Transcript Early Detection and diagnosis of Dementia

Early Detection and diagnosis of
Dementia
Dr Alice Seabourne
Consultant Old Age Psychiatrist
Greater Manchester West MH
Foundation Trust.
Context (1)
• 700, 000 people in the UK have dementia
• Annual cost of care is £17bn a year; these values are set to rise. This
is more than the cost of care for heart disease (£4bn), Stroke (£3bn)
and cancer (£2bn)
• Dementia is one of the main causes of disability in later life; in
terms of global burden of disease, it contributes 11.2% of all years
lived with disability—higher than stroke (9.5%), musculoskeletal
disorders (8.9%), heart disease (5%), and cancer (2.4%).
• Two thirds of people with dementia never receive a diagnosis
• The UK is in the bottom third of countries in Europe for diagnosis
and treatment of people with dementia.
• People with mild cognitive impairment are up to 15 times more
likely to develop Alzheimer’s disease than those with normal
cognition
Context (2)
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Dementia is a clinical syndrome characterised by a cluster of symptoms and signs
manifested by difficulties in memory, disturbances in language, psychological and
psychiatric changes, and impairments in activities of daily living.
Some types of dementia are more likely to cause troublesome non-cognitive
symptoms – it is often the non-cognitive symptoms which increase the carer
burden, patient distress and necessitate medical interventions. Apathy and
withdrawal in people with dementia can be as distressing to carers as agitation
and aggression
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Types of dementia (prevalence varies in different ages and populations)
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Alzheimer’s disease
Vascular dementia
Mixed Alzheimer’s disease and vascular dementia
Lewy body dementia
frontotemporal and other focal dementias
subcortical dementias
secondary causes of dementia syndrome (such as intracranial lesions, alcohol)
National Dementia Strategy (2009)
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Aimed to increase awareness of dementia and encourage early recognition of
declining memory function
The priority objectives are:
– good-quality early diagnosis and intervention for all; All people with dementia to have access
to a pathway of care that delivers: a rapid and competent specialist assessment; an accurate
diagnosis, sensitively communicated to the person with dementia and their carers; and
treatment, care and support provided as needed following diagnosis. The system needs to
have the capacity to see all new cases of dementia in the area.
– improved quality of care in general hospitals (40% of people in hospital have dementia with
an excess cost of £6M in an average DGH, people with dementia stay longer in hospital)
– living well with dementia in care homes – 2/3 of people in care homes have dementia and
over half are poorly occupied. Behavioural disturbance is common and are often treated with
antipsychotics
– reduced use of antipsychotic medication - There are an estimated 180,000 people with
dementia on antipsychotic drugs. In only about one third of these cases are the drugs having a
beneficial effect and there are 1800 excess deaths per year as a result of their prescription.
Alzheimer’s society Dementia Map
• Mapping the dementia gap – discrepancy between expected and actual
diagnosis rates
• North West SHA - people with dementia with a diagnosis = 41% (most
PCTs about 40%)
Bolton PCT - people with dementia with a diagnosis = 43% UK ranking - 61
out of 169 (Salford PCT 43% , Trafford PCT = 36% )
• They also extrapolate figures to 2021 where over a million people in the
UK are likely to have a dementia and estimate that in the North West
there will a 30% increase in the incidence of dementia, 29% increase in
Bolton (19% increase in Salford and Trafford).
• 2010 – 2896 people in Bolton expected to have dementia
• 2011 – 2943
• 2012 – 3026
• 2013 - 3051
• http://www.alzheimers.org.uk/dementiamap
Questions
• Is making a diagnosis important?
• Is making an early diagnosis important?
• What discourages early diagnosis?
• Are there any problems making an early diagnosis?
• How do we differentiate between normal ageing, mild cognitive
impairment and early dementia?
• How can we improve early detection?
• Are there any particular at risk populations we might consider screening?
Is making a diagnosis important?
• Making a diagnosis of dementia
– An explanation of symptoms
– Future planning
– Access to appropriate services
• Making a diagnosis of a specific dementia type
– An understanding of future care needs/ disease progression
• May avoid crises in care/inappropriate hospital appearances due to
carer stress
– Specific treatments
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cholinesterase inhibitors for Alzheimer’s disease,
SSRIs for FTD behavioural symptoms
Avoiding antipsychotics in Lewy Body dementia
Treating co-morbidities in vascular disease.
Is making an early diagnosis
important?
• Patient themselves can be more actively involved in
deciding how far they want to go with investigation
and treatment.
• Patients can be involved in service design
• Patient can indicate future care wishes
• Allows early access to appropriate medication
(possibly)
• Allows early access to psychological therapies for
patient+/- carer (possibly).
