Dementia

1
Dementia

• Dr Deborah Stinson
• Sutton CMHT for Older People
• South West London St Georges Mental Health NHS
  Trust

2
Dementia(s)

• Generic term
• Chronic, progressive dysfunction of brain
  function leading to complex cognitive decline
• Cognitive changes often with disturbances of
  mood, behaviour, personality
• Primary vs secondary dementias

3
Epidemiology

• Prevalence 1.5 at 65 yrs
• 30 at 80 yrs
• Incidence lower in men, Asian or African origin
• SDAT more common than VaD
• Average survival 8 yrs from diagnosis
• Women survive longer than men

4
Confirmed risk factors for AD

• Age
• Family history
• E4 alleles of ApoE gene

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Factors which modify risk

• Female sex
• History of head injury
• Diabetes
• Raised cholesterol
• Smoking
• Mid-life hypertension

• Low educational occupational attainment
• Low mental activity in early life
• Reduced mental physical activity in late life

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Protective effects??

• High education
• Dietary intake of antioxidants
• Unsaturated fatty acids
• Moderate alcohol intake (wine)
• But not conclusive evidence..

7
Risk factors for VaD

• Age
• Male sex
• Hypertension
• CHD
• Diabetes
• Smoking
• Raised cholesterol

8
Pathology of AD

• Cholinergic hypothesis
• Plaques abnormal amyloid (A ß)
• Tangles abnormal tau protein

9
Dementia with Lewy Bodies
Fronto-temporal Parkinsons Disease
dementia

• Intraneuronal inclusion bodies

• Aggregation tau protein

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Genetic testing

• Late onset more complicated
• No clinical use for genetic testing in late-onset
  Alzheimers Disease

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Investigations

• Routine blood tests
• Selected neuro-imaging (CT/MRI)
• Brief cognitive testing (MMSE ACE)
• Corroborative history
• For future biochemical changes ? screening
  tests?

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Cholinesterase inhibitors

• Donepezil galantamine rivastigmine
• Licensed to treat mild-moderate AD
• Modest efficacy at all stages of disease
• Reduction 1.4 points MMSE
• 1/3-1/7 will have improvement/delay in decline
• Mitigate symptoms do not change natural history
• Evidence useful in DLB ( PD)
• NICE guidance shared prescribing protocols

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Memantine

• Effect on glutaminergic system
• Useful moderate - severe AD
• Modest effect on cognition behavioural symptoms
• Has been used in combination with donepezil
• Not approved by NICE

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Behavioural psychiatric symptoms in dementia
(BPSD)

• Affective depression, anxiety, euphoria
• Personality changes
• Behavioural difficulties agitation, apathy,
  irritability, disinhibition, wandering etc.
• Hallucinations (visual most common)
• Delusions misidentification syndromes
• Eating disorders

15
BPSD

• Occur in up to 90 at some stage
• A major cause of stress in carers
• A common reason for residential/nursing home
  placement
• Difficult to treat

16
Drug treatment of BPSD

• Traditional antipsychotic drugs but ? mortality
• Atypicals best evidence, fewer EPSE, but ?risk
  of strokes
• Anti-convulsants (e.g. sodium valproate)
• Cholinesterase inhibitors
• Memantine
• Short-acting benzodiazepines
• SSRI antidepressants

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Non-drug treatment of BPSD

• Review current drug regime physical health?
• Environmental factors?
• Psychological behavioural approaches
• Carer training
• Aromatherapy
• Bright light therapy

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Depression in dementia

• Occurs in 40-50
• Treatment with antidepressant drugs (SSRIs
  preferred)
• Avoid drugs with anti-cholinergic effect
• Eliminate physical cause
• Carer training/support

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Carers needs

• High rates of physical mental problems in
  carers
• High rates of abuse (both of by patients)
• Institutionalisation can cause other problems
  e.g. guilt, depression, financial
• Aggression incontinence are main determinants
  of institutionalisation ideally plan(??)
• Carers assessment (Social Services)
• Support from Alzheimers Society, Carers Centre,
  MIND etc.

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Other matters to consider

• Driving
• Ability to manage affairs Lasting power of
  attorney, Court of Protection
• Mental Capacity Act (from April 2007)
• Attendance allowance
• Assistive technology

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NICE guidelines on dementia

• Cover health social care
• More emphasis on psychological mgt.
• Restrict use of cholinesterase inhibitors to
  moderately severe Alzheimers Disease

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Local services

• Older Peoples NSF local implementation team
• Dementia care pathway (PCT lead agency)
• Shared prescribing protocol(s)
• Primary Care
• Voluntary sector
• Social Services
• Secondary care integrated CMHT acute trusts
• Residential nursing home care

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Case histories?Questions?