DementiaDementia
What we will cover..What we will cover..
• IntroductionIntroduction
• Epidemiology and risk factorsEpidemiology and risk f...
DementiaDementia
• ‘‘a progressive and largely irreversible clinical syndromea progressive and largely irreversible clinic...
EpidemiologyEpidemiology
• In UK, it is estimated that there are approximately 700,000 people withIn UK, it is estimated t...
Risk FactorsRisk Factors
Modifiable risk factorsModifiable risk factors
• alcohol consumption  alcohol consumption  
• smo...
You are 26% less likely to develop dementia if you have three or moreYou are 26% less likely to develop dementia if you ha...
Presentation/ Clinical featuresPresentation/ Clinical features
The period from first symptoms to presentation to the GP is...
Suspect dementia when..Suspect dementia when..
• Family members report toFamily members report to
the physician aboutthe p...
Case based discussionCase based discussion
• Mrs D is a 75 year old widow with previously infrequentMrs D is a 75 year old...
Questions..Questions..
• What is the differential diagnosis?What is the differential diagnosis?
• What would you want to k...
Case discussion..Case discussion..
• The differential diagnosis could be Dementia, but also aThe differential diagnosis co...
Dementia DiagnosisDementia Diagnosis
• Diagnosis of dementiaDiagnosis of dementia
should be made onlyshould be made only
a...
HistoryHistory
• The history should be gathered from a person who has known theThe history should be gathered from a perso...
ExaminationExamination
• Check general appearance, look for evidence of self-Check general appearance, look for evidence o...
MMSEMMSE
MMSE interpretationMMSE interpretation
• 24-30 no Cognitive impairment24-30 no Cognitive impairment
• 18-23 mild cognitive...
GP Investigations..GP Investigations..
• These are aimed at detecting treatable causes…These are aimed at detecting treata...
Secondary care investigations..Secondary care investigations..
• CTCT
• MRIMRI
• Single photon emission tomography (assess...
Management..Management..
• Refer all patients to a psycho-geriatrician for conformation of the diagnosis,Refer all patient...
Cholinesterase inhib?Cholinesterase inhib?
• Cholinesterase inhibitors (donepazil rivastigmine, and galantamine)Cholineste...
Gp contract..Gp contract..
• Register of those diagnosed with dementia.Register of those diagnosed with dementia.
• The pe...
Where to get support..Where to get support..
• Local mental health team, (they have their own socialLocal mental health te...
END/ Questions?END/ Questions?
Definitions.Definitions.
• Delerium is an aDelerium is an acute confusion, transient cognitive impairment,cute confusion, ...
• II InfectionInfection
• WW WithdrawalWithdrawal
• AA Acute metabolicAcute metabolic
• TT TraumaTrauma
• CC CNS pathology...
Potentially reversible causes ofPotentially reversible causes of
cognitive impairmentcognitive impairment
• Depression (ca...
Dementia What we will cover..
Dementia What we will cover..
Dementia What we will cover..
Dementia What we will cover..
Dementia What we will cover..
Dementia What we will cover..
Dementia What we will cover..
Upcoming SlideShare
Loading in …5
×

Dementia What we will cover..

551 views
443 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
551
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
18
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Dementia What we will cover..

  1. 1. DementiaDementia
  2. 2. What we will cover..What we will cover.. • IntroductionIntroduction • Epidemiology and risk factorsEpidemiology and risk factors • Presentation/ clinical featuresPresentation/ clinical features • Case discussion of a new diagnosisCase discussion of a new diagnosis • Investigations and initial managementInvestigations and initial management • Support servicesSupport services • Types and differential diagnosisTypes and differential diagnosis • Dementia reviewDementia review • Q and A with Dr HeartmanQ and A with Dr Heartman • Coffee and cakeCoffee and cake • Management with Dr Komocki, including challengingManagement with Dr Komocki, including challenging
  3. 3. DementiaDementia • ‘‘a progressive and largely irreversible clinical syndromea progressive and largely irreversible clinical syndrome that is characterized by global deterioration in intellectualthat is characterized by global deterioration in intellectual function, behavior and personality in the presence offunction, behavior and personality in the presence of normal consciousness and perception’normal consciousness and perception’ (in an acute(in an acute confusional state the level of consciousness is impaired)confusional state the level of consciousness is impaired) • It is clinically diagnosed and is characterised by a triad ofIt is clinically diagnosed and is characterised by a triad of changes.. Memory loss, loss of another aspect ofchanges.. Memory loss, loss of another aspect of cognition, and impairment of every day life.cognition, and impairment of every day life. • If impairment of consciousness is present together withIf impairment of consciousness is present together with general intellectual impairment, then the condition isgeneral intellectual impairment, then the condition is defined as delirium or confusional state - acute or sub-defined as delirium or confusional state - acute or sub- acute.acute.
