Introduction: Dr Jane Allan MOSS MHSOP 0.3FTE Liaison/clinical
advisor at primary/secondary interface TDHB as a demonstration site
in the management of Uncomplicated Dementia (no BPSD) using a
Collaborative Care Model-GPs ands Specialist Care Part of the
Better, Sooner, More Convenient Strategy MOH MHSOP All referrals in
category uncomplicated dementia Collated by MHSOP, discussed at MDT
MOSS Allocated to MOSS to liaise with primary referrer Provide
education, guidance, treatment direction GP Liaison support and
education from Older Peoples Health Managing uncomplicated dementia
in primary care.
Slide 3
Scope of the problem Growing aged population Dementia affects
5% of people over 65 20% of people over 80 In 2002 12% of NZ pop
> 65 In 2051 25 % of NZ pop > 65 NZ over 40,000 people have
dementia Local demographic information?
Slide 4
Types of Dementia Alzheimers Disease: 50 to 60 % Vascular
Dementia: 10 to 20 % Mixed:10 % Lewy Body Dementia: 10 to 20 %
Fronto-temporal Dementia:
Survey Results: 44% Response 60% GPs confident diagnosing,
informing & referring Less confident in providing treatment,
resources & advice, follow up and management in a primary care
setting. 80% low confidence re CEM & CT scan interpretation.
GPs are keen to have support from specialists: 96% would use E-mail
consultation with specialist >80% guidelines, and further
resources 71% a phone/e-mail liaison with a specialist MHSOP nurse
>50% attend workshop or refer patients/caregiver to group
Slide 10
Slide 11
Is this memory loss normal? A 65 year old male presents
complaining of increased forgetfulness. He is worried that he is
developing dementia. What would you do?
Slide 12
Uncomplicated or Complicated? Assessment Rule out other causes:
depression, delirium, red flags Consider performing a memory test A
provisional diagnosis Age-related cognitive decline or early stage
dementia Make a plan Follow-up, investigations, advice, review,
referral
Slide 13
Rule out other causes for memory loss Depression/Delirium/Drugs
Depression Pseudo dementia Commonly causes memory impairment Often
co-exists with dementia. Memory selective or patchy, rather than
generally impaired. Duration weeks or months rather than gradual
decline Screening tool e.g. Geriatric Depression Scale Past History
Low energy, anxiety, sleep, appetite, suicidal ideas
Slide 14
Other Mental Health Problems Anxiety Stress Substance
misuse/dependence (alcohol, BZD, opiates) Sleep Disorder
Medical Conditions Cerebrovascular disease Neurodegenerative
disease Brain tumour and infections Head injury Epilepsy Thyroid
disease Malnutrition, vitamin deficiencies Chronic pain
Slide 17
Consider neurological /medical/surgical referral Patient Less
than 60 years History Rapid decline (1-2mths) in cognition or
function Unexplained neurological symptoms (severe headache,
seizures) Anticoagulants/bleeding disorder History of cancer Family
history of neurodegenerative disease e.g. Huntingtons Examination
New localising signs Atypical cognitive symptoms or presentation
Gait disturbance
Slide 18
Investigations To rule out potentially reversible factors FBC,
LFTs Serum electrolytes, calcium & glucose TSH Vitamin B12
& folate CRP ?Referral for CT/MRI- white matter changes
associated with worsening cognitive function (Survey showed 18% GPs
are confident in interpreting scan results)
Slide 19
Memory and Ageing: Whats Normal? Harder to pay attention
distractions, hearing, vision Slower at processing information (
new learning, retrieval e.g. of names) 85% forget names 60% lose
keys 50% cant remember what has just been said 40% forget faces or
directions
Slide 20
Normal age-related memory decline Subjective memory concern
Mild episodic memory impairment Preserved procedural & semantic
memory Possible mild non memory cognitive dysfunction (e.g.
