Dementia: diagnosis, assessment and treatment

Dr Catherine BryantConsultant Physician

Department of Clinical GerontologyKing’s College Hospital NHS Foundation Trust,

London

Aims

• The benefits of early assessment of dementia• The assessment of people who may have

dementia• The use of cholinesterase inhibitors in dementia

Objectives

• Be able to describe and understand the assessment process

• To understand the principles of cognitive assessment

• To understand the rationale behind use of cholinesterase inhibitors

Dementia

• Almost 700,000 people in UK with dementia (1.7 m by 2051)

• 1 in 20 people aged over 65 years have dementia

• 1 in 5 people aged over 80 years have dementia• ~ 20,000 aged under 65 years in UK have

dementia

Dementia-benefits of early diagnosis

• Early provision of support can decrease institutionalisation by 22%– Older peoples mental health teams can help with behavioural

disturbance, hallucinations and depression– Carer support and counselling

• Early diagnosis and intervention improves quality of life of people with dementia

• Early intervention has positive effects on quality of life of carers

Dementia• Dementia is a syndrome caused by disease of the

brain– Usually of a chronic or progressive nature– Impairment of multiple higher cortical functions, including

memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement

– Cognitive symptoms can be accompanied by non-cognitive symptoms, including changes in behaviour, emotional control and social functioning

Dementia-early stages• Often this phase is only apparent in hindsight and can be

misattributed to bereavement, stress or normal ageing• Loss of short-term memory• Loss of interest in hobbies and activities• Difficulty handling money• Poor judgement• Unwillingness to make decisions• Difficulty adapting to change• Irritability/distress if unable to do something• Inability to manage everyday tasks• Repetitive questioning and loss of thread of conversation

Dementia-moderate stages• Increased need for support such as reminders to eat, wash,

dress and use the lavatory• Confusion regarding time and place• Failure to recognize people and objects (agnosia)• Behavioural symptoms such as wandering and getting lost,

and hallucinations (visual and auditory)• Risky behaviour such as leaving the house in night clothes,

forgetting to turn the taps off and may leave gas unlit• Increased repetitive behaviour• Word-finding difficulty

Dementia-severe stages• Need for full assistance with washing and dressing, eating

and toileting (double incontinence)• Increasing physical frailty – reduced mobility• Increased risk of complications associated with prolonged

immobility such as constipation and chest infection• Increased confusion and restlessness such as searching

for dead relative• Increased aggressive behaviour• Disinhibition• Night disturbance• Difficulty eating and sometimes swallowing (dysphagia)• Weight loss• Gradual loss of speech

Mild Cognitive Impairment• Mild cognitive impairment is a syndrome defined as

cognitive decline greater than expected for an individual’s age and education level but that does not interfere notably with activities of daily life

• Prevalence from 3% to 19% in adults older than 65 years

• Some people with mild cognitive impairment seem to remain stable or return to normal over time, but more than half progress to dementia within 5 years

• Mild cognitive impairment can be regarded as a risk state for dementia

Mild Cognitive Impairment

• Amnestic subtype of mild cognitive impairment– Memory complaint, preferably corroborated by an informant– Memory impairment relative to age-matched and education-

matched healthy people– Typical general cognitive function– Largely intact activities of daily living– Not clinically demented

Dementia-detection• Person or family/carers notice changes

• Health professionals notice changes in a person (although person and/or family/carers do not)

• Crisis, e.g. incapacity of carer reveals dementia in a person as carer had been compensating for person with dementia

Dementia-where should the diagnosis be made?

• The diagnosis can be made in primary care

• The new Dementia Strategy suggests new services to diagnose and manage early dementia that are easy to access from primary care

• Currently: – Memory clinics– Community Mental Health – Psychiatry– Neurology– Learning disability

Dementia-assessment and diagnosis• Many conditions apart from dementia can present

with cognitive impairments,– Delirium– Depression– Side effects of medication– Other psychiatric illnesses– Substance misuse– Medical conditions like hypothyroidism or intracerebral

infections or space-occupying lesions

• A careful and comprehensive assessment with appropriate investigations is therefore necessary to arrive at a diagnosis of dementia

Dementia-assessment and diagnosis• Assessment

– History– Cognitive and mental state examination– Physical examination– Investigations

• Diagnosis may not be easy especially in the early stages of dementia

• There is no single easy test for diagnosis of dementia– Time to gather evidence and do investigations– Time to involve other health professionals

Dementia-history• History (patient and an informant)

– Presenting complaint– Past medical (especially vascular risk) and psychiatric

history– Medication– Drug and alcohol use– Family medical and psychiatric history– Changes in personality and behaviour– Assessment in changes in ability to undertake everyday

tasks– Exclusion of other conditions such as delirium and

depression

Short form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE)

www.anu.ed u.au/iqcode

Jorm, 1994

Bristol Activities of Daily Living Scale

Bucks et al, 1996

Abbreviated mental test score

Abbreviated Mental Test (AMT)Age Time (nearest hour)Address for recall YearPlace Recognise two peopleDate of birth Start of WW I Present monarch Count back: 20 to 1

Hodkinson, 1972

Folstein et al, 1975

Other Tests of Cognition

• The General Practitioner Assessment of Cognition (GPCOG) (Brodaty et al, 2002)

