Teaching session for GP registrars

1. Teaching session for GP registrars • Dr Mohinder Kapoor • Consultant Psychiatrist

2. TOPICS • RISK ASSESSMENT & MANAGEMENT • DEMENTIA • MOOD DISORDERS

3. Primary care: Older people are high users of primary care time and resources High prevalence of Dementia & Depression Public Health Older people over-represented in many care settings More treatments available e.g. anti-dementia drugs etc, with cost implications Treatment outcomes affected by psychiatric illness… Why is old age psychiatry important?

4. Dementia

5. Dementia across UK Current estimate is there are 700,000 dementia sufferers in UK Expected to double to 1.4 m in 30 years Total cost of dementia in the UK - £17 billion per annum Tripling £51billion pa in 30 years

6. Figures for Calderdale population prevalence over 65 (dementia (total) sufferers) 2010 32,100 1605 2015 36,600 1830 2020 39,800 1990

7. Facts about dementia Common but not inevitable part of aging Most of us will (or do) experience dementia directly or through someone we care about 2 thirds of people with dementia live in their own homes in the community Quality of life is as much related to the richness of interactions and relationships as to the extent of the brain disease

8. Prevalence of dementia

9. Epidemiology • Incidence rates approximately doubles with each decade over 60 • Prevalence of AD was 3% in 65-74 (Evans et al. 1989). • In the 75-84 year cohort the figure was 18.7% • 1 in 50 aged 65-70 have dementia • In the 85-94 the figure rose to 47.2%. • Currently 700,000+ people in the UK • 18,500 (2.5%) aged under 65 • Fewer cases in ethnic minorities • Risk in learning disability

10. Early diagnosis 20-40% of people with dementia receive a formal diagnosis Often too late At a time of crisis Too late for effective intervention

11. Overview of dementia Dementia (meaning "deprived of mind") is a serious cognitive disorder. Dementia is a word for a group of symptoms caused by disorders that affect the brain. Memory loss is a common symptom of dementia. However, memory loss by itself does not mean you have dementia. It is characterized by three main symptomatic domains, as shown below. Activities – inability to perform activities of daily life Behaviours – psychiatric symptoms/behavioural disturbances Cognition – neuropsychological impairments

12. Socioeconomic Impact • 150,000 people thought to be in residential/nursing home care in UK • require 24 hour care • approximate cost £20,000 per year • Assuming 50% suffer from AD - total cost of AD residential care is >£1 billion • The annual cost of treating and caring for people for AD in the UK is £5 billion.

13. AD and other dementias • Direct and indirect costs • Treatment costs • Financial and emotional costs to family • Great need for effective well organised systems of service delivery • Elderly overlooked in planning mental health and other services • Older people in community suffer from untreated depression/dementia • May lead to premature institutionalisation

14. Dementia defined • “a syndrome due to disease of the brain usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement.” • not a disease in its own right • deterioration in intellectual functioning and social behaviour • presents in a variety of ways: • causal condition • individual concerned • does not affect the brain uniformly

15. Dementia syndromes • Categorised by: • their nature • degenerative – Alzheimer’s disease, Frontotemproal dementia, Lewy Body Disease, Progressive supranuclear palsy, Huntington’s disease • vascular – multi-infarct • traumatic – head injury • infective – AIDS, prion diseases

16. Dementia syndromes • Or, categorised by: • their site • cortical – Alzheimer’s disease – cognitive changes most notable • sub-cortical – Parkinson’s – neurological and physical symptoms • multi-focal – prion diseases – severe cognitive and physical problems

17. Risk factors (AD) • Age • Inherited risk • Female • Head injury • Educational attainment • Smoking (protective) • Metal ions

18. Relative frequency • Alzheimer’s disease 55% • Vascular dementia 20% • Lewy body dementia 15% • Others 10% • questions re diagnosis of Alzheimer’s • pure AD rarely seen in clinical practice

19. Dementia Early-amnesia Yes No Behaviour changes, non-fluent aphasia Apraxia, agnosia, Fluent aphasia Parkinsonian features , Hallucinations Focal neuro signs FTD AD DLBD VAD

20. Dementia 80 year old presents with his wife to the GP. His wife is concerned because she has noticed a gradual impairment of his memory. His family has noted him to have ‘changed’ in himself. He denies any problems with his memory. He seems to be more disorientated at home. What is his most likely diagnosis? What would be your management plan?

