Managing memory problems in
primary care
Dr Uche Oguekwe
Introduction
 As the UK population is living longer , memory problems are
now seen frequently in primary care
 The RCGP curriculum statement 9 version 1.1 expects the GP to
be able to manage contacts with older patients and deal with
their unselected problems
 Dementia UK report (2007) states that there are currently
700,000 people with dementia in the UK, and this is projected to
rise to over a million by 2025. The overall cost of dementia is
estimated to be £17-18 billion a year.
 Dementia can occur at any age, but is most common in older
people, affecting one in six people over the age of 80. Early
onset dementia is defined as dementia occurring in those under
65 years of age and accounts for 2.2 % of all people with
dementia in the UK.
Scope
 Initial assessment of patient presenting with memory loss
symptom using 2 case studies
 Distinguish those with memory symptoms caused by
conditions other than dementia
 Recognise the impact of dementia on the health of the
nation
 Will briefly look at broader aspects of caring for people
with dementia, including issues around driving & noncognitive symptoms in people with dementia
Case 1 Mrs AB
 82 years old, married for 60 years, pmhx of HTN
 Husband recently diagnosed with dementia and moved to
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nursing home
Daughter came to surgery, saying her mum has been
behaving odd in the last few weeks
Called the police more than three times in four weeks,
saying a group of men have broken through her window
Making inappropriate gestures to her neighbour
Forgetting to lock her doors
Not remembering what she has done the previous day
Unkempt, weight loss and not eating much
Refusing carers at home and does not want to go into care /
nursing home
What are the issues raised
 Confidentiality?
 patient’s safety?
 Vulnerable adult/ elder abuse?
 Daughters agenda?
 Mental capacity?
 Anymore??
Assessment
 A home visit was arranged with Mrs AB with her 2
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daughters present
She scored 28/30 on MMSE
She says she is absolutely fine and that she does not
lock her door as she wants her male visitors to have
access
Denied calling the police
Agreed to have urine dip which was normal
Agreed to have blood test and referral to memory
clinic
Outcome
 Seen by memory clinic psycho geriatrician
 MMSE remained 28/30
 She now had more psychotic features
 Further questioning revealed abuse as a child and
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strong family history of mental health problems
CT scans and bloods all came back normal
A diagnosis of psychotic pseudo-dementia was made
She was started on Risperidone 0.5mg , which was
later increased to 1mg with good effect
Daughters have now signed the next of kin papers
Case 2 Mrs BC
 90 years old, seen with her husband
 Retired Consultant Obstetrician
 Her husband has noticed that she has become forgetful and
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keeps repeating herself
Forgot to turn off gas on few occasions
pmshx- HTN & hypothyroid
Ex-smoker and Etoh 5units/ week
No family history of memory problems
Bloods, Ecg and urine were all normal
MMSE 23/30- lost marks on short term memory and recall
What will you do next?
 She was referred to the memory clinic
 Repeat MMSE remained at 23/30
 A diagnosis of Alzheimer dementia was made , although
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she has risk factors for Vascular dementia
CT head and further neuro-psychological testing confirmed
probable Alzheimer's
She was started on a trial of ACHi- donepezil by the
specialist
She was also assessed by the OT who advised use of
memory aids
She has remained stable and reviewed regularly by the
PHCT.
How should GP’s assess patients with
memory problems
 Should find out what is meant by ‘memory problem’ or
‘forgetful’? Ask for specific examples, such as
forgetting days, times, appointments, names or familiar
faces. Are there problems with getting lost, speech,
using the correct words, writing or reading?
 The length of history and progression of the problem
 Any associated features such as problems with sleep,
hallucinations or change in personality
 Any change in functional ability. For example, has this
affected home life, management of finances, work , or
problems with driving
How should GP’s assess patients with
memory problems
 other important factors are features of depression or anxiety.
 E.g. sleep disturbance, lack of motivation, anhedonia (loss of
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enjoyment), poor appetite or tearfulness
Past medical (vascular risk factors , Parkinson’s disease )and
psychiatric history.
Medications including analgesics and sedatives
Social circumstances : any recent changes such as retirement, change
of housing, location or a bereavement
Alcohol intake
Smoking history
Family history of memory problems or dementia
How should GP’s assess patients
with memory problems
 A physical examination is definitely important
 The Abbreviated Mental Test Score (AMTS) -this may
suffice as screening during a 10 min consultation
 The Mini Mental State Examination ( MMSE) -this is
widely regarded as the “gold standard” test for dementiabut there are now copyright issues which prevents GP’s
from printing this off
 Asking a patient to draw a clock face and set the time to
11.10 is a useful addition to the MMSE
 An intermediate step is the Addenbrookes Cognitive
Examination (ACE)- domains tested includes attention,
memory, language, visuo- spatial skills and executive
function
Other cognitive test which may be
used in primary care
 The 7-Minute Screen
 General Practitioner Assessment of Cognition (GPCOG)
 The Mini-Cog Assessment Instrument
 The Memory Impairment Screen (MIS)
 The 6-Item Cognitive Impairment Test (6-CIT)
 The GPCOG, Mini-Cog and MIS are brief and have been
shown to be as clinically and psychometrically robust as the
MMSE. Appropriate for use in primary care.
