219 A SOLITARY AWARENESS - PROFILING TIME TO RECOGNITION OF MEMORY LOSS IN A TERTIARY MEMORY SERVICE

Background

Approximately 64,000 people live with dementia in Ireland with expected increases to 150,000 by 2045. Best practice recommends that patients benefit from timely diagnosis. Whilst the presence of cognitive impairment should prompt early referral for diagnostic clarity, patients frequently present with well-established symptoms. In order to understand this phenomenon it is important to understand the way in which symptoms are recognised by the person, companions and casual observers.

Methods

A chart review was carried out on a convenience sample of patients (n=61) diagnosed with dementia where scores were available from Clinical Dementia Rating Scale (CDR) and AD8. Data extracted included global scores and answers to direct questions regarding symptom recognition by patient and companion. Diagnosis was confirmed using the Electronic Patient Record.

Results

Mean age was 75 (range 57-87). Diagnostic breakdown comprised: Alzheimer Dementia (AD) in 67% (n=41), mixed AD/Vascular Dementia (VaD) in 19.6% (n=12); behavioural variant Fronterotemporal Dementia (bvFTD) in 1.6% (n=1), Dementia with Lewey Bodies (DLB) in 1.6% (n=1), Primary Progressive Aphasia (PPA) in 4.9% (n=3), Primary Parkinson’s Dementia (PPD) in 1.6% (n=1) and VaD in 1.6% (n=1). Average CDR Global Scale was 1.0 and average AD8 score 6/8. Family noticed symptoms of dementia an average of 12 months longer than the person themself. The incidence of anosognosia was 19% (n=12) and associated with a diagnosis of AD (91.6 %, n=11). Where anosognosia existed, symptoms of memory loss had been identified by family up to 60 months before diagnosis, with average time to recognition of 24 months. For 75% of this anosognosia group, family reported indiscernible symptoms on casual inspection (n=9).

Conclusion

Where symptoms of memory loss go unrecognised by patients and casual inspection, family may notice changes for up to five years. It is important to educate and empower the public regarding the benefit of a timely dementia diagnosis. Education should focus on supporting family to navigate sensitive conversations in the event of anosognosia and explore ways in which they might encourage timely review.

341 ROLE AND TOLERANCE OF LUMBAR PUNCTURE TESTS FOR CSF BIOMARKERS OF ALZHEIMER'S DEMENTIA IN A SPECIALIZED MEMORY CLINIC

Background

People living with mild cognitive symptoms often require clarity on the underlying aetiology of their symptoms, and with the advent of disease modifying therapies for Alzheimer’s Disease (AD), establishing diagnostic accuracy for amyloid and tau pathology in AD will become more clinically relevant. CSF biomarker analysis via Lumbar Puncture (LP) is the most accurate and cost-effective means of establishing AD pathology. This study aimed to assess memory clinic patients’ tolerance of LP as a diagnostic tool in the work-up of memory symptoms.

Methods

A consecutive sample of patients offered CSF analysis as part of their diagnostic plan in a tertiary memory service of a University Teaching Hospital were included. After clinician discussion, an LP for AD biomarker detection is offered to all patients with amnestic/non-amnestic mild cognitive impairment, or those with atypical motor-cognitive symptoms in this service.

Results

119 patients offered an LP from 2019-2020 were contacted, fifty-four (45%) of whom participated in this study. The average age was 70.1 (±7.5) years, 50% female. Forty-two (42/54, 78%) had an LP performed. More women declined an LP than men (8/12, 66%). Almost all of those who had an LP, (38/42, 90.4%) thought it yielded useful information and would recommend it for others. Side effects included mild back pain relieved with simple analgesia (11/42, 26%) and headache (3/42, 7%). There were no incidences of neurological sequelae or requirements for dural patch. Of the 12/54 (22%) who declined CSF analysis; reasons for same were pre-existing back pain (3/12, 25%), needle-phobia (3/12, 25%), and only 2/12, (16%) declined because they did not wish to know the results of the investigation.

Conclusion

This study highlights high levels of acceptance of CSF analysis when offered as part of routine care, with infrequent side effects. Most patients found the clinical information yielded was useful.

1062 GAIT SPEED AND EXECUTIVE PERFORMANCE IN PEOPLE WITH MILD COGNITIVE IMPAIRMENT

Introduction

The Motoric Cognitive Risk Syndrome has highlighted the link between cognitive and motor performance, and the associated incremental higher risk of developing dementia. There is considerable debate regarding what aspects of cognition (working memory, executive function, attention) are most associated with gait changes. This study investigates the relationship between mobility scores and cognitive profiles in individuals with Mild Cognitive Impairment (MCI) specifically with regard to executive performance and amnestic/non-amnestic profiles.

