Professor Tony ElliottProfessor Tony Elliott

Clinical DirectorClinical Director

SSS Foundation Trust SSS Foundation Trust

Dementia Vs Alzheimer’s Disease?Dementia Vs Alzheimer’s Disease?

Dementia is the medical syndrome of Dementia is the medical syndrome of memory loss, functional loss, personality memory loss, functional loss, personality change, and psychiatric symptomschange, and psychiatric symptoms

Alzheimer’s disease is the commonest Alzheimer’s disease is the commonest illness to cause dementiaillness to cause dementia

Vascular dementiaVascular dementia

FrontoTemporal dementiaFrontoTemporal dementia

Lewy Body dementiaLewy Body dementia

Alzheimer’sDisease

•Early onset•Normal onset

Vascular (Multi-infarct)

Dementia

Lewy Body Dementia

DEMENTIA

Other Dementias•Metabolic•Drugs/toxic•White matter disease•Mass effects•Infections•Parkinson’s

Fronto-Temporal

Lobe Dementias

How common is it?How common is it?

Prevalence doubles every 5 years after age Prevalence doubles every 5 years after age 6565– 5% over age 655% over age 65– 16% over age 8516% over age 85– 32% over age 9032% over age 90– (prevalence rate = total number of patients in the population at a point in time)(prevalence rate = total number of patients in the population at a point in time)

Younger age groups can be affectedYounger age groups can be affected700,000 in the UK have AD. With an ageing 700,000 in the UK have AD. With an ageing population this figure is set to rise over the population this figure is set to rise over the next 25 years.next 25 years.

Effect of demographic drift on dementia prevalence over Effect of demographic drift on dementia prevalence over the next 20 yearsthe next 20 years

0 2000 4000 6000 8000 10000 12000

Estimated Dementia Prevalence

2028

2023

2018

2013

2008

Clinical FeaturesClinical Features

Cognition: Memory LossCognition: Memory Loss

– Immediate memoryImmediate memoryinformation is remembered from the previous few secondsinformation is remembered from the previous few secondsaffected early in Alzheimer's diseaseaffected early in Alzheimer's disease

– Short-term memoryShort-term memoryinformation is remembered from the prior few minutes or hoursinformation is remembered from the prior few minutes or hoursaffected early in Alzheimer's diseaseaffected early in Alzheimer's disease

– Long-term (remote) memoryLong-term (remote) memoryinformation is remembered from many years agoinformation is remembered from many years agoaffected in later stages of Alzheimer's diseaseaffected in later stages of Alzheimer's disease

Activities of Daily Living: Self-Activities of Daily Living: Self-Neglect and Physical DeteriorationNeglect and Physical Deterioration

– Gradual decrease in abilitiesGradual decrease in abilitiesWashingWashingDressingDressingFeedingFeedingMobiltyMobiltyContinenceContinence

– Physical deteriorationPhysical deteriorationUnsteadiness, fallsUnsteadiness, fallsmuscle rigiditymuscle rigidityseizures and muscle spasms in about 10% of severe seizures and muscle spasms in about 10% of severe patientspatients

Feldman H, GraconS. In: Clinical Diagnosis and Management of Alzheimer’s Disease. 1996:239-253.

The Progress of Alzheimer’s DiseaseThe Progress of Alzheimer’s Disease

0

5

10

15

20

25

30

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9

Years

MM

SE s

core

Early diagnosis Mild-moderate Severe

Cognitive symptoms

Loss of ADL

Behavioral problems

Nursing home placement

Death

Ashford et al., 1995

What is happening in the What is happening in the Brain?Brain?

Effect on the brainEffect on the brain

The Changing Brain in Alzheimer’s Disease

No one knows what causes AD to begin, but we do know a lot about what happens in the brain once AD takes hold.

