Dementia - an LMC Update for your CPD folder
Date sent: Friday 3 October 2014
Email sent by Wessex LMCs, on Friday, 3 Oct 2014
There are nearly 850,000 people with dementia in the UK, and about 26,500 people in Hampshire. This figure is increasing significantly year on year as our population gets older and the number of elderly patients rises.
The Government launched a national Dementia Strategy in 2012 to try to help meet these challenges.
Recently the LMC organised a conference to explore health and social care aspects from a general practice point of view.
The presentations can be found on the LMC website, via the following link:
Below is a summary of the various presentations that you might wish to use as part of your CPD for your next appraisal.
Information based on presentation by Older Peoples Mental Health Consultants.
This is a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of higher cortical functions, including memory, thinking, orientation, comprehension, language, calculation, learning capability and judgment.
Consciousness is not impaired. Cognitive function is impaired and is commonly accompanied and occasionally preceded by deterioration in emotional control, social behaviour or motivation.
Must interfere with daily functioning.
At least 6 months duration.
The duration does pose problems to GPs who refer patients who they believe have dementia and once assessed in the memory clinic have a delay of a few months before the diagnosis is confirmed. The reason for the duration being so important is because some patients’ cognitive function will change and patients have in the past been assessed, diagnosed with dementia only to find their cognitive function improves and the diagnosis is delayed as a result.
This is the most common form of dementia and is caused by cortical degeneration and will frequently have the following deficits:
- Memory, recall does not improve with cues
- Gradual decline
- Early loss of insight
- Language (aphasia-word finding difficulty)
- Visuospatial (apraxia)
- Perceptual (agnosia)
At first personality and behavioural changes may be the most obvious symptoms.
In this type of dementia deficits include:
- Initiative and spontaneity
- Planning, organisation
- Decision making
- Impulse control
- Emotional control
- Working memory
This accounts for about 20% of all cases of dementia although there are many patients who have a mixed picture with Alzheimer’s disease and vascular dementia.
- Plethora of physical signs
- Stepwise decline
- This is a sub-cortical disease so there are no cortical features
- Slowness and rigidity of thinking
- Planning, organising, and sequencing mental events
- Amnesia may not be severe and fluctuates, recall improves with cues
- Daytime napping
- Struggle with mental manipulation
- Difficulty in reversing digits (find great difficulty is counting backwards)
Mild Cognitive Impairment (MCI)
About 50% will go on to develop dementia. About 10% per year of patients with MCI will develop dementia each year.
Patients with MCI are 3-5 time greater risk of developing dementia compared to the normal population.
Currently is not possible to predict which patients with MCI will go on to develop dementia.
No evidence that intervention changes the risk of developing dementia.
Anti-psychotics were introduced in the 1950s, the most common being Haloperidol, Promazine and Thioridazine.
In the last 20 years newer classes of drugs have been introduced including Risperidone and Olanzapine.
In 2004 concerns were raised due to the increased risk of stoke for patients who were prescribed these drugs.
About 90% of patients with dementia develop behaviour and psychological symptoms of dementia (BPSD) and this includes:
- Loss of inhibition
The problems with anti-psychotic drugs:
- Increased risk of stroke
- Increased mortality
- Increased risk of VTE
- Worsening cognitive function
- Sedation, Parkinsonism, dehydration and falls
Risperidone licenced for use for up to 6 weeks, in patients with Alzheimer’s disease for the treatment of moderate to severe symptoms. The benefits of treatment must outweigh the risks.
- Full discussion with the patients and carers about the risks and benefits
- Antipsychotics should be started at a low dose and increased every 2 – 4 days if no response.
- Patients who respond to treatment should have the medication withdrawn cautiously after a 6 – 12 week period.
- Half the dose for 2 weeks, and if the symptoms do not return stop after a further 2 weeks.
- Review again after a further 1 week.
- If the symptoms re-emerge reintroduce drugs at the starting dose.
