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Steven Roberts Head of dementia services Independent Nurse Prescriber Steven.roberts@lpt.nhs.uk Lincolnshire Partnership NHS Foundation Trust

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What is dementia? The different types. The risk factors? What are the early signs? Benefits of diagnosis. Treatments What can we do? Chance to ask questions. To provide an overview of:

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..an illness syndrome a collection of signs & symptoms usually caused by disease of the brain .which is progressive Dementia IS NOT forgetfulness due to normal aging whatever that may be?? Decline in cognitive abilities (memory, language, perception, attention) Changes in behaviour, mood or personality Decline in our day to day functional ability Accumulation of abnormal proteins that disrupt and kill brain cells and their connections Changes in health of the blood vessels & supply of the brain It is a chronic condition Differing patterns of onset and progression Average duration of 8 years

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The main causes (or types) are: Alzheimers disease > 62 % Vascular dementia > 17 % Lewy Body Dementia > 5 % Frontal lobe dementia > 2% Mixed dementia > 10% All effect the brain and thus the person in different patterns and ways. Important to diagnose important for drug treatment and understanding the individuals behaviour and context Gradual progression > Fluctuating cognition, visual hallucinations, parkinsonism, REM-sleep BD, falls, neuroleptic sensitivity, autonomic dysfunction, visuospatial deficits Step-wise progression, multiple strokes, > seizures, unsteady gait, depression, behaviour change, incontinence, vascular problems Gradual progression > rare, younger onset, memory initially intact, changed social conduct, speech reduction, early loss insight, emotional blunting, diet/eating changes, incontinence. Gradual progression > 3 types, early onset(rare < 10%, late onset & familial (rare < 5%); ST memory, loss of judgement, communication global impairment A mixture of both Alzheimer type and vascular type dementia

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National : Mapping the dementia gap (2010) Local : Lincolnshire PCT (2011) Currently - 10, 877 cases in Lincolnshire But only 41- 45% have been diagnosed Number of cases set to rise by 43% in the next 10 years By 78% in next 14 years Higher than National average Currently > 750,000 people with dementia in the UK Over 16,000 under the age of 65 years Estimated to be over 1 million by 2021 Lincolnshire has one of the fastest growing elderly populations in the UK

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So, who is at risk? Main Risk-Factors: Age Advancing age is the main risk. The incidence of dementia approximately doubles every 5yrs after the age of 65. Family History/Genetics > interact with life style factors. A number of genes discovered that increase the risk for AD (i.e. PS1, PS2, APOE) and Frontal lobe dementia (FTDP-17) these effect the processing of brain proteins Family history heightens risk BUT familial forms very rare (very early onset 40s). Gender Alzheimers disease more females than males Vascular dementia more males than females Diabetes & depression (stress) Recent studies (2010) showed increased risk of dementia associated with these due to links to the underlying biological processes Head injury & anaesthesia Some studies indicate that head trauma (with loss of consciousness) and anaesthesia may represent risk factors in vulnerable individuals Predicted that up to half of the cases of Alzheimers could be attributed to lifestyle choices that could be modified. Including education, smoking, physical inactivity, depression, high blood pressure, diabetes and obesity. (University of California, 2011) Predicted that up to half of the cases of Alzheimers could be attributed to lifestyle choices that could be modified. Including education, smoking, physical inactivity, depression, high blood pressure, diabetes and obesity. (University of California, 2011) SO, risk can be modified as it is a combination of genetic and individual lifestyle and environmental factors. These also give us clues as to how we can help people with dementia as well. SO, risk can be modified as it is a combination of genetic and individual lifestyle and environmental factors. These also give us clues as to how we can help people with dementia as well.

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Memory loss short-term memory, disorientation/getting lost Difficulty with familiar tasks cooking meals, organising tasks.. Problems with language word finding, naming.. Poor judgement e.g. dressing inappropriately for weather.. Trouble keeping track of things conversations, finances etc Misplacing things putting things in unusual places Changes in mood or behaviour depression, mood swings, disinhibited Change in personality irritable, suspicious, anxious, asocial etc Loss of initiative passive, increased sleeping, loss of interest etc

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Enables people to understand their condition (psychoeducation) Early access to treatment to relieve symptoms (excess disability) To access support/carer support Access to information Opening a door for future care Legal Power of Attorney, Wills, Living Wills Financial planning Life planning Early & accurate diagnosis is a National priority (NDS, 2009) .but why??

