Management of Early Dementia Dr Eleanor Mullan Consultant Psychiatrist Mental Health Services for Older People South Lee, Cork Feb 2011

Statistics Population of SHB - 550,000 Population of SHB - 550,000 12% over 65 years 12% over 65 years 1% over 85 years 1% over 85 years Highest rise in very elderly (over 85 years) Highest rise in very elderly (over 85 years) Female:male = 4:1 Female:male = 4:1 32% over 70 years live alone 32% over 70 years live alone Life Expectancy Life Expectancy  Male 78.9 (EU 80)  Female 82.4 (83.8)

Major Causes of Dementia Alzheimers Disease Alzheimers Disease Vascular Dementia Vascular Dementia Dementia Lewy Body type Dementia Lewy Body type  up to 20% of dementias Alcohol Dementia3-10% Alcohol Dementia3-10% Frontotemporal Dementia Frontotemporal Dementia Primary Progressive Aphasia Primary Progressive Aphasia Age-associated Memory impairment - AAMI Age-associated Memory impairment - AAMI

Prevalence of Alzheimers Disease  Age rangeADVaD years0.13%0.10% years0.13%0.10% years0.34%0.3% years0.34%0.3% years3.2%0.7% years3.2%0.7% years10.08%2.5% years10.08%2.5% years12.6%4.2% years12.6%4.2%

Definition of Dementia Brain Disease Brain Disease Chronic Chronic Progressive Progressive Global Global Irreversible Irreversible

Symptoms of Dementia Cognitive Impairment Cognitive Impairment  Orientation  Language  Literacy  praxic skills  memory  perceptual skills

Symptoms of Dementia - 2 Personality Change Personality Change Delusions Delusions Hallucinations Hallucinations Mood and Affect disorder Mood and Affect disorder Neurovegetative symptoms Neurovegetative symptoms Behavioural Problems Behavioural Problems

Assessment History History  Course, onset, presentation  Family history, drug and alcohol history  Medical history  Collateral Clinical Examination Clinical Examination Psychiatric Examination Psychiatric Examination  Depression! Neuropsychological Examination Neuropsychological Examination

Assessment - 2 Blood Tests Blood Tests  FBC, ESR, U+E, LFT, Ca, Phosphate  TFT, Syphilis serology, B12  Autoantibody screen  C-reactive protein  Heavy metal screen, copper  HIV  Drug screen

Assessment - 3 ECG, CXR ECG, CXR CT Scan CT Scan MRI MRI EEG EEG

Alzheimers Disease Neuropathological diagnosis Neuropathological diagnosis  neurofibrillary tangles, senile plaques  cerebrovascular disease is common in elderly and can be present with AD Presentation Presentation  memory problems for recent events, insidious onset  Cognitive deficits with social impairment Investigations Investigations  Blood tests normal  Imaging can be normal in the early stages  ?Vascular risk factors

Vascular Dementia Neuropathology Neuropathology  ischaemic and haemorrhagic brain lesions Presentation Presentation  unclear temporal relationship between vascular events and onset of dementia Investigations Investigations  vascular risk factors, neurological signs

Cortical Lewy Body Dementia Neuropathological Neuropathological  lewy bodies in cortical neurones  Senile plaques are common, rarely NFT Presentation Presentation  attention deficits, fluctuation of function  Parkinsonism, falls, transient disturbance of conscious  Neuroleptic sensitivity  visual hallucinations, delusions, disturbed sleep Investigations Investigations  can be normal  distinguishing clinical course

Alcohol-Related Dementia Neuropathological Neuropathological Presentation Presentation  History of abuse  Frontal lobe signs!  Wernicke-Korsakoff (thiamine def), peripheral neuropathy, stigma of liver disease Investigations Investigations  imaging - cortical atrophy in 50-70%  ?reversible

