
Because of the progressive nature of dementia, it is important to discuss legal considerations early. Helping Dr Zheng establish an advance care plan and appoint a power of attorney, ensures future treatment plans are based on his wishes and values, and helps to avoid problems and disagreements later in the course of the disease.
Advance Care Plans
Advance care planning is a process that will enable Dr Zheng to make decisions about his future health care in consultation with his health care providers, family members and other important people in his life. In this way, he can make his thoughts, feelings and wishes known and these can then direct ongoing care planning and assist in decisions that may need to be made in the future.
Patient’s wishes should be considered by health care workers. This is a moral and ethical requirement regardless of whether a given jurisdiction provides a legal framework for recognition of written advcance care plans.
Enduring Power of Attorney (EPA)
Dr Zheng may choose to appoint an enduring power of attorney to manage his financial affairs. He can decide whether the person he appoints can have the power to make decisions for them immediately or only after he loses capacity.
An EPA can only be made by an adult who has the capacity to make informed decisions and to understand their implications.
For more information, visit the Office of the Public Advocate.
Wills
A will allows Dr Zheng to decide how his belongings and property will be distributed after he dies and must be completed while he is deemed capable.
Guardianship Orders
In the absence of an advance care plan, or where there is dispute regarding treatment, The State Administrative Tribunal can make a Guardianship Order appointing a family member, friend or the Public Advocate to make medical and lifestyle decisions on the patient’s behalf.
It is important to continue to monitor how the patient and carers are coping with the illness, and to ensure the support they are receiving is adequate. Don’t forget that carer support is as important as patient support.
Acknowledging the family / carer demonstrates respect for their role in the patient’s life and enables the opportunity for communication about a topic that may be seen as having a stigma associated with it.
Dr Zheng and his family’s wishes for future care should be discussed during the family meeting. This should include any training that might be required and the family’s capacity to provide the required level of care. The health care team can then determine the services that are needed in order to help support Dr Zheng and his family throughout the dementia journey. Many health care specialties may be involved in this process, including, but not exclusive to, a social worker, community health nurse, occupational therapist and physiotherapist.
Patients and families should be encouraged to contact the Alzheimer’s Australia, which can provide information and support.
www.alzheimers.org.au
Mr Zheng’s family seem very concerned about him and seem prepared to act in his best interests. However cognitively impaired older people are financially and physically vulnerable. It is important to keep this in mind, especially as dementia progresses.
Click for more information on the prevention of elder abuse.
The Zheng’s have elected to care for Dr Zheng within their family unit.
In order to assess any assistance that might be required, a social worker visits them at home.
Click here to see the assessment.
The Zheng family participate in an education workshop on supportive care for patients with dementia
In discussion with a multi-disciplinary team of health professionals they made a series of changes to their home and living environment.
Support - Memory Centre
Dr Zheng has also been encouraged to develop a memory centre that will include all the items he needs to organise his life and support his memory. Items that might be included in the memory centre include:
- a clock that also shows the date
- a notepad and pen for phone messages
- a monthly wall calendar
- a diary or appointment book
- a bowl in which to place keys, wallet, glasses and other important items
He might also employ the use of external memory aids such as using lists, sticky notes or alarms used as reminders (eg. to take medication, to turn on the TV to watch the news etc).
His family are encouraged to help establish a regular routine. In addition, getting rid of clutter around the house and always putting important items and documents in the same place can facilitate an easier living situation for the person with dementia. While orienting information (ie. reminders of the date and place) can help people with Alzheimer's Disease on a day to day basis, it has no lasting effect on memory.
Support - Language
Word findings difficulties, such as those Dr Zheng has been experiencing, often occur earlier in the course of dementia in people who currently speak a language that is not their primary language.
His family, friends and others involved in his care are therefore given advice on communication.
Support - Summary
Patients with dementia benefit in many ways from early recognition of the condition. However, changes associated with early stage dementia can be subtle. You were able to make a diagnosis of dementia in Dr Zheng from the history, simple screening tests, and physical examination findings.
Memory loss or memory impairment was evident from Dr Zheng’s difficulty remembering meetings, dates, events and words, and his vague answers to certain questions.
