Dementia An Overview Steven Roberts Head of dementia

Dementia An Overview Steven Roberts Head of dementia services Independent Nurse Prescriber Steven. roberts@lpt. nhs. uk Lincolnshire Partnership NHS Foundation Trust

Aims of the Session To provide an overview of: • • What is dementia? The different types. The risk factors? What are the early signs? Benefits of diagnosis. Treatments What can we do? Chance to ask questions.

So, just what is dementia. . ? ? ?

Dementia is…. . …. not a single disease, but… • . . an illness ‘syndrome’ – a collection of signs & symptoms • • • Decline in cognitive abilities (memory, language, perception, attention) Changes in behaviour, mood or personality Decline in our day to day functional ability • …usually caused by disease of the brain • • Accumulation of abnormal proteins that disrupt and kill brain cells and their connections Changes in health of the blood vessels & supply of the brain • …. which is progressive • • • It is a chronic condition Differing patterns of onset and progression ‘Average’ duration of 8 years Dementia ‘IS NOT’ forgetfulness due to normal aging…whatever that may be? ?

There are different types… The main causes (or types) are: Ø Alzheimer’s disease > 62 % Ø Vascular dementia > 17 % Ø Lewy Body Dementia > 5 % Ø Mixed dementia > 10% Ø Frontal lobe dementia > 2% Gradual progression > 3 types, early onset(rare < 10%, late onset & familial (rare < 5%); ST memory, loss of judgement, communication – global impairment Step-wise progression, multiple strokes, > seizures, unsteady gait, depression, behaviour change, incontinence, vascular problems Gradual progression > Fluctuating cognition, visual hallucinations, parkinsonism, REM-sleep BD, falls, neuroleptic sensitivity, autonomic dysfunction, visuospatial deficits A mixture of both Alzheimer type and vascular type dementia Gradual progression > rare, younger onset, memory initially intact, changed social conduct, speech reduction, early loss insight, emotional blunting, diet/eating changes, incontinence. All effect the brain and thus the person in different patterns and ways. Important to diagnose – important for drug treatment and understanding the individuals behaviour and context

Impact on our brain…

So how big is the problem? National: Mapping the dementia gap (2010) Currently > 750, 000 people with dementia in the UK • Over 16, 000 under the age of 65 years • Estimated to be over 1 million by 2021 Local: Lincolnshire PCT (2011) Currently - 10, 877 cases in Lincolnshire • But only 41 - 45% have been diagnosed • Number of cases set to rise by 43% in the next 10 years • By 78% in next 14 years • Higher than National average Lincolnshire has one of the fastest growing elderly populations in the UK

So, who is at risk? …. well, we all are… Predicted that up to half of the cases of Alzheimer’s could be attributed to lifestyle choices that could be Mainmodified. Risk-Factors: Including education, Age smoking, physical inactivity, Advancing age is the main risk. The incidence of dementia approximately doubles every 5 yrs after the age of 65. depression, high blood pressure, SO, risk can be modified as it is a Family History/Genetics > interact with ‘life style’ factors. diabetes and obesity. • A number of genes discovered that increase the ‘risk’ for ADof (i. e. genetic PS 1, PS 2, APOE) and Frontal lobe combination and individual dementia (FTDP-17) – these effect the processing of brain proteins (University of California, 2011) environmental factors. • Family history heightens risk BUT ‘familial’lifestyle forms veryand rare (very early onset – 40’s). Gender Alzheimer’s disease – more females than males Vascular dementia – more males than females Diabetes & depression (stress) These also give us clues as to how we can help people with dementia as well. Recent studies (2010) showed increased risk of dementia associated with these – due to links to the underlying biological processes Head injury & anaesthesia Some studies indicate that head trauma (with loss of consciousness) and anaesthesia may represent risk factors in vulnerable individuals

What are the early signs? Memory loss – short-term memory, disorientation/getting lost Difficulty with familiar tasks – cooking meals, organising tasks. . Problems with language – word finding, naming. . Poor judgement – e. g. dressing inappropriately for weather. . Trouble keeping track of things – conversations, finances etc Misplacing things – putting things in unusual places Changes in mood or behaviour – depression, mood swings, disinhibited Change in personality – irritable, suspicious, anxious, asocial etc Loss of initiative – passive, increased sleeping, loss of interest etc

Are there benefits of early diagnosis? Early & accurate diagnosis is a National priority (NDS, 2009)… …. but why? ? Enables people to understand their condition (psychoeducation) Early access to treatment to relieve symptoms (excess disability) To access support/carer support Access to information ‘Opening a door’ – for future care Legal – Power of Attorney, Wills, Living Wills Financial planning Life planning

So, can dementia be treated. . ? ? ?

