Dementia

1. Dementia

2. 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

3. DefinitionMeReC Bulletin 2007; 18(1) Progressive and largely irreversible condition, characterised by widespread impairment of mental function

4. 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

5. Problems for families and carersMeReC Bulletin 2007; 18(1) Aggressive behaviour Wandering Eating problems Incontinence Delusions Hallucinations Mobility problems

6. Common causes of dementiaNCCMH. NICE Full guidance 42. 2006 • Alzheimer’s 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 Parkinson’s disease • Mixed dementia

7. 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 (<65y) comparatively rare in UK • 2.2% of all with dementia • More common in black and minority ethnic groups

8. Severity in late onset dementiaDementia UK 2007: www.alzheimers.org.uk • Mild • 55% • Moderate • 32% • Severe • 13%

9. 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%)

10. Risk factors for dementiaNCCMH. NICE Full Guideline 42. 2006 Non-modifiable risk factors Modifiable risk factors Age E4 allele of ApoE gene (for Alzheimer’s disease Female Learning diabilities (Down’s) Alcohol Smoking Hypertension Obesity Raised cholesterol Diabetes Head injury Depression Low folate and raised homocysteine levels

11. 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

12. 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

13. Mini-mental state examinationwww.sign.ac.uk/pdf/sign86.pdf

14. 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

15. 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

16. Cognitive symptoms

17. What are cognitive symptoms?

18. Cognitive symptoms affect: Judgement Memory Learning Comprehension

19. 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

20. Drug treatments • AChls • Donepezil, galantamine and rivastigmine are effective for mild to moderate Alzheimer’s 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 Alzheimer’s disease..... was currently insufficient

21. Non-cognitive symptoms

22. What are non-cognitive symptoms?

23. 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

24. 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

25. 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

26. Case study

27. Boris is an 84y old man with moderate to severe Alzheimer’s 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

28. 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

29. Are these behavioural symptoms typical of Alzheimer’s disease?

30. 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

31. Should you prescribe an antipsychotic in the evening to control his challenging behaviour as a first step?

32. 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

33. Should you refer him for assessment?

34. 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

35. 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

36. What simple things could you advise that could be carried out at home in the meantime?

37. 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

38. 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

39. When should you consider using antipsychotics?

40. NICE states they can be considered for someone with Alzheimer’s 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 Alzheimer’s unresponsive to non-pharmacological interventions and when there is a risk to self or others

41. What are the risks and benefits of antipsychotic treatment and how would you explain them?

42. 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

43. End