pharmacists in secure environments - Royal Pharmaceutical Society

f e at u r e d e m e n t i a
visual hallucinations and history of falls
[in addition to Parkinsonian features],
associated with the presence of Lewy
bodies inside nerve cells in the brain
which interrupt its normal functioning.
It accounts for approximately 15% of
dementias. Lewy bodies are also present
in Parkinson’s disease dementia, and
diagnosis is dependent on the time of
dementia symptoms in relation to onset
of parkinsonian symptoms. People
with either form display an increased
sensitivity to antipsychotics which can be
fatal.
• Frontotemporal dementia is a rare form
of dementia, and affects around 5% of
people with dementia. It often affects
the under 65s, with dramatic effects on
behaviour and personality, rather than
memory, in the early stages.
Risk factors
The main risk factor for dementia is age, but
cardiovascular factors are also important,
and people with learning difficulties (e.g.
Down’s Syndrome) may be affected earlier.
Genetic predisposition has also been
associated.
Other risk factors implicated include:
• Environmental toxins causing
neurotoxicity (e.g. excessive alcohol,
pesticides, aluminium levels in water and
diet)
• Head injury
• Gender – The prevalence is higher in men
up to the age of 74 years, but higher in
women thereafter.
• Remedial factors which can be managed
and treated:
o Hypothyroidism
o Vitamin deficiency (e.g. thiamine, B12,
folate, or iron)
o Acute confusional state (delirium)
o Space occupying lesions in the brain or
hydrocephalus
Symptoms
Disease progression varies considerably, but
broadly falls into three phases
Early Stage symptoms, often misattributed
to stress, bereavement or normal ageing
include:
• mood changes;
• loss of short-term memory;
• confusion, poor judgement, unwillingness
to make decisions;
• anxiety, agitation or distress over perceived
changes and inability to manage everyday
tasks.
Middle Stage symptoms include:
• more support required, including reminders
to eat, wash, dress and use the lavatory;
•increasingly forgetful and may fail to
recognise people; distress, aggression and
anger are not uncommon, perhaps due to
frustration;
• risks include wandering and getting lost,
leaving taps running or forgetting to light
the gas;
• may behave inappropriately e.g. dressing
incorrectly, loss of day-night cycle;
• may experience hallucinations.
Late Stage symptoms include:
• inability to recognise familiar objects,
surroundings or people – but there may be
some flashes of recognition;
• increasing physical frailty, may start to
shuffle or walk unsteadily, eventually
becoming confined to bed or a chair;
• difficulty eating and sometimes
swallowing, weight loss, incontinence and
gradual loss of speech.
Consequences of dementia
• People can live with dementia for many
years – the average time from diagnosis to
death is 11-12 years, but diagnosis is often
made late so the course of the illness can
be as long as 20 years
• Most people with dementia have at least
one co-morbidity
• Unpaid carers (mostly female family
members) provide the majority of care in
the community
• Often it is the behavioural changes in
people with dementia that distress the
family and carers the most
• The annual economic burden of lateonset
dementia is estimated to be more
than stroke, heart disease and cancer
combined, of which the majority falls to
families.
• Around one third of people with dementia
currently live in largely private sector
care homes (making up over 60 per cent
of all residents), and the trend is towards
entering care with more severe disease.
Treatments
The National Dementia Strategy (NDS)
in February 2009, outlined key areas for
addressing by healthcare professionals:
1. Ensure better knowledge about dementia
and remove the stigma
2. Ensure early diagnosis, support and
treatment for people with dementia and their
family and carers
3. Develop services to meet changing needs
better.
Pharmacological groups licensed for the
treatment of dementia in Alzheimer’s
Disease are:
• Cholinesterase inhibitors – donepezil,
rivastigmine and galantamine
• NMDA-receptor antagonist – memantine
Æ See Practice Guidance: Supporting
Patients on Medicines for Dementia
(Cognitive Enhancers)
Pharmacological treatment for dementia
should be initiated and supervised only by a
specialist experienced in the management of
dementia
Provide a medication review service to
ensure understanding of dementia
Non-pharmacological: Promoting Good
Mental & Physical Health
Encourage and support patients and their
family/carers to undertake activities and
address lifestyle issues, to promote good
mental and physical health.
Over the Counter Self-treatments –
Gingko biloba has some supporting evidence
in improving memory and concentration.
Note: Theoretical evidence suggests it may
increase the antiplatelet effects of aspirin.
Folic acid, B12 and iron Deficiencies of
these are linked with cognitive dysfunction
(confusion and/or memory problems).
However, if a deficiency has not been proven,
supplementation will generally not have any
clinical effect.
Lemon balm and Lavender Essential
Oils There is emerging evidence for use
in sleeping and agitation either via an
oil diffuser, massage or being placed on
pillowcases or clothing.
