p001What people think. Is it too early to ask? Yeah, I mean I I think the frailty is your vulnerability to your vu…
What people think. Is it too early to ask? Yeah, I mean I I think the frailty is your vulnerability to your vulnerability to disease, your ability to bounce back from an illness, so you know someone your age or my age might get a, you know, simple UTI, lower you know lower urinary tract infection might I need, might get a bit of pain, a few lower urinary symptoms, lower tract urinary symptoms, a few days of antibiotics and, And you find that someone who's 80 who might have a pre-existing uh cogn impairment, um, morning that might you know that that might really take its toll on on on an older person, they may, uh, they may get quite delirious, might not be safe to to remain at home, um, end up going into hospital, pick up another infection when they're in hospital then rather than going home it's too unsafe, they end up going, you know, uh, moving into, moving into a care home, so it's that ability to, to, to bounce back so frailty does add, um. Most complexities to this. And just to um you know elaborate on it a bit more so as we get old, you know, as we get older because there's a difference in in needs with age comes multiple physical comorbidities and and it can be difficult sometimes in, you know. In in in deciphering or it's more of a mental health presentation or a physical health presentation, you know, we know there's a strong link between chronic illness and mental health problems, so if you've got a um, you know if if if if you're affected by cardiac disease, your history of stroke, neurological disease, particularly Parkinson's, they have a strong link to, um, you know, mental health disorders and then that will affect, uh, will, will affect your management. And it's relevant for all of us, whatever specialty you go into because we know that there's a strong link between worsening physical health and mental health, but if you ignore the mental health, your, your physical health outcomes will be worse so whatever specialty you're in, even if you're in orthopaedics, you know folk folk you know address the mental health er issues to get better physical health outcomes, um, yeah well you there can often be er misdiagnosis you know similar presentations is someone's anxious, depressed state down to functional depression or is it that of um, You know, is it that they've got an underactive or hyperactive thyroid or they've got er you know, um, high calcium levels which can which can lead to a you know delirious state, is it a delirium, is it more of a more of a dementia, um, and, and a lot of my job is trying to decipher whether, you know what's dementia and what you know what might not be. Um, as we get older, the more physical health problems you're going to get. You know, the more medication's gonna get thrown at you and you've got to be thinking about the you know the interactions you know between all these medications and the effect of these medications on older people because thinking back to your you know your your vulnerability, you, you, you're gonna be more likely to experience adverse effects and you will have you have you know pharmacology, pharmacology, pharmacology teaching sorry on your on your ADME but thinking about you know your absorption as as we get older. You know you absorb drugs less readily so there might be delayed onset of action in those distribution, so as we get older your your your your body fat to water ratio, increases so a lot of the drugs you know we give a lipophillic drugs. So they're going to be hanging around the system a lot longer than you know than any other person. Um, and excretion, like, you know, you, you may lose excretion of your kidneys and, and, and if your kidneys aren't as good as as you get older, you know, they get these, uh, you know, a lot of drugs are going to hang around in your system a lot longer, so, you know we use small, you know, smaller doses of drugs we've really got to bear in mind that the the sensitivities that as you get older, um, the sensitivities of that older people may, may experience with uh with these. And yeah, I say we were talking about about the biological aspects here. There's the social aspects of ageing as well, so as we get older, you know, there's there's a lot of the patients I see have issues around lack of purpose, lack of meaningful occupation, increased social isolation, um, so when you're formulating, you know, you've really got to factor into, you know, account the the you know the biopsy social aspects. of age. Um, And as well I mean if there's one thing to, to take on it is, and you will, I'm sure this will be mentioned in other talks as well, you know, we're an ageing population we you know we're getting older, that proportion of older adults, um, you know, is growing at the moment it's about 20% of the population is over the age of 60, over the age of 65 by 2035 that's gonna be, that's gonna be a quarter. Um, and that doesn't mean that people are living longer and healthier, um, because they're not, so when I, when I, um, in 2017, um, when I had my first consultant job I remember about 800,000 people in the UK with, with dementia at that time, now we're just under a million. Um, by 2040 it's estimated to be 1.4 million, so that's, you know, a huge increase, the cost of dementia itself is gonna double by, by 2040. Um, so this is the problem in terms of how how services are set up and, and, and, and the cost. Um, uh, of, uh, ageing, you know, it's gonna be huge, and on a selfish note as well, who's gonna be, uh, you know, who's gonna be able to afford all these, all, all these pensions, these are things which, uh, yeah, which, which we think about the, the, these graphs you'll probably come across is about looking at age distribution over, over the years, 50 years ago we're in the middle and, and, and, you know, another 50 years, you can see the, the, you know, how, how we're ageing and. This is more relevant for the last few years, the shaded area is, what is that 20 in 2020, that's our age, that's population in terms of age distribution, the shaded areas with males on the left, females on the right, and you can see the outline, those are how it's gonna look and all the projected er projection of how it's gonna look in 2030. Right. Fine. If there's any questions at any point, just, just stop me, alright. So what we're gonna do is, as