Download Assessment and management of dementia in

22/03/2016
Assessment and Management of
Dementia in General Practice
Projected number of people with dementia
NB: Flat line
Leon Flicker
WA Centre For Health and Ageing
University of Western Australia
Royal Perth Hospital
2016
Source: Calculations by AIHW based
on data from Lobo et al. 2000 and
Harvey et al. 2003
Cause of Death in Australia
Years of Life Lost by Condition
In millions per year
WHO website (http://www.who.int/mental_health/neurology/dementia/en/)
WHO website (http://www.who.int/mental_health/neurology/dementia/en/)
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Dementia - ICD 10
• Syndrome due to disease of the brain
• Usually chronic and progressive - at least 6
months for a confident diagnosis
• Involves a decline in multiple higher cortical
functions including memory.
• Should attempt to avoid false positive diagnoses,
especially depression.
• Decline in intellectual functioning affecting
personal activities.
• No clouding of consciousness (delirium)
Vascular Dementia (ICD10)
• General criteria for dementia are met.
• Deficits in higher cognitive functions are unevenly
distributed. Thus memory may be quite markedly affected
while thinking, reasoning and information processing
may show only mild decline.
• Clinical evidence of focal brain damage ( > 1).
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Unilateral spastic weakness
Unilateral increased tendon reflexes
Extensor plantar response
Pseudobulbar palsy
• Evidence from history, examination or tests of significant
cerebrovascular disease which may be reasonably judged
to be aetiologically related to the dementia (eg history of
stroke, evidence of cerebral infarction).
Criteria for Lewy Body Dementia
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Dementia plus two of :
Fluctuating cognition (chronic delirium)
Recurrent visual hallucinations (well formed 80%)
Spontaneous motor features of parkinsonism (75%)
If these features are present then specificity is high
but sensitivity is low (50%).
• Cholinesterase inhibitors may improve apathy,
anxiety, hallucinations and delusions.
Alzheimer’s Disease (ICD 10)
• Primary degenerative cerebral disease with
characteristic neuropathological and neurochemical
features.
– Presence of dementia
– Insidious Onset with slow deterioration
– Absence of clinical evidence or findings from special
investigations to suggest that the mental state may be due to
other systemic or brain disease which can induce a dementia
– Absence of a sudden, apoplectic onset or of neurological
signs of focal damage such as hemiparesis, sensory loss,
visual field defects and incoordination occurring early in the
illness (although these phenomena may be superimposed
later)
Frontotemporal dementia
• Largely defined by the presence or absence of
language disturbance
– Behavioural variant
– Progressive nonfluent aphasia (PFNA)
– Semantic dementia (SD)
• Disordered executive functioning (initiation, planning)
and disinhibited behaviour
• Relatively little memory disturbance
• Anosognosia is common
Mild Cognitive Impairment
• Subjective memory complaints
• Performance on memory functioning or other
mental function below average for age
• Not dementia – no functional impairment
• At this stage prognosis uncertain
In one study > 20% improved in cognitive
function over 2 years and these changes
correlated with improvements in brain
structure Song et al J Neurol Neurosurg Psychiatry 2013; 84:71
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DSM-5
• Was published on May 18, 2013. Both neurocognitive
disorders indicate a decline from previous function
• Dementia became major neurocognitive disorder without
a necessary requirement for memory disorder and DSM5 has a new list of neurocognitive domains, with a list of
potential causative conditions.
• Mild Neurocognitive Disorder due to various putative
conditions seeks to characterize those with objective but
modest cognitive decline who are still independent in
everyday life
• There remains considerable controversy regarding the
use of DSM-5 and whether it has advanced past the
available evidence.
The “Alzheimerization” of
dementia
• This is the idea that dementia is nearly all due
to Alzheimer’s Disease
• There are comparatively little data to support
this.
• Reports have increasingly found less
correlation of Alzheimer pathology with
dementia than the original report, Blessed et al
Br J Psych 1968; 114:797
Dementia or Cognitive Frailty?
• Amyloid as the “cause” of Alzheimers dementia Masters et PNAS 1985
• Hopes were raised that within 10 years, effective interventions
that alter disease progression would be available.
• Some 30 years later, such hopes are somewhat diminished.
• Interventions based on this hypothesis were duly tested and
removed amyloid protein from the brain.
• They did not result in any clinical improvement, and in one trial
of a gamma secretase inhibitor, semagacestat, worsening.
