Download dementia 1/6/16 - Highlands Surgery

DEMENTIA 1/6/16
DR TONY O’BRIEN MD FRCP
Dementia
Common – 700,000 sufferers in the UK
Prevalence increases with age
Age
40-65 years
65-70 years
70-80 years
80+
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Prevalence
1 in 100
1 in 50
1 in 20
1 in 5
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Dementia
Chronic disorder affecting higher cortical functions,
including memory, reasoning, orientation, and
communication skills
Gradual loss of skills needed to carry out daily activities
Progressive
Dementia UK Report 2007
Dementia
Deficits in Memory and Functional abilities, plus two more categories
• Memory
• Functional abilities
• Language
• Perceptual skills
• Attention
• Constructive abilities
• Orientation
• Problem solving
Not all about memory
• 1. Age associated memory impairment
• Mild cognitive impairment
• Dementia
Dementia Diagnosis
Neuropsychological assessments – e.g. MMSE, ADAS-cog
Clinical examination
Collateral history
Brain scan
Blood tests
Distribution pathology in typical AD
(Braak and Braak 1991)
Focal dementia
YOU DO NOT NEED IMAGING TO DISTINGUISH
THESE CONDITIONS
R
PATIENT 2
ALZHEIMER’S
PATHOLOGY:
PARIETAL LOBE
→ spatial sx
PATIENT 1
ALZHEIMER’S
PATHOLOGY:
HIPPOCAMPUS
→ memory sx
L
PATIENT 3
ALZHEIMERS OR FTD
PATHOLOGY:
LEFT POSTERIOR
SUPERIOR
TEMPORAL LOBE
→ non-fluent aphasia
PATIENT 4
FTD PATHOLOGY:
LEFT LATERAL
TEMPORAL LOBE
→ fluent aphasia
Dementia
Alzheimer’s
Disease
Others
Dementia
with
Lewy Bodies
55 %
5%
15 %
Vascular
Dementia
20 %
Frontotemporal
lobe dementias
5%
Alzheimer’s
Slow insidious onset
Progressive decline
Early changes in personality – ‘depression’, agitation
Positive family history
Alzheimer’s - Pathology
Loss of cholinergic neurones
Amyloid plaques
Neurofibrillary tangles of Tau proteins
Vascular Dementia
Often abrupt onset
Step-wise progression
Focal neurological signs or symptoms
Evidence of cerebrovascular disease on brain scan
Emotional lability
Early presence of gait disturbance
Dementia with Lewy Bodies (DLB)
Sits somewhere between Alzheimer’s and Parkinson’s
2 out of 3 of
 Spontaneous features of Parkinsonism
 Visual hallucinations
 Fluctuating course
Supporting features
 Recurrent falls / syncope
 Neuroleptic sensitivity - 70 % patients affected
 Systematized delusions
Treatment of Dementia
Education, support and signposting to services
Disease modifying
Symptomatic
Drugs for behavioural disturbance
Dementia Treatment - Symptomatic
Effects vs Slowing Disease
Impairment
Mild
Placebo
Symptomatic
Disease modifying
Severe
Baseline
Treatment Period
End
(Ferris, 8/03)
Alzheimer’s Disease
Cholinesterase inhibitors
 Donepezil, Rivastigmine, Galantamine
Glutamate receptor antagonist
 Memantine
Vascular Dementia
Secondary prevention for stroke - Disease Modifying
 Antiplatelet therapy or anticoagulation if AF
 Statin
 Perindopril +/- Indapamide
Promote healthy lifestyle with regard to diet, exercise, good
diabetic control, smoking cessation, etc.
Case Study
Arthur has recently attended the memory clinic at the hospital and
has been diagnosed with dementia of the ‘mixed type’. Arthur has
a mini-mental state examination (MMSE) of 23. He has a
background history of hypertension and has fallen twice in the
last year.
Amitryptiline 50 mg nocte, Simvastatin 20 mg nocte, Zopiclone 7.5
mg nocte, Bendroflumethiazide 2.5 mg od, Aspirin 75 mg od
Suggest some possible options for management.
The Future
• Alzheimer’s: drugs spontaneous to disease-modifying..multidrug
• Vascular: earlier recognition and aggressive treatment
• Parkinsons: disease modifying drugs: single drug
• Legal situation: living will, Preferred priority care / living
• Societal moral legal debate for treatment of advanced dementia
• Ageism
Acknowledgements
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Dr John Whitear Geriatrician
Dr Lucy Coward Neurologist
S/N Christine Timms
S/N Jackie Smith