Dr. S. Hamer- Consultant Psychiatrist

Caroline Molloy- Memory Service Lead Nurse

Dementia training for GPs

January 2013

Update◦ Recognition and screening for possible dementia◦ Psychosocial support in primary care◦ Referring to specialist memory services◦ Specialist memory assessment service◦ Long term management of patients on anti

dementia drugs

Session Aims

• National and local drivers

• NDS, NICE, Prime Ministers challenge etc• All pointing to-

• Early referral for specialist assessment, to ensure timely and accurate diagnosis

• Timely diagnosis facilitates access to medication, information and support services

Context

• 700,000 with dementia in UK, predicted to double by 2050.

• Age related condition with 20% of over 85s affected.

• Under 65 account for just 2%

Epidemiology and aetiology

126, 200 people over 65 in Leicestershire County and Rutland with dementia.

Predicted to rise to 224,800 by 2025 (County and City)

Locally

Don’t really know, but probably◦ To be known by the people looking after me◦ To have choice in my care for as long as possible◦ To be sure I had/there was a plan◦ To have the opportunity to enjoy family, friends

etc◦ To know that my family are looked after/well

supported◦ Information, when I wanted it, suitable to me

What would you want if you were diagnosed with dementia?

“A syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning, capability, language, and judgement. Consciousness is not impaired.”

ICD-10

What is dementia?

Normal/typical ageing

Slower thinking and problem solving; STM takes longer, reaction time slower

Decreased attention and concentration; more distractedness and difficulty learning

Slower recall; need more hints

What is not dementia?

Typical ageing DementiaOccasionally forgets or searches for words

Frequent word-finding pauses, substitutions

Remembers recent important events; conversations are not impaired

Notable decline in memory of recent events and ability to converse

May pause to remember directions but not generally getting lost in familiar places

Gets lost in familiar places

May complain of poor memory, but able to give good examples of forgetfulness .Patient more concerned than family.

May complain of memory loss if asked, unable to give specific examples. Family more concerned than patient.

Interpersonal skills ok, managing personal care, affairs etc

Loss of interest in social activities, possible decline in functional skills

Typical ageing or dementia?

4 main types◦ Alzheimer’s disease (approx 60%)◦ Vascular (30-40%; including approx 20% dual

pathology)◦ Dementia with Lewy bodies (15%)◦ FTD (5%)

◦ NB More than 100% due to variability in studies

Types of dementia

Unique to individual and underlying cause Most may have some (but not all)

◦ Loss of short term memory◦ Word finding difficulty◦ Difficulty with familiar tasks (driving, dressing,

cooking, finances)◦ Personality change/uncharacteristic behaviour◦ Confusion, disorientation, poor judgement

Is there a common presentation?

Clinically very little difference other than age of onset

Prevalence 45-64 year olds =121 per 100,000 with Alzheimer’s disease (26%)*

Sufferers more likely to be◦ In work◦ Have dependent children◦ Be physically fit◦ Have financial commitments◦ Have rarer form of dementia

*Harvey et al 2003

Working age dementia

Many conditions may present with cognitive impairment – delirium, depression, medical conditions, side effects to medication.

Important differential diagnoses are delirium and depression, both treatable, both may co-exist with dementia

Chest infections, UTI’s, hypoxia, medications Some symptoms of dementia may not be

common/typical – (disinhibition, apathy, judgement, language, loss of learnt skills)

Also consider

Dementia Delirium Depression

Onset Insidious Acute Gradual

Duration Months/years Hours/days/weeks Weeks/months

Course Progressive/stepwise Fluctuates, worse at night

Usually worse in mornings

Thoughts Reduced interest, perseveration, delusions

May be paranoid and grandiose

Slowed, preoccupied, sad, hopeless

Perception

Hallucinations in 30-40% (usually visual)

Visual and auditory common

Mood congruent auditory

Emotion Depression, anxiety, sun downing

Anxiety/depression common, fear/agitation

Flat, unresponsive, fearful.

Common differences- 3 D’s

Losing or misplacing things Forgetting appointments, conversations,

events etc. Unable to retain names of new acquaintances Difficulty following conversations Intact ADL’s Decline over time greater than normal ageing

(on cognitive tests) Between 5-20% of older people will have MCI

at any time (dependant on definition)

What is Mild Cognitive Impairment?

