1. Specialist Memory Assessment Service-LPT
Dr. D. White - Consultant Psychiatrist
Stuart Kennedy - Memory Service Lead Nurse

2. Session Aims Update Recognition and screening for possible dementia
Accessing specialist memory services
Specialist memory assessment service
Long term management of patients on anti dementia drugs

3. Context National and local drivers
NDS, NICE, Prime Ministers challenge etc
All pointing to-
Early referral for specialist assessment, to ensure timely and accurate diagnosis
Timely diagnosis facilitates access to medication, information and support services .

4. Epidemiology and aetiology
700,000 with dementia in UK, predicted to double by 2050.
Age related condition with 20% of over 85s affected.
Under 65 account for just 2%

5. Locally
126, 200 people over 65 in Leicestershire County and Rutland with dementia, and 35,600 in Leicester City (projected figures)
Predicted to rise to 224,800 by 2025
60% of people in County remain undiagnosed
50% of people in City remain undiagnosed

6. What would you want if you were diagnosed with dementia?
Don’t really know, but probably
To be known by the people looking after me
To have choice in my care for as long as possible
To be sure I had/there was a plan
To have the opportunity to enjoy family, friends etc
To know that my family are looked after/well supported
Information, when I wanted it, suitable to me

7. What is dementia?
“A syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning, capability, language, and judgement. Consciousness is not impaired.”
ICD-10

8. Normal/typical ageing
What is not dementia?
Normal/typical ageing
Slower thinking and problem solving; STM takes longer, reaction time slower
Decreased attention and concentration; more distractedness and difficulty learning
Slower recall; need more hints

9. Typical ageing or dementia?
Occasionally forgets or searches for words
Frequent word-finding pauses, substitutions
Remembers recent important events; conversations are not impaired
Notable decline in memory of recent events and ability to converse
May pause to remember directions but not generally getting lost in familiar places
Gets lost in familiar places
May complain of poor memory, but able to give good examples of forgetfulness .
Patient more concerned than family.
May complain of memory loss if asked, unable to give specific examples. Family more concerned than patient.
Interpersonal skills ok, managing personal care, affairs etc
Loss of interest in social activities, possible decline in functional skills

10. Types of dementia? 4 main types Alzheimer’s disease (approx 60%)
Vascular (30-40%; including approx 20% dual pathology)
Dementia with Lewy bodies (15%)
Fronto-Temporal Dementia (5%)
NB More than 100% due to variability in studies

11. Classification of Alzheimer’s Disease
Based on Mini Mental State Examination (MMSE)
Mild - MMSE 21-26
Moderate - MMSE 15-20
Moderately severe - MMSE 10-14
Severe - MMSE less than 10

12. Is there a common presentation?
Unique to individual and underlying cause
Most may have some (but not all)
Loss of short term memory
Word finding difficulty
Difficulty with familiar tasks (driving, dressing, cooking, finances)
Personality change/uncharacteristic behaviour
Confusion, disorientation, poor judgement

13. Working age dementia
Clinically very little difference other than age of onset
Prevalence year olds =121 per 100,000 with Alzheimer’s disease (26%)*
Sufferers more likely to be
In work
Have dependent children
Be physically fit
Have financial commitments
Have rarer form of dementia
*Harvey et al 2003

14. Also consider
Many conditions may present with cognitive impairment – delirium, depression, medical conditions, side effects to medication.
Important differential diagnoses are delirium and depression, both treatable, both may co- exist with dementia
Chest infections, UTI’s, hypoxia, medications
Some symptoms of dementia may not be common/typical – (disinhibition, apathy, judgement, language, loss of learnt skills)

15. Common differences- 3 D’s
Dementia
Delirium
Depression
Onset
Insidious
Acute
Gradual
Duration
Months/years
Hours/days/weeks
Weeks/months
Course
Progressive/stepwise
Fluctuates, worse at night
Usually worse in mornings
Thoughts
Reduced interest, perseveration, delusions
May be paranoid and grandiose
Slowed, preoccupied, sad, hopeless
Perception
Hallucinations in 30-40% (usually visual)
Visual and auditory common
Mood congruent auditory
Emotion
Depression, anxiety, sun downing
Anxiety/depression common, fear/agitation
Flat, unresponsive, fearful.

