The Diagnosis and Management of
Dementia in primary care
Dr Suzanne Duff
Consultant Psychiatrist
POPS Northland DHB
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The extent of the problem
• Prevelence doubles every 5 yrs over the age of
60
• > 60 – 5%
• > 80 – 20%
• Affects ~38000 New Zealanders
• Will affect ~50000 by 2051
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Tom Kitwood
Dementia Reconsidered
• “Men and women who have dementia have emerged
from the places where they were hidden away: they
have walked onto the stage of history, and begun to
be regarded as persons in the full sense. Dementia as
a concept is losing its terrifying associations with the
raving lunatic in the old-time asylum. It is being
conceived of as an understandable and human
condition, and those who are affected by it have
begun to be recognised, welcomed, embraced and
heard.”
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The Dementia Syndrome (DSMIV)
• Multiple Cognitive Deficits (at least 2 of)
– Memory loss
– Aphasia
– Apraxia
– Agnosia
– Executive function
• These lead to a functional decline
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Dementia Subtypes
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Alzheimer’s ~ 60%
Vascular - 10 – 15%
Lewy Body – 12 – 15%
Fronto-temporal – 15% (usually <65yrs)
Other
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The Cognitive Changes of Normal
Ageing
• Occur over decades
• Decline mirrors that of peers
• Person able to adapt so that functioning is
maintained
– 83% forget names, approx 60% lose keys, 40%
forget faces or directions, even fewer forget what
they have just done, such as lock the door
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Mild Cognitive Impairment
• Subjective memory loss
– Without functional impairment
• 8 – 15% per year convert to dementia
– i.e. Up to 90% by year 6
• Studies now looking at amyloid imaging and
CSF markers to identify converters
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AD risk and protective factors (use it or
lose it)
• Risk
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–
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–
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Age
Family history (ApoE4)
Head trauma
Low education
Lipids & Hypertension
Early life depression
Down’s
• Protective
– Genetic (ApoE2)
– High educational level
– Longterm antiinflamatories
– Antioxidants (Vit E)
– LOW alcohol use
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Diagnosing Dementia
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Diagnosis and Assessment
• Listen to the patient – they or their families are
telling you the diagnosis
• Adjust your communication style
• A positive diagnosis can be made just as in any other
major illness
• The challenge is to obtain an early, accurate and
specific diagnosis using an effective diagnostic
process
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Clinical features of mild AD
• Cognition
– Recall
– Learning
– Word finding
– Problem
Solving
– Writing
– Judgement
– Calculation
Function
Behaviour
Work
Finances
Cooking
Reading
Hobbies
Apathy
Withdrawal
Depression
Irritability
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Issues involved in dementia diagnosis
Who wants the
diagnosis ?
How certain is the
diagnosis ?
How to break bad
news
How much do they
want to know ?
How would they prefer to
have the diagnosis
communicated ?
Time to express
loss & grief
Dementia
Diagnosis
The language to use
Consent to tell
others
Support for those
giving the diagnosis
Who wants the
prognosis ?
The timing of
information giving
The coping style of
PWD and carer
The type of
information
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CONCERNS ABOUT TELLING
• Adverse effect on the person with dementia.
• They may have difficulty understanding the
diagnosis.
• Family resistance to telling the PWD.
• Uncertainty of diagnosis.
• Fear of nihilism.
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ADVANTAGES TO TELLING
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•
•
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Allows the person to maximize their autonomy.
Avoids accidental discovery.
Relieves anxiety and uncertainty.
Avoids paternalising.
Wish to know expressed by most older persons.
Timely access to info, support & treatment.
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Guidelines for giving a dementia diagnosis
(Fearnley, McLennan & Weaks, 1997)
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Choose the setting.
Determine who is to be present.
Explore previous knowledge or experience.
Explore how much they want to know.
Discuss the diagnosis.
Discuss the future.
Discuss the help available.
Provide written information.
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Dementia or Delirium
• Dementia
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Insidious onset
Slow, gradual decline
Disorientation later
Mild variations day-day
Normal attention span
Usually fully alert
Few psychomotor changes
Physiological changes
Sleep–wake changes later
• Delirium
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Abrupt onset
Short acute illness
Marked disorientation
Very variable
Poor attention
Fluctuating alertness
Agitated/retarded
Physiological changes
common
– Sleep-wake changes common
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Dementia or Depression
• Dementia
–
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Insidious onset
Conceals disability
Near miss answers
Mood fluctuations
Stable deficits
Tries hard and not
distressed by errors
– Memory loss
predominates
• Depression
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Abrupt onset/trigger
Highlights disability
‘Don’t know’
Diurnal variation
Variable deficits
Tries less hard and
distressed by errors
– Memory and mood hand
in hand
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BPSD Assessment
• Look for the meaning or underlying triggers
• People with dementia are very sensitive to
non-verbal and environmental cues
• What might the person be reacting to?
– Environmental, Internal, Interpersonal?
• What might they be trying to communicate?
– Pain, Discomfort, Fear, Sadness, Frustration?
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BPSD Assessment - medical
• Take a history from carers and patient
• Review recent medication changes
• Physical exam
– ?Pain, constipation, UTI/URTI, alcohol withdrawal
etc
• Investigations
– MSU, FBC, U+E
– CxR, ECG
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BPSD - Assessment
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Identify specific symptoms and behaviours
Use ABC charts
Note baseline frequency
Identify possible triggers
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Drugs for BPSD
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Limited effectiveness
Low doses
Review at 2 weeks and 1 month
Trial withdrawal at 3 months
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Cognitive Enhancers
• Cholinesterase Inhibitors
• Aricept (Donepezil)
– Once daily, 5mg, 10mg
• Reminyl (Galantamine)
– Once daily, 8mg, 16mg, 24mg
• Exelon (Rivastigmine)
– Twice daily, 1.5mg, 3mg, 6mg - patch developed
• NDMA (Glutamate) receptor antagonist
– Memantine
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Cholinesterase Inhibitors
Cont.
• Similar side effect profiles
– NB Heart Block
• Similar efficacy
• Effect on ADLs, QoL, Caregiver burden now
demonstrated
• Issues re cost, access, discontinuation need to
be discussed prior
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NDHB Diagnostic Pathway
Internet based pathway to assist primary care in the
assessment, diagnosis and management of
uncomplicated dementias.
http://tomcat.dev.cactuslab.com/pathways/northla
nd-dhb-cognitive-impairment-pathway/
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Resources
Resources
• Age Concern New Zealand
– www.ageconcern.org.nz
• Alzheimer’s New Zealand
– www.alzheimers.org.nz
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