Dr Uche Oguekwe

Managing memory problems in primary care

Introduction

As the UK population is living longer , memory problems are now seen frequently in primary care

The RCGP curriculum statement 9 version 1.1 expects the GP to be able to manage contacts with older patients and deal with their unselected problems

Dementia UK report (2007) states that there are currently 700,000 people with dementia in the UK, and this is projected to rise to over a million by 2025. The overall cost of dementia is estimated to be £17-18 billion a year.

Dementia can occur at any age, but is most common in older people, affecting one in six people over the age of 80. Early onset dementia is defined as dementia occurring in those under 65 years of age and accounts for 2.2 % of all people with dementia in the UK.

ScopeInitial assessment of patient presenting with memory loss

symptom using 2 case studiesDistinguish those with memory symptoms caused by

conditions other than dementiaRecognise the impact of dementia on the health of the

nationWill briefly look at broader aspects of caring for people

with dementia, including issues around driving & non-cognitive symptoms in people with dementia

Case 1 Mrs AB82 years old, married for 60 years, pmhx of HTNHusband recently diagnosed with dementia and moved to

nursing homeDaughter came to surgery, saying her mum has been

behaving odd in the last few weeksCalled the police more than three times in four weeks,

saying a group of men have broken through her windowMaking inappropriate gestures to her neighbourForgetting to lock her doorsNot remembering what she has done the previous dayUnkempt, weight loss and not eating muchRefusing carers at home and does not want to go into care /

nursing home

What are the issues raisedConfidentiality? patient’s safety?Vulnerable adult/ elder abuse?Daughters agenda?Mental capacity?Anymore??

AssessmentA home visit was arranged with Mrs AB with her 2

daughters presentShe scored 28/30 on MMSEShe says she is absolutely fine and that she does not

lock her door as she wants her male visitors to have access

Denied calling the police Agreed to have urine dip which was normalAgreed to have blood test and referral to memory

clinic

OutcomeSeen by memory clinic psycho geriatricianMMSE remained 28/30She now had more psychotic featuresFurther questioning revealed abuse as a child and

strong family history of mental health problemsCT scans and bloods all came back normalA diagnosis of psychotic pseudo-dementia was madeShe was started on Risperidone 0.5mg , which was

later increased to 1mg with good effectDaughters have now signed the next of kin papers

Case 2 Mrs BC90 years old, seen with her husbandRetired Consultant ObstetricianHer husband has noticed that she has become forgetful and

keeps repeating herselfForgot to turn off gas on few occasionspmshx- HTN & hypothyroidEx-smoker and Etoh 5units/ weekNo family history of memory problemsBloods, Ecg and urine were all normalMMSE 23/30- lost marks on short term memory and recall

What will you do next?She was referred to the memory clinic Repeat MMSE remained at 23/30A diagnosis of Alzheimer dementia was made , although

she has risk factors for Vascular dementiaCT head and further neuro-psychological testing

confirmed probable Alzheimer'sShe was started on a trial of ACHi- donepezil by the

specialistShe was also assessed by the OT who advised use of

memory aidsShe has remained stable and reviewed regularly by the

PHCT.

How should GP’s assess patients with memory problems

Should find out what is meant by ‘memory problem’ or ‘forgetful’? Ask for specific examples, such as forgetting days, times, appointments, names or familiar faces. Are there problems with getting lost, speech, using the correct words, writing or reading?

The length of history and progression of the problemAny associated features such as problems with sleep,

hallucinations or change in personalityAny change in functional ability. For example, has this

affected home life, management of finances, work , or problems with driving

How should GP’s assess patients with memory problems

other important factors are features of depression or anxiety. E.g. sleep disturbance, lack of motivation, anhedonia (loss of

enjoyment), poor appetite or tearfulnessPast medical (vascular risk factors , Parkinson’s disease )and

psychiatric history. Medications including analgesics and sedativesSocial circumstances : any recent changes such as retirement, change

of housing, location or a bereavementAlcohol intakeSmoking historyFamily history of memory problems or dementia

How should GP’s assess patients with memory problemsA physical examination is definitely importantThe Abbreviated Mental Test Score (AMTS) -this may

suffice as screening during a 10 min consultationThe Mini Mental State Examination ( MMSE) -this is

widely regarded as the “gold standard” test for dementia-but there are now copyright issues which prevents GP’s from printing this off

Asking a patient to draw a clock face and set the time to 11.10 is a useful addition to the MMSE

An intermediate step is the Addenbrookes Cognitive Examination (ACE)- domains tested includes attention, memory, language, visuo- spatial skills and executive function

Other cognitive test which may be used in primary care The 7-Minute ScreenGeneral Practitioner Assessment of Cognition (GPCOG)The Mini-Cog Assessment InstrumentThe Memory Impairment Screen (MIS)The 6-Item Cognitive Impairment Test (6-CIT)

The GPCOG, Mini-Cog and MIS are brief and have been shown to be as clinically and psychometrically robust as the MMSE. Appropriate for use in primary care.