• Evidence of benefit to carers - carer support and
counselling at diagnosis can reduce care home
placement by 28%.
What discourages early diagnosis?
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Locally we know that people are referred for their first assessment of cognitive decline at very
different stages of their disorder.
Patient factors
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Family/carer factors
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Insight leading to patient initiated referral
Insidious onset (a slow dawning on those around the patient)
Co-morbid non-cognitive symptoms – depression, anxiety, psychosis,
An expectation that cognitive decline is an inevitable part of ageing
Denial/avoidance/a belief nothing can be done.
Carer stress, non-cognitive symptoms
Protection of the patient from the distress of diagnosis
Denial/avoidance/a belief nothing can be done
Healthcare professional factors?
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False reassurance
Lack of time
General lack of systems for early detection.
Training
Are there any problems making an
early diagnosis?
• It is more difficult to be clear about diagnosis of
dementia in the early stages – risk of over
diagnosis or false reassurance. (Normal aging v
Mild Cognitive Impairment v Early dementia)
• More difficult to be clear about exact type
• Possible problems with aftermath of diagnosis
• Needs more specialist assessment and
investigation (more costly)
– Neuroimaging
– Detailed neuropsychology
Mild Cognitive Impairment
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Not a homogenous group
Somewhat disputed concept (but it is in ICD10)
Longitudinal studies suggest that cognitive impairments in this early stage may remain relatively
constant for several years - the individual has subjective symptoms, predominantly of memory loss
and measurable cognitive deficits but without notable impairment in defined activities of everyday
life
Prospective studies have shown that people with amnestic mild cognitive impairment (the form
characterised by memory loss) are up to 15 times more likely to have developed dementia at
follow-up
People with MCI and diabetes are at increased risk of progression to dementia
Recent neuroimaging and neuropsychology studies suggest that subjective memory impairment
predicts subsequent change in hippocampal volume – subjective memory impairment probably
manifests at relatively mild levels of neurodegeneration prior to abnormalities on brief
neuropsychological tests.
Criteria for diagnosing mild cognitive impairment
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Memory complaints, preferably corroborated by an informant
Impaired memory function for age and education
Preserved general cognitive function
Intact activities of daily living
No evidence of dementia
How can we improve early detection?
• Opportunistic screening in primary care
• Targeted screening in primary care
• Self referrals to memory clinics
Detection and Diagnosis.
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Patient report – may be unreliable
Informant history,
Assessment of mood and other non-cognitive symptoms
Assessment of cognitive function
– Standardised Test v Global impression
– Which Tests?
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MMSE
ACE-R
AMTS
GPCOG
6 CIT
• Physical exam
• Blood tests
• Other tests
– ECG
– Neuroimaging (primary or secondary care)
MMSE
• Devised as a screening test (not for repeated use as in monitoring
response to cholinesterase inhibitors) – in particular to differentiate
between organic and mood related cognitive decline.
• Scored out of 30
• A score of less than 24 suggests cognitive impairment that should be
investigated further
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– performance requires intact language and is dependent on educational
attainment and cultural background.
– It can take up to 20 minutes to complete and so may be practical for regular
use only in secondary care.
– Although looks at more cognitive domains than other more simple tests, it
doesn’t cover all functions, in particular not good for frontal/executive
functions and may be evolving a FTD and score 30.
– Isn’t enough in secondary care in patients with earlier cognitive decline
ACE-R
• A test for secondary care
• Much more comprehensive than MMSE
• Includes some tests of frontal/executive
function
• Tend to use it in people who are going to score
high on MMSE
AMTS
• Often used in hospital
• Quick
• Depends on intact language and results may
be affected by educational and cultural
background
GPCOG (General Practitioner
Assessment of Cognition)
• 2 components
– Cognitive assessment conducted with patient (score>8
cognitively intact, score <5 cognitively impaired)
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Address recall
Clock drawing
Recent news events
Date
– Informant questionnaire (only do this if results of
cognitive section are equivocal ie score 5-8) –
rescored out of 15
Local Example of an early detection
strategy
• Large practice in area of multiple social deprivation – an area where
traditionally people present late with their cognitive impairment.
• Innovative GP trainee spends sessions with Old Age Psychiatry
service seeing new and follow up patients under supervision, and in
GP practice reviews people on dementia register, signposts to
appropriate services, discusses with consultant psychiatrist when
there are concerns – allows discharge of more complex people to
the GP.
• Screening at risk patients opportunistically by health staff using
6CIT.
• If score positively on 6CIT booked in for assessment with GP trainee
• GP trainee takes a history, exam, screening bloods, refers to Old Age
Psychiatry where necessary for further assessment.
