Download Specialist Memory Assessment Service-LPT

Dementia training for GPs
Dr. S. Hamer- Consultant Psychiatrist
Caroline Molloy- Memory Service Lead
Nurse
January 2013
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Update
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Recognition and screening for possible dementia
Psychosocial support in primary care
Referring to specialist memory services
Specialist memory assessment service
Long term management of patients on anti
dementia drugs
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National and local drivers
• NDS, NICE, Prime Ministers challenge etc
• All pointing to-
• Early referral for specialist assessment, to ensure
timely and accurate diagnosis
• Timely diagnosis facilitates access to medication,
information and support services
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700,000 with dementia in UK, predicted to
double by 2050.
Age related condition with 20% of over 85s
affected.
Under 65 account for just 2%
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126, 200 people over 65 in Leicestershire
County and Rutland with dementia.
Predicted to rise to 224,800 by 2025 (County
and City)
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Don’t really know, but probably
To be known by the people looking after me
To have choice in my care for as long as possible
To be sure I had/there was a plan
To have the opportunity to enjoy family, friends etc
To know that my family are looked after/well
supported
◦ Information, when I wanted it, suitable to me
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“A syndrome due to disease of the brain,
usually of a chronic or progressive nature, in
which there is disturbance of multiple higher
cortical functions, including memory,
thinking, orientation, comprehension,
calculation, learning, capability, language,
and judgement. Consciousness is not
impaired.”
ICD-10
Normal/typical ageing
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Slower thinking and problem solving; STM
takes longer, reaction time slower
Decreased attention and concentration; more
distractedness and difficulty learning
Slower recall; need more hints
Typical ageing
Dementia
Occasionally forgets or searches
for words
Frequent word-finding pauses,
substitutions
Remembers recent important
events; conversations are not
impaired
Notable decline in memory of
recent events and ability to
converse
May pause to remember directions
but not generally getting lost in
familiar places
Gets lost in familiar places
May complain of poor memory, but May complain of memory loss if
able to give good examples of
asked, unable to give specific
forgetfulness .
examples. Family more concerned
Patient more concerned than
than patient.
family.
Interpersonal skills ok, managing
personal care, affairs etc
Loss of interest in social activities,
possible decline in functional skills
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4 main types
◦ Alzheimer’s disease (approx 60%)
◦ Vascular (30-40%; including approx 20% dual
pathology)
◦ Dementia with Lewy bodies (15%)
◦ FTD (5%)
◦ NB More than 100% due to variability in studies
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Unique to individual and underlying cause
Most may have some (but not all)
◦ Loss of short term memory
◦ Word finding difficulty
◦ Difficulty with familiar tasks (driving, dressing,
cooking, finances)
◦ Personality change/uncharacteristic behaviour
◦ Confusion, disorientation, poor judgement
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Clinically very little difference other than age
of onset
Prevalence 45-64 year olds =121 per
100,000 with Alzheimer’s disease (26%)*
Sufferers more likely to be
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In work
Have dependent children
Be physically fit
Have financial commitments
Have rarer form of dementia
*Harvey et al 2003
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Many conditions may present with cognitive
impairment – delirium, depression, medical
conditions, side effects to medication.
Important differential diagnoses are
delirium and depression, both treatable,
both may co-exist with dementia
Chest infections, UTI’s, hypoxia,
medications
Some symptoms of dementia may not be
common/typical – (disinhibition, apathy,
judgement, language, loss of learnt skills)
Dementia
Delirium
Depression
Onset
Insidious
Acute
Gradual
Duration
Months/years
Hours/days/weeks
Weeks/months
Course
Progressive/stepwise
Fluctuates, worse
at night
Usually worse
in mornings
Thoughts
Reduced interest,
perseveration,
delusions
May be paranoid
and grandiose
Slowed,
preoccupied,
sad, hopeless
Perception Hallucinations in 3040% (usually visual)
Visual and auditory
common
Mood
congruent
auditory
Emotion
Anxiety/depression Flat,
common,
unresponsive,
fear/agitation
fearful.
Depression, anxiety,
sun downing
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Losing or misplacing things
Forgetting appointments, conversations,
events etc.
