Changed behaviours in dementia: Cannabinoids and other creative solutions
Changed behaviours, formerly known as BPSD, are almost ubiquitous in dementia, with prevalence rates up to 97%, although given that they are usually an expression of unmet need, the quality of care probably determines their prevalence. The recent Royal Commission into Aged Care Quality & Safety has shown us what we have known for almost 30 years, namely that there is widespread and inappropriate use of psychotropics. Notwithstanding this, the 2003 Brodaty triangle illustrating a 7-tiered model of service delivery showed a small but significant number of people with dementia who have severe or refractory changed behaviours. Moreover, the serious side effects of currently available psychotropics have necessitated a search for creative alternative solutions, such as cannabinoids. This presentation will briefly review these issues and explore the evidence for these creative solutions.
Numbness and sensory disturbance in the older patient - Untangling the wires
Sensory symptoms are often challenging to sort out in the clinic in general - even more so in the older patient who may have comorbid cognitive problems or multiple pathologies. While it is tempting to dismiss sensory symptoms altogether, they are often in fact the earliest sign of serious pathology. On the other hand it can be very easy to over interpret the ‘sensory examination’. This talk will outline a practical approach to sort out sensory symptoms using the combination of clinical assessment, neurophysiological diagnostics and imaging.
Managing Dementia Dilemmas
A diagnosis of dementia often means that there are difficult decisions to be made about activities such as driving, and where ability to make financial decisions or medical treatment decisions is reduced or lost, then activation of a power of attorney, or enduring guardianship, may need to occur. This presentation will look at ways of managing situations such as the driver who is reluctant to hand in his licence or the warring family members where there are financial or medical decisions to be made. Relevant legislation and current evidence will be reviewed to understand the possible strategies and interventions to deal with these kinds of issues.
Assessing Capacity in the Clinic - Pitfalls and Practical Advice
With an ageing population, we are all having to become increasingly savvy about our medico-legal responsibilities but it is very difficult to be sure how much knowledge we might need to have and where the responsibility lies across a range of difficult areas such as Power of Attorney, Enduring Guardianship and financial planning. This can be exceptionally challenging in the clinic, where we are often time poor. This presentation will focus on those scenarios that are all too common in the clinic and better prepare you for how to give the very best advice.
Normal Pressure Hydrocephalus - Does it exist and is there a treatment?
Everyone seems to have heard of it but no one seems able to agree on it. We are all on the look out for patients with the classic triad of parkinsonism, cognitive decline and urinary incontinence but does Normal Pressure Hydrocephalus really present like this? Do we really understand its pathophysiology? Can we be confident about the investigations that could help to diagnose it? Furthermore, does treatment work and if so, for how long? This presentation will evaluate the evidence for Normal Pressure Hydrocephalus and highlight the pragmatic approach we should be adopting in the clinic.
ASSESSING GAIT AND BALANCE IN THE OLDER PATIENT
Is there more you can do to help your Parkinson’s patients with their gait? Is imbalance a normal part of ageing? Is Romberg’s test of any use in the evaluation of ataxia? And should your patient with an MRI ‘suggestive’ of normal pressure hydrocephalus have a shunt? In this lecture, Alex Fois will address these questions and current controversies while reviewing the common causes of gait dysfunction in the outpatient clinic and their treatments – pharmacological, surgical, and neurorehabilitation.
Neurological complications of COVID-19
The SARS-CoV-2 pandemic has had multitudinous effects: medical, societal, environmental as well as financial. Numerous complications of this infection are reported in countries, such as the UK, which have experienced multiple waves of the pandemic. The impact on neurology is both direct and indirect. The care of patients with longterm medical conditions was hugely disrupted: access to face-to-face consultations was severely limited and much elective care was curtailed. Hospitalised patients with COVID-19 frequently develop deficits relating to critical illness. Acutely encephalopathy is common but it appears that encephalitis is very rare. The most frequently encountered direct complications of COVID-19 are cerebrovascular. Other neuroimmunological disorders are also reported.