I say, I'm gonna focus mainly on on dementia um during this talk, there's gonna be a few cases to to outline, alright? So with case one we've got an 83 year old female who was admitted to AMU by a GP. She was found outside a home in a confused state. She wasn't able to offer any meaningful history due to her confusion. Um, in terms of her mental state, there was evidence of visual hallucinations. She was seeing animals, rodents on the floor, she had a physical exam, there was some lower abdominal tenderness. Her blood showed a white, uh, increased white cell count, CRP, uh, had a CT head scan, so anyone being admitted with in a confusional state should get a CT head scan unless there's another obvious, obvious cause, er, for that confusion, of course, um, but the CT head scan was. Was normal, you managed to get a collateral history from uh from the son who who he describes there has been a 12 month history of cognitive decline, um, however, they had been living independently with with no need for sport up until, uh, up until this point. Uh he last saw her two days ago, when she'd been, uh, when she'd been OK, usual self and this is very out of character for her, OK. So in terms of differential, no this is quite straightforward alright and we're not gonna be catching anyone out here, but out of the differentials that are up there, what do we think's most likely? We're gonna have hands up for Alzheimer's disease? Oh Lewy body dementia. Hyperactive delirium. He's got a few hands there, the leaving tremens. I suppose there's nothing in the history about alcohol, was there, but it could be. But yeah, we're thinking first of all we've got to consider is this an acute change, is this going to be a delirium, potential for for delirium tremors, of course, if we knew what the what the patient's alcohol intake was. Uh, so what is delirium, so it's, it's acute confusional, um, it's an acute confusional state, we need to identify this because this is often missed in, you know, in, in, in hospitals, and we need to identify it because there's a physical cause for it, OK, and, and, and you know it's potentially dangerous. I haven't got the the, the, uh, these figures up there, but 20% of people with a delirium in 3 months will be dead, 40% will be dead within 12 months, so we need to be identifying, you know, delirious patients because I say there's a, there's a physical cause, you know, there's a physical cause for that, um. Your history is going to be very important to be able to er in terms of your plate of history to to try and er decipher is this an acute, you know, acute confusional state, and there's also that fluctuating pattern as well, so, you know what what are the main differences between delirium and and dementia of course is delirium's acute, but you get that fluctuating pattern whereas dementia it tends to be more of a gradual, gradual change, um, I've underlined poor attention because that is a hallmark feature of delirium, um, So usually with dementia, you attend your early moderate stages your attention er is OK but attention is affected, er right from the start with with delirium, yeah the people with delirious will be disorientated, might be confused in the speech, um, Should have underlined the hyperarousal state versus the hyperactive delirious state as opposed to the hypoactive, um, hyperactive is what you're going to be called about on the wards when you're in your F1, F2, you know, your resident doctor year because they're the patients who are going to be causing difficulties on the wards, they're the ones who are, you know, very, uh, hyper aroused, agitated, might be aggressive, hallucinating, throwing things on the ward, um, and you're gonna be asked to go and prescribe medications for for these people. The hypoactive group, you're probably not gonna be called er to see because they're not gonna be causing much of an issue on the ward, they're gonna be drowsy, in more of a stuporous sort of sort of state, they're not gonna be causing the, the staff much, you know, the nursing staff much er much issues, um, er and you get a mixed state as well where you can go um uh between, We both. And as well an important um er difference between your delirium and dementia is that with delirium you get that reversal of the er sleep-wake cycle, OK, so you might be on the day shift and might have a, yeah they've been OK today not too bad but they, but the nighttime comes, er and that's when they come alive, very agitated, er very psychotic, causing the night team, Quite a lot of, quite a lot of difficulties, so, uh, so yeah, we need to identify delirium, uh, as I say it's it's, it's often missed and just because don't expect all patients with delirium to be admitted with delirium, a lot of patients will develop it whilst they're in, uh, whilst they're in hospital, um, so yes, so the, the, the risk of mortality is as I've said, um, if you have a delirium, that's also a red flag for, for dementia, you're at 8 times, um, at higher risk of developing dementia, um, follow an episode with Liam as well. Um, and yeah, higher rates of institutionalisation as well. And this just, uh, yeah, this just helps you, you know, illustrate how you can fluctuate between a hyperactive, uh, and delirious, uh, delirious state, uh, hyper hyperactive and hyperactive, uh, state. Have, do any of you, um, if you, if you've had talks and sessions on, on delirium before, have you got any pneumonics to use to try and, as a starting point for when you're, you're faced with a delirious patient, where to start with in terms of potential causes? Any pneumonics? No, have you heard of pinch me? Yeah, has that come across? Yeah, come, come across in the previous, uh, session. So this is, I mean, this is, you know what you get taught in medical school, no matter what stage of you know, your career you're at, you always start with this, but it's a good, you know, it's a good starting point to, to consider the most common causes. Obviously it's not going to include everything. But yeah, any pain, any new onset of pain which, uh especially in the older uh older patient with a pre-existing cognitive impairment can have a big impact, you know, um. On, on cognition, yeah, infection, one of the commonest er one of the commonest causes, um look for any source of infection, er nutrition, constipation, don't er yeah underestimate the power of constipation in an older person, that can make them very