GPCOG is readily available via the patient.co.uk website for GPs to use.

Investigations A stepwise approach to investigation is required.

Routine investigations to help rule out physical causes FBC, urea and electrolytes, liver function tests, bone

profile , folate & vitamin B12 level, thyroid function tests, random or fasting blood sugar & cholesterol level

ECG, CXRUrinalysisAn assessment of cognition using one of the tools

outlined above

Diagnoses to consider in patients with memory loss

The commonest cause of significant memory impairment is AD

There are many factors that can influence cognitive decline and they include Stroke Hypothyroidism Hyperparathyroidism Recurrent head trauma Hypoperfusion Medication use Depression Alcohol and drug abuse Toxins, infections , metabolic and structural causes

 

Other possible diagnosisThere are many causes of dementia and in the early stages they will

present with mild memory impairment. The following list is far from all inclusive:

About 20% of patients with Parkinson's disease also develop dementia Dementia with Lewy body is the second only to AD as a common

cause of dementia Pick’s disease ( Fronto-temporal dementia) Huntington’s chorea Syphilis AIDS Multiple Sclerosis Creutzfeldt-jakob disease Carbon monoxide and heavy metal poisoning

ManagementThe Alzheimer’s society recommend the following non-

drug strategies to cope with memory loss:Keeping a to do listUse of memory aids such as watch, calendar and diaryRegular exerciseStop smokingAdequate sleep

Management contdGeneral safety measures such as installing smoke alarm

and gas detectors within the home of individuals with dementia

Other factors such as reduction in alcohol intake, control of HTN, diabetes and high cholesterol have all been found useful especially in VaD

Treatment of any underlying cause such as B12 def, hypothyroidism

Use of cholinesterase inhibitors (Aricept) and glutamate antagonist (memantine) as cognitive enhancers. NICE supports use of the MMSE with scores between 20 and 10 and six monthly checks, stopping when MMSE < 10

NICE recommendationNICE recommends taking the following into consideration

when assessing a possible diagnosis of dementiaThe individual’s self report of changes in memory ,

capability or moodInformant histories that support self report and add

significant new details of changesExclusion of depression and delirium as primary

pathologies, using the information from the personal and informant histories

Measurable cognitive losses, using a standardised instrument

Absence of ‘red flag’ symptoms suggesting alternative diagnoses e.g. Urinary incontinence or ataxia in apparent early dementia

Issue of drivingDriving is not necessarily prohibited in early dementia

(refer to DVLA guidelines). As with any condition, if there are any concerns (incidents, family members do not feel safe) then advise the patient not to drive until further information is available. Once a diagnosis of dementia has been made, the DVLA should be informed of this.

Broader aspects of caring for people with dementia

Non-cognitive symptoms are prevalent in dementia and can arise as dementia progresses. They can be difficult to identify and pose challenges in management.

Such symptoms include: Depression Delusions and hallucinations Agitation Wandering Swallowing problems End of life careAlthough prevalent in certain specialist settings such as care homes, these symptoms may also

occur in people with dementia being cared for at home. Regardless of the setting in which they occur, such symptoms can be distressing for both the person with dementia and also the carers involved.

summaryDiagnosis of dementia can be lengthy, complex and Staged

over time.Diagnosing the type of dementia is just the beginning of the

management process for this chronic condition. Any patient suspected of having dementia should be

referred to specialist for diagnosis – taking into account their wishes because of the irreversible and progressive nature of dementia, and the implications that this has for the patient and also their family

Early detection allows patients and their families access to information, support services, medications, and enables them to make preparation for the future

Local dementia and memory resources

Dementia team and memory clinic – mental health services for older people at Elizabeth house Gillingham- refer all cases of suspected dementia

Medway dementia advisor service- 01634 338633- offers support to those who are newly diagnosed and to those who have had dementia for some time

The 24 hour dementia helpline- 08456044391- offers information and emotional support for anyone in Kent or Medway with dementia, & their carers

Dementia web- www.dementiawebkentandmedway.org.uk offers comprehensive online info & advice about the many aspects of living with dementia and caring for someone with the condition

Use it or lose it