dr. s. hamer- consultant psychiatrist caroline molloy- memory service lead nurse dementia training...
TRANSCRIPT
Dr. S. Hamer- Consultant Psychiatrist
Caroline Molloy- Memory Service Lead Nurse
Dementia training for GPs
January 2013
Update◦ Recognition and screening for possible dementia◦ Psychosocial support in primary care◦ Referring to specialist memory services◦ Specialist memory assessment service◦ Long term management of patients on anti
dementia drugs
Session Aims
• National and local drivers
• NDS, NICE, Prime Ministers challenge etc• All pointing to-
• Early referral for specialist assessment, to ensure timely and accurate diagnosis
• Timely diagnosis facilitates access to medication, information and support services
Context
• 700,000 with dementia in UK, predicted to double by 2050.
• Age related condition with 20% of over 85s affected.
• Under 65 account for just 2%
Epidemiology and aetiology
126, 200 people over 65 in Leicestershire County and Rutland with dementia.
Predicted to rise to 224,800 by 2025 (County and City)
Locally
Don’t really know, but probably◦ To be known by the people looking after me◦ To have choice in my care for as long as possible◦ To be sure I had/there was a plan◦ To have the opportunity to enjoy family, friends
etc◦ To know that my family are looked after/well
supported◦ Information, when I wanted it, suitable to me
What would you want if you were diagnosed with dementia?
“A syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning, capability, language, and judgement. Consciousness is not impaired.”
ICD-10
What is dementia?
Normal/typical ageing
Slower thinking and problem solving; STM takes longer, reaction time slower
Decreased attention and concentration; more distractedness and difficulty learning
Slower recall; need more hints
What is not dementia?
Typical ageing DementiaOccasionally forgets or searches for words
Frequent word-finding pauses, substitutions
Remembers recent important events; conversations are not impaired
Notable decline in memory of recent events and ability to converse
May pause to remember directions but not generally getting lost in familiar places
Gets lost in familiar places
May complain of poor memory, but able to give good examples of forgetfulness .Patient more concerned than family.
May complain of memory loss if asked, unable to give specific examples. Family more concerned than patient.
Interpersonal skills ok, managing personal care, affairs etc
Loss of interest in social activities, possible decline in functional skills
Typical ageing or dementia?
4 main types◦ Alzheimer’s disease (approx 60%)◦ Vascular (30-40%; including approx 20% dual
pathology)◦ Dementia with Lewy bodies (15%)◦ FTD (5%)
◦ NB More than 100% due to variability in studies
Types of dementia
Unique to individual and underlying cause Most may have some (but not all)
◦ Loss of short term memory◦ Word finding difficulty◦ Difficulty with familiar tasks (driving, dressing,
cooking, finances)◦ Personality change/uncharacteristic behaviour◦ Confusion, disorientation, poor judgement
Is there a common presentation?
Clinically very little difference other than age of onset
Prevalence 45-64 year olds =121 per 100,000 with Alzheimer’s disease (26%)*
Sufferers more likely to be◦ In work◦ Have dependent children◦ Be physically fit◦ Have financial commitments◦ Have rarer form of dementia
*Harvey et al 2003
Working age dementia
Many conditions may present with cognitive impairment – delirium, depression, medical conditions, side effects to medication.
Important differential diagnoses are delirium and depression, both treatable, both may co-exist with dementia
Chest infections, UTI’s, hypoxia, medications Some symptoms of dementia may not be
common/typical – (disinhibition, apathy, judgement, language, loss of learnt skills)
Also consider
Dementia Delirium Depression
Onset Insidious Acute Gradual
Duration Months/years Hours/days/weeks Weeks/months
Course Progressive/stepwise Fluctuates, worse at night
Usually worse in mornings
Thoughts Reduced interest, perseveration, delusions
May be paranoid and grandiose
Slowed, preoccupied, sad, hopeless
Perception
Hallucinations in 30-40% (usually visual)
Visual and auditory common
Mood congruent auditory
Emotion Depression, anxiety, sun downing
Anxiety/depression common, fear/agitation
Flat, unresponsive, fearful.
Common differences- 3 D’s
Losing or misplacing things Forgetting appointments, conversations,
events etc. Unable to retain names of new acquaintances Difficulty following conversations Intact ADL’s Decline over time greater than normal ageing
(on cognitive tests) Between 5-20% of older people will have MCI
at any time (dependant on definition)
What is Mild Cognitive Impairment?
