Dementia Care

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  1. 1. GP Presentation: Dementia Update Belinda McCall Consultant in Elderly Medicine Trust lead for Dementia Lewisham and Greenwich NHS Trust
  2. 2. Scope of the problem What is dementia Early diagnosis Treatment Behavioural and psychological symptoms of dementia and Antipsychotics The Lewisham Memory Service The future Outline
  3. 3. 6% of individuals over 651 20% of individuals over 80 850,000 cases in UK currently2 Current cost of dementia 14.3bn more than stroke, heart disease and cancer combined Number of people with dementia will increase by 40% in next 15 years 1. Lobo et al 2001 2. Alzheimers research UK 2015 Dementia epidemiology
  4. 4. 2/3 people with dementia are at home Unpaid carers save the tax payer 5.4 billion a year Annual economic burden of late onset dementia is 14.3 billion-most falls on families The National Audit Office estimated the xs cost at more than 6 million / yr in an average general hospital. NHS care 1.17 billion a year Costs of dementia
  5. 5. Alzheimer's and other dementias
  6. 6. Is a clinical syndrome Characterised by difficulties in memory, language, psychological and psychiatric changes, and impairments in activities of daily living. Is one of the main causes of disability in later life In terms of global burden, it contributes 11.2% of all years lived with disability Higher than stroke (9.5%); musculoskeletal disorders (8.9%); heart disease (5%); cancer (2.4%) (Alzheimers Society. Dementia UK: the full report.London;AS.2007) Dementia
  7. 7. Risk factors for AD
  8. 8. Hypthyroidism May lead to a dementia syndrome Hypercalcaemia May mimic dementia Hypoglycaemia May be associated with confusion and symptoms similar to dementias Nutritional deficiencies May be associated with the dementia syndrome Kidney and liver disorders Liver disease and dysfunction, often secondary to alcohol abuse, may lead to the dementia syndrome (90% of alcoholics develop dementia) Infections Chronic infections may be associated with a dementia-like condition. Conditions such as borrelioses, neurosyphilis and HIV can lead to dementia and should be considered when the patient's lifestyle or history indicates risk. AIDS-related dementia is probably a direct consequence of HIV infecting the central nervous system (CNS) Normal pressure hydrocephalus This is a brain potentially reversible disorder caused by blockage of the flow of the CSF. It leads to enlargement of the ventricles and compression of brain tissue. As a result brain atrophy and dementia can occur. Structural brain imaging techniques such as CT scanning can establish whether this disease has caused the dementia Some potentially reversible causes of the dementia syndrome
  9. 9. Cognitive function Progressive loss of short-term memory Difficulty in registration and recall of new information Language problems e.g. repetition Poor or reduced judgement Behavioural changes Aggression, disinhibition, social withdrawal, wandering, disorientation Inability to perform usual activities of daily living Psychiatric problems Associated mood disorder Delusions/hallucinations Physical debility Self-neglect Incontinence Falls Clinical Presentation
  10. 10. Common types of dementia: 1. Alzheimers dementia (60% cases) 2. Vascular dementia (20% cases) 3. Lewy body dementia (15% cases) 4. Frontotemporal dementia (FTD) 20% cases below 65yrs 5. Rarer causes: Hypothyroidism Normal pressure hydrocephalus Dementia in movement disorders e.g. PD, PSP Vitamin B12/folate deficiency Wernicke-Korsakoff dementia Neurosyphilis HIV/AIDS dementia Huntingtons disease Hypercalcemia Creutzfield-Jacob disease (CJD)
  11. 11. Prevalence of Dementia Sub types
  12. 12. Characterised by 3 groups of symptoms Cognitive dysfunction Memory loss, language difficulties, executive function (loss of higher level planning, intellectual coordination skills), visuospatial skills, attention Psychiatric symptoms & behavioural disturbances Depression, anxiety, delusions, agitation Difficulties performing ADLs Complex activities: driving, shopping Basic activities: dressing, eating unaided A person with AD is 30% more likely to display clinical features of dementia if they have coexisting symptoms of vascular disease (JAMA 1997;277:813-7) Alzheimers Disease (AD)
  13. 13. The pathogenesis of AD is poorly understood Pathways believed to contribute to neuronal dysfunction and death include: Decreased acetylcholine synthesis and impaired cholinergic function Glutamatergic excitotoxicity Direct toxicity of amyloid peptide Mitochondrial dysfunction Increased oxidative stress Activation of apoptotic pathways Release of inflammatory mediators Impaired calcium signalling and regulation These pathways represent targets for existing and novel AD therapies Pathogenesis of Alzheimers Disease
