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Dementia & Primary Care
Dementia & Primary Care
25th January 2011
Dr Henk Parmentier
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Why dementia and Primary Care?
• A 66 year old lady plucks up courage to go to her
General Practitioner because she is concerned about a
lump in her breast.
• “Well” says her doctor “this kind of thing is not
uncommon at your age, but I don‟t really have time to do
a proper examination even though I would be quite
capable of giving you a diagnosis.
• Anyway the examination is quite embarrassing and
waiting for further tests is only going to make you
anxious.
3
Why dementia and Primary Care?
• Treatment can be very painful and disfiguring and really you‟ve had a pretty good innings anyway.
• I would suggest that you come back in a couple of years time and if there are metastases we could give you some sedation to take your mind off the pain.
• By that time, however, you should be thinking of selling your house and moving into a hospice.”
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Dementia- Introduction
Amberley Lodge Care Home
• situated in Purley
• Continuing Care Ward
Old Age Psychiatrists Croydon PCT
• Nursing Home Unit
• Residential Unit
• Respite beds for Alzheimer Society
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Buckingham Palace
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Buckingham Palace
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Buckingham Palace
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Dementia- Introduction
• Why dementia and Primary Care?
– The theme of Alzheimer's Awareness Week® 2002 was:
“Feeling the Pulse: primary care and dementia”
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Dementia- Introduction
• Why dementia and Primary Care?
– The first place people go if they are worried about dementia is usually their GP.
– Early detection is essential:
• Anti dementia drugs should be initiated in early stages of dementia
• Future health care, social and legal choices can still be discussed with patient
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Dementia
• Dementia: irreversible condition involving
progressive deterioration of cognitive
function and behaviour sufficiently severe
to affect activities of daily living
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Dementia
• Progressive
• Irreversible
• Loss of cognitive functions (memory, language, learnt movement, etc)
• With associated decline in overall
functioning and a change in personality
• Without clouding of consciousness
(delirium)
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Dementia
• There are over 55 illnesses which can
cause dementia
• Alzheimer‟s disease and vascular
dementia together 80% of all dementias
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Dementia spectrum
vascular dementias5%
vascular dementias + AD10%
AD65%
AD + Lewy body dementia5%
Lewy body dementia7%
other dementias8%
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Dementia Spectrum
• Alzheimer’s disease
– Parietal-temporal distribution
• Vascular dementia
– Multi infarct, Binswanger (subcortical)
• Drugs and toxins
– Alcohol
• Intracranial masses
– Tumor, subdural masses, brain abscess
• Anoxia
• Trauma / head injury
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Dementia Spectrum
• Normal pressure hydrocephalus
• Neuro degenerative disorders
– Parkinson‟s, Huntington‟s, Pick‟s (frontotemporal), Amyotrophic Lateral Sclerosis, Lewy body dementia (visual hallucinations), Wilson‟s……..
• Infections
– CJD, AIDS, neurosyphilis
• Nutritional disorders
– Wernicke-Korsakoff (thiamine def.), vit B12 def., folate def.
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Dementia Spectrum
• Metabolic disorders
– Hypo / hyperthyroidism, renal
insufficiency, hepatic insufficiency
• Chronic inflammatory disorders
– Lupus, Multiple Sclerosis
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Prevalence of dementia
• 1 in 20 over 65 years
• 1 in 10 over 75 years
• 1 in 5 over age of 85
• From 2000 patients, 1 or 2 news cases will present
yearly (incidence) and at any point there will be 14
people with various stages of dementia
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Dementia – some facts
• Behavioural and psychiatric disturbances are present
in up to 90% of dementia patients at some point over the
course of their illness
• Lack of detection occurs in 48% of patients with AD
and diagnosis is often delayed until the patient is
experiencing severe symptoms
• Patients live up to 10 years after the onset of symptoms
• Estimated: 26% women and 21% men over 85yo have
some form of dementia
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Dementia – some facts
• It will become increasingly common
• People will be interested in getting help as
awareness of the condition spreads and
treatments become widely available
• Doctors now can do a lot to help
• An early diagnosis allows the family, the
doctor and the patient to prepare for the
future.