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3 types of drug intervention.. 1: Curative where disease is eradicated No treatments available 2: Disease Modifying where treatment alters course of illness No treatments available 3: Symptomatic treatment aimed at minimising impact of illness Treatments available current level of drug therapy

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What are they? What are they? Cholinesterase Inhibitors Donepezil (Aricept), Rivastigmine(Exelon) Galantamine (Reminyl) What are they for? Mild to moderate Alzheimers disease (can worsen FTD) To improve daily functioning. Concentration ? Behaviours that challenge What is the evidence? Controversy cost effectiveness High potential for side-effects heart, breathing, falls, upset stomach Modest benefit approx 40% (NNT = 14: 1 in every 14 benefit) Also: Memantine: works by different mechanism For severe Alzheimers disease (MMSE of 10 points or less) To improve functioning/behaviours that challenge Modest benefit again approx 40% NNT = 14: 1 in every 14 benefit)

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YesThe Big Five for Optimal Brain Function Growing evidence that some lifestyle practices can slow or prevent issues that compromise mental function - The BIG FIVE: 1.Physical activity 2.Nutrition 3.Mental stimulation 4.Socialization 5.Creativity and attitude stress reduction The very GOOD NEWS for the most part these are issues you can do something about RIGHT AWAY, RIGHT NOW...

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Body & Mind For starters .What is good for your heart is ALSO good for your brain Share common risk factors...cholesterol, high blood pressure, obesity, arterial damage, plaque build up SO ..when you watch your cholesterol, maintain a healthy weight, and exercise for your heart, your brain benefits too.

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Researchers looking at memory loss in older adults are becoming increasingly interested in the role played by diet and exercise. 1: Physical Activity: 2:Nutrition: Daily, at least two and a half hours per week: Daily tasks (use the stairs, gardening, vigorous cleaning) Swimming (works joints/muscles without drag of gravity) Dancing or aerobics (exercises brain as well, fun) Biking/stationary bike (but protect your brain with a helmet!!) Tai-chi, yoga, Qui gon (strength, balance, concentration, de-stress) Walking, walking, walking.. Clutch of new studies indicate that walking 5 miles per week associated with lower risks of dementia (observed increased size of brain in areas associated with memory) Uni. Pittsburgh > walking 5-6 miles a day slows the progress of dementia in those showing MCI or AD. Basics: your brain needs good fuel! Avoid: saturated fats, processed meats, simple carbohydrates, salt; Pile on: fruits, veggies, complex carbohydrates, grains & nuts, Oily fish & Omega-3 fatty acids Anti-oxidants: links with dementia : Vitamins E & C diet rich in fruit & veg, green tea, blueberris, red-wine, ginko biloba etc Mediterranean diet fruit, veg, olive oil, legumes, grains and fish associated with reducing risk of dementia. Nutrition can help manage vascular risk- factors & diabetes associated with dementia

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Exercise your brain. Education is neuroprotective. Brain trainers. Puzzles, games, sensory stimulation, crosswords, reading, CST etc. BUT - Appropriate level - adapt to changing abilities! `Use it or lose it! 3: Mental stimulation..remain socially connected. Humans are social creatures Appropriate socialization Work with known difficulties not against Trust in and inform others to help. 4: Socialisation Things socialisation does for your brain: Lowers your blood pressure > risk of stroke Improves immune function Lowers memory loss by keeping mind active Things socialisation does for your brain: Lowers your blood pressure > risk of stroke Improves immune function Lowers memory loss by keeping mind active

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and manage stress and spirit.. 5: Creativity, attitude & spirit: Manage and be aware of stress: Antidepressants (depression as risk factor) Aromatherapy, diet and exercise (e.g. tai chi, yoga etc.) Meditation (mindfulness the here and now) As dementia emerges your emotional life grows.. Just as your brain dictates your feelings, your feelings affect your brain > stress hormones!!. Be creative be human! Music (singing for the brain) Art (art therapy) Dancing Adapt and support in the now Mood & behaviour as coping defences? Communication (e.g. SPECAL) adapt activities to present abilities Adapt and support in the now Mood & behaviour as coping defences? Communication (e.g. SPECAL) adapt activities to present abilities Music can: Reduce anxiety, aid sleep, lower blood pressure, reduce stress hormones. The creative brain: memory for music and emotion are in a different part of the brain from memory about things and is often intact much longer in even sever dementia Music can: Reduce anxiety, aid sleep, lower blood pressure, reduce stress hormones. The creative brain: memory for music and emotion are in a different part of the brain from memory about things and is often intact much longer in even sever dementia This means these intact abilities can be tapped into in dementia

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Dementia many different ways Dementia is a collection of signs and symptoms presents in many different ways and people experience it differently. Due to changes in the brain different types Multiple risks Multiple risks not one thing alone genes & lifestyle/environment. identify early Important to identify early to plan, understand, manage and support. Drug treatments currently limited to symptom relief do not cure! Lifestyle changes Lifestyle changes can reduce risks & maximise wellbeing there are things we can all do NOW!

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