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Gwyn Higginson. Cognitive Behavioural Psychotherapist.

Long term conditions -‘brains at risk’ -mild cognitive impairment subtypes Dementia –early detection and prevention opportunities in IAPT pathways. Gwyn Higginson. Cognitive Behavioural Psychotherapist. Mental health and Vascular Wellbeing Service.

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Gwyn Higginson. Cognitive Behavioural Psychotherapist.

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  1. Long term conditions -‘brains at risk’ -mild cognitive impairment subtypes Dementia –early detection and prevention opportunities in IAPT pathways. Gwyn Higginson. Cognitive Behavioural Psychotherapist. Mental health and Vascular Wellbeing Service. North staffs Combined Healthcare trust Commissioned by Stoke on Trent PCT 2008 Gwyn Higginson 2012

  2. Referrals to Mental health and vascular wellbeing service CBT service and partnerships. • Mental health access point. • GP’s • Stoke PCT IAPT referral pathway • Stoke Primary Care Long term condition services pathway. Gwyn Higginson 2012

  3. ‘Brain at Risk’-Organic changes. Gwyn Higginson 2012

  4. Mild Cognitive Impairment (MCI)Subtypes …..Amnestic and Non amnestic Different subtypes of MCI are recognized. New classifications distinguishes between amnestic and non amnestic forms of MCI. Gwyn Higginson 2012

  5. Mild Cognitive Impairment : Amnestic • The amnestic form, where MEMORY impairment predominates, is often a precursor for clinical Alzheimer’s disease with brain volume loss. GP consultation…….. • Cognitive concern reflecting a change in cognition reported by patient or informant or clinician • (i.e., historical or observed evidence of decline over time) • Enabling revealing and supported journey to Memory clinic pathway earlier prescription memory enhancing medication and support services for sufferer And carer.

  6. Mild cognitive Impairment : Non amnestic‘Brains at Risk’BowlerJ (2005) Vascular Cognitive Impairment. J Neurol Neurosurg Psychiatry ;76 ‘The importance of VCI lies in the fact that vascular disease is the largest single identifiable risk factor for dementia apart from age and the only one currently treatable. .......primary prevention requires the recognition of the presence of risk factors in a susceptible host, termed “brain-at-risk” (fig 1).’ Gwyn Higginson 2012

  7. Mild Cognitive Impairment Non amnestic • Vascular risk factor profile. Associated with individual patterns of cerebrovascular disease. • Unique patterns of information processing may occur – MEMORY problems may not be the primary symptom. • The most common impairment being executive dysfunction and slowed processing. • Other forms include potential precursor stages for some Vascular or frontotemporal dementias. • Individuals and family may not be aware of the processing difficulty.

  8. Mild Cognitive impairment-Non Amnestic/Vascular Cognitive Impairment Large vessel ischaemia Cardiac emboli Atheroma Infarcts-stroke/TIA Small vessel ischaemia White matter hyperintensities (leukoaraiosis) Watershed /lacuna infarcts. Gwyn Higginson 2012

  9. Role of MRI brain scans. (VCI) Use of MRI brain scan-reveals. Large vessel infarctions- Small vessel infarctions- Watershed infarctions- White matter hyperintensities- CT may not reveal silent small vessel infarctions. Refs: Barkof. F, Smithuis. R, (2010) Dementia :Role of MRI. Radiology Assistant 23/6/2010 Filley and Anderson (2011) Dementia: Five new things. Neurology Clinical Practice supplement 2 s26-s30 Gwyn Higginson 2012

  10. Physical HealthLong term Conditions – The Vascular Risk Factors. Gwyn Higginson 2012

  11. …… ‘Brains at Risk’- Vascular Risk Factors (clinical)See pathway alerter check list Diagnosed- • Hypertension. • Hyperlipidemia. • Diabetes. • Atrial Fibrillation. • TIA (transitory ischaemic attack) • Stroke (not acute) • Cardiac, carotid and peripheral artery disease, • Cardiac surgery. E.g. Bypass graft/stents Gwyn Higginson 2012

  12. …… ‘Brains at Risk’- Vascular Risk Factors (lifestyle)See pathway alerter check list • Smoking • Alcohol/substance • Weight • Diet • Exercise levels. Gwyn Higginson 2012

  13. Graph Showing Cumulative Hazard for dementia in subjects with and without diabetes or pre-diabetes (from Xu et al paper) Accelerated Progression From Mild Cognitive Impairment to Dementia in People With Diabetes Weili Xu1,2, Barbara Caracciolo1, Hui-Xin Wang1, Bengt Winblad1,3, Lars Bäckman1, Chengxuan Qiu1 Laura Fratiglioni1,4 Gwyn Higginson 2012

