DementiaDementia

What we will cover..What we will cover..

• IntroductionIntroduction• Epidemiology and risk factorsEpidemiology and risk factors• Presentation/ clinical featuresPresentation/ clinical features• Case discussion of a new diagnosisCase discussion of a new diagnosis• Investigations and initial managementInvestigations and initial management• Support servicesSupport services• Types and differential diagnosisTypes and differential diagnosis• Dementia reviewDementia review• Q and A with Dr HeartmanQ and A with Dr Heartman

• Coffee and cakeCoffee and cake

• Management with Dr Komocki, including Management with Dr Komocki, including challenging behaviour, drugs, and capacity.challenging behaviour, drugs, and capacity.

DementiaDementia• ‘‘a progressive and largely irreversible clinical a progressive and largely irreversible clinical

syndrome that is characterized by global syndrome that is characterized by global deterioration in intellectual function, behavior and deterioration in intellectual function, behavior and personality in the presence of normal consciousness personality in the presence of normal consciousness and perception’ and perception’ (in an acute confusional state the (in an acute confusional state the level of consciousness is impaired)level of consciousness is impaired)

• It is clinically diagnosed and is characterised by a It is clinically diagnosed and is characterised by a triad of changes.. Memory loss, loss of another triad of changes.. Memory loss, loss of another aspect of cognition, and impairment of every day aspect of cognition, and impairment of every day life.life.

• If impairment of consciousness is present together If impairment of consciousness is present together with general intellectual impairment, then the with general intellectual impairment, then the condition is defined as delirium or confusional state condition is defined as delirium or confusional state - acute or sub-acute. - acute or sub-acute.

EpidemiologyEpidemiology• In UK, it is estimated that there are approximately 700,000 In UK, it is estimated that there are approximately 700,000

people with dementia which cost around £17 billion a year, people with dementia which cost around £17 billion a year, (heart disease is 4 billion, stroke is 3 billion, cancer is 2 billion)(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 A GP with 2000 registered patients will have 12-15 pts with dementia, around half will be undiagnosed. There will be 2 new dementia, around half will be undiagnosed. There will be 2 new presentations a year.presentations a year.

• Incidence is around 5% of >65 and Incidence is around 5% of >65 and 25% of over 8525% of over 85

• Alzheimer's accounts for 60%, Alzheimer's accounts for 60%, cerebrovascular disease 10%, Lewy cerebrovascular disease 10%, Lewy body dementia10%, Picks/ body dementia10%, Picks/ frontotemporal dementia 5%, 15 % frontotemporal dementia 5%, 15 % mixed and rarer causes e.g. alcohol mixed and rarer causes e.g. alcohol abuse and head traumaabuse and head trauma

• On average pts with dementia live On average pts with dementia live for 5 years from emergence of for 5 years from emergence of symptoms and 3.5 years from time symptoms and 3.5 years from time of diagnosis, (delay to present and of diagnosis, (delay to present and delay to formally diagnose).delay to formally diagnose).

Risk FactorsRisk Factors

Modifiable risk factorsModifiable risk factors • alcohol consumption   alcohol consumption   • smoking – particularly for smoking – particularly for

Alzheimer's Alzheimer's • obesity obesity • hypertension hypertension • hypercholesterolaemia hypercholesterolaemia • head injury head injury • education and mental stimulationeducation and mental stimulation• Social interactions/ contacts.Social interactions/ contacts.

Non modifiable risk factorsNon modifiable risk factors • age – advancing age is the most important risk factor in age – advancing age is the most important risk factor in

developing dementia developing dementia • learning disabilities – in people with Down’s syndrome, dementia learning disabilities – in people with Down’s syndrome, dementia

develops 30–40 years earlier than in a normal person develops 30–40 years earlier than in a normal person • gender – rate of dementia is higher in women than in men gender – rate of dementia is higher in women than in men

(specially for Alzheimer's disease) (specially for Alzheimer's disease) • genetic factorsgenetic factors

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

Presentation/ Clinical Presentation/ Clinical featuresfeaturesThe period from first symptoms to presentation to the GP is The period from first symptoms to presentation to the GP is

currently somewhere between 12 and 18 months, (and currently somewhere between 12 and 18 months, (and again there is a similar time lag from that point of again there is a similar time lag from that point of recognition to time of formal diagnosis)recognition to time of formal diagnosis)

Many patients have preserved positive personality traits and Many patients have preserved positive personality traits and personal attributes but the following features may become personal attributes but the following features may become evident as the disease progresses: evident as the disease progresses:

• memory loss, memory loss, • language impairment, language impairment, • disorientation, disorientation, • changes in personality, changes in personality, • difficulty in carrying out daily activities, difficulty in carrying out daily activities, • self-neglect self-neglect • psychiatric symptoms - apathy, depression or psychosis psychiatric symptoms - apathy, depression or psychosis • unusual behavior - aggression, sleep disturbance or unusual behavior - aggression, sleep disturbance or

disinhibited sexual behaviordisinhibited sexual behavior• Most patients with dementia lose insight into their condition Most patients with dementia lose insight into their condition

at a nearly stage and fail to report lapses in memory and at a nearly stage and fail to report lapses in memory and behaviourbehaviour

Suspect dementia when..Suspect dementia when..

