Table of Contents
Introduction
- Wash hands
- Introduce self
- Ask Patient’s and relative’s names
- Explain the need for a collateral history
- Establish their relation to the patient
Presenting complaint
- Confusion/memory loss
History of presenting complaint
- Onset: determine if it is acute, chronic, or acute-on-chronic (establish baseline function and cognition)
- Progression: slowly progressive (Alzheimer’s), step-like (vascular)
- Triggers: infection, stress
- Associated symptoms
- Depression
- Psychiatric symptoms: hallucinations/delusions
- Behavioural change: agitation, aggression, wandering, disinhibition, calling out
- Sleeping pattern: awake at night (Alzheimer’s), early morning waking (depression), fluctuating consciousness (delirium)
- Cognitive disturbances: aphasia, apraxia, agnosia, difficulty planning/organising
Past medical history
- Ask about: Parkinson’s disease, vascular disease/diabetes, head injuries, recent infections
- Psychiatric history
Drug history
- Blood pressure/diabetes medication
- Parkinson’s drugs
- Alzheimer’s drugs: galantamine, donepezil, rivastigmine
- New medications
- Allergies
Family history
- Related conditions, e.g. dementia, vascular disease, depression
Social history
- Living situation, carer/home support
- Mobility/walking aids
- Effect on function/coping with activities of daily living: washing, dressing, cooking, cleaning
- Working/driving
- Smoking, alcohol and other cardiovascular risk factors
- RISK
- To self: wandering, leaving gas on, abuse, neglect by self or others
- To others: aggression, risky behaviour
- Carer’s needs: empathise with the demands; ask about stress, coping, and support
Ending
- ICE (Ideas, Concerns, Expectations): how does the relative/carer expect you to help? What are they worried about?
- Summarise situation and patient needs. Thank relative.
Causes of dementia
- Alzheimer’s: most common; prevalence increases with age; some genetic association. Slowly progressive. Presents with memory/cognitive impairment (5A’s: Anomia, Apraxia, Agnosia, Amnesia, Aphasia). Due to generalised atrophy of cortex with amyloid plaques and neurofibrillary tangles.
- Vascular Dementia: stepwise deterioration. Often have multiple cardiovascular risk factors. May have focal neurology. CT head may show areas of ischemia or small vessel disease.
- Lewy-Body Dementia: progressive dementia with daily fluctuations of awareness due to Lewy bodies in the cerebral cortex. Parkinsonian features (e.g. bradykinesia, tremor, rigidity) and psychiatric symptoms (e.g. hallucinations) are common.
- Other causes/differentials: frontotemporal lobe dementia, Creutzfeldt-Jakob disease, depression (‘pseudodementia’), HIV, Huntington’s disease, normal pressure hydrocephalus, space-occupying lesion, nutritional deficiencies (thiamine, nicotinic acid, B12), alcohol abuse, neurosyphilis, hypothyroidism, autoimmune/paraneoplastic