Method

Participants diagnosed with MCI, (Clinical Dementia Rating scale global score of ≤0.5, sum of boxes score ≤ 4.0), attending a regional specialist memory service had a three-meter Timed Up and Go (TUG) gait assessment and multi-domain neuropsychiatric assessment undertaken. Amnestic neuropsychiatric profile was defined as Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) delayed memory subset score < 1SD i.e. ≤16th centile below norm for age/education. Executive function performance was assessed using the Executive Interview (EXIT-25) where higher scores reflect poorer executive performance.

Results

Data was reviewed for 161 patients with MCI; 53% (86/161) women. 80% (129/161) had an amnestic neuropsychiatric profile, mean age 73.8 ± 7.2 (51–94). 20% (32/161) had non-amnestic MCI, mean age 74 ± 7.07 (60–87). There was no significant difference in TUG results between amnestic and non-amnestic MCI patients (11.2 ± 3.3 vs 10.7 ± 3.1 p = NS). There was a significant increase in TUG values with worsening executive function performance [EXIT-25 score 0–9 (88/161) mean TUG = 10.5 ± 3.3 seconds vs EXIT-25 score 10–14 (43/161) mean TUG =11.9 ± 2.8 seconds vs EXIT-25 score 15–25 (30/161) mean TUG = 12.1 ± 3.9 seconds; p = 0.021] which persisted after controlling for age, gender and other relevant cofactors.

Discussion

Reflective of the importance of frontal lobe integration to the respective tasks, subtle differences in gait performance are associated with executive function performance regardless of predominant amnestic or non-amnestic MCI profile.

89 CSF BIOMARKER UTILITY IN SUPPORTING ALZHEIMER’S DISEASE DIAGNOSIS: CLINICAL PERSPECTIVES FROM AN IRISH REGIONAL SPECIALIST MEMORY SERVICE

Background

CSF (cerebrospinal fluid) biomarkers [amyloid- beta-42 (AB-42), phosphorylated tau (p-tau)] are increasingly used in supporting clinical diagnosis of Alzheimer’s Disease (AD). Both elevated CSF p-tau and reduced AB-42 are necessary for pathological diagnosis of AD. The aim of this study is to apply recent international recommendations to patients attending a regional specialist memory service, evaluating consistency with detailed clinical, neuroimaging, and neuropsychological ad-phenotype profiling.

Methods

All patients age < 80, with mild/subjective cognitive and/or atypical neurobehavioral symptoms, non-significant vascular burden on neuroimaging, and without contraindication to lumbar puncture are offered CSF analysis. Clinical diagnosis was ascribed on the basis of specialist multi-disciplinary consensus review. We undertook a case-note and database retrospective review of those who had ad-biomarker CSF analysis, collecting demographic, clinical phenotype diagnosis, and neuropsychological performance. Data was extracted and analysed using SPSS v.25.

Results

One-hundred-sixteen patients underwent CSF biomarker testing. Forty-nine patients (42%) had positive AD-CSF biomarkers, 41/49 (84%) of whom presented with common ad phenotypes (Amnestic/Logopenic PPA/PCA). Twenty patients (17%) had negative ad-CSF (elevated AB-42, and low p-tau) studies, and half of those (10/20, 50%) had a consistent atypical non-AD clinical phenotype. Patients with negative ad-CSF were younger and tended to have non-amnestic neuropsychological profile. Therefore there was a mismatch in 18/69 (26%) people in these groups with definitive +/− ad biomarker results and ad/Non-ad clinical phenotype. A further forty seven (40%) patients had indeterminate CSF studies with one or other changes in AB-42 or p-tau, but not both as is necessary for definitive diagnosis.

Conclusion

Incorporation of CSF biomarker analysis is quickly being established as a key component of the neurocognitive/dementia diagnostic pathway. However, there are challenges and limitations arising as they are applied in clinical settings, and further research is warranted to explore variations between pathological results and clinical phenotype presentation.

144 DEVELOPING AN INTEGRATED POST DIAGNOSTIC PATHWAY FOR PERSONS LIVING WITH DEMENTIA—EXPERIENCES OF A REGIONAL SPECIALIST MEMORY SERVICE

Background

The frequently heterogeneous nature of a dementia presentation confers the need for a personalised approach to post-diagnostic supports. It’s an essential right for persons living with dementia (PlwD) and their families/supporters to have access to a comprehensive diagnosis and a responsive holistic pathway of care thereafter. We report our development of an integrated specialist-clinic/community post-diagnostic pathway responsive to the evolving personal needs of PlwD and their care-supporters.

Methods

This pathway was developed in an iterative inclusive-design methodology with input from hospital/community clinical specialists, health and social care professionals, senior nursing, PlwD and their care supporters. The post-diagnostic process starts at diagnosis disclosure, followed for all six-weeks later with a designated post diagnostic clinic, where a single point of contact to address any concerns in between visits is established.

