Download Guidelines for the treatment of dementia in general practice

Huntingdon Primary Care Trust
October 2008
Guidelines for the Treatment of Dementia in
General Practice
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DEMENTIA PROTOCOL
GENERAL INFORMATION
The prevalence of dementia is 7% of those aged 75-79, 9% aged 80-84 and 24% aged over 85. Estimated
number of people with dementia in the South Cambridgeshire and Cambridge City localities is
approximately 2,320 (65 years +) MRC Cognitive Function in Ageing Study. Population: Exeter April 2003
CAUSES
 50% Alzheimer’s disease (AD)
 10% Lewy Body dementia (LBD)
 10% Vascualr dementia (VaD)
secondary to hypertension and atherosclerosis
 20% Mixed VaD and AD
 Alcohol-related dementia
RARE CAUSES
 Fronto-temporal dementia
 Neurosyphilis
 Creutzfeld-Jacob disease
 Vitamin B6 (thiamine) deficiency (alcoholism)
 Normal pressure hydocephalus
 Tumour
It is worth screening for the following
potentially treatable causes:
Depressive pseudodementia
/Depression induced dementia
Acute confusional state
Hypothyroidism
Vitamin B12 deficiency
Tumour
See Appendix 1 for diagnostic
classifications
STAGES/SYMPTOMS
MILD
MODERATE
SEVERE
Marked memory disorder
Subtle loss of activities of daily living
Behavioural change
Language problems
Psychiatric problems
Loss of capacity
Personality changes
Wandering
Aggression
Incontinence
Loss of language
FEATURES SUGGESTIVE OF A RAPID DECLINE







Severe aphasia
Caregiver distress
Concomitant vascular disease
Early myoclonus
Non-AD dementias
Early extrapyramidal signs
Psychosis, hallucinations may be Lewy Body Dementia see Pharmacological Treatments
YOUNG ONSET DEMENTIA
Early onset dementia, or younger onset dementia (YOD) is usually used to describe people under the
age of sixty five with any form of dementia. Although most dementias affect people who are elderly,
occasionally younger people are diagnosed with dementia. Dementia has been diagnosed in people in
their 50’s, 40’s and even in their 30’s. Dementia in younger people is much less common than
dementia occurring after the age of 65. For this reason it can be difficult to diagnose and its incidence
in the community is still not clear.
Causes of YOD may vary. Alzheimer’s is only a quarter of the dementias in this age group and others
such as fronto-temporal, vascular, Huntingdon’s, Parkinson’s, alcohol-induced dementias and other
much rarer conditions usually screened for by neurologists. Also see ** on page 3.
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PHYSICAL EXAMINATION
The aim of physical examination is to discover any treatable physical condition that may cause dementia or
exacerbate the symptoms of dementia, especially acute confusional state/delirium.
INVESTIGATIONS









Full blood count
ESR
Serum Vit B12, Folate
Blood glucose
Urea and electrolytes
Serum Calcium
Liver function
Thryoid function
ECG if considering Acetylcholinesterase inhibitors
And if specifically indicated:



Urinanalysis
Syphilis/HIV serology
CXR only if there are chest symptoms or signs or a history of malignancy
COGNITIVE TESTS
You cannot make a diagnosis of dementia using screening measures but they may help with the decision of
whether to make a referral to a specialist service/memory clinic:

Mini Mental State Examination (MMSE) –Not sensitive for early diagnosis, patients could have a
developing dementia even when scoring in the normal range (27-30) www.alzheimers.org.uk
Appendix 2

Carer/Patient Self Report of Persistent Progressive Memory Problems – Probably one of the most
sensitive and most natural methods of determining whether a patient should be referred.

