Presentation on theme: "Specialist Memory Assessment Service-LPT"— Presentation transcript:
1Specialist Memory Assessment Service-LPT Dr. D. White - Consultant PsychiatristStuart Kennedy - Memory Service Lead Nurse
2Session Aims Update Recognition and screening for possible dementia Accessing specialist memory servicesSpecialist memory assessment serviceLong term management of patients on anti dementia drugs
3Context National and local drivers NDS, NICE, Prime Ministers challenge etcAll pointing to-Early referral for specialist assessment, to ensure timely and accurate diagnosisTimely diagnosis facilitates access to medication, information and support services.
4Epidemiology 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%
5Locally126, 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 202560% of people in County remain undiagnosed50% of people in City remain undiagnosed
6What would you want if you were diagnosed with dementia? Don’t really know, but probablyTo be known by the people looking after meTo have choice in my care for as long as possibleTo be sure I had/there was a planTo have the opportunity to enjoy family, friends etcTo know that my family are looked after/well supportedInformation, when I wanted it, suitable to me
7What 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
8Normal/typical ageing What is not dementia?Normal/typical ageingSlower thinking and problem solving; STM takes longer, reaction time slowerDecreased attention and concentration; more distractedness and difficulty learningSlower recall; need more hints
9Typical ageing or dementia? Occasionally forgets or searches for wordsFrequent word-finding pauses, substitutionsRemembers recent important events; conversations are not impairedNotable decline in memory of recent events and ability to converseMay pause to remember directions but not generally getting lost in familiar placesGets lost in familiar placesMay 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 etcLoss of interest in social activities, possible decline in functional skills
10Types 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
11Classification of Alzheimer’s Disease Based on Mini Mental State Examination (MMSE)Mild - MMSE 21-26Moderate - MMSE 15-20Moderately severe - MMSE 10-14Severe - MMSE less than 10
12Is there a common presentation? Unique to individual and underlying causeMost may have some (but not all)Loss of short term memoryWord finding difficultyDifficulty with familiar tasks (driving, dressing, cooking, finances)Personality change/uncharacteristic behaviourConfusion, disorientation, poor judgement
13Working age dementiaClinically very little difference other than age of onsetPrevalence year olds =121 per 100,000 with Alzheimer’s disease (26%)*Sufferers more likely to beIn workHave dependent childrenBe physically fitHave financial commitmentsHave rarer form of dementia*Harvey et al 2003
14Also considerMany 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 dementiaChest infections, UTI’s, hypoxia, medicationsSome symptoms of dementia may not be common/typical – (disinhibition, apathy, judgement, language, loss of learnt skills)
15Common differences- 3 D’s DementiaDeliriumDepressionOnsetInsidiousAcuteGradualDurationMonths/yearsHours/days/weeksWeeks/monthsCourseProgressive/stepwiseFluctuates, worse at nightUsually worse in morningsThoughtsReduced interest, perseveration, delusionsMay be paranoid and grandioseSlowed, preoccupied, sad, hopelessPerceptionHallucinations in 30-40% (usually visual)Visual and auditory commonMood congruent auditoryEmotionDepression, anxiety, sun downingAnxiety/depression common, fear/agitationFlat, unresponsive, fearful.
16What is Mild Cognitive Impairment? Losing or misplacing thingsForgetting appointments, conversations, events etc.Unable to retain names of new acquaintancesDifficulty following conversationsIntact ADL’sDecline over time greater than normal ageing (on cognitive tests)Between 5-20% of older people will have MCI at any time (dependant on definition)
17Conversion of MCI to dementia Previously opinion suggested about 10% per annum would develop dementiaProbably 10-15% (dependant on definition and cause)Current thinking suggests not just a transitional stage, but some may stay static or even improve
18Screening 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.
19GPCOG 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 impairmentIncorporated into SystmOne as template
21Patients with potential dementia- when to refer. Refer to packsSpecific functioning problemsCognitive impairment (GPCOG 5-8 patient informant or MMSE <26 with functional decline)Atypical features, carer stress/concernMood symptoms and need to distinguish from pseudodementiaGPCOG 9 or MMSE but no functional problems or distress monitoring 6 monthly
22LEICESTER CITY DEMENTIA CARE ADVISERS Work in Primary and Secondary CareEmployed by Leicester City Council from Oct 20118 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 cafésReferrals 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
23When referring-STM, and other problems with cognition. LTM, specific examplesDuration of problem, how long since recognisedAssociated symptoms; mood, sleep, personalityVascular risk factors, past medical and psychiatric historyFunctional abilities and risk assessment. NICE recommends and we requirePhysical examRoutine bloods (FBC, U&E, LFT, Thyroid function, glucose, calcium, B12, Folate)ECG, to prevent delays in starting medication?Screening GPCOG/MMSE.
