Dementia by CN07J4



       Callum Wilson
   Question 1
   Vascular dementia is the most common
    form of dementia (True/False)
   Question 2
   Vascular dementia is characterised by a
    stepwise decline in cognition or function
   Question 3
   There is strong evidence to suggest
    secondary prevention/ risk reduction
    slows the progress of dementia (True/
   Question 4
   Almost all patients with mild cognitive
    impairment will progress to dementia
    (True / False)
   Question 5
   Drugs used for symptomatic treatment
    in Alzheimer’s disease include
    donepezil, galantamine and rivastigmine
    (True / False)
   Question 6
   Olanzapine and risperidone are safe
    antipsychotics to use in elderly patients
    with dementia (True/False)
   Question 7
   The benefit gained by the use of
    antipsychotics does not extend past 3
    months (True/False)
   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)
   Question 9
   Severe impairment on MMSE is an
    indication for starting AchEi drugs
   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

   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
   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
   Agnosia – inability to recognize or associate meaning
    to a sensory perception
   Acalculia – inability to perform arithmetical
   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
   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
   Fluctuations in cognition (especially attention and
   Visual hallucinations
   Spontaneous extrapyramidal signs such as rigidity or
    slowing (mild parkinsonism)
   Bradykinesia (paucity of movement)
Clinical features of fronto-temporal
   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
Symptoms of mild cognitive impairment

   Frequently losing or misplacing things
   Frequently forgetting conversations,
    appointments, or events
   Difficulty remembering the names of new
   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
   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
   Referral to Consultant Psychiatrist for
    Diagnostic Assessment
   Referral to Memory Nurses for monitoring
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
   No Dementia
   Mild Cognitive Impairment
   Dementia- Alzheimer’s Disease
   Dementia-Other Types
   Other Psychiatric Problems-Depression
Outcome: Mild Cognitive Impairment

   Neuroimaging to establish underlying
   Re-assess in 6-12 months to monitor for any
    progressive cognitive decline
   Lifestyle advice- control of vascular risk
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
   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
Drug treatments in dementia
Secondary Prevention –limited evidence

Symptomatic treatments:
  Acetyl Cholinesterase Inhibitors

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
   Increased mortality rate 1.6-1.7 fold with ‘typical’
    antipsychotics due to heart failure, sudden death and
   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
   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

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