Home > Information for doctors >Tutorials > Dementia tutorial
Francisco Machado
4th April 2000
Feedback and comments to fran@abersychan.demon.co.uk
Contents
| Some initial thoughts |
| Presentation. |
| “Will I get dementia?” |
| Caring for carers |
1.
What are your main concerns about dementia and it’s management in GP
2.
Consider the following case history
Case History
Mrs Jones 65 years, comes to see you because she is fed up with her
relatives interfering with her life. “I know I am a little forgetful but I am
not going demented”. She wants a check up so she can tell her relatives
everything is OK.
What do you do?
Next week Mrs Jones husband and daughters come to see you. They want to
know what is wrong with Mrs Jones. What would you do now?
Mrs Jones deteriorates. How can you help her family?
Now consider the following questions
1.
What are the components of the dementia syndrome?
2.
How common is dementia?
3.
How can dementia be recognized?
4.
How is it inherited?
5.
What drug treatments are available, what do they treat?
6.
What are the effects of looking after a patient with dementia on their
carers?
7.
Who can help?
8.
What is an enduring power of attorney?
Read on some of the answers may be here J
Dementia
Dementia is a syndrome with many causes
An individual may have more than one cause!
Mnemonic “5 As”
Amnesia
First sign noticed by relatives
Symptoms
·
Loosing everyday objects
·
Missing appointments
·
Repeating the same thing in conversations
·
Phoning relatives repeatedly
Tests
·
Registration and recall of name and address
·
Registration and recall of three independent words
Aphasia
Usually nominal
Apraxia
·
May be the prime cause of loss of independence
·
E.g. may gradually affect the ability to dress, eat and
toilet
·
Test by asking individual to draw a clock face
Agnosia
Inability to recognise sensory stimuli despite
intact peripheral senses
·
Unable to recognise family
·
Unable to recognise a car as something that can run
them over
Personality
and Behaviour changes
1.
Patient has often no insight
2.
Apathy may be profound and must always consider
depression
3.
Loss of social skills e.g. social gaffes
4.
Aggression and social disinhibition
Multi-infarct Dementia.
·
Step wise
·
PMH of CVA
·
Relative preservation of personality
·
Emotional lability
List size of
2000 patients dementia:
incidence of 1.6 new
patients/GP/year
prevalence of
3.6 patients consulting/GP/year
workload of
7.4 consultations/GP/ year.
The incidence and
prevalence of dementia increase with increasing age. Identifying early cases of
dementia is not easy as
Complaints of
subjective memory impairment are not a good indicator of dementia; a history of
loss of function is more indicative (B).
Population screening for dementia in the over 65s is not recommended; a case finding approach is recommended
Alzheimer
Disease Society Fact Sheet.
Alzheimer's disease does sometimes run in families, but
this is uncommon. Some rare cases of the disease, which tend to occur in people
younger than usual, are known to be passed on in the genes from one generation
to the next. In these cases, the probability that close family members
(brothers, sisters and children) will develop Alzheimer's disease is one in two.
Most cases of Alzheimer's disease are not of the type that is passed on
genetically. If a family member suffers from the non-genetic form of the
disease, the risk to close relatives is around three times higher than the risk
for a person of a similar age who has no family history of the disease. It is
thought that in these cases a person's genes may contribute to the development
of the disease but do not cause it directly.
Identifying
patients with dementia
Patient's or
carer's history
·
Insight diminishes as
dementia progresses making the patient's history less reliable.
·
In assessing a person with
cognitive impairment, a history of memory problems should be sought from the
carer as well as the patient. The carer might be able to complete the
short mental questionnaire which is a screening tool that is
sensitive to mild dementia
·
Dementia and other
psychiatric symptoms (delusions or hallucinations, or both, usually persecutory
in nature and simple in type) may coexist.
·
The general practitioner's
clinical judgment alone compares unfavorably with the use of formal cognitive
testing in the diagnosis of dementia.
·
General practitioners
should consider using formal cognitive testing to enhance their clinical
judgment.
Mini-mental
state examination
·
The mini-mental state
test. Full test can be cumbersome.
·
The mini-mental state
examination may be influenced by
verbal fluency,
age,
education,
social grouping
·
Four items of the
mini-mental state examination are predictors of dementia:
orientation to day,
spell WORLD backwards,
recall three words,
write a sentence.