Unable to retain names of new acquaintances
Difficulty following conversations
Intact ADL’s
Decline over time greater than normal ageing
(on cognitive tests)
Between 5-20% of older people will have MCI
at any time (dependant on definition)
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Previously opinion suggested about 10% per
annum would develop dementia
Probably 10-15% (dependant on definition
and cause)
Current thinking suggests not just a
transitional stage, but some may stay static
or even improve
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RCGP recommend MMSE, GP-COG, 6CIT or
Mini-Cog
Copyright issue with MMSE
Locally (see pathway) GP-COG for screening
and MMSE for review (waiting for DoH
guidance on this)
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2 components – cognitive assessment and
informant questionnaire.
Informant questionnaire only needed if
cognitive score is score is 5-8 inclusive.
Score of 3 or less on informant questionnaire
strongly supports cognitive impairment
◦ Available on EMIS/SystmOne
◦ Specific functioning problems
◦ Cognitive impairment (GPCOG 5-8 patient + 0-3
informant or MMSE <26 with functional decline)
◦ Atypical features, carer stress/concern
◦ Mood symptoms and need to distinguish from
pseudodementia
◦ Offer referral to Memory Adviser at this point
◦ GPCOG 9 or MMSE 26 - 30 but no functional
problems or distress monitoring 6 monthly
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For support of patients with memory problems in
primary care
Contract awarded to Alzheimer’s Society October
2012
7 Memory Advisers (+ Manager) ensuring equitable
cover of all geographic areas across the county
Provide information, advice, support and planning
Can help practices to populate registers
Referrals from GP practices and/or memory clinic
◦ NB Voluntary Service Organisers (Age UK) currently support
CMHT’s/memory clinics following diagnosis.
◦ STM, and other problems with cognition. LTM,
specific examples
◦ Duration of problem, how long since recognised
◦ Associated symptoms; mood, sleep, personality
◦ Vascular risk factors, past medical and psychiatric
history
◦ Functional abilities and risk assessment
◦ NICE recommends and we require:
◦ Physical exam
◦ Routine bloods (FBC, U&E, LFT, Thyroid function,
glucose, calcium, B12, Folate)
◦ ECG, to prevent delays in starting medication
◦ Screening GPCOG/MMSE
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Basic data- full name of client, DOB, gender,
address, postcode etc
Telephone number including where possible
that of family member/contact
Employment status, ethnic origin, religion
Language spoken; is there a need for an
interpreter?
Narrative of patient presentation
GP COG desirable
SystmOne and EMIS referral form
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Refer to packs
Routine referral from GP incl. bloods and
ECG
Referral triaged and allocated to memory
service for assessment
Structured assessment
Diagnosis and core interventions
Initial advice on driving
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Payment by results (PbR) mental health
clusters
18 – 21 are organic mental health clusters
Cluster 18/19 will follow memory pathway
and if eligible for AChEi the shared care
protocol
Clusters 19, 20, 21 will remain under CMHT
if input is required
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Donepezil (Aricept)
◦ 5 and 10 mg (oro-dispersible tablet available)
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Galantamine (Remenyl/Acumor)
◦ 8mg, 16mg and 24mg capsules (maintenance 1624mg). Solution 4mg/ml
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Rivastigmine (Exelon)
◦ 1.5mg, 3mg, 4.5mg, 6mg capsules
◦ Oral solution 2mg/ml
◦ Transdermal patch 4.6mg and 9.5mg/24hr
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Memantine (Ebixa) Starter pack titrates up
to 20mg OD within 4 weeks. Oral solution
5mg/0.5ml
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Cholinergic hypothesis of Alzheimer’s disease
suggests that a decline in cognitive function
is linked to loss of cholinergic transmission in
hippocampus and cortex.
AChEi’s inhibit the cholinesterase enzyme
from breaking down acetylcholine, increasing
both the level, and duration of the
neurotransmitter acetylcholine.
Licensed in mild to moderate Alzheimer’s.
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Acts on Glutamatergic system by blocking
NMDA Glutamate receptors.
This is thought to be neuro-protective and
possibly disease-modifying.
Approved for use in moderate to severe
Alzheimer’s disease
Severe Alzheimer’s - drug of choice
Moderate Alzheimer’s - intolerant of, or
contra-indication to AChEi’s
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Improvement in cognition by an average of
10%
Roughly equivalent of 6 months usual decline
ADLs and functioning may remain above
baseline for 6-12 months for most and up to
2 years for some.
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Usually mild
◦ Diarrhoea, muscle cramps, fatigue, nausea,
vomiting, insomnia.
◦ Headache, pain, common cold, abdominal
disturbance, dizziness.
◦ Rarely : Syncope, bradycardia, sinoatrial and
atrioventricular block.