- BPSD can persist and treatment with atypical antipsychotic may be needed in long term (but should be reviewed every 3 months).
|Drug||Starting dose||Optimum dose|
|Risperidone||250 ug bd||500ug bd|
|Olanzapine||2.5mg od||5 – 10mg od|
|Quertiapine||25mg od||25 – 150 mg daily|
|5mg od||10mg od|
|Key Symptom||First Line||Second Line|
ModerateAgitation and anxiety
SevereAgitation and anxiety
Clonazepam (Lewy Body)
Information based on presentations given by Dr Nicola Decker and Dr Emer Forde, two inspirational GPs who have an interest in dementia care.
Nicola is a GP in North Hampshire, the CCG GP lead for dementia and a NICE Fellow. She talked about How do you become a “dementia friendly” Practice and does this benefit the Practice or the patient?
It is worth looking at Nicola’s presentation which is full of useful information.
Here is the link to a Dementia friendly practice toolkit.
The Dementia Friendly Practice work was supported by the Wessex Academic Health Science Network and the outcomes are currently being evaluated with a view to encouraging wider implementation of the project.
Emer is a GP in Poole and talked about improving diagnosis and the care of patients living with dementia.
Emer’s presentation looks at the CCG strategy, a locality dementia plan, and dementia friendly communities. Emer’s practice has produced a very simple but effective dementia action plan.
It often appears that a growing problem like this means that general practice is required to undertake additional work, but do we always make effective use of social care and the voluntary sector. This presentation showed some of the collaboration that Emer’s practice and locality are undertaking with these organisations.
This led nicely into the final section which explored some examples of the care and support provided by the local authority and a number of voluntary organisations.
The Department of Health, a CCG and the Royal College of GPs have produced a document called: Dementia Revealed: What Primary Care needs to know.
Social Care and the Voluntary Sector
This presentation was undertaken by Hampshire County Council but each local authority has an adult services section which will have a dementia action plan.
They should be working in partnership with the CCG and the voluntary sector to ensure the co-ordination of services in your area.
The Voluntary Sector
There was a short presentation from the Alzheimer’s Society and the Princess Royal Trust.
In Hampshire there are dementia advisors and dementia support workers.
Dementia Advisor Service
In Hampshire Dementia Advisors are able to support GPs, take referrals and signpost people with dementia on to other appropriate organisations. The service is provided by The Alzheimer’s Society and Andover Mind.
- is available to anyone with a diagnosis of dementia
- can support GP’s by giving information and having a presence in surgeries
- is also available to people with a suspected dementia to help support them through the diagnostic process
- focuses on well-being rather than illness
- supports people to think about how they can come to terms with and live well with dementia
- assists with the health and social care support available to people with a diagnosed dementia and their carers
- offers advice on state benefits and planning for the future
Please telephone: 023 92 892034 for services provided by The Alzheimer’s Society in:
- New Forest
- Isle of Wight
Please telephone: 01264 353363 for services provided by Andover Mind in:
- Basingstoke and Deane
- Test Valley
In your area I am sure there are similar organisations who are superb contact points for patients and GPs for information and help.
The LMC will seek information from each CCG relating to services and contacts and publish this on our website.
Dementia Lunch & Learn Package
The Dementia Lunch and Learn package is FREE to all Wessex Practices as Wessex LMCs is keen to support all the national work on Dementia and sees this resource as a major way in getting some messages across to all who work in general practice.
This training resource is to give everyone a basic idea of what dementia is and what the common symptoms are. It looks briefly too at the main risk factors to dementia. Subsequently, there are the tools which can be used to enable you to become a dementia friendly practice.
The aim of the session is to widen awareness of the illness and the effect it can have on patients and how as a practice you can make changes to enhance the care of your dementia patients.
There are some useful video clips in the resource, so access to an internet connection would be useful if that is available. However – they are not essential.
Please do not be daunted by all the suggestions within the iSPACE programme – just making a few changes in the right direction is a great start.
All staff should benefit from this – and please encourage locums to join you if you run a lunchtime session for all staff.
Here are some further resources for learning around Dementia:
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
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