Dementia Dr Deborah Stinson Sutton CMHT for Older People South West London & St George’s Mental Health NHS Trust

Dementia(s): Generic term “Chronic, progressive dysfunction of brain function leading to complex cognitive decline” Cognitive changes often with disturbances of mood, behaviour, personality Primary vs secondary dementias

Epidemiology: Prevalence 1.5% at 65 yrs 30% at 80 yrs Incidence lower in men, & Asian or African origin SDAT more common than VaD Average survival = 8 yrs from diagnosis Women survive longer than men

Confirmed risk factors for AD: Age Family history E4 alleles of ApoE gene

Factors which modify risk: Female sex History of head injury Diabetes Raised cholesterol Smoking Mid-life hypertension Low educational & occupational attainment Low mental activity in early life Reduced mental & physical activity in late life

Protective effects?? High education Dietary intake of antioxidants Unsaturated fatty acids Moderate alcohol intake (wine) But not conclusive evidence…..

Risk factors for VaD: Age Male sex Hypertension CHD Diabetes Smoking Raised cholesterol

Pathology of AD: Cholinergic hypothesis Plaques – abnormal amyloid (A β) Tangles – abnormal tau protein

Dementia with Lewy Bodies Fronto-temporal Dementia with Lewy Bodies Fronto-temporal & Parkinson’s Disease: dementia: Intraneuronal inclusion bodies Aggregation tau protein

Genetic testing: Late onset more complicated No clinical use for genetic testing in late-onset Alzheimer’s Disease

Investigations: Routine blood tests Selected neuro-imaging (CT/MRI) Brief cognitive testing (MMSE; ACE) Corroborative history For future – biochemical changes → screening tests?

Cholinesterase inhibitors: Donepezil; galantamine; rivastigmine Licensed to treat mild-moderate AD Modest efficacy; at all stages of disease Reduction 1.4 points MMSE 1/3-1/7 will have improvement/delay in decline Mitigate symptoms; do not change natural history Evidence useful in DLB (& PD) NICE guidance; shared prescribing protocols

Memantine: Effect on glutaminergic system Useful moderate - severe AD Modest effect on cognition & behavioural symptoms Has been used in combination with donepezil Not approved by NICE

Behavioural & psychiatric symptoms in dementia (BPSD): Affective – depression, anxiety, euphoria Personality changes Behavioural difficulties – agitation, apathy, irritability, disinhibition, wandering etc. Hallucinations (visual most common) Delusions & misidentification syndromes Eating disorders

BPSD: Occur in up to 90% at some stage A major cause of stress in carers A common reason for residential/nursing home placement Difficult to treat

Drug treatment of BPSD: Traditional antipsychotic drugs – but ↑ mortality Atypicals – best evidence, fewer EPSE, but ↑risk of strokes Anti-convulsants (e.g. sodium valproate) Cholinesterase inhibitors Memantine Short-acting benzodiazepines SSRI antidepressants

Non-drug treatment of BPSD: Review current drug regime; physical health? Environmental factors? Psychological & behavioural approaches Carer training Aromatherapy Bright light therapy

Depression in dementia: Occurs in 40-50% Treatment with antidepressant drugs (SSRIs preferred) Avoid drugs with anti-cholinergic effect Eliminate physical cause Carer training/support

Carers’ needs: High rates of physical & mental problems in carers High rates of abuse (both of & by patients) Institutionalisation can cause other problems – e.g. guilt, depression, financial Aggression & incontinence are main determinants of institutionalisation – ideally plan(??) Carer’s assessment (Social Services) Support from Alzheimer’s Society, Carers’ Centre, MIND etc.

Other matters to consider: Driving Ability to manage affairs – Lasting power of attorney, Court of Protection Mental Capacity Act (from April 2007) Attendance allowance Assistive technology

NICE guidelines on dementia: Cover health & social care More emphasis on psychological mgt. Restrict use of cholinesterase inhibitors to moderately severe Alzheimer’s Disease

Local services: Older People’s NSF – local implementation team Dementia care pathway (PCT lead agency) Shared prescribing protocol(s) Primary Care Voluntary sector Social Services Secondary care – integrated CMHT; acute trusts Residential & nursing home care

Case histories? Questions?