Dr Gillian Collighan

The main problems at the beginning, and at the end of the dementia pathway

•Present detection rate•Why is detection rate so low

•Red Flags for dementia• Behavioural and Psychological Symptoms

of Dementia (BPSD)

OVERVIEW

•One in three people over the age of 65 will end their lives with dementia

•Only 48% of people living with dementia, living in the UK ever receive a diagnosis

• Diagnosis rates vary from as low as 35% in Southwest England,

to over 70% in parts of Scotland and Northern Ireland• Without a diagnosis,

people with dementia cannot receive the support, information and

treatment that they need to live well with dementia• State of the Nation Report ( DOH November 2013)

KEY FACTS

•NHS East Suffolk and Ipswich CCG 46.09%•NHS West Suffolk CCG 41.84%•NHS West Norfolk CCG 34.9%

•NHS Norwich South CCG 43.85%•NHS North Norfolk CCG 42.6%

•NHS Great Yarmouth and Waveney CCG 49.22%

Data: 2012/13, re-baselined from pre-April 2013 PCT data

DEMENTIA DIAGNOSIS RATES LOCALLY

•Set to improve diagnosis rates, so that by March 2015 2/3rds of the estimated number

of people with dementia should receive a diagnosis of dementia .

•From 2013/2014 an enhanced service contract will help improve diagnosis in high risk groups, cardiovascular risk, long term neurological conditions, and people with

learning disabilities

THE NATIONAL GOAL SET BY NHS ENGLAND

WHY DO WE MISS THE DIAGNOSIS?

1. Heterogeneity of disease and presentation2. Screening tools too blunt and memory

focussed3. Patient factors

4. Problems with the relatives and informant history

5. Social factors6. Medical profession attitudes

7. Problems within secondary care

PREVALENCE OF DEMENTIA SUBTYPES IN OVER 65’S by diagnosis

Alzheimer’s Society

PREVALENCE OF DEMENTIA SUBTYPES IN OVER 65’S By

Pathology

Alzheimer's Disease 60%

Lewy Body 15%-20%Vascular 20%

•Amnesic Type Alzheimer’s•Aphasic (Logopenic) Type Alzheimer’s

•Frontal Type Alzheimer’s•Posterior Cortical Atrophy Type

Alzheimer’s

SUBTYPES OF ALZHEIMER’S

DEMENTIA

Types of dementia

Cortical Subcortical Mixed

Alzheimer’s •Presents with degrees of amnesia, aphasia,

apraxia and agnosia•Memory, language, skills, geographical

disorientation

CORTICAL DEMENTIA

Vascular Small Vessel Disease and Lewy Body/Parkinson's Disease

•Slowing, lack of spontaneous movement, paucity of facial expression,

•Difficulties in retrieval of words ‘tip of the tongue’•Executive Dysfunction -problems with high end skills

•Problems with gait and continence as disease progresses

SUBCORTICAL DEMENTIA

FRONTAL/EXECUTIVE DYSFUNCTION

Five circuits link the subcortex to the frontal lobes

•Apathy and Inertia•Attention and Concentration

•Reasoned Judgement•Decision Making

•Sequenced Activities•Error Checking

•LOSS OF INSIGHTSOCIAL FAÇADE AND MEMORY FAIRLY GOOD

VASCULAR COGNITIVE IMPAIRMENT AND SMALL

VESSEL DISEASE

•Traditionally Multi infarct dementia has held centre stage

•Commonest vascular dementia in memory clinics is small vessel disease

•Spectrum disorder, ranges from vascular cognitive impairment (MCI) to full blown dementia

•Characterised by slowness, apathy, inertia, progressing to gait (Marche a petit pas) and

continence difficulties•Often have marked executive dysfunction

LEWY BODY DEMENTIA

•May present with subtle cognitive symptoms•Slowing, ‘tip of the tongue’, apathy and inertia

•Poverty of facial expression and spontaneous movement- no tremor

•Visual hallucinations may not be apparent initially

•Additional clues-REM sleep disorder, anosmia, often long history of constipation or IBS symptoms, frequent mood

disorder predating other symptoms by years. Marked fluctuation from day to day

•Cognitive change will be picked up by MOCA and ACEIII

•GPCOG- Tests memory and visuospatial skills•6-CIT-Tests memory, orientation and mental

manipulation• AMTS-Test of memory only

(Memory weighted tests designed to pick up Alzheimer’s)

•MOCA-Tests memory, executive function and visuospatial

•ACE-III-Tests memory, language, visuospatial and executive function

COMMON SCREENING TESTS

•Loss of insight•Social façade maintained until late in the

disease process•Patient less likely to present as disease

progresses

•PARTICULAR PROBLEMS WITH DELAYED DIAGNOSIS IF PATIENT HAS A PROBLEM WITH MOBILITY, EYESIGHT OR

HEARING

MISSED AND DELAYED DIAGNOSIS- PATIENT

FACTORS

THE SOCIALLY ISOLATED PATIENT

•1/3 of people with dementia live alone•Common from the age of 80 years onwards

•Partner has predeceased them•May have no children, or little contact with

themOften present in crisis, as no-one to advocate

on their behalf•Present in secondary care following falls

and delirium

• Relative may be more impaired than the patient•Spouse is the non-dominant partner, and cannot get

the patient to attend clinic•Spouse is physically unwell and reliant on the patient•Spouse has always done everything so patient is not

tested•Beliefs and assumptions that this is part of normal

ageing

• INVESTED INTEREST IN KEEPING THE PATIENT AT HOME/ OR DRIVING

PROBLEMS WITH RELATIVES AND THE INFORMANT HISTORY

PHYSICIAN ATTITUDES

•Concern that telling the patient the diagnosis will upset them, and nothing can

be done anyway•Concern that post diagnostic support is

insufficient•Concern it may be time consuming

ATTITUDES IN SECONDARY CARE

•PBR has changed the way we work•Treat the presenting complaint only-tunnel vision

