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Caring for People with Dementia in Primary Care:
Diagnosis and Management
Ngaire Kerse, John Scott, Michal Boyd
Mary, continued...
Dear DrThanks for seeing Mary, an elderly woman with mild Alzheimer's
disease.Her family recently asked for advice about drugs for dementia,
and also are concerned about her safety in light of an episode when she went driving one night and couldn’t find her way to her daughter’s house, although its nearby and she’s been there many times before. Should she be driving? Should we consider drug treatment?Many thanks
Dr XLocal GP practice
When to refer?
• Depends on local resources• Differing models of care• Differing strengths and weaknesses in both
primary and secondary care locally/ generally• Waitemata Model/ Counties Model• When you need to!
Secondary Care Contribution?
• Diagnosis• Drugs• EPOA• Residential Care• BPSD
Diagnosis
• “typical” Alzheimer's disease– Steady progression over months, 1-2 years– Absence of “psychiatric” features – Medically “well”, no slowing/ parkinsonism/ gait
abnormalities– Memory affected at first, then other domains– Social graces often preserved– Mostly manageable in primary care e.g CDHB
health pathways
Specialist Diagnosis
• Subtyping/ management• Rare syndromes diagnosis• Red flag symptoms (early hallucinations, falls,
severe fluctuations, • Suspected physical illness/ medication
contribution
Drugs
• No major breakthroughs on the horizon– Good evidence of no effect from statins/ NSAIDs
• Current drugs:– Modest effectiveness (≈ 1-2 MMSE points, several
months “back”, mild global improvements)– 30% in trials dropped out (GI s/e)– ECG before prescription– Discuss always, offer often, prescribe sometimes,
continue occasionally, stop ??
Changes in ADAS-Cog (70 point scale)
Drugs
Donepezil Aricept, Donepezil-Rex Tablet,daily Early to
moderate disease.Generic donepezil subsidised.Evidence of deterioration after cessation.No evidence one drug better than another.
Rivastigmine Exelon Patch,Tablet bd
Glantamine Reminyl CR Tablet, daily
What to tell patients/ families• Cholinesterase inhibitors are a temporary remedy. • They may hold the progression of AD for 6 months• They don’t work for everyone, and there’s no way to know if they
will help except trialling them• A significant proportion of people don’t tolerate them• They don’t doesn't halt the underlying disease • They may work better in people with hallucinations / fluctuations
suggesting LB disease• They don’t work as well for vascular dementia• If you miss the drug for more than a few days, you have to go back
to the beginning• They need to be stopped if they don’t work
EPOA
• One of the key reasons for early diagnosis• Often people are referred for competency
assessments when they are too severely affected to assign an EPOA.
• Everyone needs an EPOA!
Driving
• A vexed issue. • Driving deteriorates with dementia
progression, but when is the right time to stop?• Classic conflict of personal autonomy vs public
safety• ½ - ¾ of those with mild dementia can pass a
driving test and are probably safe to drive (JAGS 2005, 53, p94)
• But which ¼ are unsafe?
Clues someone may be unsafe• Not useful:
– Self rating– MMSE
• Useful:– Family/ spouse reports esp. if they have driven with the person– Previous accident– Severity of dementia correlates with risk– Self restriction of driving
• No good office test will tell you if someone is safe to drive!• LTSA guidance not helpful• If concerns and person unwilling to cease driving, ORDT with OT
is needed
Mary, continued...
Dear DrThanks for seeing Mary, an elderly woman with mild Alzheimer's
disease.Her family recently asked for advice about drugs for dementia,
and also are concerned about her safety in light of an episode when she went driving one night and couldn’t find her way to her daughter’s house, although its nearby and she’s been there many times before. Should she be driving? Should we consider drug treatment?Many thanks
Dr XLocal GP practice
Dementia Services
What are your biggest concerns?What are the biggest gaps locally in your area?