  4. 4. EpidemiologyEpidemiology • In UK, it is estimated that there are approximately 700,000 people withIn UK, it is estimated that there are approximately 700,000 people with dementia which cost around £17 billion a year, (heart disease is 4dementia which cost around £17 billion a year, (heart disease is 4 billion, stroke is 3 billion, cancer is 2 billion)billion, stroke is 3 billion, cancer is 2 billion) • A GP with 2000 registered patients will have 12-15 pts with dementia,A GP with 2000 registered patients will have 12-15 pts with dementia, around half will be undiagnosed. There will be 2 new presentations aaround half will be undiagnosed. There will be 2 new presentations a year.year. • Incidence is around 5% of >65 and 25%Incidence is around 5% of >65 and 25% of over 85of over 85 • Alzheimer's accounts for 60%,Alzheimer's accounts for 60%, cerebrovascular disease 10%, Lewy bodycerebrovascular disease 10%, Lewy body dementia10%, Picks/ frontotemporaldementia10%, Picks/ frontotemporal dementia 5%, 15 % mixed and rarerdementia 5%, 15 % mixed and rarer causes e.g. alcohol abuse and headcauses e.g. alcohol abuse and head traumatrauma • On average pts with dementia live for 5On average pts with dementia live for 5 years from emergence of symptoms andyears from emergence of symptoms and 3.5 years from time of diagnosis, (delay to3.5 years from time of diagnosis, (delay to present and delay to formally diagnose).present and delay to formally diagnose).
  5. 5. Risk FactorsRisk Factors Modifiable risk factorsModifiable risk factors • alcohol consumption  alcohol consumption   • smoking – particularly for Alzheimer'ssmoking – particularly for Alzheimer's • obesityobesity • hypertensionhypertension • hypercholesterolaemiahypercholesterolaemia • head injuryhead injury • education and mental stimulationeducation and mental stimulation • Social interactions/ contacts.Social interactions/ contacts. Non modifiable risk factorsNon modifiable risk factors • age – advancing age is the most important risk factor in developingage – advancing age is the most important risk factor in developing dementiadementia • learning disabilities – in people with Down’s syndrome, dementia developslearning disabilities – in people with Down’s syndrome, dementia develops 30–40 years earlier than in a normal person30–40 years earlier than in a normal person • gender – rate of dementia is higher in women than in men (specially forgender – rate of dementia is higher in women than in men (specially for Alzheimer's disease)Alzheimer's disease) • genetic factorsgenetic factors
  6. 6. You are 26% less likely to develop dementia if you have three or moreYou are 26% less likely to develop dementia if you have three or more close friends according to the American journal of public health.close friends according to the American journal of public health.
