dementia is a progressive and largely irreversible clinical syndrome that is characterised by widespread impairment of mental function 
associated with a decline in activities of daily living and impairment in social function 
is often preceded by mild cognitive impairment, eg subtle problems with day to day memory, planning, language, attention 
most common causes are :
usually insidious in onset
develops slowly but steadily over several years
predominantly affects older people
due to small vessel disease or multiple infarcts
often follows a fluctuating course and may follow a stepwise pattern (although not necessarily) [24,25] − onset can be gradual in people with subcortical ischaemic vascular dementia
progressive dementia with microscopic protein deposits
associated with Parkinson's disease symptoms
other dementias include:
other focal dementias, eg posterior cortical atrophy 
mixed dementias − includes AD with vascular dementias, and AD with DLB 
early-onset (or young-onset) dementia refers to dementia that develops before age 65 years – it is relatively uncommon, accounting for 2% of people with dementia in the UK
Incidence and prevalence:
dementia affects about 800,000 people in the UK 
dementia is principally a disease of older people, affecting :
1.5% of people age 65-69 years
2.4% of people age 70-74 years
6% of people age 75-79 years
13.3% of people age 80-84 years
20% of people age 85-89 years
AD accounts for about 60% of cases 
vascular dementia accounts for 15-20% of cases 
DLB accounts for about 15% of cases although is widely believed to be under diagnosed [7,25]
neuroimaging shows there is a strong overlap between Alzheimer's disease and vascular dementia 
General risk factors include :
Down's syndrome and other learning disorders
history of psychiatric problems, particularly depression 
limited social network
risk factors for cardiovascular disease:
excessive alcohol consumption
lack of or limited exercise 
depends on the cause of the dementia 
varies from person to person since the course of the condition and pattern of symptoms varies 
median survival from onset estimated at 7 years for AD 
early-onset dementia tends to progress more rapidly 
almost all people with dementia eventually develop a range of cognitive difficulties (memory, language, attention/orientation, visuoperceptual, executive function)  as well as one or more psychological, or behavioural problems (behavioural and psychological symptoms of dementia [BPSD]), eg:
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
An information sheet to hand out to patients and carers about local support groups is attached
Part of the Reading Well Books on Prescription for Dementia scheme - Available to borrow free of charge from North Somerset public libraries
First Steps to Living with Dementia by Simon Atkins
Dementia Positive by John Killick
Hearing the Person with Dementia: Person-Centred Approaches to Communication for Families and Caregivers by Bernie McCarthy
Dancing with Dementia: My Story of Living Positively with Dementia by Christine Bryden
Dear Dementia: The Laughter and the Tears by Ian Donaghy
Still Alice by Lisa Genova
Losing Clive to Younger Onset Dementia: One Family’s Story by Helen Beaumont
Telling Tales About Dementia: Experience of Caring By Lucy Whitman
The Little Girl in the Radiator: Mum, Alzheimer’s and Me by Martin Slevin
But Then Something Happened: A Story of Everyday Dementia by Chris Carling
For relatives and carers:
When Someone You Love Has Dementia by Susan Elliot-Wright
And Still the Music Plays: Stories of People with Dementia by Graham Stokes
Can I Tell You About Dementia? A Guide for Family, Friends and Carers by Jude Welton
Dementia: Support for Family and Friends by Dave Pulsford and Rachel Thompson
10 Helpful Hints for Carers: Practical Solutions for Carers Living with People with Dementia by June Andrews and Allan House
Seeing Beyond Dementia: A Handbook for Carers with English as a Second Language by Rita Salomon
The person with dementia may demonatrate disturbed behaviour as a result of a relatively straight forward problem which could be solved without specialist input.
It is helpful to work through some of the common potential causes of behavioural disturbance (see 'Apply PAIN approach to problem solving' box below) before requesting specialist input.
PAIN is an acronym which helps to ensure that potential causes of disturbed behaviour are systematically considered:
· P = Physical problems i.e. medical review for e.g. infection; pain
· A = Activity-related, e.g. dressing , washing
· I = Iatrogenic e.g. side effects of drugs e.g. psychiatric and CNS treatments
· N = Noise i.e. consider the physical environment
Pain is a common cause of behavioural problems in people with dementia.
May be missed as some people with dementia may not express the presence of pain in the usual way.
Paracetamol has been shown to be effective at improving behavioural problems, is safe and compatible with most other medications.
Constipation is a recognised contributor to behavioural problems.
The carer may be able to report problems with bowel movements if the person with dementia cannot.
Regular laxitives can be safe and effective.
