Transcript Depression in late life

Making the diagnosis well: experience
from the Newcastle Memory Service
John O’Brien
Institute for Ageing and Health
Newcastle University and Northumberland,
Tyne and Wear NHS Trust
Why diagnose dementia?
Iliffe et al, 2003
• Excluding remedial causes
• Provides certainty, allows understanding
• Information about illness and prognosis
• Allows planning for future
• Appropriate subtype specific management
• Allows search for common co-morbid symptoms and
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conditions and their treatment
Medico-legal issues
Early access to services/benefits
Wider benefits (planning services, research)
Myth
Diagnosis of dementia is
easy
Fact
Diagnosis of dementia is
not easy
Why?
• “Normal Ageing”
• Mild Cognitive Impairment (“MCI”)
• Dementia
• Depression
• Anxiety
• Physical disorder
• Delirium
• Secondary to medication
• Other brain pathology (space occupying lesion)
• Etc
Fact
Diagnosis of dementia is
not easy
Diagnosis of subtype of dementia is
even more challenging
DSM-IV Criteria for AD
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Development of multiple cognitive deficits manifested
by both
– Memory impairment
– One or more of the following deficits (aphasia, apraxia,
agnosia, disturbance in executive function)
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Deficits cause significant impairment in social and
occupational functioning
Represent a decline from previous level of functioning
Not accounted for by another disorder
NINDS-AIREN Criteria for VaD
(Roman et al, 1993)
Dementia (memory and 2 or more
domains)
 Cerebrovascular disease (focal neurology
and CVD on brain imaging)
 Link between the 2 (3 months or
abrupt/fluctuating clinical course)
 Possible VaD if brain imaging negative or
relationship (3/12) not clear
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NINDS Neuroimaging Criteria
for VaD
• Topography
•Large vessel strokes
•Extensive white matter change
•Lacunes (frontal/basal ganglia)
•Bilateral thalamic lesions
• Severity
•Large vessel lesion of dominant
hemisphere
•Bilateral strokes
•WML affecting >25% white matter
(Price et al, 2005)
Accuracy of DLB diagnosis
Sensitivity
Specificity
PPV
Mega et al. 1996
0.75
0.79
1.00
Litvan et al. 1998
0.18
0.99
0.75
Holmes et al. 1999
0.22
1.00
1.00
Luis et al. 1999
0.57
0.90
0.91
Lopez et al. 1999
0.00
1.00
0.00
Verghese et al. 1999
0.61
0.84
0.48
Hohl, et al. 2000
0.80
0.80
0.80
McKeith et al. 2000
0.83
0.91
0.96
Lopez et al. 2002
0.23
1.00
1.00
Litvan et al. Mov Disord 2003; 18:467-486
New Criteria for Probable DLB
McKeith et al, Neurology, 2005
• Cognitive decline sufficient to interfere with
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social/occupational function
CORE features (at least one core + one suggestive or 2
core features must be present):
• Fluctuation
• Recurrent visual hallucinations
• Spontaneous parkinsonism
• Suggestive features:
• REM sleep behaviour disorder
• Neuroleptic sensitivity
• Dopaminergic abnormalities in basal ganglia on SPECT/PET
One core or suggestive feature sufficient for Possible DLB
www.nice.org.uk
NICE/SCIE Guidelines
Comprehensive assessment, including:
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history from patient and informant
medication review
mental state exam, including cognitive testing
physical examination
Investigations
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Routine blood screen
HIV/ Syphilis if indicated
MSU if delirium suspected
CXR if indicated
NICE/SCIE Guidelines
Neuroimaging
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Structural imaging should be used to exclude other cerebral
pathologies and to help establish the subtype diagnosis
MRI is preferred modality to assist with early diagnosis and detect
sub-cortical vascular changes, though CT can be used
HMPAO SPECT should be used to help differentiate between AD,
VaD and FTD if the diagnosis is in doubt
FP-CIT SPECT should be used to help establish the diagnosis of
DLB if the diagnosis is in doubt
EEG and CSF measurement should not be used as
routine investigations
NICE/SCIE Guidelines
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A diagnosis of subtype of dementia should be made by
healthcare professionals with expertise in differential
diagnosis using standardised and validated criteria
Newcastle Memory Clinic
• Currently 1-2 days/week
• Staffing:
• Consultant and ST4-6 doctor sessions
• Psychologist and psychology assistant
• Clinic nurse
• OT
• Others as needed (e.g. speech therapy)
• Two stop shop
1. Baseline appointment
• Basic screen (MMSE and routine bloods) before
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referral
First appointment approx 1.5 hours:
• Informant history
• Bristol Activities of Daily Living scale (BADL)
• Informant questionnaire on cognitive decline (IQCODE)
• Patient history
• Mental state
• Hospital anxiety and depression
• Focussed physical exam
• Basic cognitive testing
• Addenbrooke’s Cognitive exam
• Rey Auditory Verbal Learning Test
• National Adult Reading Test (pre-morbid IQ)
Further investigations
• Further history/ information
• Other assessments
• Formal neuropsychological testing
• OT/ SW/ Speech and language
• Neurology/ geriatric medicine
• Investigations
• Neuroimaging (CT, MRI, SPECT)
• Other
• EEG/ ECG
• Other bloods
• Lumbar puncture
2. Review appointment
• 6-8 weeks later
• Case discussed at MDT
• Second appointment lasts 30-45 mins:
• Patient and (usually) carer seen together
• Investigations explained
• Diagnostic disclosure started
• Management plan outlined
• Follow-up arrangements made
Proposed new diagnostic criteria for early AD
Dubois et al, Lancet Neurology, 2007
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Core diagnostic criteria
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Gradual and progressive change in memory function reported
by patients or informants over more than 6 months
Objective evidence of significantly impaired episodic memory
Plus one or more of supportive features
A. Presence of medial temporal lobe atrophy on MR
B. Abnormal CSF biomarkers
C. Bilateral temporal/parietal hypo-metabolism on PET/ SPECT
And other biomarkers as they are validated (e.g. Amyloid imaging)
Potential disease modifying treatments for AD
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Amyloid vaccination approaches
» Active Aß immunization
» Passive Aß immunization
» Aß aggregation inhibitors
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Tau (TauRx, inhibits aggregation)
Metal chelaters
Anti-inflammatories
Statins
Dimebon
Conclusions
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Specialist Memory Clinic/ Memory Assessment and Management
Service (MAMS) has advantages:
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Development of core team with expertise
Structured environment/ protocol for assessment
Facilitates standardisation of approach and multi-team working
Easier access to investigations/ imaging when required
Allows patient and carer to be assessed together
Resource for teaching and research
Focus for patient and carer centred education and training
Hospital based service can have outreach (domiciliary) arm and vice versa
Allows management to follow seamlessly from assessment and diagnosis
A two stop shop is better than a one stop shop
Try to future proof services against (or at least be aware of)
possible future changes in diagnosis and management
THANK YOU
j.t.o’[email protected]