Treatment

• Delirium
• Dementia
• Alzheimer’s disease
• Vascular dementia
• Dementia with Lewy Bodies (DLB)
• Frontotemporal dementia (Pick’s disease)
• Prion diseases
• Huntington’s disease
• Head Injury

Delirium (Acute confusional state, acute organic syndrome)

Management involves identifying and treating the underlying cause, careful nursing and use of medication to relieve agitation.

Dementia

Most causes of dementia are incurable. A few are reversible, for example normal pressure hydrocephalus, chronic sub-dural haematomas, benign tumours, chronic hypocalcaemia, hypothyroidism, Addison’s disease, hypopituitarism, Cushing’s disease, vitamin B12 and B1 deficiency, and infections such as neurosyphylis and infections associated with HIV.

In recent years, drug treatment has become available which may improve certain features of Alzheimer’s disease, such as memory. The drugs currently licenced for use in the UK are acetyl cholinesterase inhibitors and Memantine, a NMDA receptor antagonist.

Other drugs such as anti-psychotics may be used to control symptoms such as anxiety or agitation. Depression may be treated with antidepressants.

Alzheimer’s disease

The mainstay of treatment is social support and increasing assistance with day-to-day activities.

At some point residential nursing care is likely to be required. The trigger for this is likely to be a behavioural aspect rather than cognitive decline. For carers, the commonest “management difficulties” are severely disrupted sleep pattern or aggressive behaviour.

The management of Alzheimer’s disease has changed in recent years with the recognition that the rate of deterioration can be slowed by the use of medication. The drugs currently licenced in the UK are the:

Acetylcholinesterase inhibitors that include Rivastigmine (brand name Exelon), Galantamine (brand name Reminyl) and Donepezil (brand name Aricept) are recommended for use in mild and moderate Alzheimer’s disease. Treatment should only be initiated by a specialist physician. They produce modest improvements in cognition in 25 to 50% of patients.

People with mild dementia may be followed up for monitoring of progression to a stage when Acetylcholinesterase inhibitors may be appropriately prescribed.

The NMDA (N methyl D aspartate) receptor antagonist - Memantine (brand name Ebixa) is approved for use in moderate to severe Alzheimer’s disease.

Vascular dementia

Treatment is directed at the underlying cause, for example by treating cardiac emboli (blood clots from the heart) or hypertension. Some studies have shown acetylcholinesterase inhibitors to be effective but they are not currently licensed for use in this condition.

Dementia with Lewy Bodies (DLB)

In addition to the treatment of Parkinsonism and psychiatric symptoms, some studies have shown acetylcholinesterase inhibitors to be effective but they are not currently licensed for use in this condition.

Fronto-temporal dementia (Pick’s disease)

There is no specific treatment.

Prion diseases

There is no specific treatment.

Huntington’s disease

There is no specific treatment for the dementia.

Head Injury

Initial assessment and treatment is carried out in the Accident and Emergency Department. People with the more severe head injuries are admitted for assessment and further treatment.

Once the person’s condition is stable, they are usually transferred to a rehabilitation unit, which provides long-term treatment, initially as an inpatient, and subsequently as an outpatient.

Recovery from traumatic brain injury is complex and variable and can take a very long time. Initial recovery is very rapid but various functions may recover over different time scales making it a very difficult problem to assess and manage.

Rehabilitation is carried out by a multidisciplinary team, has to be tailored to individual needs, and requires that the person and the family is involved from the start.

The multidisciplinary team includes doctors (neurologists and rehabilitation physician), nurses, physiotherapists, occupational therapists, psychologists, speech therapists, social workers and orthoptists. Treatment for physical problems includes prevention of contractures, management of spasticity, retraining of movement control and co-ordination and management of communication difficulties.

Management of cognitive impairment requires assessment of the extent of impairment and subsequent disability by a clinical neuro-psychologist. Natural recovery can take up to two years, further small changes can take place over five years or more from the date of injury and there is debate as to whether neuro-psychological treatments accelerate recovery. However, coping strategies can be designed that reduce disability. Treatment of behavioural problems involves the use of behavioural modification techniques.

Depression, anxiety and occasionally more profound psychiatric disorders such as psychosis, mania or obsessive compulsive disorder are amenable to standard psychiatric treatment.

Personality changes and emotional problems are managed by counselling or formal psychotherapy although there is debate about the effectiveness of these interventions; provision of information to family and employers; support to carers in the form of information, counselling, advice, practical help at home and respite breaks.

Later rehabilitation involves retraining of independent living skills such as cooking, shopping and community mobility and social skills and ongoing behavioural management for inappropriate social behaviour

In legal settlements it is now common for a case manager to be appointed to coordinate the wide range of health, social and employment professionals involved in rehabilitation.

Amended May 2011