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What happens in Alzheimer’s Disease
• Self destruction of brain cells
• Distinctive pathology (plaques and
tangles)
• Shrinkage of the brain
• Selective and early destruction of certain
nerves using Acetylcholine- involved with
memory, mood, alertness, etc
• Eventually all the brain involved
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Presentation
• Patient may complain of forgetfulness, or
feeling depressed or anxious or may be
unaware of memory loss
• Families may also cover up or minimise
memory loss or loss of function
• Families may ask for help at any stage:
failing memory, decline in functioning or
behavioural problems
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Alzheimer’s Disease
• Subtle start
• Steady (i.e. continuing) decline
• A decline (shrinkage) from previous
functioning starting first from most
complex tasks / demanding situations
• Changes in behaviour can also be first
presentation
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Alzheimer’s Disease: Cognitive changes
• Amnesia- memory loss: forgetting, short term memory loss first and most severe
• Aphasia – language difficulties (naming, misuses words and decreased vocabulary)
• Apraxia – difficulty in manipulating objects (e.g. clothes, household appliances, etc)
• Agnosia – difficulty in recognising things and people (e.g.names and identity of people, places, physical illness, self neglect, fires, etc) and social nuances
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Alzheimer’s Disease: Behavioural changes
• Mood – usually depression, rarely mania
• Delusions – usually
theft, suspiciousness, impostors, infidelity
• Hallucinations – auditory and visual, can
be secondary to cognitive problems
• Behaviour:
aggression, wandering, disinhibition, over
eating, sleep disturbance
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Alzheimer’s Disease:
Functional changes (Activities of Daily living)
• Complex ADLs: paying
bills, taxes, complex repair jobs, unfamiliar
recipes, travelling in new areas
• Basic ADLs: familiar household
tasks, familiar cooking, basic self
care, grooming,
• Basic Functions: eating, drinking, bodily
functions
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Other types of dementiaVascular dementia
• Slow starvation or sudden strokes (multi-
infarct) – a mixed bag
• Have cardiovascular risk factors
• Sudden onset and step-wise deterioration
• slower thinking,
• Depression and sundowning commoner
• Gait disturbance, incontinence
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Other types of dementiaLewy Body Dementia
• Rare, potentially disastrous effect of major
tranquillisers
• Fluctuating consciousness
• Vivid visual hallucinations
• Parkinsonian features
• Autonomic dysfunction: falls, fluctuating
heart rate or blood pressure, etc
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Dementia: how to test ?
• Screening questions: ask age and date of
birth, news in recent 2 weeks, time to
nearest hour and date, ask to draw two
interlocking pentagons
• Cognitive tests suitable for GPs:
– AMTS (Abbreviated Mental test Score)
– MMSE (Mini Mental State Examination)
– 6-CIT (6 item cognitive impairment test)
– Clock Drawing
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Abbreviated Mental test Score
EACH QUESTION SCORES ONE POINT
1. Age
2. Time to nearest hour
3. An address - for example 42 West Street - to be repeated by the patient at
the end of the test
4. Year
5. Name of hospital, residential institution or home address, depending on
where the patient is situated
6. Recognition of two persons - for example, doctor, nurse, home help etc
7. Date of birth
8. Year first world war started
9. Name of present monarch
10.Count backwards from 20 to 1
A SCORE OF LESS THAN SIX SUGGESTS DEMENTIA
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Mini Mental State Examination (MMSE)
• Orientation
– What is the (year) (season) (date) (day) (month)? 5
– Where are we: (country) (city) (part of city) (number of flat/house)
(name of street)? 5
• Registration
– Name three objects: one second to say each.
– Then ask the patient to name all three after you have said them.
– Give one point for each correct answer.
– Then repeat them until he learns all three.
– Count trials and record. 3
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Mini Mental State Examination (MMSE)
• Attention and calculation
– Serial 7s: one point for each correct.
