The Diagnosis and Management of Dementia in primary care

1. The Diagnosis and Management of Dementia in primary care Dr Suzanne Duff Consultant Psychiatrist POPS Northland DHB

2. The extent of the problem • Prevelence doubles every 5 yrs over the age of 60 • > 60 – 5% • > 80 – 20% • Affects ~38000 New Zealanders • Will affect ~50000 by 2051

3. Tom KitwoodDementia Reconsidered • “Men and women who have dementia have emerged from the places where they were hidden away: they have walked onto the stage of history, and begun to be regarded as persons in the full sense. Dementia as a concept is losing its terrifying associations with the raving lunatic in the old-time asylum. It is being conceived of as an understandable and human condition, and those who are affected by it have begun to be recognised, welcomed, embraced and heard.”

4. The Dementia Syndrome (DSMIV) • Multiple Cognitive Deficits (at least 2 of) • Memory loss • Aphasia • Apraxia • Agnosia • Executive function • These lead to a functional decline

5. Dementia Subtypes • Alzheimer’s ~ 60% • Vascular - 10 – 15% • Lewy Body – 12 – 15% • Fronto-temporal – 15% (usually <65yrs) • Other

6. The Cognitive Changes of Normal Ageing • Occur over decades • Decline mirrors that of peers • Person able to adapt so that functioning is maintained • 83% forget names, approx 60% lose keys, 40% forget faces or directions, even fewer forget what they have just done, such as lock the door

7. Mild Cognitive Impairment • Subjective memory loss • Without functional impairment • 8 – 15% per year convert to dementia • i.e. Up to 90% by year 6 • Studies now looking at amyloid imaging and CSF markers to identify converters

8. AD risk and protective factors (use it or lose it) • Risk • Age • Family history (ApoE4) • Head trauma • Low education • Lipids & Hypertension • Early life depression • Down’s • Protective • Genetic (ApoE2) • High educational level • Longterm anti-inflamatories • Antioxidants (Vit E) • LOW alcohol use

9. Diagnosing Dementia

10. Diagnosis and Assessment • Listen to the patient – they or their families are telling you the diagnosis • Adjust your communication style • A positive diagnosis can be made just as in any other major illness • The challenge is to obtain an early, accurate and specific diagnosis using an effective diagnostic process

11. Clinical features of mild AD • Cognition Function Behaviour • Recall Work Apathy • Learning Finances Withdrawal • Word finding Cooking Depression • Problem Reading Irritability Solving Hobbies • Writing • Judgement • Calculation

12. Issues involved in dementia diagnosis Who wants the diagnosis ? How certain is the diagnosis ? Who wants the prognosis ? How to break bad news Time to express loss & grief How much do they want to know ? Dementia Diagnosis How would they prefer to have the diagnosis communicated ? The language to use Consent to tell others The timing of information giving Support for those giving the diagnosis The coping style of PWD and carer The type of information Issues involved in dementia diagnosis Issues involved in dementia diagnosis Issues involved in dementia diagnosis Issues involved in dementia diagnosis Issues involved in dementia diagnosis Issues involved in dementia diagnosis Issues involved in dementia diagnosis Who wants the diagnosis ? How certain is the diagnosis ? Who wants the diagnosis ? How certain is the diagnosis ? Who wants the diagnosis ? How certain is the diagnosis ? Who wants the diagnosis ? How certain is the diagnosis ? How to break bad news Who wants the prognosis ? Who wants the diagnosis ? How certain is the diagnosis ? How to break bad news Who wants the prognosis ? Who wants the diagnosis ? How certain is the diagnosis ? How to break bad news Who wants the prognosis ? Who wants the diagnosis ? How certain is the diagnosis ? How to break bad news Who wants the prognosis ? How to break bad news Who wants the prognosis ? How much do they want to know ? Time to express loss & grief How to break bad news Who wants the prognosis ? How much do they want to know ? Time to express loss & grief How to break bad news Who wants the prognosis ? Dementia Diagnosis How much do they want to know ? Time to express loss & grief Dementia Diagnosis How much do they want to know ? Time to express loss & grief Dementia Diagnosis How much do they want to know ? Time to express loss & grief How would they prefer to have the diagnosis communicated ? Dementia Diagnosis How much do they want to know ? Time to express loss & grief How would they prefer to have the diagnosis communicated ? Dementia Diagnosis The language to use How much do they want to know ? Time to express loss & grief How would they prefer to have the diagnosis communicated ? Dementia Diagnosis The language to use How would they prefer to have the diagnosis communicated ? Dementia Diagnosis The language to use How would they prefer to have the diagnosis communicated ? The language to use How would they prefer to have the diagnosis communicated ? Consent to tell others The language to use How would they prefer to have the diagnosis communicated ? The timing of information giving Consent to tell others The language to use The timing of information giving Consent to tell others The language to use The timing of information giving Consent to tell others Support for those giving the diagnosis The timing of information giving Consent to tell others Support for those giving the diagnosis The timing of information giving The type of information Consent to tell others Support for those giving the diagnosis The timing of information giving The type of information Consent to tell others Support for those giving the diagnosis The coping style of PWD and carer The timing of information giving The type of information Support for those giving the diagnosis The coping style of PWD and carer The type of information Support for those giving the diagnosis The coping style of PWD and carer The type of information Support for those giving the diagnosis The coping style of PWD and carer The type of information The coping style of PWD and carer The type of information The coping style of PWD and carer The coping style of PWD and carer