Previously opinion suggested about 10% per annum would develop dementia
Probably 10-15% (dependant on definition and cause)
Current thinking suggests not just a transitional stage, but some may stay static or even improve
Conversion of MCI to dementia
RCGP recommend MMSE, GP-COG, 6CIT or Mini-Cog
Copyright issue with MMSE Locally (see pathway) GP-COG for screening
and MMSE for review (waiting for DoH guidance on this)
Screening
2 components – cognitive assessment and informant questionnaire.
Informant questionnaire only needed if cognitive score is score is 5-8 inclusive.
Score of 3 or less on informant questionnaire strongly supports cognitive impairment
◦ Available on EMIS/SystmOne
GPCOG
◦ Specific functioning problems◦ Cognitive impairment (GPCOG 5-8 patient + 0-3
informant or MMSE <26 with functional decline)◦ Atypical features, carer stress/concern◦ Mood symptoms and need to distinguish from
pseudodementia◦ Offer referral to Memory Adviser at this point
◦ GPCOG 9 or MMSE 26 - 30 but no functional problems or distress monitoring 6 monthly
Patients with potential dementia- when to refer.
For support of patients with memory problems in primary care
Contract awarded to Alzheimer’s Society October 2012
7 Memory Advisers (+ Manager) ensuring equitable cover of all geographic areas across the county
Provide information, advice, support and planning Can help practices to populate registers Referrals from GP practices and/or memory clinic
◦ NB Voluntary Service Organisers (Age UK) currently support CMHT’s/memory clinics following diagnosis.
LEICESTERSHIRE COUNTY AND RUTLANDMEMORY ADVISER SERVICE
◦ STM, and other problems with cognition. LTM, specific examples
◦ Duration of problem, how long since recognised◦ Associated symptoms; mood, sleep, personality◦ Vascular risk factors, past medical and psychiatric
history◦ Functional abilities and risk assessment◦ NICE recommends and we require:◦ Physical exam◦ Routine bloods (FBC, U&E, LFT, Thyroid function,
glucose, calcium, B12, Folate)◦ ECG, to prevent delays in starting medication◦ Screening GPCOG/MMSE
When referring-
Basic data- full name of client, DOB, gender, address, postcode etc
Telephone number including where possible that of family member/contact
Employment status, ethnic origin, religion Language spoken; is there a need for an
interpreter? Narrative of patient presentation GP COG desirable SystmOne and EMIS referral form
Referral letter.
Refer to packs Routine referral from GP incl. bloods and
ECG Referral triaged and allocated to memory
service for assessment Structured assessment Diagnosis and core interventions Initial advice on driving
Specialist Memory assessment Pathway
Clustering Payment by results (PbR) mental health
clusters 18 – 21 are organic mental health clusters Cluster 18/19 will follow memory pathway
and if eligible for AChEi the shared care protocol
Clusters 19, 20, 21 will remain under CMHT if input is required
Donepezil (Aricept)◦ 5 and 10 mg (oro-dispersible tablet available)
Galantamine (Remenyl/Acumor)◦ 8mg, 16mg and 24mg capsules (maintenance 16-
24mg). Solution 4mg/ml Rivastigmine (Exelon)
◦ 1.5mg, 3mg, 4.5mg, 6mg capsules◦ Oral solution 2mg/ml◦ Transdermal patch 4.6mg and 9.5mg/24hr
Memantine (Ebixa) Starter pack titrates up to 20mg OD within 4 weeks. Oral solution 5mg/0.5ml
Licensed treatments
Cholinergic hypothesis of Alzheimer’s disease suggests that a decline in cognitive function is linked to loss of cholinergic transmission in hippocampus and cortex.
AChEi’s inhibit the cholinesterase enzyme from breaking down acetylcholine, increasing both the level, and duration of the neurotransmitter acetylcholine.
Licensed in mild to moderate Alzheimer’s.
Donepezil, Galantamine and Rivastigmine.
Acts on Glutamatergic system by blocking NMDA Glutamate receptors.
This is thought to be neuro-protective and possibly disease-modifying.
Approved for use in moderate to severe Alzheimer’s disease
Severe Alzheimer’s - drug of choice Moderate Alzheimer’s - intolerant of, or
contra-indication to AChEi’s
Memantine
Improvement in cognition by an average of 10%
Roughly equivalent of 6 months usual decline
ADLs and functioning may remain above baseline for 6-12 months for most and up to 2 years for some.