·
Reducing the mini-mental
state examination to two items, recall and orientation for place reduces the
specificity only slightly.
In the clock
drawing test, the accuracy of the fourth quadrant of the clock face shows the
greatest sensitivity (87.5%) and specificity (82.3%) for dementia.
Deterioration in
four domains of instrumental activities of daily living are significantly
associated with cognitive impairment. These domains are:
·
managing medication,
·
using the telephone,
·
coping with a budget,
·
and using transportation
Need to screen for
physical causes as some may be the cause of dementia and may be reversible.
People with dementia experience physical morbidity to the same degree as the
general population, but are likely to underreport their symptoms.
Routine tests are
performed:
·
FBC and ESR,
·
biochemistry,
·
serum calcium and
phosphate,
·
thyroid function,
·
simple urine analysis,
·
B12
·
LFTs
The clinical course
of dementia of the Lewy body type differs from that of Alzheimer's disease,
showing clear fluctuations with the following clinical features:
·
complex visual
hallucinations (48%)
·
auditory hallucinations
(14%)
·
paranoid delusions (57%)
·
clouding of consciousness
(81%),
·
falls or collapses (38%),
·
depression (38%),
·
extrapyramidal features
(9.5%)
Depression is
common in patients with dementia
and is associated with an increase in mortality. It is easier to diagnose early
in the illness and responds to treatment in most cases.
Consider a trial of
antidepressant medication evaluated against explicit criteria such as activities
of daily living, level of functioning, behavioural disturbance, and biological
features of recent onset. It is more likely to improve these than any
significant change in cognitive function.
·
Any underlying causes of
behavioural disorder, for example, an acute physical illness, environmental
distress, or physical discomfort, should be excluded . Where underlying causes
are identified they should be managed before prescribing drugs for the
behavioural disorder .
·
General practitioners
should, wherever possible, resist using tranquillisers routinely to control
behaviour disorders in dementia .
·
In crisis situations, the
short term use of neuroleptic drugs may be appropriate.
·
There is a relation
between delusions and aggressive behaviour; aggressive behaviour should be
assessed with this in mind .
·
The care setting and the
attitudes of carers (or care teams in an institutional setting) may influence
the emergence of behavioural problems.
BMJ editorial.
·
often open
·
only for a short period
e.g. < 3 months therefore side effects may not be recognised
·
lump all “behavioural”
symptoms together and this may mask possible effects as behavioural symptoms may
have a diferent pharmacological basis.
Dementia is a common condition, and sufferers have a particularly high risk of adverse treatment
responses, so it
is important to have clear evidence that treatments are both effective and safe.
There is an urgent need for double blind trials focusing on specific behavioural
or psychological signs in dementia, with designs that allow for the high rates
of spontaneous remission, especially studies using cholinesterase inhibitors and
non-pharmacological intervention strategies.
Falls are increased
in people with dementia.
•Medication,
wandering, and reversible confusion contribute to the risk of falls (B).
•People with
dementia who fall are more likely to fall again (B).
•The risk of
falls is not associated with the severity of the dementia but with the
functional capability of the person, and is increased in more capable people
(B).
Aspirin is of
benefit in preventing vascular events or vascular death in patients with a
history of prior transient ischaemic attack or stroke . Atrial fibrillation has
been shown to have an association with cerebrovascular dementia.
Both reviews and
studies show small improvements of variable sustainability. Those who will
respond to hydergine cannot be predicted in advance.
There is no
consistent evidence of clinical benefit from vasodilators in dementia.
Most recent
developments in the drug management of AD have focused on drugs which inhibit
acetylcholinesterase and thus increase the availability of acetylcholine within
the brain.
The evidence to
date is that treatments based on the cholinergic hypothesis are essentially
symptomatic. No substantial data support the hypothesis that these
medications modify the disease that is, delay its progression.
Tacrine has a
moderate effect on cognitive function, but this effect does not seem to
translate to differences in activities of daily living scores. Tacrine has
potentially serious side effects e.g. hepatotoxicity, although in patients who received the drug in clinical trials
these did not seem to lead to permanent damage. The side effects lead to large
number of withdrawals from treatment, and these, coupled with the expense
involved in regular hepatic monitoring, seem to mediate against the use of
tacrine.