• The most parsimonious explanation is that amyloid
accumulates as part of the brain’s repair mechanism.
• Not all people progress to dementia from MCI and that some
actually improve over time Song et al J Neur, Neurosurg Psych 2013
• Would explain high rates in Indigenous Australians, effects of
physical activity, education, dementia following delirium etc
DSM-5 Cognitive Domains
• Complex attention, which includes sustained attention, divided attention,
selective attention and information processing speed
• Executive function, which includes planning, decision making, working
memory, responding to feedback, inhibition and mental flexibility
• Learning and memory, which includes free recall, cued recall, recognition
memory, semantic and autobiographical long term memory, and implicit
learning
• Language, which includes object naming, word finding, fluency, grammar
and syntax, and receptive language
• Perceptual-motor function, which includes visual perception,
visuoconstructional reasoning and perceptual-motor coordination
• Social cognition, which includes recognition of emotions, theory of mind
and insight
Dementia or Cognitive Frailty?
Age, neuropathology and dementia Savva et al N Engl J Med 2009; 360:2302
The association between the presence of dementia and Alzheimer
pathology decreases with age
• 5 separate pathologies
associated with
“Alzheimers-type dementia”
• Plaques and tangles
• Microvascular Lesions
• Atrophy
• Hippocampal sclerosis
• Cortical Lewy Bodies
(White L 2009)
Spectrum of Possibilities
1. We will develop a series of interventions which will be effective,
cheap and these interventions will not be prone to side-effects. We
will then provide these interventions universally e.g. BP treatment,
vitamins, physical activity, smoking cessation, cognitive
stimulation….
2. The major disease process causing dementia is a single disease
process, called Alzheimer Disease. This disease process has a
stable pathogenic pathway with specific inhibitors. It is thus
possible to devise a specific strategy to target those individuals
who are highly likely to develop the disease.
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Can we diagnose Alzheimers Disease before clinical
symptoms? Preclinical AD
1. Amyloid-β accumulation PET amyloid imaging and/or low Aβ42 on CSF assay
2. Biomarker evidence of synaptic dysfunction and or early neurodegeneration (Stage 2 =
evidence of amyloid positivity + presence of one or more additional AD markers)
a. Elevated CSF tau or phospho-tau
b. Hypometabolism in an AD-like pattern
c. Cortical thinning/grey matter loss in AD-like anatomic distribution and/or hippocampal
atrophy on volumetric MRI
3. Evidence of subtle cognitive decline
How do we apply this? Schneider Lancet Neurology 2013
The AIBL investigators postulate a17-year preclinical period for
AD, consisting of a presymptomatic phase of about 13 or 14
years until episodic memory impairment, and a symptomatic,
pre-dementia phase of 4 years, on average. ..It is evident that a
substantial majority will die earlier than in 17 years and not
develop dementia.
Assessment and Management of
Dementia
• Assessment is closely interlinked with management.
• There has been an increase in interest in this area
because of the cholinesterase inhibitors.
• These symptomatic treatments for Alzheimer's Disease
mandate the need for comprehensive assessment of
people with Alzheimer's Disease and their carers.
• These assessments have the potential to provide more
benefit than the medications themselves though better
access to services and general support.
Recommended screening tools for
cognitive impairment
Early or Timely Diagnosis?
• A diagnosis should be made as soon as possible in every
individual case - Driven by personal and professional
experiences of delays in access to diagnosis and support.
• Currently no high quality evidence that diagnosis before the
usual point of clinical presentation leads to long term
improvements for people with dementia and their families.
“policy cart before the research horse.”
• “Early” versus “screening”
• Potential harms of premature diagnosis
– Diversion of resources from activities of proven value
– Misclassification of substantial numbers of people
– Overdiagnosis and overtreatment
– Raising levels of anxiety in the population, particularly
among older people.
Domains of Assessment
• Cognition
• Functioning
– Activities of daily living
– Instrumental Activities of Daily Living
• Informant information
– Related to cognitive decline
– Abnormal behaviour
• Carer Assessment
– (Medical) Type of dementia & medical comorbidities
Brodaty et al
MJA 2003 178: 231-234
Modified Mini Mental Exam (3MS)
Mini Mental State Exam (MMSE)
The Alzheimer’s Disease Assessment Scale - Cognition (ADAS-Cog)
General Practitioner Assessment of Cognition (GPCOG)
Psychogeriatric Assessment Scale (PAS)
Rowland Universal Dementia Assessment Scale (RUDAS)
Kimberley Indigenous Cognitive Assessment (KICA-Cog)
Montreal Cognitive Assessment (MoCA)
Frontal Assessment Battery (FAB)
EXIT 25
Addenbrooke’s Cognitive Examination (ACE-R now replaced by ACE-III)
Source: www.dementia-assessment.com.au
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Noncognitive Symptoms in
Alzheimer’s Disease
• Personality changes often occur before obvious cognitive
impairment - Range from progressive passivity to marked
hostility.