• Family members report Family members report to the physician about to the physician about memory impairment but memory impairment but the patient denies it the patient denies it

• The patient is The patient is questioned, he/she looks questioned, he/she looks at the carer for an at the carer for an answer - the ‘head-answer - the ‘head-turning sign’ turning sign’

Case based discussionCase based discussion

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

Questions..Questions..

• What is the differential diagnosis? What is the differential diagnosis? • What would you want to know in the What would you want to know in the

history?history?• What would you look for/ do on What would you look for/ do on

examination?examination?• What investigations would you do?What investigations would you do?• What would your initial management What would your initial management

be if this were Dementia?be if this were Dementia?

Case discussion..Case discussion..

• The differential diagnosis could be Dementia, but The differential diagnosis could be Dementia, but also a bereavement reaction, depression, or delirium also a bereavement reaction, depression, or delirium secondary to a medical condition.secondary to a medical condition.

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

Dementia DiagnosisDementia Diagnosis

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

HistoryHistory• The history should be gathered from a person who has known The history should be gathered from a person who has known

the patient for a period of six months at least and if possible the patient for a period of six months at least and if possible directly from the patient and includes:directly from the patient and includes:– age age – medical and psychiatric history of the family e.g. - dementia or medical and psychiatric history of the family e.g. - dementia or

other mental health problems other mental health problems – origin and progression of conditionorigin and progression of condition

• associations:associations:– myoclonusmyoclonus– seizures seizures – depression, anxiety depression, anxiety – (can get depressive psudo dementia BUT depression is also a (can get depressive psudo dementia BUT depression is also a

feature of dementia!)feature of dementia!)• past and present medical and psychiatric history - e.g. past and present medical and psychiatric history - e.g.

diabetes, hypertension, cerebrovascular disease diabetes, hypertension, cerebrovascular disease • exposure to toxins: exposure to toxins:

– alcoholalcohol– lead lead – drugs e.g. barbiturates drugs e.g. barbiturates

• WE SHOULD BE ASKING PEOPLE WITH POSSIBLE DEMENTIA IF WE SHOULD BE ASKING PEOPLE WITH POSSIBLE DEMENTIA IF THEY WISH TO KNOW THE DIAGNOSIS AND WHO WE CAN THEY WISH TO KNOW THE DIAGNOSIS AND WHO WE CAN SHARE IT WITHSHARE IT WITH

ExaminationExamination• Check general appearance, look for evidence of Check general appearance, look for evidence of

self-neglect, malnutrition, abuse.self-neglect, malnutrition, abuse.

• Examine, attention and concentration, Examine, attention and concentration, orientation, long and short term memory, orientation, long and short term memory, language, praxis and executive function.language, praxis and executive function.

• Formal Cognitive tests…Formal Cognitive tests…• MMSE most commonMMSE most common• GP-COGGP-COG• 6-item cognitive impairment test (6CIT)6-item cognitive impairment test (6CIT)• Abbreviated mental test score (AMTS)Abbreviated mental test score (AMTS)• Mini-CogMini-Cog• Memory impairment screenMemory impairment screen

MMSEMMSE

MMSE interpretationMMSE interpretation

• 24-30 no Cognitive impairment24-30 no Cognitive impairment

• 18-23 mild cognitive impairment18-23 mild cognitive impairment

• 0-17 severe cognitive impairment0-17 severe cognitive impairment

GP Investigations..GP Investigations..

• These are aimed at detecting treatable causes…These are aimed at detecting treatable causes…

• FBCFBC• UEUE• ESFESF• LFTLFT• Ca2+Ca2+• TFTTFT• GluGlu• B12, folateB12, folate• MSUMSU• CXRCXR• (VDRL HIV ONLY IF SPECIFIC REASON, NOT ROUTENE)(VDRL HIV ONLY IF SPECIFIC REASON, NOT ROUTENE)• ?ECG if tx with cholinesterase drugs considered.?ECG if tx with cholinesterase drugs considered.

Secondary care Secondary care investigations..investigations..• CT CT

• MRIMRI

• Single photon emission tomography Single photon emission tomography (assesses regional blood flow)(assesses regional blood flow)

• Dopamine scan (to detect Lewy body Dopamine scan (to detect Lewy body diseasedisease

• Carotid doplerCarotid dopler

• ECG (if tx with cholinesterase drug ECG (if tx with cholinesterase drug considered)considered)

Management..Management..• Refer all patients to a psycho-geriatrician for conformation of the diagnosis, Refer all patients to a psycho-geriatrician for conformation of the diagnosis,

exclusion of treatable causes and ongoing specialist support and exclusion of treatable causes and ongoing specialist support and assessment.assessment.

• Refer to a social worker and/or CPN for community support.Refer to a social worker and/or CPN for community support.

• Support carers and put them in contact with resources with regards to Support carers and put them in contact with resources with regards to benefits, self help groups and respite care.benefits, self help groups and respite care.

