Managing dementia together - Dr. Adrian Treloar 1.4 MB

Managing dementia together
Dr Adrian Treloar
FRCP MRCGP MRCPsych

Joint care
• Dementia - a multiagency approach but
very importantly
– An illness with shared responsibility
between primary and secondary care
– Dementia advisor
– Medical support

What can memory clinics do?
• Advise upon diagnosis
• Do some assessment
• Initiate treatment
• Monitor response to treatment
• Advice, brokerage, and access to other services.
• Give hope
• And we can do it really well with very high user
satisfaction

How many can we treat?
• Probably a caseload of 400 per full-time
consultant, but of course we have many
other commitments for our consultants
• Therefore no more than 500 per borough
• There are 3 to 4,000 people with
dementia in each borough
• So we need help

What does primary care need to do
• Case finding
• Being aware of dementia
• Physical assessments, optimising physical
health because that improves mental health
• Refer for diagnosis and consideration of
treatment
• Some follow up
• Ongoing prescribing of anti-dementia drugs.

Maximising care to people with
dementia
• What we have has worked very well and
we are treating about 25% of people
with dementia.
• Develop joint care between you and us,
with shared care notes and protocols.
• Improve the process of what we do

Alzheimers (70%)
• Good physical
• Make as well as possible
• Avoid drugs that worsen confusion
– Anti-cholinergics
– Bladder medicines
– Anti-psychotics
– Constipating meds etc
– Drugs that lower sodium

• Treat chest , low oxygen and heart
failure. ACE probably best.
• Try anti-dementia drugs

Vascular dementia (50%)
• Good physical
• Make as well as possible
• Avoid drugs that worsen confusion
– Anti-cholinergics
– Bladder medicines
– Anti-psychotics
– Constipating meds etc
– Drugs that lower sodium

• Treat chest , low oxygen and heart
failure. ACE probably best.
• Aspirin, statins etc for early cases (not
much of an evidence base but seems
right and it does impart hope
• Try anti-dementia drugs, they do work a
bit and it is hard to tell for sure what
dementia you are treating.

Lewy Body or Parkinson's
dementia (20%)
• Respond as well or better to antidementia
drugs
• But high mortality due to anti-psychotics
and so these are dangerous in this type
of dementia

Can you count? Can you tell?
• Alzheimers 70%
• Vascular 50%
• Lewy Body 20%
• Others 15%
• So a lot of comorbidity
• And classic vascular presentations may
respond amazingly well to cholinesterase
inhibitors.

• Not a lot
Do scans help ?

• The most powerful
treatment of all
Rx 70kg qds

Aspiring to the best
Who is this?

• Is another woman
cared for at home
just two weeks
before she died of
dementia.
And this?

Grace
• Grace was
discharged from
Dementia Nursing
care at the request of
her husband in 1995
• Doctors (me!)
advised would not
work and risky
• But eventually
agreed to take the
risk
• And went home

Before and after going into a
care home
Complex multi-infarct
dementia
A lot of distress
hard for Drs to see what to
do
Rapid deterioration in
institutional care
Need for regular
adjustments of treatment

Before discharge from another
home and after going home

Grace died in January 2004
• And was cremated.
• With a reception at her golf club afterwards
Grace enjoying watching the
golf on telly in 2003

So why is this so rare ?
• Obstructions
• No services to support care at home
• Poor funding
• Poor access to NHS continuing Care money
• Poor access to specialist advice
– Not seen by Palliative Care Services
– Dementia services do not think of this as their job
– Neurologists don’t do it either
– GPs do not and do not really have the expertise
So no-one does it.

Currently
• No funded services till very recently
• Hope for home service in Greenwich unfunded but has
cared for 54 people with dementia at home and 33 of
those have died at home or very shortly after leaving
home . Successful and highly rated service
• Croydon Palliative care of dementia service
• Service in North London
• Housing 21 Dementia voice Project just started up in
Lisson Grove, North London

What is needed?
• Enthusiasm
• Commitment
• A sense of care
• Knowledge and
expertise

Equipment
• Indispensable:
• Continence pads and sheets (13/13)
• Commode (11/13)
• Hospital Bed with Mattress and mattress elevator(10/13)
• Very useful:
• Chair and cushion (8/13)
• Wheelchair (8/13) Electric hoist (8/13)
• Hospital bed (7/13) Zimmerframe (7/13)
• Chair (7/13)
• Other useful equipment:
• Shower bath aids
• Toilet raiser
• Shower wet room
• Shower stool
• number/13 = results from Hope for Home evaluation

• Carers
• Appliances
• Input from GP but also specialists
especially psychiatry
• Manipulation of drugs
• Use of anti-psychotics If needed
• Palliative care expertise
• Appropriate use of antibiotics

Appliances
• Bed
• With raise of
bed and
• Raising
backrest

Chair and cushions
Proper pressure
cushions, allowing
longer comfort.

Wheelchair

Bath seat
• Goes up and down

Commode
• Available on
request in
Greenwich, no
reason needed
• Other varieties
available

Zimmer
• Even if
not used
by
patient!

Hoist, (with moving and handling training!)

And a second hoist for transfer from chair to
commode, with cleaning etc

Essential equipment
• Carpet cleaner
• Complete with
operators!

Good regular carers
• With control of these
by carers and not
statutory services
• Amazingly reliable
• Fantastic skills
• Really caring and
motivated (except
for one or two)

Money
• Between £50 and
£850 per week.
• Continuing care
issues
• Freedom to
purchase care
issues
• Direct payments

Broad range of expertise
including dementia specialists
GP
maximum involvment
medium
no
DN
maximum involvment
medium
no
SW
maximum involvment
medium
no
OAP
maximum involvment
Palliative care team
(Macmillan/ Ellenor etc.)
Carers Centre
Crossroads (or similar)
Expertise from other voluntary orgs
Volcare (or similar)
Link (or similar)
Advice and support from friends etc
2/13
cases
4/13
cases
2/13
cases
1/13 case
2/13
cases
2/13
cases

So it can and should be done
• Also note that good quality care in nursing
and residential care is also essential, for the
majority who cannot in fact be managed at
home.
– Because they do not have a carer who can
provide for them at home
– Because their needs are better met and they are
more comfortable in a care home than at home.
• But they too must be well cared for and
reviewed etc.

Living well with dementia
Who has
dementia?
Is it ethical to
give this patient
chips?
Is it ethical to
allow the carer
to eat chips?

Good practice
• Identify distress
• Consider its cause
• Diagnose as best
you can
• Remember the wide
variety of causes
and then
• Treat

Good outcomes
• Discuss with families/carers the current
situation
• Deal with distress
• Promote good care
• Insist upon the best services
• Accompany them upon their journey
• Tell us when we get it wrong

Distress a key and central symptom
• Proper understanding of the symptoms of
distress
– Anger/ Frustration
– Aggression/Agitation
– Fear/ Anxiety
– Tearfulness/ misery
– Pain when still
– Discomfort on moving
– Restlessness
– Insomnia
– Calling out/ vocalisation
Are these symptoms
different from pain in the
physical sense?
Is mental pain as
important a symptom as
physical pain?
Does one merit treatment
and not the other?