  14. 14. Multiple cognitive deficits, including memory impairment and at least one of: Aphasia - problems with language (receptive and expressive) Apraxia - inability to carry out purposeful movements even though there is no motor or sensory impairment Agnosia - failure to recognise things and especially people Decreased need for sleep Cognitive deficits severe enough to interfere with occupational and/or social functioning Cognitive deficits represent a decline from previously higher function These deficits do not occur exclusively during the course of delirium DSM IV Criteria for diagnosis of dementia:
  15. 15. Molecular Targets for Current AD Therapies
  16. 16. Plaques and tangles senile plaque and neurofibrillary degeneration (silver impregnation)
  17. 17. MCI vs. Alzheimers Disease
  18. 18. Criteria for diagnosis: Memory complaints, preferably corroborated by an informant Impaired memory function for age and education Preserved general cognitive function Intact activities of daily living No evidence of dementia Prospective studies have shown that people with amnestic mild cognitive impairment are up to 15 times more likely to have developed dementia at follow-up Mild Cognitive Impairment
  19. 19. Vascular dementia is the second most common cause of dementia, after Alzheimer's disease. It accounts for up to 20 % of all dementias and is caused by brain damage from cerebrovascular or cardiovascular problems - usually strokes. It also may result from genetic diseases, endocarditis or amyloid angiopathy. It may coexist with Alzheimer's disease. Unlike people with Alzheimer's disease, people with vascular dementia often maintain their personality and normal levels of emotional responsiveness until the later stages of the disease. People with vascular dementia frequently wander at night and often have other problems commonly found in people who have had a stroke, including depression and incontinence.
  20. 20. In Lewy body dementia, cells die in the brain's cortex , and the substantia nigra. Many of the remaining nerve cells in the substantia nigra contain abnormal structures called Lewy bodies that are the hallmark of the disease. The symptoms of Lewy body dementia overlap with Alzheimer's disease in many ways and may include memory impairment, poor judgment, and confusion. Lewy body dementia typically also includes visual hallucinations, parkinsonian symptoms such as a shuffling gait (walk) and flexed posture, and day-to-day fluctuations in the severity of symptoms. Patients with Lewy body dementia live an average of 7 years after symptoms begin. There is no cure for Lewy body dementia, and treatments are aimed at controlling the parkinsonian and psychiatric symptoms of the disorder. Rivastigmine can be used to manage symptoms.
  21. 21. Abnormal processing of tau protein Insidious onset, slow progression Predominantly affects the frontal and anterior temporal lobes Rare over age 65 Behavioural features, impulsivity, personality change, urinary incontinence, disinhibition Can develop non-fluent aphasia, economy of speech or repetition Memory and visuospatial ability are relatively preserved in the early stages
  22. 22. Early diagnosis
  23. 23. History (collateral) Cognitive function assessments AMT < 8 (needs further assessment) GPCOG (9 points) MOCA (30 points) MMSE (30 point) Score 25 (normal) Score 19 24 (mild) Score 10 18 (moderate) Score 9 (severe) Does not test executive function, so possible to have a normal score and still have cognitive deficits Addenbrookes Cognitive Examination (ACE-R) 100 point Score < 82 suggestive of dementia Clinical examination Exclude other pathology Look for clues of self-neglect Diagnosis
  24. 24. Early Diagnosis Healthy Individual Memory Occasional lapses Orientation fully Judgement & problem solving Solves everyday problems Outside home Independent functioning At home Activities & interests maintained Personal care Fully capable Early Dementia Memory Loss of memory for recent events Orientation Variable disorientation in time & space Judgement & problem solving Some difficulty with complex problems Outside home Engaged in some activities but not independently. May appear normal At home More difficult tasks & hobbies abandoned Personal care Needs some prompting
  25. 25. Timely diagnosis allows people to make future plans, reduces crises, delays institutionalisation and provides support for carers (Prince et al., 2011). Some evidence of increase in quality of life and decrease in carer stress. Reassures worries taken seriously, confirms suspicions Reduced prescribing conflicts Reduced safeguarding events (ADASS) Lower risk of unnecessary hospital admission (Kernow, BANES) Identification of treatable physical and psychiatric causes Treatment of co-morbid conditions Instigation of pharmacological symptomatic treatments Early diagnosis is still a ke