1. Managing memory problems in primary care
Dr Uche Oguekwe

3. Introduction
As the UK population is living longer , memory problems are now seen frequently in primary care
The RCGP curriculum statement 9 version 1.1 expects the GP to be able to manage contacts with older patients and deal with their unselected problems
Dementia UK report (2007) states that there are currently 700,000 people with dementia in the UK, and this is projected to rise to over a million by The overall cost of dementia is estimated to be £17-18 billion a year.
Dementia can occur at any age, but is most common in older people, affecting one in six people over the age of 80. Early onset dementia is defined as dementia occurring in those under 65 years of age and accounts for 2.2 % of all people with dementia in the UK.

4. Scope
Initial assessment of patient presenting with memory loss symptom using 2 case studies
Distinguish those with memory symptoms caused by conditions other than dementia
Recognise the impact of dementia on the health of the nation
Will briefly look at broader aspects of caring for people with dementia, including issues around driving & non- cognitive symptoms in people with dementia

5. Case 1 Mrs AB 82 years old, married for 60 years, pmhx of HTN
Husband recently diagnosed with dementia and moved to nursing home
Daughter came to surgery, saying her mum has been behaving odd in the last few weeks
Called the police more than three times in four weeks, saying a group of men have broken through her window
Making inappropriate gestures to her neighbour
Forgetting to lock her doors
Not remembering what she has done the previous day
Unkempt, weight loss and not eating much
Refusing carers at home and does not want to go into care / nursing home

6. What are the issues raised
Confidentiality?
patient’s safety?
Vulnerable adult/ elder abuse?
Daughters agenda?
Mental capacity?
Anymore??

7. Assessment
A home visit was arranged with Mrs AB with her 2 daughters present
She scored 28/30 on MMSE
She says she is absolutely fine and that she does not lock her door as she wants her male visitors to have access
Denied calling the police
Agreed to have urine dip which was normal
Agreed to have blood test and referral to memory clinic

8. Outcome Seen by memory clinic psycho geriatrician MMSE remained 28/30
She now had more psychotic features
Further questioning revealed abuse as a child and strong family history of mental health problems
CT scans and bloods all came back normal
A diagnosis of psychotic pseudo-dementia was made
She was started on Risperidone 0.5mg , which was later increased to 1mg with good effect
Daughters have now signed the next of kin papers

9. Case 2 Mrs BC 90 years old, seen with her husband
Retired Consultant Obstetrician
Her husband has noticed that she has become forgetful and keeps repeating herself
Forgot to turn off gas on few occasions
pmshx- HTN & hypothyroid
Ex-smoker and Etoh 5units/ week
No family history of memory problems
Bloods, Ecg and urine were all normal
MMSE 23/30- lost marks on short term memory and recall

10. What will you do next? She was referred to the memory clinic
Repeat MMSE remained at 23/30
A diagnosis of Alzheimer dementia was made , although she has risk factors for Vascular dementia
CT head and further neuro-psychological testing confirmed probable Alzheimer's
She was started on a trial of ACHi- donepezil by the specialist
She was also assessed by the OT who advised use of memory aids
She has remained stable and reviewed regularly by the PHCT.

11. How should GP’s assess patients with memory problems
Should find out what is meant by ‘memory problem’ or ‘forgetful’? Ask for specific examples, such as forgetting days, times, appointments, names or familiar faces. Are there problems with getting lost, speech, using the correct words, writing or reading?
The length of history and progression of the problem
Any associated features such as problems with sleep, hallucinations or change in personality
Any change in functional ability. For example, has this affected home life, management of finances, work , or problems with driving

12. How should GP’s assess patients with memory problems
other important factors are features of depression or anxiety.
E.g. sleep disturbance, lack of motivation, anhedonia (loss of enjoyment), poor appetite or tearfulness
Past medical (vascular risk factors , Parkinson’s disease )and psychiatric history.
Medications including analgesics and sedatives
Social circumstances : any recent changes such as retirement, change of housing, location or a bereavement
Alcohol intake
Smoking history
Family history of memory problems or dementia

13. How should GP’s assess patients with memory problems
A physical examination is definitely important
The Abbreviated Mental Test Score (AMTS) -this may suffice as screening during a 10 min consultation
The Mini Mental State Examination ( MMSE) -this is widely regarded as the “gold standard” test for dementia- but there are now copyright issues which prevents GP’s from printing this off
Asking a patient to draw a clock face and set the time to is a useful addition to the MMSE
An intermediate step is the Addenbrookes Cognitive Examination (ACE)- domains tested includes attention, memory, language, visuo- spatial skills and executive function

14. Other cognitive test which may be used in primary care
The 7-Minute Screen
General Practitioner Assessment of Cognition (GPCOG)
The Mini-Cog Assessment Instrument
The Memory Impairment Screen (MIS)
The 6-Item Cognitive Impairment Test (6-CIT)
The GPCOG, Mini-Cog and MIS are brief and have been shown to be as clinically and psychometrically robust as the MMSE. Appropriate for use in primary care.
GPCOG is readily available via the patient.co.uk website for GPs to use.

