Dementia Awareness Workshop Dr Olivia Abrahim - GP Femeeda Padhani – Pharmacist Barnet CEPN

1. Dementia Awareness Workshop Dr Olivia Abrahim - GP Femeeda Padhani – Pharmacist Barnet CEPN

2. bARNET CEPN • Community Education Provider Network aiming to develop a local community-based workforce to meet the needs of the local population. • Our CEPN’s vision is that the patient is the focus of all our activities and that we work collaboratively across all boundaries and have a shared vision of improving the value of educational training in clinical and social care to the population of Barnet.   • We want to be known as a responsive organisation that listens to the workforce and acts proactively. We want every member of the workforce to be respected and empowered to fulfill their potential as we believe that a valued workforce delivers excellent care.

3. What the cepn can do for you • Create community structure for educational events and networking • The current theme is “Complex patients” • We’d like your ideas for future events!

4. Outline • Introductions • Living with Dementia • Dispelling myths and stigmas • Key symptoms and signs • Memory assessment • Management options • Local services and resources • Dementia Friends

5. Introductions

6. Introductions • What is your experience of dementia in your work setting? • What aspects do you find most challenging?

7. What is dementia? • Dementia is an umbrella term for a group of conditions caused by disease of the brain, usually of a chronic or progressive nature. It affects memory and cognition, which can reduce the ability of a person to perform core activities of daily living, such as dressing and washing

8. Living with dementia

9. Dispelling Myths and Stigmas

10. ‘Dementia is a • normal part of the ageing process’

11. Key facts • Dementia is a group of symptoms that occur when the brain is affected by specific diseases • The diseases that cause dementia include Alzheimer’s disease and Vascular Dementia • Approximately 850,000 people in the UK have dementia. 72,009 of these live in London (4,169 in Barnet). These figures increase year by year • Most older people do not get dementia • Dementia is more common in older people but can affect people of any age

12. ‘People with dementia often get things wrong because they don’t try hard enough’

13. Normal Healthy Brain Alzheimer's Disease

14. Over 100 types of dementia • Alzheimer’s disease- atrophy and a significant loss of neurons in areas of the brain associated with memory and cognitive function such as cerebral cortex • Vascular dementia – multifocal and diffuse lesions affects neuronal networks involved in cognition, behaviour, execution and memory. Damage caused by small strokes or injury to the vessels from high blood pressure

15. “Try to understand how hard it is for us…it’s just that you can’t see the missing bits that we are having to cope without” Christine Bryden, person with dementia

16. ‘Many people with dementia feel lonely, anxious or depressed’

17. Feelings • Nearly two thirds of people with dementia who live on their own say they feel lonely* • The majority of people with dementia say they have lost confidence and they feel anxious or depressed* • We need to be aware of people’s feelings and show empathy • Our relationships with people with dementia can help them feel less isolated and more positive * Figures from Alzheimer’s Society Dementia 2013 report

18. ‘Dementia robs people of their identity’

19. Dementia causes loss of some abilities, but the person is still there.

20. Signs and Symptoms

21. ‘Dementia involves more than just • memory loss’

22. Symptoms • The symptoms of dementia include: • memory problems • difficulty with everyday tasks • disorientation • confusion • problems with communication and reasoning • problems with recognition and perception • Dementia is a progressive condition and symptoms will gradually get worse

23. ‘If an older person suddenly becomes confused, it’s likely they have developed dementia’

24. A sudden state of confusion is unlikely to indicate dementia. Delirium – an acute, temporary state of confusion triggered by physical factors: Delirium ·urinary tract infection ·pneumonia ·side effects of medication ·trauma ·poor diet ·dehydration ·diabetes ·kidney failure ·pain ·heart disease ·constipation · bladder catheterisation ·hip fracture ·hypothermia · sleep deprivation ·surgery ·immobility ·alcohol withdrawal • Older people are more susceptible to delirium • The risk of delirium is higher for people with dementia

25. Signs of delirium • Changes in cognitive function – eg confusion, disorientation • Changes in perception – eg hallucinations • Sleep/wake cycle disturbance • Changes in social behaviour and/or mood • Sudden onset • Fluctuating symptoms • Distractibility – difficulty focusing attention • Impaired consciousness – either hyper-alert and agitated (hyperactive delirium) or very lethargic, sleepy and difficult to rouse (hypoactive delirium)

26. Why is it important to diagnose dementia?

27. Why is diagnosis important? • Access to treatments • Advance planning • Determining number of dementia sufferers helps plan care and services on a local and national level

28. FIRST STEPS…. • Currently no specific diagnostic investigation available • No specific diagnostic investigations available • Concerns raised by patient, carer, family or health care professional • History and examination • Memory assessment tools in primary care- quick, easy to do and validated. Can be done by a variety of people including HCSW & pharmacists • Blood tests: FBC, TFT, renal, liver, calcium, Vitamin B12, folic acid, fasting glucose, ESR • Brain MRI scan • Consider referral to Memory Clinic

