Preadmission diagnosis

The UK Medical Research Council Cognitive Function and Ageing Study suggests that the prevalence of dementia in over-65s in 2011 is actually lower (6.5%) than that predicted (8.3%) in 1991.^{Reference Matthews, Arthur and Barnes13} Nevertheless, less than half of people with dementia receive a formal diagnosis and many people with dementia and their carers are still not living well with the condition, and quality of life remains extremely varied. One-third of the people with dementia live on their own in the community and two-thirds of them feel lonely.¹⁴ Early detection and timely intervention with provision of highest quality care to those who have dementia is widely promoted. However, screening for dementia in the general population could lead to over treatment, unnecessary expense and diverting resources from those who have been diagnosed with dementia. Therefore screening for dementia is controversial and there is insufficient evidence to recommend for or against routine screening for dementia in primary care.^{Reference Le Couteur, Doust, Creasey and Brayne10,Reference Brayne, Fox and Boustani15–17}

Onset and progression

The typical age of onset varies according to the type of dementia, but in general it is uncommon before the fifth decade. Frontotemporal dementia has an earlier age of onset than Alzheimer's disease (AD). Dementia due to AD has an insidious onset and a gradual progression. Vascular dementia can have an abrupt onset following one particular ischaemic episode, or there may be more gradual emergence.

Cognitive deficits^{Reference Kansagara and Freeman18,Reference Grand, Caspar and MacDonald9}

Amnesia: Complaints about poor memory are the most frequent presention of dementia. In addition to deficits in episodic memory (e.g. personally related events occurring in a specific situation) there are accompanying losses in semantic memory (e.g. facts and vocabulary) and visuospatial memory (e.g. remembering pictures or faces)

Aphasia: Deficits in cortical language production may occur. The earliest manifestation is word finding difficulties and usually an impairment in the naming of objects (nominal aphasia). As dementia progresses problems in the comprehension of language develop (receptive aphasia) and expression of language shows syntactical errors and simplification of sentence structure. In severe stages there is marked poverty of speech, with the repetition of short simple sentences on favourite themes, and eventually mutism may occur.

Executive functions: Damage to the frontal lobes and their connections leads to inflexibility in thinking, and difficulties in problem solving, planning and sequencing.

Acalculia: Patients may show an inability to read, write and comprehend numbers.

Apraxia: There may be a failure to carry out complex motor tasks due to deficits in central higher cortical control of movement. Ideomotor apraxia refers to the inability to carry out a motor task to command (e.g. asking a patient to wave). Dressing dyspraxia refers to difficulty in sequencing their order of clothing and constructional apraxia is the failure to adequately reproduce a two- or three-dimensional drawing.

Agnosia: This is inability to recognize scenes or objects despite normal visual acuity and fields. (e.g. mistaking the dustbin for the toilet or the kettle for the teapot). Prosopognosia is failure to recognize a familiar face.

Behavioural changes^{Reference Kansagara and Freeman18,Reference Hooker, Bowman and Coehlo20}

Mood changes: Alterations in mood are extremely common in dementia, with depression being the most common. Major depression has been reported in 21% of dementia patients in clinical settings and 13% in the community.^{Reference Ballard, Patel, Solis, Lowe and Wilcock21} Depression decreases quality of life of dementia sufferers and may reduce the duration of survival.^{Reference Burns, Lewis, Jacoby and Levy22}

Apathy: This is diminished motivation manifesting itself as listlessness in which the patient has lost the drive to engage in activities. Apathy is probably the most common (72%) behavioural change in AD in the community.

Agitation: Painful inner tension associated with excessive motor, verbal or vocal activity may occur. Examples of motor activity include repetitive, purposeless movements including pacing, restlessness, wandering, foot tapping, fiddling with clothes or other objects. Vocal agitation includes repetitive utterances, groaning and shouting.

Psychotic symptomsReference Nagahama, Okina, Suzuki, Matsuda, Fukao and Murai²³

Hallucinations are defined as ‘perceptions occurring in the absence of a stimulus’ and occur in 20–30% of patients with AD. Visual hallucinations are more prevalent in patients with Lewy body dementia (LBD) (70–80%). Delusions are common in dementia and often include beliefs that objects have been stolen, a spouse has been unfaithful, or that intruders have been in the house.