This talk will briefly describe current understanding of COVID-19 pathophysiology and relate this where possible to the commoner neurological complications of this syndrome.
SUBTYPES OF ALZHEIMER’S: HOW DO YOU TELL AND WHY DOES IT MATTER?
The neurodegenerative diseases show strong links between the anatomical regions or functional networks of the brain that are affected and the symptomatology- at least in the earlier stages. Alzheimer’s is no exception- whilst the earliest pathology is found in the medial temporal lobe, subsequent spread of both amyloid and tau pathology tends to be initially confined to a single network- in most cases the default mode network, presenting predominantly with amnestic symptoms. However other subtypes of Alzheimer’s can involve posterior cortical regions, presenting with visuospatial changes, language networks/regions and networks underlying executive function (and thus especially frontal regions). These subtypes can be called amnestic (typical) AD, Posterior Cortical Atrophy, Logopenic Aphasia and Behavioural (frontal) Variant AD. The clue to diagnosis is initial presentation and the pattern of hypometabolism seen on FDG PET- amyloid PET and tau PET are far less useful in distinguishing subtypes. Does accurate diagnosis matter? Yes- for many reasons. For instance, we should not expose those with Behavioural variant Frontotemporal Dementia (FTD) to cholinesterase inhibitors, and we should not exclude those with AD subtypes mimicking FTD (language and behavioural presentations) from participating in anti-amyloid and other AD trials- or enter those with Behavioural variant AD into FTD trials. As biomarkers become more accessible and accurate (eg plasma Aβ and tau) it is important that we understand how they track to clinical presentations. Accurate diagnosis, as always, does matter.
Sleep Disturbances in the Older Patient
Deteriorating sleep quality is regarded as being part and parcel of getting older. However, should we just accept fragmented sleep as the norm or do patients deserve better. What are the keys to identifying reversible causes to explore their early, mid and late insomnia? When and how should we be looking for Obstructive Sleep Apnoea, Restless Legs Syndrome and dream enactment (REM Sleep Behaviour Disorder). Possibly most importantly, what treatments can we offer this cohort of older patients and what are the pitfalls to avoid.
ASSESSMENT OF SPEECH AND LANGUAGE DISORDERS
Speech and language disturbances are often a trigger for referral to a neurologist or geriatrician. In particular, neurodegenerative disorders can present with varying combinations of progressive dysarthria, dysphonia, or aphasia. Confusing descriptive terms and acronyms can be disorientating for the non-expert.
In this talk, we will outline a framework for conceptualizing speech and language disorders in older patients. An approach to clinical assessment, interpretation of relevant neuropsychological testing, and neuroimaging of speech and language disorders will be presented, along with multiple video case examples. Several conditions will be considered including functional speech disorder, spasmodic dysphonia, Parkinson’s disease, motor neuron disease, progressive non-fluent aphasia, logopenic aphasia, and semantic dementia.
WHERE SPECIALTIES COLLIDE: DELIRIUM, LATE ONSET PSYCHIATRY AND DLB
Cognitive fluctuations, which include pronounced variations in alertness and arousal, are a core feature of Dementia with Lewy bodies (DLB) and share similar characteristics to delirium. Previous episodes of delirium have been shown to occur in up to a quarter of patients with DLB compared to AD. Furthermore, there is a growing literature suggesting that delirium can predict the development of dementia, and even accelerate cognitive decline. Similarly, work has shown that DLB may present as a primary psychiatric disorder later in life, with late-onset psychosis and major depression being more common presentations. In preparation for a new era of potential disease-modifying therapies, new research criteria have been proposed for prodromal DLB, which includes a new entity of ‘delirium-onset DLB’ and ‘psychiatric-onset DLB’. In this talk, diagnosis of DLB and prodromal DLB will be discussed. The evolving literature regarding the connection between delirium, late-onset psychosis and neurodegeneration will also be summarized as well as helpful clinical tips for the clinical work up of such patients.