Specialist Memory Assessment Service-LPT Dr. D. White - Consultant Psychiatrist Stuart Kennedy - Memory Service Lead Nurse

Session Aims Update Recognition and screening for possible dementia Accessing specialist memory services Specialist memory assessment service Long term management of patients on anti dementia drugs

Context National and local drivers NDS, NICE, Prime Ministers challenge etc All pointing to- Early referral for specialist assessment, to ensure timely and accurate diagnosis Timely diagnosis facilitates access to medication, information and support services .

Epidemiology and aetiology 700,000 with dementia in UK, predicted to double by 2050. Age related condition with 20% of over 85s affected. Under 65 account for just 2%

Locally 126, 200 people over 65 in Leicestershire County and Rutland with dementia, and 35,600 in Leicester City (projected figures) Predicted to rise to 224,800 by 2025 60% of people in County remain undiagnosed 50% of people in City remain undiagnosed

What would you want if you were diagnosed with dementia? Don’t really know, but probably To be known by the people looking after me To have choice in my care for as long as possible To be sure I had/there was a plan To have the opportunity to enjoy family, friends etc To know that my family are looked after/well supported Information, when I wanted it, suitable to me

What is dementia? “A syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning, capability, language, and judgement. Consciousness is not impaired.” ICD-10

Normal/typical ageing What is not dementia? Normal/typical ageing Slower thinking and problem solving; STM takes longer, reaction time slower Decreased attention and concentration; more distractedness and difficulty learning Slower recall; need more hints

Typical ageing or dementia? Occasionally forgets or searches for words Frequent word-finding pauses, substitutions Remembers recent important events; conversations are not impaired Notable decline in memory of recent events and ability to converse May pause to remember directions but not generally getting lost in familiar places Gets lost in familiar places May complain of poor memory, but able to give good examples of forgetfulness . Patient more concerned than family. May complain of memory loss if asked, unable to give specific examples. Family more concerned than patient. Interpersonal skills ok, managing personal care, affairs etc Loss of interest in social activities, possible decline in functional skills

Types of dementia? 4 main types Alzheimer’s disease (approx 60%) Vascular (30-40%; including approx 20% dual pathology) Dementia with Lewy bodies (15%) Fronto-Temporal Dementia (5%) NB More than 100% due to variability in studies

Classification of Alzheimer’s Disease Based on Mini Mental State Examination (MMSE) Mild - MMSE 21-26 Moderate - MMSE 15-20 Moderately severe - MMSE 10-14 Severe - MMSE less than 10

Is there a common presentation? Unique to individual and underlying cause Most may have some (but not all) Loss of short term memory Word finding difficulty Difficulty with familiar tasks (driving, dressing, cooking, finances) Personality change/uncharacteristic behaviour Confusion, disorientation, poor judgement

Working age dementia Clinically very little difference other than age of onset Prevalence 45-64 year olds =121 per 100,000 with Alzheimer’s disease (26%)* Sufferers more likely to be In work Have dependent children Be physically fit Have financial commitments Have rarer form of dementia *Harvey et al 2003

Also consider Many conditions may present with cognitive impairment – delirium, depression, medical conditions, side effects to medication. Important differential diagnoses are delirium and depression, both treatable, both may co- exist with dementia Chest infections, UTI’s, hypoxia, medications Some symptoms of dementia may not be common/typical – (disinhibition, apathy, judgement, language, loss of learnt skills)

Common differences- 3 D’s Dementia Delirium Depression Onset Insidious Acute Gradual Duration Months/years Hours/days/weeks Weeks/months Course Progressive/stepwise Fluctuates, worse at night Usually worse in mornings Thoughts Reduced interest, perseveration, delusions May be paranoid and grandiose Slowed, preoccupied, sad, hopeless Perception Hallucinations in 30-40% (usually visual) Visual and auditory common Mood congruent auditory Emotion Depression, anxiety, sun downing Anxiety/depression common, fear/agitation Flat, unresponsive, fearful.

What is Mild Cognitive Impairment? Losing or misplacing things Forgetting appointments, conversations, events etc. Unable to retain names of new acquaintances Difficulty following conversations Intact ADL’s Decline over time greater than normal ageing (on cognitive tests) Between 5-20% of older people will have MCI at any time (dependant on definition)

Conversion of MCI to dementia Previously opinion suggested about 10% per annum would develop dementia Probably 10-15% (dependant on definition and cause) Current thinking suggests not just a transitional stage, but some may stay static or even improve

Screening RCGP recommend MMSE, GP-COG, 6CIT or Mini-Cog Copyright issue (MMSE, GP-COG, Mini-Cog?) Locally (see pathway) GP-COG for screening and MMSE for review.