Medications

Drug prescribing increases with age and number of co-morbidities.^{Reference Ramage-Morin29} Polypharmacy is defined as either use of five or more concurrent medications, or at least one potentially inappropriate drug. Half of older people aged between 65 and 74 years and two-thirds of those aged 75 and over, are affected by polypharmacy including conventional and complementary medicines.^{Reference Morgan, Williamson, Pirotta, Stewart, Myers and Barnes30} This is associated with adverse outcomes including hospital admissions, falls, delirium and mortality.^{Reference Hilmer and Gnjidic31,Reference Jyrkkä, Enlund, Korhonen, Sulkava and Hartikainen32} It is often difficult to establish a clear association between a specific drug and cognitive disturbance as multiple factors are involved in causing cognitive decline, but the risk of drug-related cognitive toxicity increases with the number of medications prescribed. The classes of drugs that commonly impair cognition and function include narcotic analgesics, sedatives, tricyclic anti-depressants, anti-histamines and anti-cholinergic drugs. There is conflicting evidence that psychotropic medications are associated with higher numbers of falls in people with dementia,^{Reference Taylor, Lord, Delbaere, Mikolaizak and Close33,Reference Banerjee34} though there is clear evidence that these medications are associated with increased falls risk in cognitively intact people.^{Reference Hartikainen, Lonnroos and Louhivuori35} Histamine H2 receptor antagonists, digoxin and beta-blockers can also cause acute or chronic confusion. Other classes of drugs that can result in acute confusion include Parkinson's disease (PD) medication, anti-convulsants, steroids and fluoroquinolone antibiotics.^{Reference von Moltke, Greenblatt, Romach and Sellers36} Drugs that either singly or in combination could impair electrolytes, causing postural hypotension, hypothermia, gait disorder or gastrointestinal disturbance, can indirectly lead to worsening confusion or function. Thus older people presenting with a new onset confusion or worsening cognition should have their medications reviewed and withdrawal of any possible offending agent, if practical, would be logical. Drugs given to older people with cognitive impairment should be prescribed with great care, adhering to the principle of ‘starting low and going slow’.^{Reference Milton, Hill-Smith and Jackson37}

Activities of daily living

Low scores or poor performance on formal cognitive screening in the absence of functional disability is not sufficient to diagnose dementia. The impact of cognitive impairment should be demonstrated to effect global functioning. The ADLs initially affected are complex or instrumental ADLs, like shopping, handling finances, driving, cooking, or using the telephone, followed by basic ADL including bathing, dressing, toileting, transfer, continence or feeding. Therefore functional assessment is mandatory before a diagnosis of dementia can be established.

Mild dementia may not present with obvious functional impairments and cognitive deficits can be hidden by carer support. However, it is not uncommon to see older people with worsening dementia presenting to healthcare services with ‘inability to cope’ or ‘social admission’, due to increasing functional dependence after death of a spouse. The assessment of functional limitations is best completed by careful interview of the person and someone who knows them well and direct observation of the person's abilities.

There are many validated scales to complete functional assessments, including the Katz index of independence in activities of daily living (Katz ADL),^{Reference Katz, Ford, Moskowitz, Jackson and Jaffe38} the modified Blessed dementia scale (DS),^{Reference Erkinjuntti, Hokkanen, Sulkava and Palo39} the instrumental activities of daily living scale (IADL)^{Reference Lawton and Brody40} and the Functional Assessment Questionnaire (FAQ),^{Reference Pfeffer, Kurosaki, Harrah, Chance and Filos41} Functional Assessment Staging Test (FAST),^{Reference Sclan and Reisberg42} Barthel Activities of Daily Living Index,^{Reference Mahoney and Barthel43} Alzheimer's Disease Co-operative Study – Activities of Daily Living Inventory (ADCS-ADL),^{Reference Galasko, Bennet and Sano44} Disability Assessment for Dementia (DAD)^{Reference Gélinas, Gauthier, McIntyre and Gauthier45} and Bristol activities of daily living.^{Reference Bucks, Ashworth, Wilcock and Siegfried46}

