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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 1. False 2. True 3. False 4. False 5. True 6. False 7. True 8. True 9. False 10. True Questions?
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