Assess the Caregiver
While collateral information from the caregiver is essential in the assessment of dementia, be sure to assess for caregiver stress and implement strategies to decrease it. You can use these strategies:
- Enlist additional supports, both informal and formal, for example, by referring the patient to a home care agency.
- Support the caregiver in managing challenging behaviours.
- Discuss the role of respite care.
- Identify and treat caregiver depression.
- Provide psychoeducation and direct caregivers to psychoeducational and self-help materials (see the resources section on page 249).
Assess Functional Abilities
Any change in functional abilities in older adults should trigger an evaluation for dementia.
Assessing functional abilities is emphasized here because dementia and comorbid medical conditions may affect functioning.
The level of support necessary to care for a person with dementia in the community will depend on how functional abilities affect self-care.
Obtain reports from the patient and caregivers about any change in activities of daily living. Instrumental activities are impaired before basic activities of daily living.
Review changes in these basic activities of daily living:
Review changes in these instrumental activities of daily living:
- household maintenance
- finance management
- meal preparation
- telephone use (especially knowledge of emergency contacts)
- medication management.
Cessation of driving is inevitable for all older adults with progressive dementia. Discussions about driving cessation should begin early in the course of illness.
With patients who have early dementia, discuss strategies to reduce risk of accidents. This can include limiting driving to familiar environments, driving only while supervised, driving only in the daytime and minimizing distractions in the vehicle.
Moderate to severe dementia is a contraindication to driving. Moderate dementia involves the loss of two or more instrumental activities of daily living. Severe dementia indicates an inability to perform one or more basic activities of daily living.
Canadian guidelines suggest that cognitive impairment associated with loss of ability to complete two instrumental activities of daily living means that the person is likely unfit to continue driving. (See the publication Determining Medical Fitness to Operate Motor Vehicles in the resources section.)
- Consider medical problems and medications that may elevate the risk for unsafe driving.
- Be familiar with your province’s requirements for reporting fitness to drive.
- Beyond dementia, assess other critical factors required for driving (i.e., mobility, vision, emotional stability, other medical conditions).
Review the patient’s driving history, asking about:
- recent accidents or near misses
- incidents of becoming disoriented or lost while driving
- previous driving habits.
Assess Capacity for Treatment, Managing Finances and Personal Care
Capacity refers to the ability to understand information about decisions and to appreciate how that information applies to the person’s situation. Capacity is task- and situation-specific. Incapacity in one area does not necessarily mean that the person is incapable in all areas of decision making.
There are several important areas to assess in determining capacity:
- treatment decisions
- consent to long-term care
- testamentary capacity (ability to complete a will)
- capacity to assign a power of attorney.
Assess Future Plans
Discuss matters such as:
- writing wills
- making advanced directives
- assigning powers of attorney for care and finances
- planning for advancing care needs (home supports, long-term care).
Involve the family in discussions about the course of dementia and long-term care planning.
- The Primary Care Practitioner Role
- Screening & Assessment
- Resources & References