Assessment of Younger people with Dementia

1. Assessment of Younger people with Dementia Dr Ashok Krishnamoorthy Consultant Psychiatrist Wrexham

2. Learning objectives • To Share our practise of assessment process • To provide some insight in to challenging areas of assessment • To highlight cognitive assessment methods • To focus on warning signs where action is needed quickly

3. Overview • What is dementia ? • Aspects of community assessments • Screening referrals • Presenting Symptoms • Assessing comorbid Medical conditions • Assessing comorbid Psychiatric conditions • Warning signs of other illnesses • Alcohol related cognitive disorders • Domains of assessment

4. Other uncovered but important issues • Arriving at diagnosis • Disclosing diagnosis • Genetic testing and heritable forms of dementias • Post diagnostic counselling • Challenges of providing Day care • Carer support • Management of behavioural symptoms

5. Dementia –? Definition • a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning. (Oxford dictionary) • DSM IV requires memory deficit + deficit in one other domain – language,perception,visuospatial function,calculaion,judgement,abstraction,problem solving skills

6. National Dementia Strategy - England • a syndrome which may be caused by a number of illnesses in which there is progressive decline in multiple areas of function, including decline in memory, reasoning, communication skills and the ability to carry out daily activities. Alongside this decline, individuals may develop behavioural and psychological symptoms such as depression, psychosis, aggression and wandering, which cause problems in themselves, which complicate care

7. Dementia • Cluster of symptoms – syndrome • Usually progressive • Insidious in onset • Cognitive deficits – Global, single domain global • Personality change • Behaviour problems • Primary or secondary

8. Community Assessments • Symptom presentation is different • Possibility of other sign. Medical / Neuro disorders • Service user might in work (assessment timings needs flexibility) • Young families • Often referral could seen as a surprise to families • Expectations from the families • Impact on occupation/driving/finances is huge

9. Screening Referrals • Reason for referral – needs to be clear • Age group • Has the referral been discussed with service user ? • Medical history & involvement of other professionals • Recent investigations • Learning disability, significant alcohol misuse • Co morbid psychiatric disorders • Medications • Has any screening tolls been used?

10. Presenting symptoms 1.Memory related Forgetting,misplacing,repetitive questioning 2.Language related Word finding, decreased fluency , not making sense 3.Behavioural problems Temperamental,agitation,apathy,depression,aggression, Psychosis, Personality change 4.Neurological Disorder MS,MND,PD,HD,Stroke 5.ADLs  - loss of skills

11. Assessing comorbid Medical conditions • Diabetes Mellitus – type 1 and 2 – Glycemic control, over treatment, vascular risk factor • Hypertension – Vascular risk factor, end organ damage • Hypercholestrolemia,smoking • TIA,CVA,peripheral vascular disease • Cardiac disorders – IHD,AF,valavular heart disease • Nervous system disorders – Parkinson’s disease, Huntington’s disease,MND,MS,PSP • Thyroid disorders,adrenal,parathyroid diseases • Heavy metal exposure,posoning, head injury

12. Assessing comorbid Psychiatric conditions • Depression – poor concentration,apathy,psychomotor retardation • Schizophrenia – Working memory,learning,expressive receptive language, face recognition, prosody, negative symptoms, executive dysfunction • Bipolar disorders - attention, executive function, visuospatial skills and verbal memory • Personality disorders • Anxiety disorders

13. Warning signs of other illnesses • Sudden alteration in consciousness • Deviation of mouth, loss of function of a limb / weakness • Sudden loss of vision /blurring/tunnel vision • Episodic alteration in consciousness,incontinence,unawareness • Involuntary movements- tremors,jerks,rhythmical movements • Recent onset gait disorders • Sudden loss of consciousness • Loss of sensation • Atrophy of small muscles of hand,fasciculations,weakness

14. Other factors to consider • Bereavement • Work related stress • Adjustment disorder / somatoform disorders • Chronic fatigue syndrome • Drug effects – codeine, other opiates,BDZ,Anti cholinergic, antiepileptic agents

