Dementia

An irreversible and progressive condition characterized by a global deterioration of a persons cognitive abilities

Dementia is not curable so the focus is on

♦ Risk reduction
♦ Timely diagnosis
♦ Early intervention
 There remains some uncertainty as to future scale of dementia epidemic- population ageing destined to play greatest role ( affects 800,000 people in UK and this number set to double by 2040 )
 GP often the first point of contact for people with dementia and their families
 Population screening is not envisaged ( no single test and does not satisfy the WHO screening criteria )
 Most expensive health-care issue in the UK- worldwide most important contributor to dependence and disability
 Dementia is 
chronic brain 
failure and 
delirium is acute 
brain failure.
There remains some uncertainty as to future scale of dementia epidemic- population ageing destined to play greatest role ( affects 800,000 people in UK and this number set to double by 2040 ) A Canadian study ( Drummond et al 2016 ) has shown a crude prevalence estimate of 7.7 % and that estimates of dementia rose with increasing age
Dementia was also fond more in those with co-morbid conditions as diabetes , depression , epilepsy and Parkinsonism GPs are often the first point of contact for people with dementia and their families and global estimates of dementia in primary care settings have ranged from 5 % to 10 % Population screening is not envisaged ( no single test and does not satisfy the WHO screening criteria ) Most expensive health-care issue in the UK- worldwide most important contributor to dependence and disability Poonjan et al 2019 report that dementia affects about 47 million people worldwide and is related to dependence , poor QoL , institutionalization and mortality WHO reports that worldwide about 50 million people have dementia with about 10 million new cases every year Alzheimer disease is the most common cause of dementia ( 60-70 % cases ) , other dementias including Lewy body dementia , frontotemporal degeneration , vascular dementia and mixed dementias are often indistinguishable and may co-exist with Alzheimer disease

Morbidity and mortality –Dementia is a progressive degenerative brain disorder There is no cure for dementia so the focus is on risk reduction , timely diagnosis and early intervention Dementia is one of the most disabling chronic diseases with enormous human , societal and economic cost People with dementia may also suffer with pain which is both under assessed and underrated ( Chandler R et al 2014 ) in the US Alzheimer disease was the 6th leading cause of death among people of all ages and the 5th leading cause among people aged 65 and over It has been observed that patients with dementia usually survive 7-10 years after onset of symptoms It is now known that between 2000 and 2018 ( in the US ) deaths from stroke , HIV and heart disease decreased while reported deaths from Alzheimer’s increased by 142.6 %

ICD 10 Memory decline – evident in learning new information Decline in atleast one other domain of cognition such as
♦ judging and thinking
♦ planning and organizing
to a degrees that interferes with daily functioning Some change in one or more aspects of social behaviour eg
♦ emotional liability
♦ irritability
♦ apathy
♦ coarsening of social behavior There should be corroborative evidence that the decline has been present for atleast 6 months

Risk factors-Age- most important risk factor
for eg Alzheimers disease increases in prevalence from < 1 % below the age of 60 to > 40 % above 85 yrs of age Mild cognitive impairment – convert to dementia at a rate of approximately 10 % / year Genetics Cardiovascular disease ( modifiable )
○ diabetes
○ smoking
○ hypercholestorolemia ( good evidence )
○ hypertension
○ obesity

Physical activity ( even low intensity such as walking ) has protective effect ( CKS NHS) 
( BMJ 2017- Physical activity , cognitive decline and risk of 
dementia 28 year follow-up of Whitehall II cohort study found no evidence of a neuroprotective effect of physical activity )
 Depression – inconsistent evidence
A recent study has shown that dementia does not seem to increase the risk for dementia , but depressive symptoms in later life could be a feature of dementia preclinical phase ( BMJ 2017) Stroke ( good evidence ) Mid- life hearing loss ( BBC July 2017 ) Excessive alcohol consumption Living near major roads ( BMJ 2017 ) Parkinsons disease Multiple sclerosis HIV Learning disabilities (Association between Alzheimers dis and Down’s synd ) Social status , education ( failure to complete secondary education )

Dementia can be hard to recognize and early symptoms can be missed-insidious onset and symptoms may resemble normal ageing. The WHO stages of dementia can be helpful in identifying and recognizing symptoms suggestive of dementia.

early stage –Onset is gradual and symptoms are often overlooked. Common symptoms include
 forgetfulness loosing track of time becoming lost in familiar places.