21. Alzheimer's Disease Progressive, Irreversible condition S-T memory affected first Amnesia, Aphasia, Apraxia, Agnosia Behavioural, personality and psychiatric symptoms 5% of people over age of 65 Depletion of Acetylcholine implicated Other NT’s involved- 5HT, NA, glutamate

22. Clinical features • Amnesia- recent memories initially affected • Aphasia- Language problems • Agnosia- difficulty recognising and naming objects e.g. autoprosopagnosia • Apraxia- difficulties in complex tasks • Visuospatial difficulties

23. Clinical features • Functional impairment- often most impact on individual- e.g. finances, dressing/personal hygiene • Mood disorders • Psychosis- delusions and hallucinations • Personality change- “living bereavement” • Other behavioural manifestations

24. Symptoms • Problems remembering: • ‘’When I try to remember things, it goes further away from me’ • Find it hard to find the right words: • ‘I don't put the right word in the right place’ • Can't understand what people are saying: • ‘A direct question brings me up short’ • Have problems recognising people: • ‘I knew him from somewhere, but I couldn't remember where’ • Find it more difficult to complete tasks and solve problems: • ‘Cooking has become more difficult. I have problems working out what comes next’ • Find it harder to concentrate: • ‘My mind wanders sometimes’

25. Changes in dementia • often subtle onset • only recognised after diagnosis • memory, language, behaviour, personality • symptom under-reporting, lack of self-awareness • gradual loss of self or ‘personhood’

26. Neuropsychiatric: Personality and Behavioural Changes Personality Changes Behavioural Changes • indifference • lack of concern • decreased interest • reduced affection • poor motivation • agitation • depression • delusions • hallucinations • stubbornness • resistance to care • suspicion • abusive language • hiding articles • outbursts • restlessness • wandering • sundowning • catastrophic reactions

27. Alzheimer's disease-diagnosis MMSE-screening test, not diagnostic, 24/30 further investigations may be required Bloods- FBC, ESR, LFTs, Renal Function tests, TFTS, blood sugar, B12 and folate, Urine C&S, ECG, CXR CT/MRI if any significant history or positive findings or suspect infarct or SOC

28. Drug therapies • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine • Memantine • Vitamin E, ginko biloba • NSAIDs • Simvastatin • Antidepressants • Antipsychotics

29. Dementia (2) 75 year old man with sudden impairment of memory is taken to Emergency department by his. He was noted to have ‘slumped in his chair’ at home a week ago but recovered shortly after. He seems to be more confused at night time What is his most likely diagnosis? What would be your management plan?

30. Vascular Dementia Unequal distribution of deficits in higher cognitive functions and other relatively spared Focal brain damage CBV disease evident Abrupt onset/stepwise progression Vascular risk factors

31. Clinical issue: differentiation of diseases Evidence suggests that vascular dementia can co-exist with Alzheimer’s Disease leading to diagnostic confusion and mixed forms of dementia. Vascular lesions may also contribute to the severity of AD [Snowdon, 1997]. Neuroimaging studies showing cerebrovascular disease – infarcts or deep white matter ischaemia – support the diagnosis of vascular dementia.

32. Dementia (3) 60 year old woman presents to the emergency department with her daughter. Her daughter is worried because she is having increased number of falls with fluctuations in her alertness. Over the past few days, she has become increasingly agitated as she is experiencing visual hallucinations of elves playing the piano in her house. She has a resting tremor What is your differential diagnosis? What would be your management plan?