Results

Iterative review cycles have identified integral components of an effective pathway: Guidance to live well with their personal manifestation of dementia; Acknowledgment of biopsychosocial elements of care; Timely access to comprehensive geriatric assessment via ambulatory hub MDT and/or and Integrated care team for older persons offering home assessment & intervention; Prevention of ‘harmful-events’ e.g. falls/delirium/hospitalisation; Timely access to therapies e.g. SLT/OT focussed on enhanced life at home/assistive technology; facilitation and planning of palliative care.

Other aspects include signposting to community resources and forward planning e.g. Citizen’s Information Centres; Peer support and education through designated training; Promotion of brain health- Exercise Programmes; social/cognitive stimulation e.g. Men’s sheds, Walking groups & Memory Resource Rooms; Opportunities for research involvement; Enhanced relationships with national organisations e.g. embedded ASI dementia advisor.

Conclusion

This approach has developed into a fully integrated holistic care-pathway where specialist-clinic, ambulatory-hospital, community older persons, and third sector services work together to provide the right care, at the right time, in the right place for PlwD and their families.

140 FAMILY DEMENTIA SUPPORT TRAINING—AN INTEGRATED CARE APPROACH

Background

There are approximately 64,000 people living with a diagnosis of dementia in Ireland. This number is expected to double to 150,000 by 2045. The growing need for post diagnostic support has been accentuated by the fact that we are living through an unprecedented Pandemic. Our Dementia Training Network identified the need for a localised educational resource for families supporting those diagnosed with dementia across our service.

Methods

Following a successful pilot in association with the Alzheimer’s Society of Ireland, staff from the Specialist Memory Service, Integrated Care Team, and Primary Care created a service-informed 6 week course aimed at supporting families. A focus group preceded the first course to establish preferred content. The course delivered education on Dementia; Post Diagnostic Steps; Communication; Non cognitive symptoms; Nutrition & hydration; Assistive Technology; Forward planning and Self-care. The multi-dimensional nature of staff delivering the course creates a rich tapestry of advice and information. All staff involved work together to identify, refer and support families living with dementia in the local area. The group takes place in an accessible location and time which accommodates families. Each course attendee completes a questionnaire prior to and after commencing the group. The level of satisfaction will be measured following every course.

Results

By the end of 2021, the group will have delivered education and support to 36 families. The automatic referral of all families to this resource will assist in building up confidence to support and enhance self-care. The combined participants from the catchment area will become a network of families joined together on their journey.

Conclusion

This innovative service collaboration enhances the integrated nature of the Post Diagnostic Care pathway. The Integrated care approach has served to enrich the programme and allow for timely support and advice regarding localised supports.

66 BRAIN HEALTH CLINIC: DEVELOPING INNOVATIVE OPPORTUNITIES TO INTERVENE IN MODIFIABLE VASCULAR RISK FACTORS (VRF) TO IMPROVE COGNITIVE AGEING

Background

It is now well established that VRF place immense burden on cognition, including white matter changes, decreased cerebral perfusion and neuro-inflammation.

An innovative Brain Health Clinic (BHC) was developed aligned to a specialist memory service to educate people at risk of or living with mild cognitive symptoms, about positive brain health and subsequently design a ‘Personalised Prevention Plan’ to optimise cognitive ageing.

The aim of this study is to report the opportunities identified and addressed to mitigate vascular risk-related cognitive decline in people attending the Brain Health Clinic.

Methods

Modifiable VRF (including HbA1c, cholesterol, Body Mass Index (BMI), smoking, alcohol intake and hypertension) were examined in people who attended the BHC between October 2019 and July 2021. In addition to VRFs, sleep, physical activity, sensory, social, and psychological measures are measured and reported to individuals.

The VRF values were examined based on current guidelines from the European Society of Cardiology (2018).

Results

Forty-five people (mean age 72.6 years, 62.2% females) were included. The average number of modifiable VRF’s per person was 3, and a total of 119 VRF’s were identified overall. One patient had six modifiable VRF’s identified, and 2/45 had none.

The most common VRF was elevated BMI present in 33/45 (73.3%). 12/45 (27%) patients were ex-smokers, while 5/45 (11%) still smoked. 5/45 (11%) consumed excess alcohol. 15/45 (33.3%) had elevated cholesterol.

29/45 (64.4%) had elevated systolic blood pressure. Of these, 10/45 (22.2%) were known but poorly-controlled and 19/45 (42.2%) were identified de novo. Similarly, only 1/45 (2.2%) had known diabetes but poorly-controlled, while 9/45 (20.0%) had impaired glucose tolerance identified de novo.

Conclusion

The BHC aligned to a memory service provides an opportunity to identify modifiable VRF for declining cognition, and supports people in addressing these by sign-posting to relevant services.