confused, um, hydration, hypoxia. Medication, so talking about medication, there's various, well, a lot of medications you're going to be prescribing which can have an impact on uh, on cognition, particularly due to the effect uh or due to the anticholinergic er er side effects. Um, as well, withdrawal states as well. I remember, uh, a lady which sticks in my mind was, um, she came into hospital for a, uh, I think it was a hip operation, uh, she'd had two days post, uh, post-op, she became very agitated, very aggressive, hallucinating, she was in a six bedded bay by herself because she was, she was that aggressive, and looking at her medication, you can see on the GP summary she had 3 milligrammes of lorazepam a day, and she wasn't prescribed it, and I asked her why, what's happened to that lorazepam, the, You know, the, the, uh, surgical doctor said well, she's 80, why would an 80 year old want to go on 3 milligrammes of lorazepam, that's dangerous, so they've stopped it, obviously she'd been on it for 2030 years, so she was in a benzo withdrawal state which is a bit present will present very similar to uh your your delirium tre tremens, and very dangerous, so, so consider any medication changes, not just new ones which have been started, but any which have been, Any of which have been stopped, um, environmental changes, electrolyte changes, you use using your confusion, um er blood screen to er to to to assess for that, um, yeah, we don't always find the cause of delirium, um, which is very unsatisfying but um, Um, yeah, about 20-30% of cases where it's not, it's not an obvious cause, but that's a good place to start. Um, there are some, um, assessment of delirium, uh, screening tools, so this, you know, you might have heard, you know, you might have, uh, heard about your AMTS or your mocker or your 6IT, which is like cognitive, um, where you get a cognitive score. This is just a tool to help you identify what might be delirium or not, and when you know the feats of delirium, this is pretty, you know, pretty straightforward, but there's 4 parts. Obviously you can all see that there's A, B, C, and D, and you need A and B. And then one of either C or D, so A as we said, it's an acute and fluctuating course of uh confusion, B is your inattention, that's your hallmark feature of delirium, so the best, I mean the way I test uh your attention at the uh at the bedside is get them to give you the months of the year backwards, OK, so, does take a bit of, uh, you know, a bit of concentration to do that for anyone, but anyone who struggles to, um, Pain is uh he's suffering delirium, they'll really struggle with, with that task, so that's why there's others, there's serial sevens, there's digit span, reverse digit span you might want to do, um, but yeah, so acute and fluctuating. Um, there's a degree of inattention, then either C or D, so C is your disorganised thinking, so that can cross the very confused, um, confused speech, and then D is your altered level of consciousness, so that's either your hyperactive state or your, or your drowsy state, that's helping you identify the, um, yeah, pick out the, um, hyperactive and the and the hyperactive deliriums. So the confusion assessment method is, is what I use, you may see, um. Uh, 480, which I think has been increasingly used, uh, onwards, but there's 4 parts to it if you score 4 or more than that suggests a, uh, a delirium, but it's covering the same, um, you know, the, the, the same domains that we've, that we've touched upon. OK, so as I said, you know, we need to identify we need to treat the cause, um, keep you know wherever you can keep them in a side room, low stimulus environment is going to be important, try and get some consistency with the carers to reduce er confusion, er involve family where you know wherever you can, try to keep people as orientated as er as possible, always think of sensory impairment, if they need glasses, they need hearing aids, make sure they've got them because that will increase um, Uh, increased confusion, um, when you're asked to go and see patients who are extremely distressed, agitated, aggressive on the wards, um, what are you going to give them? Have you, have you done geriatric placements yet or no, um, it's difficult because whatever you're gonna give them is gonna, is gonna be risky, the, the, they often often the medications you're gonna see onwards which people prescribe are your lorazepam or diazepam, so you see your benzodiazepines. Um, and they're problematic because they may, they might calm someone, so it's an anxiolytic, so it might be and and it is, it is sedative if you have, have enough of it, but it might alleviate that, uh, that agitation, um, but it's gonna make the confusion worse, it's gonna make them more unsteady, it's gonna increase the risk of falls, um, so you've gotta, you've gotta, you've gotta be careful, um, and, and, and only use them on an as required basis rather than just giving them, you know, er, regularly. Um, in terms of what medication has a licence, a haloperidol, which is an older, uh, typical antipsychotic, does have a licence in, in delirium, um, might be more helpful if you're particularly psychotic, you know, hallucinating, you know, paranoid, um, but that comes with its own side effects as, um, as well, so there's cardiac side effects, movement side effects, increased risk of, uh, falls, and all cause mortality is always higher on in patients with, uh, confusion on, um, on antipsychotics. An increased risk of stroke as well as you've got a pre-existing dementia. Um, and one thing, you know, one thing to remember as well, especially in the, in the older vulnerable person, um, or frailer, frailer adult, uh, recovery can take a while, just because they've had the 5 day course of antibiotics doesn't mean that the confusion will have resolved after 5 days. It can take weeks, it can take, uh, it can take months. Um, Prevention is just as important as say a lot of patients don't get admitted to hospital in a delirious state, they'll develop it whilst they're there, especially when it's really hot and, and, and you know they they're not getting there, the uh, you know, the regular hydration which uh. Which might, you know, increase confusion, um, obviously it's a foreign environment anyway for them um but yeah just risk factors, the older person who's got a pre-existing er cognary impairment or a known dementia, that increases the risk