Other: Abbreviated Mental Test Score (AMTS), Geriatric Depression Scale (GDS)
Appendices 3 & 4
WHEN TO REFER TO OLDER PEOPLE’S MENTAL HEALTH SERVICE (CMHT OP)
Appendices 6 & 7






Uncertainty about diagnosis
Request for second opinion
Persistent psychiatric symptoms such as psychosis or depression
Risk to self and others
For treatment with anti-dementia drugs
Severe behavioural problems or BPSD (i.e. behavioural and psychological symptoms associated with
dementia) where environmental factors have been excluded
When to consider neurological assessment and neurology referral :
 Neurological signs or symptoms
 Acute onset /rapid decline
 Fits /Blackouts/gait disturbances
 New headaches
 Head injury
 Hx of tumour that metastasises
 Young onset dementia **
** In most cases, complaints of memory problems before the age of 65 are usually associated with depression
or other psychological problems. If GP is uncertain whether it is a true complaint or associated with another
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mental health problem it is best to refer the patient to the Adult Mental Health Team for screening assessment.
If the problem seems most likely to be an early onset dementia, the patient should be referred to a multidisciplinary clinic where there is a psychiatrist, neurologist and neuro-psychologist present in order to screen
for much rarer causes of dementia in this age group. Locally this is done at the Memory clinic at
Addenbrooke’s Hospital by Prof. John Hodges’ team. Please see contact details below.
PHARMACOLOGICAL TREATMENT OF DEMENTIA
Acetycholinesterase Inhibitors (AchEI’s) i.e. Donepezil, Rivastigmine and Galantamine are licensed for the
symptomatic treatment of moderate severity Alzheimer’s disease. They must be used in accordance with
NICE Technology Appraisal no. 19 (amended September 2007), which states that:
 The patient’s MMSE score must be between 10 and 20 points.
 If MMSE does not fairly reflect the severity of the disease health professionals should use a different
method to judge severity.
 The likelihood of compliance must be assessed and carer’s views of the patient’s condition should be
sought.
 Treatment must be initiated by a specialist.
 If General Practitioners are to take over prescribing, they should do so under an agreed shared-care
protocol.
 Treatment should be continued only if there has been an improvement or no deterioration in MMSE
score two to four months after reaching maintenance dose of the drug. Thereafter patients who
continue on the drug should be reviewed by MMSE score and global, functional and behavioural
assessment every six months.
Local Shared Care Guidelines have been produced by the Cambridge Joint Prescribing Group (CJPG). These
include a summary of prescribing information such as dose titration, contra-indications and adverse effects as
well as where the responsibility for monitoring lies i.e. with the GP if the patient is not in contact with secondary
care for other mental health needs and with the MH Team for those who need secondary mental health care.
Memantine is an N-methyl-D-aspartate (NMDA) antagonist and was launched in October 2002 for the
treatment of moderately severe to severe Alzheimer’s disease. It’s use is not currently supported by the
Cambridgeshire Joint prescribing Group (JPG), but it may be prescribed for a small number of patients by
specialists within the Cambridgeshire and Peterborough Mental Health Trust.
Management of BPSD/ behavioural disturbance in dementia






Consider possible reasons for the disturbance in behaviour and exclude/treat any underlying conditions
(e.g. UTI, constipation, pain or discomfort).
Analyse the behaviour and attempt to identify possible trigger factors. It may be helpful to use an A-B-C
analysis (Antecedents – Behaviour – Consequences) to understand the function of the behaviour. Personcentred approaches also encourage us to regard behaviours as a communication of needs, so meeting the
expressed need may impact on the behaviour.
Attempt non-drug interventions:
reality orientation and reassurance
environmental modifications (e.g. change to care routines, orientation cues)
education – carer focussed, social support
activity/distraction
sensory stimulation – appropriate lighting etc
Consider aromatherapy: Melissa (lemon balm) or lavender oil have been shown to be at least as effective
as neuroleptic drugs at treating agitation, with very few side effects.
Drug treatment should be used only for serious problems (e.g. delusions/hallucinations: risk of injury to the
patient or others) or in the presence of severe distress. Any drug used should be commenced at the lowest
possible dose, reviewed regularly and, whenever possible, used for short-term treatment only.
Example of drug treatment:
o Haloperidol 0.5mg up to bd +/- Lorazepam 0.5mg once nocte for 7days
o If after a week the patient is very unsettled switch to Quetiapine 25-50mg BD or Olanzapine 2.55mg once nocte or Risperidone 0.5-1mg BD.
o If after another week there is still no improvement, refer to CMHT
Antipsychotics are commonly used but evidence of their efficacy is limited and the list of adverse effects must
be considered. In particular:
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


