Dementia

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Dementia
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Background

• Definition
• Symptoms
• Problems for families and carers
• Common causes of dementia
• Prevalence
• Severity in late onset
• Costs
• Risk factors
• Diagnosis and assessment
• Memory services

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DefinitionMeReC Bulletin 2007 18(1)

• Progressive and largely irreversible condition,
  characterised by widespread impairment of mental
  function

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SymptomsMeReC Bulletin 2007 18(1)

• Memory loss
• Language impairment
• Disorientation
• Changes in personality
• Difficulties carrying out daily activities
• Self-neglect
• Psychiatric symptoms
• Out of character behaviour

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Problems for families and carersMeReC Bulletin
2007 18(1)

• Aggressive behaviour
• Wandering
• Eating problems
• Incontinence
• Delusions
• Hallucinations
• Mobility problems

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Common causes of dementiaNCCMH. NICE Full
guidance 42. 2006

• Alzheimers disease (60)
• Progressive decline in cognitive function,
  ability to function, and behaviour
• Vascular dementia (15-20)
• Less predictable decline, sometimes relative
  stability if vascular disease is stabilised, but
  can show sudden stepwise deterioration in
  cognitive function with vascular events
• Lewy bodies (DLB) (15-20)
• Progressive decline, often superimposed with
  fluctuating variations in cognitive function
• Less common causes
• Frontotemporal dementia (2nd most common in
  young-onset)
• Atypical dementia
• 3-4 caused by Parkinsons disease
• Mixed dementia

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Prevalence of dementiaDementia UK 2007
www.alzheimers.org.uk

• 700000 in UK in 2005
• 1.1 of population
• 1 in 88 of population
• Early onset (lt65y) comparatively rare in UK
• 2.2 of all with dementia
• More common in black and minority ethnic groups

Age (y) F() M() Total ()
65-69 1.0 1.5 1.3
70-74 2.4 3.1 2.9
75-79 6.5 5.1 5.9
80-84 13.3 10.2 12.2
85-89 22.2 16.7 20.3
90-94 29.6 27.5 28.6
95 34.4 30.0 32.5
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Severity in late onset dementiaDementia UK
2007 www.alzheimers.org.uk

• Mild
• 55
• Moderate
• 32
• Severe
• 13

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Cost of dementiaDementia UK 2007
www.alzheimers.org.uk

• Total costs 17.03 billion per annum (25472 per
  person with late onset dementia
• Costs included those provided by formal care
  agencies as well as the financial value of unpaid
  informal care provided by family and friends
• Dementia drug costs for 2006/2007 accounted for
  43 million (about 700000 items) www.epact.net
• Accomodation (41)
• Informal care (36)
• Social services (15)
• NHS (8)

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Risk factors for dementiaNCCMH. NICE Full
Guideline 42. 2006

• Non-modifiable risk factors

• Modifiable risk factors

• Age
• E4 allele of ApoE gene (for Alzheimers disease
• Female
• Learning diabilities (Downs)

• Alcohol
• Smoking
• Hypertension
• Obesity
• Raised cholesterol
• Diabetes
• Head injury
• Depression
• Low folate and raised homocysteine levels

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• In middle aged and older people, vascular and
  other modifiable risk factors should be reviewed
  and appropriately treated
• The following interventions should not be
  prescribed as specific treatments for the primary
  prevention of dementia
• Statins
• HRT
• Vitamin E
• NSAIDs
• Potentially protective factors
• Long term use of NSAIDs
• Control of CV risk factors
• Regular exercise
• Engagement in leisure and cognitively stimulating
  activities

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Dementia diagnosis and assessmentMeReC Bulletin
2007 18(1)

• Many conditions can present with cognitive
  impairments. Diagnosis requires comprehensive
  assessments and appropriate invesigations
• Currently only 1/3 of people with dementia
  receive a formal diagnosis at any time during
  their illness
• Insufficient evidence for population screening
• Refer people who show signs of mild cognitive
  impairment for assessment, which includes use of
  a standardised assessment instrument eg MMSE