• Decreased emotional expression, increased stubbornness,
diminished initiative, greater suspiciousness.
• Delusions in up to 50% of patients with paranoid delusions
being the most common.
• Hallucinations, usually visual in up to 25% of patients.
• Depression and anxiety in up to 40% of patients.
Dementia - Diagnostic Protocol
There are two main uses for this information:
Case Identification
Severity and Impact Profile
Positive
Cognition
Informant information on
Cognitive decline
ADL and IADL
Carer evaluation
? Depression, behaviour
If: Short history, acute
illness, depression
More intensive medical
assessment is mandatory
Dementia Disclosure
Analogous to cancer
• You see a 75 year old male patient with normal
cognitive function and a central mass on chest X-ray.
• Sputum cytology reveals non small cell lung cancer
• Do you discuss with his wife whether he can “take”
the diagnosis and then collude to shield him from the
diagnosis?
• He dies without ever knowing the diagnosis
• This was STANDARD treatment for patients with
cancer before 1960. Oken D. What to tell cancer patients. A study of medical attitudes.
Journal of the American Medical Association1961;175:1120–8.
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Why disclose dementia diagnosis?
•
Patient has a right to know (or not to know)
•
Helps to avoid later confusion and ambiguity
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Starting point for sharing information
•
Fosters a collaborative relationship between the patient and
healthcare professional
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Makes future communications easier
•
Enables patient and carer to plan for the future
•
Enables patient to start sorting out legal, financial and practical
issues
•
Maintains openness in the relationship with the patient
Foy et al, 2007
shop
23rd
June
2012
Cholinesterase - Inhibitors
• Donepezil or rivastigmine or galantamine.
• Initial treatment of mild to moderately severe AD
• Confirmation of diagnosis must be by a
specialist/consultant physician (psychiatrist).
• The authority must include the result of the baseline
MMSE, and if this result is at least 25 points, you can
include ADAS-cog.
• May be allowed to use CIBIC if particular group eg
CALD, previous intellectual impairment etc
• Up to a maximum of 1 month’s therapy plus 5 repeats
• Need to demonstrate improvement within 6 months, to
continue treatment.
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Memantine
(Cochrane review McShane et al 2006)
• Low affinity N-methyl-D-aspartate (NMDA) type receptor
antagonists, such as memantine, might prevent excitatory
amino acid neurotoxicity without interfering with the
physiological actions of glutamate necessary for learning and
memory.
• Memantine has a small beneficial, clinically detectable effect
on cognitive function and functional decline measured at 6
months in patients with moderate to severe Alzheimer's
Disease (AD). (PBS MMSE 10-14)
• In patients with mild to moderate dementia, the small
beneficial effect on cognition was not clinically detectable in
those with vascular dementia and barely detectable in those
with AD.
• It is well tolerated. Slightly fewer patients with moderate to
severe AD taking memantine develop agitation, but there is
no evidence either way about whether it has an effect on
agitation which is already present.
Background
CLINICAL PRACTICE
GUIDELINES AND PRINCIPLES
OF CARE FOR PEOPLE WITH
DEMENTIA
NEW practice guidelines for the diagnosis and treatment of dementia in
Australia promise to help frontline health care professionals to improve the
quality and consistency of the care they offer their dementia patients,
according to a Clinical Focus published online (March 14 2016) by the
Medical Journal of Australia
Purpose
• Guidelines synthesise existing evidence.
• Guidelines can improve health outcomes and
increase the efficiency and quality of care.
(Grimshaw
2004)
• The NHMRC and ACSQHC agreed that
Guidelines for Dementia should be prioritised.
• Funding received via the NHMRC Cognitive
Decline Partnership Centre to review existing
guidelines and adapt for the Australian context.
• An agreed standard of care for diagnosis
and management of dementia.
• Apply to home, residential and hospital
settings.