GPCOG 2 components – cognitive assessment and informant questionnaire. Informant questionnaire only needed if cognitive score is score is 5-8 inclusive. Score of 3 or less on informant questionnaire strongly supports cognitive impairment Incorporated into SystmOne as template

Patients with potential dementia- when to refer. Refer to packs Specific functioning problems Cognitive impairment (GPCOG 5-8 patient + 0-3 informant or MMSE <26 with functional decline) Atypical features, carer stress/concern Mood symptoms and need to distinguish from pseudodementia GPCOG 9 or MMSE 26 - 30 but no functional problems or distress monitoring 6 monthly

LEICESTER CITY DEMENTIA CARE ADVISERS Work in Primary and Secondary Care Employed by Leicester City Council from Oct 2011 8 X Dementia Care Advisors. 1Based in SPOC, 2 in the East, 2 in the West and 3 in the South. Provide information, advice, support, signposting assessments, encourage socialisation, carry out carer assessments and support memory cafés Referrals currently come from LPT/CMHT/ Memory Clinic and all referrals have to come through SPOC (tel. 2527004) Referrals will also come from GP practices under the Shared Care Agreement

When referring- STM, and other problems with cognition. LTM, specific examples Duration of problem, how long since recognised Associated symptoms; mood, sleep, personality Vascular risk factors, past medical and psychiatric history Functional abilities and risk assessment. NICE recommends and we require Physical exam Routine bloods (FBC, U&E, LFT, Thyroid function, glucose, calcium, B12, Folate) ECG, to prevent delays in starting medication? Screening GPCOG/MMSE .

Referral letter. Basic data- full name of client, DOB, gender, address, postcode etc Telephone number including where possible that of family member/contact Employment status, ethnic origin, religion Language spoken; is there a need for an interpreter? Narrative of patient presentation. GP COG desirable SystmOne and EMIS referral form

Specialist Memory assessment Pathway Refer to packs Routine referral from GP incl. bloods and ECG Referral triaged and allocated to memory service for assessment Structured assessment Diagnosis and core interventions Initial advice on driving

Clustering Payment by results (PbR) mental health clusters 18 – 21 are organic mental health clusters Cluster 18/19 will follow memory pathway and if eligible for AChEi the shared care protocol Clusters 19, 20, 21 will remain under CMHT if input is required

Coffee Break

Licensed treatments Donepezil (Aricept) Galantamine (Remenyl) 5 and 10 mg (oro-dispersible tablet available) Galantamine (Remenyl) 8mg, 16mg and 24mg capsules (maintenance 16- 24mg). Solution 4mg/ml Rivastigmine (Exelon) 1.5mg, 3mg, 4.5mg, 6mg capsules Oral solution 2mg/ml Transdermal patch 4.6mg and 9.5mg/24hr Memantine (Ebixa) Starter pack titrates up to 20mg OD within 4 weeks. Oral solution 5mg/0.5ml

Donepezil, Galantamine and Rivastigmine. Cholinergic hypothesis of Alzheimer’s disease suggests that a decline in cognitive function is linked to loss of cholinergic transmission in hippocampus and cortex. AChEi’s inhibit the cholinesterase enzyme from breaking down acetylcholine, increasing both the level, and duration of the neurotransmitter acetylcholine. Licensed in mild to moderate Alzheimer’s.

Memantine Acts on Glutamatergic system by blocking NMDA Glutamate receptors. This is thought to be neuro-protective and possibly disease-modifying. Approved for use in moderate to severe Alzheimer’s disease Severe Alzheimer’s - drug of choice Moderate Alzheimer’s - intolerant of, or contra-indication to AChEi’s

Benefits of AChEi Improvement in cognition by an average of 10% Roughly equivalent of 6 months usual decline ADLs and functioning may remain above baseline for 6-12 months for most and up to 2 years for some.

Side effects (AChEi) Usually mild Diarrhoea, muscle cramps, fatigue, nausea, vomiting, insomnia. Headache, pain, common cold, abdominal disturbance, dizziness. Rarely : Syncope, bradycardia, sinoatrial and atrioventricular block.