of er er of delirium. Um, but these are the things we've covered in terms of polypharmacy. I have this, you won't we don't, you're not gonna read that, but, but I have this list at the back of my computer, um, just, just as a prompt, so this is the anticholinergic burden scale, so, um. Oh, the drugs on your left, uh, score 1, the ones in the middle score 2, the ones on the right score 3, and you add them up and if you're getting 3 or more, um, that has a significant impact on, um, on cognition, um, so yeah, you know, you've got an older person in hospital who's on Codeine for the, you know, for the hip, um, they might not be sleeping, so they might be given a bit of Promethazine at night, um, they might have some bladder problems, um, Uh, so you, you, they're on a, uh, medication to reduce bladder, um, irritability, and suddenly you've got a score of 9 and they're extremely confused, so it's just, just a prompt to, to, you know, remind ourselves of what we're prescribing and the potential, um, anticholinergic effects which older people are particularly, uh, Yeah, uh, prone to developing. OK, you're with them so far, yeah? Excellent, right, OK. So in terms of your second case, this time we've got a 74 year old man. He's brought to A&E following a fall at home. Uh, there's a limited history from the patient, there's difficulties recalling what has happened. Um, doesn't remember falling. He's aware he's he's in hospital though in terms of his past medical history, he's got diabetes, er, arthritis, and kidney disease and, uh, high blood pressure. On his mental state, there's no psychomotor disturbances, there's some word finding difficulties, however, his speech is otherwise fluent, uh, he's reactive in his, uh, effects, no concerns with his mood, there's no evidence of psychosis. Physical examination's normal, no obvious injuries following his fall. You do a confusion blood screen, so anyone who presents in a in a confused state, I will always um ask for these bloods um. But those are unremarkable. Again he had a CT head scan, there's no acute changes, um, no you know evidence of any bleeds. There's some mild small vessel changes, um, and then it does comment on some mild to moderate medial temporal lobe atrophy. So you need a collateral history, you don't have much history from the patient, you ring the daughter, they say, well there's been some mild confusion which started about 18 months ago, which has gradually, uh, progressed since then. Um, he's forgetting recent conversations, appointments, quite repetitive in his speech, misplacing items around that home, he's finding items in the usual places. Um, his long term memories thinking back to his early adult life and childhood's not too bad, um. But he can't tell you what he's done with his day er when she rings. It's generally very good in his mood, um still er sees his family which he enjoys. He's got good mobility, needs support managing his bills and er with his shopping and he's waiting for a home care package to start. OK. So you want to explore the cognition further, so you um. You're doing Adam Brooks cognitive examination, which that you won't, uh, that's more of a detailed uh cong assessment. Did anyone come across an Adam Brooks before, yeah? So it's out of 100, you're not just looking at memory, you're looking at various cognitive domains like your attention, orientation, language, visual spatial abilities. If you're score an 80 or 80 or more out of 100 then that's OK but it's not just the overall score you're looking at, you're looking at where you're losing the marks from, it's gonna be more significant. Um, it's always helpful looking at scores over time as well. Um, this patient, they score 72 out of 100, which is not too bad, but, um, loses a few marks in attention orientation, um, a few marks in fluency, doesn't do too bad at all on language and visual spatial, but you can see the majority of marks are lost in that memory domain, so scoring 10 out of 26. OK, so that's a bit more, a bit more significant. So coming back to to this list. Hands up for Alzheimer's? Do you think it's most likely diagnosis, we've got a few hands there. Anyone for Lewy body? Anyone for depression? Anyone for hyperactive delirium? No, eye doctor, it's easy, isn't it? So yeah, why do we think, why do we think that? Why do we think, why, why do we think Alzheimer's? With a few confident hands, so I, I don't think that. Anyone? Very shy blood. OK, yeah, yeah, so for a dementia diagnosis coming up to this uh this uh you know, ICE 11 criteria, yeah, you want more than one concrete domain don't you, yeah. Does it have to be a mem memory? doesn't have to be memory, no, but usually mem usually the memory is involved. um, why are we thinking Alzheimer's? So in terms of other, other domains, yeah, but I've, I've just seen, well, I, I dialnosed uh a lady with uh for the temporal dementia on, on Friday, we'll, we'll, we'll come come to FTV later. Her memory was pretty good, um, her memory score was normal, executive function was. It Um, and social cognition and judgement, so there's, there's various cognitive domains, um, um, and, and with, yeah, and, and, and with, with dementia, I most of my job when it, when you're seeing, uh, people with dementia it's not managing natural cognitive, uh, uh, effects, it's a non-cognitive features, so the psychosis, the mood disorders, the, uh, behavioural disturbances, um, which, uh, can be more, you know, can can be quite problematic. So in terms of why we're thinking Alzheimer's in that particular, so so it points out doesn't it, there's that early episodic memory loss, so the more recent memories get affected um earlier than longer term memories, which is typical about Alzheimer's, it's forgetting the conversations you've had earlier that that day rather than you know earlier life events, um, so usually with Alzheimer's that's the first when you're taking your late history they might, they might come to you with a two year history of um of memory problems, you need to be asking them and asking, Family, you know what were the first things they noticed if it's uh if you'd met your early episodic memory loss, which is the first thing you've noticed you're thinking it's er. Alzheimer's, um, there might be some word finding difficulties as well, er, which can happen, um, early on, as it, as all dementias do as they progress, um, they will start involving multiple. Remains as