Next patient please Dementia Clare Hawley 2018
I have no conflict of interest to declare Dr Clare Hawley Associate Specialist Cardiology Chesterfield Royal Hospital GPwSI Refractory Angina Hon Clinical Lecturer Cardiology University of Bradford
Case: HC age 63 years 1st met in 21 years ago on cardiac rehab 1997 anterior MI with VF arrest (age 46) 1999 angiogram was normal & LV function preserved 2012 chest pains returned after Mum died & was referred to back to cardiology Her husband had stopped her taking all medication 5 years ago & had not attended annual reviews Ex smoker, not diabetic, TC=6.5, FH unknown Re-started Aspirin, Atorvastatin & Bisoprolol Re married & all was well
2017 2017 chest pains returned Causing great anxiety to HC & new husband Chest pain daily on exertion & emotion Several attendances in A&E: ECG & troponin ve Given omeprazole for reflux ETT: 9 mins, minimal chest pain, no ECG changes ECG: SR 62 bpm & BP 118/78 mmhg Isosorbide mononitrate added Referred to Angina Management Programme
Angina Management Programme DNA first 2 appointments despite letter & phone calls Attended with new partner & stepson Difficulty explaining her symptoms & impact on life Co-lateral history provided by husband CP daily, distressing for all Cognitive impairment Problems with memory & word finding Loss of executive function: planning, organizing Physical: Hearing loss, dizzy spells & a bit clumsy Forgets medication & how to use GTN
Impact on angina management Reaction & response to chest pain depends on: what we think is happening another heart attack what we believe the consequences will be - death memories of something similar previous MI & arrest reactions of others panic 999, concern & caring Understanding angina & addressing misconceptions is key to management which is a challenge in people cognitive impairment Educating partners & carers is essential * Foreman RD. Ann Rev Physiol 1999
Case: HC dementia work up No single diagnostic test Diagnosis based on history Cognitive function 6 CIT Exclusion of other causes Referred to memory clinic FBC, ESR, TSH, U&E, LFT, glucose, B12, Folate MRI: marked chronic ischaemic microvascular disease with tiny lacunar infarcts guidance.nice.org.uk/cg42
Case: HC outcome HC & husband attended all the AMP classes HC has less angina, feels better but not sure why Husband has a better understanding of angina & no longer panics when she gets angina - no admissions or cardiac testing, regular walks Husband sees to the medication & is listed as an alternative contact for appointments Husband has applied for Lasting Power of Attorney Access support through Memory Service
In females, death rate from CV disease has halved since 2001, whilst death rate from dementia & has doubled Trends in age-standardised mortality rates from leading causes of death, females, 2001-2015 Source: PHE analysis of ONS mortality data
Dementia is a growing healthcare problem Not just the elderly affects 1 in 1400 people 40-64 years Numbers are set to double in next 30 years Half those with dementia do not have a formal diagnosis
There are more than 100 conditions that can cause symptoms of dementia
Alzheimer's disease (AD) 60% Changes in brain chemistry & structure Amyloid plaques & TAU tangles Neuro-transmitters are less effective Insulin resistance & vascular changes Gradual onset & progressive Early short term memory loss Loss of executive function & other symptoms later
Vascular dementia (VaD) 20% Cerebrovascular disease - stroke/tia single-infarct multi-infarct often silent subcortical small-vessel disease cerebral amyloid angiopathy Physical symptoms & cognitive impairment Lose executive functioning first & memory loss later Sudden or gradual onset with stepwise decline Mixed VaD and AD in 10%
Risk factors for developing VaD are the same as other CVD Previous stroke or MI (doubles the risk) Also CABG (4 in10) AF, following cardiac arrest Modifying vascular risk factors in midlife reduces risk HBP is single most important modifiable risk factor Treating hypertension, especially after a stroke Less benefit as age increases Jellinger KA. Pathology & pathogenesis of vascular cognitive impairment-a critical update. Front Aging Neurosci. 2013
Role of drugs in VaD is limited Offer usual secondary prevention Non drug interventions 4 licensed drugs for dementia: Anticholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine Glutamine receptor antagonists: Memantine Not a cure dementia but slow progression of mild-moderate AD & mixed dementia Not recommended for pure VaD Cholinesterase inhibitors for Alzheimer s disease. Cochrane Database Syst Rev2006;1
What about Statins Mixed reports Cochrane Review of trials comparing statin v placebo in elderly people with normal cognitive function showed no reduction in developing dementia with statins Meta analysis of observational data found people on high dose statins used for 3-25 years had 30% reduced risk of developing dementia Short-term memory-loss and confusion, has been widely reported in the media but not proven Statins & Cognition: Systematic Review & Meta-analysis of Short &Long-term Cognitive Effects doi:10.1016/j.mayocp.2013.07.013
Prevention About half the burden of dementia could be reduced by encouraging people to follow 4 of the Big Five: 1. Moderate exercise 2. Not smoking 3. Normal BMI 4. Eating healthily 5. Alcohol in moderation Caerphilly Cohort Study PLOS one 2013
Summary People with CVD are living longer and may go on to develop dementia. Risk factors for dementia are similar to other CVD and modification in midlife can reduce the risk Look out for out of character DNAs, failing to collect prescriptions, frequent unplanned admissions Enlist the help of family members/carers to ensure: medications are taken & stop non essentials appointments are kept Making the diagnosis excludes reversible causes, allows for planning & access to treatment & support
Thank you
Our patients with AF Forget OAC OD OAC Impact on Warfarin/NOAC Forget advice Appointments Take OTC stuff
Our patients with HF Forget their meds OD their meds Forget their appts
Our patients with angina Drug adherence Understanding Follow up 999 advice Frequent admissions Frequent appointments same illness