1. Dementia Dr Chandra Prajapati FRCP, FRCPI Consultant Physician

2. Dementia a serious loss of global cognitive function in a previously unimpaired person, beyond what might be expected from normal ageing

3. Delirium 1.Acute onset and fluctuating course 2.Inattention –Difficulty focussing attention –Easily distractible 3.Disorganised thinking –Disorganised / incoherent / unclear / unpredictable switching 4.Altered level of consciousness –Vigilant /hyperactive –Drowsy→ comatose /hypoactive

4. Delirium vs. Dementia Delirium or acute confusional state, is a syndrome presenting as severe confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity. –Reversible –May last up to six months Dementia is a non-specific syndrome affecting memory, attention, language and problem solving lasting more than six months –Later complicated by orientation and behaviour problems –10% may have reversible cause

5. Dementia Currently 35.6 million sufferer worldwide Number likely to increase > 60 million by 2030 In UK –Currently 800,000 –By 2021 10,00,000 –By 2051 17,00,000 SASH area –Current number is as high as would be expected by 2051 in other areas

6. Dementia Dementia care cost worldwide = IHD+DM+cancer care Dementia care in 2010 @ 604 Billion USD 1% of world GDP If dementia care were a country, it would be 18 th largest economy in the world

7. CAIDE dementia risk score

8. CAIDE Dementia score Likelihoods of Dementia risk in 20 years ScoreRisk 0-5 1% 6-71.9% 8-94.2% 10-117.4% 12-1516.4% When the cut-off was set at 9 points or more, the sensitivity was 0.77, the specificity was 0.63, and the negative predictive value was 0.98

9. Dementia types Alzheimer Vascular Lewy Body dementia Fronto-temporal dementia Cortico-basal degeneration –PD –Alien Hand syndrome –Apraxia –Aphasia

10. Type of dementia Fixed memory loss –Traumatic brain injury –Hypoxic-ischaemic brain injury –Alcohol –Infections i.e encephalitis Slowly progressive –Alzheimer –Vascular dementia –Post infections Rapidly Progressive –CJD –Others: Alzheimer, LBD, FTD, CBD, PSP

11. Dementia in younger age group Uncommon under 65 –Consider Alzheimer –Familial causes i.e. FTD, Huntington’s disease –Frequent head trauma i.e. boxers ( dementia pugilistica) and footballers –Vascular antiphospholipid syndrome CADASIL(cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) MELAS (mitochondrial encephalopathy, lactic acidosis and stroke like symptoms) Homocysinuria Binswanger disease ( sub cortical white matter atrophy due to small vessel disease)

12. Dementia in younger age group Rare under 40 –Consider familial Alzheimer –Drugs –Alcohol –Metabolic disorders –Infections i.e HIV, Cryptococcal infection, syphilis, Lymes diasease etc

13. Assessment Specialist assessment –AMTS –MMSE –Clock draw test –Trail making test Exclude other causes i.e. depression, anxiety Consider carer views; DO NOT SOLELY RELY ON ASSESSMENT

14. Diagnostic tests Bloods –FBC, Electrolytes and calcium, Glucose, B12,Folate, TFTs, TPHA Radiology –CT/MRI –Functional Neuroimaging i.e. SPECT or PET Brain Biopsy!

15. MRI Alzheimer vs Control

16. MRI in Alzheimer

17. SPECT Perfusion SPECT scan showing evidence of biparietal and bitemporal hyperperfusion in a) an Alzheimer's disease case compared to b) a control subject.

18. MRI in Dementia

19. Progression of MTA in Alzheimer

20. MRI – Vascular Dementia

21. MRI Vascular dementia

22. DaT in LBD

23. Management 10% may have reversible cause – Treat the cause i.e. B12, Folate, Levothyroxine Remaining – NO CURE Pharmacological –Acetylcholine esterase inhibitor Donepezil (Aricept) Galantamine (Reminyl) Rivastigmine (Exelon) –NMDA (N-Methyl-D-Aspartate) receptor blocker Memantine (Ebixa)

24. Management Symptom management AVOID ANTIPSYCHOTICS Carer Support –Consider carer’s views Dementia support/crisis team Specialist care at home or in care homes Severe dementia – Holistic care, advance care planning, Palliative care

25. Barrier to dementia care ↓ Inactivity in seeking + Offering help Stigmata of Dementia False belief Nothing Available False belief Nothing can be done

26. Thank you