Light therapy Evidence from small studies
suggests positive benefits on behavioural
problems from light therapy during winter
months.
Practice Points
for Pharmacists
• Identify people possibly at risk. All
people concerned about memory
impairment; losing objects (keys,
wallets etc) should be signposted to
their GP or specialist memory services
• Offer educational support and
advice and ensure the patient and/
or carer understands how their
medication works and the importance
of continuing to take them. Reassure
them about any concerns such as side
effects and refer as appropriate.
• Signpost to organisations that can
support their educational needs and
prepare them for the future - support
may also be required with advance
directives, wills, finances and the
home environment.
• Poorly compliant patients may
benefit from a once daily preparation
(particularly in polypharmacy) and/or
use of compliance aids with support.
Provide family / carers with advice to
support compliance.
• Swallowing difficulties: consider
alternative formulations for patients
with swallowing difficulties and/or
problems with dose titration.
• Offer a prescription collection and
delivery service
• Encourage self-care in terms of
increasing exercise, taking part in
social activities and doing activities,
which stimulate brain function, such
as crossword puzzles, jigsaw puzzles
or Sudoko.
• Alcohol should be avoided – due to
added effects of drowsiness
• Check for interactions including
OTC remedies. See www.bnf.org for
interactions.
•Gingko biloba: Concomitant use of
aspirin may increase its antiplatelet
effects (avoid combination or use
cautiously). Ensure the patient’s
prescriber is aware if ginkgo biloba
is being taken and any signs of
increased bruising are investigated.
• Establish links with the local
Dementia Advisor for liaison – to
support people in local community
with dementia, to reduce stigma
associated with the illness and to
promote the early recognition of
signs and symptoms with appropriate
referral.
The National Dementia Strategy promotes
the implementation of a local Dementia
Advisor to provide support and information
as and when it is needed. The emphasis
is on proactive engagement of healthcare
professionals rather than a response to a
person who is in distress and no longer
coping. Pharmacists by promoting good
mental and physical health activities can
further help improve the quality of life for
people with dementia and their families.
Levels of pharmaceutical care
services for supporting patients
with dementia
In general pharmacists can:
• Recognise possible symptoms of dementia
especially when responding to symptoms
and refer as appropriate
• Provide lifestyle advice and support
• Signpost to local and/or national support
resources.
Æ See Useful Resources section
Level 1: Pharmacists can:
• Provide a medication review service
to ensure understanding of dementia by
patient and/or their family/carers; provide
treatment support; and address any side
effects and adherence problems. Patients
receiving their dementia medication from
secondary care services for the first time
may not have had access to pharmacist
advice and support .
Level 2: Pharmacists can offer:
• Support for healthy lifestyle interventions
(for patients and/or family/carers),
including:-
Smoking cessation counselling and
provision of nicotine replacement therapy
(NRT)
Advice on use of use of alcohol: NHS
Choices: http://www.nhs.uk/Livewell/
over60s/Pages/Tipsforcuttingdown.aspx
Diet and exercise support and advice -
see Top Tips for eating more fruit and
vegetables at http://www.5aday.nhs.uk/
topTips/default.html
Vascular risk checks and weight
management
• Pharmaceutical care of vulnerable patients
e.g. daily dispensing; compliance charts;
monitored dose systems
• Recognise symptoms of declining
cognitive function: poor functioning in
activities of daily living (e.g. washing,
dressing, self neglect, poor repeat
collection, behavioural and mood changes)
and liaise with the community mental
health team, the GP and/or specialist
services to optimise patient care.
• Support the local Dementia Advisor -
provision of pharmaceutical care education
and information in dementia management.
• Review of inappropriate prescribing of
antipsychotics
Level 3 Specialist Mental Health Level;
Pharmacists role in effective care for
those with dementia
Pharmacist Prescribers; Pharmacists with
Special Interest; or those with appropriate
interest, training and support could develop
an integrated service with colleagues in
secondary care - including prescribing,
diagnosis and support
Other specialist pharmacists e.g. working
in care homes, community or intermediate
care hospitals could also support the earlier
recognition of the illness and appropriate
referral
Pharmacists can:
• Provide early-symptom detection
assessments with referral to a specialist
as appropriate (with appropriate required
training) e.g. Folstein Mini Mental State
Examination.
• Provide medicine education sessions
• Monitor response and side effects
• Suggest therapeutic change if poor
response
• Prescribe (if appropriately trained) in
collaboration with healthcare team and
Community Mental Health Team if
appropriate
• Provide (if appropriately trained) support
on non-pharmacological treatments
• Support commissioners in service redesign
so that medicines management is
integral to care pathways.
Æ
28 Pharmacy Professional | March 2010 March 2010 | Pharmacy Professional 29