Dementia

Callum Wilson

Quiz

Question 1 Vascular dementia is the most

common form of dementia (True/False)

Quiz

Question 2 Vascular dementia is characterised

by a stepwise decline in cognition or function (True/False)

Quiz

Question 3 There is strong evidence to

suggest secondary prevention/ risk reduction slows the progress of dementia (True/ False)

Quiz

Question 4 Almost all patients with mild

cognitive impairment will progress to dementia (True / False)

Quiz

Question 5 Drugs used for symptomatic

treatment in Alzheimer’s disease include donepezil, galantamine and rivastigmine (True / False)

Quiz

Question 6 Olanzapine and risperidone are

safe antipsychotics to use in elderly patients with dementia (True/False)

Quiz

Question 7 The benefit gained by the use of

antipsychotics does not extend past 3 months (True/False)

Quiz

Question 8 The use of Acetyl cholinesterase

inhibitors gives an improvement of only 10% in cognitive assessment tests over the first 6 months of use (True/False)

Quiz

Question 9 Severe impairment on MMSE is an

indication for starting AchEi drugs (True/False)

Quiz

Question 10 Normal pressure hyrdrocephalus is

characterised by a triad of abnormal gait, urinary incontinence and gradual cognitive decline (True/False)

Dementia across UK Current estimate is there are over

800,000 dementia sufferers in UK Expected to double in 30 years

Total cost of dementia in the UK - £17 billion per annum, Tripling £51billion pa in 30 years

Figures for Calderdale

population prevalence over 65

(dementia (total) sufferers)2010 32,100 1605 2015 36,600 18302020 39,800 1990

Key aims of Dementia Care

Reduce risks for dementia-mid life Increase public understanding Ensure early recognition of dementia Good diagnosis, communicated well

at the right time Ensure optimum treatment Social support

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

What are the common forms of dementia?

There are four main types of dementia: Alzheimer’s disease (60%; of cases)

Vascular dementia (30–40%; including about 20% where dual pathology exists)

Dementia with Lewy bodies (15% of cases)

Fronto-temporal dementia (5%) Percentages total more than 100

because of variability in studies

How is Alzheimer’s disease characterised?

Alzheimer’s disease may be characterized by a diffuse pattern of cortical deficits including: Aphasia – loss or impairment of language caused by brain dysfunction

Apraxia – inability to execute learned movements on command

Agnosia – inability to recognize or associate meaning to a sensory perception

Acalculia – inability to perform arithmetical calculations

Agraphia – inability to write Alexia – inability to read

Vascular dementia Vascular dementia is the second most

common cause of dementia. It results from vascular or circulatory lesions or from diseases of the cerebral vasculature leading to ischaemia or infarction.

Clinical features of vascular dementia

problems concentrating and communicating depression accompanying the dementia symptoms of stroke, such as physical

weakness or paralysis memory problems (although this may not

be the first symptom) a 'stepped' progression, with symptoms

remaining at a constant level and then suddenly deteriorating

epileptic seizures periods of acute confusion.

Clinical features of vascular dementia

Other symptoms may include: hallucinations (seeing things that do not exist) delusions (believing things that are not true) walking about and getting lost physical or verbal aggression restlessness incontinence.

Clinical features of Dementia with Lewy Bodies

Dementia of six months’ duration with: Periods of confusion

Fluctuations in cognition (especially attention and alertness)

Visual hallucinations Spontaneous extrapyramidal signs such as

rigidity or slowing (mild parkinsonism) Bradykinesia (paucity of movement)

Clinical features of fronto-temporal dementia

Impairments in social skills

Change in activity level

Decreased Judgment

Changes in personal habits

Alterations in personality and mood

Changes is one's customary emotional responsiveness

Symptoms of mild cognitive impairment

Frequently losing or misplacing things Frequently forgetting conversations,

appointments, or events Difficulty remembering the names of

new acquaintances Difficulty following the flow of a

conversation Intact activities of daily living

Most Cases of Mild Cognitive Impairment Do Not Become Dementia

The number of patients with mild cognitive impairment (MCI) who progress to dementia is at least half of what it was previously believed to be, new research suggests.

A large meta-analysis showed that the cumulative risk over 10 years ranged between 30% and 50%, depending on whether the studies that were analyzed used a definition of MCI that included subjective memory complaints.

Most Cases of Mild Cognitive Impairment Do Not Become Dementia

Until now, the prevailing opinion was that the progression rate from MCI to dementia was about 10% per year, or a 100% conversion to dementia over 10 years.