Review medication that might be contributing to constipation and discontinue if possible (e.g codeine, anticholinergics)
Infection should always be considered as a possible cause, particularly of the urinary tract or chest.
Urinary tract infection (UTI):
Early empiric treatment of UTI may rapidly resolve problems
If treatment is successful, consider supplying the carer with urine sample pots and an emergency supply of a suitable antibiotic in anticipation of the situation recurring - this may be effective at preventing the need for acute admission of the patient
Consider documenting any specific behavioural symptoms and successful treatment
Empiric treatment of chest infection may rapidly resolve behavioural problems, particularly if there is co-existent lung disease
If treatment is successful, consider supplying the carer with an emergency supply of a suitable antibiotic in the event of the situation recurring - this may be effective at preventing the need for acute admission
Consider documenting any specific behavioural symptoms and successful treatment
Environmental triggers to behavioural problems cannot usually be easily identified from the type of behaviour but include:
a change of environment (e.g. moving house, admission to hospital or care home)
a change of carer
new co-residents in the care home
over stimulation (e.g. loud noises, bright lights)
Management of these problems may involve:
carer education and reassurance
modification of lighting
provision of quiet place for the person to sit at busy times
Once an effective change has been identified, recording it may help manage future behavioural problems for that person
Depression should be considered where behavioural problems exist. Interventions include:
daily psychosocial intervention involving 10-30 minutes of one-to-one conversation or activity tailored to the person's interests, ability and past experiences. This may be delivered by the main carer, a friend or a member of the family
singing, particularly favourite old songs
completion of a personal preferences leaflet such as This is me is particularly useful if the person is in a care home.
Sleep disturbances may be reported by the patient or carer. Approaches to improve the sleep pattern could include:
reduce day time napping
encourage day time activities like singing, walking
agree with the carer realistic expectations of sleep duration
short-term low dose of sedative drug use (e.g zopiclone)
If mild to moderate symptoms adopt a watchful waiting approach. Contact family for their views; consider non-pharmalogical approaches e.g.
NICE supported alternatives, such as
specialist psychological therapy which focuses on understanding the roots of the behavioural problem and thereby modifying it.
Consider specialised psychosocial support: for patient and carer.
See nodes below if referral required at this stage to AWP via the Primary Care Liaison Service.
Only consider pharmacological treatment if there is psychosis, depression or behaviour where there is extreme risk of distress.
There is little evidence base for the treatment of behavioural and psychological sypmtoms of dementia (BPSD) in vascular dementia or stroke related dementia. The cholinesterase inhibitors (donepezil, galantamine, rivastigmine) and memantine are not licensed for the treatment of pure vascular dementia and should not be used. Prescribers are advised to follow the guidance for Alzheimer's Disease but to use with extreme caution drugs with an established increased cerebrovascular risk (i.e. antipsychotics)
Please see the attached useful guidelines on prescribing choices from Southern Health NHS Foundation Trust
The use of either typical or atypical antipsychotics in patients with dementia worsens cognitive function; increases the risk of cerebrovascular events (~3x) and increases mortality rate (~2x).
They should only be used after full discussion with the patient (where the patient has capacity to understand) and carer about the possible benefits and likely risks. Risk is likely to increase with increasing age and if other risk factors for cerebrovascular events are present e.g. diabetes; hypertension, cardiac arrhythmias; smoking and existing evidence of stroke or vascular dementia.
If antipsychotic treatment is considered necessary avoid typical neuroleptics and start atypical doses low (usually one half normal elderly dose, such as Risperidone 250mcg) and increase every 2 -4 days if no response.
Patients who respond to treatment should have the drug cautiously withdrawn after 6-12 weeks. Halve the dose for two weeks and if no re-emerging symptoms stop after a further 2 weeks. Review again after one week. If symptoms re-emerge reintroduce the drug at starting dose. Behaviour and Psychological Symptoms of Dementia can persist and treatment with atypical antipsychotics may be needed in the long term but should be reviewed on a 3 monthly basis.
Patients with Dementia with Lewy Bodies or Parkinson's Disease Dementia are particularly vulnerable to neuroleptic sensitivity reactions and also have marked extrapyramidal side effects. Advice from a specialist is advised before starting neuroleptics.
Urgent Referrals to the Primary Care Liaison Service
PCLS will no longer be accepting urgent referrals by letter or fax, this must be done via telephone to 01934 836406
If they receive any urgent referrals this way they will be contacting your surgery to inform you that the GP will need to telephone and discuss the referral with a clinician due to the potential severity and risk.
Please also note that all routine referrals sent to PCLS must include your patient summary.
The PCLS referral form is available as an EMIS template