Parmentier 03

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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.

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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.

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• 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

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– Repeat the following: 'No ifs, ands or buts„

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– Follow a three-stage command: 'Take a paper

in your right hand, fold it in half and put it on

the floor'

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– Read and obey the following: Close your eyes

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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

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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

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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

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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

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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

Henk.parmentier@gmail.com