Stop after five answers.
Alternatively spell 'world' backwards.
5
• Recall
– Ask for the three objects repeated above.
Give one point for each correct.
3
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Mini Mental State Examination (MMSE)
• Language
– Name a pencil, and watch
2
– Repeat the following: 'No ifs, ands or buts„
1
– Follow a three-stage command: 'Take a paper
in your right hand, fold it in half and put it on
the floor'
3
– Read and obey the following: Close your eyes
1
35
Mini Mental State Examination
(MMSE)
• A score of 20 or less generally suggests dementia but may also be found in acute confusion, schizophrenia or severe depression.
• A score of less than 24 may indicate dementia in some patients who are well educated and who do not have any of the above conditions.
• Serial testing may be of value to demonstrate a decline in cognitive function in borderline cases.
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Treatment in primary care
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How would you treat dementia?NICE guidelines
• Donepezil (Aricept®), Rivastigmine (Exelon®) and
Galantamine (Reminyl®) are available on the NHS but:
– Diagnosis of Alzheimer‟s disease must be made in a specialist
clinic
• Including test of cognitive, global and behavioural
functioning, and activities of daily living
• Judgement about the likelihood of compliance
• Only specialist should initiate treatment; may be continued by GP
• Carers view should be sought before and during treatment
– Further assessment after 2 to 4 months; then every 6 months
– Drug to be discontinued when MMSE below 12
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How would you treat dementia?
• Anti-oxidants: Vitamin E (400 to 2000
I.U. daily) fairly safe second line
treatment, can be supplemented with
Vitamin E (500 mg daily)
• Gingko Biloba (120 mg to 240 mg of
standardised extract daily) has anti-
oxidant and circulation enhancing
properties, at best effects compare to
ACHEIs
42
How would you treat dementia?
Glutamate modulator
memantine
• Fairly safe to use
• Main side effects are vertigo, restlessness, excitation, fatigue, diarrhoea
• Risk of fits
• Only drug evaluated for severe dementia
• Insight might come back !!!!!!
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How would you cope with aggression?
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How would you cope with aggression?
• Food
• Infections
• Constipation
• Environment
• Side effects medication
• Pain
• Sedation
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How would you cope with
aggression?
• Food
– HUNGER MAKES
AGGRESSIVE !
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Jan-99 Feb-99 Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 May-00 Jun-00 Jul-00 Aug-00 Sep-00 Oct-00 Nov-00 Dec-00
HUNGER MAKES AGGRESSIVE
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Sedation
• (Atypical) antipsychotics
• Acetylcholinesterase inhibitors
• Benzodiazepines
• Antidepressants: trazodone
• antihistamines
48
Would you treat other illnesses ?
• Based on do not resuscitate policy
• What would the patient have liked to be
done?
– Full care: intensive care inclusive
experimental treatment
– Normal care: hospital care
– Minimal care: use of limited
antibiotics, surgery for treatable illnesses
– Palliative care: keep warm, dry and pain free
49
Would you treat other illnesses ?
• We discuss this with patient and / or relatives soon after admission to continuing care ward: end of life decisions
• Put it in writing with copy in medical records and summary letter to relatives and GP
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Dementia
end of life decisions
• Dementia is a terminal disease
• Therefore patient and relatives need to be
prepared for end of life
– Will to be made up
– Financial situation sorted
– How much medical input at end of life?
• Living will
• No resuscitation policy to be discussed
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Dementia
Palliative Care
• Ethical issues surround investigation and
treatment when the patient develops
serious physical illness. Present structures
address these problems tangentially at
best.
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Dementia
ethics
Primary Care Ethics
EDITED BY DEBORAH BOWMAN
AND JOHN SPICER
ISBN-10 1 85775 730 0
ISBN-13 9781857757309
Radcliffe
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Chapter 5
Ethical considerations in the primary care of the elderly demented patient
Henk Parmentier, John Spicer and Ann King
How am I today?
Well, generally speaking,
Standing up
In a sitting down situation.
Thank you