33. Lewy body dementia Fluctuations in cognition with alterations in attention and alertness Recurrent vivid visual hallucinations Motor features of Parkinsonism Possible repeated falls, syncope neuroleptic sensitivity

35. Prescribing Antipsychotics in dementia Summary of evidence When can prescribing of antipsychotics be justified Assessment prior to prescribing Choice of drugs How long to treat

36. Risks associated with Antipsychotic Treatment CSM 2004 - apparent 2-3 fold increase risk of cerebrovascular event in people with dementia prescribed olanzapine & risperidone. Not recommended. 2005- increased mortality rate (1.6-1.7fold) also with ‘typicals’ or conventional antipsychotics due to heart failure, sudden death, pneumonia) No evidence to say any antipsychotic is safer than another

37. DH report on antipsychotics in the management of dementiaNov 2009 Prof Sube Banerjee 150 000 people given antipsychotics unnecessarily Only 1 in 5 gain benefit Cause of extra 1 800 deaths per annum amongst elderly Benefit does not extend beyond 3 months

38. When are antipsychotic justified NICE/SCIE guideline 42 NOV 2006 Offer a pharmacological intervention in the first instance ONLY if the patient is severely distressed or there is an immediate risk of harm to the person or to others. Psychosis Severe agitation

39. Assessment before prescribing physical health depression possible undetected pain or discomfort side effects of medication individual biography environmental factors behavioural and functional analysis

40. Check list Discussion about risks and benefits with patient and or carer Assessment of cerebrovascular risk factors Consider the effect of co-morbid conditions such as depression

41. Principles of prescribing • Identify target symptom • Aim to reduce agitation or aggression without sedation • Start low go slow • Avoid high doses and combinations. • Time limited with regular review (3 mthly or as needed).

42. Antipsychotics in dementia

43. Prescribing follow up Based on the current evidence in relation to prescribing antipsychotic drugs in dementia we recommend an ongoing prescription of no more than 3 months as the evidence suggests there can be serious adverse effects from antipsychotic drugs for patients with dementia. In addition these drugs may become ineffective after this time . We suggest you review medication after three months with a view to gradually withdrawing the antipsychotic over 1-2 weeks. You should then review the patient’s progress and only consider a further short term prescription if the target symptom for which medication was prescribed recurs on discontinuation. If you need further advice about prescribing please contact Dr …...Team leader ….... Pharmacist………

44. Management: carers • Support for the family • Practical advice to enhance/compensate for memory deficits- “memory training” • Education • Advice on communication • Self help groups • Financial and legal help • Practical support from social services etc.

45. NATIONAL AUDIT OFFICE • Half of people not diagnosed • Lack of training and awareness • “not uncommon” for GPs to dismiss dementia as “normal effects of aging” • Specialist services were patchy • Support from CMHTs “varied considerably” • Many CMHTs have no social worker • 2/3 of people with dementia are cared for in the community with carers losing employment/pensions/lower earning and depression • Access to home care restricted

46. NICE key priorities • Non discrimination • Valid consent • Carers • Coordination and integration of care • Memory services

47. Key priorities continued • Structural imaging • Behaviour that challenges • Training • Mental health needs in acute hospitals

48. Dementia-Diagnosis • History and informant history • Mode of onset/course/pattern of impairment • Behavioural disturbance-wandering/aggression • Co-morbid depression • MSE • Geriatric depression scale to rule out depression

49. Dementia Biopsychosocial approach Aim to keep elderly person in own surroundings as long as possible Continuing care and support to relatives/carers Memory clinics Treat any underlying physical disorders that can lead to acute confusional states

50. Dementia • Alzheimer’s- Acetyl-cholinesterase inhibitors- • MMSE between 10-20 • Dose reviewed regularly • Treat other co-morbid conditions • Anxiety and depression- antidepressants • Paranoia and hallucinations-Antipsychotics • Behavioural symptoms-antipsychotics, • SSRI’s and mood stabilisers • Insomnia with hypnotics