attention) No functional impairment or behavioural
abnormalities
Slide 21
Symptoms Changes in memory Reasoning Judgement Recognition
Language Orientation Mood Motivation Personality Ability to perform
ADLs
Slide 22
Normal age-related forgetfulness Mild Cognitive Impairment
Dementia Sometimes misplaces itemsFrequently misplaces itemsForgets
what an item is used for. Puts it in an inappropriate place
Momentarily forgets a persons name Frequently forgets names &
slow to recall May not remember knowing a person Occasionally has
to search for a word Finding words becomes more difficult Starts to
lose language skills. Withdraws socially Occas. forgets an
errandBegins to forget eventsLoses sense of day & time May
forget event from distant past May forget more recent events or new
info Working memory impaired. Difficulty learning or remembering
new info Driving-may forget to turn, quickly re-orients Temporarily
lost. Trouble with maps Easily lost in familiar places-st for hours
Jokes about memory loss Worries about memory loss. Family &
friends notice lapses. May have little or no awareness of cognitive
problems
Slide 23
Mild Cognitive Impairment Most maintain cognitive ability at a
functioning level throughout life. 20% of 65 yr olds have MCI; 5 %
have dementia MCI may be a precursor to dementia. Meta-analysis
study reported annual conversion from MCI to dementia is 5-10% per
yr Many people with MCI did NOT progress to dementia with 10 years
follow-up. Objectively impaired memory testing (MMSE >=26 BUT
ADLs INTACT)
Slide 24
Criteria for Diagnosing Dementia Impairment of memory and one
or more of Aphasia: production/understanding language disturbed
Apraxia: trouble carrying out motor activities Agnosia: failure to
recognise, identify objects, people, places Executive functioning:
sequencing, planning, organising, judgements & abstracting
Slide 25
Must interfere with work, social activities or relationships
and represent a significant decline in the persons functioning (ask
about managing money, using the phone, transport, taking
medications ) Gradual onset and continuing decline. Other physical
or mental conditions that can look like dementia have to be
excluded * Person may not be aware of changes may have to ask
permission to speak to someone who knows them well
Slide 26
Describing Dementia-DSM 1V Early Onset: Before 65 years Late
onset: After 65 years Uncomplicated: Alzheimers or vascular
dementia with no BPSD or complex co-morbidities Complicated: with
delusions, depressed mood or behavioural disturbance/or have signs
of another neurodegenerative disorder e.g. gait disturbance,
extra-pyramidal symptoms, focal or lateralising neurological signs
(e.g. Parkinsons, Huntingtons)
Vascular Dementia Gradual or sudden episodes of ischaemia
Several small CVA, TIAs Course variable: sudden then leveling
period More likely gait, urinary problems Predisposed: High blood
pressure, diabetes, elevated lipids, smoking, family history of
vascular disease. CT scan: indications of ischaemia
Slide 29
Barriers to Early Detection Misidentification by the family of
early signs as normal aging process Social skills often maintained
Denial and lack of insight by patient Reluctance to report symptoms
(patient and caregiver)stigma Lack of definitive screening
tools
Slide 30
Early Diagnosis and Discussion Benefits Risks Baseline &
monitoring allows earlier intervention with support, reduces risks
of accidents, driving, abuse and hospital admission People can
prepare Enduring Power of Attorney, wills Move homes, visit family
overseas Better understanding of changes No cure but treatment can
alter the course of the illness Impact persons self-esteem Threaten
their independence Affect relationships Employment Future Plans
change Clinical judgement as to timing of discussion 62%
reasonably/very confident
Slide 31
Is a memory test needed? Diagnosis is mainly from the history
provided by patient and informant Memory tests help confirm and
quantify impairment Conversation Clues How did they answer
questions? Hesitation to find words, recall facts, sequence events?
Anomalies in language use? Is reported impairment beyond what you
classify as normal.
Slide 32
Which Memory Test? Brief, standardised screening appropriate in
primary care setting Survey results showed 75% used MMSE (30) and
40% MMSE (12) 18% use mini-cog -repeat 3 words; draw clock, no.s
& time; recall words 80% used a memory test if cognitive
problems were suspected 13% cognitive screen patients over 74 for
DRIVING medical 0% follow-up those with dementia 6 monthly with
screening 60% perform cognitive screen themselves 17% have nursing
staff perform memory screening (driving test)
Slide 33
Which memory test? Test% GPs Time taken Interpreting
ScoresSensitivity & specificity MMSE8-10mins Age, education,
language & cultural bias, used for 30 years Insensitive to mild
alzheimers (