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?