Dr Zheng’s apathy with his usual activities and inability to schedule or plan his day suggests a disturbance in executive functioning, which is corroborated on his clock-drawing screen.
The lack of any precipitating event is consistent with a gradual onset of cognitive decline.
Dr Zheng was diagnosed with Dementia (Alzheimer’s Type).
An advanced care plan was established, wills finalised and an enduring power of attorney appointed.
Further advice for Dr Zheng included:
- staying physically active
- eating a healthy, balanced diet
- striving to stay mentally active
- giving himself more time to complete tasks
You are asked to review Dr Zheng again 4 years later. His dementia has progressed significantly in the last 6-9 months and his family are finding it more difficult to cope with his care.
Review history through the links below before proceeding to assessments
- History of Presenting Complaint
- Medical History
- Medication History
- Social History
Henry Zheng is a 75 year old retired dentist from China, who was diagnosed with Alzheimer’s Disease 6 years ago. At the time of diagnosis, his main problems were memory loss, aphasia and some decline in executive functioning.
Recently he has become more forgetful, confused, agitated and has had angry outbursts. On a few occasions, he has gone wandering and been unable to find his way home. Once this happened during the night when he went out in his pyjama’s. He now often forgets family members’ names and is having difficulties with several activities of daily living. He has also started speaking less and less English and has reverted to his language of birth. He becomes very frustrated when Australian friends don’t understand his Cantonese.
He has been having hallucinations, but last week he experienced an episode that frightened not only himself, but his family also. This prompted them to bring him in for review. They would like to know more about how they can help him.
Since being diagnosed with Dementia, Dr Zheng has been relatively well. He has had a recent fall. He became distressed while wandering and tripped on a step. He was assessed at Narembeen District Hospital but had sustained no serious injury.
He also had a serious chest infection 18 months ago, which required hospitalisation. This was successfully resolved with antibiotics and Chinese herbs.
Dr Zheng was started on anti-cholinesterase inhibitors 18 months after his initial diagnosis. He did show some improvement after commencing treatment, but continued to deteriorate after 13 months. Pharmacologic therapy for his dementia was discontinued about a year ago as he was getting nausea and diarrhoea, and his family did not think the drug was helping any longer.
Since his diagnosis, Dr Zheng has gradually withdrawn from virtually all social activities. He is no longer able to play golf, mahjong or do crossword puzzles. Mrs Zheng does still encourage him to dance at home and he seems to get great enjoyment out of this.
His family have provided and continue to provide excellent loving care for Dr Zheng, but are finding it increasingly difficult to manage his physical and behavioural care needs.
Dr Zheng stopped driving 3 years ago.
Dr and Mrs Zheng Interview
In order to determine history relevant to the present complaint, you will need to ask Dr Zheng a series of questions. You have been advised that Dr Zheng frequently reverts to speaking Cantonese and therefore arrange for an interpreter to be present. He also relies on his wife more and more for communication and you therefore feel it is appropriate to interview them together on this occasion.
- Hello Dr Zheng. How do you feel you are going these days?
- The letter from your GP says that you might have been experiencing a few additional problems recently that have caused you some distress, is that right?
- How are you managing generally? Are there any aspects of day-to-day life that are troubling you?
- Are there any activities that you used to enjoy that you can't participate in anymore?
Mrs Zheng Interview
- Mrs Zheng, how are you and your family coping?
- And how do you feel your husband is coping?
- Are there any aspects of day-to-day life that are troubling you?
Examine Dr Zheng to determine his current state of health.
General Appearance:
Dr Zheng is slow to react to instructions. No tremor is observed. He is slightly dishevelled, but appears anxious and distracted.
Height: 160cms
Weight: 65kgs (5kg weight loss over 4 years)
Temperature: 37.3
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
Consider the investigations that might be useful in the investigation of Dr Zheng’s continuing cognitive decline.
Lab Investigations
Please click on each of the following to obtain Dr Zheng's.........