• Relevant to health professionals,
researchers, administrators, policy
makers.
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Guideline Adaptation
Committee
Prof Robert Cumming (Chair)
A/Prof Meera Agar
Prof Kaarin Anstey
Prof Elizabeth Beattie
Prof Henry Brodaty
Prof Tony Broe
Prof Lindy Clemson
Prof Maria Crotty
Ms Margaret Dietz
Prof Brian Draper
Prof Leon Flicker
Content
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Ethical and legal issues
Barriers to care
Considerations for CALD populations
Considerations for ATSI peoples
Diagnosis and assessment
Models of care
Training for staff and students
Promoting independence
Cognitive training and rehabilitation
Acetylcholinesterase inhibitors and memantine
Nutritional supplements
Management of BPSD (non-pharmacological and pharmacological)
Support for carers
Palliative and end of life care
Dignity in Care
Recommendation: “Health and aged care professionals should provide personcentred care, by identifying and responding to the individual needs and
preferences of the person with dementia, their carer(s) and family. The 10
Principles of Dignity in Care should be used as the standard by which care is
delivered and evaluated” (PP)
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2
Zero tolerance of all forms of abuse.
Support people with the same respect you would want for yourself
or a member of your family.
3 Treat each person as an individual by offering a personalised
service.
4 Enable people to maintain the maximum possible level of
independence, choice and control.
5 Listen and support people to express their needs and wants.
6 Respect people’s privacy.
7 Ensure people feel able to complain without fear of retribution.
8 Engage with family members and carers as care partners.
9 Assist people to maintain confidence and a positive self-esteem.
10 Act to alleviate people’s loneliness and isolation.
Ms Meg Friel
Ms Louise Heuzenroeder
A/Prof Susan Koch
Prof Sue Kurrle
Prof Rhonda Nay
Prof Dimity Pond
Dr Jane Thompson
Ms Yvonne Santalucia
A/Prof Craig Whitehead
A/Prof Mark Yates
Types of recommendations
Type of
recommendati
on
Evidence
based
recommendati
on (EBR)
Consensus
based
recommendati
on
Description
Recommendation formulated after a systematic review of the
evidence, with a rating of the overall quality of the evidence and
supporting references provided.
Recommendation formulated in the absence of adequate
evidence, when a systematic review of the evidence has failed to
identify sufficient studies meeting the inclusion criteria for that
clinical question to inform a recommendation.
(CBR)
Practice point
(PP)
A recommendation that is outside the scope of the search
strategy for the systematic evidence review, or for which a
systematic review was not conducted, and is based on expert
opinion.
Timely diagnosis
• “General population screening for dementia should not be
undertaken.” (CBR)
• “Concerns or symptoms should be explored when first raised,
noted or reported by the person, carer(s) or family and should
not be dismissed as ‘part of ageing’.” (PP)
• “Medical practitioners working with older people should be
alert to cognitive decline, especially in those aged 75 years
and older.” (CBR)
Evidence: There were no studies identified that evaluated
screening for cognitive impairment in the general population.
Potential harms and benefits are unknown.
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Memory assessment specialists
and services
•
•
“People with a possible diagnosis of dementia should be offered referral to memory
assessment specialists or services for a comprehensive assessment.” (EBR)
“Memory assessment specialists and services should offer a responsive service to
aid timely diagnosis and should be able to organise a full range of assessment,
diagnostic, therapeutic and rehabilitation services to accommodate the needs of
people with different types and severities of dementia as well as the needs of their
carer(s) and families living in the community. Referrals for required health and aged
care services should be made directly by the specialists or the memory assessment
service.” (PP)
Evidence: One Australian RCT found improved psychosocial status for carers at six
months after visiting a memory clinic compared to those visiting a GP (Logiudice
1999). An RCT and economic evaluation in the Netherlands found no evidence of a
significant difference in cost between memory clinics and general practitioner care
(Meeuwsen 2012).
Training staff
•
“Health and aged care organisations should ensure that all staff working with people with
dementia receive dementia-care training (attitude, knowledge and skill development) that is
consistent with their roles and responsibilities. Training should reflect programs that have
been shown to optimise care for people with dementia. Effective programs tend to be:
delivered face-to-face by someone experienced in dementia care; scheduled over several
training sessions; involve ongoing mentoring or support from someone experienced in
dementia care; and, utilise active learning techniques such as problem solving, case based
training and role plays.” (EBR)
•
“Training programs should be comprehensive and have a strong focus on communicating
effectively with the person with dementia and his or her carer(s) and family and
recognising, preventing and managing behavioural and psychological symptoms of
dementia. Staff should be trained in the principles of person-centred care and how these
principles are applied in practice.” (EBR)
Evidence: There are a number of RCTs that demonstrate that training programs in residential
care settings (as described above) can reduce symptoms such as agitation, reduce
restraint use and improve the quality of care.
