Forgetfulness and Dementia

- Including NICE update

Key points for primary care

One Day Essential | Neurology

Friday 25 January 2019
Key LearningPoints
Key Learning Points

• Review primary care role in dementia

• The Living Well pathway
• Nice guidelines update June 2018 –
changes for primary care
• Driving and dementia – new guidelines
Forgetfulness
Forgetfulness

• Patients say “GP didn’t listen”

• Not always dementia

• Dementia is one of the things most

patients over 55 years say they are most
frightened to develop.
Dementia is:

• Cognitive defects severe enough to

interfere with occupational or social
Dementia
functioning, but is:
not associated with
delirium, and representing a decline in
function
Prevalence
Prevalence ofofDementia
Dementia

• AGE is main risk factor

• 1 in 688 people under 65 years

• 1 in 14 people aged over 65 years
• 1 in 6 people over 80 years
Forgetfulness – –the
Forgetfulness the 4 “Ds”
4 “Ds”

• Not all cognitive decline = Dementia

• Delirium – infection, renal failure, tumour

• Drugs – prescribed and alcohol
• Depression – and anxiety
• Dementia
Dementia notjust
Dementia not justMemory
Memory
Well Pathwayfor
Well Pathway forDementia
Dementia

• PREVENTING WELL
• DIAGNOSING WELL
• SUPPORTING WELL
• LIVING WELL
• DYING WELL
Preventing Well
Preventing Well

• Blackfriars Consensus Statement 2014

• What’s Good for Heart is Good for Head

• Manage vascular risk factors
• Increase activity
• Avoid social isolation
• Reduce unsafe alcohol levels
Timely diagnosis
Timely dagnosis advantages
advantages

• Patient can START TREATMENT

• Patient & carer RELIEVED to understand
• Better PLANNING- care , housing, health
• Avoid UNPLANNED ADMISSIONS
• Helps better care in HOSPITAL STAY
• Plan LEGAL ISSUES
Diagnosing Well
Diagnosing Well

• Dementia is a clinical diagnosis made

from the history not test results.
• Friends or family may recognize the
problem rather than the individual.
• “How would they get on it you left them
home alone for the weekend?”
• Collateral history – consider IQCODE
Planning
Planning aaReferral
Referral

• History from patient and family

• Test of cognition with validated brief
structured cognitive instrument
• Blood tests to exclude other reversible
causes
• +/- ECG
• Refer to Memory Assessment Service
Dementia diagnostic
Dementia diagnostic service
service

• Assessment for mood disorder

• More extensive cognitive testing
• Consider brain imaging
• Consider neuropsychology testing
• NICE guideline – if diagnosis of
Alzheimer’s not clear FDG-PET or
Perfusion SPECT or LP for Tau or
amyloid beta 1-42
Diagnosing Well
Diagnosing Well

• Make diagnosis including subtype of

dementia
• Start treatment
• Post diagnostic support
• Communicate diagnosis
• Develop care plan – including advance
care planning
Types ofDementia
Types of Dementia
Alzheimer’s Disease
Alzheimer’s Disease

• Most common
• Abnormal proteins form in plaques and
tangles causing brain cells to lose
connections and then die
• Most prominent symptom is memory loss
• Often person is less aware of their
symptoms
Vascular Dementia
Vascular Dementia

• Occurs with suboptimal blood supply to

the brain
• Seen on imaging with increased vascular
changes in brain
• Can feature fluctuating levels of cognition
day to day.
• History of stepwise progression
Dementia withLewy
Dementia with Lewy Bodies
Bodies

• 10-15% of cases
• Features of Alzheimer’s disease and
Parkinson’s disease
• Typical symptoms of hallucinations and
problems with movement
Early OnsetDementia
Early Onset Dementia

• More likely to be a rarer subtype of

dementia
• More likely to be hereditary than in late
onset – around 10% seem inherited
• Social implications can be different
• Referral for diagnosis may be to
neurology
MCI:MildCognitive Impairment
MCI:MildCognitive Impairment

