“Dementia is a ‘global disaster waiting to happen’ and the biggest health and care problem
of a generation”.
BBC News 10 December 2013
“Dementia is a ticking time bomb and with the global cost of dementia care expected to
reach over $1 trillion by 2030 we cant afford to do nothing ... We need accurate diagnosis,
effective treatment and improved care and support to avoid serious economic and social
impacts”
Dr Gillings, World Dementia Envoy, April 2014
Initial priorities
- Improving dementia diagnosis and services
- Reducing avoidable emergency admissions
- Reducing preventable deaths
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Is there any benefit to patients in having a diagnosis?
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How can we increase our diagnosis rates?
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What is the local dementia pathway? Do all patients have to be referred?
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How can we utilise the skills of the wider team (e.g. Practice nurses and Advanced Nurse
Practitioners)?
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Dementia toolkit
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Does coding matter?
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What is the new Dementia Identification Scheme?
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Stigma and fear of diagnosis
GPs not making a diagnosis because:
◦ Not seen as a priority
◦ Lack of confidence in making a diagnosis
◦ Concerns about stigmatising someone
◦ ‘Little value’ because ‘nothing can be done’
◦ Belief that drugs don’t work
◦ Not aware of local services
◦ Perception of little support for patients and carers after diagnosis
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Through screening (and reviewing patients >75yrs and those in nursing homes)
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Through referring to new Memory Support and Assessment Service
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Through diagnosing ourselves – Dorset dementia pathway
September 2013
186
July 2014
210
October 2014
246
% increase over 13 months
32% (60/186)
Expected register 430
57% (Target 65% by 31/3/15)
To meet CCG 65% Target 280
34 new diagnosis
* Funding for patient care
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By helping to reduce stigma and increasing public understanding
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By education of the wider primary health care team
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By being ‘Dementia friendly’ GP surgeries
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Through screening
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Through referring to new Memory Support and Assessment Service
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Through diagnosing ourselves
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By promoting quality of life and social integration for people with dementia
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By coding correctly
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By diagnosing, recording and following up MCI
* Dementia: 10 key steps to improving timely diagnosis
http://dementiapartnerships.com/wp-content/uploads/sites/2/DPC-resource-pack-v3.pdf
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By coding correctly
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By diagnosing, recording and following up Mild Cognitive Impairment
By helping to reduce stigma and increasing public understanding
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Poole Dementia Action Group: Cross community group working to improve the lives of people with
dementia and their families: Council, Poole Wellbeing Collaborative, Third sector organisations, Arts,
Library, Local business, Nursing homes, Poole Central GPs
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‘Dementia Friendly’ activities leaflet
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Launch of Poole as a ‘Dementia Friendly’ town, May 2014
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Dementia awareness training for retailers: Poole Central funding
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Memory Cafe, Poole High Street
By helping people to live well with dementia
NICE QS30: Quality standard for supporting people to live well with dementia
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10 Quality standards including:
◦ Physical and mental health and wellbeing
◦ Maintaining and developing relationships
Involvement and contribution to the community
◦ Leisure activities of interest and choice
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Quality of life & social integration clinics in all practices
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Carers drop in support in all practices
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Dementia Enhanced Service
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Patients over 60 and ‘high risk’ because of smoking, alcohol, obesity, COPD
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New Dementia Identification Scheme: 1 October 2014- 31 March 2015
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Practices will be paid £55 per additional patient added to the dementia register
Diagnosis can be made without referral to a secondary care service
LMC - review nursing homes, patients seen in memory clinics
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Should we be diagnosing Mild Cognitive Impairment?
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Do the drugs work – and what’s new?
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Prevention – what really reduces the risk of dementia?
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The current pathway
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(How can we manage behavioural and psychological symptoms?)
Pensioner told she had dementia and sold her
house to pay for care is told 18 months later
there is NOTHING wrong with her
•Family were advised she would need round-theclock care in special home
•Mrs Hill's daughter sold her house to fund the
new accommodation
•She hated living in new home and said she
didn't believe she had dementia
•After 18 months, her worried daughter sought
the opinion of another doctor
•He declared she had mild cognitive impairment
- not the same as dementia
•'Furious' family moved her out of specialist
home, and Mrs Hill now happier
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Aim to help to distinguish between MCI and
dementia and what to do with MCI
Aim to demystify ACHeis and the evidence
of their efficacy
Summary of prevention( risk factors)
Managing BPSD ( this would be a separate
talk)
Future treatments
Discussion about diagnosing MCI in primary
care?
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Is a syndrome( not a single disease entity).
Acquired later in life and is, progressive.
Results in progressive impairment in
social/occupational, personal, cognitive
functioning
Usually takes months to manifest.
