MEMORY PROBLEMS IN PRIMARY CARE Tom Gamble ST1 Small Group 26/5/10

Case Scenario:  Mrs KW is a 58 year old woman who comes to you about her memory. She has noticed that she sometimes forgets what she’s doing around the house (goes upstairs then can’t remember why), and her children say she sometimes repeats herself. Her mother had Alzheimer’s dementia and she is concerned that she might be ‘going the same way’.  You are already running behind in this clinic. Outline how you would approach this consultation in 10 minutes.

Dementia Assessment:  History: collateral history useful.  Always ask about depression/anxiety symptoms  Remember alcohol Hx in elderly  PMHx: Diabetes, hypertension, CVA  Risk factors: Age, learning disability, gender, genetic, alcohol, smoking, obesity, hypertension, hypercholestrolaemia, head injury, low IQ.  Screening tests: Mini-mental state examination /10 (AMTS) and /30 (MMSE); 6 item cognitive impairment test (6 CIT); GP Assessment of Cognition Score (GPCOG)

Dementia Investigations:  Aimed at detecting treatable causes:  FBC/U&E  Blood glucose;TFTs;LFTs  B12/folate levels  Lipid profile  (Syphillis/HIV serology)  Consider MSU/CXR  +/- CT head

Dementia types:  Alzheimer’s Disease (60%): insidious onset, slow progressive decline  Vascular Dementia (15-20%): more sudden onset, classically step wise decline(but difficult to observe this)  Mixed dementia: increasingly recognised, subsection of both above categories.  Dementia in Parkinson’s disease: 20-60% of people with the Parkinson’s affected: memory, mood and executive functioning affected.  Lewy Body Dementia: Characteristics of Alzheimers/Parkinson’s but characterised by visual hallucinations, fluctuating alertness and sleep problems  Others: Picks disease (frontal symptoms); normal pressure hydrocephalus (wide based gait); Huntingtons disease; HIV.

Management:  Refer to memory clinic for definitive diagnosis & initiation management  Encourage cognitive stimulation: groups, active cognitive activity (not TV!)  Pharmacological treatment: cognitive enhancers licenced in moderate Alzheimer’s dementia (MMSE or on clinical assessment). Initiated in secondary care, and should be assessed 6 monthly  Treat comorbid disorders: depression/anxiety (remember CBT, exercise, animal therapy)

Other Issues:  Lasting power of attorney (replaced enduring power of attorney 2007): 2 versions, LPA Property and Financial Affairs; LPA Health and Welfare  LPA Health and Welfare: One or more people can make decisions on applicant’s behalf when applicant no longer has capacity  Includes decisions regarding medical treatment, home circumstances/residential care, social service input  A GP may be asked to be a ‘certificate provider’ – confirm that the applicant understands the implications of LPA and isn’t under undue pressure  LPA must be registered with Office of the Public Guardian

Other Issues 2:  Living Will: Applicant specifies in advance what circumstances they don’t wish to receive specified treatments.  Differs from LPA in that it refuses treatment, whereas LPA HW gives attorney power to consent to or refuse treatment.