DEMENTIA 1/6/16 DR TONY O’BRIEN MD FRCP

Dementia Common – 700,000 sufferers in the UK Common – 700,000 sufferers in the UK Prevalence increases with age Prevalence increases with age Age years years years 80+ Prevalence 1 in in 50 1 in 20 1 in 5

Dementia Chronic disorder affecting higher cortical functions, including memory, reasoning, orientation, and communication skills Chronic disorder affecting higher cortical functions, including memory, reasoning, orientation, and communication skills Gradual loss of skills needed to carry out daily activities Gradual loss of skills needed to carry out daily activities Progressive Progressive Dementia UK Report 2007

Dementia Deficits in Memory and Functional abilities, plus two more categories Memory Memory Functional abilities Functional abilities Language Language Perceptual skills Perceptual skills Attention Attention Constructive abilities Constructive abilities Orientation Orientation Problem solving Problem solving

Not all about memory 1. Age associated memory impairment Mild cognitive impairment Dementia

Dementia Diagnosis Neuropsychological assessments – e.g. MMSE, ADAS-cog Neuropsychological assessments – e.g. MMSE, ADAS-cog Clinical examination Clinical examination Collateral history Collateral history Brain scan Brain scan Blood tests Blood tests

Distribution pathology in typical AD (Braak and Braak 1991)

Focal dementia YOU DO NOT NEED IMAGING TO DISTINGUISH THESE CONDITIONS PATIENT 1 ALZHEIMER’S PATHOLOGY: HIPPOCAMPUS → memory sx PATIENT 3 ALZHEIMERS OR FTD PATHOLOGY: LEFT POSTERIOR SUPERIOR TEMPORAL LOBE → non-fluent aphasia PATIENT 4 FTD PATHOLOGY: LEFT LATERAL TEMPORAL LOBE → fluent aphasia L R PATIENT 2 ALZHEIMER’S PATHOLOGY: PARIETAL LOBE → spatial sx

Dementia Alzheimer’s Disease Alzheimer’s Disease Vascular Dementia Vascular Dementia Dementia with Lewy Bodies Dementia with Lewy Bodies Frontotemporal lobe dementias Frontotemporal lobe dementias Others 55 % 20 % 15 % 5 %

Alzheimer’s Slow insidious onset Slow insidious onset Progressive decline Progressive decline Early changes in personality – ‘depression’, agitation Early changes in personality – ‘depression’, agitation Positive family history Positive family history

Alzheimer’s - Pathology Loss of cholinergic neurones Loss of cholinergic neurones Amyloid plaques Amyloid plaques Neurofibrillary tangles of Tau proteins Neurofibrillary tangles of Tau proteins

Vascular Dementia Often abrupt onset Often abrupt onset Step-wise progression Step-wise progression Focal neurological signs or symptoms Focal neurological signs or symptoms Evidence of cerebrovascular disease on brain scan Evidence of cerebrovascular disease on brain scan Emotional lability Emotional lability Early presence of gait disturbance Early presence of gait disturbance

Dementia with Lewy Bodies (DLB) Sits somewhere between Alzheimer’s and Parkinson’s Sits somewhere between Alzheimer’s and Parkinson’s 2 out of 3 of 2 out of 3 of Spontaneous features of Parkinsonism Spontaneous features of Parkinsonism Visual hallucinations Visual hallucinations Fluctuating course Fluctuating course Supporting features Supporting features Recurrent falls / syncope Recurrent falls / syncope Neuroleptic sensitivity - 70 % patients affected Neuroleptic sensitivity - 70 % patients affected Systematized delusions Systematized delusions

Treatment of Dementia Education, support and signposting to services Disease modifying Symptomatic Drugs for behavioural disturbance

Dementia Treatment - Symptomatic Effects vs Slowing Disease Impairment Treatment Period EndBaseline Severe Mild Placebo Symptomatic Disease modifying (Ferris, 8/03)

Alzheimer’s Disease Cholinesterase inhibitors Donepezil, Rivastigmine, Galantamine Glutamate receptor antagonist Memantine

Vascular Dementia Secondary prevention for stroke - Disease Modifying Secondary prevention for stroke - Disease Modifying Antiplatelet therapy or anticoagulation if AF Antiplatelet therapy or anticoagulation if AF Statin Statin Perindopril +/- Indapamide Perindopril +/- Indapamide Promote healthy lifestyle with regard to diet, exercise, good diabetic control, smoking cessation, etc. Promote healthy lifestyle with regard to diet, exercise, good diabetic control, smoking cessation, etc.

Case Study Arthur has recently attended the memory clinic at the hospital and has been diagnosed with dementia of the ‘mixed type’. Arthur has a mini-mental state examination (MMSE) of 23. He has a background history of hypertension and has fallen twice in the last year. Amitryptiline 50 mg nocte, Simvastatin 20 mg nocte, Zopiclone 7.5 mg nocte, Bendroflumethiazide 2.5 mg od, Aspirin 75 mg od Suggest some possible options for management.

The Future Alzheimer’s: drugs spontaneous to disease-modifying..multidrug Vascular: earlier recognition and aggressive treatment Parkinsons: disease modifying drugs: single drug Legal situation: living will, Preferred priority care / living Societal moral legal debate for treatment of advanced dementia Ageism

Acknowledgements Dr John Whitear Geriatrician Dr Lucy Coward Neurologist S/N Christine Timms S/N Jackie Smith