• 6-Item Cognitive Impairment Test (6-CIT) (Brooke & Bullock, 1999)

• The clock drawing test, useful for assessing praxis and executive function (Sunderland et al, 1989)

Psychiatric Co-morbidity

• Depression-complex relationship to dementia– People with depression and cognitive impairment highly likely to

have dementia diagnosed during follow up– People with dementia may also have depression (~12%)

Delirium• Delirium may be the first presentation of an underlying

dementing illness– Dementia is a strong risk factor for delirium– Delirium can be fully reversible but it may not be especially if

already have underlying dementia

Physical examination

• Neurological disease e.g. stroke, Parkinsonism• Vascular disease

Investigations (1)• Looking for “reversible” causes of dementia (<5%)• FBC• ESR and CRP• U&E, LFTs, Calcium• Thyroid function• B12 and folate• Optional

– HIV– Syphillis

• Other tests based on clinical need, e.g. MSU if delirium a possibility

Investigations (2)

• Neuroimaging– Intra-cerebral lesions– Distinguishing types of dementia

• Structural scans– CT– MRI

• Functional scans– PET/SPECT– DatSCAN

Disclosing the diagnosis

• Most people with early dementia want to know their diagnosis

• Need to provide accurate information and ongoing support to people with dementia and their family/carers

• Ongoing support with coordinated health and social care plans designed to maximise independence

Treatment in dementia• Coordinated care• Promoting and maintaining independence• Psychological interventions for patients• Education and training for carers• Management of non-cognitive symptoms and

challenging behaviour• Management of co-morbid psychiatric conditions

(depression)

Cholinesterase inhibitors (ChEIs) in AD (1)

• Donepezil, rivastigmine and galantamine• Licensed in the UK for “symptomatic treatment of mild to

moderately severe dementia of the Alzheimer type”• Inhibit acetylcholinesterase and increase the levels of

acetylcholine in the brain• The evidence of their effectiveness in treating AD is

based on trials randomised placebo controlled trials of 6- 12 months duration

Cholinesterase inhibitors (ChEIs) in AD (2)

• Placebo controlled trials show– Significantly improved cognitive performance– Improved global state of patient– Benefits of treatment also seen on measures of activities of

daily living and behaviour

Cholinesterase inhibitors (ChEIs) in AD (3)

• Treatment effects of ChEIs are not large• They should be prescribed as part of an overall care plan

and management strategy• 1/3 improve, 1/3 the same, 1/3 progress• No evidence of superior efficacy of one drug• Donepezil better tolerated than rivastigmine• Start low dose and titrate up to minimise side effects• Commonest side effects are gastrointestinal (take with

food)

Cholinesterase inhibitors (ChEIs) in AD (4)

• Prior to starting ChEIs a baseline should be established for cognitive function, global functioning, neuropsychiatric symptoms and activities of daily living

• I use MMSE, Bristol ADL, global impression of change scale +/- Neuropsychiatric Inventory (NPI)

• All patients should have an ECG to exclude cardiac conduction problems

• Patients should be reassessed after once they have been on a stable maintenance dose for 3 months and then 6 monthly

• Stop the drug if it is not working

Cholinesterase inhibitors (ChEIs) in AD (5)

• NICE guidelines– NICE technology appraisal guidance 111 (amended) Donepezil,

galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer’s disease

– National Clinical Practice Guideline Number 42 A NICE–SCIE Guideline on supporting people with dementia and their carers in health and social care

• On going debate about cost effectiveness

NICE technology appraisal guidance 111• Moderate AD

– MMSE 10-20– Initiation by specialist– Involve carers– 6 monthly assessments using MMSE and global, functional

and behavioural assessment

• MMSE may not help identify if AD of moderate severity if:– Learning disability– Communication issues– Then use another “appropriate method of assessment”

National Clinical Practice Guideline Number 42

• Moderate AD MMSE 10-20• Professionals should not rely on the MMSE score in

certain circumstances– MMSE > 20, who have moderate dementia as judged by significant

impairments in functional ability and personal and social function compared with premorbid ability

– MMSE < 10 because of a low premorbid attainment or ability or linguistic difficulties who have moderate dementia as judged by an assessment tool sensitive to their level of competence

– People with learning disabilities– People who are not fluent in spoken English or in the language in

which the MMSE is applied

Memantine (currently not recommended by NICE except in research)

• Memantine is a non-competitive NMDA-receptor antagonist that affects glutamate transmission

• Licensed for the treatment of moderate to severe AD• It is predominantly used when treatment with ChEIs

is no longer considered effective but could be considered in patients who can tolerate or have not responded to treatment with ChEIs

• Memantine produces significant effects on cognition, activities of daily living, global impression of change scales and behavioural scales

• Evidence that memantine added to donepezil treatment may improve activities of daily living, cognition and neuropsychiatric symptoms

Comprehensive assessment in Dementia (1)

– OT– PT– SALT– GPs/community nurses– Psychiatry– Palliative care– Social services– Voluntary services– Alzheimer’s Society (dementia advisors, dementia support

workers)

Comprehensive assessment in Dementia (2)

• Comprehensive medical assessment• Falls• Delirium• Continence• Vascular risk• Medication review• Co-morbid medical conditions