Caring for People with Dementia in Primary Care: Diagnosis and Management Ngaire Kerse, John Scott, Michal Boyd

Mary, continued... Dear Dr Thanks for seeing Mary, an elderly woman with mild Alzheimer's disease. Her family recently asked for advice about drugs for dementia, and also are concerned about her safety in light of an episode when she went driving one night and couldn’t find her way to her daughter’s house, although its nearby and she’s been there many times before. Should she be driving? Should we consider drug treatment? Many thanks Dr X Local GP practice

When to refer? Depends on local resources Differing models of care Differing strengths and weaknesses in both primary and secondary care locally/ generally Waitemata Model/ Counties Model When you need to!

Secondary Care Contribution? Diagnosis Drugs EPOA Residential Care BPSD

Diagnosis “typical” Alzheimer's disease – Steady progression over months, 1-2 years – Absence of “psychiatric” features – Medically “well”, no slowing/ parkinsonism/ gait abnormalities – Memory affected at first, then other domains – Social graces often preserved – Mostly manageable in primary care e.g CDHB health pathways

Specialist Diagnosis Subtyping/ management Rare syndromes diagnosis Red flag symptoms (early hallucinations, falls, severe fluctuations, Suspected physical illness/ medication contribution

Drugs No major breakthroughs on the horizon – Good evidence of no effect from statins/ NSAIDs Current drugs: – Modest effectiveness (≈ 1-2 MMSE points, several months “back”, mild global improvements) – 30% in trials dropped out (GI s/e) – ECG before prescription – Discuss always, offer often, prescribe sometimes, continue occasionally, stop ??

Changes in ADAS-Cog (70 point scale)

Drugs DonepezilAricept, Donepezil-Rex Tablet, daily Early to moderate disease. Generic donepezil subsidised. Evidence of deterioration after cessation. No evidence one drug better than another. RivastigmineExelon Patch, Tablet bd GlantamineReminyl CR Tablet, daily

What to tell patients/ families Cholinesterase inhibitors are a temporary remedy. They may hold the progression of AD for 6 months They don’t work for everyone, and there’s no way to know if they will help except trialling them A significant proportion of people don’t tolerate them They don’t doesn't halt the underlying disease They may work better in people with hallucinations / fluctuations suggesting LB disease They don’t work as well for vascular dementia If you miss the drug for more than a few days, you have to go back to the beginning They need to be stopped if they don’t work

EPOA One of the key reasons for early diagnosis Often people are referred for competency assessments when they are too severely affected to assign an EPOA. Everyone needs an EPOA!

Driving A vexed issue. Driving deteriorates with dementia progression, but when is the right time to stop? Classic conflict of personal autonomy vs public safety ½ - ¾ of those with mild dementia can pass a driving test and are probably safe to drive (JAGS 2005, 53, p94) But which ¼ are unsafe?

Clues someone may be unsafe Not useful: – Self rating – MMSE Useful: – Family/ spouse reports esp. if they have driven with the person – Previous accident – Severity of dementia correlates with risk – Self restriction of driving No good office test will tell you if someone is safe to drive! LTSA guidance not helpful If concerns and person unwilling to cease driving, ORDT with OT is needed

Mary, continued... Dear Dr Thanks for seeing Mary, an elderly woman with mild Alzheimer's disease. Her family recently asked for advice about drugs for dementia, and also are concerned about her safety in light of an episode when she went driving one night and couldn’t find her way to her daughter’s house, although its nearby and she’s been there many times before. Should she be driving? Should we consider drug treatment? Many thanks Dr X Local GP practice

Dementia Services What are your biggest concerns? What are the biggest gaps locally in your area?