The Memory Assessment and Treatment Service (MATS) Dr. Liam Higgins Consultant Psychiatrist

Introduction Dementia National Drivers – Dementia Strategy and Guidelines Proposed new clinics

What is Dementia? Dementia is a syndrome due to disease of the brain, usually of a chronic progressive nature, in which there is a disturbance of multiple higher cortical functions. Consciousness is not clouded Often accompanied and sometimes preceded by deterioration in emotional control, social behaviour or motivation

ICD-10 definition Evidence of each of the following: A decline in memory, Mostly in new learning (verbal and non-verbal) Mild, Moderate, Severe A decline in other cognitive abilities: judgement & thinking Absence of clouding of consciousness A decline in emotional control/motivation/social behaviour Duration at least six months; if shorter the diagnosis is tentative

Early Symptoms Struggling to remember recent events Forgetting names Repeated questioning Misplaced objects Others commenting on forgetfulness Anxiety/depression

Epidemiology UK 700,000 (2008); 1.4 million (2038) Cost £17 billion (2008); £50 billion (2038) 60yrs-65yrs – 1.6% doubling every 5 years Under 65: male > female; over 65: female > male Lobo A et al (2000) C) 2.2% of those affected with dementia are under 65

Causes of dementia Alzheimer’s Disease Mixed Vascular Dementia Dementia with Lewy Bodies Fronto temporal Dementia Others

Treatable/Reversible causes Deficiency (B12, Folic acid, Thiamine) Electrolyte imbalances (chronic) Metabolic (uraemia, hepatic problems) Endocrine (hypothyroidism) Normal Pressure Hydrocephalus Tumour/trauma (SOL & SDH) Infection/Inflammation (HIV, SLE etc) Alcohol, toxins and drugs

Alzheimer’s Disease General criteria for dementia Insidious onset with slow deterioration No evidence of other possible causes of dementia CT scan: generalised cerebral atrophy, more in the medial temporal lobe

Vascular Dementia Uneven impairment of cognitive functions There is clinical evidence of focal brain damage Abrupt onset and stepwise deterioration Evidence of stroke, hypertension, other risk factors for vascular disease Personality relatively preserved, emotional lability Large vessel infarct: Small ischaemic changes

Lewy Body Dementia Core features: Fluctuating cognition Recurrent well formed and detailed visual hallucinations Features of parkinsonism Suggestive features: Repeated falls Sensitivity to antipsychotics

Fronto temporal Dementia Early decline in social interpersonal conduct Impairment in regulation of personal conduct Emotional blunting Loss of insight Neuropsychology: impaired frontal lobe tests Imaging: Frontal and/or anterior temporal abnormality

The National Dementia Strategy Ensure better knowledge Help everyone to understand dementia better. Get rid of the stigma attached to dementia 2) Ensure early diagnosis Only about a third of people with dementia ever have a proper diagnosis 3) Develop services

Early diagnosis Liaison services Education National Dementia Strategy Carers assessments Dementia Advisors Support at home

NICE Guidelines (PACE Guidelines) Early identification in Primary Care Consider referring people with signs of mild cognitive impairment (MCI) for assessment at memory assessment services Be aware of the increased risk of dementia in people with learning disabilities The possibility of dementia in other high risk groups (for example people who have had a stroke or have a neurological condition such as Parkinson’s disease)

Diagnosis and assessment History taking Physical examination Review of medication to identify any drugs That may impair cognitive functioning Conduct formal cognitive testing using standardised instrument, such as Mini Mental State Examination (MMSE) General Practitioner Assessment of Cognition (GPCOG) 6 Item Cognitive Impairment Test (6-CIT)

Investigation of Suspected dementia Conduct a basic dementia screen at the time of presentation, usually in primary care. Include: -routine haematology -biochemistry tests (electrolytes, calcium, glucose, and renal and liver function) -thyroid function tests -serum vitamin B12 and folate levels

The proposed memory clinics 3 clinics a week 3 different sites in North Bradford

Structures of the Clinics History, Mental State Examinations Addenbrooke’s Cognitive assessment – Revised (ACE-R) Carer assessment Input from Alzheimer’s society Medication commenced and titrated (according to NICE guidelines)

Access to services Financial help Medication The benefits of receiving a diagnosis Carer support Information and support