•Often recognised that patient is confused, but nothing done until third or fourth readmission

•Concern that onward referral for memory assessment will delay discharge

There is now an enhanced Liaison Team and Dementia Intensive Support Team (DIST) in the General Hospital

•Medication mix ups•Unexplained weight loss

•Poor control of chronic illness•Episodes of delirium with minor insult

•Post bereavement acopia•Late onset mood disorders

RED FLAGS

CHRONIC ILLNESS

•Parkinson’s Disease•REM Sleep Disorder•Multiple Sclerosis

•Motor Neurone Disease•Learning Disability

•Diabetes•Cardiovascular Disease

BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF

DEMENTIA (BPSD)

Main subtypes;•Physically aggressive behaviour

•Physically non-aggressive•Verbally non-aggressive

•Verbally aggressive

•Psychosis related behaviour•Mood related behaviour

REPORTED FREQUENCY OF BPSD

Perceptual•Delusions 20–73%

•Misidentifications 23–50%•Hallucinations 15–49%

Affective•Depression up to 80%

•Mania 3–15%(Finkal et al 1998)

BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF

DEMENTIA

•90% of dementia patients experience BPSD

•Mild to moderate BPSD has potentially reversible causes, often resolves within four

weeks•Delirium must be excluded

•Physical problems such as dehydration, pain, infection, electrolyte imbalances,

constipation and polypharmacy

ASSESSMENT OF BPSD

•Various rating scales•Underlying dementia diagnosis and

severity•Psychological and psychosocial assessment

• Physical health problems, excluding delirium

•Review of medication

ASSESSMENT OF BPSD

•Charting of behaviour (ABC)•Assessment of environment

•Assessment of communication and carer interaction

•Assessment of safety

MANAGEMENT OF BPSD

•Psychological•Behavioural

•Environmental•Pharmacological

PHARMACOLOGICAL INTERVENTIONS-DRUGS USED

•Antidepressants•Benzodiazepines

•Acetyl cholinesterase inhibitors•Memantine NMDA receptor inhibitors

•Antipsychotics UNDER SPECIAL CONDITIONS

SEVERE BPSD-WHEN TO GIVE MEDICATION

•Where there is significant distress to the individual, or aggression that results in

significant risk to patient or others•Where non-pharmacological treatments

have failed•It is required in order to assess and

investigate patient fordelirium –physical exam , BP, pulse and

blood screen

PHARMACOLOGICAL INTERVENTION

•Changes in cognition should be assessed and recorded

•Initial low dose and titrated upwards•Treatment time limited and reviewed

(every three months or according to clinical need)

PHARMACOLOGICAL INTERVENTION

•Risperidone antipsychotic of choice (NICE) for use in BPSD of Alzheimer's disease•Treatment rationale and side effects should be discussed with patient and

relatives•Target symptoms must be described, and

reviewed

ANTIPSYCHOTIC USE IN DELIRIUM

•In hyperactive delirium patient can be very agitated

•In these cases Haloperidol or Olanzapine, and/or lorazepam are recommended (NICE)

•Important to decide whether you are dealing with delirium or BPSD as different

Antipsychotics recommended

BPSD AND CAPACITY

•May not have capacity to consent to treatment

•Relevance to mental capacity act must be considered and documented

•When medication given need to consult with patient, relative and carers

•If covert medication is used this must follow local policy

THE END

Community Memory Assessment Service

Helen Whight: Community Services Manager, NSFTKaren Blades: IESCCG Clinical Lead for Dementia

Remodeling the Memory Assessment Service

Principles of Community Memory Assessment

•

39

In partnership with IESCCG, NSFT is working with GPs to establish 10 new locality clinics (referred to as Lead GPs) which are distributed across the region.

The service will work alongside existing organisations, such as Age UK, Alzheimer’s Society, Suffolk Family Carers and Sue Ryder, to support dementia-related activities and initiatives and support people to access local provision.

Specialist dementia practitioners, employed to deliver the service, will spend a good proportion of their time in GP Practices. This will enable them to raise awareness of dementia and improve the skills of practice staff in spotting early signs of dementia.

PATHWAY : KEY FEATURES

Patient Pathway

6 Week Target from Referral to Diagnosis6 Week Target from Referral to Diagnosis

How to Refer to the Service

42

•

Referral Form

• SystmOne Practices can use an online referral template

• It can only be used if the patient consents to share their data with NSFT

• If consent is given many of the fields are pre-populated

• Location of template can be managed by each practice

• Alternatively secure email to CMAS.

• Referrals made to Access and Assessment will be sent on

43

Ravenswood

A12

A143

A140A14

Coastal IDT

Central IDTIpswich IDT

Stowmarket

Hadleigh Debenham

Leiston Orchard St

Barrack Lane

Bury St Edmunds

Sudbury

Diss

Eye

Felixstowe

LeistonStowmarket

Debenham

Hadleigh

Bildeston

Wickham Market

Ravenswood

Distribution of Lead GP Practices

Negotiations with a further three practices are

ongoing

Timescales 2014