14.2 Dementia Care and the Irish National Dementia Strategy
Key Takeaways
- RCSI lists Dementia as a topic heading citing the Irish National Dementia Strategy, Alzheimer Society of Ireland material on diagnosing dementia, and the 4AT, and names dementia as a current example for the older person care OSCE station.
- The Irish National Dementia Strategy was published by the Department of Health in December 2014 and set out six priority action areas including better awareness and understanding, timely diagnosis and intervention, integrated services, training and education, research and information systems, and leadership.
- Alzheimer's disease is the commonest cause of dementia, followed by vascular dementia, dementia with Lewy bodies and frontotemporal dementia, and mixed pathology is common in older people.
- People with dementia with Lewy bodies have a marked sensitivity to antipsychotic medication, which can cause severe and sometimes irreversible reactions.
- Behavioural and psychological symptoms of dementia are usually communication of an unmet need, so the response is to look for pain, infection, constipation, fear, boredom or overstimulation before considering medication.
Dementia Care and the Irish National Dementia Strategy
RCSI lists Dementia as a topic heading, citing the Irish National Dementia Strategy, Alzheimer Society of Ireland material on diagnosing dementia, and the 4AT. Dementia also appears as a current example for the older person care OSCE station, alongside deconditioning and frailty. RCSI's reading list further includes the NMBI professional guidance on working with older people.
What Dementia Is
Dementia is a syndrome, not a single disease: a progressive, acquired decline in two or more cognitive domains - memory, language, executive function, attention, visuospatial ability, social cognition - sufficient to interfere with everyday independence, in the absence of delirium.
| Type | Approximate share | Characteristic features |
|---|---|---|
| Alzheimer's disease | The commonest cause | Insidious onset; early short-term memory loss; word-finding difficulty; gradual, steady decline |
| Vascular dementia | Second commonest | Often stepwise decline after cerebrovascular events; early executive dysfunction and slowed processing; focal neurological signs; shares risk factors with stroke |
| Dementia with Lewy bodies | Less common but important | Fluctuating cognition, vivid visual hallucinations, parkinsonism, REM sleep behaviour disorder, frequent falls, and marked antipsychotic sensitivity |
| Frontotemporal dementia | Younger onset | Early personality and behavioural change, disinhibition, loss of empathy, or progressive language impairment, with memory relatively preserved early |
Mixed pathology - most often Alzheimer's with vascular disease - is common in older people, so features overlap in practice.
The safety point. In dementia with Lewy bodies, antipsychotic medication can provoke severe, sometimes irreversible sensitivity reactions with marked rigidity, reduced consciousness and autonomic instability. This is one reason why reaching for an antipsychotic in a distressed person with dementia is not a neutral act.
Diagnosis
Diagnosis rests on history - including collateral history, which is essential - cognitive assessment, physical examination, and investigations to exclude reversible contributors: thyroid function, vitamin B12 and folate, calcium, glucose, renal and liver function, infection screen, and brain imaging where indicated. Depression and delirium must both be excluded or treated, because either can mimic dementia.
Timely diagnosis is a priority of the National Dementia Strategy. It allows the person to plan while they still have capacity - to make an advance healthcare directive, appoint a decision-making assistant or co-decision-maker under the Assisted Decision-Making (Capacity) Act 2015, arrange their affairs and access supports.
The Irish National Dementia Strategy
The Irish National Dementia Strategy was published by the Department of Health and launched in December 2014. It set out six priority action areas, with objectives and actions under each:
- Better awareness and understanding - reducing stigma and improving public and professional understanding of dementia.
- Timely diagnosis and intervention - supporting earlier diagnosis and access to post-diagnostic support.
- Integrated services, supports and care for people with dementia and their carers - including home supports, day services and improved acute hospital care.
- Training and education for the health and social care workforce.
- Research and information systems - building the evidence base and better data.
- Leadership - national oversight and implementation.
The strategy contained 35 actions in total and has since been reviewed and built on, including through work on a national model of care for dementia. For the test, the examinable core is that Ireland has a national dementia strategy, published in December 2014 by the Department of Health, organised around these priority action areas - and that its emphasis on timely diagnosis, integrated community support and workforce education shapes how dementia care is expected to be delivered.
Person-Centred Dementia Care
The governing idea is that the person is not reducible to their diagnosis: identity, biography, relationships and preferences persist, and care either supports personhood or erodes it.
Practical expression on a ward:
- Know the person. Use the personal information document the family completes - what they like to be called, their history and occupation, their routine, what comforts them, what distresses them, how they take their tea.