All scales have their own advantages and limitations, but all can potentially help discriminate mild dementia in comparison with those with no cognitive impairment. The scales that assess complex social functional activities are better in detecting dementia compared with those scales that involve basic ADLs.^{Reference Juva, Mäkelä and Erkinjuntti47} The Functional Assessment Staging Test (FAST) is one of the most well validated measures of the course of AD.^{Reference Sclan and Reisberg42} It is a seven-stage scale that follows a sequence of gradual functional loss from normal ageing to severe AD. Evidence of an acute skip forwards in the stages in FAST can help alert the clinician of possible delirium or an acute vascular event. ADCS-ADL is an inventory of informant-based items to assess basic and instrumental ADL for patients with AD. It is appropriate to apply in community and institutional care settings. DAD is very sensitive to measure clinically significant change in functional abilities of an individual with dementia living in the community, but is of limited value in the hospital setting.

Timely recognition of functional difficulties may arrest further decline, postponing the need for care home placement. The functional assessment scales can only provide guidance on different stages of dementia and are not widely used in everyday clinical practice, but are standard practice to assess efficacy of treatment in research studies.

Mobility and falls risk

Dementia is associated with impaired mobility and is an independent risk factor for falling.^{Reference Ballard, Shaw, Lowery, Mckeith and Kenny48} People with dementia are 2–3 times more likely to fall,^{Reference Tinetti, Speechley and Ginter49} but an incidence has been reported up to 8 times that of controls.^{Reference Allan, Ballard, Rowan and Kenny50} There is a paucity of adequate studies evaluating fall risk factors in cognitively impaired older people.^{Reference Härlein, Dassen, Halfens and Heinze51} However, dementia severity,^{Reference Kobayashi, Kusuma Wati, Yamamoto, Sugiyama and Sugai52} unstable gait,^{Reference Kobayashi, Kusuma Wati, Yamamoto, Sugiyama and Sugai52} impaired stability when standing^{Reference Taylor, Lord, Delbaere, Mikolaizak and Close33,Reference Whitney, Close, Jackson and Lord53} and ADL limitations^{Reference Whitney, Close, Jackson and Lord53,Reference Salva, Roque and Rojano54} have been shown to be associated with increased risk of falling in dementia. Falls risk is higher in people with LBD and Parkinson's disease dementia (PDD)^{Reference Ballard, Shaw, Lowery, Mckeith and Kenny48,Reference Allan, Ballard, Rowan and Kenny50} and falls are more common in the presence of behavioural disturbances like wandering or agitation, incontinence and overactive bladder symptoms. Exposure to polypharmacy has been associated with falls in people with dementia, although the use of psychotropic medications has conflicting evidence for higher falls risk in dementia patients.^{Reference Taylor, Lord, Delbaere, Mikolaizak and Close33,Reference Banerjee34}

Physical activity interventions for people with intact cognition have been shown to be effective in improving balance and reducing falls, but there is lack of evidence for exercise as an intervention for fall prevention in older people with cognitive impairment. A systematic review on exercise programmes concluded there was no significant improvement in gait and balance in older people with dementia,^{Reference Suttanon, Hill, Said and Dodd55} but a recent study showed significant improvement in motor performance and balance after an exercise programme in frail older people with mild to moderate dementia, though falls as an outcome was not studied.^{Reference Hauer, Schwenk, Zieschang, Essig, Becker and Oster56} Multifactorial interventions were not effective in preventing falls in older people with cognitive impairment and dementia presenting to the accident and emergency department after a fall.^{Reference Shaw, Bond and Richardson57} However, CGA, management and rehabilitation in a specialized orthogeriatric ward compared with usual care on the orthopaedic ward has been shown to reduce falls post-operatively, both overall and in participants with dementia.^{Reference Stenvall, Olofsson and Lundstrom58}