Are there drugs to treat dementia? 3 types of drug intervention. . 1: Curative – where disease is eradicated • No treatments available 2: Disease Modifying – where treatment alters course of illness • No treatments available 3: Symptomatic treatment – aimed at minimising impact of illness • Treatments available – current level of drug therapy

‘Anti-dementia’ drugs…. What are they? Cholinesterase Inhibitors • Donepezil (Aricept), Rivastigmine(Exelon) Galantamine (Reminyl) What are they for? • Mild to moderate Alzheimer’s disease (can worsen FTD) • To improve ‘daily functioning’. Concentration • ? Behaviours that challenge What is the evidence? • Controversy – cost effectiveness • High potential for side-effects – heart, breathing, falls, upset stomach • Modest benefit – approx 40% (NNT = 14: 1 in every 14 benefit) Also: Memantine: works by different mechanism • For severe Alzheimer’s disease (MMSE of 10 points or less) • To improve functioning/behaviours that challenge • Modest benefit – again approx 40% NNT = 14: 1 in every 14 benefit)

So, is there anything else we can do. . ? ? ?

Yes…The ‘Big Five’ for Optimal Brain Function Growing evidence that some lifestyle practices can slow or prevent issues that compromise mental function - The BIG FIVE: 1. Physical activity 2. Nutrition 3. Mental stimulation 4. Socialization 5. Creativity and attitude – stress reduction The very GOOD NEWS – for the most part these are issues you can do something about – RIGHT AWAY, RIGHT NOW…. . .

Body & Mind… For starters…. ’What is good for your heart is ALSO good for your brain’ Arterial disease Heart Attacks Strokes Share common risk factors. . . cholesterol, high blood pressure, obesity, arterial damage, plaque build up…SO… …. . when you watch your cholesterol, maintain a healthy weight, and exercise for your heart, your brain benefits too.

…stay healthy… Researchers looking at memory loss in older adults are becoming increasingly interested in the role played by diet and exercise…. 1: Physical Activity: • • • Daily, at least two and a half hours per week: Daily tasks (use the stairs, gardening, vigorous cleaning) Swimming (works joints/muscles without drag of gravity) Dancing or aerobics (exercises brain as well, fun) Biking/stationary bike (but protect your brain with a helmet!!) Tai-chi, yoga, Qui gon (strength, balance, concentration, de-stress) • Walking, walking…………………. . 2: Nutrition: Clutch of new studies indicate that walking 5 miles per week associated with lower risks of dementia (observed increased size of brain in areas associated with memory) Uni. Pittsburgh > walking 5 -6 miles a day slows the progress of dementia in those showing MCI or AD. Basics: your brain needs good fuel! Nutrition can help Avoid: saturated fats, processed meats, simple carbohydrates, salt; manage vascular risk. Pile on: fruits, veggies, complex carbohydrates, factors & diabetes grains & nuts, Oily fish & Omega-3 fatty acids Mediterranean diet – fruit, veg, olive oil, legumes, grains and fish – associated with reducing risk of dementia. associated with dementia Anti-oxidants: links with dementia : • Vitamins E & C – diet rich in fruit & veg, green tea, blueberris, red-wine, ginko biloba etc…

. . use your mind & connect. . 3: Mental stimulation ‘Exercise’ your brain…. • • Education is neuroprotective. Brain trainers. Puzzles, games, sensory stimulation, crosswords, reading, CST etc. BUT - Appropriate level - adapt to changing abilities! `Use it or lose it!’ 4: Socialisation. . remain socially connected. • • Humans are social creatures Appropriate socialization Work with known difficulties not against Trust in and inform others to help. Things socialisation does for your brain: • Lowers your blood pressure > risk of stroke • Improves immune function • Lowers memory loss by keeping mind active

…and manage stress and spirit. . As dementia emerges your emotional life grows. . 5: Creativity, attitude & spirit: Just as your brain dictates your feelings, your feelings affect your brain > stress hormones!!. Manage and be aware of stress: • • Antidepressants (depression as risk factor) Aromatherapy, diet and exercise (e. g. tai chi, yoga etc. ) Meditation (mindfulness – the here and now) Be creative – be human! • • • Music (singing for the brain) Art (art therapy) Dancing Adapt and support in the ‘now’… Mood & behaviour as coping defences? Communication (e. g. SPECAL) adapt activities to present abilities Music can: Reduce anxiety, aid sleep, lower blood pressure, reduce stress hormones. The creative brain: memory for music and emotion are in a different part of the brain from memory about ‘things’ and is often intact much longer in even sever dementia This means these intact abilities can be tapped into in dementia

Summary…at last!! Dementia is a collection of signs and symptoms –presents in many different ways and people experience it differently. Due to changes in the brain – different types Multiple risks – not one thing alone – genes & lifestyle/environment. Important to identify early – to plan, understand, manage and support. Drug treatments – currently limited to symptom relief – do not cure! Lifestyle changes can reduce risks & maximise wellbeing – there are things we can all do NOW!

`THANK YOU Any questions. . ? ? ? …. . if you are you still awake? ? ?