Management of Early Dementia

Dr Eleanor Mullan Dr Eleanor Mullan

Consultant PsychiatristConsultant Psychiatrist

Mental Health Services for Older PeopleMental Health Services for Older People

South Lee, CorkSouth Lee, Cork

Feb 2011Feb 2011

Statistics

Population of SHB - 550,000Population of SHB - 550,000 12% over 65 years12% over 65 years 1% over 85 years1% over 85 years Highest rise in very elderly (over 85 years)Highest rise in very elderly (over 85 years) Female:male = 4:1Female:male = 4:1 32% over 70 years live alone32% over 70 years live alone Life ExpectancyLife Expectancy

Male 78.9 (EU 80)Male 78.9 (EU 80) Female 82.4 (83.8)Female 82.4 (83.8)

Major Causes of Dementia

Alzheimers DiseaseAlzheimers Disease Vascular DementiaVascular Dementia Dementia Lewy Body typeDementia Lewy Body type

up to 20% of dementiasup to 20% of dementias Alcohol Dementia3-10%Alcohol Dementia3-10% Frontotemporal DementiaFrontotemporal Dementia Primary Progressive AphasiaPrimary Progressive Aphasia Age-associated Memory impairment - AAMIAge-associated Memory impairment - AAMI

Prevalence of Alzheimers Disease

Age rangeAge range ADAD VaDVaD 30-64 years30-64 years 0.13%0.13%

0.10%0.10% 65-69 years65-69 years 0.34%0.34% 0.3%0.3% 70-79 years70-79 years 3.2%3.2% 0.7%0.7% 80-89 years80-89 years 10.08%10.08% 2.5%2.5% 90-99 years90-99 years 12.6%12.6% 4.2%4.2%

Definition of Dementia

Brain DiseaseBrain Disease ChronicChronic ProgressiveProgressive GlobalGlobal IrreversibleIrreversible

Symptoms of Dementia

Cognitive ImpairmentCognitive Impairment OrientationOrientation LanguageLanguage LiteracyLiteracy praxic skillspraxic skills memorymemory perceptual skillsperceptual skills

Symptoms of Dementia - 2

Personality ChangePersonality Change DelusionsDelusions HallucinationsHallucinations Mood and Affect disorderMood and Affect disorder Neurovegetative symptomsNeurovegetative symptoms Behavioural ProblemsBehavioural Problems

Assessment

HistoryHistory Course, onset, presentationCourse, onset, presentation Family history, drug and alcohol historyFamily history, drug and alcohol history Medical historyMedical history CollateralCollateral

Clinical ExaminationClinical Examination Psychiatric ExaminationPsychiatric Examination

Depression!Depression! Neuropsychological ExaminationNeuropsychological Examination

Assessment - 2

Blood TestsBlood Tests FBC, ESR, U+E, LFT, Ca, PhosphateFBC, ESR, U+E, LFT, Ca, Phosphate TFT, Syphilis serology, B12TFT, Syphilis serology, B12 Autoantibody screenAutoantibody screen C-reactive proteinC-reactive protein Heavy metal screen, copperHeavy metal screen, copper HIVHIV Drug screenDrug screen

Assessment - 3

ECG, CXRECG, CXR CT ScanCT Scan MRIMRI EEGEEG

Alzheimers Disease

Neuropathological diagnosisNeuropathological diagnosis neurofibrillary tangles, senile plaquesneurofibrillary tangles, senile plaques cerebrovascular disease is common in elderly and can be cerebrovascular disease is common in elderly and can be

present with ADpresent with AD PresentationPresentation

memory problems for recent events, insidious onsetmemory problems for recent events, insidious onset Cognitive deficits with social impairmentCognitive deficits with social impairment

InvestigationsInvestigations Blood tests normalBlood tests normal Imaging can be normal in the early stagesImaging can be normal in the early stages ?Vascular risk factors?Vascular risk factors

Vascular Dementia

NeuropathologyNeuropathology ischaemic and haemorrhagic brain lesionsischaemic and haemorrhagic brain lesions

PresentationPresentation unclear temporal relationship between vascular unclear temporal relationship between vascular

events and onset of dementiaevents and onset of dementia InvestigationsInvestigations

vascular risk factors, neurological signsvascular risk factors, neurological signs

Cortical Lewy Body Dementia NeuropathologicalNeuropathological

lewy bodies in cortical neuroneslewy bodies in cortical neurones Senile plaques are common, rarely NFTSenile plaques are common, rarely NFT

PresentationPresentation attention deficits, fluctuation of functionattention deficits, fluctuation of function Parkinsonism, falls, transient disturbance of consciousParkinsonism, falls, transient disturbance of conscious Neuroleptic sensitivityNeuroleptic sensitivity visual hallucinations, delusions, disturbed sleepvisual hallucinations, delusions, disturbed sleep

InvestigationsInvestigations can be normalcan be normal distinguishing clinical coursedistinguishing clinical course

Alcohol-Related Dementia

NeuropathologicalNeuropathological PresentationPresentation

History of abuseHistory of abuse Frontal lobe signs!Frontal lobe signs! Wernicke-Korsakoff (thiamine def), peripheral Wernicke-Korsakoff (thiamine def), peripheral

neuropathy, stigma of liver diseaseneuropathy, stigma of liver disease InvestigationsInvestigations

imaging - cortical atrophy in 50-70%imaging - cortical atrophy in 50-70% ?reversible?reversible