15. Alcohol related cognitive disorders • How many years ? • Typical drinking pattern • Binging or continuous drinking • Average drinks per day • No of Units per week • Withdrawal features • Tolerance • Physical complications – cirrhosis, jaundice, peptic ulcer disease ,peripheral neuropathy,freq falls • Psychological complications

16. Alcohol related Dementia Probable Alcohol Related Dementia A. The criteria for the clinical diagnosis of Probable Alcohol Related Dementia include the following: • 1. A clinical diagnosis of dementia at least 60 days after the last exposure to alcohol. • 2. Significant alcohol use as defined by a minimum average of 35 standard drinks per week for men (28 for women) for greater than a period of 5 years. The period of significant alcohol use must occur within 3 years of the initial onset of Dementia.

17. B. The diagnosis of Alcohol Related Dementia is supported by the presence of any of the following: • 1. Alcohol related hepatic, pancreatic, gastrointestinal, cardiovascular, or renal disease ie other end-organ damage. • 2. Ataxia or peripheral sensory polyneuropathy (not attributable to other specific causes). • 3. Beyond 60 days of abstinence, the cognitive impairment stabilizes or improves. • 4. After 60 days of abstinence, any neuroimaging evidence of ventricular or sulcal dilatation improves. • 5. Neuroimaging evidence of cerebellar atrophy, especially of the vermis.

18. D. Clinical features that are neither supportive nor cast doubt on the diagnosis of Alcohol Related Dementia included: • 1. Neuroimaging evidence of cortical atrophy. • 2. The presence of periventricular or deep white matter lesions on neuroimaging in the absence of focal infarct(s). • 3. The presence of the Apo lipoprotein e4 allele. Mixed Dementia • A diagnosis of mixed dementia is reserved for clinical cases that appear to have more than one cause for dementia. • The classification of probable or possible should continue to be used to convey the certainty of the diagnosis of ARD. The classification of mixed dementia should not be used to convey uncertainty of the diagnosis or to imply a differential diagnosis.

19. The diagnosis of Possible Alcohol Related Dementia may be made when there is: • 1. A clinical diagnosis of dementia at least 60 days after the last exposure to alcohol. • 2. Either: Significant alcohol use as defined by a minimum average of 35 standard drinks per week for men (28 for women) for 5 or more years. However, the period of significant alcohol use occurred more than 3 years but less than 10 years prior to the initial onset of cognitive deficits. • Or Possibly significant alcohol use as defined by a minimum average of 21 standard drinks per week for men (14 for women) but • no more than 34 drinks per week for men (27 for women) for 5 years. The period of signi®cant alcohol use must have occurred within 3 years of the onset of cognitive deficits.

20. Alcohol Dementia • Clinical diagnosis of Dementia • Significant alcohol consumption – 28-35 drinks per week • Deficits even after 60 days of abstinence • After abstinence it improves / stabilises • Other alcohol related end organ damage

21. Korsakoff’s Syndrome • Mild Retrograde amnesia • Poor new learning (anterograde amnesia) • Confabulation • Peripheral neuropathy • Poor STM • Emotional disturbances • Perceptual disturbances • Carries poor prognosis – chronic memory impairment

22. Domains of assessment - Cognitive • Consciousness • Orientation • Concentration • Executive functions • Frontal lobe functions • Praxis,agnosia,acalculia • Language tests – naming, reading, writing, fluency, repetition • Memory tests – STM,LTM • New learning ability

23. Behavioural Assessment • Delusions • Hallucinations • Agitation or aggression • Depression or dysphoria • Elation • Disinhibition • Apathy / indifference • Irritability / lability • Motor disturbance • Sleep • Appetite and eating

24. ADLs

25. Scales • Cognitive –MOCA,ACE-R,CAMCOG,CERAD • Frontal lobe assessment – FAB,EXIT25 • Behavioural – NPI , BEHAVE-AD,PBA HD • ADLs- OT assessment,ADL scale, Bristol ADL scale