• High quality referrals at an earlier stage than expected for the
population.
6 CIT (1)
• Devised for use in primary care
• More reliable than MMSE for screening in
primary careInverse (error) scored.
• Maximum score 28
• Normal score 0-7
• Score of 8 or more significantly abnormal.
6CIT (2)
• Six questions
– What year is it?
– What month is it?
– Give the patient a 5 component name and address
phrase to remember (such as John, Smith, 42, High
Street, Bedford)
– About what time is it (within one hour)
– Count backwards from 20-1
– Say the months of the year in reverse
– Ask the patient to repeat the address phrase
requested earlier
Are there any particular groups we
should be screening?
• High risk groups
– People over 80?
– People in residential/nursing home care?
– People with multiple vascular risk factors
(especially diabetes?)
Take home messages
• We are only diagnosing 40% of individuals with
dementia.
• Late diagnosis is associated with worse
outcomes/lack of future planning.
• It is probably of benefit to have systems in place
to detect early memory disorders as early
detection and diagnosis may have benefits to
health and social care economy
• Using structured assessments devised for use in
primary care can increase case finding and
promote earlier diagnosis.
Cholinesterase inhibitors
– A NICE Muddle
• Previous guidelines
– AD, Mild to moderate (MMSE over 10)
– Monitoring
• Current guidelines
– AD Moderate (MMSE 10-20)
– Monitoring
• Likely new NICE guidelines
– AD Mild to Moderate (MMSE over 10)
– Monitoring
Cholinesterase Inhibitors (1)
• 3 drugs – no evidence any difference in efficacy but
tolerability, pharmacokinetic and cost differences
• Locally: Donepezil>Galantamine>Rivastigmine (about
300 people at a time)
• Contraindications
– Cardiac conduction abnormalities
– Severe reversible airways disease
– Actively bleeding GI ulcer
• Side effects
– Nausea and vomiting
– Activation and Agitation
Cholinesterase inhibitors (2)
• Do they work?
• What happens when they do work?
• Are there any predictors of who will be a good
responder?
• How do we monitor?
• How do we decide to stop the drugs?
• How do we stop the drugs?
Cholinesterase Inhibitors (3)
• In Lewy Body Dementia
• For non-licensed indications (eg MMSE under
10)
Memantine (Ebixa)
• Licensed for use in moderate to severe Alzheimer’s
disease
• Widely used on the continent
• Initially rejected by NICE on grounds lack of cost
effectiveness
• Likely that NICE will now approve for
– Severe AD
– Moderate AD where can’t use cholinesterase inhibitors
• Have used in some patients with severe problems in
hospital with mixed benefits
• Significant resource implications to using it widely.
Dementia Treatment Clinic
• 1 OT and 1 nurse
• 300+ patients
• 6/12ly DTC reviews with 6 or 12/12ly medical review
• Patient diagnosed with AD/LBD by Old Age Psych. ECG OK and liable to be
compliant with meds
• DTC see patient at home with carer prior to starting drugs – assessments
of cognition, function, non-cognitive symptoms and carer views
• DTC contact GP to prescribe drugs as per OAPsych letter
• DTC contact patient after initiation of medication to check re side effects.
Remain point of contact for information re drugs.
• DTC review patient at 6/12 (repeat assessments)
• OAPsych review response to treatment at 6/12 and decide if should
continue
• Reviews continue 6/12ly until no longer effective
What do we have/how does it work
now?
• 3 consultants and 3 CMHTs (everything for people over 65) – GP
aligned
• CMHTs have psychologist, CPNs, Specialist SWs STR workers, OT and
Admiral nurse – wide range of skills
• No access for over 65s or people with organic disorders to primary
care mental health psychology
• Access to the Crisis Team (but remain under the care of OAPsych
consultant and don’t take people with organic disorders)
• In-patient beds locally on RBH site (20 male, 20 female)
• Dementia in-reach team
• Firwood day care
• Firwood respite in-reach service
• Liaison service (consultant and nurse)
Referrals
• All referrals screened daily by consultant –
anything urgent is dealt with
• Weekly referral meeting – discuss the referrals
and allocate to appropriate person for
assessment
• Rarely don’t see someone (unless the referral
only talks about counselling which we don’t
provide)
• Mostly seen fairly promptly
What could we do better/differently?
What do people get stuck with?
• Where do people with early onset dementia (ie before age
65) people go for assessment?
• How can we improve advanced planning/crisis planning?
(Including end of life care planning)
• What crises do you get stuck with and what can be done to
improve this?
• Using the Mental Capacity Act
– To get people into physical hospital beds
– DOLS.
• What should we do about resolving delirium after hospital
admission?
• Red drugs