General Management

History, Examination, InvestigationsHistory, Examination, Investigations Clear Diagnosis – Clear Diagnosis – distinguish from delirium + distinguish from delirium +

pseudodemntiapseudodemntia AAMIAAMI Other medical specialities - neurology, geriatricianOther medical specialities - neurology, geriatrician Information in stagesInformation in stages Carer supportCarer support

General Management - 2

Informing the patientInforming the patient Consent to treatmentConsent to treatment Driving, collateral, Driving, collateral,

visuospatial, dyspraxia, frontal lobe signsvisuospatial, dyspraxia, frontal lobe signs Testimentary capacityTestimentary capacity Power of attorneyPower of attorney Available servicesAvailable services Carer supportCarer support

General Management - 3

PsychologyPsychology Social CareSocial Care MedicationMedication Self-help groupsSelf-help groups Voluntary Groups - ASIVoluntary Groups - ASI Carer support groups - respite, education, Carer support groups - respite, education,

training, informationtraining, information

Management of Alzheimers Disease - 1

Symptomatic treatment - cholinesterase inhibitorsSymptomatic treatment - cholinesterase inhibitors Donepezil, Rivastigmine, GalantimineDonepezil, Rivastigmine, Galantimine Memantine, N-methyl-D-aspartate blocker -increase Memantine, N-methyl-D-aspartate blocker -increase

glutamateglutamate Modest benefits - memory, QOL, behaviourModest benefits - memory, QOL, behaviour Benefit = 3-6 month delay/remission of symptomsBenefit = 3-6 month delay/remission of symptoms 15-20% dramatic improvements15-20% dramatic improvements Delay in symptomatic declineDelay in symptomatic decline Evidence for benefit of early treatment?Evidence for benefit of early treatment? Behavioural problems associated with dementiaBehavioural problems associated with dementia CostCost

Management of Alzheimers Disease - 2

Patient Selection and suitabilityPatient Selection and suitability diagnosis of dementiadiagnosis of dementia mild to moderate dementia - MMSE 10-26/30mild to moderate dementia - MMSE 10-26/30 relatively independent? - nursing home residentsrelatively independent? - nursing home residents Compliance assuredCompliance assured ability to give informed consentability to give informed consent discuss criteria for discontinuationdiscuss criteria for discontinuation Absence of medical contra-indicationsAbsence of medical contra-indications ?Use in vascular dementia - controversial, no licence?Use in vascular dementia - controversial, no licence

Management of Alzheimers Disease - 3

Contra-indications - no serious issuesContra-indications - no serious issues Heart block, bradycardia<50/minHeart block, bradycardia<50/min Active peptic ulcerationActive peptic ulceration Severe asthmaSevere asthma

Side-effects of cholinesterase inhibitorsSide-effects of cholinesterase inhibitors GIT - appetite loss, nausea, vomiting, diarrhoeaGIT - appetite loss, nausea, vomiting, diarrhoea

Management of Alzheimers Disease - 6

Treatment DiscontinuationTreatment Discontinuation discussion at commencement of treatmentdiscussion at commencement of treatment Absence of clinically significant benefit after 6-Absence of clinically significant benefit after 6-

8/128/12 Drug holiday if in doubt?Drug holiday if in doubt? Poor compliancePoor compliance poor tolerabilitypoor tolerability side-effectsside-effects

Management of Alzheimers Disease – 7 – Treatment options which have not been proven by DB/RCT Anti-inflammatoryAnti-inflammatory PrednisolonePrednisolone HRTHRT Vitamin E (2000IU)Vitamin E (2000IU) Gingko bilobaGingko biloba

Management of Vascular Dementia

Underlying vascular diseaseUnderlying vascular disease Risk factorsRisk factors

Cardiac assessmentCardiac assessment Carotid diseaseCarotid disease Cerebral embolic diseaseCerebral embolic disease HypertensionHypertension Blood cholesterolBlood cholesterol DiabetesDiabetes SmokingSmoking HypothyroidismHypothyroidism

Management of Lewy Body Dementia

Clear diagnosis to all health professionalsClear diagnosis to all health professionals Avoid neuroleptics - increase mortality?Avoid neuroleptics - increase mortality? Cholinesterase InhibitorsCholinesterase Inhibitors L-dopa for PD!L-dopa for PD!

Management - alcohol dementia

Abstain from alcoholAbstain from alcohol halt progression, ?reversehalt progression, ?reverse

General Management - 2

Informing the patientInforming the patient Consent to treatmentConsent to treatment Driving, collateral, Driving, collateral,

visuospatial, dyspraxia, frontal lobe signsvisuospatial, dyspraxia, frontal lobe signs Testimentary capacityTestimentary capacity Power of attorneyPower of attorney Available servicesAvailable services Carer supportCarer support

General Management - 3

PsychologyPsychology Social CareSocial Care MedicationMedication Self-help groupsSelf-help groups Voluntary Groups - ASIVoluntary Groups - ASI Carer support groups - respite, education, Carer support groups - respite, education,

training, informationtraining, information