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What is new in Dementia in General Practice?
Dr Peter Bagshaw, GP partner at Willow Surgery, Downend
Clinical Lead Dementia, Mental Health, Learning Difficulties and Adult Safeguarding at South Gloucestershire CCG
Director South West Strategic Clinical Network
Section Editor Mental Health and Dementia, Chronic Conditions
The Well Pathway
....a useful framework
A Better Well Pathway
Cure Well. Get on with life
.....or Prevent Well, ditto
• Blackfriars Consensus The Lancet, volume 383, no 9931, p1805–1806, 24 May 2014
“The Blackfriars Consensus on brain health and dementia” Paul Lincoln et al
• FINGER studyThe Lancet, volume 385, no 998 p2255–2263 6 June 2015
“A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial” Tiia Ngandu, et al
Plus other studies worldwide
Evidence for Prevention
Evidence from epidemiology: CFAS IIA two decade dementia incidence comparison from the Cognitive Function and Ageing Studies I and IIThe Cognitive Function and Ageing Studies has examined dementia in older people aged 65+ for over
two decades. Incidence (new cases/population/time) is the best measure for comparing change between populations. CFAS II measured dementia in 3 sites across the UK finding a marked drop in incidence of dementia age for age in the 65+ population, mostly driven by changes in men. There have been major changes in health in people aged 65 and over during this period, with longer life and reductions in risk factors (e.g. smoking), increases in protective factors (e.g. education) and better management of some health conditions. This study is robust because the same methods were used at each time point so the change is not just because of changes in the way that we measure dementia.
FindingsAt 2 years CFAS I interviewed 5,156 (76% response) with 5,288 interviewed in CFAS II (74% response).
Here we report a 20% drop in incidence (95% CI: 0–40%), driven by a reduction in men across all ages above 65.
InterpretationIn the UK we estimate 209,600 new dementia cases per year. This study was uniquely designed to test
for differences across geography and time. A reduction of age-specific incidence means that the numbers of people estimated to develop dementia in any year has remained relatively stable.
ReferenceA two decade dementia incidence comparison from the Cognitive Function and Ageing Studies I and II.
Matthews FE, Stephan BCM, Robinson L, Jagger C, Barnes LE, Arthur A, Brayne C, Cognitive Function and Ageing Studies (CFAS) Collaboration. 2016, Nature Communications
Implications for General Practice
• Can give a coherent message on healthy lifestyle to all groups
• Increased incentive as dementia the most feared diagnosis in the over 50’s (and now the leading cause of death)
• High risk groups already under review (hypertension, CHD, diabetes)
• Mild Cognitive Impairment another high risk group, suitable for primary care follow-up
“What’s good for the heart is good for the brain”
Source Gov.uk
Source Alzheimers Society New Zealand
Management of Mild Cognitive Impairment (MCI)
Dr Jill Rasmussen, Dr Christopher Kipps, Dr Nick Cartmell, Dr Peter Bagshaw
Introduction
It is estimated that 5-20% of people over 65 have MCI, with 5-10% of those converting annually to Dementia, usually Alzheimer’s disease1. There are currently no clear and consistent guidelines for dealing with this condition, and practice varies from area to area. Dementia was found in a recent survey to be the most feared diagnosis in over 50s, yet we often currently give patients with a diagnosis of MCI no support, and can increase their anxiety by giving them the diagnosis.
Following the Blackfriars consensus, we now have clear evidence of interventions which reduce the risk of developing dementia. We have clinics, generally nurse-led, currently embedded in primary care to monitor other long term conditions embedded in all practices. We also have the IT support which allows an efficient recall of patients coded as having MCI, although coding remains an issue in the field of dementia. In addition, the message of prevention is consistent with messages already given by our current chronic disease nurses, as "what is good for the heart is good for the brain", and we already give the same message contained in the Blackfriars consensus to current patients with hypertension, CHD and diabetes. In addition, this group of patients is an important cohort for future trials, and having them systematically coded and monitored would have additional benefits in terms of accessibility for such trials. This paper gives recommended guidelines for the management of MCI in primary and secondary care.
Background
People with a memory or other cognitive complaint where dementia is considered a possible cause may be referred to one of a number of specialists (geriatrician, neurologist, old age psychiatrist), to memory clinics, or diagnosed in Primary Care. Theoutcomes of the referral include:
► Diagnosis of a subtype of dementia
► Depression, or other non-neurodegenerative cause of cognitive complaint
► Cognitive impairment that does not meet criteria for dementia diagnosis
► Other possible neurodegenerative disorder that requires further evaluation
► No definitive diagnosis, patient to be reviewed
► Reassurance that nothing is wrongp1
Reduced Stigma
“Dementia as a Chronic disease”
http://www.chronicconditions.co.uk/opinion/all/6
Primary Care DiagnosisDiagnosing Dementia in Primary care
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Memory Problem Suspected
From patient, hospital, screening, other alerts from primary care
Use mini-cog to screen for memory problems
If negative, reassure or review 6 months at GP discretion (for instance if
patient/family feel deterioration in mental functioning but insufficient to
score on mini-cog)
If memory problems confirmed
Review medication
Exclude depression, infection
Blood tests: FBC, C&Es, folate, glucose, LFTs, B12, TFTs and Ca.