well, there's non-cognitive aspects which which I mentioned before, haven't gone into it, it won't go into any detail in terms of the um neuropathological um you know findings in in Alzheimer's but um, But with Alzheimer's you do get these abnormal er clumps of protein, these alpha beta plaques and uh hydrophosphorylated tau as well which er if you cut up some you know uh an Alzheimer's brain, this is the uh pathology you're going to be seeing, um, won't go into any of the you know any detail of um of, of how that happens, but you need to bear this in mind in terms of uh you know, in terms of dementia diagnosis and treatment. Not much has changed over the last 30-40 years, but there's a lot going to be changing over the next 10 years in terms of diagnosis, so we are using more um, Uh, biomarkers in helping diagnosis, um, diagnosing dementia is wrong in 30% of patients, I think this, you know, is going to change with the onset of these biomarkers, at the moment you are getting, uh, CSF biomarkers, um, uh, amyloid beta and, and, and the tau, and, and there's a lot of research going into plasma biomarkers, there's going to be blood tests in the next few years which are gonna help in diagnosing, uh, these things as well. Um, Look at the CT scan didn't show much, did it, but it did comment on medial temporal lobe atrophy. Um, do you think that's significant? Yeah, what struct the medial temporal lobe has in your anatomy, what sort of structure involves? Any thoughts? You know, so in terms of episodic memory loss, um, you know, you, you'll look at the, look at your medial temporal, um, The cortical structure, particularly your hippocampus, yeah, so. First note, the first changes you're gonna usually see on a on a CT scan or an MRI scan is hippocampal atrophy, um, so that CT report did comment on some medial temporal lobe uh atrophy. You get the some, some rare forms of Alzheimer's which, um, we don't need to go into any detail, but in terms of a CT head, hopefully that's, um, sort of clear, so which is the normal brain, right or left? And I'm going to be brave, which is a normal one. They're right, yeah, yeah, yeah, nice tombra, that's what you that's what you want. These arrows here, so the these are looking at your medial cortical um. medial temporal lobe structure, sorry, so on the right, on the normal brain, you see the um see the white arrows, yeah, that's, that's the, you know, nice big fat hippocampal area. Compare it to your left, it's much skinnier, and these are the red arrows, um, that's the uh radial temporal horn width, so as you get cortical atrophy, obviously the space gets filled up with uh with fluid, um, so some radiologists will report radial temporal horn width, and as that's getting bigger, that's. A sign that your your medial temporal lobe cortex is, is shrinking. I think, I think they use a cut off for about 5 millimetres depending on the. Depending on age, um, so yeah, there's quite significant atrophy, um, on the, on the left side. You can use, um, uh, MRI as well, which is this is more of a visual score, but 0 on the top left is normal, uh, so I'm not tall enough to to reach on and then it progresses down to number 4 which is severe er medial temporal lobe atrophy. On the bottom right one. So I don't have a, I don't have a Oh no, I didn't show up on that. But anyway, OK, so in terms of pharmacological management, so. Uh, these medications have been around for, you know, quite some time, acetylcholinesterase inhibitors, so, um, with, with Alzheimer's and, er, some other dementia as well, you will get, um, reduced acetylcholine which is involved in memory and attention, uh, so this slows the breakdown of acetylcholine. Um, so donepezil, glantamine, rivastigmine, you've probably come across if you've, uh, uh, in your older age, uh, older adult placements, um, they, they tend to be used for your mild to moderate, um, Alzheimer's, and then memantine works differently, that's used in more than moderate severe stages of, uh, Alzheimer's, and that's an NMDA receptor antagonist. So with, with as dementia progresses or as Alzheimer's progresses, you'd get, um, Uh, toxicity from excess glutamate and that, so that slows, uh, that slows it down, so you'll see plenty of, you know, donepezil, themantines being, uh, being prescribed, um. And they do have a modest effect um on cognition that can in some er er scenarios as well help with the more behavioural um er aspects of er of dementia as well. Medication is just part of it, of course you know the team I work in, there's occupational therapists, we're getting a new er getting a new psychologist, it's very much a multidisciplinary er approach, um cognitive stimulation, cognitive rehabilitation therapy is um er important, we need to address the er occupational therapy needs er obviously the social support. Help maintain er people's independence as long as possible, um, treat comorbid mental health problems so. The, the, the, the risk of depression is very high in, in, uh, in, in dementia, maybe 20% of people with dementia will express, will experience psychosis, so these are comorbid, um, The aspects we need to, we need to be treating, and I've put immuno immunotherapy there as well, I don't know if if you're paying much attention to advances in dementia, but there's been a lot, a lot about this in the news over the last year, um, you know we've had these cognitive enhancing medications for a lot of years there hasn't been much change, um, other than newer there's well there's a few um er new angles which research is focused on but particularly what what's you know er, Quite ahead at the moment is monoclonal antibodies, so you you you see monoclonal antibodies immune things like autoimmune arthritis and such, but these um uh these uh these antibodies are, uh, You have been helped to target these abnormal, uh, protein clumps like the amyloid beta plaques which, uh, which we mentioned, um, NICE haven't recommended them just yet, um, I think that's gonna change in the next 5 years, they're they're really expensive, um, and it's not just the drug itself but the investigations prior to giving these drugs are quite expensive, but I think that will, that will change, they are using them quite a bit in uh in other countries, um. Fine. OK. So moving on to to case three, we've got a 78-year-old lady. She was taken to a GP by her husband due to vivid nightmares including hitting her husband during her sleep. There's