A bit of history Alzheimer's disease – named after Alois ...
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A bit of history Alzheimer's disease – named after Alois ... Presentation Transcript

  • 1. A bit of history
    • Alzheimer’s disease – named after Alois Alzheimer who first described it back in 1906
    • Now dementia affects 24 million people world-wide, 60% in developing countries.
    • 0.5 million people in UK.
    • Comes third in disability indices.
  • 2. Dementia
    • Loss of intellectual functions including memory.
    • Deterioration in ability to carry out day to day activities.
    • Changes in social behaviour.
  • 3. Alzheimers dementia
    • Most common form.
    • Behaviour changes often take form of apathy and social withdrawal but also behavioural disturbance.
    • Leads to death of selected nerve cells in the CNS.
    • Average survival post diagnosis 8-10 years.
  • 4. Vascular dementia
    • Role of vascular events in aetiology of dementia poorly understood.
    • Onset may be abrupt or may be stepwise progression.
    • Physical problems are more common than in AD.
  • 5. Lewy body dementia
    • Fluctuation of awareness from day to day.
    • Signs of Parkinsonism
    • Visual hallucinations or delusions.
    • Similar to dementia seen in patients with Parkinson’s disease (affects 75% after 10 years).
  • 6. The others
    • Fronto-temporal dementia.
    • CJD.
    • Mixed dementia.
  • 7. Diagnosis
    • History
      • Ideally using diagnostic criteria eg. DSM4
    • Cognitive testing
      • MMSE
    • Screening for reversible causes
      • Only if clinically indicated
      • Assess for depression
    • Imaging
      • CT +/- SPECT
  • 8. Non-pharmacological interventions
    • Supporting care givers
    • Cognitive stimulation
    • Environment design
    • Physical activities
    • Recreational activities
  • 9. Cholinesterase inhibitors
    • Inhibit the enzymatic breakdown of acetylcholine.
    • Efficacy on reducing cognitive decline of three main drugs the same.
    • Donepezil possibly better tolerated.
    • Long term use may delay institutionalisation.
  • 10. Donepezil
    • Can be used to treat cognitive decline in mild-mod AD and vascular dementia.
    • Reduces psychotic symptoms and some behavioural problems in mild-mod AD.
    • Treatment daily doses of 5mg or above.
  • 11. Galantamine
    • Can be used for treatment of cognitive decline in AD and mixed dementias.
    • Can be used for Mx of associated symptoms including functional ability in AD.
    • Higher doses up to 24mg/day more effective; slow dose escalation improves tolerability.
  • 12. Rivastigmine
    • Shown to reduce cognitive decline and improve associated symptoms in patients with AD and Lewy body dementia.
  • 13. Memantine
    • NMDA receptor antagonist.
    • Small benefits in wide range of measures and activities of daily living in patients with mild-mod AD and vascular dementia but not statistically significant.
    • Insufficient evidence to back up its use.
  • 14. Ginkgo Biloba
    • Studies looked at use in dementias
    • Has a positive effect on cognition and function but less than cholinesterase inhib.
    • Benefit most pronounced in advanced AD.
    • Safe though interacts with medicines e.g. increased clotting time on warfarin.
    • Needs to be used for 1 year to see improvements.
  • 15. Use of Antipsychotics
    • Are effective for treatment of behavioural problems.
    • Older and atypical forms have similar efficacy.
    • Risk of stroke with atypical antipsychotics.
    • Significant SE profile – needs monitored.
    • No causal link to accelerated progression of dementia.
  • 16. Things that don’t work
    • Anti-inflammatories
    • Hydroxychloroquine
    • Prednisolone
    • Melatonin
    • Oestrogens
    • Selegiline
  • 17. The cholinesterase inhibitors debate
    • Use limited by NICE to moderate dementia (MMSE 10-20).
    • Yearly cost of £1000/pt.
    • 1/3 of patients stop after 3mths due to SE.
    • Challenged in courts on basis that economic model not released for scrutiny.
    • Are rigid cut-offs in MMSE a fair way to assess eligibility for treatment?
  • 18. The cholinesterase inhibitors debate
    • Less than 20% of patients with dementia treated with these meds.
    • Cost 30% more in UK than Europe.
    • Poor standard of care compared to other countries
      • 1/3 of patients receive a formal diagnosis
      • Use of cholinesterase inhibitors less widespread.
  • 19. Current NICE guidelines
    • Donepezil, Galantamine and Rivastigmine used in mild-mod severe AD
      • MMSE 10-20
      • Initiated by specialist
      • R/V every 6/12
      • Only continued if MMSE >= 10 and clinically worthwhile.
  • 20. Current NICE guidelines
    • Memantine not recommended
    • Patients already on Tx can continue until considered appropriate to stop.