Falls in patients with dementia will remain a challenge, but it is possible that multifactorial interventions for potentially modifiable factors could reduce incidence of falls in patients with mild to moderate dementia. All patients with dementia should have assessment of their bone health and prescription of vitamin D, calcium and/or bisphosphonates if appropriate should be considered. Nursing home residents with dementia are at highest risk of sustaining injury after a fall and should have falls prevention strategies in place.^{Reference van Doorn, Gruber-Baldini and Zimmerman59} The medication review, simple flexible muscle strengthening and a balance training exercises programme, and management of symptomatic postural hypotension and depression could be the core elements to reduce falls in people with dementia.^{Reference Allan, Ballard, Rowan and Kenny50,Reference Tinetti, Baker and McAvay60}

Oral and dental hygiene

Higher levels of oral diseases and conditions including dental caries, dental plaques, and missing teeth have been reported in people with dementia.^{Reference Chalmers and Pearson61} Poor oral health can be commonly observed and it is challenging to provide good and regular oral hygiene care to older people with dementia. Oral hygiene can be compromised secondary to impaired sensory functions, reduced physical dexterity, functional dependence and behavioural problems which include reluctance and resistivity to support basic oral hygiene. Medications including anti-cholinergics, diuretics, anti-depressants and anti-psychotics can result in adverse effects on oral health. Other possible reasons leading to poor oral hygiene include medical conditions like diabetes, swallowing problems, functional dependence, salivary gland dysfunction, and inadequate use of dental care or lack of teeth.^{Reference Chalmers and Pearson61}

The Oral Health Assessment Tool (OHAT) for dental and oral health status screening has been validated for use by nursing staff in care home residents^{Reference Kayser-Jones, Bird, Paul, Long and Schell62} including those with cognitive impairment^{Reference Chalmers, King, Spencer, Wright and Carter63} and might usefully be applied in hospital settings. Enhanced engagement of carers with oral hygiene care strategies, timely identification of oral health problems and appropriate use of dental consultations are effective in preventing oral diseases.

Skin problems

Older people in general are at higher risk of skin problems including pruritus, eczematous dermatitis, purpura, venous insufficiency and pressure ulcers. Risk of pressure ulcers increases with severity of dementia, due to associated restricted mobility and poor oral intake. Other factors that can result in pressure ulcers are sarcopenia, loss of protective fat, dehydration, incontinence, behaviour problems, polypharmacy and poor expression of personal physical needs. Pressure ulcers can be prevented if early signs of skin damage are detected and treated. General personal hygiene, healthy balanced diet, avoiding excessive heat and moisture, avoiding friction and promoting continence and mobility are usually sufficient to reduce risk of pressure ulcers.

Elimination and toileting needs

As dementia advances, people usually encounter urinary incontinence initially, followed by faecal incontinence. They may have difficulty in expressing their needs to use the toilet, identifying the bathroom and its appropriate use at later stages. The progress to these problems can be very upsetting for the person and caregivers and may lead to hospitalization. Continence assessment is an essential part of the person-centred dementia care plan, where care should be equally centred on the cognitive deficits, physical abilities, functional capabilities and psychological impact of suffering from dementia. Continence problems can be secondary to impaired mobility, arthritic pain, inappropriate clothing or dexterity. Lack of a healthy balanced diet or dehydration can lead to constipation.

Drug reviews, identification of urinary tract infection and management of constipation or enlarged prostate all contribute to a broad appraisal of continence issues. Assessment of precipitating factors and promotion of regular toileting, easy accessibility to toilet and use of walking aids can reduce elimination problems. Use of appropriate continence pads and limiting fluid intake in the evenings may reduce nocturnal incontinence. Drugs are available for overactive bladder, but need very careful prescribing after formal assessment as they have limited efficacy and may worsen cognition and behaviour.

