I met with a young patient who has dementia (F00.02 Dementia in Alzheimer's disease, early onset, severe) and his wife.
They'd had a chequered course before relocating to be with family, so moving in to my patch. They've input from social services, our local Alzheimer's Society branch, myself, my nursing colleagues and a Support Time and Recovery (STAR) worker. The patient's never been to hospital, we're all pretty community focussed and see them there to give advice (no Council Tax to pay, get Attendance Allowance etc), to give emotional support, to give practical support (our STAR worker visits once a week to care for him so his wife can pop out and get a break), to offer other helpful ways to cope (they're starting day respite with us tomorrow), to answer queries (this week they were wondering why his walking up stairs was worse) and to look at medication.
His MMSE is 2/30, his dementia is severe. Donepezil is being used to treat Behavioural and Psychological Symptoms of Dementia (BPSD) not to maintain cognitive levels any more. When his MMSE dropped from moderate to severe the donepezil was withdrawn. He became upset, irritable, distraught and withdrawn, shouting and resistsing personal care. When re-introduced he became active, animated and appreciative (most of the time) of his wife's input. The donepezil is doing the man good.
Now, with so many people involved, a lot of information was gained before I met with him and his wife. What was embarassing for the senior nurse was that the medication she said our patient was taking, "Just donepezil," wasn't quite true. She and I saw them this week. When I was talking about mood swings, irritability, frustration emerging when attending to ADLs and forgetfulness, his wife chipped in that she gave him an antidepressant they still had lying around, "but only once or twice a month." He also received over the counter medication for coughs, colds, constipation and pain too. The nurse was scarlet, couldn't believe that the history I got was so different from what she's ellicited just a couple days ago after spending 2 hours with them. I'd not see it as a big thing, they spoke at length with her about practical care but spoke at length with me about symptoms, progression and medication.
I remember as a junior doctor the injustice of me taking a lengthy history then my patient saying something different to my Registrar or Consultant. People do, though. It can be that going through things once then raises more thoughts. It can be that stirring thoughts around in that direction leads on to more detail and depth when asked again.
Anyway, one outcome from me spending an hour with them talking through their dementia care was that he regularly wasn't swallowing his medication. I don't feed at the trough at all, I don't take anything from drug companies (not even biros). But credit where it's due, their orodispersible donepezil is A Good Thing. She puts it on his tongue, it instantly melts and dissolves, all is well.
Without medication, he's unwell. With it, life's better for him and his wife. The medication's formulated in a way that folk with severe dementia can take it.