Dementia

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 1830
2020 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 Inhibitors
Antipsychotics
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 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

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 Answers
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Dementia

by cardiacinfo

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Dementia

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