The diagnosis of dementia - 1 Dr Johan Schoeman Consultant in Old Age Psychiatry SEPT in Luton and Bedfordshire 2 nd November 2010

Overview NICE Guidance Diagnosis in Memory Assessment Service

NICE Guidance NICE HTA 111 – Prescription of Donepezil, Galantamine and Rivastigmine for Moderate Dementia of Alzheimer’s disease ‘Only specialists in the care of patients with dementia (that is, psychiatrists including those specialising in learning disability, neurologists, and physicians specialising in the care of the elderly) should initiate treatment’

NICE Guidance Base prescription for Dementia of Alzheimer’s disease on: - Global impression - Activities of daily living - Behaviour - Cognition

Diagnosis in MAS 1. ‘The story’ of forgetfulness 2.Cognitive testing 3.Medical and Psychiatric History 4.Exclusion of Depression and Delirium 5.Radio-imaging

1. ‘The story of forgetfulness Patient’s opinion: - ‘I have a very good memory’ - ‘It is no worse than another person of my age’ - ‘Now that is a problem. It is terrible’ Collateral Informant: - When was problem first noticed - Onset: sudden/gradual - Recently become worse - What is worst aspect of forgetfulness - What is worst behaviour related to forgetfulness

Information gathered Becoming lost in familiar surroundings Losing things more often than before Becoming quieter in company Forgetting names of loved ones Talking more about past than present Repeating same questions over again Forgetting conversations

Information gathered Not remembering new information Difficulty finding right word Losing interest in enjoyable activities Short term memory difficulties Loss of orientation: time→place→person Difficulty in checking change Decreased interest in personal care

Activities of daily living Bathing, Grooming, Dressing Snack and hot drink preparation Meal preparation Medication concordance Household appliances Managing finances Shopping Driving AMPS – Assessment of Motor and Process Skills 1 1 Fisher 2003

AMPS Observational assessment measuring quality of person’s ADL Rates – effort, efficacy, safety, independence - 16 motor and 20 process skill items - > 100 standardised ADL tasks For example: Actions carried out to make jam sandwich -

AMPS (a) walk to cupboard (b) find and select correct bread (search/choose) (c) reach for, grasp (grip), and lift bag of bread (d) transport the bread to workspace (f) effectively hold, open bread by removing twist tie (handle, manipulate) (g) initiate next step of putting jam on bread (h) spread jam with appropriate amount of force so that bread does not tear or crush (calibrate) (j) use a knife (not spoon) to cut sandwich and (k) clean up workspace (restore)

BPSD Behavioural and Psychological symptoms of dementia BEHAVE-AD 1 : - Delusions - Hallucinations - Activity disturbance - Aggression - Diurnal variation - Mood - Anxieties

Paranoid and delusional ideation ‘Others are stealing things’ ‘Residence is not home’ ‘Spouse is an imposter’ Delusion of abandonment Delusion of infidelity Suspiciousness Hallucinations Visual hallucinations Auditory hallucinations Olfactory hallucinations Tactile hallucinations Activity disturbances Wandering Purposeless activity Inappropriate activity BEHAVE-AD

Aggressiveness Verbal outburst Physical threats and/or violence Agitation other than above Diurnal rhythm disturbances Day/night disturbances Affective disturbances Tearfulness Depressed mood Anxieties and phobias Anxiety about upcoming events Fear of being alone BEHAVE-AD

Questions and Discussion