Dementia

1. Dementia

2. What we will cover.. • Introduction • Epidemiology and risk factors • Presentation/ clinical features • Case discussion of a new diagnosis • Investigations and initial management • Support services • Types and differential diagnosis • Dementia review • Q and A with Dr Heartman • Coffee and cake • Management with Dr Komocki, including challenging behaviour, drugs, and capacity.

3. Dementia • ‘a progressive and largely irreversible clinical syndrome that is characterized by global deterioration in intellectual function, behavior and personality in the presence of normal consciousness and perception’ (in an acute confusional state the level of consciousness is impaired) • It is clinically diagnosed and is characterised by a triad of changes.. Memory loss, loss of another aspect of cognition, and impairment of every day life. • If impairment of consciousness is present together with general intellectual impairment, then the condition is defined as delirium or confusional state - acute or sub-acute.

4. In UK, it is estimated that there are approximately 700,000 people with dementia which cost around £17 billion a year, (heart disease is 4 billion, stroke is 3 billion, cancer is 2 billion) A GP with 2000 registered patients will have 12-15 pts with dementia, around half will be undiagnosed. There will be 2 new presentations a year. Incidence is around 5% of >65 and 25% of over 85 Alzheimer's accounts for 60%, cerebrovascular disease 10%, Lewy body dementia10%, Picks/ frontotemporal dementia 5%, 15 % mixed and rarer causes e.g. alcohol abuse and head trauma On average pts with dementia live for 5 years from emergence of symptoms and 3.5 years from time of diagnosis, (delay to present and delay to formally diagnose). Epidemiology

5. Modifiable risk factors alcohol consumption   smoking – particularly for Alzheimer's obesity hypertension hypercholesterolaemia head injury education and mental stimulation Social interactions/ contacts. Non modifiable risk factors age – advancing age is the most important risk factor in developing dementia learning disabilities – in people with Down’s syndrome, dementia develops 30–40 years earlier than in a normal person gender – rate of dementia is higher in women than in men (specially for Alzheimer's disease) genetic factors Risk Factors

6. You are 26% less likely to develop dementia if you have three or more close friends according to the American journal of public health.

7. Presentation/ Clinical features The period from first symptoms to presentation to the GP is currently somewhere between 12 and 18 months, (and again there is a similar time lag from that point of recognition to time of formal diagnosis) Many patients have preserved positive personality traits and personal attributes but the following features may become evident as the disease progresses: • memory loss, • language impairment, • disorientation, • changes in personality, • difficulty in carrying out daily activities, • self-neglect • psychiatric symptoms - apathy, depression or psychosis • unusual behavior - aggression, sleep disturbance or disinhibited sexual behavior • Most patients with dementia lose insight into their condition at a nearly stage and fail to report lapses in memory and behaviour

8. Suspect dementia when.. • Family members report to the physician about memory impairment but the patient denies it • The patient is questioned, he/she looks at the carer for an answer - the ‘head-turning sign’

9. Case based discussion • Mrs D is a 75 year old widow with previously infrequent attendance at the surgery until the death of her husband 2 months ago. Her son lives a few doors down . Despite missing her husband she denies having any problems coping without him, but presents with vague symptoms often muddling up her appointment days and times. Her son calls the surgery concerned about the state of the house and his mother’s hygiene. She has been going to the shops as usual, but is stock-piling tins that she never seems to open, and there is no fresh food in the house. He is going to take her to live with him for the time being but wants you to investigate.

10. Questions.. • What is the differential diagnosis? • What would you want to know in the history? • What would you look for/ do on examination? • What investigations would you do? • What would your initial management be if this were Dementia?

11. Case discussion.. • The differential diagnosis could be Dementia, but also a bereavement reaction, depression, or delirium secondary to a medical condition. • Old age is often associated with bereavement, social isolation, physical and mental disability, and all these factors could be having an impact. Mrs D was able to cope while her husband was alive, possibly because he carried out many of the essential tasks. With a pt who presents with a multitude of physical problems the initial focus is on excluding any physical cause while considering grief reaction, depression, or dementia. It is also worth bearing in mind these can all present together, eg dementia is a risk factor for depression!

12. Dementia Diagnosis • Diagnosis of dementia should be made only after through assessment which should include history, cognitive and mental state examination, physical examination, appropriate investigations and a review of medication which might affect cognitive function.