16. What is Mild Cognitive Impairment?
Losing or misplacing things
Forgetting appointments, conversations, events etc.
Unable to retain names of new acquaintances
Difficulty following conversations
Intact ADL’s
Decline over time greater than normal ageing (on cognitive tests)
Between 5-20% of older people will have MCI at any time (dependant on definition)

17. Conversion of MCI to dementia
Previously opinion suggested about 10% per annum would develop dementia
Probably 10-15% (dependant on definition and cause)
Current thinking suggests not just a transitional stage, but some may stay static or even improve

18. Screening RCGP recommend MMSE, GP-COG, 6CIT or Mini-Cog
Copyright issue (MMSE, GP-COG, Mini-Cog?)
Locally (see pathway) GP-COG for screening and MMSE for review.

19. GPCOG 2 components – cognitive assessment and informant questionnaire.
Informant questionnaire only needed if cognitive score is score is 5-8 inclusive.
Score of 3 or less on informant questionnaire strongly supports cognitive impairment
Incorporated into SystmOne as template

21. Patients with potential dementia- when to refer.
Refer to packs
Specific functioning problems
Cognitive impairment (GPCOG 5-8 patient informant or MMSE <26 with functional decline)
Atypical features, carer stress/concern
Mood symptoms and need to distinguish from pseudodementia
GPCOG 9 or MMSE but no functional problems or distress monitoring 6 monthly

22. LEICESTER CITY DEMENTIA CARE ADVISERS
Work in Primary and Secondary Care
Employed by Leicester City Council from Oct 2011
8 X Dementia Care Advisors. 1Based in SPOC, 2 in the East, 2 in the West and 3 in the South. Provide information, advice, support, signposting assessments, encourage socialisation, carry out carer assessments and support memory cafés
Referrals currently come from LPT/CMHT/ Memory Clinic and all referrals have to come through SPOC (tel )
Referrals will also come from GP practices under the Shared Care Agreement

23. When referring-
STM, and other problems with cognition. LTM, specific examples
Duration of problem, how long since recognised
Associated symptoms; mood, sleep, personality
Vascular risk factors, past medical and psychiatric history
Functional abilities and risk assessment. NICE recommends and we require
Physical exam
Routine bloods (FBC, U&E, LFT, Thyroid function, glucose, calcium, B12, Folate)
ECG, to prevent delays in starting medication?
Screening GPCOG/MMSE .

24. Referral letter.
Basic data- full name of client, DOB, gender, address, postcode etc
Telephone number including where possible that of family member/contact
Employment status, ethnic origin, religion
Language spoken; is there a need for an interpreter?
Narrative of patient presentation.
GP COG desirable
SystmOne and EMIS referral form

26. Specialist Memory assessment Pathway
Refer to packs
Routine referral from GP incl. bloods and ECG
Referral triaged and allocated to memory service for assessment
Structured assessment
Diagnosis and core interventions
Initial advice on driving

27. Clustering Payment by results (PbR) mental health clusters
18 – 21 are organic mental health clusters
Cluster 18/19 will follow memory pathway and if eligible for AChEi the shared care protocol
Clusters 19, 20, 21 will remain under CMHT if input is required

28. Coffee Break

29. Licensed treatments Donepezil (Aricept) Galantamine (Remenyl)
5 and 10 mg (oro-dispersible tablet available)
Galantamine (Remenyl)
8mg, 16mg and 24mg capsules (maintenance mg). Solution 4mg/ml
Rivastigmine (Exelon)
1.5mg, 3mg, 4.5mg, 6mg capsules
Oral solution 2mg/ml
Transdermal patch 4.6mg and 9.5mg/24hr
Memantine (Ebixa) Starter pack titrates up to 20mg OD within 4 weeks. Oral solution 5mg/0.5ml

30. Donepezil, Galantamine and Rivastigmine.
Cholinergic hypothesis of Alzheimer’s disease suggests that a decline in cognitive function is linked to loss of cholinergic transmission in hippocampus and cortex.
AChEi’s inhibit the cholinesterase enzyme from breaking down acetylcholine, increasing both the level, and duration of the neurotransmitter acetylcholine.
Licensed in mild to moderate Alzheimer’s.

31. Memantine
Acts on Glutamatergic system by blocking NMDA Glutamate receptors.
This is thought to be neuro-protective and possibly disease-modifying.
Approved for use in moderate to severe Alzheimer’s disease
Severe Alzheimer’s - drug of choice
Moderate Alzheimer’s - intolerant of, or contra-indication to AChEi’s

32. Benefits of AChEi Improvement in cognition by an average of 10%
Roughly equivalent of 6 months usual decline
ADLs and functioning may remain above baseline for 6-12 months for most and up to 2 years for some.