• Discuss the diagnosis and prepare them as best you can for the progression Discuss the diagnosis and prepare them as best you can for the progression of the disease.of the disease.

• Broach medico-legal issuesBroach medico-legal issues

• Treat concurrent problems (UTI, anaemia, depression) as they make Treat concurrent problems (UTI, anaemia, depression) as they make dementia worse.dementia worse.

• Management of memory loss, e.g. pill dispensers and notebook tasksManagement of memory loss, e.g. pill dispensers and notebook tasks

• For Alzheimer's disease consider cholinesterase inhibitorsFor Alzheimer's disease consider cholinesterase inhibitors• For vascular dementia reduce risk factors (alcohol, Htx, obesity, dm, For vascular dementia reduce risk factors (alcohol, Htx, obesity, dm,

cholesterol)cholesterol)• Look out for and treat depression and psychosisLook out for and treat depression and psychosis

• Ongoing support and review of condition/ needsOngoing support and review of condition/ needs

Cholinesterase inhib?Cholinesterase inhib?• Cholinesterase inhibitors (donepazil rivastigmine, and Cholinesterase inhibitors (donepazil rivastigmine, and

galantamine) correct low acetylcholine levels in Alzheimer's galantamine) correct low acetylcholine levels in Alzheimer's disease, resulting in a small but worthwhile improvement in disease, resulting in a small but worthwhile improvement in memory energy and mood. 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 These should be started and reviewed (every 6 months) by secondary care though shared care can allow GP to monitor secondary care though shared care can allow GP to monitor tolerability and side effectstolerability and side effects

• Common side effects include nausea, diarrhoea, vivid dreams Common side effects include nausea, diarrhoea, vivid dreams and leg cramps. Bradychardia is almost invariable.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.

Gp contract..Gp contract..

• Register of those diagnosed with dementia.Register of those diagnosed with dementia.

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

Where to get support..Where to get support..

• Local mental health team, (they have their own Local mental health team, (they have their own social services package to try and give more social services package to try and give more continuity)continuity)

• South derbyshire CVS, is a signposting organisation South derbyshire CVS, is a signposting organisation which can offer support 017773749087which can offer support 017773749087

• www.derbyshirecarers.co.ukwww.derbyshirecarers.co.uk

• Alzhymers society. Alzhymers society. www.alzhymers.org.ukwww.alzhymers.org.uk 0845300033608453000336

• Dementia Care trust Dementia Care trust www.dct.org.ukwww.dct.org.uk o8704435325 o8704435325• Carers UK Carers UK www.carersonline.org.ukwww.carersonline.org.uk 08088087777 08088087777• Age concern Age concern www.ace.org.ukwww.ace.org.uk• Pick’s disease support group Pick’s disease support group www.pdsg.org.ukwww.pdsg.org.uk• Princess Royal trust for carers Princess Royal trust for carers help@carers.orghelp@carers.org

www.carers.orgwww.carers.org

END/ Questions?END/ Questions?

Definitions.Definitions.

• Delerium is an aDelerium is an acute confusion, transient cognitive impairment, cute confusion, transient cognitive impairment, Fluctuating cognitionFluctuating cognition– global cognitive impairmentglobal cognitive impairment– ReversibleReversible

• Main defect: attention -->Main defect: attention -->– less aware of surroundingsless aware of surroundings– easily distractibleeasily distractible– trouble with concentration & commandstrouble with concentration & commands

• Main aspects of cog. disordered: Main aspects of cog. disordered: thinking, perception, memorythinking, perception, memory– + + sleep-wake cycle, disorientation, sleep-wake cycle, disorientation, LOC LOC– + + or or psychomotor activity psychomotor activity– +/- emotional +/- emotional ‘s and irritability ‘s and irritability

• II Infection Infection

• WW Withdrawal Withdrawal• AA Acute metabolic Acute metabolic• TT Trauma Trauma• CC CNS pathology CNS pathology• HH Hypoxia Hypoxia

• DD Deficiencies Deficiencies• EE Endocrine Endocrine• A A Acute vascular/MI Acute vascular/MI• TT Toxins-drugs Toxins-drugs• HH Heavy metals Heavy metals

Potentially reversible causes of Potentially reversible causes of cognitive impairmentcognitive impairment• Depression (can get depressive psudo dementia BUT Depression (can get depressive psudo dementia BUT

depression is also a feature of dementia!)depression is also a feature of dementia!)• Subdural heamatomaSubdural heamatoma• HypothyroidismHypothyroidism• Chronic severe hyponatraimiaChronic severe hyponatraimia• Vit B12 deficency Vit B12 deficency • NeurosyphilisNeurosyphilis• VasculitisVasculitis• Paraneoplastic syndromeParaneoplastic syndrome• Wipples diseaseWipples disease• Normal pressure hydrocephalus, (ventricular dilation + triad Normal pressure hydrocephalus, (ventricular dilation + triad

of dementia incontinence and gait disturbance)of dementia incontinence and gait disturbance)