Use of antipsychotics Concerns around over use and side effects Cerebrovascular adverse effects (atypicals and typicals Behavioural and environmental approach first Multisensory stimulation, bright light therapy, aromatherapy

General guidance Target specific symptoms Start low and titrate up Time limited (review after 3/12 stable) Evidence for risperidone and olanzapine for physical aggression, agitation and psychosis Long term use leads to cognitive decline and falls Discontinue gradually (unless severe side effects) Some people need to stay on them http://www.rcpsych.ac.uk/pdf/bpsd.pdf

GP monitoring For all types of dementia 6 monthly review Functional, behavioural, carer, dementia advisor feedback Driving capability (see packs) Medication concordance, S/E, efficacy Carer strain Behavioural and psychological symptoms of Dementia (BPSD) Dedicated Memory Service Lead Nurse linked to each CCG for liaison/advice

Referral back to CMHT Urgent – goes to CMHT as usual Advice regarding medication – phone memory service nurse or consultant psychiatrist Stuart Kennedy 01530 453800 Dr White (City W) 0116 2252761 Dr Prettyman (City W) 0116 2252752 Dr Hinchliffe (City E) 0116 2255964 Dr Chakrabarti (City E) 0116 2255911 We will see again if significant behavioural and psychological symptoms of dementia (BPSD) or complex needs

Discontinuation of medication NICE recommend that all patients who fall into severe category are “considered” for discontinuation of AChEIs May still be beneficial for Behavioural and Psychological Symptoms of Dementia (BPSD) even if cognition has declined Less cost implication now Consider if experiencing harmful effects or deteriorated to extent of palliative care Discuss with carers

Enhanced Service 2013/14 Facilitates 1st 2 strands of NDS by Encouraging practices to screen populations with suspected dementia, (proposed DES and health checks in GMS contract) Refer more patients appropriately to Memory Assessment Clinic Agreeing to continue monitoring of treatment under Shared Care Agreement Practices will Nominate lead GP Maintain adequate records following read codes in clinical records Subject to approval Draft document

Enhanced service A draft LES for GP shared care has been developed and will be refreshed following agreement of the 2013/14 enhanced services Updates will be communicated through locality meetings, practice manager meetings and newsletters

Vignettes

Vignettes Case 1 73 year old man, brought to see you by wife who has noticed forgetfulness over last 12 months. Asking repetitive questions, can’t remember conversations or appointments. Wife frustrated, patient can’t really see a problem. Able to wash, dress and perform household chores. Driving without any problems. Scores 6/9 on patient GPCOG and 3/6 on informant section.

Vignettes Case 2 67 year old woman who comes to see you very concerned about her memory. Anxious that she is not functioning as well as she used to. Complains of forgetting where she has put things, needing to rely on calendar for appointments. Lives alone, fully independent with activities of daily living. Worried about Alzheimer’s disease. Scores 9/9 on GPCOG

Vignettes Case 3 79 year old woman Initially seen by GP with cognitive impairment Son is main carer Referred to memory clinic Diagnosed with Alzheimer’s disease and commenced on Donepezil After 3 months, has been stable on 10mg Memory clinic write to you asking you to continue prescription under SCA and review in primary care

Vignettes Case 4 89 year old man with diagnosis of vascular dementia for 3 years, on no psychiatric medication Under 6 monthly review Wife phones to say that he has become increasingly agitated now He appears paranoid and suspicious of her She is frightened of him He keeps trying to leave the house and is clearly disorientated in time and place Initial examination reveals no acute cause for deterioration such as UTI

Vignettes Case 5 84 year old woman in residential home 5 year history of Alzheimer’s, on galantamine Now severely cognitively impaired Persistent poor appetite and refusal to eat No obvious physical cause Very frail Family reluctant for her to be admitted or have further physical investigations

Vignettes Case 6 69 year old man diagnosed with Alzheimer’s at memory clinic 9 months ago Driving assessed at memory clinic – DVLA informed of diagnosis, no visuospatial problems Stable on donepezil prescribed by GP Attends for 6 monthly review in primary care Now unable to draw interlocking pentagons Has had some minor scrapes in his car, but feels he is able to drive safely Despite your advice not to, he is adamant that he will continue to drive

Any Questions?