Velnacrine maleate
is pharmacologically identical to the primary metabolite of tacrine. Similar in
efficacy to tacrine, velnacrine also leads to substantial hepatotoxicity and
seems, on current evidence, to have no advantage over tacrine.
Donepezil has shown
a moderate effect on cognitive function in short term treatment trials of
patients with mild to moderate Alzheimer's disease (I). These changes in
cognitive function have not been accompanied by measured changes in quality of
life, and evidence of the effects on activities of daily living is inadequate.
Whether donepezil is a worthwhile treatment for Alzheimer's disease has not been
established by current trials, and longer term randomised trials are required to
evaluate its benefits and costs.
North of England
guidelines advise against continuing with long term scripts for donepezil even
when it is initiated in hospital.
Secondly, trials to date have focused on patients with mild to moderate
disease. There is little evidence that these medications work in patients with
either incipient dementia or advanced disease.
Thirdly, concerns have been raised about how these modest increases in
cognition and global impression translate into clinical effects that can be used
in a total care package for people with dementia.
Evidence for the
effectiveness of Ginkgo biloba extract in dementia, from a large randomised
controlled trial, suugests that the
NNT for a 4 point improvement in the cognitive subscale of the Alzheimer's
disease assessment scale at one year of follow up has been calculated as
7.9 (95% confidence interval 4.2 to 67); for a significant improvement
in the geriatric assessment by relative's rating instrument (a daily living and
social behaviour score assessed by family members) it was 7.0 (3.3 to
97). The dose of G biloba extract was 120 mg a day.
Le Bars PL, Katz
MM, Berman N, Itil TM, Freedman AM, Schatzberg AF, for the North American RGb
Study Group. A placebo-controlled, double-blind, randomized trial of an extract
of Ginkgo biloba for dementia. JAMA 1997; 278: 1327-1332 [Medline] .
·
Carer support groups,
though generally perceived as beneficial and helpful, do not reduce the burden
or alter the stress of looking after someone with a dementing illness.
·
Although information is
seen as valuable by carers and best given in a standardised way, it does not
alter outcome
·
Respite services offer
satisfaction and relief to carers and may delay institutionalisation of the care
recipient, but they do not seem to change the overall wellbeing of the carer.
·
Formal training for carers
may reduce their psychological morbidity and may delay institutionalisation of
the dementing person.
·
Day care delays
institutionalisation by reducing the influence of exhaustion and stress on the
carer. Day care does not influence cognitive function. The only activity of
daily living influenced by day care is dressing skills. In one study, intensive
community support with a counselling package for a person with dementia and
their carer appeared to increase the likelihood of staying at home.
·
Depression is common in
carers, and is not particularly associated with the relationship of the carer to
the patient or to any previous history of depression in the carer.
·
Depression in carers is
not eased by institutionalisation or death of the care recipient, nor by
membership of a support group.
·
Low income is associated
with depression in carers.
·
Depression becomes more
likely as care recipients deteriorate, especially if behavioural problems are
evident or there are greater care needs, or both.
·
Carers experience
dissatisfaction with the medical care of their demented relatives in the areas
of information received (leaflets, education) and dealing with carer distress.
Factors in carers
that increase "the burden of care" are usually secondary to the caring
role and include:
stress,
vulnerability,
deterioration in social networking,
economic issues
Male and female
carers experience the impact of care equally, although men are less likely to
discuss it.
The impact of care
continues for carers even after the care recipient is placed in a nursing home
and may be greater than in carers continuing to offer care at home.
Stressors perceived
by the carer vary over time as the caring situation and the presentation of the
dementia change.
A good discussion of the issues surrounding mental incapacity can be
found at
http://www.bmj.com/cgi/content/full/313/7050/156
Alzheimers Disease Society
This is an excellent website with a
huge amount of information. The links pages are also very comprehensive.
Reference:
Martin Eccles. North of England
evidence based guidelines development project: guideline for the primary care
management of dementia. BMJ 1998;317:802-808.
Leon Flicker.
Acetylcholinesterase inhibitors for Alzheimer's disease
Clive Ballard Treating
behavioural and psychological signs in Alzheimer's disease.BMJ 1999;319:138-139
( 17 July )
Burns A. Old Age psychiatry. Update
14 January 1999. 23-30.
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Francisco Machado MM