Absence of any other treatable causes
Parietal
lobe
Parietal lobe
Frontal lobe
Frontal
lobe
hippocampus
Temporal lobe
Occipital lobe
Occipital lobe
Cingulate gyrus
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Chronic cognitive disorder ( a research
construct)
Usually presents with deficits in one domain
(eg memory, executive functionning)
Intact ADLs
Not progressive
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The rough rule of 1/3rds
Psychiatric Disorders/misc
MCI
Vascular
Unknown
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Often associated with discrete vascular
insults ( cortical/subcortical)
This makes diagnosis in primary care harder (
no access to structural imaging)
No functional decline
Cognitive association with predominant
executive/ memory component
6-CIT
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Addenbrookes Cognitive
Examination¹ (ACE, ACE-R) – 15-20
minutes
•Less reliance on verbal function than
MMSE
•Executive function tested more
•Includes MMSE items
•Excellent reliability and accuracy in
diagnosis ( 88%)
•No cost
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Screening - 6-CIT
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•Designed for use in primary care screening
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•Takes 3-4 minutes
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•Scoring 0-28
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•10/11 cut-off sensitive (82%) and specific ( 90%)
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•Scoring complex and needs familiarity
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•No copyright issues for health care staff
Brooke & Bullock 1999 I J Ger Psychiat
Mini Mental State Examination
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Mathurananth et al 2000¹,
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•Best known screening test for cognitive impairment
•Takes 10 minutes
•Ceiling and floor effects
•Validated in many languages
•23/24 cut-off frequently used
•Widely taught and (mis)understood
•Copyright issues now troublesome
Folstein et al 1975
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Uncertain ( still under research(ed))
Definite risk factor for developing dementia
Generally 10% risk of conversion annually
So half of MCI have a 50% chance of
developing dementia over a 5 year period
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Metanalysis of established independent risk
factors
Looked at factors that were associated with a
10-20% risk reduction per decade
CVS risk factors
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Physical inactivity
Smoking
Hypertension
Obesity
Diabetes
3 different acetylcholinesterase inhibitors for the treatment of
mild to moderately Alz Dementia/mixed dementia
1) Donepezil
2) Galantamine
3) Rivastigmine
 All equally effective at optimal doses and similar SE profile
 Different formulations
 Memantine (NMDA antagonist) used in moderate to severe Alz
dementia and those intolerant/CI to ACHeis
 Memantine has evidence in improving BPSD
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Treatment for prodromal/early
Alzheimers
Targets Kennedy pathway and
synthesis of cell membrane
Nutritional supplement
Significant improvements in
cognition over 24 weeks on
NTB compared to control on
RCT
Costs attached approx £3/day
per day
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Memory Support & Assessment Service
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Intermediate Care Service for Dementia
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Social services - Carers in Crisis
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Third sector – Dementia Friendly Activities in Poole
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In operation since Sep 2014 across all of Dorset
Triaging and cognitive assessment service for patients
of all ages across Dorset
CCG commissioned with Alzheimers society providing
initial assessment and post-diagnostic support
OPMH consultants providing the diagnosis and
commencement of treatment in the form of cognitive
enhancer
Follow up by memory nurses by telephone and formal
review 2-3/12 to establish on cognitive enhancers
Annual follow up
Step 1 – GP
OPMH
CMHT
Step 2 – Memory Adviser
Step 3 – Memory Assessment Nurse
Major
BPSD
Step 4 – Consultant Appointment for Diagnosis
Step 5 – Post Diagnostic Support
MCI/Vascular
Dementia
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Most patients with dementia have these
Multiple simultaneous symptoms
Present throughout the course of the disease
May remit but highly recurrent
Likely to be problematic for most carers
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7 point scale
1 –not at all difficult
7 very difficult
BPSD
Type of Dementia
Physical
PICID
Pain
Infections
Constipation
Iatrogenic
Dehydration
Depression
Psychosis/violence
Environment x Treatment
Anxiety
Environment x Treatment
Environment xTreatment
BPSD
The’ minefield’
Antipsychotic
Useful in aggression and psychosis
-ve
Worsens epilepsy
Falls
Strokes
EPSE
Benzodiazepines
Useful in short term
Can be used with epilepsy
Mood stabilisers
Carbamezepine
mood disorders
Some evidence helps in agitation
Memantine
-ve
Can worsen gait/falls
Can cause paradoxical worsening agitation
Tachyphylaxis
Sedating
-ve
Worsens gait
Strong drug interactions
Nausea
-ves
ACHeis
Can worsen anxiety
Memantine poor efficacy in psychosis
Useful in agitation
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Risperidone
Low doses 0.25-1mg in divided doses
2-3X increase in CVS/CVA events
Phase specific
Quetiapine ineffective, worsens cognition and
causes postural instability
Thank you