Benefits of AChEi
Usually mild◦ Diarrhoea, muscle cramps, fatigue, nausea,
vomiting, insomnia.◦ Headache, pain, common cold, abdominal
disturbance, dizziness.◦ Rarely : Syncope, bradycardia, sinoatrial and
atrioventricular block.
Side effects (AChEi)
Use of antipsychotics Concerns around over use and side effects Cerebrovascular adverse effects (atypicals
= typicals Behavioural and environmental approach
first Multisensory stimulation, bright light
therapy, aromatherapy
General guidance Target specific symptoms Start low and titrate up Time limited (review after 3/12 stable) Evidence for risperidone and olanzapine for
physical aggression, agitation and psychosis Long term use leads to cognitive decline
and falls Discontinue gradually (unless severe side
effects) Some people need to stay on them http://www.rcpsych.ac.uk/pdf/bpsd.pdf
GP monitoring For all types of dementia 6 monthly review Functional, behavioural, carer, dementia
advisor feedback Driving capability (see packs) Medication concordance, S/E, efficacy Carer strain Behavioural and psychological symptoms of
Dementia (BPSD) Dedicated Memory Service Lead Nurse
linked to each CCG for liaison/advice
Referral back to CMHT Urgent – goes to CMHT as usual Advice regarding medication – phone
memory service nurse or consultant psychiatrist
Caroline Molloy 01509 568680 Dr Hamer (Charnwood) 0116 295 2415 Dr Suribhatla (NWL) 0116 225 2754 Dr Subramaniam (H+B) 01455 443600 We will see again if significant behavioural
and psychological symptoms of dementia (BPSD) or complex needs
Discontinuation of medication NICE recommend that all patients who fall
into severe category are “considered” for discontinuation of AChEIs
May still be beneficial for Behavioural and Psychological Sypmtoms of Dementia (BPSD) even if cognition has declined
Less cost implication now Consider if experiencing harmful effects or
deteriorated to extent of palliative care Discuss with carers
Facilitates 1st 2 strands of National Dementia Strategy by
Encouraging practices to screen populations with suspected dementia (proposed DES and health checks in GMS contract)
Refer more patients appropriately to Memory Assessment Clinic
Agreeing to continue monitoring of treatment under Shared Care Agreement
Practices will◦ Nominate lead GP◦ Maintain adequate records following read codes in
clinical records
Enhanced Service 2013/14
Enhanced service A draft LES for GP shared care has been
developed and will be refreshed following agreement of the 2013/14 enhanced services
Updates will be communicated through locality meetings, practice manager meetings and newsletters
Case 1 73 year old man, brought to see you by wife who
has noticed forgetfulness over last 12 months. Asking repetitive questions, can’t remember
conversations or appointments. Wife frustrated, patient can’t really see a
problem. Able to wash, dress and perform household
chores. Driving without any problems. Scores 6/9 on patient GPCOG and 3/6 on
informant section.
Case 2 67 year old woman who comes to see you very
concerned about her memory. Anxious that she is not functioning as well as she
used to. Complains of forgetting where she has put things,
needing to rely on calendar for appointments. Lives alone, fully independent with activities of
daily living. Worried about Alzheimer’s disease. Scores 9/9 on GPCOG.
Vignettes
Case 3 79 year old woman Initially seen by GP with cognitive impairment Referred to Memory Adviser who supports son as
main carer Referred to memory clinic Diagnosed with Alzheimer’s disease and
commenced on Donepezil After 3 months, has been stable on 10mg Memory clinic write to you asking you to continue
prescription under SCA and review in primary care
VignettesCase 4 89 year old man with diagnosis of vascular
dementia for 3 years, on no psychiatric medication Under 6 monthly review Wife phones to say that he has become increasingly
agitated now He appears paranoid and suspicious of her She is frightened of him He keeps trying to leave the house and is clearly
disorientated in time and place Initial examination reveals no acute cause for
deterioration such as UTI
Vignettes Case 5 84 year old woman in residential home 5 year history of Alzheimer’s, on
galantamine Now severely cognitively impaired Persistent poor appetite and refusal to eat No obvious physical cause Very frail Family reluctant for her to be admitted or
have further physical investigations
Vignettes Case 6 69 year old man diagnosed with Alzheimer’s at
memory clinic 9 months ago Driving assessed at memory clinic – DVLA informed
of diagnosis, no visuospatial problems Stable on donepezil prescribed by GP Attends for 6 monthly review in primary care Now unable to draw interlocking pentagons Has had some minor scrapes in his car, but feels he
is able to drive safely Despite your advice not to, he is adamant that he
will continue to drive