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Mini-mental state examinationwww.sign.ac.uk/pdf/
sign86.pdf
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Structural imaging for diagnosisNICE-SCIE GG 42.
2006

• Structural imaging should be used to assist in
  the diagnosis or dementia, to aid in the
  differentiation of type of dementia and to
  exclude other cerebral pathology
• MRI is the preferred modality to assist with
  early diagnosis and detect subcortical vascular
  changes, although CT scanning could also be used

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Memory servicesNICE-SCIE GG 42. 2006

• Memory assessment services should be the single
  point of referral for all people with a possible
  of suspected diagnosis of dementia
• Services may be provided by a memory assessment
  clinic or by community mental health teams

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Cognitive symptoms
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What are cognitive symptoms?
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• Cognitive symptoms affect
• Judgement
• Memory
• Learning
• Comprehension

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Non-drug treatments

• There are a wide range of psychological or
  psychosocial interventions, but availability
  varies greatly
• CBD
• Life review
• Cognitive stimulation (group)
• Reminiscence therapy
• Music
• Recreational activity (arts and crafts)
• Sensory stimulation
• People with mild to moderate dementia of all
  types should be given the opportunity to
  participate in a structured group cognitive
  stimulation programme (irrespective of any drug
  prescribed for the treatment of cognitive symptoms

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Drug treatments

• AChls
• Donepezil, galantamine and rivastigmine are
  effective for mild to moderate Alzheimers
  disease with no difference in efficacy between
  the drugs
• The evidence available on long term effectiveness
  of AChls on outcomes of importance to patients
  and carers eg quality of life and delayed time to
  nursing home placement is limited and largely
  inconclusive
• It is not possible to predict who will gain
  significant benefit
• NICE recommends use of AChls in moderate dementia
  (MMSE 10-20) only
• Memantine
• The evidence to determine the clinical
  effectiveness of memantine in either the whole
  population of moderately severe to severe
  Alzheimers disease..... was currently
  insufficient

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Non-cognitive symptoms
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What are non-cognitive symptoms?
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• Emotional, psychotic and behavioural disorders
• eg depression, anxiety, agitation, insomnia,
  delusions, hallucinations
• NICE uses the term behaviours that challenge to
  encompass a wide range of non-cognitive
  difficulties
• Eg aggression, agitation, wandering, hoarding,
  sexual dysinhibition, apathy and disruptive vocal
  activity such as shouting and mobility problems
• These features are important because they cause
  particular distress to patients, place burden on
  carers, are associated with more rapid cognitive
  decline and promote transfer to nursing homes

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How should behavioural symptoms be managed?NICE
dementia guideline no 42 November 2006

• Early assessment to establish likely factors that
  may generate, aggravate or improve challenging
  behaviours
• Including depression, undetected pain or
  discomfort, side effects of medication and
  psychosocial factors
• Write and review regularly individually tailored
  care plans
• Non-drug interventions should be used initially
• Antipsychotic drugs should be avoided for mild to
  moderate behavioural problems because of possible
  increased risk of cerebrovascular events and
  death
• Avoid antipsychotic drugs in dementia with Lewy
  bodies are these people may be particularly
  sensitive to severe adverse reactions

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When can antipsychotic drugs be considered?NICE
dementia guideline No 42 November 2006

• For severe non-cognitive symptoms (psychosis /or
  agitated behaviour causing severe distress) if
• Full discussion with patient/carer about possible
  side effects and likely risks and in particular
  CVD risk factors and increased risk of
  stroke/TIA, and
• Target symptoms identified, quantified and
  documented
• Starting dose is low then titrated upwards, and
• Treatment is time limited and regularly reviewed
  (every 3m or according to clinical need)
• For people with DLB carefully monitor for
  neuroleptic sensitivity reactions and
  extrapyramidal side effects

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Case study
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• Boris is an 84y old man with moderate to severe
  Alzheimers disease who is exhibiting behaviours
  that are challenging to his carer
• He was diagnosed 5y ago
• He was initiated on donepezil 2y ago on a trial
  basis but was discontinued as there were no
  apparent benefits and he was very nauseous
• Last year he fell and broke his ankle leading to
  a significant deterioration in his mental and
  physical health. He is looked after by his 80y
  old wife but is unable to do much for himself.
  She is unable to contemplate him going into a
  nursing home. She has help daily from a
  volunteer helped from a local charity who helps
  get him up, and stays with him a couple of times
  a week to enable her to shop and meet friends

