"Am I losing my marbles"

Prof. Philip Morris

Over the next few years this will be a question many doctors will hear from patients. And some of us will perhaps ask this of ourselves! As the leading edge of the ‘baby boomer’ generation moves through their 60’s and 70’s many of them will start to wonder if memory complaints are the start of more serious cognitive problems or dementia. It is crucial to distinguish sinister memory problems from benign complaints that just become more common with age. Forgetting one’s keys, reading glasses, or difficulty finding a word or two in a conversation are more common as we age but are not concerning as long as they are not occurring all the time. On the other hand, frequently needing to be reminded of what one has already been told or getting lost in previously familiar situations are more worrying symptoms that can indicate serious memory problems.


It is clinically important to determine whether memory complaints reflect ‘normal’ aging or are evidence of developing pathology. Memory and cognitive testing can assist this process. Office (or ‘bedside’) testing is commonly done with the Mini Mental State Exam (MMSE). While quick and easy to administer it is not detailed enough to provide a dependable evaluation of cognition and memory, especially in mildly affected patients. I find the Addenbrooke’s Cognitive Assessment – Revised (ACE-R) a more useful test. The ACE-R includes the MMSE but covers more cognitive domains in depth (attention/orientation, memory, verbal fluency, language, visuo-spatial) (1). The test is easy to administer and takes no more than 20 to 25 minutes in most cases. A practice nurse can administer the test. The ACE-R is scored out of 100. Scores in the mid 80’s suggest serious cognitive impairment or dementia. Most healthy elderly individuals will score in the 90’s. The ACE-R can identify patterns of cognitive and memory impairment that are useful in differentiating Alzheimer’s disease from fronto-temporal dementia variants, vascular cognitive impairment, and Lewy body dementia. Some experience with interpretation of the test is needed. Occasionally more extensive cognitive testing is required and referral to a neuropsychologist should be considered. Computer-based cognitive testing programs can be helpful in some cases.

Having decided that the patient has cognitive impairment, what are the clinical conditions to consider? Where mild memory difficulties are the primary presentation, then mild cognitive impairment (MCI) – amnesic type, may be the problem. These patients do not show problems in other cognitive domains (such as attention, concentration, language, visuo-spatial skills, and executive functions). Many MCI patients remain stable over time but a proportion (perhaps up to a third) do deteriorate and covert into dementia over a two to four year period. These cases may be individuals with very early manifestations of Alzheimer’s disease. Unfortunately, it is not yet possible to predict with any certainty which patients will get worse as we are not clear about the causes of MCI. If cognitive impairment extends beyond memory to other domains then a diagnosis of dementia is more likely. In the ‘baby boomer’ age group and older the main dementia conditions to consider are Alzheimer’s disease, vascular cognitive impairment, a combination of Alzheimer’s disease and vascular cognitive impairment, Lewy body dementia, dementia associated with Parkinson’s disease and other sub-cortical degenerations, and fronto-temporal dementia variants (semantic dementia, progressive non-fluent aphasia, and behavioral variant). Reversible causes of dementia need to be excluded (such as vitamin deficiencies or hormonal disturbances). Depressive illness and delirium can also masquerade as dementia.

Thorough investigation of cognitive impairment involves a screening physical and neurological exam as well as routine blood tests and neuro-imaging studies. A list of possibly relevant laboratory tests follows. However, the choice of tests will depend on the clinical circumstances. Consider ordering FBC, ESR, CRP, E/LFT’s, Mg, thyroid function, cholesterol and lipid profile, vitamin’s B12, B1, B6, and D, folic acid, homocysteine, APO-e genotype, HIV and syphilis serology, and urine analysis. An MRI brain scan is the most useful brain imaging study (a CT is an alternative for patients unsuitable for MRI). In addition to the usual report ask the radiologist to comment on regional and general atrophy, hippocampal volume, ventricle size, and presence of deep white matter ischemia. Single photon emission tomography (SPECT) (and PET if available) provides information on cerebral perfusion activity patterns that can help differentiate between Alzheimer’s disease, vascular cognitive impairment, Lewy body dementia, and fronto-temporal dementia. An EEG is sometimes indicated when delirium or unusual dementia conditions or seizure disorders are being considered. In the near future CSF studies of amyloid and tau protein fragments will also help with diagnosis.