Management of symptoms
“To assist the carer(s) and family help the person
with dementia who is experiencing behavioural and
psychological symptoms of dementia, carer(s) and
family should be offered interventions which involve:
•carer skills training in managing symptoms and
communicating effectively with the person with
dementia
•meaningful activity planning
•environmental redesign and modification to improve
safety and enjoyment
•problem solving and management planning.” (EBR)
Diagnosis of dementia
• Comprehensive assessment (history taking, cognitive
and mental state examination, physical examination,
medication review, exclusion of other causes)
• Basic screen (routine haematology, biochemistry,
thyroid function, serum Vit B12 and folate)
• Regular assessment for comorbidities and key
psychiatric features (eg depression and psychosis)
• Routine use of diagnostic technologies (eg biomarkers
for β-amyloid or neuronal injury (eg. 18Ffluorodeoxyglucose Positron Emission Tomography
[FDG-PET] or CSF tau) is considered premature
Management of symptoms
Recommendations support:
• Attempting to minimise symptoms by
considering unmet needs and lowered stress
threshold
• Comprehensive assessment by a
professional with skills in this area (eg ABC
approach)
• Objective measurement to monitor the type
and patterns
• Non-pharmacological approaches in the first
instance
Management of symptoms pharmacological
The Guidelines recommend:
• Trial of analgesic medication where the person is
suspected to be in pain due to distress
• Trial of SSRI antidepressants for agitation
(citalopram has the strongest evidence)
• Avoiding antipsychotics in people with mild to
moderate symptoms
• There is uncertainty around the efficacy of
antidepressants in the treatment of depression in
people with dementia. Larger trials have not
shown benefit.
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Management of symptoms pharmacological
Management of symptoms
• People with severe symptoms causing distress to
themselves or others may be offered treatment with an
antipsychotic. Risperidone and olanzapine have the
strongest evidence for agitation/aggression. Conditions
of use are outlined in the recommendations.
• Recommendations provided regarding use of parenteral
medication (noting that oral medication should be offered
first).
“Where people with dementia have moderate to
severe behavioural and psychological
symptoms of dementia that puts themselves or
others at risk, referral to a specialist service for
the management of behavioural and
psychological symptoms should occur.” (PP)
DBMAS, new Severe Behaviour Response
Teams (SBRTs)
Support for carers
“Carer(s) and family should have access to programs designed to provide support and
optimise their ability to provide care for the person with dementia. Programs should be
tailored to the needs of the individual and delivered in the home or at another accessible
location. Programs should be delivered over multiple sessions and include:
•education regarding dementia and its consequences
•information regarding relevant services including respite
•referral to support organisations such as Alzheimer’s Australia or Carers Australia
•development of individualised strategies and building carer skills to overcome specific
problems experienced by the person with dementia as reported by the carer
•training in providing care and communicating most effectively with the person with
dementia
•support and information regarding coping strategies to maintain their own wellbeing
including stress management
•training in the use of pleasant and meaningful activities as a strategy to engage the
person with dementia” (EBR)
End of life care
• Should be consistent with the person’s Advance Care Plans.
• Health and aged care staff and carers and families should
continue to offer people with dementia food and drink by
mouth.
• Nutritional support, including artificial (tube) feeding, should
be considered if dysphagia is thought to be a transient
phenomenon, but artificial feeding should not generally be
used in people with severe dementia
• Any decision about rehydration should be made in conjunction
with the carer(s) and family after providing them with up-todate information on the potential benefits and harm.
• Ethical and legal principles should be applied in all decision
making (see NHMRC Guide on ethics and decision making in
palliative care for older people)
Carers should be offered respite and be provided with information on how to join a mutual
support group
Conclusion
• The Guidelines are a tool: they provide
clinicians with recommendations detailing
an agreed standard of care
• Evidence based medicine considers the
person’s preferences and clinical
judgement
• Dissemination alone is rarely sufficient –
translation can be challenging and should
be guided by a knowledge translation
framework
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