Previously opinion suggested about 10% per annum would develop dementia

Probably 10-15% (dependant on definition and cause)

Current thinking suggests not just a transitional stage, but some may stay static or even improve

Conversion of MCI to dementia

RCGP recommend MMSE, GP-COG, 6CIT or Mini-Cog

Copyright issue with MMSE Locally (see pathway) GP-COG for screening

and MMSE for review (waiting for DoH guidance on this)

Screening

2 components – cognitive assessment and informant questionnaire.

Informant questionnaire only needed if cognitive score is score is 5-8 inclusive.

Score of 3 or less on informant questionnaire strongly supports cognitive impairment

◦ Available on EMIS/SystmOne

GPCOG

◦ Specific functioning problems◦ Cognitive impairment (GPCOG 5-8 patient + 0-3

informant or MMSE <26 with functional decline)◦ Atypical features, carer stress/concern◦ Mood symptoms and need to distinguish from

pseudodementia◦ Offer referral to Memory Adviser at this point

◦ GPCOG 9 or MMSE 26 - 30 but no functional problems or distress monitoring 6 monthly

Patients with potential dementia- when to refer.

For support of patients with memory problems in primary care

Contract awarded to Alzheimer’s Society October 2012

7 Memory Advisers (+ Manager) ensuring equitable cover of all geographic areas across the county

Provide information, advice, support and planning Can help practices to populate registers Referrals from GP practices and/or memory clinic

◦ NB Voluntary Service Organisers (Age UK) currently support CMHT’s/memory clinics following diagnosis.

LEICESTERSHIRE COUNTY AND RUTLANDMEMORY ADVISER SERVICE

◦ STM, and other problems with cognition. LTM, specific examples

◦ Duration of problem, how long since recognised◦ Associated symptoms; mood, sleep, personality◦ Vascular risk factors, past medical and psychiatric

history◦ Functional abilities and risk assessment◦ NICE recommends and we require:◦ Physical exam◦ Routine bloods (FBC, U&E, LFT, Thyroid function,

glucose, calcium, B12, Folate)◦ ECG, to prevent delays in starting medication◦ Screening GPCOG/MMSE

When referring-

Basic data- full name of client, DOB, gender, address, postcode etc

Telephone number including where possible that of family member/contact

Employment status, ethnic origin, religion Language spoken; is there a need for an

interpreter? Narrative of patient presentation GP COG desirable SystmOne and EMIS referral form

Referral letter.

Refer to packs Routine referral from GP incl. bloods and

ECG Referral triaged and allocated to memory

service for assessment Structured assessment Diagnosis and core interventions Initial advice on driving

Specialist Memory assessment Pathway

Clustering Payment by results (PbR) mental health

clusters 18 – 21 are organic mental health clusters Cluster 18/19 will follow memory pathway

and if eligible for AChEi the shared care protocol

Clusters 19, 20, 21 will remain under CMHT if input is required

Coffee Break

Donepezil (Aricept)◦ 5 and 10 mg (oro-dispersible tablet available)

Galantamine (Remenyl/Acumor)◦ 8mg, 16mg and 24mg capsules (maintenance 16-

24mg). Solution 4mg/ml Rivastigmine (Exelon)

◦ 1.5mg, 3mg, 4.5mg, 6mg capsules◦ Oral solution 2mg/ml◦ Transdermal patch 4.6mg and 9.5mg/24hr

Memantine (Ebixa) Starter pack titrates up to 20mg OD within 4 weeks. Oral solution 5mg/0.5ml

Licensed treatments

Cholinergic hypothesis of Alzheimer’s disease suggests that a decline in cognitive function is linked to loss of cholinergic transmission in hippocampus and cortex.

AChEi’s inhibit the cholinesterase enzyme from breaking down acetylcholine, increasing both the level, and duration of the neurotransmitter acetylcholine.

Licensed in mild to moderate Alzheimer’s.

Donepezil, Galantamine and Rivastigmine.

Acts on Glutamatergic system by blocking NMDA Glutamate receptors.

This is thought to be neuro-protective and possibly disease-modifying.

Approved for use in moderate to severe Alzheimer’s disease

Severe Alzheimer’s - drug of choice Moderate Alzheimer’s - intolerant of, or

contra-indication to AChEi’s

Memantine

Improvement in cognition by an average of 10%

Roughly equivalent of 6 months usual decline

ADLs and functioning may remain above baseline for 6-12 months for most and up to 2 years for some.

Benefits of AChEi

Usually mild◦ Diarrhoea, muscle cramps, fatigue, nausea,

vomiting, insomnia.◦ Headache, pain, common cold, abdominal

disturbance, dizziness.◦ Rarely : Syncope, bradycardia, sinoatrial and

atrioventricular block.