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• Boris has always been mild mannered, jovial and
  fairly compliant
• Recently he has become withdrawn, grumpy and
  agitated. He sometimes becomes distressed and
  abusive when people try to help him. He
  occasionally shouts out obscenities especially in
  the evening before bed, as if having an imaginary
  argument with someone
• She has called you for help

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Are these behavioural symptoms typical of
Alzheimers disease?
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• Symptoms may include agitation, aggression,
  sexual disinhibition, wandering, hoarding,
  apathy, sleep disturbance and disruptive vocal
  activity (shouting, repeated questioning)
• Some behaviours may result from psychological
  symptoms such as hallucinations, delusions,
  depression or anxiety

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Should you prescribe an antipsychotic in the
evening to control his challenging behaviour as a
first step?
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• No
• Try non-drug measures first
• Use antipsychotics only if there is severe
  distress or immediate risk of harm to the person
  with dementia or others
• Do not use in mild to moderate non-cognitive
  symptoms because of increased risk of
  cerebrovascular events and death

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Should you refer him for assessment?
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• NICE-SCIE guidelines state those who develop
  non-cognitive symptoms that cause them
  significant distress or develop behaviour that
  challenges should be offered assessment as early
  as possible
• The aim is to establish the likely factors that
  may generate, aggravate or improve such behaviour
• Develop individually tailored care plans that
  help carers and staff address the behaviour that
  challenges. They should be reviewed regularly

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The assessment

• Physical health
• Depression
• Undetected pain or discomfort
• Side effects of medication
• Individual biography including religious beliefs,
  spiritual and cultural identity
• Psychosocial factors
• Physical environment factors

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What simple things could you advise that could be
carried out at home in the meantime?
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• Create a calming and relaxing environment and use
  activities which distract from difficult
  behaviours and relieve boredom which may be a
  trigger factors
• NICE recommends a range of interventions for
  delivery by a range of health and social care
  staff and volunteers with appropriate training
  and supervisions. The response to each modality
  should be monitored and the care plan adapted
  accordingly

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• Pets
• Encourage relaxation, provide distraction,
  comfort, stimulate conversation, provide
  opportunity for exercise and social contact
• Aromas (lavender oil)
• Massage
• Remove competing noises
• Ensure adequate lighting using nightlights for
  reassurance
• Music therapy
• Background music
• Physical activity including tai chi or housework
• Reminiscing activities eg photos, books or
  scrapbooks

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When should you consider using antipsychotics?
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• NICE states they can be considered for someone
  with Alzheimers disease who has severe
  non-cognitive symptoms (psychosis /- agitated
  behaviour causing significant distress) if the
  following conditions are met
• Full discussion with the patient /- carers about
  risks and benefits
• Changes in condition should be assessed and
  recorded at regular intervals. Consider
  alternative medication if necessary
• Target symptoms should be identified, quantified
  and documented. Changes in symptoms should be
  assessed and recorded regularly
• Consider effects of co-morbid conditions such as
  depression
• The dose should start low and titrate upwards
• Treatment should be time limited and regularly
  reviewed
• Risperidone is the only antipsychotic licensed
  for challenging behaviours in dementia. The
  license is for short-term treatment (up to 6
  weeks) of persistent aggression in those with
  moderate to severe Alzheimers unresponsive to
  non-pharmacological interventions and when there
  is a risk to self or others

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What are the risks and benefits of antipsychotic
treatment and how would you explain them?
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• Death
• Cerebrovascular events (stroke)
• Extrapyramidal symptoms
• Hypotension
• Sedation
• Anticholinergic effects
• 180000 treated in UK per year
• 36000 derive some benefit
• There are an additional 1620 cerebrovascular
  events (half of which may be severe)
• Additional 1800 deaths on top of those expected

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End