Mohammed T. Abou-Saleh

ACUTE MANAGEMENT OF DEMENTIA 315they ease the load on carers and help them to feel less alone withthe problem. An incontinence service providing pads andcollecting soiled sheets and garments for laundering is a hugehelp. Financial recognition of the work that has to be done in theform of an attendance allowance is often greatly appreciated,although the sum may not be great. Day hospitals and respiteadmissions have been demonstrated to reduce scores measuringstress and strain in carers 19 . Relatives’ support groups, personalcounselling by a community psychiatric nurse, social worker,psychologist or doctor and, where feelings in the household arerunning high, family therapy 20 , may all have their place. It isimportant for the key worker to keep in touch with the situation,to be easily available and able to offer extra assistance, e.g.admission to hospital or a home, as and when that is needed. Thecredibility of the service is seriously jeopardized if the help that allrecognize to be required cannot in fact be given.An interesting field study in Cambridge 21 randomly divideddemented people living alone or at home with others into thosewho received routine care and those who received extra homecare. Extra care made no significant difference to those living withothers, but those living alone were far more likely to be in aresidential home 2 years into the study if they were getting extracare than if they were not! This was less a demonstration of theineffectiveness of community care than an indication that thosewho received it were correctly placed where they needed to be atthe appropriate time.The demented who live alone are especially in need of closemonitoring by the key worker. Those who will accept help areobviously an easier proposition than those who will not. Thehome help is the chief provider of ‘‘hands-on’’ care, and may berequired from 2 h/week to 6 h/day (at which stage, of course, thecost is not negligible). Meals on wheels not only support nutritionbut also provide regular human contact, as do lunch clubs, daycentres and day hospitals for those who can make their way thereor be taken to them. Community (‘‘district’’) nurses may getpatients up, bathe them, help them to bed and give theirmedication—but the supply of such skilled staff is not limitless.Reliable, trustworthy volunteers are useful in befriending, doingsmall chores and running errands. Financial arrangements need tobe made with banks, post offices, lawyers, social workers andwhoever either holds the power of attorney or has been nominatedas the Receiver by such a body as England’s Court of Protection 22 .Demented people seriously at risk who refuse help mayoccasionally be compelled into care or placed on a guardianshiporder under mental health legislation (UK) 22 . This, or the decisionnot to take such an action, is usually the result of a caseconference, often convened by a social worker, and attended byrelatives, neighbours, nurses, home helps and their organizers, thegeneral practitioner, the psychiatrist and perhaps concernedvolunteers, clergy and the police. Often the conclusion is thatwhat cannot be achieved by persuasion cannot be achieved, so aclose eye is to be kept on the subject of the conference until he/shebecomes more willing to accept help, falls ill and goes intohospital or dies, or confounds expectations by living on in muchthe same state for years!Staff in hospitals and homes need to be trained to givedemented people proper care, by example and experience as wellas by precept. The inculcation of respect is a good starting point—breezy, patronizing familiarity may give offence. It is important tolearn not to take umbrage, to blame, to accuse of attentionseekingor provocation and to avoid futile arguments. A spacious,bright, cheerful environment and a full, appropriate programme,including some conversation, entertainment (a sing-song is muchpreferable to the ubiquitous television, but people should be freeto opt out), exercise and bringing visitors into the regime help toprevent problems arising from boredom and inaction.Alertness to health problems may prevent some of theexacerbation of confusion by physical illness. Depression afflictsnot a few demented people, causing agitation and restlessness byday and night. A trial of antidepressant therapy is indicated, butthe old antidepressants are too powerfully anticholinergic,sedative or hypotensive to be the first choice. Serotonin-specificreuptake inhibitors are to be preferred, and citalopram 20 mgdaily has been shown to improve depressive symptoms indementia in a placebo-controlled study 23 . Rarely, in those whoappear severely depressed, are not eating and who may have ahistory of severe depression, there could be a place forelectroconvulsive therapy.A full day’s activities reduce sleep problems (and patients canoften catch up on their sleep by day) but carers need sleep, and theuse of a hypnotic for a restless patient may thus be justified. Noneis ideal, but among those to be considered are temazepam, a verypopular benzodiazepine, 20–40 mg (which may induce a hangover);zopiclone, a cyclopyrrolone, 3.75–7.5 mg; chlormethiazole,a short-acting drug which occasionally causes sneezing, 250–500 mg, at night; or chloral hydrate, in tablet form (the equivalentof 414 mg in a tablet), one or two at night.There is no perfect neuroleptic in old age psychiatry: all cancause as much trouble from side effects, notably drowsiness,extrapyramidal symptoms and falls, as any benefit they bring.Demented people seem particularly susceptible to such side effectsand to tardive dyskinesia 24 . However, where the urgent control ofa very disturbed patient is necessary in a setting where alternativesare not practicable, one of the major tranquillizers may bewarranted 21 . The butyrophenone haloperidol, 5–10 mg i.m. or i.v.(often with procyclidine 10 mg through the same needle to preventacute extrapyramidal reactions) is a most useful drug, and can berepeated up to 6-hourly. Once the acute crisis is over it may bereplaced by one of the newer, ‘‘atypical’’ antipsychotics, risperidone(0.5–2 mg, twice a day), olanzepine (5 mg once or twice aday), with fewer extrapyramidal side-effects than haloperidol 25and shown by meta-analysis 26 effectively to ameliorate symptomsof psychosis, aggression and agitation. Very popular, andreasonably safe, although quite sedative and anticholinergic, isthioridazine, 10–100 mg, up to four times a day.REFERENCES1. Department of Health. Epidemiological Overview of the Health ofElderly People. London: Central Health Monitoring Unit, 1991.2. Bergmann K, Foster E, Justin A et al. Management of the dementedelderly in the community. Br J Psychiatr 1978; 132: 441–7.3. Gilleard C, Gilleard E, Gledhill K et al. Caring for the elderlymentally infirm at home: a survey of the supporters. J EpidemiolComm Health 1984; 38: 319–25.4. Reisberg B, Ferris S, de Leon M, Crook T. The global deteriorationscale for assessment of primary degenerative dementia. Am J Psychiat1982; 139: 1136–9.5. Wade J, Hachinski V. Multi-infarct dementia. In Pitt B, ed., Dementiain Old Age. Edinburgh: Churchill Livingstone, 1987.6. Burns A, Jacoby R, Levy R. Psychiatric phenomena in Alzheimer’sdisease. III: Disorders of mood. Br J Psychiat 1990; 157: 81–6.7. Norman A. Mental Illness in Old Age: Meeting the Challenge.London: Centre for Policy on Ageing, 1982.8. Homer A, Gilleard C. Abuse of elderly people by the carers. Br Med J1990; 301: 1359–62.9. Johnston M, Wakeling A, Graham N, Stokes F. Cognitiveimpairment, emotional disorder and length of stay of elderlypatients in a district general hospital. Br J Med Psychol 1987; 60:133–9.10. Pitt B. The mentally disordered old person in the general hospitalward. In Judd F, Burrows G, Lipsitt D, eds, Handbook of Studies onGeneral Hospital Psychiatry. Oxford: Elsevier, 1991.