Pet Scan of Normal Brain

Pet Scan of Alzheimer’s Disease Brain

AD and the Brain

Slide 19

Senile PlaquesSenile Plaques

Normal Brain CellsNormal Brain Cells

Neurotransmitters (AChE)– being sent – message being

communicated to the next cell

Normal Brain CellsNormal Brain Cells

Once the message is sent, then enzymes lock onto the messenger

chemicals and take them out of circulation so a new message can be

sent

plaquestangles

Less neurotransmit

terFurther to go to get to the

next cell

Enzymes (AChE inhibitors) – get to them BEFORE they

deliver their message

Brain Cells with Alzheimer’sBrain Cells with Alzheimer’s

Risk Factors and Causes of Risk Factors and Causes of Alzheimer’s DiseaseAlzheimer’s Disease

Risk FactorsRisk Factors

AgeAgeGenderGenderGeneticGenetic– family historyfamily history– apolipoprotein E4 – chromosome 19apolipoprotein E4 – chromosome 19– genetic mutations - chromosomes 1, 14, 21genetic mutations - chromosomes 1, 14, 21

Down’s syndromeDown’s syndromeHead traumaHead trauma?High Cholesterol?High CholesterolHypertensionHypertension

Preventative FactorsPreventative Factors

Balanced dietBalanced diet

ExerciseExercise

Mentally activeMentally active

2 glasses of red wine a day…2 glasses of red wine a day…

Treatments for Alzheimer’s DiseaseTreatments for Alzheimer’s Disease

Anti-dementia drugs eg AriceptAnti-dementia drugs eg Aricept

MemantineMemantine

AspirinAspirin

Ginkgo BilobaGinkgo Biloba

Vit EVit E

Aromatherapy?Aromatherapy?

Alzheimer’s drugs provide FAKE messenger

chemicals that distract the enzymes. They attach

to the Fake AChE & the message can get thru

What do Alzheimer’s drugs DO?What do Alzheimer’s drugs DO?

Aricept, Exelon, Reminyl Aricept, Exelon, Reminyl

Anti-Dementia Drug PrescribingAnti-Dementia Drug PrescribingOctober 2008 – December 2008October 2008 – December 2008

Birmingham EBirmingham ECoventry TeachingCoventry TeachingDudleyDudleyHeart of BirminghamHeart of BirminghamHerefordHerefordN. StaffordshireN. StaffordshireSandwellSandwellShropshire CountyShropshire CountyS. BirminghamS. BirminghamStoke on TrentStoke on TrentTelford & WrekinTelford & WrekinWalsall TeachingWalsall TeachingWarwickshireWarwickshireWolverhampton CityWolverhampton CityWorcestershireWorcestershireS StaffordshireS StaffordshireSolihullSolihullWarwickshireWarwickshireCentral and EasternCentral and EasternHaveringHaveringBromleyBromleyWorcestershireWorcestershireWessexWessexBexley Care TrustBexley Care TrustWestern CheshireWestern CheshireS.E.EssexS.E.Essex

0.00 0.125 0.250.00 0.125 0.25 0.375 0.375 0.50 0.50 0.75 0.75 0.875 0.875 Patients 65 yrs and overPatients 65 yrs and over

Memory Service National Memory Service National Accreditation ProgrammeAccreditation Programme

To assess and accredit memory services To assess and accredit memory services for people with dementia for people with dementia

Involves external accreditation review of Involves external accreditation review of Memory ServiceMemory Service

MSNAP Process Telford & Wrekin MSNAP Process Telford & Wrekin

Commenced April 2010Commenced April 2010

3 Month period of self review asking 3 Month period of self review asking carers and service users about the servicecarers and service users about the service

Peer Review October 2010Peer Review October 2010

Telford and Wrekin Memory Service Telford and Wrekin Memory Service accredited with excellence January 2011 accredited with excellence January 2011

AromatherapyAromatherapy

Several Placebo –Controlled trials Several Placebo –Controlled trials (Holmes et al 2003)(Holmes et al 2003)

Significant efficacy few S/EsSignificant efficacy few S/Es

Melissa (lemon balm) or Lavender OilMelissa (lemon balm) or Lavender Oil

Method of delivery variableMethod of delivery variable

Prolonged massage not necessary Prolonged massage not necessary component of treatmentcomponent of treatment

