Transcript Core business for general practice: recognition of and

Core business for general
practice: recognition of and
response to dementia
Ngaire Kerse
Professor, General Practice and Primary Health Care,
University of Auckland
Steve Iliffe
Professor of Primary Care for Older People
University College London
Practice Based Commissioner, Brent PCT
www.evidem.org.uk
What is dementia?
• A complex multi-factorial syndrome.
Querfurth H , Laferla M Alzheimer’s Disease N.
Engl J Med 2010;362:329-44
• Memory loss plus one other
impaired cognitive domain
• Not rocket science
How do you know you are normal?
HEALTHY
Memory
Occasional lapses
Orientation
Full in time, space & person
Judgement & problem-solving
Solves everyday problems
Outside home
Independent functioning
At home
Activities & interests maintained
Personal care
Fully capable
Based on the Clinical Dementia Rating scale (CDR) Hughes CP et al A New Clinical Scale for the
staging of Dementia Br J Psychiatry 1982;140:566-572
Global assessment ~ early
dementia
Memory
Loss of memory for recent events
Orientation
Variable disorientation in time & place
Judgement & problemsolving
Some difficulty with complex problems
Outside home
Engaged in some activities but not
independently: may appear ‘normal’
At home
More difficult tasks & hobbies abandoned
Personal care
Needs some prompting
Cognitive impairment & dementia
Global cognitive functioning
Normal ageing
A
D1
B
Linguistic skill
and general
intelligence
decline over
decades
D2
C
Symptomatic but
pre-diagnostic
phase with brain
compensation
occurring, over
several years
D
E
Symptomatic &
post-diagnosis
phase, with
progressive decline
over years
Dementia trajectory
Time
Cognitive assessment
• Mini-Mental State
Examination (MMSE)
• 6CIT
• GPCog
• MOCA
• Verbal fluency
• Clock drawing
Diagnosis
• Informant history
• Cognitive function tests
• Blood screen (FBC,
thyroid function)
• Scanning
NICE 2006
Psychosocial support
• Regular doctor-initiated contact
– Catastrophic thinking, beliefs attitudes fears
• Review global assessment
– Focus on ‘still do’, reframe as a disability
• Manage co-morbidities
• Review support needed
• Carer’s health
Robinson L et al for the DENDRON Primary Care Clinical Studies
Group Primary care & dementia: 2 Case management, carer
support & the management of behavioural and psychological
symptoms IJGP 2009; Nov 27 [Epub ahead of print]
Core business in general practice
•
•
•
•
Continuity of contact
Population reach
Pattern recognition
Problem solving not
protocol driven
• Systematised care
Mary
• 75 yrs, widowed 2
yrs, Hx breast cancer
age 50
• Complains of losing
her keys, forgetting
appointments, even
left her best dress at
the drycleaners for 2
months
Now
• MMSE 26
• Depressive symptoms
• Offer treatment
– Talking, exercise and drugs
• Improves
2 years time
• Brought by daughter
• Noticed definite change
(you have too)
• Disheveled
• MMSE 22
• diagnosis
• ?Alzheimers type
• Bloods, request imaging