 GPCOG is readily available via the patient.co.uk website
for GPs to use.
Investigations
 A stepwise approach to investigation is required.
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Routine investigations to help rule out physical causes
FBC, urea and electrolytes, liver function tests, bone
profile , folate & vitamin B12 level, thyroid function
tests, random or fasting blood sugar & cholesterol
level
ECG, CXR
Urinalysis
An assessment of cognition using one of the tools
outlined above
Diagnoses to consider in patients with
memory loss
 The commonest cause of significant memory impairment is AD
There are many factors that can influence cognitive decline and they include
 Stroke
 Hypothyroidism
 Hyperparathyroidism
 Recurrent head trauma
 Hypoperfusion
 Medication use
 Depression
 Alcohol and drug abuse
 Toxins, infections , metabolic and structural causes
Other possible diagnosis
There are many causes of dementia and in the early stages they will
present with mild memory impairment. The following list is far from all
inclusive:
 About 20% of patients with Parkinson's disease also develop dementia
 Dementia with Lewy body is the second only to AD as a common cause
of dementia
 Pick’s disease ( Fronto-temporal dementia)
 Huntington’s chorea
 Syphilis
 AIDS
 Multiple Sclerosis
 Creutzfeldt-jakob disease
 Carbon monoxide and heavy metal poisoning
Management
The Alzheimer’s society recommend the following nondrug strategies to cope with memory loss:
 Keeping a to do list
 Use of memory aids such as watch, calendar and diary
 Regular exercise
 Stop smoking
 Adequate sleep
Management contd
 General safety measures such as installing smoke alarm and
gas detectors within the home of individuals with dementia
 Other factors such as reduction in alcohol intake, control of
HTN, diabetes and high cholesterol have all been found
useful especially in VaD
 Treatment of any underlying cause such as B12 def,
hypothyroidism
 Use of cholinesterase inhibitors (Aricept) and glutamate
antagonist (memantine) as cognitive enhancers. NICE
supports use of the MMSE with scores between 20 and 10
and six monthly checks, stopping when MMSE < 10
NICE recommendation
NICE recommends taking the following into consideration
when assessing a possible diagnosis of dementia
 The individual’s self report of changes in memory ,
capability or mood
 Informant histories that support self report and add
significant new details of changes
 Exclusion of depression and delirium as primary
pathologies, using the information from the personal and
informant histories
 Measurable cognitive losses, using a standardised
instrument
 Absence of ‘red flag’ symptoms suggesting alternative
diagnoses e.g. Urinary incontinence or ataxia in apparent
early dementia
Issue of driving
 Driving is not necessarily prohibited in early dementia
(refer to DVLA guidelines). As with any condition, if
there are any concerns (incidents, family members do
not feel safe) then advise the patient not to drive until
further information is available. Once a diagnosis of
dementia has been made, the DVLA should be
informed of this.
Broader aspects of caring for people
with dementia
Non-cognitive symptoms are prevalent in dementia and can arise as dementia
 They can be difficult to identify and pose challenges in management.
progresses.
Such symptoms include:
 Depression
 Delusions and hallucinations
 Agitation
 Wandering
 Swallowing problems
 End of life care
Although prevalent in certain specialist settings such as care homes, these symptoms may also
occur in people with dementia being cared for at home. Regardless of the setting in which they
occur, such symptoms can be distressing for both the person with dementia and also the carers
involved.
summary
 Diagnosis of dementia can be lengthy, complex and Staged
over time.
 Diagnosing the type of dementia is just the beginning of the
management process for this chronic condition.
 Any patient suspected of having dementia should be
referred to specialist for diagnosis – taking into account
their wishes because of the irreversible and progressive
nature of dementia, and the implications that this has for the
patient and also their family
 Early detection allows patients and their families access to
information, support services, medications, and enables
them to make preparation for the future
Local dementia and memory
resources
 Dementia team and memory clinic – mental health services for
older people at Elizabeth house Gillingham- refer all cases of
suspected dementia
 Medway dementia advisor service- 01634 338633- offers
support to those who are newly diagnosed and to those who
have had dementia for some time
 The 24 hour dementia helpline- 08456044391- offers
information and emotional support for anyone in Kent or
Medway with dementia, & their carers
 Dementia web- www.dementiawebkentandmedway.org.uk
offers comprehensive online info & advice about the many
aspects of living with dementia and caring for someone with the
condition
Use it or lose it