been occasional forgetfulness, although not too significant. There's been a recent history of falls. Um, these changes have been noticed over the last 6 months. Husband also reported that she's been seeing things, particularly, uh, animals. Um, she needs more support with the household tasks. On mental state exam, uh, on, on examination there's a mass-like facial expression, she seems mentally quite slowed down, there's some attention deficits. Um, she denies any mood symptoms. She had a 6 IT scoring 10 out of 28. Has anyone heard of a 60 IT? Is that something you've come across? GPs will use it, we use it a lot as a cognitive screening tool, but if you score 8 or more, then that means you need to, you know, explore that further. Um, Physical examinations, reduced arm swing on walking, um. All the confusion bloods which we mentioned before are are normal. CT head scan doesn't show much, just some mild changes which you might get with with age. Coming back to the Adam Brooks, um, so attention orientation 14 out of 18, so losing a few marks there, memory, 20 out of 26, so not too, not too bad. Uh, language is OK, visual spatial, more, yeah more marks lost in the visual spatial domain, and 70 out of 70 out of 100, so yeah, it is below the cutoff we'd expect. OK, differentials now then, so who thinks we might be looking at a front temporal dementia? How about Lewy body dementia? Have you got a hand, fishy hands. Yeah, depression with psychosis? Hyperactive delirium. Ah, there's plenty of you, don't commit, is there? Yeah, we'll do body dementia. So this is, this is one which. Is is underrecognised. And I'll show you a slide later in terms of the proportion of dementias. Lewy body. It's about 20% of dementias. Are caused by lew body disease and we pick up about 5% of them, it's really under, Under under diagnosed, uh but in terms of pathology, um you get these alpha synuclein um uh aggregates so again another type of abnormal protein, um, When you're getting Lewy body dementia and also Parkinson's disease as well, um, you've heard of all what's the difference between dementia with Lewy bodies, um, Parkinson's disease dementia, they're on the same spectrum and you're looking at the same pathology, but it's a time course of how things evolve over time so if you've got someone who is um who's got a history of Parkinson's over the last few years, who goes on to develop dementia-like syndrome, you're gonna be diagnosed in dementia with Parkinson's disease, um, but if the er dementia, the cognitive, um, The profile presents initially then it's going to be dementia with Lewy body, but you're looking at the same sort of pathology just developed in a you know. order um And memory can be well preserved er early on as well. So we use the McKeith criteria, so these were, these were revised about 89 years ago, um, Louis body, it, it's strange how it's underrecognizable because it presents quite differently all from, from the rest of dementias, possibly because that, you know, maybe that's the reason it's, it's underrecognizable, but if you look at, look at the clinical features, what I've been telling you about dementia being slowly, you know, insidious onset, you know, very gradually. And it's progression and attention is pretty intact early on. This is a bit different because this looks a bit like, you know, a, a delirium picture doesn't it, so with the dementia of the Lewy body, your, your, your cognition can can follow quite a fluctuating course. Recurrent visual hallucinations, so delirium is uh is uh you know, your psychosis, particularly visual hallucinations being, being most common with dementia and Lewy body, um, Visual hallucinations are very common, and we're not just talking about oh I've just seen a flashing lights or a shadow, people can can experience really vivid complex, um, you know, scenes, you know, I've got a lion, elephants, tigers in my living room, there's an army in my garden, you really er complex er visual scenes that they might see, um, REM sleep behaviour disorders, anyone heard of that? No, so, so this, so in the revised criteria this this went from supportive up to a a a core clinical feature. We, um, our REM sleep behaviours so and, and you know in in in the scenario that, um, or in the case we've we've just, uh, uh, given you there where the spouse is reporting well they're very active when they're asleep and lashing out and things like that they're acting out dreams, um, so what sleep phase do we normally remember our dreams from, it's that REM sleep phase and what are we doing during that phase, so during REM sleep what are we doing? Anything, what what what our bodies doing? So they shouldn't be doing anything, you should be in an atonic phase, yes, so when you're you're doing that REM sleep phase, you should be effectively paralysed, um, in REM sleep disorder, you start losing that that paralysis, so you start moving, getting up during your dreams and doing things and if you're running away or fighting, you're gonna be lashing out and it's gonna be very disturbed, disturbed nights, so it's usually the spouses which or partners who's in the in in in the bed of course who um, Who reports that and as well it can be the first sign so if you've got it if you, you know, if you take a history close enough, uh, partners might be able to tell you actually yeah that that started about, you know, 6 months a year before you know the the confusion started. So with it being on the spectrum of of Parkinson's, you're gonna get the, you know, uh feats of Parkinsonism as well as your bradykinesia, tremor, rigidity, OK. So these are your core, you know, your core criteria which you see in in in Lewy body, the supporting clinical features as well, so it's very er tempting when you've got someone experiencing visual hallucinations to give them an antipsychotic. What might happen with these patients if you give them antipsychotics? In terms of Parkinsonism. Yeah, yeah, they're gonna get worse, yeah, um so you've got someone who's already depleted of of dopamine and you're gonna give them drugs which are going to deplete that further so you're giving them drugs to help the, help the hallucinations but you're making them more stiff um. So it's gonna be very sensitive to to antipsychotics. Um, yeah, postural instability is quite common in our country with a history of falls, uh, severe autonomic dysfunction as well, which you get in Parkinson's. And