Diagnosis and Early Management of Dementia

1. Diagnosis and Early Management of Dementia Madeleine Adams Occupational Therapist Team Leader SACS Cognitive Services madeleine.adams@easternhealth.org.au Ph: 9955 1230 Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health

2. Overview • Eastern Health SACS Cognitive Service • How to refer - Inclusion/Exclusion Criteria • Cognitive enhancing medication • Future Planning

3. Eastern Health Cognitive Service Cognitive, Dementia and Memory Service (CDAMS) Geriatric Evaluation and Management (GEM) Knox, Maroondah, Monash, Manningham, Whitehorse, Yarra Ranges

4. CDAMS • CDAMS targets people with early changes that may include: • Increased forgetfulness of recent events • Changes in language skills • Difficulty with complex tasks • Decreased interest in hobbies and activities • Slowed thinking • Altered behaviour

5. CDAMS Service & Location • CDAMS operates at two sites: • Wantirna Health • Services clients from mainly from council areas of Monash, Whitehorse, Knox, Manningham • Yarra Ranges Health (Lilydale) • Services clients mainly from council areas of Yarra Ranges and Maroondah

6. CDAMS - Referral Criteria • For cognitive assessment where: • No previous diagnosis of dementia • Diagnosis is the primary reason for referral • Specialist diagnosis is required for medication • Person is medically stable • Person agrees to attend

7. CDAMS - Exclusion Criteria Recent onset of cognitive decline Urgent assessment People with longstanding impairment (e.g. ABI) People aged < 50 complaining of memory problems in the context of stress, anxiety, depression People whose diagnosis is known People requiring neuropsychological assessment only

8. CDAMS - Exclusion Criteria People with moderate to severe dementia symptoms People with complex psychiatric conditions who may also have cognitive changes People who are physically unable to attend the clinic

9. GEM • People with more severe impairment may be more appropriate for GEM: • Difficulties managing own personal care • Becoming lost in own home • Difficulties recognizing family and friends • Have a diagnosis but need Geriatrician advice for a medication trial

10. GEM – Service & Location • GEM operates at two sites: • Peter James Centre (East Burwood) • Wantirna Health • Clients attend closest clinic or fastest appointment

11. GEM Referral Criteria • Referral is for cognitive assessment and diagnosis is the primary reason for referral • Specialist opinion is required for consideration or review of medication • The person is medically stable • The person is physically able to attend centre based appointments • The person agrees to attend or can be persuaded by family/carer

12. GEM Exclusion Criteria • Recent onset of cognitive decline • People with complex psychiatric conditions • People with early changes to memory and thinking or who require multidimensional evaluation • People from a CALD background are strongly preferred to be referred to CDAMS for cognitive assessment • Where carer stress or need for counselling/education/community supports is the primary reason for referral

13. GEM Exclusion Criteria • People whose diagnosis is known and behavioural or psychological disturbance is the primary issue • People requiring allied health/nursing assessment and treatment • People who are physically unable to attend the clinic • Referrals for testamentary capacity or neuropsychological assessment only

14. Referral to CDAMS/GEM Referrals are received via the Access Unit at Peter James Centre on the EH SACS referral form Anyone can refer to CDAMS and GEM, however it is our strong preference that the GP is involved Wait times vary contact EH Access Unit Ph: 9881 1100

16. Cognitive Enhancing Medication Both GEM and CDAMS provide this service For people given a diagnosis of Alzheimer’s Disease or Dementia with Lewy Bodies Involves screening for risk factors and consideration of side effects Standardised cognitive testing before and after a 6 month trial

17. Cognitive Enhancing Medication • Two main types of medication • Acetylcholinesterase inhibitors • Mild-moderate dementia • Mematine • Moderate –severe dementia • Both work by moderating the effects of neurotransmitters in the brain

19. Treatment Options • The current medication is only available for a diagnosis of Alzheimer’s Disease (or mixed dementia) • Medication is initiated as a trial - client can receive 6 months supply through PBS, but needs to demonstrate a beneficial effect of the medication to qualify for ongoing PBS subsidy.

20. CRITERIA FOR CONTINUED PBS SUBSIDY • Improvement of 2 points or more in MMSE • Improvement (decrease) of 4 points or more in ADAS-Cog score

21. Medication Issues • The medication can have side effects so there needs to be consideration of the benefit versus the risk • Trial needs to be well managed - start at a low dose and increase to full dose after 1 month if well tolerated • Client needs to reliably take medications/assistance needs to be organised • If no improvement is seen, ongoing prescriptions must be privately purchased.

22. Future Planning • CDAMS provides advice about future planning in the context of a dementia diagnosis • This involves looking at: • Driving ability • Legal Issues – eg. Enduring Powers of Attorney • Advanced Care Planning • Services, supports and residential care

23. Future Planning • Linkage with services from community service providers: • Alzheimer's Australia Victoria (AAV) • Living With Memory Loss programs • Counselling/Education • Memory Lane Café • Planned Activity Groups/Day Centres