Transcript Dementia Assessment. FEB 2011

Management of Early Dementia
Dr Eleanor Mullan
Consultant Psychiatrist
Mental Health Services for Older People
South Lee, Cork
Feb 2011
Statistics
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Population of SHB - 550,000
12% over 65 years
1% over 85 years
Highest rise in very elderly (over 85 years)
Female:male = 4:1
32% over 70 years live alone
Life Expectancy
Male 78.9 (EU 80)
 Female 82.4 (83.8)
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Major Causes of Dementia
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Alzheimers Disease
Vascular Dementia
Dementia Lewy Body type
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up to 20% of dementias
Alcohol Dementia3-10%
Frontotemporal Dementia
Primary Progressive Aphasia
Age-associated Memory impairment - AAMI
Prevalence of Alzheimers Disease
Age range
 30-64 years
 65-69 years
 70-79 years
 80-89 years
 90-99 years
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AD
0.13%
0.34%
3.2%
10.08%
12.6%
VaD
0.10%
0.3%
0.7%
2.5%
4.2%
Definition of Dementia
Brain Disease
 Chronic
 Progressive
 Global
 Irreversible
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Symptoms of Dementia
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Cognitive Impairment
 Orientation
 Language
 Literacy
 praxic skills
 memory
 perceptual skills
Symptoms of Dementia - 2
Personality Change
 Delusions
 Hallucinations
 Mood and Affect disorder
 Neurovegetative symptoms
 Behavioural Problems
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Assessment
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History
Course, onset, presentation
 Family history, drug and alcohol history
 Medical history
 Collateral
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Clinical Examination
Psychiatric Examination
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Depression!
Neuropsychological Examination
Assessment - 2
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Blood Tests
 FBC, ESR, U+E, LFT, Ca, Phosphate
 TFT, Syphilis serology, B12
 Autoantibody screen
 C-reactive protein
 Heavy metal screen, copper
 HIV
 Drug screen
Assessment - 3
ECG, CXR
 CT Scan
 MRI
 EEG
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Alzheimers Disease
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Neuropathological diagnosis
 neurofibrillary tangles, senile plaques
 cerebrovascular disease is common in elderly
and can be present with AD
Presentation
 memory problems for recent events, insidious
onset
 Cognitive deficits with social impairment
Investigations
 Blood tests normal
 Imaging can be normal in the early stages
Vascular Dementia
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Neuropathology
 ischaemic and haemorrhagic brain lesions
Presentation
 unclear temporal relationship between vascular
events and onset of dementia
Investigations
 vascular risk factors, neurological signs
Cortical Lewy Body Dementia
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Neuropathological
 lewy bodies in cortical neurones
 Senile plaques are common, rarely NFT
Presentation
 attention deficits, fluctuation of function
 Parkinsonism, falls, transient disturbance of
conscious
 Neuroleptic sensitivity
 visual hallucinations, delusions, disturbed sleep
Investigations
 can be normal
 distinguishing clinical course
Alcohol-Related Dementia
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Neuropathological
Presentation
 History of abuse
 Frontal lobe signs!
 Wernicke-Korsakoff (thiamine def), peripheral
neuropathy, stigma of liver disease
Investigations
 imaging - cortical atrophy in 50-70%
 ?reversible
General Management
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History, Examination, Investigations
Clear Diagnosis – distinguish from delirium +
pseudodemntia
AAMI
Other medical specialities - neurology, geriatrician
Information in stages
Carer support
General Management - 2
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Informing the patient
Consent to treatment
Driving, collateral,
 visuospatial, dyspraxia, frontal lobe signs
Testimentary capacity
Power of attorney
Available services
Carer support
General Management - 3
Psychology
 Social Care
 Medication
 Self-help groups
 Voluntary Groups - ASI
 Carer support groups - respite, education,
training, information
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Management of Alzheimers Disease - 1
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Symptomatic treatment - cholinesterase inhibitors
Donepezil, Rivastigmine, Galantimine
Memantine, N-methyl-D-aspartate blocker -increase
glutamate
Modest benefits - memory, QOL, behaviour
Benefit = 3-6 month delay/remission of symptoms
15-20% dramatic improvements
Delay in symptomatic decline
Evidence for benefit of early treatment?
Behavioural problems associated with dementia
Cost
Management of Alzheimers Disease - 2
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Patient Selection and suitability
 diagnosis of dementia
 mild to moderate dementia - MMSE 10-26/30
 relatively independent? - nursing home
residents
 Compliance assured
 ability to give informed consent
 discuss criteria for discontinuation
 Absence of medical contra-indications
 ?Use in vascular dementia - controversial, no
licence
Management of Alzheimers Disease - 3
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Contra-indications - no serious issues
 Heart block, bradycardia<50/min
 Active peptic ulceration
 Severe asthma
Side-effects of cholinesterase inhibitors
 GIT - appetite loss, nausea, vomiting, diarrhoea
Management of Alzheimers Disease - 6
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Treatment Discontinuation
 discussion at commencement of treatment
 Absence of clinically significant benefit after 68/12
 Drug holiday if in doubt?
 Poor compliance
 poor tolerability
 side-effects
Management of Alzheimers Disease – 7
– Treatment options which have not been
proven by DB/RCT
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Anti-inflammatory
Prednisolone
HRT
Vitamin E (2000IU)
Gingko biloba
Management of Vascular Dementia
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Underlying vascular disease
Risk factors
 Cardiac assessment
 Carotid disease
 Cerebral embolic disease
 Hypertension
 Blood cholesterol
 Diabetes
 Smoking
 Hypothyroidism
Management of Lewy Body Dementia
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Clear diagnosis to all health professionals
Avoid neuroleptics - increase mortality?
Cholinesterase Inhibitors
L-dopa for PD!
Management - alcohol dementia
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Abstain from alcohol
 halt progression, ?reverse
General Management - 2
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Informing the patient
Consent to treatment
Driving, collateral,
 visuospatial, dyspraxia, frontal lobe signs
Testimentary capacity
Power of attorney
Available services
Carer support
General Management - 3
Psychology
 Social Care
 Medication
 Self-help groups
 Voluntary Groups - ASI
 Carer support groups - respite, education,
training, information
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