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Dementia

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  • 1. Dementia Callum Wilson
  • 2. Quiz
    • Question 1
    • Vascular dementia is the most common form of dementia (True/False)
  • 3. Quiz
    • Question 2
    • Vascular dementia is characterised by a stepwise decline in cognition or function (True/False)
  • 4. Quiz
    • Question 3
    • There is strong evidence to suggest secondary prevention/ risk reduction slows the progress of dementia (True/ False)
  • 5. Quiz
    • Question 4
    • Almost all patients with mild cognitive impairment will progress to dementia (True / False)
  • 6. Quiz
    • Question 5
    • Drugs used for symptomatic treatment in Alzheimer’s disease include donepezil, galantamine and rivastigmine (True / False)
  • 7. Quiz
    • Question 6
    • Olanzapine and risperidone are safe antipsychotics to use in elderly patients with dementia (True/False)
  • 8. Quiz
    • Question 7
    • The benefit gained by the use of antipsychotics does not extend past 3 months (True/False)
  • 9. 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)
  • 10. Quiz
    • Question 9
    • Severe impairment on MMSE is an indication for starting AchEi drugs (True/False)
  • 11. Quiz
    • Question 10
    • Normal pressure hyrdrocephalus is characterised by a triad of abnormal gait, urinary incontinence and gradual cognitive decline (True/False)
  • 12. 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
  • 13. Figures for Calderdale
    • population prevalence over 65 (dementia (total) sufferers)
    • 2010 32,100 1605
    • 2015 36,600 1830
    • 2020 39,800 1990
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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.
  • 19. 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.
  • 20. 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.
  • 21. 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)
  • 22. 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
  • 23. 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
  • 24. 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.
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. 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
  • 29.  
  • 30. Psychiatric Assessment
    • History of Presenting Problem
    • Previous History of Illness
    • Social History
    • Family History
    • Medical Problems
    • Current Medication
    • Physical Examination
    • Mental State Examination
  • 31. Diagnosis
    • No Dementia
    • Mild Cognitive Impairment
    • Dementia- Alzheimer’s Disease
    • Dementia-Other Types
    • Other Psychiatric Problems-Depression
  • 32. 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
  • 33. Outcome: Mild Dementia 1
    • Cognitive assessment
    • Clinical picture
    • Functional impairment
    • Neuroimaging findings
    • Medical condition
    • Risk issues
    • Social circumstances
  • 34. 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
  • 35. Outcome: Moderate Dementia
    • Initiate dementia treatment if:
    • Alzheimer’s Type
    • Mixed Alzheimer’s and Vascular Type
    • No contraindications to prescribing
  • 36. 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
  • 37. Drug treatments in dementia
    • Secondary Prevention –limited evidence
    • Symptomatic treatments :
    • Acetyl Cholinesterase Inhibitors
    • Antipsychotics
    • Antidepressants
  • 38. 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
  • 39. Licensed treatment of dementia Acetyl 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
  • 40. 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.
  • 41. 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.
  • 42. 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
  • 43. 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.
  • 44. 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
  • 45. 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
  • 46. Quiz Answers
    • False
    • True
    • False
    • False
    • True
    • False
    • True
    • True
    • False
    • True
  • 47. Questions?