29. Memory assessment tools • Mini-COG: 2-4 minutes • Mini Mental State Examination (MMSE): 10 minutes • GPCOG: 5 minutes, carers interview as well • Abbreviated Mental Test Scores (AMTS): 5 minutes • The Mini-Cog is less affected by subject ethnicity, language, and education, and can detect a variety of different dementias. Moreover, the Mini-Cog detects many people with mild cognitive impairment

30. Management • Social support for patient and carer • Non-Pharmacological Treatments • Pharmacological Treatments • Advance Care Planning • End of Life Care

31. Non-Pharmacological • Cognitive behavioural therapy / Cognitive stimulation – activities with some degree of cognitive processing, often group-based • Multisensory stimulation • Music therapy • Art therapy • Dancing • Massage • Aromatherapy • Structured exercise programmes • Animal-assisted therapy

32. PHARMACOLOGICAL – NICE 2011 • Donepezil, rivastigmine, galantamine (cholinesterase inhibitors) • Memantine (a partial agonist of NMDA receptors)

33. PHARMACOLOGICAL – NICE 2011 • Donepezil, rivastigmine, galantamine (cholinesterase inhibitors) • Mild-moderate Alzheimer's dementia • Lewy body dementia with non-cognitive symptoms that cause significant distress (rivastigmine only) • Not disease-modifying but may slow down cognitive decline • Common side-effects include nausea, anorexia, dizziness, headache and diarrhoea. • Memantine (a partial agonist of NMDA receptors) • Moderate Alzheimer's disease if intolerant to anticholinesterase inhibitors • Severe Alzheimer’s disease • improvements in cognition, ADLs and behaviour at 6m • Common side-effects include constipation, dizziness, headache, hypertension and somnolence. • Treatment should be continued whilst it has beneficial effects on cognitive, functional or behavioural symptoms.

34. Challenging Behaviour • eg. agitation, aggression • Treat any underlying cause eg. pain, depression • Non-pharmacological interventions: aromatherapy, multi-sensory stimulation, use of music and dance, animal-assisted therapy, massage • Anti-psychotics – increased risk stroke

35. Advance Care Planning • Advance statements (written statement of preferences, wishes, beliefs and values regarding future care) • Advance decisions (decision to refuse treatments in future) • Lasting power of attorney – patients appoints someone to make decisions on their behalf should they lose capacity (health and welfare, property and affairs) • Preferred place of care

36. End of Life Care • Palliative Care Team • Resuscitation status • Ceiling of treatment

37. Imagine….

38. IMAGINE… • What are your feelings? 2) What made things difficult for you? Think about: • The symptoms of dementia • Other peoples communication • The environment 3) What would have helped?

39. ‘Everyone who comes into contact with a person with dementia influences how they feel and how they cope’

40. What can you do in your role to improve the care of people with dementia? How can you work collaboratively to improve the care of people with dementia?

41. WE MAKE MATTERS WORSE FOR PEOPLE WITH DEMENTIA IF WE… • Make the person feel like a nuisance • Fail to give them the help, explanations, reassurance or reminders they need • Ignore them • Treat them as if they are stupid, childlike or inferior • Dismiss their feelings • Talk too fast, ask too many questions or say too much at once • Talk over the person’s head • Take away their sense of control • Let the environment become too noisy, busy or otherwise confusing

42. WE CAN HELP A PERSON WITH DEMENTIA BY… • Noticing if the person seems to need help • Being friendly, calm and unhurried • Giving clear explanations, using visual prompts if necessary, and checking that the person understands • Giving reminders, if needed • Taking time to listen, showing kindness and empathy • Getting to know the person as an individual and developing a friendly relationship with them • Recognising physical needs – eg signs of delirium • Recognising social and cultural needs – eg using the name the person wishes to be known by • Keeping the environment calm and easy to navigate – eg clear signs at eye level

43. Finally reducing risk.. • Growing evidence suggests that brain health is closely linked to heart and blood vessel health • The risk of developing dementia appears to increase as a result of conditions that damage heart or blood vessels. • These include high blood pressure, heart disease, stroke, diabetes and high cholesterol levels • The prevention and treatment of modifiable risk factors will be important in future for reducing impact of dementia on individuals and society • No evidence to suggest that aluminium exposure increases overall risk of dementia

44. Everyone who comes into contact with people with dementia can make a positive difference Maybe we can find ways of working collaboratively as healthcare professionals to improve the care and experience of patients with dementia

45. Local Services and Resources Clare Charlton Health Commissioner - Older People Barnet CCG

46. Dementia FRIENDS • Dementia Friends is a social action movement, run by Alzheimer’s Society as one strand of its work to create Dementia Friendly Communities. • Dementia Friends aims to help people understand what dementia is, how it can affect a person, and how we can each help people affected by dementia. To become a dementia friend you need to: • 1)    Agree that you want to be a Friend (You have the choice) • 2)    Commit to undertake an action (on action postcards) to help people who are living with dementia; e.g. something that you have learnt from the training today that you could implement into your working practice. • 3) You will also receive a dementia friends badge

47. Questions?

48. Contacts • barnet.cepnpharmacy@nhs.net • oliviaabrahim@nhs.net CEPN WEBSITE • http://cepn.barnetccg.nhs.uk/events/