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Concerns around over use and side effects
Cerebrovascular adverse effects (atypicals =
typicals
Behavioural and environmental approach first
Multisensory stimulation, bright light therapy,
aromatherapy
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Target specific symptoms
Start low and titrate up
Time limited (review after 3/12 stable)
Evidence for risperidone and olanzapine for
physical aggression, agitation and psychosis
Long term use leads to cognitive decline and
falls
Discontinue gradually (unless severe side
effects)
Some people need to stay on them
http://www.rcpsych.ac.uk/pdf/bpsd.pdf
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For all types of dementia
6 monthly review
Functional, behavioural, carer, dementia
advisor feedback
Driving capability (see packs)
Medication concordance, S/E, efficacy
Carer strain
Behavioural and psychological symptoms of
Dementia (BPSD)
Dedicated Memory Service Lead Nurse linked
to each CCG for liaison/advice
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Urgent – goes to CMHT as usual
Advice regarding medication – phone memory
service nurse or consultant psychiatrist
Caroline Molloy 01509 568680
Dr Hamer (Charnwood) 0116 295 2415
Dr Suribhatla (NWL) 0116 225 2754
Dr Subramaniam (H+B) 01455 443600
We will see again if significant behavioural
and psychological symptoms of dementia
(BPSD) or complex needs
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NICE recommend that all patients who fall
into severe category are “considered” for
discontinuation of AChEIs
May still be beneficial for Behavioural and
Psychological Sypmtoms of Dementia (BPSD)
even if cognition has declined
Less cost implication now
Consider if experiencing harmful effects or
deteriorated to extent of palliative care
Discuss with carers
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Facilitates 1st 2 strands of National Dementia
Strategy by
 Encouraging practices to screen populations with
suspected dementia (proposed DES and health checks
in GMS contract)
 Refer more patients appropriately to Memory
Assessment Clinic
 Agreeing to continue monitoring of treatment under
Shared Care Agreement
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Practices will
◦ Nominate lead GP
◦ Maintain adequate records following read codes in
clinical records
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A draft LES for GP shared care has been
developed and will be refreshed following
agreement of the 2013/14 enhanced services
Updates will be communicated through
locality meetings, practice manager meetings
and newsletters
Case 1
 73 year old man, brought to see you by wife who
has noticed forgetfulness over last 12 months.
 Asking repetitive questions, can’t remember
conversations or appointments.
 Wife frustrated, patient can’t really see a problem.
 Able to wash, dress and perform household chores.
 Driving without any problems.
 Scores 6/9 on patient GPCOG and 3/6 on informant
section.
Case 2
 67 year old woman who comes to see you very
concerned about her memory.
 Anxious that she is not functioning as well as she
used to.
 Complains of forgetting where she has put things,
needing to rely on calendar for appointments.
 Lives alone, fully independent with activities of daily
living.
 Worried about Alzheimer’s disease.
 Scores 9/9 on GPCOG.
Case 3
 79 year old woman
 Initially seen by GP with cognitive impairment
 Referred to Memory Adviser who supports son as
main carer
 Referred to memory clinic
 Diagnosed with Alzheimer’s disease and commenced
on Donepezil
 After 3 months, has been stable on 10mg
 Memory clinic write to you asking you to continue
prescription under SCA and review in primary care
Case 4
 89 year old man with diagnosis of vascular dementia
for 3 years, on no psychiatric medication
 Under 6 monthly review
 Wife phones to say that he has become increasingly
agitated now
 He appears paranoid and suspicious of her
 She is frightened of him
 He keeps trying to leave the house and is clearly
disorientated in time and place
 Initial examination reveals no acute cause for
deterioration such as UTI
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Case 5
84 year old woman in residential home
5 year history of Alzheimer’s, on galantamine
Now severely cognitively impaired
Persistent poor appetite and refusal to eat
No obvious physical cause
Very frail
Family reluctant for her to be admitted or
have further physical investigations
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Case 6
69 year old man diagnosed with Alzheimer’s at
memory clinic 9 months ago
Driving assessed at memory clinic – DVLA informed
of diagnosis, no visuospatial problems
Stable on donepezil prescribed by GP
Attends for 6 monthly review in primary care
Now unable to draw interlocking pentagons
Has had some minor scrapes in his car, but feels he is
able to drive safely
Despite your advice not to, he is adamant that he will
continue to drive
Peter Cannon – GP
Sam Hamer – Consultant psychiatrist
Caroline Molloy – Memory service lead nurse
Memory service adviser