‘Typical’ antipsychotics such as Haloperidol can cause a wide range of side effects, including sedation,
confusion and extrapyramidal effects, and are particularly dangerous in Lewy Body dementia.
‘Atypical’ antipsychoics are better tolerated but are associated with an increased risk of stroke. The
CSM has advised that Risperidone or Olanzapine should not be used for the treatment of behavioural
symptoms of dementia and that a risk of stroke with other antipsychotics (none of which is licensed for
this indication) cannot be excluded. Quetiapine has also recently been shown to worsen cognitive
function and with no particular improvement of behaviour. However, the risk of side effects needs to be
weighed up against quality of life and occasionally these medications are used because they cause
less side effects.
It is recommended that no antipsychotics should be prescribed to patients with Lewy Body dementia or
Parkinson’s disease except on specialist advice.
Depression is under-diagnosed in people with dementia and should always be considered. If drug treatment
is indicated the first line choice should usually be an SSRI (e.g. Citalopram). The elderly frequently do not
tolerate Fluoxetine well. However if sedation is required Lofepramine/ Mirtazepine may be a suitable
alternative.
Hypnotics (e.g. Temazepam or Zopiclone) can be considered for the short-term treatment of sleep
disturbances unresponsive to practical sleep hygiene measures.
More detailed guidance, produced following the CSM restriction on Risperidone and Olanzapine, is available at
http://www.rcpsych.ac.uk/college/faculty/oap/BPSD.pdf
Reviewed:
October 2008
Reviewed by :
Dr Emma Tiffen (GP),
Dr Annalise Owen (Psychiatrist for OPMH)
Dr Vanya Johnson(Psychiatrist for OPMH)
Next review:
October 2010
Presented to and ratified by OPMH
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Appendix 1
Diagnostic Classifications of Dementia
Classification: ICD 10
F00
F01
F02
Dementia in Alzheimer’s Disease
Vascular dementia
Dementia in other diseases
Pick’s disease
Creutzfeldt – Jacob disease
Huntington’s disease
Parkinson’s disease
Dementia in HIV disease
Others
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Appendix 2
Mini Mental State Examination
WWW.ALZHEIMERS.ORG.UK
The MMSE is a good instrument for assessing cognitive function, but takes up to 10 minutes and cannot fit
easily into a standard consultation.
Orientation
What is the (year) (season) (date) (day) (month)?
Where are we: (country) (city) (part of city)
(number of flat/house) (name of street)?
Registration
Name three objects: one second to say each.
Then ask the patient to name all three after you have said them.
Give one point for each correct answer.
Then repeat them until he learns all three.
Count trials and record.
5
5
3
TRIALS
Attention and calculation
Serial 7s: one point for each correct.
Stop after five answers.
Alternatively spell ‘world’ backwards.
Recall
Ask for the three objects repeated above.
Give one point for each correct.
Language
Name a pencil and watch (two points).
Repeat the following: ‘No ifs, ands or buts’ (one point).
Follow a three-stage command: ‘Take a paper in your right
hand, fold it in half and put it on the floor’ (three points).
Read and obey the following: Close your eyes (one point).
Write a sentence (one point).
Copy a design (one point).
5
3
9
Total score (out of 30)
INSTRUCTIONS FOR ADMINISTRATION OF MINI MENTAL STATE EXAMINATION
Orientation
1. Ask the date. Then ask specifically for parts omitted, for example, ‘Can you also tell me what season it is?’
Score 1 point for each correct.
2. Ask in turn, ’Can you tell me the name of this place?’ (town, country, etc). Score 1 point for each correct.
Registration
Ask the patient if you may test his or her memory. Then say the names of three unrelated objects, clearly and
slowly, about one second for each. After you have said all three, ask him or her to repeat them. This first
repetition determines the score (0-3) but keep saying them until he or she can repeat all three, up to six trials.
If he or she does not eventually learn all three, recall cannot be meaningfully tested.
Attention and calculation
Ask the patients to begin with 100 and count backwards by 7. Stop after five subtractions (93, 86, 79, 72, 65).
Score the total number of correct answers. If the patient cannot or will not perform this task, ask him or her to
spell the word ‘world’ backwards. The score is the number of letters in correct order, e.g. dlrow 5, dlowr 3.
Recall
Ask the patient if he or she can recall the three words you previously asked him or her to remember.
Score 0-3.