- Blood Screening
- Cognitive Screening Test
Conclusion
Based on your interview with Dr and Mrs Zheng, your physical examination and investigations, it appears that Dr Zheng’s Alzheimer’s disease is progressing but he is otherwise physically well.
In order to address his future care needs and investigate his family’s wishes for this care, you arrange a referral to the Aged Care Assessment Team (ACAT).
Mrs Zheng has expressed concern over her ability to adequately meet her husband’s increasing care needs. She is also growing more and more tired. The family is adamant that they would like to continue to care for him at home, but his care needs have become more complex and they feel the time may have come to enlist some extra help. They would also like to learn more about how they can best manage Dr Zheng’s more challenging behaviours.
In order to assess Dr Zheng’s level of physical and functional decline, and help determine what care and support service needs are required, a home assessment is necessary. This will allow the assessor to determine how well Dr Zheng is coping at home with everyday tasks, his level of social support and any safety measures that may need to be implemented in the home.
Everyday tasks are often referred to as activities of daily living (ADLs) and IADLS (Instrumental Activities of Daily living) ranging from washing, eating and dressing to using the telephone and paying bills.
Involved in this assessment are the occupational therapist, social worker, community health nurse, Barbara Delahunty and family GP, Dr Farmer (MMBS)
- Home Assessment
- Functional Assessment
The ACAT found Dr Zheng’s living environment to be safe and clean.There are some simple modifications identified that will make it safer for him. In order to address the issue of night time falling, the Occupational Therapist (OT) recommended the installation of a motion sensored night light, that will come on automatically if Dr Zheng is to rise during the night. In addition, grab rails have been installed in the bathroom and toilet and non-slip mats in all wet areas. All loose rugs have been removed, carpet edges fixed and electrical cords secured. An uncluttered furniture layout was suggested to avoid tripping hazards and creating a safe, familiar environment.
Even in severe cases, physical restraints are never recommended as they can contribute to the development of physical health problems.
The team enquired about how Mrs Zheng is coping with being the primary carer for her husband and discussed at length the different carer support options that are available. Respite services were also discussed. The Zheng family are aware that they can access support services and respite care for Dr Zheng through Carer Respite Services, HACC or ACAT.
Dr Zheng is has a loving family to help care for his safety, hygiene and nutrition needs.
He is currently unable to perform the majority of Activities of Daily Living (ADL’s) and Independent Activities of Daily Living (IADL’s) without some level of help and/or supervision. Specifically, he needs help with planning, daily hygiene and food preparation. Up until now, the Zheng family has been providing 100% of Dr Zheng’s care. A case manager has now been assigned to help establish a CACP and will continue to monitor or changes support services as required.
Mrs Zheng would still like to take charge of Dr Zheng’s showering, dressing, feeding and grooming but has agreed to some home help and community respite care arranged through HACC.
Unfortunately, Narembeen does not have a respite care facility, but in-home respite can be arranged for periods of a few hours up to a whole day, when Mrs Zheng feels she needs a break. Fortunately Narembeen is a close knit community. The case manager will keep a close watch on this to ensure that Mrs Zheng’s needs are also attended to and facilitate carer support where required.
All non-pharmacological approaches to behavioural symptoms of dementia should be considered in a person-centred framework.
It is important to maintain Dr Zheng’s comfort, security, connection to others, acceptance within his family and community and participation in activities that are meaningful. Click to find the advice given to the Zheng's regarding caring for Dr Zheng in the context of his challenging behaviours.
- Angry outbursts
- Wandering
- Hallucinations
Mrs Zheng is advised to speak with all friends and family to let them know her husband may be agitated or angry if they approach him too fast or get too close to him if he is unprepared. It is important that close contact with people is maintained, but it must be done in a way in which Dr Zheng is comfortable.
Restraints are rarely justified to prevent wandering, as they can increase agitation and the risk of physical health problems. To help prevent Dr Zheng from wandering outside, it is recommended that his family install a lock at the very top of the front and back door. His family should continue the bush walks, gardening and outdoor dancing as much as possible, to keep him stimulated and increase his exposure to different environments.