13. History • The history should be gathered from a person who has known the patient for a period of six months at least and if possible directly from the patient and includes: • age • medical and psychiatric history of the family e.g. - dementia or other mental health problems • origin and progression of condition • associations: • myoclonus • seizures • depression, anxiety • (can get depressive psudo dementia BUT depression is also a feature of dementia!) • past and present medical and psychiatric history - e.g. diabetes, hypertension, cerebrovascular disease • exposure to toxins: • alcohol • lead • drugs e.g. barbiturates • WE SHOULD BE ASKING PEOPLE WITH POSSIBLE DEMENTIA IF THEY WISH TO KNOW THE DIAGNOSIS AND WHO WE CAN SHARE IT WITH

14. Examination • Check general appearance, look for evidence of self-neglect, malnutrition, abuse. • Examine, attention and concentration, orientation, long and short term memory, language, praxis and executive function. • Formal Cognitive tests… • MMSE most common • GP-COG • 6-item cognitive impairment test (6CIT) • Abbreviated mental test score (AMTS) • Mini-Cog • Memory impairment screen

15. MMSE

16. MMSE interpretation • 24-30 no Cognitive impairment • 18-23 mild cognitive impairment • 0-17 severe cognitive impairment

17. GP Investigations.. • These are aimed at detecting treatable causes… • FBC • UE • ESF • LFT • Ca2+ • TFT • Glu • B12, folate • MSU • CXR • (VDRL HIV ONLY IF SPECIFIC REASON, NOT ROUTENE) • ?ECG if tx with cholinesterase drugs considered.

18. Secondary care investigations.. • CT • MRI • Single photon emission tomography (assesses regional blood flow) • Dopamine scan (to detect Lewy body disease • Carotid dopler • ECG (if tx with cholinesterase drug considered)

19. Management.. • Refer all patients to a psycho-geriatrician for conformation of the diagnosis, exclusion of treatable causes and ongoing specialist support and assessment. • Refer to a social worker and/or CPN for community support. • Support carers and put them in contact with resources with regards to benefits, self help groups and respite care. • Discuss the diagnosis and prepare them as best you can for the progression of the disease. • Broach medico-legal issues • Treat concurrent problems (UTI, anaemia, depression) as they make dementia worse. • Management of memory loss, e.g. pill dispensers and notebook tasks • For Alzheimer's disease consider cholinesterase inhibitors • For vascular dementia reduce risk factors (alcohol, Htx, obesity, dm, cholesterol) • Look out for and treat depression and psychosis • Ongoing support and review of condition/ needs

20. Cholinesterase inhib? • Cholinesterase inhibitors (donepazil rivastigmine, and galantamine) correct low acetylcholine levels in Alzheimer's disease, resulting in a small but worthwhile improvement in memory energy and mood. • NICE recommended as an option in the management of patients with Alzheimer’s disease of moderate severity only (that is those with a MMSE score of 10-20 points) • These should be started and reviewed (every 6 months) by secondary care though shared care can allow GP to monitor tolerability and side effects • Common side effects include nausea, diarrhoea, vivid dreams and leg cramps. Bradychardia is almost invariable. • The drug should only be continued while the patient’s MMSE score remains at or above 10 points and their global, functional and behavioral condition remains at a level where the drug is considered to be having a worthwhile effect.

21. Gp contract.. • Register of those diagnosed with dementia. • The percentage of patients diagnosed with dementia whose care has been reviewed in the preceding 15months. This should include an assesment of support needs of the patient and their carer and a review of co-ordination arrangements with secondary care.

22. Where to get support.. • Local mental health team, (they have their own social services package to try and give more continuity) • South derbyshire CVS, is a signposting organisation which can offer support 017773749087 • www.derbyshirecarers.co.uk • Alzhymers society. www.alzhymers.org.uk 08453000336 • Dementia Care trust www.dct.org.uk o8704435325 • Carers UK www.carersonline.org.uk 08088087777 • Age concern www.ace.org.uk • Pick’s disease support group www.pdsg.org.uk • Princess Royal trust for carers help@carers.orgwww.carers.org

23. END/ Questions?

25. Definitions. • Delerium is an acute confusion, transient cognitive impairment, Fluctuating cognition • global cognitive impairment • Reversible • Main defect: attention --> • less aware of surroundings • easily distractible • trouble with concentration & commands • Main aspects of cog. disordered: thinking, perception, memory • +  sleep-wake cycle, disorientation, LOC • +  or psychomotor activity • +/- emotional  ‘s and irritability

26. I Infection • W Withdrawal • A Acute metabolic • T Trauma • C CNS pathology • H Hypoxia • D Deficiencies • E Endocrine • A Acute vascular/MI • T Toxins-drugs • H Heavy metals

33. Potentially reversible causes of cognitive impairment • Depression (can get depressive psudo dementia BUT depression is also a feature of dementia!) • Subdural heamatoma • Hypothyroidism • Chronic severe hyponatraimia • Vit B12 deficency • Neurosyphilis • Vasculitis • Paraneoplastic syndrome • Wipples disease • Normal pressure hydrocephalus, (ventricular dilation + triad of dementia incontinence and gait disturbance)