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Language
Naming: Show the patient a wrist-watch and ask him or her what it is. Repeat for pencil. Score 0 – 2.
Repetition: Ask the patient to repeat the sentence after you. Allow only one trial. Score 0 or 1.
Three-stage command: Give the patient a piece of plain blank paper and repeat the command. Score 1 point
for each part correctly executed.
Reading: On a blank piece of paper, print the sentence ‘Close your eyes’ in letters large enough for the patient
to see clearly.
Ask him or her to read it and do what it says. Score 1 point only if her or she actually closes his eyes.
Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate
a sentence, it is to be written spontaneously. It must contain a subject and verb and be sensible. Correct
grammar and punctuation are not necessary.
Copying: On a clean piece of paper, draw intersecting pentagons (as below), each side about one inch and
ask him or her to copy it exactly as it is. All ten angles must be present and two must intersect to score 1
point. Tremor and rotation are ignored.
A score of 20 or less generally suggests dementia but may also be found in acute confusion, schizophrenia or
severe depression. A score of less than 24 may indicate dementia in some patients who are well educated
and who do not have any of the above conditions. Serial testing may be of value to demonstrate a decline in
cognitive function in borderline cases.
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Appendix 3
Abbreviated Mental Test Score
Each Question Scores One Point
1.
Age
[ ]
2.
Time to nearest hour
[ ]
3.
An address – for example 42 West Street To be repeated by the patient at the end of the test
[ ]
4.
Year
[ ]
5.
Name of hospital, residential institution or home
address, depending on where the patient is situated
[ ]
6.
Recognition of two persons – for example, doctor
Nurse, home help etc….
[ ]
7.
Date of birth
[ ]
8.
Year first world war started
[ ]
9.
Name of present monarch
[ ]
10.
Count backwards from 20 to 1
[ ]
Total Score (out of 10)
A score of six or less suggests dementia
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Appendix 4
The Geriatric Depression Scale
Suitable as a screening test for depressive symptoms in the elderly. Ideal for evaluating the clinical severity of
depression, and therefore for monitoring treatment.
It is easy to administer, needs no prior psychiatric knowledge and has been well validated in many
environments – home and clinical.
The original GDS was a 30 item questionnaire – time consuming and challenging for some patients (and staff).
Later versions retain only the most discriminating questions; their validity approaches that of the original form.
The most common version in general geriatric practice is the 15 – item version.
Instructions
Undertake the test orally. Obtain a clear yes or no answer. If necessary, repeat the question. Cross off either
yes or no for each question (depressive answers are bold/italicised). Count up 1 for each depressive answer.
Scoring Intervals 0-4 No depression 5 –10 Mild depression 11+ Severe depression.
1. Are you basically satisfied with your life?
Yes No
2. Have you dropped many of your activities and interests?
Yes No
3. Do you feel happy most of the time?
Yes No
4. Do you prefer to stay at home rather than going our and doing new things?
Yes No
If none of the above responses suggests depression, STOP HERE. If any of the above responses
suggests depression ask questions 5 –15.
5. Do you feel that life is empty?
Yes No
6. Do you often get bored?
Yes No
7. Are you in good spirits most of the time?
Yes No
8. Are you afraid that something bad is going to happen to you?
Yes No
9. Do you feel helpless?
Yes No
10. Do you feel that you have more problems with memory than most?
Yes No
11. Do you think it is wonderful to be alive?
Yes No
12. Do you feel pretty worthless the way you are now?
Yes No
13. Do you feel full of energy?
Yes No
14. Do you feel that your situation is hopeless?
Yes No
15. Do you think that most people are better off than you are?
Yes No
Reference
1. Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric
depression scale. Van-Marwijk-HW; Wallace-P; de-Bock-GH; Hermans-J; Kaptein-AA; Mulder-JD Br-JGen-Pract. 1995 Apr; 45(393): 195-9
2. Screening for anxiety and depression in elderly medical outpatients. Neal-RM; Baldwin-RC. Age-Ageing.
1994 Nov; 23(6): 461-4
http://www.jr2.ox.ac.uk/geratol/GDSdoc.htm
http://www.stanford.edu/~yesavage/GDS.html
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Appendix 5
Referral Criteria to CMHT OP
The team will accept referral from any source.
Referral criteria for all disciplines:

There is an enduring mental health problem requiring a referral to the team. The mental health
problem is such that it significantly affects the person’s way of life, in that they require help to function
on a daily basis from professionals with specialist skills to assess and treat the needs of this age
group. The guiding factor in establishing acceptance to these teams will be the effect of the illness or
problem on the person or carer, the associated risks or needs in relation to their mental illness or
-problem.

The individual must live within the remit of the Cambridgeshire & Peterborough Mental Health Trust,
be over 65 years of age or whose needs are best met by CMHT OP.

There must be a mental health problem identified as the primary need at the time of referral – and at
least one of the following:
o
o
o
o
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Referral in consultation with GP or Psychiatrist for a specialist MH intervention
Users needs appear complex or volatile
Crisis related to a high degree of risk where there is a need for protection of self and/or others
 At risk to self due to significant behavioural problems
 At risk of abuse
Possible use of legislation required
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Appendix 6
The following Referral Proforma is available on EMIS:
Referral to Secondary Mental Health Services, Huntingdon
Cambridge and Peterborough Mental Health Partnership NHS Trust
Park House, Nursery Road, Huntingdon PE29 3RJ If urgent fax to: 01480 415175
From: (Surgery)
GP:
Crisis:
Assessment within 24 hours
Soon:
Next Assessment Clinic
Routine:
When appointment available
Service:
Adult
Older Adult
16-64
≥ 65
phone duty desk
allocation option - Domiciliary
Clinic
Catchment area:
:
Name of Patient
DOB:
Sex:
Hospital number:
Current Address:
Telephone:
Ethnicity
Interpreter required
NOK /Carer’s Details if different: ………………………………………………………………
Referrer (if not GP):
Contact details:
Current Presenting Problems:
Is the patient aware of this referral: Yes
No
If not, why not?.............................
If patient not aware of referral, why?......................................................................................
Reason for Referral:
? Admission
Treatment advice
Confirmation of Diagnosis
(pharmacological/psychological)
Home help/care support
(Has patient been referred to PCT social services? Yes
No
)
Other question/s you would like assessment to address: ~[Free Text:other questions you would like assessor
to address]
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Details of Risk Assessment:
Suicide/Deliberate Self Harm
Neglect/Vulnerability
Violence
Forensic History
Lives alone
Lives with others
Local support
Please specify details: ~[Free Text:details of risk assessment]
Other situation factors: ~[Free Text:situational factors]
Brief description of mental state:
Medication:
Past psychiatric drugs:
BMI:
Investigations: (please attach)
Memory
FBC, ESR, U+E, LFT, GGT, Corrected Ca, TFT, Glucose, (Vit B12, Folate if indicated), ECG
Depression
FBC, U+E, TFT, Glucose, (GGT if positive alcohol history)
On Lithium
Recent Lithium level