Lewy body, um, sometimes you don't need to do any particular scans, so CT scans and MRI scans might be pretty normal, uh, in the early moderate stages of er of Lewy body. There's no particular patterns like you get with Alzheimer's with the medial temporal lobe loss, with Lewy body, there's a typical pattern that you, you might pick up on in the, um, your mild moderate stages, um, but we do have, um, Uh, uh, we do have what we call a dopamine, uh, uh, transporter scans or a DAT scan, um, so for those, those scenarios where you're a bit unsure, usually from the history, you might be pretty convinced this is a lewd body, we don't need to do any more scans than just a, just a CT scan, uh, but if you're a bit on the fence, unsure, we can, um, uh, we can request DAT scans, which, yes I do have one, And next, sorry, that's, I don't that that doesn't come out very clear on here, but your normal scan is on the left and abnormal is on the right, so this, uh, radioactive tracer is binding to dopamine transporter proteins and you should get these nice bright, uh, bright commas, um, but you said on, on the, on the right side, side on the abnormal scan, they, uh, you'll lose that comma shape, turning to, to, to full stops, so that's someone who's gonna have a either a Lewy body or a Parkinson's, um. Um, uh, disease. OK, in terms of managing them, yeah, you can give this, it's still nice and you can still give your donepezils and and and memantines in, in Lew body and Parkinson's dementia, there's um there's some evidence for, for using those with this diagnosis, as I mentioned before, It can be really challenging to manage these patients in terms of the non-cognitive effects, you know, the psychosis, the distressing visual hallucinations they might uh they might experience, um, so you're almost forced to try and use a bit of, uh, you try and use low dose antipsychotics to manage that, and if you're gonna do that, use quetiapine or clozapine because they're less likely to, um, they have a, yeah, they have less of an impact on um on dopamine. Um, neurologists will often use, uh, clozapine, um, but we, we tend to use more quetiapine because the clozapine comes with a whole host of other, um, effects which, um, you know, risks and, and, and adverse effects. Um, Fine. Right, in terms of types of dementia, obviously we've mentioned a few uh a few already, what's the most common type of dementia? Yeah, Alzheimer's, what sort of percentage do you think of dementia is Alzheimer's? Yeah, a bit, a bit less, we were about 60 to 70, um. Yeah, about 6-70% of, uh, dementia, Alzheimer's, mentioned Lewy body, I've got 15 there, is more like on, on postmortem studies, that's about 20%, um, so we, we, we under diagnose Lewy body. Um, frontotemporal is much less, uh, in terms of dementia as a whole, but you know, a few percent, however, in the under 65 population, that's about 40%, so. In under sixty-fives, the commonest dementia is still Alzheimer's, but um, those patients with FTD um that's a much bigger, bigger proportion, um, Yeah, a lot of your vascular risk factors are also risk factors for Alzheimer's, so you do get a lot of mixed Alzheimer's er vascular out there as well, and there's there's other causes as well which we wouldn't have, um, time to, to go into. Um, Vascular, well, I vascular dementia can present differently depending on where the, the, the, the infarcts are, depending on which area of the cortex in terms of, you know, cortical infarcts, whether it, um, you know, affects your language more, memory, visual-spatial, um. We see more diagnose a lot more of the um of of subcortical vascular dementia, so with your you know with the acute onset contrape after a stroke, well that's something you're gonna have to monitor because contrape after a stroke it is common, is that something which is going to progress with a stepwise progression as you get more strokes, so rather than a gradual decline, you see, you would describe as more stepwise progression as you're having, when you're having strokes moving, uh, moving forward, but as I say we normally see subcortical vascular dementia where, um, You know, you, you're talking small in fact in subcortical structures which accumulate over time so it can give a picture of quite a er gradual er deterioration, um and you will see that I've done some scan er er er scans on the next slide to show you those um uh those changes and we we with the most subcortical er vascular picture, you typically you see quite, you know, slowing down of er ability to process information, attention deficits, you might get some gait disturbance er there as well. Um, so like usually they'll have a, a number of vascular risk factors in terms of blood pressure and, uh, and, and, and diabetes and such. Um, some radiologists report on the Physika score. Um, so on the top, yeah, top row that's a score of 1, at the bottom it's 3, and you can see on this scan, the white here. Is are your uh are your infarcts and you can see it you know the worst um you your worst score at the bottom there quite confluent areas of um of in fact over time so you're not usually we're not gonna see that as a, uh, well usually that that that will present as it would with a history of chronic, uh, chronic decline as those in fact accumulate. Um, You wouldn't be treating these patients with um you know, with your cholinester cholinesterase inhibitors or or or memantine, there's not any evidence for for them uh being effective in in vascular dementia, you're gonna be managing the vascular risk factors, you're managing blood pressure in particular. It's much less common but something we need to to mention is from the temporal dementia, the ones you might, you know, think about when you come across these in case studies are the ones with behavioural changes, so again as I mentioned, the, the, the, the lady I saw on Friday was, um, your memory was pretty good, but it's the behaviour which changed over time, over 1 to 2 years, which was really quite uh quite marked. You get uh personality changes, might become more irritable, apathetic, not picking up on social cues, being very rude and abrupt on, on interaction, um. might make comments to people in the street where you To be inappropriate and normally they would they wouldn't have done, um. I remember a chapter when I was a junior where one of the the wife brought him into uh you know, to the doctor to get him checked and he said