  7. 7. Presentation/ Clinical featuresPresentation/ Clinical features The period from first symptoms to presentation to the GP is currentlyThe period from first symptoms to presentation to the GP is currently somewhere between 12 and 18 months, (and again there is asomewhere between 12 and 18 months, (and again there is a similar time lag from that point of recognition to time of formalsimilar time lag from that point of recognition to time of formal diagnosis)diagnosis) Many patients have preserved positive personality traits and personalMany patients have preserved positive personality traits and personal attributes but the following features may become evident as theattributes but the following features may become evident as the disease progresses:disease progresses: • memory loss,memory loss, • language impairment,language impairment, • disorientation,disorientation, • changes in personality,changes in personality, • difficulty in carrying out daily activities,difficulty in carrying out daily activities, • self-neglectself-neglect • psychiatric symptoms - apathy, depression or psychosispsychiatric symptoms - apathy, depression or psychosis • unusual behavior - aggression, sleep disturbance or disinhibitedunusual behavior - aggression, sleep disturbance or disinhibited sexual behaviorsexual behavior • Most patients with dementia lose insight into their condition at aMost patients with dementia lose insight into their condition at a nearly stage and fail to report lapses in memory and behaviournearly stage and fail to report lapses in memory and behaviour
  8. 8. Suspect dementia when..Suspect dementia when.. • Family members report toFamily members report to the physician aboutthe physician about memory impairment butmemory impairment but the patient denies itthe patient denies it • The patient is questioned,The patient is questioned, he/she looks at the carerhe/she looks at the carer for an answer - the ‘head-for an answer - the ‘head- turning sign’turning sign’
  9. 9. Case based discussionCase based discussion • Mrs D is a 75 year old widow with previously infrequentMrs D is a 75 year old widow with previously infrequent attendance at the surgery until the death of her husbandattendance at the surgery until the death of her husband 2 months ago. Her son lives a few doors down . Despite2 months ago. Her son lives a few doors down . Despite missing her husband she denies having any problemsmissing her husband she denies having any problems coping without him, but presents with vague symptomscoping without him, but presents with vague symptoms often muddling up her appointment days and times. Heroften muddling up her appointment days and times. Her son calls the surgery concerned about the state of theson calls the surgery concerned about the state of the house and his mother’s hygiene. She has been going tohouse and his mother’s hygiene. She has been going to the shops as usual, but is stock-piling tins that she neverthe shops as usual, but is stock-piling tins that she never seems to open, and there is no fresh food in the house.seems to open, and there is no fresh food in the house. He is going to take her to live with him for the time beingHe is going to take her to live with him for the time being but wants you to investigate.but wants you to investigate.
  10. 10. Questions..Questions.. • What is the differential diagnosis?What is the differential diagnosis? • What would you want to know in theWhat would you want to know in the history?history? • What would you look for/ do onWhat would you look for/ do on examination?examination? • What investigations would you do?What investigations would you do? • What would your initial management be ifWhat would your initial management be if this were Dementia?this were Dementia?
  11. 11. Case discussion..Case discussion.. • The differential diagnosis could be Dementia, but also aThe differential diagnosis could be Dementia, but also a bereavement reaction, depression, or delirium secondarybereavement reaction, depression, or delirium secondary to a medical condition.to a medical condition. • Old age is often associated with bereavement, socialOld age is often associated with bereavement, social isolation, physical and mental disability, and all theseisolation, physical and mental disability, and all these factors could be having an impact. Mrs D was able tofactors could be having an impact. Mrs D was able to cope while her husband was alive, possibly because hecope while her husband was alive, possibly because he carried out many of the essential tasks. With a pt whocarried out many of the essential tasks. With a pt who presents with a multitude of physical problems the initialpresents with a multitude of physical problems the initial focus is on excluding any physical cause whilefocus is on excluding any physical cause while considering grief reaction, depression, or dementia. It isconsidering grief reaction, depression, or dementia. It is also worth bearing in mind these can all presentalso worth bearing in mind these can all present together, eg dementia is a risk factor for depression!together, eg dementia is a risk factor for depression!
  12. 12. Dementia DiagnosisDementia Diagnosis • Diagnosis of dementiaDiagnosis of dementia should be made onlyshould be made only after through assessmentafter through assessment which should includewhich should include history, cognitive andhistory, cognitive and mental statemental state examination, physicalexamination, physical examination, appropriateexamination, appropriate investigations and ainvestigations and a review of medicationreview of medication which might affectwhich might affect cognitive function.cognitive function.
