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

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

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

    • 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.
    • Dementia
      • Loss of intellectual functions including memory.
      • Deterioration in ability to carry out day to day activities.
      • Changes in social behaviour.
    • 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.
    • 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.
    • 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).
    • The others
      • Fronto-temporal dementia.
      • CJD.
      • Mixed dementia.
    • 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
    • Non-pharmacological interventions
      • Supporting care givers
      • Cognitive stimulation
      • Environment design
      • Physical activities
      • Recreational activities
    • 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.
    • 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.
    • 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.
    • Rivastigmine
      • Shown to reduce cognitive decline and improve associated symptoms in patients with AD and Lewy body dementia.
    • 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.
    • 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.
    • 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.
    • Things that don’t work
      • Anti-inflammatories
      • Hydroxychloroquine
      • Prednisolone
      • Melatonin
      • Oestrogens
      • Selegiline
    • 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?
    • 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.
    • 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.
    • Current NICE guidelines
      • Memantine not recommended
      • Patients already on Tx can continue until considered appropriate to stop.