well I lived with it for so long and then he just started peeing in Tesco car park when we were doing the big shop and he just did not understand why that was inappropriate or walking around naked in front of his young grandchildren, not did not understand why that was why that wasn't appropriate, um. They might present quite blunted apathetic, so you might wonder if they're depressed, but they don't describe feeling depressed, it's just more of an apathetic or, or, or blunting of uh of effect that you're that you'll see, um, and dietary change as well is a big, uh, yeah, is a you know, it is a flag for FTD think of particularly if they suddenly start eating a lot of sweet food. So if you, um, you know, I like cake just like anyone else, but after a slice or two you think, OK, no, no, I should slow down, that I don't, I don't know. Wouldn't too good for me, but that that switch which tells them to slow down and stop has just gone so they can go into the fridge and eat all the trifle and all the bit like that tiger who came to tea but you know they they you you you'll hear that story, well they went downstairs to the kitchen one night and, I got up in the morning, the fridge was empty and there was just vomit on the floor cos they will eat and eat until they er yeah. Until they're sick, um, and as well your frontal lobe is is is uh you know where you were organise all your uh high level processing, your judgement, your planning, um, and, and so you'll you'll you'll pick up on those deficits as well. You do, so you get a behavioural variant of er of FTD you also get er language variants as well, so semantic aphasia where er or or progressive non-fluent aphasia, um. And it's more frontal lobe and it's part of your, uh, you know, your, your broca's area, you'll get that expressive language er deficit where they understand that having difficulties getting the words out, but it's staccato, it's effortful, they'll get very frustrated because you know, they know what they want to say and the words just, uh, don't know, don't come out, whereas the semantic aphasia, the language is quite fluent but nonsensical, but they're not too bothered about it because the comprehension is gone as well, so they're quite, you know, uh, indifferent to that. OK, um, so as I said, I focused on the focused on the, you know, the dementias there, the the the commoner types of dementia, um. I'm just gonna briefly mention before we finish about psychosis in the er psychosis in the elderly, just a few I suppose take home messages with psychos and the elderly. As, as, as we get older, you know, typically when you think of psychosis and you're thinking of your schizophrenias for instance, which you're gonna see on your working age team, you can still get schizophrenia which um develop in, in, in later life, but it, but it is much less, much less common, you do get schizophrenia. Which developed in the 60s, you do get it in the developed you know uh in the, in the 80 plus but it's much less common, typically you'll think of schizophrenia as something which starts in uh late adolescence early adult life and and and and you're right, it, you know, it does. So when you are you know presented with patients um, Developing psychosis in laid flat, think of other things first, rule out the other things, dementia, you know, Dementias you can't present with um you know psychotic features or, for instance the there might be that history of memory problems there but they just haven't got raised and that they haven't you know been addressed by anyone, it's only when they start hearing voices or or developing delusions that people you know er take them to see er see doctors so, any late onset psychosis, think is there a dementia, is there delirium, if it's quite acute, always think delirium, um, one with an acute psychotic er er presentation. Um, sensory impairment as well, you know, we get a lot of older adults who um. They have quite visual, um, yeah, visual deficits, um, and they were similar to Louis Body, they will see quite vivid visual hallucinations. I've got a quick slide on Charles Bonnet after, but as well with, um, The hearing as well, so patients who have, uh, hearing impairments are much more likely to develop auditory hallucinations, uh, and such, so make sure that any sensory impairment is, um, is addressed, obviously as we keep talking about in, in the early slides on unbelieving, think about what medications you, you, you're giving, um, Is it a steroid induced psychosis, for instance, you obviously see quite you know quite a bit of that, so think you know the the take home message there is think of other, don't just go for your functional schizophrenia er your delusional sort of, think of organic causes er first. Of course patients can still experience uh you know, a psychotic depression, so we won't go into any, any detail on that, you'll you'll you'll cover that in uh er in other talks, um, you do get late onset schizophrenia, which the profile is a bit different with older adults, so, uh, with, um, you know, with younger people who develop schizophrenia, um, that can affect personality, you get those negative symptoms of schizophrenia which will have been talked about, um, that's less likely with late. For you usually personality is um is preserved, you know, your negative symptoms and thought disorder are uh you know are less common in late onset schizophrenia. Um, yeah, I've just put, uh, I put paraphrenia at the top. It's an old term paraphrenia now, but you might, you might see that in some places, uh, but paraphrenia, think of it as being, you know, late onset schizophrenia, um. I did want to mention. Oh yeah, er Charles Bonnet syndrome as well because this will. Um, you, you will see this, particularly with, with, er, older people with age-related macular degeneration, uh, they will present with, again, similar to what we said with Lewy body, er, quite vivid visual hallucinations, um, and this is simply because the eyes aren't getting the sensory informa, sorry, the brain's aren't getting the sensory information from the eyes as it as it used to and it sort of makes makes things up, but it's important to identify it because antipsychotics don't really work, they're quite ineffective, um, Patients usually have better insight into these hallucinations with Charles Bonnet than they would with er you know, a delirium or, or, or a dementia. So yeah, usually insight is is is.