Treatment of mild cognitive impairment is directed towards preventing further deterioration and maximizing cognitive function. Interventions that focus on reducing risk factors for dementia and enhancing protective factors against dementia are the most appropriate. Memory clinics that offer these types of cognitive enhancement programs are available in some areas. Treatment of dementia depends on the type of dementia involved. Comprehensive management involves symptom treatment (usually with cognitive enhancing medication and psychotropic drugs), education and support for patient and carer/family, and cognitive enhancement programs. Symptomatic treatment for Alzheimer’s disease is available in the form of cholinesterase inhibitors (donepezil tablets, galantamine capsules, and rivastigmine patches) and the glutamate NMDA receptor antagonist memantine. These medications can improve cognitive function (particularly attention and memory) and dampen behavioral disturbances (such as psychosis, agitation, depression and anxiety), and maintain function over the longer term. If a patient shows benefit the medication should be continued. Dose increases may be needed. Although only approved for subsidy under the PBS for Alzheimer’s disease, these medications can help in other dementia conditions that have overlapping neuropathology with Alzheimer’s disease (Lewy body dementia, vascular cognitive impairment). Specialist consultation (physician, geriatrician, or psychiatrist) is required to gain access to PBS authority support for these medications.

Unfortunately, no disease modifying agents are available for the common dementia conditions at the moment. Much research is underway in this area. In the future it is possible that with early detection of individuals at risk of dementia the application of disease modifying (or ‘curative’) interventions will prevent dementia onset. Then no longer will patients have to ask if they are “losing their marbles”!

1. Mioshi E et al. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006; 21: 1078–1085.

Conclusion
Unfortunately, no disease modifying agents are available for the common dementia conditions at the moment. Much research is underway in this area. In the future it is possible that with early detection of individuals at risk of dementia the application of disease modifying (or ‘curative’) interventions will prevent dementia onset. Then no longer will patients have to ask if they are “losing their marbles”!

Reference(s)

1. Mioshi E et al. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006; 21: 1078–1085.

New Service for Health Care Professionals

ReachOutPro.com.au provides access and advice for health care professionals on a range of technologies and online resources that can be used to enhance the effectiveness of psychosocial support and mental health care provided to young people.

  

You can:

• Gain quick access to resources and information for young people
• Learn about new technologies and what they mean to young people
• Find answers to questions like "what is social networking?" and "why is it so important for me to know?"
• Get instructions based on clinician experience on how to incorporate technology into clinical practice
• Get advice on how to make clinical practice more efficient using technology
• Access new research and websites that can be useful in your practice

More information is available here

Promoting mental health - are we focussing on the most needy sector of our rural communities?

A study that investigated the relationship between levels of mental health and well-being (in terms of self-reported levels of distress) with employment and occupational status of rural residents was undertaken as a component of the Australian Rural Mental Health Study and reported. Psychological distress was measured using Kessler-10, with an additional item addressing functional impairment (days out of role).

The highest levels of distress and functional impairment were reported by those permanently unable to work and the unemployed group with rates of ‘caseness’ (likely mental health disorder) varying from 57% to 69%,compared with 34% of farmers and farm managers and 29% of health workers. This paper will present the findings of the study and discuss the policy implications of this study in relation to;
(1) impact of drought and climate change on rural restructuring and employment;
(2) key target populations in rural communities for mental health promotion, and (3) ensuring access to mental health services and support for the unemployed sector in rural communities.

A Prof Lyn Fragar - Ass Prof Australian Centre for Agricultural Health & Safety, Moree, NSW

Meeting Primary Mental Health Care Needs of the people who live in the Rural and Remote Areas of Central Australia

Since January 2010, the Royal Flying Doctor Service, Alice Springs Base has provided an outreach primary mental health service. Three Mental Health Nurses comprise this new service which covers the region north east to south east of Alice Springs.