General Management History, Examination, Investigations History, Examination, Investigations Clear Diagnosis – distinguish from delirium + pseudodemntia Clear Diagnosis – distinguish from delirium + pseudodemntia AAMI AAMI Other medical specialities - neurology, geriatrician Other medical specialities - neurology, geriatrician Information in stages Information in stages Carer support Carer support

General Management - 2 Informing the patient Informing the patient Consent to treatment Consent to treatment Driving, collateral, Driving, collateral,  visuospatial, dyspraxia, frontal lobe signs Testimentary capacity Testimentary capacity Power of attorney Power of attorney Available services Available services Carer support Carer support

General Management - 3 Psychology Psychology Social Care Social Care Medication Medication Self-help groups Self-help groups Voluntary Groups - ASI Voluntary Groups - ASI Carer support groups - respite, education, training, information Carer support groups - respite, education, training, information

Management of Alzheimers Disease - 1 Symptomatic treatment - cholinesterase inhibitors Symptomatic treatment - cholinesterase inhibitors Donepezil, Rivastigmine, Galantimine Donepezil, Rivastigmine, Galantimine Memantine, N-methyl-D-aspartate blocker -increase glutamate Memantine, N-methyl-D-aspartate blocker -increase glutamate Modest benefits - memory, QOL, behaviour Modest benefits - memory, QOL, behaviour Benefit = 3-6 month delay/remission of symptoms Benefit = 3-6 month delay/remission of symptoms 15-20% dramatic improvements 15-20% dramatic improvements Delay in symptomatic decline Delay in symptomatic decline Evidence for benefit of early treatment? Evidence for benefit of early treatment? Behavioural problems associated with dementia Behavioural problems associated with dementia Cost Cost

Management of Alzheimers Disease - 2 Patient Selection and suitability Patient Selection and suitability  diagnosis of dementia  mild to moderate dementia - MMSE 10-26/30  relatively independent? - nursing home residents  Compliance assured  ability to give informed consent  discuss criteria for discontinuation  Absence of medical contra-indications  ?Use in vascular dementia - controversial, no licence

Management of Alzheimers Disease - 3 Contra-indications - no serious issues Contra-indications - no serious issues  Heart block, bradycardia<50/min  Active peptic ulceration  Severe asthma Side-effects of cholinesterase inhibitors Side-effects of cholinesterase inhibitors  GIT - appetite loss, nausea, vomiting, diarrhoea

Management of Alzheimers Disease - 6 Treatment Discontinuation Treatment Discontinuation  discussion at commencement of treatment  Absence of clinically significant benefit after 6- 8/12  Drug holiday if in doubt?  Poor compliance  poor tolerability  side-effects

Management of Alzheimers Disease – 7 – Treatment options which have not been proven by DB/RCT Anti-inflammatory Anti-inflammatory Prednisolone Prednisolone HRT HRT Vitamin E (2000IU) Vitamin E (2000IU) Gingko biloba Gingko biloba

Management of Vascular Dementia Underlying vascular disease Underlying vascular disease Risk factors Risk factors  Cardiac assessment  Carotid disease  Cerebral embolic disease  Hypertension  Blood cholesterol  Diabetes  Smoking  Hypothyroidism

Management of Lewy Body Dementia Clear diagnosis to all health professionals Clear diagnosis to all health professionals Avoid neuroleptics - increase mortality? Avoid neuroleptics - increase mortality? Cholinesterase Inhibitors Cholinesterase Inhibitors L-dopa for PD! L-dopa for PD!

Management - alcohol dementia Abstain from alcohol Abstain from alcohol  halt progression, ?reverse

General Management - 2 Informing the patient Informing the patient Consent to treatment Consent to treatment Driving, collateral, Driving, collateral,  visuospatial, dyspraxia, frontal lobe signs Testimentary capacity Testimentary capacity Power of attorney Power of attorney Available services Available services Carer support Carer support

General Management - 3 Psychology Psychology Social Care Social Care Medication Medication Self-help groups Self-help groups Voluntary Groups - ASI Voluntary Groups - ASI Carer support groups - respite, education, training, information Carer support groups - respite, education, training, information