• Minor problems with cognition, worse

than expected from normal aging, but not
severe enough to diagnose as dementia
as not significantly interfering with daily
life.
• Annual review important as around 10%
could become dementia each year
Pharmacological Intervention
Pharmacological Intervention

• Some changes with NICE update 2018

• 3 Acetylcholinesterase inhibitors used as
monotherapy for mild to moderate
Alzheimer’s disease
• Donepezil, Galantamine, Rivastigmine
• If AChE Inhib contraindicated or not
tolerated use Memantine (NMDA
receptor antagonist) as monotherapy
Pharmacological Intervention
Pharmacological Intervention

• Consider Memantine in addition to AChE

Inhibitors for Moderate Alzheimer’s
• Offer Memantine in addition to AChE
inhibitors for Severe Alzheimer’s
• Don’t stop AChE Inhibitors because of
severity of Alzheimer’s disease alone
• If person is taking AChE inhibitors
already, primary care prescriber can start
Memantine
Memantine
Memantine

• NMDA receptor antagonist

• Blocks glutamate effects
• Glutamate released in increased
amounts in Alzheimer’s disease
• Can slow progression of symptoms like
disorientation, may help delusions,
aggression and agitation
Primary careuse
Primary care useMemantine
Memantine

• http://www.londonscn.nhs.uk/wp-
content/uploads/2018/12/dem-
memantine-dec18.pdf
Medication
Medication ininDementia
Dementia

• Dementia with Lewy Body – donepezil or

rivastigmine
• Vascular dementia – only consider AChE
Inhibitors or memantine if comorbidity of
Alzheimer’s disease i.e. mixed dementia
• Frontotemporal dementia – don’t use
AChE Inhibitor or memantine
Meds
Meds &&Cognitive
CognitiveImpairment
Impairment

• Consider anticholinergic burden

• Tools available to review
• http://medichec.com/
• Consider de prescribing in elderly
Living Well
Living Well

• Offer a range of activities to promote

wellbeing suitable for people with
dementia
• Peer support
• CST – cognitive stimulation therapy
• Group reminiscence therapy
• Access to research
Supporting Well
Supporting Well

• Offer psychoeducation and skills training

to carers
• Dementia friendly communities
• Respite stays / day centres
• Support to establish power of attorney
• Telecare advice
• Avoiding hospital admissions
Care Planning
Care Planning

• Importance of regular review of condition,

treatment, changes to symptoms,
evaluation of carer needs, signposting to
services, driving, power of attorney….

• Dementia is a progressive neurological

condition – changing picture so plan
ahead
Dying Well
Dying Well

• In place of persons preference

• Avoiding unnecessary interventions
• Discussions to establish a persons
wishes needs to occur prior to their loss
of capacity
Driving withDementia
Driving with Dementia
https://research.ncl.ac.uk/driving-and-
dementia/consensusguidelinesforclinicians/Final%20Guidelin
e.pdf
Driving withDementia
Driving with Dementia

• DVLA guidance
• Person with dementia may be able to
drive but must notify the DVLA (Group1
licence Car and Motorcycle)
• Group 2 licence must not drive and must
inform DVLA (Bus and Lorry)
• Decision around safety to drive involves a
discussion with person and collateral info
Red Flagsfor
Red Flags fordriving
driving safety
safety

• Any near misses or at fault accident

• Parking problems
• Driving excessively slowly
• Delayed reactions
• Passenger becoming more active co-pilot
• Passenger or driver feeling unsafe
Primary carerole
Primary care roleinin Dementia
Dementia

• Promote prevention
• Identify at risk and symptomatic people
and refer for diagnosis
• Care planning incl: advance care
planning, driving, consideration of
medication, Carer support
• Dementia is long term degenerative
condition needing primary care support
Questions?
Questions?

• Nburnie@nhs.net
• Dr Nerida Burnie