Late stages –Patient looses independence and has 
near total dependence and inactivity. Memory disturbances are serious and physical signs and symptoms become more obvious, symptoms include
 becoming unaware of time and place faces difficulty in recognising relatives and friends increased need for assisted self care difficulty walking experiences behaviour changes that may escalate and include aggression


Middle stages-In middle stage the signs and symptoms become clearer and more restricting and can include
 becoming forgetful of recent events and people’s names becoming lost at home having difficulty with communication requiring help with personal care experiencing behaviour changes as wandering and repeated questioning

Delirium and depression are the most common DD Identity / Address 
modifiable risk factors-
 RISK REDUCTION an imp public
 health measure.

NICE guidance –Ask about cognitive , behavioural and psychological symptoms What impact are they having on the persons life A collateral history can be valuable If this is a 3rd party consultation – for e.g relatives carers presenting with concerns – consider using a structured instrument as
○ Informant Questionnaire on Cognitive Decline in the Elderly
( IQCODE ) or the Functional Activities Questionnaire ( FAQ ).

Tests / examine –Conduct a physical examination
○ Look for focal neurological signs
○ Gait and balance disturbances
○ CVS signs as hypertension and arrhythmias
○ Weight loss ( neglect )
○ Vision , hearing Blood tests to r/o reversible causes of cognitive decline as FBC ,ESR ,Urea and electrolytes , HbA1c ,TFT ,Calcium ,Vit B12 and folate ,MSU.

Referral –If reversible causes ruled out like
 delirium depression sensory impairment for e.g hearing impairment cognitive impairment from medicines associated with increased anti-cholinergic burden

If the presentation is with rapidly progressive dementia ( RPD ) – this may need a neurological assessment to rule out conditions as
 Creutzfeldt- Jakob disease ( rare degenerative fatal brain disorder , typical presentation is at age 60. Initial presentation may be with failing memory , behavioral changes , lack of coordination and visual disturbances ) Prion diseases Atypical presentations of other neurodegenerative disorders curable conditions as autoimmune encephalopathies some infections neoplasms.
Rapidly progressive dementia need to be differentiated from slowly progressive dementia which happens over a few years. RPDs develop over weeks to months

NICE recommends a referral to neurology if RPD is suspected but does not specify urgency . It would be prudent to consider an urgent referral clearly mentioning that you suspect RPD backed by good history.

Living well with dementia is a national programme started in 2009 with a vision for transforming dementia services in England Scotland has a National dementia strategy which aims to transform services and improve outcome for people affected by dementia About 30 % of risk factors for dementia are modifiable and preventable , primary care has a vital role in addressing these which includes conditions as hypertension and diabetes. The National Collaborating Centre for Mental Health report in 2018 has identified barriers that delay people from seeking help and being diagnosed with dementia as
○ poor recognition and understanding of symptoms
○ reluctance to seek help or disclose symptoms -stigma
○ a poor understanding of the benefits and the need of a timely diagnosis of dementia
○ reluctance in healthcare professionals to make a diagnosis Local initiatives support GPs to diagnose and record on practice system – for e.g patients in nursing / residential homes The Diagnosing Advanced Dementia Mandate ( DiADeM ) is a tool which supports GPs in diagnosing dementia for people living with advanced dementia in a care home setting. This tool is supported by the Alzheimer’ s society and can be downloaded from their website- find it under links Once a diagnosis has been established ensure
○ record the diagnosis accurately on the register
○ advance care planning where applicable
○ continue prescribing medications as initiated and titrated by memory services
○ consider measures to reduce unplanned admissions
○ if mild cognitive impairment is diagnosed – consider an annual review and beware that 10-15 % of people diagnosed with MCI go on to develop dementia The most common SEs of donepezil , rivastigmine and galantamine ( cholinesterase inhibitors ) are loss of appetite , nausea , vomiting and diarrhoea.
SEs from memantine are less common /severe and may include dizziness , headaches , tiredness , raised BP and constipation

 Assess
 
 cognitionMini-mental state examination General practitioner assessment of cognition
GPCOG ( takes no longer than 5 mins ) 6-Item cognitive impairment test 
(takes 3-4 mins 0-8 is normal >= 8 suggest cognitive impairment ) Mini-cog assessment instrument ( takes 2-4 mins ) Memory impairment screen ( around 4 mins ) Abbreviated mental test score History from person / carers/ relatives Assess co-morbidities Risk factors Medications Look for focal neurological signs Gait and balance disturbances CVS signs as hypertension and arrhythmias Weight loss ( neglect ) Vision , hearing FBC ESR Urea and electrolytes Hba1c TFT Calcium Vit B12 and folate MSU , CXR and ECG if clinically indicated.

