DementiaDementia

Dr Deborah StinsonDr Deborah StinsonSutton CMHT for Older PeopleSutton CMHT for Older People

South West London & St George’s Mental South West London & St George’s Mental Health NHS TrustHealth NHS Trust

Dementia(s):Dementia(s):

Generic termGeneric term ““Chronic, progressive dysfunction of Chronic, progressive dysfunction of

brain function leading to complex brain function leading to complex cognitive decline”cognitive decline”

Cognitive changes often with Cognitive changes often with disturbances of mood, behaviour, disturbances of mood, behaviour, personalitypersonality

Primary vs secondary dementiasPrimary vs secondary dementias

Epidemiology:Epidemiology:

Prevalence 1.5% at 65 yrsPrevalence 1.5% at 65 yrs 30% at 80 yrs30% at 80 yrs Incidence lower in men, & Asian or Incidence lower in men, & Asian or

African originAfrican origin SDAT more common than VaDSDAT more common than VaD Average survival = 8 yrs from Average survival = 8 yrs from

diagnosisdiagnosis Women survive longer than menWomen survive longer than men

Confirmed risk factors Confirmed risk factors for AD:for AD: AgeAge Family historyFamily history E4 alleles of ApoE geneE4 alleles of ApoE gene

Factors which modify Factors which modify risk:risk: Female sexFemale sex History of head History of head

injuryinjury DiabetesDiabetes Raised cholesterolRaised cholesterol SmokingSmoking Mid-life Mid-life

hypertensionhypertension

Low educational & Low educational & occupational occupational attainmentattainment

Low mental Low mental activity in early lifeactivity in early life

Reduced mental & Reduced mental & physical activity in physical activity in late lifelate life

Protective effects??Protective effects??

High educationHigh education Dietary intake of antioxidantsDietary intake of antioxidants Unsaturated fatty acidsUnsaturated fatty acids Moderate alcohol intake (wine)Moderate alcohol intake (wine)

But not conclusive evidence…..But not conclusive evidence…..

Risk factors for VaD:Risk factors for VaD:

AgeAge Male sexMale sex HypertensionHypertension CHDCHD DiabetesDiabetes SmokingSmoking Raised cholesterolRaised cholesterol

Pathology of AD:Pathology of AD:

Cholinergic hypothesisCholinergic hypothesis Plaques – abnormal amyloid (A Plaques – abnormal amyloid (A ββ)) Tangles – abnormal tau proteinTangles – abnormal tau protein

Dementia with Lewy Bodies Dementia with Lewy Bodies Fronto-temporal Fronto-temporal & Parkinson’s & Parkinson’s Disease: dementia:Disease: dementia: Intraneuronal Intraneuronal

inclusion bodiesinclusion bodies Aggregation tau Aggregation tau

proteinprotein

Genetic testing:Genetic testing:

Late onset more complicatedLate onset more complicated No clinical use for genetic testing in No clinical use for genetic testing in

late-onset Alzheimer’s Diseaselate-onset Alzheimer’s Disease

Investigations:Investigations:

Routine blood testsRoutine blood tests Selected neuro-imaging (CT/MRI)Selected neuro-imaging (CT/MRI) Brief cognitive testing (MMSE; ACE)Brief cognitive testing (MMSE; ACE) Corroborative historyCorroborative history For future – biochemical changes → For future – biochemical changes →

screening tests?screening tests?

Cholinesterase Cholinesterase inhibitors:inhibitors: Donepezil; galantamine; rivastigmineDonepezil; galantamine; rivastigmine Licensed to treat mild-moderate ADLicensed to treat mild-moderate AD Modest efficacy; at all stages of diseaseModest efficacy; at all stages of disease Reduction 1.4 points MMSEReduction 1.4 points MMSE 1/3-1/7 will have improvement/delay in 1/3-1/7 will have improvement/delay in

declinedecline Mitigate symptoms; do not change natural Mitigate symptoms; do not change natural

historyhistory Evidence useful in DLB (& PD)Evidence useful in DLB (& PD) NICE guidance; shared prescribing protocolsNICE guidance; shared prescribing protocols

Memantine:Memantine:

Effect on glutaminergic systemEffect on glutaminergic system Useful moderate - severe ADUseful moderate - severe AD Modest effect on cognition & Modest effect on cognition &

behavioural symptomsbehavioural symptoms Has been used in combination with Has been used in combination with

donepezildonepezil Not approved by NICENot approved by NICE

Behavioural & psychiatric Behavioural & psychiatric symptoms in dementia symptoms in dementia (BPSD):(BPSD): Affective – depression, anxiety, euphoriaAffective – depression, anxiety, euphoria Personality changesPersonality changes Behavioural difficulties – agitation, Behavioural difficulties – agitation,

apathy, irritability, disinhibition, apathy, irritability, disinhibition, wandering etc.wandering etc.