The Zheng’s are advised not to react to these with fear or tell Dr Zheng what he is seeing isn’t really there. Validation therapy is sometimes helpful and advocates that rather than trying to bring Dr Zheng back to their reality, they enter his reality. This develops empathy with the person and facilitates trust and a sense of security. Rather than correcting Dr Zheng’s beliefs, his family will aim to acknowledge and empathise with his feelings. For example, ”don’t worry, the snake won’t bite Jeremy. He is safe in his bedroom”.
Dr Zheng has only had one episode of visual hallucinations that really frightened him. He is not showing other signs of psychosis or overly aggressive behaviour, so pharmacotherapy is not considered appropriate at this time. If his hallucinations worsen, or if he becomes more aggressive or psychotic in the future, treatment with low dose Haloperidol or Risperidone may be considered to try and reduce his distressing symptoms. It is important to use very low doses to avoid harmful side effects.
As a family, the Zhengs will all start working on a “This is Your Life” book, to help Dr Zheng remember all the things that have happened to him throughout his life in China and in Australia. He will be encouraged to have as much input into this book as possible.
With the help of a CACP, the Zheng’s are able to manage Dr Zheng’s home care. The option of respite care and additional help around the home has ensured that both May and Mrs Zheng have more time to look after their own health and social needs.
You can now complete the post-module test to see how you went
Module Feedback
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The physiotherapy consult finds her Berg balance scale is 27/56. She has difficulty transferring, turning, reaching and balancing on one foot. The physio recommends some lower limb strengthening and gait exercises and some mild exercises to help rebuild her wasted quadriceps. It is important that Mrs Scott maintains participation in physical activity, in order to maintain muscle strength and joint range of movement and to improve her balance.
The physiotherapist prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for hands and her leg extensors (which can be performed as a home program).
The physiotherapist uses models of anatomy to explain the physiology of voiding and bladder control problems. To help reduce stress incontinence, Mrs Scott’s pelvic floor muscles are assessed and found to be lax. Mrs Scott has been performing the exercises prescribed by the NCA, so the physiotherapist checks her technique to ensure she is doing them correctly. Further advice was needed to refine technique. Mrs Scott is aware that she needs to do these exercises at least 5 times per day, every day in order to recondition her pelvic floor.
To further address urge incontinence Mrs Scott will perform timed voiding, as advised by the NCA.
Fortunately, Mrs Wood has a normal CT scan.
CT is a relatively inexpensive, quick and non-invasive scan that produces images of brain structures such as the grey matter, white matter, cerebrospinal fluid cavities and blood vessels. These images may also reveal abnormalities such as tumours, strokes, and head injuries. The role of CT imaging in the diagnosis of dementia is primarily one of exclusion. Evidence based guidelines suggest that structural neuro-imaging with either CT or MRI scan is appropriate in the routine initial evaluation of patients with dementia.
MRI is a structural neuro-imaging method that provides images of the brain and other anatomical structures. Some studies using MRI have demonstrated that medial temporal lobe (MTL) atrophy can be predictive of Dementia Alzheimer’s Type (DAT) and that has been associated with neuropsychological and post-mortem data. MRI may assist in the diagnosis of DAT.
An MRI may be obtained if it is suspected that the patient has dementia, however MRI is not required to make a diagnosis of dementia
Dr Zheng’s brain MRI is provided below:
Brain imaging indicates volume loss, consistent with dementia. No evidence of masses or vascular disease.
General Appearance:
Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Observations:
Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even
Cognitive Testing
MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.
Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.
General Appearance:
Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.
Height: 184cms
Weight: 98kg (which has remained constant)
Please move your cursor over Mr Scott as if you were examining him. You must complete the examination before you go on.
General Appearance:
Mrs Scott looks well. She is reactive but has restricted mobility.
Height: 164cms
Weight: 76kg (which has remained constant)
Please move your cursor over Mrs Scott as if you were examining her. You must complete the examination before you go on.
Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.
General Appearance:
No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.
Height: 160cms
Weight: 70kgs
Temperature: 37.1
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Appearance:
General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning looks happy and healthy.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning appears well. She is well presented, and is in high spirits.
Height: 178cms
Weight: 66kg (an increase of 1 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.
Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