Vision and hearing

Individuals with hearing loss are prone to develop dementia,^{Reference Lin, Metter, O’Brien, Resnick, Zonderman and Ferrucci64} and hearing loss is commonly reported in people with dementia. All patients with hearing impairment require thorough examination and presence of dementia should not preclude assessment for a hearing aid. Hearing aids do not improve cognitive function or reduce behavioural disturbance, but have been shown to improve global measures of change.^{Reference Allen, Burns and Newton65}

Sight loss is common in people with dementia, is under-diagnosed and can complicate accurate assessment of ADLs. People with dementia may further experience visuoperceptual difficulties like visual hallucinations, colour misperception and problems with background contrast and depth perception. Diagnosis by involving optometrists to assess vision, or ophthalmologists to examine eyes for the causes of sight loss, is a first step in defining appropriate interventions. Simple measures such as regular eye sight testing, wearing the correct glasses, minimizing visual and physical obstacles, using colours and contrasts to mark out different areas and assistive technologies, such as automatic lights, audio labels or audio books, can minimize the risks and improve outcome.

Pain

Pain should be considered to be the fifth vital sign, as discomfort and distress can lead to BPSD and may result in inappropriate sedative prescriptions.^{Reference Corbett, Husebo and Malcangio66} Pain assessment involves a holistic evaluation of the person on first presentation of pain, followed up with regular review. Pain assessment should include the site of pain, type, precipitating factors and impact of pain on the individual. In those individuals who cannot verbally communicate, observation or collateral history from a caregiver is often helpful.^{Reference Achterberg, Pieper and van Dalen-Kok67}

Physical examination should look for for any skin bruise or infection, constipation, reduced range of joint movement, vertebral tenderness, or recent injury or fracture. There are several pain scales available that can be used at different stages of dementia. The numerical rating scales are most useful in the earlier stages of dementia. In the later stages it is usually a history from a caregiver, or change in a person's behaviour that helps in evaluation of the severity of pain. However, specific pain screening tools such as ‘Assessment of Discomfort in Dementia (ADD)’ are available. ADD is a systematic tool that can be used by nurses to make a differential assessment and treatment plan for both physical pain and affective discomfort experienced by people with dementia. The tool involves assessing pain history, physical examination and administration of analgesics and giving analgesics as needed.^{Reference Kovach, Noonan, Griffie, Muchka and Weissman68}

Nutrition

Poor nutrition is one of the major health problems faced by those caring for older people, but in people with dementia it is especially challenging to maintain good nutrition. There can be a loss of taste and smell in the early stages of dementia, in addition to reduced appetite and dry mouth. Cognitive impairment and inability to communicate lead to progressive difficulties in obtaining food or planning cooking. Nutrition is often overlooked in favour of other aspects of care. The UK National Dementia Audit report in 2013 showed disappointing results overall and a lack of attention to basic care needs.^{Reference Young, Hood, Gandesha and Souza5} Nutritional assessments were undertaken in fewer than 10% of patients in some hospitals.^{Reference Young, Hood, Gandesha and Souza5}

Nutritional assessment should start with estimating the degree of malnutrition, dietary intake and habits, other risk factors like poor oral hygiene, presence of any behavioural problems, constipation, pain or simply needs for assistance during meal time. In addition understanding the feeding skills of the person with dementia could play an important role in maintaining health and wellbeing. The person with dementia may simply forget to eat or drink, and therefore need regular prompting or assistance at mealtimes. Better interaction between the nurse or carer providing assistance and the person with dementia is associated with a better dietary intake.^{Reference Riviere, Gillette-Guyonnet and Andrieu70} Regular nutritional assessments using the Malnutrition Universal Screening Tool (MUST) can be helpful to identify those who are malnourished or at risk of malnutrition.^{Reference Elia69} It is a five-step screening tool and has been validated to be used both in hospitals and community by all care workers.

Psychological needs, socio-cultural and spiritual considerations

The concept of person-centred care in dementia rests on several important principles: the human value of those being cared for, individuality, personality and life experiences, the importance of the person's perspective, and the significant value of relationships and interactions with others. Carer needs and support to help enhance the care given to the person with dementia is emphasized by the term ‘relationship-centred care’.^2,3 These principles can be recalled by the acronym VIPS – value, individualization, perspective and social/psychological. Psychological/practical strategies used to stimulate the mind of those with dementia include reminiscence, cognitive stimulation therapy, multisensory stimulation and music and art therapy.^{Reference Røsvik, Kirkevold, Engedal, Brooker and Kirkevold71} As dementia advances ‘failure free’ activities are important.

