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Dementia

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Dementia Dr Deborah Stinson Sutton CMHT for Older People South West London & St George s Mental Health NHS Trust Dementia(s): Generic term Chronic, progressive ... – PowerPoint PPT presentation

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Title: 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

5
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

6
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

10
Genetic testing
  • Late onset more complicated
  • No clinical use for genetic testing in late-onset
    Alzheimers Disease

11
Investigations
  • Routine blood tests
  • Selected neuro-imaging (CT/MRI)
  • Brief cognitive testing (MMSE ACE)
  • Corroborative history
  • For future biochemical changes ? screening
    tests?

12
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

13
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

14
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

17
Non-drug treatment of BPSD
  • Review current drug regime physical health?
  • Environmental factors?
  • Psychological behavioural approaches
  • Carer training
  • Aromatherapy
  • Bright light therapy

18
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

19
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.

20
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

21
NICE guidelines on dementia
  • Cover health social care
  • More emphasis on psychological mgt.
  • Restrict use of cholinesterase inhibitors to
    moderately severe Alzheimers Disease

22
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

23
Case histories?Questions?
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