A bit of history <ul><li>Alzheimer’s disease – named after Alois Alzheimer who first described it back in 1906 </li></ul><...
Dementia <ul><li>Loss of intellectual functions including memory. </li></ul><ul><li>Deterioration in ability to carry out ...
Alzheimers dementia <ul><li>Most common form. </li></ul><ul><li>Behaviour changes often take form of apathy and social wit...
Vascular dementia <ul><li>Role of vascular events in aetiology of dementia poorly understood. </li></ul><ul><li>Onset may ...
Lewy body dementia <ul><li>Fluctuation of awareness from day to day. </li></ul><ul><li>Signs of Parkinsonism </li></ul><ul...
The others <ul><li>Fronto-temporal dementia. </li></ul><ul><li>CJD. </li></ul><ul><li>Mixed dementia. </li></ul>
Diagnosis <ul><li>History </li></ul><ul><ul><li>Ideally using diagnostic criteria eg. DSM4 </li></ul></ul><ul><li>Cognitiv...
Non-pharmacological interventions <ul><li>Supporting care givers </li></ul><ul><li>Cognitive stimulation </li></ul><ul><li...
Cholinesterase inhibitors <ul><li>Inhibit the enzymatic breakdown of acetylcholine. </li></ul><ul><li>Efficacy on reducing...
Donepezil <ul><li>Can be used to treat cognitive decline  in mild-mod AD and vascular dementia. </li></ul><ul><li>Reduces ...
Galantamine <ul><li>Can be used for treatment of cognitive decline in AD and mixed dementias. </li></ul><ul><li>Can be use...
Rivastigmine <ul><li>Shown to reduce cognitive decline and improve associated symptoms in patients with AD and Lewy body d...
Memantine <ul><li>NMDA receptor antagonist. </li></ul><ul><li>Small benefits in wide range of measures and activities of d...
Ginkgo Biloba <ul><li>Studies looked at use in dementias </li></ul><ul><li>Has a positive effect on cognition and function...
Use of Antipsychotics <ul><li>Are effective for treatment of behavioural problems. </li></ul><ul><li>Older and atypical fo...
Things that don’t work <ul><li>Anti-inflammatories </li></ul><ul><li>Hydroxychloroquine </li></ul><ul><li>Prednisolone </l...
The cholinesterase inhibitors debate <ul><li>Use limited by NICE to moderate dementia (MMSE 10-20).  </li></ul><ul><li>Yea...
The cholinesterase inhibitors debate <ul><li>Less than 20% of patients with dementia treated with these meds. </li></ul><u...
Current NICE guidelines <ul><li>Donepezil, Galantamine and Rivastigmine used in mild-mod severe AD </li></ul><ul><ul><li>M...
Current NICE guidelines <ul><li>Memantine not recommended  </li></ul><ul><li>Patients already on Tx can continue until con...
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A bit of history Alzheimer's disease – named after Alois ...

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

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