Aims of Interventions for Carers Aims of Interventions for Carers in Telford and Wrekinin Telford and Wrekin

Increase awareness Increase awareness

Support person with dementia and carers Support person with dementia and carers in own homein own home

Mobilise available community resourcesMobilise available community resources

Increase links with Agencies eg Increase links with Agencies eg Alzheimer’s SocietyAlzheimer’s Society

Aim to reduce “CARER STRESS”Aim to reduce “CARER STRESS”

Dementia

Dependency and problem

behaviours

Burden on caregiver

Caregiver strain-Psychological

- physical- financial

- social

Protective factors

•Practical support

•Family help•Problem

focused coping

Exacerbating factors

•Social isolation

•Lack of knowledge

•Poor Skills

•Immature coping

•Guilt

•Poor relationship

•High expressed emotion

What about local services What about local services and developments?and developments?

Dementia Workstream Dementia Workstream

Multi professional group Multi professional group

Monitoring community developments for Monitoring community developments for dementia specific teams dementia specific teams

Aim to treat people in place of residence Aim to treat people in place of residence and reduce avoidable admissions and reduce avoidable admissions

Telford Dementia Home Treatment team Telford Dementia Home Treatment team in placein place

Consultant Psychologist appointed Consultant Psychologist appointed

Increasing Healthcare staff for Increasing Healthcare staff for People with DementiaPeople with Dementia

March/April 2011March/April 2011Mental Health Community team has been Mental Health Community team has been strengthened by recruitment of additional 7 strengthened by recruitment of additional 7 workersworkers3 Band 6 nurses 3 Band 6 nurses 2 Band 5 nurses2 Band 5 nurses2 support workers2 support workersInduction and training has taken place for Induction and training has taken place for the new team members the new team members

Recent Service AchievementsRecent Service Achievements

• Primary Care Liaison Worker - Primary Care Liaison Worker - appointed appointed

• Admiral Nurse - appointed Admiral Nurse - appointed • Strategic Commissioning Group for Strategic Commissioning Group for

Dementia- established Dementia- established • Investment in Additional resources in Investment in Additional resources in

Carer’s RespiteCarer’s Respite

Working with patientsWorking with patients

  5 Dementia Advisers from Alz Society 5 Dementia Advisers from Alz Society have started in Jan 2011  to link in with have started in Jan 2011  to link in with Community Teams and signpost the Community Teams and signpost the service users and carers  to local servicesservice users and carers  to local services

Regular monthly clinic in the Lightmoor Regular monthly clinic in the Lightmoor View care home View care home

Positive impact in reducing the number of Positive impact in reducing the number of admissions to Shelton Hospital admissions to Shelton Hospital 

Involving our Service usersInvolving our Service users

User/carers involved in the recruitment of User/carers involved in the recruitment of staff for dementia teamsstaff for dementia teams

““Speak out Forums” – updates on service Speak out Forums” – updates on service developmentsdevelopments

Users/carers representatives are involved Users/carers representatives are involved in the new hospital buildin the new hospital build

““DARE to make a difference”DARE to make a difference”

Dementia Awareness Raising and Dementia Awareness Raising and Education Education

Raising awareness of the dementias Raising awareness of the dementias among local school children and among local school children and businessesbusinesses

Developed with funding from the PCTDeveloped with funding from the PCT

Led by Dr Ejaz Nazir Consultant Led by Dr Ejaz Nazir Consultant PsychiatristPsychiatrist

Environmental DesignEnvironmental Designin the New Hospitalin the New Hospital

Inpatient unit Finland

"Only put off until tomorrow what you are "Only put off until tomorrow what you are willing to die having left undone." willing to die having left undone." Pablo Picasso 1881-1973, Artist Pablo Picasso 1881-1973, Artist

Professor Tony ElliottProfessor Tony Elliott

Clinical DirectorClinical Director

SSS Foundation Trust SSS Foundation Trust