  13. 13. HistoryHistory • The history should be gathered from a person who has known theThe history should be gathered from a person who has known the patient for a period of six months at least and if possible directly frompatient for a period of six months at least and if possible directly from the patient and includes:the patient and includes: – ageage – medical and psychiatric history of the family e.g. - dementia or othermedical and psychiatric history of the family e.g. - dementia or other mental health problemsmental health problems – origin and progression of conditionorigin and progression of condition • associations:associations: – myoclonusmyoclonus – seizuresseizures – depression, anxietydepression, anxiety – (can get depressive psudo dementia BUT depression is also a feature of(can get depressive psudo dementia BUT depression is also a feature of dementia!)dementia!) • past and present medical and psychiatric history - e.g. diabetes,past and present medical and psychiatric history - e.g. diabetes, hypertension, cerebrovascular diseasehypertension, cerebrovascular disease • exposure to toxins:exposure to toxins: – alcoholalcohol – leadlead – drugs e.g. barbituratesdrugs e.g. barbiturates • WE SHOULD BE ASKING PEOPLE WITH POSSIBLE DEMENTIA IFWE SHOULD BE ASKING PEOPLE WITH POSSIBLE DEMENTIA IF THEY WISH TO KNOW THE DIAGNOSIS AND WHO WE CANTHEY WISH TO KNOW THE DIAGNOSIS AND WHO WE CAN SHARE IT WITHSHARE IT WITH
  14. 14. ExaminationExamination • Check general appearance, look for evidence of self-Check general appearance, look for evidence of self- neglect, malnutrition, abuse.neglect, malnutrition, abuse. • Examine, attention and concentration, orientation, longExamine, attention and concentration, orientation, long and short term memory, language, praxis and executiveand short term memory, language, praxis and executive function.function. • Formal Cognitive tests…Formal Cognitive tests… • MMSE most commonMMSE most common • GP-COGGP-COG • 6-item cognitive impairment test (6CIT)6-item cognitive impairment test (6CIT) • Abbreviated mental test score (AMTS)Abbreviated mental test score (AMTS) • Mini-CogMini-Cog • Memory impairment screenMemory impairment screen
  15. 15. MMSEMMSE
  16. 16. MMSE interpretationMMSE interpretation • 24-30 no Cognitive impairment24-30 no Cognitive impairment • 18-23 mild cognitive impairment18-23 mild cognitive impairment • 0-17 severe cognitive impairment0-17 severe cognitive impairment
  17. 17. GP Investigations..GP Investigations.. • These are aimed at detecting treatable causes…These are aimed at detecting treatable causes… • FBCFBC • UEUE • ESFESF • LFTLFT • Ca2+Ca2+ • TFTTFT • GluGlu • B12, folateB12, folate • MSUMSU • CXRCXR • (VDRL HIV ONLY IF SPECIFIC REASON, NOT ROUTENE)(VDRL HIV ONLY IF SPECIFIC REASON, NOT ROUTENE) • ?ECG if tx with cholinesterase drugs considered.?ECG if tx with cholinesterase drugs considered.
  18. 18. Secondary care investigations..Secondary care investigations.. • CTCT • MRIMRI • Single photon emission tomography (assessesSingle photon emission tomography (assesses regional blood flow)regional blood flow) • Dopamine scan (to detect Lewy body diseaseDopamine scan (to detect Lewy body disease • Carotid doplerCarotid dopler • ECG (if tx with cholinesterase drug considered)ECG (if tx with cholinesterase drug considered)
  19. 19. Management..Management.. • Refer all patients to a psycho-geriatrician for conformation of the diagnosis,Refer all patients to a psycho-geriatrician for conformation of the diagnosis, exclusion of treatable causes and ongoing specialist support andexclusion of treatable causes and ongoing specialist support and assessment.assessment. • Refer to a social worker and/or CPN for community support.Refer to a social worker and/or CPN for community support. • Support carers and put them in contact with resources with regards toSupport carers and put them in contact with resources with regards to benefits, self help groups and respite care.benefits, self help groups and respite care. • Discuss the diagnosis and prepare them as best you can for the progressionDiscuss the diagnosis and prepare them as best you can for the progression of the disease.of the disease. • Broach medico-legal issuesBroach medico-legal issues • Treat concurrent problems (UTI, anaemia, depression) as they makeTreat concurrent problems (UTI, anaemia, depression) as they make dementia worse.dementia worse. • Management of memory loss, e.g. pill dispensers and notebook tasksManagement of memory loss, e.g. pill dispensers and notebook tasks • For Alzheimer's disease consider cholinesterase inhibitorsFor Alzheimer's disease consider cholinesterase inhibitors • For vascular dementia reduce risk factors (alcohol, Htx, obesity, dm,For vascular dementia reduce risk factors (alcohol, Htx, obesity, dm, cholesterol)cholesterol)
  20. 20. Cholinesterase inhib?Cholinesterase inhib? • Cholinesterase inhibitors (donepazil rivastigmine, and galantamine)Cholinesterase inhibitors (donepazil rivastigmine, and galantamine) correct low acetylcholine levels in Alzheimer's disease, resulting in acorrect low acetylcholine levels in Alzheimer's disease, resulting in a small but worthwhile improvement in memory energy and mood.small but worthwhile improvement in memory energy and mood. • NICE recommended as an option in the management of patients with Alzheimer’s disease of moderate severity only (that is those with a MMSE score of 10-20 points) • These should be started and reviewed (every 6 months) byThese should be started and reviewed (every 6 months) by secondary care though shared care can allow GP to monitorsecondary care though shared care can allow GP to monitor tolerability and side effectstolerability and side effects • Common side effects include nausea, diarrhoea, vivid dreams andCommon side effects include nausea, diarrhoea, vivid dreams and leg cramps. Bradychardia is almost invariable.leg cramps. Bradychardia is almost invariable. • The drug should only be continued while the patient’s MMSE score remains at or above 10 points and their global, functional and
  21. 21. Gp contract..Gp contract.. • Register of those diagnosed with dementia.Register of those diagnosed with dementia. • The percentage of patients diagnosed with dementia whoseThe percentage of patients diagnosed with dementia whose care has been reviewed in the preceding 15months. Thiscare has been reviewed in the preceding 15months. This should include an assesment of support needs of the patientshould include an assesment of support needs of the patient and their carer and a review of co-ordination arrangementsand their carer and a review of co-ordination arrangements with secondary care.with secondary care.
