OVERCOMING THE CHALLENGES OF MANAGING CHRONIC DISEASES IN PERSONS WITH DEMENTIA DEMENTIA, THE BRAIN AND HOW IT WORKS AND WHY YOU MATTER
LEARNING OBJECTIVES Be familiar with the diagnostic criteria for dementia Understand how dementia affects the brain and therefore function Recognise the different types of dementia and how they impact on functional ability Identify the different cognitive domains and their role in the clinical problems faced by patients Recognise the role of community support in managing patients with dementia
MYTHBUSTING People are born with a fixed number of neurons and are unable to regenerate brain tissue People with dementia have no ability to learn and therefore are not suitable for rehabilitation programs After a brain injury most of the recovery is in the first couple of weeks and there is little improvement later
NEUROPLASTICITY AND DEMENTIA Watch this space
DEMENTIA DIAGNOSIS DEFINITIONAL CHANGE Driven by high failure rate of AD trials 99.6% Trials targeting prodromal AD/ preclinical AD New Definitions DSM-5 MCI = minor neurocognitive disorder Dementia = Major neurocognitive disorder NIA-AA Cognitive and behaviour change with decline Need informant history and cognitive testing IWG 2 Must have amnestic syndrome and positive biomarkers Allows for prodromal diagnosis
DSM -V DEFINITION OF DEMENTIA Major Neurocognitive disorder = Dementia Minor Neurocognitive disorder = MCI Identified 6 cognitive domains No longer necessary to have impairment in memory Still need to show functional impairment
CLINICAL DEFINITION OF DEMENTIA Characterised by decline in cognition in one or more cognitive domains Must be a deterioration from baseline Must interfere with daily function and independence Changes not occurring only during delirium Not better accounted for by another mental disorder
COGNITIVE DOMAINS Memory and learning Recalling instructions Forgetting appointments Forgetting medications Executive function Reduced organisation/planning Reduced motivation/initiation Complex Attention Visuospatial /perceptual motor Inability to recognize equipment Language Inability to understand instructions Inability to comprehend written instructions Inability to convey concerns Social cognition
CLINICAL FEATURES OF DIFFERENT TYPES OF DEMENTIA Alzheimer s dementia Vascular dementia Mixed dementia episodic memory impairment visuo-spatial issues executive dysfunction reduced speed of thinking executive dysfunction visuospatial including apraxia Dementia with Lewy bodies Motor parkinsonism Hallucinations Fluctuations in attention Fronto temporal dementia Behavioural problems Language dysfunction Other Alcohol Parkinson s disease dementia
SYMPTOMS. Memory
SYMPTOMS. Memory Thinking planning & Behaviour
SYMPTOMS. Memory Thinking planning & Behaviour Speaking understanding speech
SYMPTOMS. Memory Thinking planning & behaviour Speaking understanding speech Your sense of where your body is in relation to things around you.
SYMPTOMS. Memory Thinking planning & Behaviour Speaking understanding speech Your sense of where your body is in relation to things around you. Ability to interpret what the eyes see
COGNITIVE SCREENING TOOLS GPCOG Recommended by NHMRC RUDAS Validated for CALD and limited education, some training required MMSE Copyright issues, ceiling and floor effects MOCA includes executive function items, more time consuming Specific tests clock face, delayed recall, fluency
ISSUES THAT ARE IMPACTING ON THE MANAGEMENT OF PATIENTS WITH DEMENTIA AND OTHER COMORBIDITIES Patients are not having their dementia diagnosed Other patient factors impacting on disease presentation Systemic factors
WHY ARE PATIENTS NOT BEING DIAGNOSED Stigma of dementia Patients under-report problems due to fear of implications of diagnosis Health practitioners not trained to adequately assess cognition Tendency to attribute change to ageing Belief that dementia is untreatable and therefore not worth making a diagnosis
INTERPLAY OF OTHER FACTORS Mood Sleep Pain Delirium Medications Concerns about loss of autonomy Sensory impairments Alcohol and drug use
SYSTEMIC ISSUES Access to specialist care especially in rural and regional areas Funding issues Transport Silos of healthcare Need for strong advocacy voice
HOW CAN DEMENTIA IMPACT ON CHRONIC DISEASE MANAGEMENT Medication compliance Inability to monitor disease Inability to respond in an emergency Inability to adhere to management plans Impaired language function Discrimination leading to reduced access to treatments offered eg rehabilitation Impaired problem solving Associated mood & anxiety issues Inability to use equipment appropriately
WHY WHAT YOU DO MATTERS.. Evidence of the benefit of socialisation in slowing functional decline Evidence of the benefits of exercise in slowing functional decline Possible benefits from non contingent reinforcement in patients with behavioural issues Cochrane review in 2012 found benefit in cognitive stimulation programs for patients with mild to moderate dementia- BUT trials were variable quality and some small numbers MORE RESEARCH NEEDED
TAKE HOME MESSAGES Accurate diagnosis matters A number on a screening test is not a diagnosis Treatment needs to be individualised Many people with dementia can remain active and engaged members of society for years Supported self management is the key YOU CAN MAKE A DIFFERENCE