CT (unless inappropriate) Head views with Coronals: ask “is there
sufficient neurological evidence to support a diagnosis of vascular
dementia?”
Seek information from carers where possible
Confirm with patient they have a memory problem. Support can be offered
at this stage
Discuss with memory nurse with bloods and CT results if appropriate. (If
confident, GP can make diagnosis and initiate treatment if uncomplicated,
patient over 75) Memory nurse will advise. Depending on patient, may
carry out further testing, agree diagnosis or refer to memory clinic
At diagnosis, see patient
Give diagnosis (this may sometimes be mixed or suspected)
Give information and support to patient and carers (see support pack)
Place on dementia register, inform HV/CM as appropriate
If vascular, address vascular risks.
If Alzheimer’s or mixed, consider prescribing Donepezil (see guidelines)
Follow up at 3-6 months or as Donepezil guidelines
• Doubled service capacity at minimal extra cost. Waiting time for diagnosis reduced from 8-9 months to 4-6 weeks.
• Increased primary care awareness and expertise, increased diagnosis rates from 38% to 58% in first year, increased cost-effectiveness (comparative studies show cost reduction of about a third).
• Brings service into line with other areas: primary care deals with straightforward cases, freeing up specialist services.
• Freed up memory nurses to visit patients at home. Now able to give attention to housebound and those with more complex needs.
• Reduced complaints (previously about 3/week over waiting times, since pilot introduction, ZERO).
• Clear NICE-compliant pathways, studied subsequently and shown to be safe and effective (Edana Minghella, Sam Creavin et al).
• Faster, more accessible diagnosis. Patients can receive gold standard diagnosis without needing to travel to a memory clinic.
• Reduced stigma, reduced travel, reduced anxiety. Familiar family doctor gives diagnosis and treatment.
• Keeps the family doctor at the centre of the process. This is vital for a long-term condition where help will be needed at several stages of the Dementia journey.
• Recently adopted as the gold standard for the South West region, widely emulated elsewhere. Now recognised as having important national impact on service delivery.
....and the results
Improved Post-Diagnostic Support
A transformation in society including:
Dementia Action Alliances, Dementia-friendly communities, Dementia Friends, Dementia advisors/Navigators, Integrated frailty services, Dementia Liaison services, Memory Cafes, Singing for the brain, Exercise for the brain, sporting memories, Dementia-friendly parking.....
....and much more
....and The Dogs that Didn’t Bark
1. Solanezumab Expedition 3
“By the close of this year, the Indianapolis-based Fortune 500 pharmaceutical company Lilly , whose products have included the antidepressant Prozac and human insulin, will release the results of Expedition 3, a study testing a drug that targets amyloid in persons with mild stage dementia caused by Alzheimer’s disease.
The drug Lilly is testing, solanezumab, or “sola” for short, targets amyloid. If Expedition 3 shows that patients on sola “do better” than patients on placebo, the field’s long adolescence will end, and Alzheimer’s doctors will have a new drug to prescribe and also a new way to talk about the disease. They’ll likely start calling it a “disorder of amyloid accumulation.”
When this happens, Alzheimer’s disease will gain a business model. Thought leaders will assemble, advertisements will flourish, and the media will start spreading the news: We finally have a new treatment for Alzheimer’s disease! People will want their amyloid test and, if necessary, the drug. As these events rapidly unfold, Alzheimer’s doctors such as myself will end our prolonged and largely unsupervised adolescence in the therapeutic basement. We’ll step into the adult world of Big Pharma with a “druggable target.”
Jason Karlawish Forbes Magazine Nov 11, 2016 @ 07:15 AM 9,989 views
s
2. Targeted funding in Primary Care
• “Retirement” of DES. Local financial pressures mean no money for LES. QOF remains, but incentives are relatively low.
• Keeping the political high profile of dementia (Prime Minister’s Challence, G20 etc) is difficult with other pressures
• Dramatic changes in primary care dementia care (donepezil coming off-patent, primary care diagnostic pathways, improved community support) now settled in.
• Other pressures on GP’s, difficult to maintain enthusiasm.
...despite Dementia now being the single largest cause of death
3. Dementia Diagnosis rates
• Nationally “job done” (67.1%)
• Pressure remains on GP’s and CCGs to achieve two-thirds diagnosis rates
• Rates have now flattened, and even dropped in some areas
• CFAS authors have confirmed their figures were national, not intended for local extrapolation
• The IAF have introduced a second metric, proportion of patients reviewed by GP in previous year, confirming the shift in focus to post-diagnostic support
