Dementia

The Medicine of the Older Person symposium was held on Thursday 19 March 2020 at the Royal College of Physicians of Edinburgh.

The head turning sign was first described as such more than 20 years ago but only recently have empirical studies of the sign in large cohorts of patients being assessed for cognitive disorders been reported. Although precise operationalisation of the sign has differed between studies, nevertheless it appears to be frequently observed in cognitive clinic patient cohorts, more so in Alzheimer’s disease than in other dementias and with an intermediate frequency in mild cognitive impairment.

When close to death, people stop eating. In neurodegenerative conditions swallowing may become unsafe, and artificial nutrition and hydration (ANH) may be proposed or requested. But nutrition is surrounded by other considerations: opportunity, help, environment, enjoyment, mood, social being and symbolic importance. Poor care or deliberate attempts to end life might also result in poor nutrition and dehydration.

The prevalence of dementia in the UK is rising rapidly and is predicted to double over the next 30 years. The NHS in England has been told to push for a rapid rise in dementia diagnosis rates, so that by 2015, two out of three cases are identified. The Prime Minister has raised the ‘dementia challenge’ as a priority for the NHS. While there is agreement on the need for action, debate arises over the nature of that intervention.

When Bridget Driscoll, a 44-year-old mother of two died after being struck by a motor vehicle, considered to be the first motor vehicle fatality in UK and possibly the world, the coroner stated ‘I trust this sort of nonsense will never happen again’.1 Sadly, the coroner, medical practitioners and general public would be deeply and repeatedly disappointed. It was 1896. Motor vehicles were a curiosity. Drivers did not undergo any form of testing, be it medical fitness, driving ability or otherwise, and there were no licensing regulatory agencies.

This symposium covered a wide range of conditions of interest to the geriatrician, the general physician and the general practitioner, including demographic shift, the epidemiology of ageing, diabetes in older people, investigation and management of falls, an update on stroke (including the role of neurovascular clinics, stroke thrombolysis and rehabilitation) and the management of coronary heart disease in the elderly.

Parkinson’s disease is a chronic, progressive, neurodegenerative condition that damages central nervous system pathways. In addition to the wellrecognised motor features of the disease, patients commonly experience nonmotor symptoms including neuropsychiatric complications. These symptoms may precede motor symptoms and have a very significant impact on quality of life for patients and their carers.

Keywords Dementia, depression, impulsivity, neuropsychiatric, Parkinson’s, psychosis

Recent research has thrown considerable doubt on the claim that King George III suffered from variegate porphyria, but indicates that he suffered recurrent attacks of mania as part of his bipolar disorder. George III’s last episode of ill health occurred during the final decade of his life (1810–20). This has been diagnosed as chronic mania with an element of dementia. During this period the king was blind and possibly deaf, which may have contributed to his psychiatric condition.

An immunocompromised patient with non-specific neurological symptoms and signs, along with rapid cognitive decline evolving over three to four weeks, can present a diagnostic challenge. Here we report rapidly progressive dementia in a patient with systemic lupus erythematosus, who was subsequently diagnosed with sporadic Creutzfeldt-Jakob disease (sCJD). This case illustrates the need for prompt investigations to consider an alternative diagnosis where significant history fails to yield an explanation.