The service works in collaboration with the General Practice Network NT (Alice Springs) and the NT Mental Health Service. Aboriginal Mental Health Workers will work in conjunction with the Service to build mental health literacy amongst the Indigenous population.Federal Government funding was granted to set up this service to provide greater access to Mental Health Care for people in rural and remote Australia.

Like their city counterparts, people who live in rural and remote communities experience mental illness at the rate of one in five. However for people in these locations, distance,availability of appropriate services and stigma surrounding mental illness can complicate treatment and management of common mental disorders. This paper explores the issues associated with delivering primary MH Care to those living in the remote Aboriginal Communities and to others living in remote locations for reasons of employment.

Mrs Lynne Henderson - Royal Flying Doctors, Alice Springs, NT

Community resilience following natural disasters

In March 2010, rural and remote Queensland experienced major flooding from Springsure, west of Gladstone in Central Queensland, west to Bedourie and south along the NSW border which equates to an area the size of Victoria.

Charleville was inundated by two major floods within a week and 140 residents were relocated to an evacuation centre at the showgrounds, appoximately 200 homes were flood affected in Roma. The town of St George experienced a once in a century flood resulting in the relocation of 30 aged care residents and 8 hospital patients to Brisbane.

In the face of adversity, many smaller communities and primary producers suffered stock and crop losses and were isolated. However resilience was displayed through true community spirit by volunteering to restore services, making contact and engagement with the neighbours, contending with post disaster issues such as insurance, health and personal needs.Community resilience following natural disasters in rural and remote areas can be addressed by the adaption of the basic concepts of emergency management such as prevention, preparedness, response and recovery strategies.

These principles need to be linked by the adaption of basic disaster connectedness strategies to reduce distress and provide basic needs. To improve resilience, the connection with social supports for the establishment of brief or ongoing contacts with primary support persons or other sources is necessary for the continuum of care. The well established local networks such as, primary producer groups, churches, schools and service groups highlight the community spirit with primary interventions.

Meanwhile collaborative services from local, state, federal and non-government agencies do assist with ongoing recovery strategies.

Conclusion
The continuum of care process and supportive strategies will in time reduce the human – social impact and strengthen the resilience and mental health of communities that have faced adversity.

Mr Greg Eustace - Principal Advisor Emergency Management, Mental Health Directorate, Qld Health, QLD

14th Pacific Rim College of Psychiatrists Scientific Meeting is being held at the Brisbane Convention and Exhibition Centre

The 14th Pacific Rim College of Psychiatrists Scientific Meeting is being held at the Brisbane Convention and Exhibition Centre from the 28th - 30th October 2010.

The conference program will feature over 140 presenters.

The list of Keynote, Workshop and Symposium speakers and topics can be viewed here.

Conference registration is now open online. You can view full details here

E-mental health research & development

E-hub is an initiative of the Centre for Mental Health Research at the Australian National University. e-hub develops and evaluates websites that deliver psycho-education and psychological nterventions for common mental health problems, as well as clinical and consumer networking.
A range of the e-hub’s projects have explored the importance and quality of health information on the Internet, and the use of the Internet for disseminating public health information on depression.

The goals of e-hub are to:

+ Investigate and evaluate markers of high quality web information in mental health.
+ Investigate the usefulness of these markers for community use of Internet material.
+ Develop and evaluate web interventions that reduce symptoms and stigma in the community.
+ Evaluate methods such as targeting and tailoring to determine optimal methods for improving mental health outcomes.
+ Develop and evaluate web interventions that improve communication amongst researchers, and clinical teams, and provide infrastructure to community and general practice research trials.
+ Evaluate models for the integration of web information and interventions into mainstream mental health services.
+ Promote and integrate quality health sites internationally.

Online Self-help Programs for Mental Health e-hub provides web services free of charge to the public. Click here to download a flier describing these programs (pdf, 45kb).