15. Investigations
A stepwise approach to investigation is required. Routine investigations to help rule out physical causes
FBC, urea and electrolytes, liver function tests, bone profile , folate & vitamin B12 level, thyroid function tests, random or fasting blood sugar & cholesterol level
ECG, CXR
Urinalysis
An assessment of cognition using one of the tools outlined above

16. Diagnoses to consider in patients with memory loss
The commonest cause of significant memory impairment is AD
There are many factors that can influence cognitive decline and they include
Stroke
Hypothyroidism
Hyperparathyroidism
Recurrent head trauma
Hypoperfusion
Medication use
Depression
Alcohol and drug abuse
Toxins, infections , metabolic and structural causes

17. Other possible diagnosis
There are many causes of dementia and in the early stages they will present with mild memory impairment. The following list is far from all inclusive:
About 20% of patients with Parkinson's disease also develop dementia
Dementia with Lewy body is the second only to AD as a common cause of dementia
Pick’s disease ( Fronto-temporal dementia)
Huntington’s chorea
Syphilis
AIDS
Multiple Sclerosis
Creutzfeldt-jakob disease
Carbon monoxide and heavy metal poisoning

18. Management
The Alzheimer’s society recommend the following non- drug strategies to cope with memory loss:
Keeping a to do list
Use of memory aids such as watch, calendar and diary
Regular exercise
Stop smoking
Adequate sleep

19. Management contd
General safety measures such as installing smoke alarm and gas detectors within the home of individuals with dementia
Other factors such as reduction in alcohol intake, control of HTN, diabetes and high cholesterol have all been found useful especially in VaD
Treatment of any underlying cause such as B12 def, hypothyroidism
Use of cholinesterase inhibitors (Aricept) and glutamate antagonist (memantine) as cognitive enhancers. NICE supports use of the MMSE with scores between 20 and 10 and six monthly checks, stopping when MMSE < 10

20. NICE recommendation
NICE recommends taking the following into consideration when assessing a possible diagnosis of dementia
The individual’s self report of changes in memory , capability or mood
Informant histories that support self report and add significant new details of changes
Exclusion of depression and delirium as primary pathologies, using the information from the personal and informant histories
Measurable cognitive losses, using a standardised instrument
Absence of ‘red flag’ symptoms suggesting alternative diagnoses e.g. Urinary incontinence or ataxia in apparent early dementia

21. Issue of driving
Driving is not necessarily prohibited in early dementia (refer to DVLA guidelines). As with any condition, if there are any concerns (incidents, family members do not feel safe) then advise the patient not to drive until further information is available. Once a diagnosis of dementia has been made, the DVLA should be informed of this.

22. Broader aspects of caring for people with dementia
Non-cognitive symptoms are prevalent in dementia and can arise as dementia progresses.
They can be difficult to identify and pose challenges in management.
Such symptoms include:
Depression
Delusions and hallucinations
Agitation
Wandering
Swallowing problems
End of life care
Although prevalent in certain specialist settings such as care homes, these symptoms may also occur in people with dementia being cared for at home. Regardless of the setting in which they occur, such symptoms can be distressing for both the person with dementia and also the carers involved.

23. summary
Diagnosis of dementia can be lengthy, complex and Staged over time.
Diagnosing the type of dementia is just the beginning of the management process for this chronic condition.
Any patient suspected of having dementia should be referred to specialist for diagnosis – taking into account their wishes because of the irreversible and progressive nature of dementia, and the implications that this has for the patient and also their family
Early detection allows patients and their families access to information, support services, medications, and enables them to make preparation for the future

24. Local dementia and memory resources
Dementia team and memory clinic – mental health services for older people at Elizabeth house Gillingham- refer all cases of suspected dementia
Medway dementia advisor service offers support to those who are newly diagnosed and to those who have had dementia for some time
The 24 hour dementia helpline offers information and emotional support for anyone in Kent or Medway with dementia, & their carers
Dementia web- offers comprehensive online info & advice about the many aspects of living with dementia and caring for someone with the condition

25. Use it or lose it