33. Side effects (AChEi) Usually mild
Diarrhoea, muscle cramps, fatigue, nausea, vomiting, insomnia.
Headache, pain, common cold, abdominal disturbance, dizziness.
Rarely : Syncope, bradycardia, sinoatrial and atrioventricular block.

34. Use of antipsychotics Concerns around over use and side effects
Cerebrovascular adverse effects (atypicals and typicals
Behavioural and environmental approach first
Multisensory stimulation, bright light therapy, aromatherapy

35. General guidance Target specific symptoms Start low and titrate up
Time limited (review after 3/12 stable)
Evidence for risperidone and olanzapine for physical aggression, agitation and psychosis
Long term use leads to cognitive decline and falls
Discontinue gradually (unless severe side effects)
Some people need to stay on them

36. GP monitoring For all types of dementia 6 monthly review
Functional, behavioural, carer, dementia advisor feedback
Driving capability (see packs)
Medication concordance, S/E, efficacy
Carer strain
Behavioural and psychological symptoms of Dementia (BPSD)
Dedicated Memory Service Lead Nurse linked to each CCG for liaison/advice

37. Referral back to CMHT Urgent – goes to CMHT as usual
Advice regarding medication – phone memory service nurse or consultant psychiatrist
Stuart Kennedy
Dr White (City W)
Dr Prettyman (City W)
Dr Hinchliffe (City E)
Dr Chakrabarti (City E)
We will see again if significant behavioural and psychological symptoms of dementia (BPSD) or complex needs

38. Discontinuation of medication
NICE recommend that all patients who fall into severe category are “considered” for discontinuation of AChEIs
May still be beneficial for Behavioural and Psychological Symptoms of Dementia (BPSD) even if cognition has declined
Less cost implication now
Consider if experiencing harmful effects or deteriorated to extent of palliative care
Discuss with carers

39. Enhanced Service 2013/14 Facilitates 1st 2 strands of NDS by
Encouraging practices to screen populations with suspected dementia, (proposed DES and health checks in GMS contract)
Refer more patients appropriately to Memory Assessment Clinic
Agreeing to continue monitoring of treatment under Shared Care Agreement
Practices will
Nominate lead GP
Maintain adequate records following read codes in clinical records
Subject to approval
Draft document

40. Enhanced service
A draft LES for GP shared care has been developed and will be refreshed following agreement of the 2013/14 enhanced services
Updates will be communicated through locality meetings, practice manager meetings and newsletters

42. Vignettes

43. Vignettes
Case 1
73 year old man, brought to see you by wife who has noticed forgetfulness over last 12 months.
Asking repetitive questions, can’t remember conversations or appointments.
Wife frustrated, patient can’t really see a problem.
Able to wash, dress and perform household chores.
Driving without any problems.
Scores 6/9 on patient GPCOG and 3/6 on informant section.

44. Vignettes
Case 2
67 year old woman who comes to see you very concerned about her memory.
Anxious that she is not functioning as well as she used to.
Complains of forgetting where she has put things, needing to rely on calendar for appointments.
Lives alone, fully independent with activities of daily living.
Worried about Alzheimer’s disease.
Scores 9/9 on GPCOG

45. Vignettes Case 3 79 year old woman
Initially seen by GP with cognitive impairment
Son is main carer
Referred to memory clinic
Diagnosed with Alzheimer’s disease and commenced on Donepezil
After 3 months, has been stable on 10mg
Memory clinic write to you asking you to continue prescription under SCA and review in primary care

46. Vignettes
Case 4
89 year old man with diagnosis of vascular dementia for 3 years, on no psychiatric medication
Under 6 monthly review
Wife phones to say that he has become increasingly agitated now
He appears paranoid and suspicious of her
She is frightened of him
He keeps trying to leave the house and is clearly disorientated in time and place
Initial examination reveals no acute cause for deterioration such as UTI

47. Vignettes Case 5 84 year old woman in residential home
5 year history of Alzheimer’s, on galantamine
Now severely cognitively impaired
Persistent poor appetite and refusal to eat
No obvious physical cause
Very frail
Family reluctant for her to be admitted or have further physical investigations

48. Vignettes
Case 6
69 year old man diagnosed with Alzheimer’s at memory clinic 9 months ago
Driving assessed at memory clinic – DVLA informed of diagnosis, no visuospatial problems
Stable on donepezil prescribed by GP
Attends for 6 monthly review in primary care
Now unable to draw interlocking pentagons
Has had some minor scrapes in his car, but feels he is able to drive safely
Despite your advice not to, he is adamant that he will continue to drive

49. Any Questions?