  14. CBT : The mental health alerter Gwyn Higginson 2012

  15. Present at GP’s and in mental health services. • Anxiety • Low mood • Frustration/anger • Panic, agoraphobia, social phobia. • Guilt • Shame Gwyn Higginson 2012

  16. Alerter check list. ‘Brains at risk’ Gwyn Higginson 2012

  17. Assessment and formulation • Awareness ‘brain at risk’. • Shame sensitive assessment • Bully of capable self revealed. • Use of multimodal model to formulate processing difficulties. Interacting cognitive subsystems. • Compassion focus framework re threat system linked to internal/external shame. Gwyn Higginson 2012

  18. Assessment and formulation?Adding internal environment time dimension. Quality of thoughts Mood Physical symptoms Behaviours Thoughts Quality Speed Head/speech Images Gwyn Higginson 2012

  19. Bully of the capable self…..Ref: Paul Gilbert The Compassionate mind Critical thinking/shame Sooth by withdrawal or attack? No understanding of trigger Why? Seeking behaviour activated Emotional Memory Threat focus Emotional memory Soothing/safe Emotional memory ICS pattern of information processing problem Gwyn Higginson 2012

  20. Explore in response to potential experience of slowed processing executive function • Anxiety Slowed processing –always catching up—links to worry and rumination. • Frustration and anger-self comparison how used to due things. Unable to turn on or off actions. • Panic –slowed processing • Guilt-Impact on others, self blame. • Low-unable to initiate plan or organise activities. • Shame- Then low as repeated experience? Gwyn Higginson 2012

  21. Compassionate ReframeRef: Paul Gilbert The Compassionate mind. Seeking behaviour activated Emotional Memory Education-vascular risks, impact on processing unique pattern. Recognising purpose of critical thoughts/bully of capable self to keep safe. Soothing/safe Emotional memory Threat focus Emotional memory Learn to step back tolerate and self sooth. Gwyn Higginson 2012

  22. IAPT-Knowing the hidden trigger Knowing the trigger is a relief- for patient. New language of MCI. Can look at specific patterns of processing difficulty and speed of processing and related emotional distress in response to this experience.. ‘Its not your fault’. For therapist-treatment failure to success/new options. Learning to accept and tolerate identified processing difficulty. For family or significant others, new ways to respond. Gwyn Higginson 2012

  23. PREVENTION OPPORTUNITIES • Impact of long term stress on vascular risks e.g. panic and BP. Diabetes and inflammatory system. Impact of shame on immune system. • UNDERSTANDING COMPLIANCE PROBLEMS IN LONG TERM CONDITIONS-opportunities for long tern condition teams to adapt how information is given and prompted.

  24. The new language of MCI...Prevention opportunities.User champions • I can explain to others. I only was able to describe either physical symptoms or mood problems -panic, I now can discuss processing difficulties and the pattern I have and how it affects me. I know why I wasn’t managing my long term condition now-My diagnosis has helped the diabetic nurses know adapt the information I need about my diabetes and using prompts. I have been able to come off insulin and my diabetes is stable. Gwyn Higginson 2012

  25. Specific Suicide mode of mind Hopeless-no one recognising processing problems Powerless-due to processing problems and executive dysfunction. Entrapped-by processing difficulties. Gwyn Higginson 2012

  26. Mental Health and Vascular Wellbeing Service. • Alerter checklist. • CBT shame sensitive assessments, formulation. • ICS/compassion focused approaches. • Partnerships-Long term conditions teams with IAPT • Partnerships…life style programmes. Shapes buddy system. • Partnerships Memory clinic. • Training-IAPT team (RETHINK) locally and in west midlands - monies from workforce deanery and link to Dr K Saad (dementia QIPP) lead to roll out service model and pathway. Cited as best practice. • Training heart failure/coronary. care/diabetic teams/O/T’s • National training of IAPT /CBT therapists. • Mental health Access teams. • Take Heart Support Group and user champions.

  27. CBT supporting QIPP for dementia in IAPT pathways. Bringing together new partners. • ‘Case identification at the earliest possible stage affords the greatest opportunity for treatment that may slow the rate of progression’ Bowler (2007) • Improve treatment compliance for long term conditions. • Improve wellbeing. Use WEMWBS and 5 ways to wellbeing. • Innovation of IAPT services structure and CBT assessment and treatments. Gwyn Higginson 2012

  28. Final thought......... • Crossing age boundaries. • Service sees clients aged 40 plus. • Older adult knowledge and skills informing general adult services when age boundaries removed. Gwyn Higginson 2012

  29. Don’t forget......... Look after your brain and your brain will look after your mood?

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