The document discusses dementia and primary care. It notes that the general practitioner (GP) is usually the first place people go if worried about dementia, so early detection by the GP is important. It provides information on diagnosing and treating dementia, including guidelines on prescribing medications. It also addresses dealing with behavioral issues like aggression, treating other illnesses, end of life decisions, and the ethics of caring for elderly demented patients in primary care.

1. Dementia & Primary Care Dementia & Primary Care 25th January 2011 Dr HenkParmentier

2. 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.”

4. 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

5. Buckingham Palace

6. Buckingham Palace

7. Buckingham Palace

8. Dementia- Introduction Why dementia and Primary Care? The theme of Alzheimer's Awareness Week® 2002 was: “Feeling the Pulse: primary care and dementia”

9. 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

10. Dementia Dementia: irreversible condition involving progressive deterioration of cognitive function and behaviour sufficiently severe to affect activities of daily living

11. 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)

12. Dementia There are over 55 illnesses which can cause dementia Alzheimer’s disease and vascular dementia together 80% of all dementias

13. Dementia spectrum

14. 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

15. 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.

16. Dementia Spectrum Metabolic disorders Hypo / hyperthyroidism, renal insufficiency, hepatic insufficiency Chronic inflammatory disorders Lupus, Multiple Sclerosis

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

26. 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

28. 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

29. 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

30. 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

31. Abbreviated Mental test ScoreEACH QUESTION SCORES ONE POINT Age Time to nearest hour An address - for example 42 West Street - to be repeated by the patient at the end of the test Year Name of hospital, residential institution or home address, depending on where the patient is situated Recognition of two persons - for example, doctor, nurse, home help etc Date of birth Year first world war started Name of present monarch Count backwards from 20 to 1 A SCORE OF LESS THAN SIX SUGGESTS DEMENTIA

32. 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

33. 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

34. 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 Write a sentence 1 Copy a design 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.

37. Treatment in primary care

40. 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

41. 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 !!!!!!

43. How would you cope with aggression?

44. How would you cope with aggression? Food Infections Constipation Environment Side effects medication Pain Sedation

45. How would you cope with aggression? Food HUNGER MAKES AGGRESSIVE !

46. HUNGER MAKES AGGRESSIVE

47. 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

50. Dementiaend 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

51. DementiaPalliative Care Ethical issues surround investigation and treatment when the patient develops serious physical illness. Present structures address these problems tangentially at best.

52. Dementiaethics Primary Care Ethics EDITED BY DEBORAH BOWMAN AND JOHN SPICER ISBN-10 1 85775 730 0 ISBN-13 9781857757309 Radcliffe

53. 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.

54. Thank you Henk.parmentier@gmail.com