What is ‘early onset dementia’?

There are two types of dementia with early onset: (i) presenile dementias; and (ii) senile dementias with early onset. Most patients who develop dementia before 65 years of age have Alzheimer's disease (AD). The remainder are likely to have vascular dementia (VaD), frontotemporal dementia, head injury, alcohol intoxication, or metabolic disorder. Presenile dementias, caused by frontotemporal lobar degeneration, progressive supranuclear palsy, and corticobasal degeneration, usually occur in patients of presenile and are rarely seen in patients of senile age. Although the factors responsible for the accelarted onset of the illness are not fully known, genetic abnormalities appear to be important in some types of presenile dementia, such as frontotemporal dementia with parkinsonism linked to chromosome 17. Conversely, senile dementias such as sporadic AD and VaD commonly occur in patients of senile age. These disorders may also occur in patients of presenile age, although less frequently. Alzheimer's disease was originally classified as a ‘presenile dementia’. Since the 1980s, ‘senile dementia of Alzheimer type’ (SDAT) and ‘Alzheimer's disease’ have been considered to belong to the same pathological entity and both are now known as ‘dementia of Alzheimer's type (DAT)’ or merely ‘Alzheimer's disease’. Rapid progression of cognitive impairment with neuropsychological syndromes and neurological symptoms has been considered a characteristic of early onset AD. However, recently, neurological symptoms such as spastic paraparesis, seizures, and myoclonic convulsions have been reported to occur infrequently in early onset AD, although language problems and visuospatial dysfunctions are common. There are at least three dominant genes that have been identified in cases of familial Alzheimer's disease with early onset, namely the amyloid precursor gene (APP), and the genes encoding presenilin 1 (PSEN1) and presenilin 2 (PSEN2). Therefore, genetic abnormalities are important factors contributing to the earlier onset of the illness. It is also important to investigate the pathophysiological mechanism in relation to genetic abnormalities, environmental factors, physical illnesses, and metabolic disturbances to understand the processes underlying the development of dementia with early onset.     

‘IMPAIRED JUDGEMENT’ A USEFUL SYMPTOM OF DEMENTIA?

‘Impaired judgement’ remains a diagnostic (and predictive) criterion for delirium, dementia and substance-related disorders, and yet its diagnosis and measurement are hampered by the absence of an operational definition. Most of the important research into judgement as a psychological function has been carried out in developmental and industrial psychology, in the experimental analysis of perception, medical diagnosis and legal decision-making. Models generated in these fields, although important, are only tangentially relevant to ‘impaired judgement’ as it is met with in clinical practice. This article explores some models of judgement and their application to dementia. It concludes that judgement is not a unitary function but a composite of subroutines. Hence, both low- and high-level analyses are required: the former to explore aetiology, differential diagnosis and treatment, the latter for the assessment of psychosocial competence. A model for the understanding of judgement is also suggested.     

‘What becomes of demented patients referred to a psychogeriatric unit?’ An approach to audit

A 1-year follow-up study was undertaken of a random sample of 40 elderly patients living at home given a diagnosis of "dementia" after referral to the Psychogeriatric Department at St Charles' Hospital, London, W10. Eighteen (45%) patients were admitted to institutional care. There was an association between physical disability and institutionalization. A similar tendency was observed for social disturbance and hospital admission. The 1-year survival rate for the sample was 82.5%. All the seven patients who died were moderately/severely demented. Twenty-three patients (55%) had informal key carers. Half of these showed considerable stress according to the General Health Questionnaire and the Strain Scale scores. All the recommendations made by the psychogeriatric team were carried out without much delay.     

‘Are you allowed to say that?’ using video materials to provide accessible information about psychology services

The White Paper ‘Valuing People’ [ Department of Health (DoH) (2001) Valuing people: a new strategy for learning disability for the 21st century, London, HMSO] indicates that people with a learning disability need to become more actively involved in the decisions that affect their lives. This includes being offered active choices in access to health services. Psychologists, therefore, need to think about how to give people with learning disabilities enough relevant information in an accessible way to promote informed consent to treatment. This study investigates how much information adults with mild and moderate learning disabilities understand about psychology services, before and after watching a video designed to explain what seeing a psychologist entails. The video was shown to 19 participants at a local Social Education Centre. Participants’ knowledge increased significantly after watching the video. They were able to answer questions about its content better when asked after short sections of the video when presented, rather than after an uninterrupted presentation.     

‘DO NOT RESUSCITATE’: HOW? WHY? AND WHEN?

Objective. The main objective was to discover who had ‘Do Not Resuscitate’ (DNR) status, why, how, when and by whom these decisions were made. Design, setting and patients. The medical and nursing notes of all inpatients (139) (age range 16–100 years) in an inner city district general hospital on a single day were examined to determine the resuscitation status, age, sex and diagnosis of each patient. Result. A decision not to resuscitate had been taken in 28 (20%) of the cases. ‘Do Not Resuscitate’ (DNR) patients were significantly older and more likely to suffer from malignant and cardiorespiratory disease. Patients with dementia and other psychiatric disorders were not significantly more often labelled DNR. Evidence of consultation for these decisions was lacking and the recording erratic. Conclusions. (1) There is a great need to devise and implement comprehensive guidelines. (2) There is need for appropriate and comprehensive documentation outlining the reasons why and how the decision was taken, who was consulted and review date. (3) This is an important area for audit.