13. CONCERNS ABOUT TELLING • Adverse effect on the person with dementia. • They may have difficulty understanding the diagnosis. • Family resistance to telling the PWD. • Uncertainty of diagnosis. • Fear of nihilism.

14. ADVANTAGES TO TELLING • Allows the person to maximize their autonomy. • Avoids accidental discovery. • Relieves anxiety and uncertainty. • Avoids paternalising. • Wish to know expressed by most older persons. • Timely access to info, support & treatment.

15. Guidelines for giving a dementia diagnosis(Fearnley, McLennan & Weaks, 1997) • Choose the setting. • Determine who is to be present. • Explore previous knowledge or experience. • Explore how much they want to know. • Discuss the diagnosis. • Discuss the future. • Discuss the help available. • Provide written information.

16. Dementia or Delirium • Dementia • Insidious onset • Slow, gradual decline • Disorientation later • Mild variations day-day • Normal attention span • Usually fully alert • Few psychomotor changes • Physiological changes • Sleep–wake changes later • Delirium • Abrupt onset • Short acute illness • Marked disorientation • Very variable • Poor attention • Fluctuating alertness • Agitated/retarded • Physiological changes common • Sleep-wake changes common

17. Dementia or Depression • Dementia • Insidious onset • Conceals disability • Near miss answers • Mood fluctuations • Stable deficits • Tries hard and not distressed by errors • Memory loss predominates • Depression • Abrupt onset/trigger • Highlights disability • ‘Don’t know’ • Diurnal variation • Variable deficits • Tries less hard and distressed by errors • Memory and mood hand in hand

18. BPSD Assessment • Look for the meaning or underlying triggers • People with dementia are very sensitive to non-verbal and environmental cues • What might the person be reacting to? • Environmental, Internal, Interpersonal? • What might they be trying to communicate? • Pain, Discomfort, Fear, Sadness, Frustration?

19. BPSD Assessment - medical • Take a history from carers and patient • Review recent medication changes • Physical exam • ?Pain, constipation, UTI/URTI, alcohol withdrawal etc • Investigations • MSU, FBC, U+E • CxR, ECG

20. BPSD - Assessment • Identify specific symptoms and behaviours • Use ABC charts • Note baseline frequency • Identify possible triggers

21. Drugs for BPSD • Limited effectiveness • Low doses • Review at 2 weeks and 1 month • Trial withdrawal at 3 months

22. Cognitive Enhancers • Cholinesterase Inhibitors • Aricept (Donepezil) • Once daily, 5mg, 10mg • Reminyl (Galantamine) • Once daily, 8mg, 16mg, 24mg • Exelon (Rivastigmine) • Twice daily, 1.5mg, 3mg, 6mg - patch developed • NDMA (Glutamate) receptor antagonist • Memantine

23. Cholinesterase InhibitorsCont. • Similar side effect profiles • NB Heart Block • Similar efficacy • Effect on ADLs, QoL, Caregiver burden now demonstrated • Issues re cost, access, discontinuation need to be discussed prior

24. NDHB Diagnostic Pathway Internet based pathway to assist primary care in the assessment, diagnosis and management of uncomplicated dementias. http://tomcat.dev.cactuslab.com/pathways/northland-dhb-cognitive-impairment-pathway/

25. Resources

26. Resources • Age Concern New Zealand • www.ageconcern.org.nz • Alzheimer’s New Zealand • www.alzheimers.org.nz