Treatment and care should take into account patients’ needs and preferences, past and present and their decision-making capacity. People with dementia should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals and family. The Mental Capacity Act (UK) provides a statutory framework for decision making on behalf of adults aged 16 or over who lack capacity to consent to their care or treatment.⁷² The act also aims to balance an individual's right to make decisions for themselves with their right to be protected from harm if they lack capacity to make decisions to protect themselves. Concerned professionals may arrange multidisciplinary ‘best interest meetings’ surrounding important decisions for those who lack capacity, in liaison with carers.

Only since the mid-1970s has the term ‘dementia’ been used for older people with significant cognitive impairment. In developed countries and western societies, dementia is now mostly considered as a disease process. However, in other parts of world it is often still viewed as a normal part of ageing, brought about by a range of causes including spirits.^{Reference Downs73} The social meaning of ageing may differ among ethnic groups, class and gender and there may be stigma attached to the diagnosis of dementia. It is important to assess a person's language, ethnic background, cultural beliefs, personality, education, family experience, socioeconomic status and life experience to complete dementia assessment holistically and to provide person-centred care.

Spirituality is regarded as a basic characteristic of all people, vital to health and wellbeing and, for those of religious faith, this relationship gives meaning and purpose to life. With the emphasis on person-centred care in dementia it is important to consider spirituality in effective care planning.

Mental state examination

This considers the following categories:

Appearance and behaviour: evidence of self-neglect and poor personal hygiene, clothing appropriate to the season, sensory impairments, apathy, engagement and rapport, eye contact.

Speech: rate, volume content, dysphasia, dysarthria, dysfluency, dysphonia, perseveration, echolalia, agitation, psychomotor retardation.

Mood: anxiety, depression, elevation, incongruity, lability.

Thoughts: cognitive speed, confabulation, paranoid delusions, misidentification syndromes (e.g. mirror sign).

Perception: hallucinations – visual (LBD/delirium) musical, tactile and less commonly auditory.

Cognition: using a screening tool, for example Addenbrooke's Cognitive Examination that examines orientation, attention, memory, verbal fluency, language and visuospatial skills.

Insight: can cause distress and frustration.

Cognitive screening tools and high-risk groups

Screening tools for diagnosing dementia and other causes of cognitive impairment in patients in general hospitals are not well studied.^{Reference Jackson, Wilson and Sheehan74} A diagnosis is usually reached when a carer or relative raises concerns about memory or safe discharge to the original place of residence during hospital admission. In the UK, screening is currently not recommended in primary care and community settings, as there is lack of convincing evidence of cost benefit and effectiveness. It also raises training issues for social and healthcare staff. However, screening for dementia should be applied to older people falling into high-risk categories, for example those with a history of delirium, PD, recurrent falls or stroke.

Delirium was a strong risk factor for incident dementia and cognitive decline in the oldest-old in a population-based cohort study.^{Reference Davis, Muniz Terrera and Keage75} Delirium has also been reported to be associated with faster decline in cognitive test scores in memory clinic patients.^{Reference Fong, Jones and Shi76} The diagnosis of delirium and its duration has been reported to be independently associated with risk of long-term cognitive impairment and also acceleration of decline in existing dementia in the hospitalized patient in care of elderly medical wards^{Reference Witlox, Eurelings, de Jonghe, Kalisvaart, Eikelenboom and van Gool77}, or surgical^{Reference Robinson, Raeburn, Tran, Angles, Brenner and Moss78,Reference Lundstrom, Edlund, Bucht, Karlsson and Gustafson79} or intensive care settings.^{Reference Girard, Jackson and Pandharipande80}

In PD, cognitive impairment is one of the most common and disabling non-motor symptoms but it is not routinely screened for in clinical practice. The prevalence of mild cognitive impairment in new or early diagnosed patients with PD (PD-MCI), varies from 20 to 30%,^{Reference Foltynie, Brayne, Robbins and Barker81–Reference Wang, Zhang, Li, Wen and Xu83} whereas the point prevalence rate of dementia in PD is about 40%.^{Reference Aarsland, Andersen, Larsen, Lolk and Kragh-Sorensen84}

