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Huntingdon Primary Care Trust October 2008 Guidelines for the Treatment of Dementia in General Practice D:\148092907.doc 1 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. D:\148092907.doc 2 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 D:\148092907.doc 3 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: D:\148092907.doc 4 ‘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 D:\148092907.doc 5 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 D:\148092907.doc 6 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. D:\148092907.doc 7 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. D:\148092907.doc 8 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 D:\148092907.doc 9 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 D:\148092907.doc 10 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 D:\148092907.doc 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 11 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] D:\148092907.doc 12 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 D:\148092907.doc 13 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 D:\148092907.doc 14 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: D:\148092907.doc 15 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 D:\148092907.doc St Neots Office Tel: 01480 218643 Crossroads The Primrose Centre Primrose Lane Huntingdon PE29 1WG Tel: 01480 415154 16