24Referral letter.Basic data- full name of client, DOB, gender, address, postcode etcTelephone number including where possible that of family member/contactEmployment status, ethnic origin, religionLanguage spoken; is there a need for an interpreter?Narrative of patient presentation.GP COG desirableSystmOne and EMIS referral form
26Specialist Memory assessment Pathway Refer to packsRoutine referral from GP incl. bloods and ECGReferral triaged and allocated to memory service for assessmentStructured assessmentDiagnosis and core interventionsInitial advice on driving
27Clustering Payment by results (PbR) mental health clusters 18 – 21 are organic mental health clustersCluster 18/19 will follow memory pathway and if eligible for AChEi the shared care protocolClusters 19, 20, 21 will remain under CMHT if input is required
29Licensed treatments Donepezil (Aricept) Galantamine (Remenyl) 5 and 10 mg (oro-dispersible tablet available)Galantamine (Remenyl)8mg, 16mg and 24mg capsules (maintenance mg). Solution 4mg/mlRivastigmine (Exelon)1.5mg, 3mg, 4.5mg, 6mg capsulesOral solution 2mg/mlTransdermal patch 4.6mg and 9.5mg/24hrMemantine (Ebixa) Starter pack titrates up to 20mg OD within 4 weeks. Oral solution 5mg/0.5ml
30Donepezil, 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.
31MemantineActs 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 diseaseSevere Alzheimer’s - drug of choiceModerate Alzheimer’s - intolerant of, or contra-indication to AChEi’s
32Benefits of AChEi Improvement in cognition by an average of 10% Roughly equivalent of 6 months usual declineADLs and functioning may remain above baseline for 6-12 months for most and up to 2 years for some.
33Side 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.
34Use of antipsychotics Concerns around over use and side effects Cerebrovascular adverse effects (atypicals and typicalsBehavioural and environmental approach firstMultisensory stimulation, bright light therapy, aromatherapy
35General 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 psychosisLong term use leads to cognitive decline and fallsDiscontinue gradually (unless severe side effects)Some people need to stay on them
36GP monitoring For all types of dementia 6 monthly review Functional, behavioural, carer, dementia advisor feedbackDriving capability (see packs)Medication concordance, S/E, efficacyCarer strainBehavioural and psychological symptoms of Dementia (BPSD)Dedicated Memory Service Lead Nurse linked to each CCG for liaison/advice
37Referral back to CMHT Urgent – goes to CMHT as usual Advice regarding medication – phone memory service nurse or consultant psychiatristStuart KennedyDr 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
38Discontinuation of medication NICE recommend that all patients who fall into severe category are “considered” for discontinuation of AChEIsMay still be beneficial for Behavioural and Psychological Symptoms of Dementia (BPSD) even if cognition has declinedLess cost implication nowConsider if experiencing harmful effects or deteriorated to extent of palliative careDiscuss with carers
39Enhanced 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 ClinicAgreeing to continue monitoring of treatment under Shared Care AgreementPractices willNominate lead GPMaintain adequate records following read codes in clinical recordsSubject to approvalDraft document
40Enhanced serviceA draft LES for GP shared care has been developed and will be refreshed following agreement of the 2013/14 enhanced servicesUpdates will be communicated through locality meetings, practice manager meetings and newsletters
43VignettesCase 173 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.
44VignettesCase 267 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
45Vignettes Case 3 79 year old woman Initially seen by GP with cognitive impairmentSon is main carerReferred to memory clinicDiagnosed with Alzheimer’s disease and commenced on DonepezilAfter 3 months, has been stable on 10mgMemory clinic write to you asking you to continue prescription under SCA and review in primary care
46VignettesCase 489 year old man with diagnosis of vascular dementia for 3 years, on no psychiatric medicationUnder 6 monthly reviewWife phones to say that he has become increasingly agitated nowHe appears paranoid and suspicious of herShe is frightened of himHe keeps trying to leave the house and is clearly disorientated in time and placeInitial examination reveals no acute cause for deterioration such as UTI
47Vignettes Case 5 84 year old woman in residential home 5 year history of Alzheimer’s, on galantamineNow severely cognitively impairedPersistent poor appetite and refusal to eatNo obvious physical causeVery frailFamily reluctant for her to be admitted or have further physical investigations
48VignettesCase 669 year old man diagnosed with Alzheimer’s at memory clinic 9 months agoDriving assessed at memory clinic – DVLA informed of diagnosis, no visuospatial problemsStable on donepezil prescribed by GPAttends for 6 monthly review in primary careNow unable to draw interlocking pentagonsHas had some minor scrapes in his car, but feels he is able to drive safelyDespite your advice not to, he is adamant that he will continue to drive