  22. 22. Where to get support..Where to get support.. • Local mental health team, (they have their own socialLocal mental health team, (they have their own social services package to try and give more continuity)services package to try and give more continuity) • South derbyshire CVS, is a signposting organisationSouth derbyshire CVS, is a signposting organisation which can offer support 017773749087which can offer support 017773749087 • www.derbyshirecarers.co.ukwww.derbyshirecarers.co.uk • Alzhymers society.Alzhymers society. www.alzhymers.org.ukwww.alzhymers.org.uk 0845300033608453000336 • Dementia Care trustDementia Care trust www.dct.org.ukwww.dct.org.uk o8704435325o8704435325 • Carers UKCarers UK www.carersonline.org.ukwww.carersonline.org.uk 0808808777708088087777 • Age concernAge concern www.ace.org.ukwww.ace.org.uk • Pick’s disease support groupPick’s disease support group www.pdsg.org.ukwww.pdsg.org.uk • Princess Royal trust for carersPrincess Royal trust for carers help@carers.orghelp@carers.org www.carers.orgwww.carers.org
  23. 23. END/ Questions?END/ Questions?
  24. 24. Definitions.Definitions. • Delerium is an aDelerium is an acute confusion, transient cognitive impairment,cute confusion, transient cognitive impairment, FluctuatingFluctuating cognitioncognition – global cognitive impairmentglobal cognitive impairment – ReversibleReversible • Main defect: attention -->Main defect: attention --> – less aware of surroundingsless aware of surroundings – easily distractibleeasily distractible – trouble with concentration & commandstrouble with concentration & commands • Main aspects of cog. disordered:Main aspects of cog. disordered: thinking, perception, memorythinking, perception, memory – ++  sleep-wake cycle, disorientation,sleep-wake cycle, disorientation, LOCLOC – ++  oror psychomotor activitypsychomotor activity – +/- emotional+/- emotional  ‘s and irritability‘s and irritability
  25. 25. • II InfectionInfection • WW WithdrawalWithdrawal • AA Acute metabolicAcute metabolic • TT TraumaTrauma • CC CNS pathologyCNS pathology • HH HypoxiaHypoxia • DD DeficienciesDeficiencies • EE EndocrineEndocrine • AA Acute vascular/MIAcute vascular/MI • TT Toxins-drugsToxins-drugs • HH Heavy metalsHeavy metals
  26. 26. Potentially reversible causes ofPotentially reversible causes of cognitive impairmentcognitive impairment • Depression (can get depressive psudo dementia BUT depression isDepression (can get depressive psudo dementia BUT depression is also a feature of dementia!)also a feature of dementia!) • Subdural heamatomaSubdural heamatoma • HypothyroidismHypothyroidism • Chronic severe hyponatraimiaChronic severe hyponatraimia • Vit B12 deficencyVit B12 deficency • NeurosyphilisNeurosyphilis • VasculitisVasculitis • Paraneoplastic syndromeParaneoplastic syndrome • Wipples diseaseWipples disease • Normal pressure hydrocephalus, (ventricular dilation + triad ofNormal pressure hydrocephalus, (ventricular dilation + triad of dementia incontinence and gait disturbance)dementia incontinence and gait disturbance)

×