- Preserve routine. Keep to the person's usual times for waking, eating and sleeping wherever the ward allows.
- Support independence. Prompt and enable rather than take over. Doing everything for someone accelerates functional loss.
- Involve the person in decisions to the greatest extent possible. Capacity is decision-specific and time-specific, and the Assisted Decision-Making (Capacity) Act 2015 presumes capacity until the contrary is shown.
- Support the carer. Family carers are partners in care with expertise you do not have, and their own health and exhaustion are legitimate clinical concerns.
Communication
| Do | Avoid |
|---|---|
| Approach from the front; make eye contact; say who you are each time | Approaching from behind or startling |
| Short, simple sentences; one instruction at a time | Long explanations with multiple steps |
| Allow time - silence while the person processes is not a gap to fill | Rushing, finishing sentences, speaking for them |
| Closed or two-option questions where open ones overwhelm | Open questions requiring recall of detail |
| Use gesture, demonstration and visual cues | Relying on speech alone |
| Validate the emotion behind what is said | Arguing, correcting or reality-orientating harshly |
| Reduce background noise; ensure glasses and hearing aids are in place | Competing with a television and three conversations |
On correcting the person. If someone asks to go home to a spouse who died years ago, repeatedly telling them their spouse is dead makes them grieve afresh each time. Acknowledge the feeling, respond to what is underneath it, and redirect: "You're missing him. Tell me about him." That is not lying; it is responding to the emotion rather than litigating the fact.
Responding to Distressed Behaviour
Behavioural and psychological symptoms of dementia - agitation, calling out, resistance to care, wandering, aggression, apathy - are best understood as communication of an unmet need by someone who can no longer articulate it.
Work through the possibilities before reaching for medication:
| Possible need | Check |
|---|---|
| Pain | Use a behavioural pain tool; consider a trial of analgesia - untreated pain is a leading cause of agitation in dementia |
| Toileting | Urinary retention, constipation, a full bladder, needing help to the toilet |
| Infection or delirium | Screen with the 4AT; an acute change in a person with dementia is delirium until proven otherwise |
| Hunger, thirst, temperature | Basic comfort needs |
| Fear and disorientation | Unfamiliar place and faces, being woken by strangers, procedures not explained |
| Overstimulation | Noise, lights, too many people, a busy bay |
| Understimulation and boredom | Nothing to do for twelve hours |
| Sensory deprivation | Missing glasses and hearing aids |
| Medication | New drugs, anticholinergics, withdrawal |
Then apply non-pharmacological responses: a calm and consistent approach, meaningful activity, music, reminiscence, family presence, and a walk rather than a chair alarm. Medication is a last resort for severe distress or risk, at the lowest effective dose for the shortest time, with a documented review date - and with particular caution in suspected Lewy body dementia.
The Hospital as a Hazard
Admission is genuinely dangerous for a person with dementia. It is unfamiliar, noisy, disorientating, and full of interventions that tether people to beds.
| Risk | Nursing response |
|---|---|
| Delirium superimposed on dementia | Screen with the 4AT on admission and repeat; never attribute new confusion to the dementia |
| Falls | Falls risk assessment, familiar footwear, lowered bed, call bell in reach, supervised mobility, avoid restraint |
| Functional decline and deconditioning | Get the person up, dressed in their own clothes and moving; Get Up, Get Dressed, Get Moving applies directly |
| Malnutrition and dehydration | MUST screening, finger foods, assistance, protected mealtimes, coloured crockery to aid visual contrast, food and fluid charts |
| Pressure injury | Reduced mobility and reduced ability to report discomfort; SSKIN bundle |
| Ward moves | Minimise them; each move resets orientation |
| Being lost in the system | Use the ward's dementia identifier where one exists, so every member of staff knows to adjust their approach |
| Communication at discharge | Involve the carer from day one; dementia-specific discharge planning, public health nurse, home supports, day services and Alzheimer Society of Ireland supports |
RCSI's reading list also includes the JAM Card - the "Just A Minute" card, which a person can show to indicate they need a little more time and patience. Recognising and responding to it is a small, concrete marker of dementia-aware and disability-aware practice.
A woman with moderate Alzheimer's disease repeatedly asks to go home to her husband, who died six years ago. Each time she is told he has died she becomes acutely distressed. What is the most appropriate response?
A patient with dementia with Lewy bodies becomes agitated at night. A colleague suggests requesting an antipsychotic. What is the most important consideration?
Which statement about the Irish National Dementia Strategy is accurate?