References

1. Geschwind, Michael D. “Rapidly Progressive Dementia.”Continuum (Minneapolis, Minn.)vol. 22,2 Dementia (2016): 510-37. doi:10.1212/CON.0000000000000319
2. Dementia Revealed : What Primary Care Needs to know A primer for General Practice Dr Elizabeth Barrett et al NHS England 2014
3. Dementia Partnerships: Dementia 10 Key Steps to Improving Timely Diagnosis A resource pack for Commissioners and General Practitioners 3rd edition January 2014
4. The assessment of dementia in primary care E Dodd et al Journal of Psychiatric and Mental Health Nursing October 2015
5. Dementia: timely diagnosis and early intervention BMJ 2015 ;350 :h3029
6. Dealing with dementia Br J Gen Pract 2015 ; 65 ( 637 ) :387
7. Risk factors for dementia Factsheet 450 April 2016
8. A brief pragmatic resource for general practitioners NHS England Version 1 Published January 2015
9. Creutzfeldt-Jakob disease Fact-Sheet National Institute of Neurological Disorders and Stroke via https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Creutzfeldt-Jakob-Disease-Fact-Sheet#:~:text=Creutzfeldt-Jakob disease (CJD),and runs a rapid course.
10. Leeds dementia pathway via http://www.yhscn.nhs.uk/media/PDFs/mhdn/Dementia/Meetings/RDL%2028062016/8.%20Leeds%20dementia%20pathway%20-%20version%201.0%20final%20-%20Feb%202016.pdf
11. Cerejeira, J et al. “Behavioral and psychological symptoms of dementia.” Frontiers in neurology vol. 3 73. 7 May. 2012, doi:10.3389/fneur.2012.00073 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3345875/
12. (2020), 2020 Alzheimer’s disease facts and figures. Alzheimer’s Dement., 16: 391-460. doi:10.1002/alz.12068
13. Dementia Mortality in the United States, 2000–2017 by Ellen A. Kramarow, Ph.D., and Betzaida Tejada-Vera, M.S. National Vital Statistics Reports Volume 68, Number 2 March 14, 2019 https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_02-508.pdf
14. Ravi, Samuel. “Dementia Mortality: Estimates of survival after the onset of dementia range from 4 to 12 years.” Indian journal of psychiatry vol. 53,2 (2011): 178-9. doi:10.4103/0019-5545.82565
15. Chandler R, Bruneau B (2014) Barriers to the management of pain in dementia care. Nursing Times; 110: 28; 12-16.
16. Aminzadeh, Faranak et al. “A review of barriers and enablers to diagnosis and management of persons with dementia in primary care.” Canadian geriatrics journal : CGJ vol. 15,3 (2012): 85-94. doi:10.5770/cgj.15.42
17. Dementia: assessment, management and support for people living with dementia and their carers NICE guideline Published: 20 June 2018 www.nice.org.uk/guidance/ng97
18. van der Flier WM, Scheltens P Epidemiology and risk factors of dementia
    Journal of Neurology, Neurosurgery & Psychiatry 2005;76:v2-v7.
19. WHO Dementia Key facts https://www.who.int/news-room/fact-sheets/detail/dementia
20. Drummond, Neil et al. “Prevalence and management of dementia in primary care practices with electronic medical records: a report from the Canadian Primary Care Sentinel Surveillance Network.” CMAJ open vol. 4,2 E177-84. 28 Apr. 2016, doi:10.9778/cmajo.20150050
21. National Collaborating Centre for Mental Health. The Dementia Care Pathway. Full implementation guidance. London: National Collaborating Centre for Mental Health; 2018 via https://www.rcpsych.ac.uk/docs/default-source/improving-care/nccmh/dementia/nccmh-dementia-care-pathway-full-implementation-guidance.pdf?sfvrsn=cdef189d_6