Side effects (AChEi)

Use of antipsychotics Concerns around over use and side effects Cerebrovascular adverse effects (atypicals

= typicals Behavioural and environmental approach

first Multisensory stimulation, bright light

therapy, aromatherapy

General guidance Target specific symptoms Start low and titrate up Time limited (review after 3/12 stable) Evidence for risperidone and olanzapine for

physical aggression, agitation and psychosis Long term use leads to cognitive decline

and falls Discontinue gradually (unless severe side

effects) Some people need to stay on them http://www.rcpsych.ac.uk/pdf/bpsd.pdf

GP monitoring For all types of dementia 6 monthly review Functional, behavioural, carer, dementia

advisor feedback Driving capability (see packs) Medication concordance, S/E, efficacy Carer strain Behavioural and psychological symptoms of

Dementia (BPSD) Dedicated Memory Service Lead Nurse

linked to each CCG for liaison/advice

Referral back to CMHT Urgent – goes to CMHT as usual Advice regarding medication – phone

memory service nurse or consultant psychiatrist

Caroline Molloy 01509 568680 Dr Hamer (Charnwood) 0116 295 2415 Dr Suribhatla (NWL) 0116 225 2754 Dr Subramaniam (H+B) 01455 443600 We will see again if significant behavioural

and psychological symptoms of dementia (BPSD) or complex needs

Discontinuation of medication NICE recommend that all patients who fall

into severe category are “considered” for discontinuation of AChEIs

May still be beneficial for Behavioural and Psychological Sypmtoms of Dementia (BPSD) even if cognition has declined

Less cost implication now Consider if experiencing harmful effects or

deteriorated to extent of palliative care Discuss with carers

Facilitates 1st 2 strands of National Dementia Strategy by

Encouraging practices to screen populations with suspected dementia (proposed DES and health checks in GMS contract)

Refer more patients appropriately to Memory Assessment Clinic

Agreeing to continue monitoring of treatment under Shared Care Agreement

Practices will◦ Nominate lead GP◦ Maintain adequate records following read codes in

clinical records

Enhanced Service 2013/14

Enhanced service A draft LES for GP shared care has been

developed and will be refreshed following agreement of the 2013/14 enhanced services

Updates will be communicated through locality meetings, practice manager meetings and newsletters

Vignettes

Case 1 73 year old man, brought to see you by wife who

has noticed forgetfulness over last 12 months. Asking repetitive questions, can’t remember

conversations or appointments. Wife frustrated, patient can’t really see a

problem. Able to wash, dress and perform household

chores. Driving without any problems. Scores 6/9 on patient GPCOG and 3/6 on

informant section.

Case 2 67 year old woman who comes to see you very

concerned about her memory. Anxious that she is not functioning as well as she

used to. Complains of forgetting where she has put things,

needing to rely on calendar for appointments. Lives alone, fully independent with activities of

daily living. Worried about Alzheimer’s disease. Scores 9/9 on GPCOG.

Vignettes

Case 3 79 year old woman Initially seen by GP with cognitive impairment Referred to Memory Adviser who supports son as

main carer Referred to memory clinic Diagnosed with Alzheimer’s disease and

commenced on Donepezil After 3 months, has been stable on 10mg Memory clinic write to you asking you to continue

prescription under SCA and review in primary care

VignettesCase 4 89 year old man with diagnosis of vascular

dementia for 3 years, on no psychiatric medication Under 6 monthly review Wife phones to say that he has become increasingly

agitated now He appears paranoid and suspicious of her She is frightened of him He keeps trying to leave the house and is clearly

disorientated in time and place Initial examination reveals no acute cause for

deterioration such as UTI

Vignettes Case 5 84 year old woman in residential home 5 year history of Alzheimer’s, on

galantamine Now severely cognitively impaired Persistent poor appetite and refusal to eat No obvious physical cause Very frail Family reluctant for her to be admitted or

have further physical investigations

Vignettes Case 6 69 year old man diagnosed with Alzheimer’s at

memory clinic 9 months ago Driving assessed at memory clinic – DVLA informed

of diagnosis, no visuospatial problems Stable on donepezil prescribed by GP Attends for 6 monthly review in primary care Now unable to draw interlocking pentagons Has had some minor scrapes in his car, but feels he

is able to drive safely Despite your advice not to, he is adamant that he

will continue to drive

Q+A Panel

Peter Cannon – GP Sam Hamer – Consultant psychiatrist

Caroline Molloy – Memory service lead nurseMemory service adviser