This research suggests that instead of always being an invariable transitional state between normal aging and dementia, MCI is a condition in which some patients stay static and some even improve

Role of Calderdale Memory Service

Screening assessment and early detection of dementia

Comprehensive psychiatric assessment Neuropsychological testing Laboratory investigations Neuro imaging-CT/MRI Scans Diagnosis Treatment and monitoring Counselling and support Signposting Link with other agencies

Assessment Process

Referral to Single Point of Entry Referral allocated to CMHT for initial

memory assessment Referral to Consultant Psychiatrist for

Diagnostic Assessment Referral to Memory Nurses for

monitoring treatment

Initial Assessment Tools

Standard screening proforma Mini Mental State Examination Bristol Activities of Daily Living Scale Sainsbury Risk Assessment Summary Assessment of Risk and

Needs

Psychiatric Assessment

History of Presenting Problem Previous History of Illness Social History Family History Medical Problems Current Medication Physical Examination Mental State Examination

Diagnosis

No Dementia Mild Cognitive Impairment Dementia- Alzheimer’s Disease Dementia-Other Types Other Psychiatric Problems-Depression

Outcome: Mild Cognitive Impairment

Neuroimaging to establish underlying pathology

Re-assess in 6-12 months to monitor for any progressive cognitive decline

Lifestyle advice- control of vascular risk factors

Outcome: Mild Dementia 1

Cognitive assessment Clinical picture Functional impairment Neuroimaging findings Medical condition Risk issues Social circumstances

Outcome Mild Dementia 2

Explanation of the outcome of the assessment

Referral to Alzheimer’s society/Carer support

Memory groups Advice re LPA, wills etc, attendance

allowance CMHT Psychological treatment

Outcome: Moderate Dementia

Initiate dementia treatment if: Alzheimer’s Type Mixed Alzheimer’s and Vascular Type No contraindications to prescribing

Follow Up Initial contact by memory nurse Titration as per protocol Referral to primary care for shared care

prescribing after four months Six monthly follow up by memory nurse Psychiatric outpatients follow up of

complex cases

Drug treatments in dementia

Secondary Prevention –limited evidence

Symptomatic treatments:Acetyl Cholinesterase InhibitorsAntipsychotics

Antidepressants

Secondary prevention

For the secondary prevention of dementia, vascular and other modifiable risk factors should be reviewed in people with dementia, and if appropriate, treated

smoking, excessive alcohol consumption, obesity, diabetes, hypertension raised cholesterol

Licensed treatment of dementiaAcetyl cholinesterase inhibitors AchE

Donepezil (Aricept®) 5 and 10mg tablets

Galantamine (Reminyl®) Capsules 8mg, 16mg & 24mg, Solution 4mg /mL

Rivastigmine (Exelon®) Patches® 4.6mg and 9.5mg Capsules 1.5mg, 3mg,4.5mg and 6mg Rivastigmine oral solution 2mg/ml

Uses recommended by NICE

People with Alzheimer’s Disease of moderate severity.

Non-cognitive symptoms including hallucinations, delusions, This includes patients with Lewy Body Dementia and mild, moderate or severe Alzheimer’s Disease.

People with mixed dementia where Alzheimer’s Disease is considered to be the dominant condition.

People with mild Alzheimer’s Disease currently receiving

a Cholinesterase Inhibitor may continue to receive the prescription until they, their carers and/or specialist consider it appropriate to stop.

Mode of action

Postulated to provide a beneficial effect by augmenting cholinergic function.

Inhibit the enzyme acetyl cholinesterase that is responsible for the breakdown of acetylcholine.

When the drug inhibits this enzyme the breakdown of acetylcholine is slowed down and therefore cholinergic neurotransmission is increased.

What are the Benefits of AchEi

30 placebo controlled trials in the treatment of Alzheimer’s disease

Improvement in cognition by average of 10% as measured by cognitive assessment tests

(equivalent of 6 months usual decline) Level of day to day functioning remains above

the baseline for 6-12 months for most and up to 2 years

Side effects usually mild

Diarrhoea, muscle cramps, fatigue, nausea, vomiting, insomnia.Headache, pain, common cold, abdominal disturbance, dizziness.

Rarely : Syncope, bradycardia, sinoatrial and atrioventricular block.

Antipsychotics in dementia

Apparent 2-3 fold increase of CVA in people with dementia prescribed olanzapine and risperidone – not recommended

Increased mortality rate 1.6-1.7 fold with ‘typical’ antipsychotics due to heart failure, sudden death and pneumonia

No evidence to suggest any antipsychotic is safer than others.

Only 1 in 5 gain benefit 150,000 people given unnecessarily causing

1,800 deaths per year

Antipsychotics in dementia

Benefit does not extend beyond 3 months

NICE guidance - 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

Quiz Answers1. False2. True3. False4. False5. True6. False7. True8. True9. False10. True

Questions?