The Diagnosis and Management of Dementia in primary care
Dr Suzanne DuffConsultant Psychiatrist
POPS Northland DHB
1
The extent of the problem
• Prevelence doubles every 5 yrs over the age of 60
• > 60 – 5%• > 80 – 20%• Affects ~38000 New Zealanders• Will affect ~50000 by 2051
2
Tom KitwoodDementia Reconsidered
• “Men and women who have dementia have emerged from the places where they were hidden away: they have walked onto the stage of history, and begun to be regarded as persons in the full sense. Dementia as a concept is losing its terrifying associations with the raving lunatic in the old-time asylum. It is being conceived of as an understandable and human condition, and those who are affected by it have begun to be recognised, welcomed, embraced and heard.”
3
The Dementia Syndrome (DSMIV)
• Multiple Cognitive Deficits (at least 2 of)– Memory loss– Aphasia– Apraxia– Agnosia– Executive function
• These lead to a functional decline
4
Dementia Subtypes• Alzheimer’s ~ 60% • Vascular - 10 – 15%• Lewy Body – 12 – 15%• Fronto-temporal – 15% (usually <65yrs)• Other
5
The Cognitive Changes of Normal Ageing
• Occur over decades• Decline mirrors that of peers• Person able to adapt so that functioning is
maintained– 83% forget names, approx 60% lose keys, 40%
forget faces or directions, even fewer forget what they have just done, such as lock the door
6
Mild Cognitive Impairment
• Subjective memory loss – Without functional impairment
• 8 – 15% per year convert to dementia– i.e. Up to 90% by year 6
• Studies now looking at amyloid imaging and CSF markers to identify converters
7
AD risk and protective factors (use it or lose it)
• Risk– Age– Family history (ApoE4)– Head trauma– Low education– Lipids & Hypertension– Early life depression– Down’s
• Protective– Genetic (ApoE2)– High educational level– Longterm anti-
inflamatories– Antioxidants (Vit E)– LOW alcohol use
8
Diagnosis and Assessment
• Listen to the patient – they or their families are telling you the diagnosis
• Adjust your communication style• A positive diagnosis can be made just as in any other
major illness• The challenge is to obtain an early, accurate and
specific diagnosis using an effective diagnostic process
10
Clinical features of mild AD
• Cognition Function Behaviour– Recall Work Apathy– Learning Finances Withdrawal– Word finding Cooking Depression– Problem Reading IrritabilitySolving Hobbies– Writing– Judgement– Calculation
11
12
DementiaDiagnosis
How certain is the diagnosis ? Who wants the
prognosis ?
How to break bad news
How much do they want to know ?
Time to express loss & grief
The language to useHow would they prefer to have the diagnosis communicated ?
Consent to tell others
Support for those giving the diagnosis
The timing of information giving
The type of information
The coping style of PWD and carer
Who wants the diagnosis ?
Issues involved in dementia diagnosis
CONCERNS ABOUT TELLING
• Adverse effect on the person with dementia.• They may have difficulty understanding the
diagnosis.• Family resistance to telling the PWD.• Uncertainty of diagnosis.• Fear of nihilism.
13
ADVANTAGES TO TELLING
• Allows the person to maximize their autonomy.• Avoids accidental discovery.• Relieves anxiety and uncertainty.• Avoids paternalising.• Wish to know expressed by most older persons.• Timely access to info, support & treatment.
14
Guidelines for giving a dementia diagnosis(Fearnley, McLennan & Weaks, 1997)
• Choose the setting.• Determine who is to be present.• Explore previous knowledge or experience.• Explore how much they want to know.• Discuss the diagnosis.• Discuss the future.• Discuss the help available.• Provide written information.
15
Dementia or Delirium
• Dementia– Insidious onset– Slow, gradual decline– Disorientation later– Mild variations day-day– Normal attention span– Usually fully alert– Few psychomotor changes– Physiological changes– Sleep–wake changes later
• Delirium– Abrupt onset– Short acute illness– Marked disorientation– Very variable– Poor attention– Fluctuating alertness– Agitated/retarded– Physiological changes
common– Sleep-wake changes common
16
Dementia or Depression
• Dementia– Insidious onset– Conceals disability– Near miss answers– Mood fluctuations– Stable deficits– Tries hard and not
distressed by errors– Memory loss
predominates
• Depression– Abrupt onset/trigger– Highlights disability– ‘Don’t know’– Diurnal variation– Variable deficits– Tries less hard and
distressed by errors– Memory and mood hand
in hand
17
BPSD Assessment• Look for the meaning or underlying triggers• People with dementia are very sensitive to
non-verbal and environmental cues• What might the person be reacting to?– Environmental, Internal, Interpersonal?
• What might they be trying to communicate?– Pain, Discomfort, Fear, Sadness, Frustration?
18
BPSD Assessment - medical
• Take a history from carers and patient• Review recent medication changes• Physical exam– ?Pain, constipation, UTI/URTI, alcohol withdrawal
etc• Investigations– MSU, FBC, U+E– CxR, ECG
19
BPSD - Assessment
• Identify specific symptoms and behaviours• Use ABC charts• Note baseline frequency• Identify possible triggers
20
Drugs for BPSD
• Limited effectiveness• Low doses• Review at 2 weeks and 1 month • Trial withdrawal at 3 months
21
Cognitive Enhancers• Cholinesterase Inhibitors• Aricept (Donepezil) – Once daily, 5mg, 10mg
• Reminyl (Galantamine) – Once daily, 8mg, 16mg, 24mg
• Exelon (Rivastigmine) – Twice daily, 1.5mg, 3mg, 6mg - patch developed
• NDMA (Glutamate) receptor antagonist– Memantine
22
Cholinesterase InhibitorsCont.
• Similar side effect profiles– NB Heart Block
• Similar efficacy• Effect on ADLs, QoL, Caregiver burden now
demonstrated• Issues re cost, access, discontinuation need to
be discussed prior
23
NDHB Diagnostic PathwayInternet based pathway to assist primary care in the
assessment, diagnosis and management of uncomplicated dementias.
http://tomcat.dev.cactuslab.com/pathways/northland-dhb-cognitive-impairment-pathway
/
24
Resources
• Age Concern New Zealand– www.ageconcern.org.nz
• Alzheimer’s New Zealand– www.alzheimers.org.nz
26