Recurrent falls^{Reference van Doorn, Gruber-Baldini and Zimmerman59} may be the first indicator of impaired memory, judgement, orientation or visuospatial perception. The incidence of falls in older people with cognitive impairment and dementia is more than double in comparison with cognitively intact older people.^{Reference Tinetti, Speechley and Ginter49}

Stroke is a risk factor for dementia and 10% can develop new dementia soon after first stroke, and more than a third after recurrent stroke. The strong association of multiple strokes and post-stroke dementia warrants optimum acute stroke care and secondary prevention in reducing the burden of dementia.^{Reference Pendlebury and Rothwell85}

Co-ordination and integration of health and social care

Multidisciplinary team working, information sharing and communication among staff, carers and patients is necessary to ensure that all staff coming into contact with people suffering from dementia are aware of their diagnosis and associated needs. ‘This is Me’ or a similar document can be used to record personal information, preferences and communication requirements.⁸⁶ Developing a dementia champion role^{Reference Crabtree and Mack87} and access to old age liaison psychiatry may enhance team working and care of people with dementia in general hospitals, though they have a poor evidence base. The RAID (Rapid Assessment Interface and Discharge) service has shown an effective, enhanced service model for older people who are at risk for dementia and has shown good outcomes with quality improvements in the care of older people.^{Reference Singh, Ramakrishna and Williamson88} The development of a rapid response and comprehensive team integrated into the everyday working of an acute hospital may lead to significant savings in health service provision.

All people with suspected dementia or known dementia using in-patient services should be assessed by a specialist with interest in dementia or old age psychiatry liaison team in order to have a joint care plan with social care professionals and relatives.^{Reference Singh, Ramakrishna and Williamson88} Health and social care managers should co-ordinate and integrate working across all agencies involved in the treatment and care of people with dementia and their carers⁸⁹ and a combined care plan by health and social care services should be in place to address their specific needs. The frequency of formal reviews should be agreed and a responsible named health or social care staff member should be assigned for each person with dementia.⁸⁹

Documentation of cognitive impairment among hospitalized older individuals has shown to be insufficient.^{Reference Young, Hood, Gandesha and Souza5,Reference Laurila, Pitkala, Strandberg and Tilvis90} Discharge plans should record details about ongoing health care needs of people with dementia and BPSD observed by staff. The discharge summary should also include discussions undertaken with the patient and their carers about appropriate place of discharge.

Drug treatment

Three acetylcholinesterase inhibitors (AChEi) are used for mild to moderate AD, and all are available in oral formulation. Donepezil has an additional advantage of an orodispersible preparation, galantamine is available in syrup form and rivastigmine as a topical skin patch. For moderate or severe AD and those who are intolerant of, or have contraindications to the use of AChEi, the N-methyl-D-aspartate receptor antagonist memantine can be used. All of these medication may also play a role in some patients to help control non-cognitive symptoms, e.g. apathy, irritability, aggression and hallucinations.

Those who are a significant risk to themselves or others due to aggression should be managed in a low stimulation environment and clinicians should aim for an optimal response without sedation. However, drugs may have to be used for severe aggression or psychosis when the person is a serious threat to themselves or others, and the lowest effective dose should then be used and monitored closely. Oral medication should be the first choice. NICE guidelines for dementia recommends specific drugs if the intramuscular route is employed, namely haloperidol or lorazepam.

Palliative care

Dementia is often not seen as a life-threatening illness and end-of-life care received is often poor, and is not equal to other life-limiting illnesses.^{Reference Crowther, Wilson, Horton and Lloyd-Williams91} The frequency of common symptoms experienced by people with dementia is similar to those in cancer patients, but people with dementia experience the symptoms for a longer period and need more help from social services.^{Reference McCarthy, Addington-Hall and Altmann92} Most very old individuals with severe dementia in the community die away from usual place of residence, and hospitals remain the most common place of death.^{Reference Perrels, Fleming and Zhao93}

Ideally, health and social care professionals should discuss preferences with the person with dementia while they still have capacity and record advance care planning statements, advance decisions to refuse particular treatments, preferred place of care in future and lasting power of attorney.^{Reference Crabtree and Mack87}