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Dementia& Alzheimer’s disease.

Dementia& Alzheimer’s disease.

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Dementia309. Presentation Transcript

  • 1. Dementia Prepared by: Dr. Mohamed Sheikhani. From BMJ Feb 2009.
  • 2.
    • Dementia is a clinical syndrome characterised by a cluster of symptoms/signs manifested by difficulties in memory, disturbances in language, psychological&psychiatric changes, &impairments in ADL.
    • Alzheimer’s disease is a specific disease entity&is the commonest cause of dementia.
  • 3. Introduction:
  • 4. The burden:
    • 12 million worldwide have dementia, increase to 25 million by 2040.
    • The annual cost of care is £17bn (>heart disease, stroke,cancer).
    • Dementia is one of the main causes of disability in later life, contributes 11.2% of all years lived with disability—higher than stroke (9.5%), musculoskeletal disorders (8.9%), heart disease (5%), & cancer (2.4%).
  • 5. Benefits of early diagnosis:
    • Identification of treatable physical & psychiatric causes
    • Treatment of co-morbid conditions.
    • Initiation of psychosocial support
    • Start of pharmacological symptomatic treatments.
  • 6. Barriers of early diagnosis:
    • Early recognition is not easy because of:
    • The insidious/variable onset of the syndrome, sometimes without a clear demarcation until late in the disease process.
    • Patients, families& general practitioners may all be reluctant to diagnose dementia because it is such a serious& largely unmodifiable disease that still carries a huge burden of stigma.
    • Family members may gradually take over social roles from the patient, protecting him or her from difficulties in daily life&delaying the conscious recognition of the disorder by offsetting impairments.
  • 7. Suspicion &diagnosis:
    • Depends on the triad of patient report, informant history& assessment of cognitive function.
    • Awareness that memory problems in old age, particularly when deteriorating& interfering with daily activities, may be the harbinger of dementia is the most important factor in recognition.
    • The most commonly used cognitive assessment tool is the minimental state examination, scored out of 30: a score of <24 suggests dementia&performance requires intact language &dependent on educational attainment& cultural background.
    • It can take up to 20 minutes to complete& so may be practical for use only in secondary care.
    • The GP assessment of cognition test& 2 other cognitive screening tests (the mini-cog assessment instrument& the memory impairment screen) are as clinically /psychometrically robust as &more appropriate for use in primary care.
    • The six item cognitive impairment test designed for use in general practice& produces more reliable results than the MMSE.
  • 8.  
  • 9. Dementia diagnosis:
    • 1.GP recommended to perform some routine investigations (standard blood screening, CXR if H/O chest problems& ECG if heart disease is suspected) before referring the patient for a specialist secondary care
    • 2. The exclusion of potentially reversible conditions ( as normal pressure hydrocephalus) & the confirmation of the dementia pathology via detailed neurocognitive assessment &if available, CT.
    • This allows the subtyping of dementia important for prognosis & treatment, as Alzheimer’s disease, the only one of the dementias in which symptom modification with drug treatment is possible.
    • The diagnostic process may be interative&extended.
    • From first symptom to presentation to GP takes about 18 months, with a similar time to diagnosis thereafter.
    • This time period can be shortened by using a structured educational intervention based on adult learning principles &conducted as a workshop in general practice.
  • 10.  
  • 11. Dementia or depresion:
    • The comorbidity of depressive dementia symptoms is high.
    • People with dementia syndrome have high rates of depression & people with depression often have prominent complaints of memory loss, neuropsychological deficits & often organic brain changes.
    • The awareness of the overlap between these disorders is clinically important because clinical trials have shown that antidepressant treatment can be beneficia.
  • 12. Subtype of dementia :
    • The causes are important because different types of dementia can have different courses, with different patterns of symptoms&can respond differently to treatment:
    • Alzheimer’s disease can be modified with cholinesterase inhibitors
    • Lewy body dementia differs from the other types because of the dominance of motor symptoms (like Parkinson’s disease)& the salience of visual hallucinations&antipsychotic drugs may have adverse effects.
    • In vascular disease means co-morbidities can be treated.
    • It is important to differentiate between different types of dementia because patients/relatives have the right to a definitive diagnosis.
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  • 18. Mental capacity assessment:
    • The Mental Capacity Act 200512 is complex& all those working with older people need to be aware of its principle:
    • Adults are assumed to have capacity unless proved otherwise
    • Individuals must be given all available support before concluding that they cannot make decisions for themselves
    • People must retain the right to make what may be seen as eccentric & unwise decisions.
    • Anything done for a person without capacity must be in their best interests &should restrict their rights& basic freedoms as little as possible.
    • Doctors are being asked to assess capacity in people with cognitive impairment.
    • The medical assessment is based on a person’s ability to understand what is being asked, retain the information long enough to make a judgment& be able to express that judgment& may vary over time &are specific to a decision.
  • 19. Psychiatric/behavioral symptoms treatment:
    • As agitation, pacing around, wandering, getting lost.
    • up to 90% will experience such symptoms to some degree at some time, particularly in the middle&later stages , can lead to high levels of stress in carers& may be one of the crucial factors leading to care home admission.
    • Management requires a thorough clinical assessment to exclude treatable causes such as infection or pain.
    • Non-drug approaches should be used where possible& specialist advice sought.
    • 20-50% of people with dementia in institutional care receive antipsychotic drugs,despite widespread concerns over their hazards.
  • 20.  
  • 21. Alzheimer’s disease
    • A chronic progressive neurodegenerative disorder characterised by 3 primary groups of symptoms
    • 1. Cognitive dysfunction( memory loss, language difficulties); executive dysfunction ( loss of higher level planning & intellectual coordination skills).
    • 2.Psychiatric symptoms/behavioural disturbances— depression, hallucinations, delusions, agitation—termed non-cognitive symptoms
    • 3. Difficulties with performing ADL ( “instrumental” for more complex activities such as driving/ shopping & “basic” for dressing / eating unaided).
    • The symptoms of Alzheimer’s disease progress from mild symptoms of memory loss to very severe dementia.
    • Increasingly, coexistence of vascular disease& Alzheimer’s disease is being recognised clinically, pathologically& epidemiologically.
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