Hallucinations (visual most common)Hallucinations (visual most common) Delusions & misidentification syndromesDelusions & misidentification syndromes Eating disordersEating disorders

BPSD:BPSD:

Occur in up to 90% at some stageOccur in up to 90% at some stage A major cause of stress in carersA major cause of stress in carers A common reason for A common reason for

residential/nursing home placementresidential/nursing home placement Difficult to treatDifficult to treat

Drug treatment of BPSD:Drug treatment of BPSD: Traditional antipsychotic drugs – but ↑ Traditional antipsychotic drugs – but ↑

mortalitymortality Atypicals – best evidence, fewer EPSE, Atypicals – best evidence, fewer EPSE,

but ↑risk of strokesbut ↑risk of strokes Anti-convulsants (e.g. sodium valproate)Anti-convulsants (e.g. sodium valproate) Cholinesterase inhibitorsCholinesterase inhibitors MemantineMemantine Short-acting benzodiazepinesShort-acting benzodiazepines SSRI antidepressantsSSRI antidepressants

Non-drug treatment of Non-drug treatment of BPSD:BPSD: Review current drug regime; Review current drug regime;

physical health?physical health? Environmental factors?Environmental factors? Psychological & behavioural Psychological & behavioural

approachesapproaches Carer trainingCarer training AromatherapyAromatherapy Bright light therapyBright light therapy

Depression in dementia:Depression in dementia:

Occurs in 40-50% Occurs in 40-50% Treatment with antidepressant Treatment with antidepressant

drugs (SSRIs preferred)drugs (SSRIs preferred) Avoid drugs with anti-cholinergic Avoid drugs with anti-cholinergic

effecteffect Eliminate physical causeEliminate physical cause Carer training/supportCarer training/support

Carers’ needs:Carers’ needs:

High rates of physical & mental problems in High rates of physical & mental problems in carerscarers

High rates of abuse (both of & by patients)High rates of abuse (both of & by patients) Institutionalisation can cause other problems – Institutionalisation can cause other problems –

e.g. guilt, depression, financiale.g. guilt, depression, financial Aggression & incontinence are main Aggression & incontinence are main

determinants of institutionalisation – ideally determinants of institutionalisation – ideally plan(??)plan(??)

Carer’s assessment (Social Services)Carer’s assessment (Social Services) Support from Alzheimer’s Society, Carers’ Support from Alzheimer’s Society, Carers’

Centre, MIND etc.Centre, MIND etc.

Other matters to Other matters to consider:consider: DrivingDriving Ability to manage affairs – Lasting Ability to manage affairs – Lasting

power of attorney, Court of power of attorney, Court of Protection Protection

Mental Capacity Act (from April Mental Capacity Act (from April 2007)2007)

Attendance allowanceAttendance allowance Assistive technologyAssistive technology

NICE guidelines on NICE guidelines on dementia:dementia: Cover health & social careCover health & social care More emphasis on psychological More emphasis on psychological

mgt.mgt. Restrict use of cholinesterase Restrict use of cholinesterase

inhibitors to moderately severe inhibitors to moderately severe Alzheimer’s DiseaseAlzheimer’s Disease

Local services:Local services:

Older People’s NSF – local implementation Older People’s NSF – local implementation teamteam

Dementia care pathway (PCT lead agency)Dementia care pathway (PCT lead agency) Shared prescribing protocol(s)Shared prescribing protocol(s) Primary CarePrimary Care Voluntary sectorVoluntary sector Social ServicesSocial Services Secondary care – integrated CMHT; acute Secondary care – integrated CMHT; acute

truststrusts Residential & nursing home careResidential & nursing home care

Case histories?Case histories?

Questions?Questions?