Other agencies involved: ………………………………………………….
Children under 16 year living with the patient?
If so please give names and DOB:
Further Comments:
Signature:
Print name: …………………………………………………. Designation:………………………………………………
\\EMIS5208A\MSWDocs\Referral to Secondary Mental Health Service1111.rtf
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Appendix 7
For those practices not using EMIS the following form is an example of an ideal referral form and contains the
kind of information, which would be most useful to the Older Adult Mental Health Services.
Referring GP:
Surgery
Patients Name:
Date of Birth:
Address:
Telephone No:
Carers Name:
Relationship:
Contact:
Does the patient live alone:
Yes/No
Dementia
Depression
Cognitive Screen used yes/no
MMSE yes/no score =
AMTS yes/no score =
Geriatric Depression Scale used yes/no
GDS 4 yes/no score:
GDS 15 yes/no score:
Brief Description of the Problem:
Any previous psychiatric history: Yes/No
Details:
Medical History
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Physical examination and abnormal findings:
Medication:
Other professionals involved (if known)
Results of Tests:
FBC, ESR
Profile
Thyroid function
Glucose
Urea and electrolytes
Urinalysis
B12 & Folate
Serum Calcium
Liver function
Normal [
Normal [
Normal [
Normal [
Normal [
Normal [
Normal [
Normal [
Normal [
]
]
]
]
]
]
]
]
]
Abnormal [
Abnormal [
Abnormal [
Abnormal [
Abnormal [
Abnormal [
Abnormal [
Abnormal [
Abnormal [
]
]
]
]
]
]
]
]
]
If results are abnormal please
enclose
Reason for Referral: (Tick box(es) that apply)
Dementia
Psychiatric Symptoms
Confirm Diagnosis
Behavioural Problems
Activity of Daily Living
Patient at Risk
Risk to others
Anti Dementia Drugs
(MMSE above 12)
[
[
[
[
[
[
[
]
]
]
]
]
]
]
Depression
Suicidal
[
Psychotic symptoms
[
Motor retardation
[
Agitation
[
Not eating/drinking
[
Poor compliance/not responding [
Diagnosis uncertain
[
]
]
]
]
]
]
]
Any other information:
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Contact Details
Older People’s Community Mental Health
Newtown Centre
Nursery Road
Huntingdon
Cambs
PE29 3RJ
Tel: 01480 415357 (Dr V Johnson)
Tel: 01480 415364 (Dr A Owen/Dr Barapatre)
Fax: 01480 415175
CMHT Older People
Newtown Centre
Nursery Road
Huntingdon
Cambs
PE29 3RJ
Tel: 01480 415357/5364
Assistive Technology
For information :
Collette Dowson (OT)
Nursery Road
Newtown Centre
Huntingdon
Cambs
PE29 3RJ
Tel: 01480 415357/5364
Fax: 01480 415175
Mental Health Day Services
Cynthia Lisle (manager) Four Seasons Day Centre
Hawthorn Ward
Huntingdon
PE29 6NT
Tel: 01480 357168
Fax: 01480 416468
Memory Clinic Addenbrooke’s Hospital (for early onset dementia)
Dept.of Neurology
Addenbrooke’s Hospital
Cambridge
CB2 2QQ
Age Concern
County Office 2 Victoria Street
Alzheimers Society
Chatteris
Newtown Centre
Cambs
Nursery Road
PE16 6AP
Huntingdon
Tel:
01354
696677
Cambs
Fax: 01354 696119
PE29 3RJ
Tel/Fax: 01480 415235
Carers Support
See CMHT OP above
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St Neots Office Tel: 01480 218643
Crossroads
The Primrose Centre
Primrose Lane
Huntingdon
PE29 1WG
Tel: 01480 415154
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