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

2. 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

3. 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

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

5. 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

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

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

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

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

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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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.

20. 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

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

22. 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

23. Case histories? Questions?