Primary care doctors /General Practitioners are sometimes criticised for failing to recognise dementia in its early stages. Old age psychiatrists, neurologists or geriatricians take on the tasks of recognition, diagnosis (subtyping) and post-diagnostic support, and some Primary care doctors /General Practitioners welcome this division of labour as a way of avoiding the demanding tasks of dementia recognition and response. However, the rising prevalence of dementia syndromes in an ageing population is undermining the ability of secondary care specialists to fulfil their tasks of timely recognition, diagnosis and support. Primary care doctors /General Practitioners will be encouraged to take over some secondary care tasks. This will pose problems for Primary care doctors /General Practitioners, who may not have been trained to work with people with dementia, and who may not be able to incorporate such work into their practice even when trained. This symposium will explore the current and future challenges Primary care doctors /General Practitioners face in recognising and responding to dementia, and outline some lessons from four European countries (Ireland, Spain, Portugal and England). Themes to be presented include:

• Barriers to the recognition of dementia,

• The dementia-specific educational needs of Primary care doctors/General Practitioners,

• Interprofessional education of community-based primary care teams,

• Case management of people with dementia in primary care,

• IT solutions to problems of support for people with dementia.

• Effective dementia-care interventions in primary care post-diagnostic care pathways,

• Systemically-inspired brief interventions in primary care.

Chair: Emeritus Professor Steve Iliffe, Centre for Ageing Population Studies, University College London [England]; co-chair: Professor Manuel Gonçalves-Pereira, Professor of Behavioural Medicine and Psychiatry, Nova Medical School, Universidade Nova de Lisboa [Portugal]

Speakers:

Dr Tony Foley, Lecturer Department of General Practice, University College Cork [Ireland]

Professor Manuel A. Franco, Head of Psychiatry and Mental Health Department. University Rio Hortega Hospital (Valladolid) [Spain]

Dr Conceição Balsinha, General Practitioner & Assistant professor/PhD student, Nova Medical School, Universidade Nova de Lisboa & Professor Manuel Gonçalves-Pereira, Nova Medical School, Universidade Nova de Lisboa [Portugal]

Emeritus Professor Steve Iliffe, Centre for Ageing Population studies, University College London [England]

As the World Population continues to expand, the number of individuals affected by Alzheimer’s Disease and other Dementias is also rapidly increasing. The number of individuals living with dementia is expected to increase to 131.5 million by 2050. (Prince et al., 2015) Behavioral and Psychological Symptoms of Dementia (BPSD) are highly prevalent, affecting up to 80% of individuals with dementia. (Garre-Olmo, Lopez-Pousa et al. 2010) BPSD has significant negative consequences for morbidity, mortality, and quality of life in those with dementia. Unfortunately, available treatments for BPSD are often limited or inconsistent in their efficacy and prone to severe adverse drug effects such as increased mortality.(Schneider, Dagerman et al. 2006) It is increasingly clear that current approaches are inadequate and novel treatments for BPSD need to be explored and researched. This symposium will draw on the available research literature as well as clinical experiences and case examples to provide up to date information on some of the newest treatment options available for BPSD. Dr. Melanie Gentry will discuss the use of telemedicine and other forms of technology to improve diagnosis and treatment of individuals with BPSD. Dr. Baruth will discuss the rapidly growing interest in the use of medical marijuana and cannabinoids in the management of BPSD. Dr. Lindsey will review the evidence for neuromodulation techniques including electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS). Dr. Leal will review environmental and behaviorally based interventions. Garre-Olmo, J., S. Lopez-Pousa, J. Vilalta-Franch, M. de Gracia Blanco and A. B. Vilarrasa (2010). “Grouping and trajectories of the neuropsychiatric symptoms in patients with Alzheimer's disease, part I: symptom clusters.” J Alzheimers Dis 22(4): 1157-1167.

This symposium will review the latest data on the influence of environmental design and its attributes on the cognitive and psychological wellbeing of older adults living with dementia. The presenters will cover the myriad ways in which the physical environment of care can adapt to the changing demands of older adults with sensory, motor and cognitive deficits and foster optimal functioning and quality of life. The role of emerging technologies will also be reviewed as they complement the contribution of the design of the physical environment to the wellbeing of older adults with cognitive impairment. Information will be offered through a review of the existing research literature as well as case studies that illustrate the impact of environmental modification on fostering wellbeing and minimizing the emergence of the behavioral and psychological symptoms of dementia. The presenters will represent and integrate sensibilities that have emerged from the fields of architecture, cognitive neuroscience and psychology.

Alzheimer’s disease (AD) and dementia has emerged as a significant societal issue and a global priority. The prevalence of dementia is rising more rapidly in low and middle income countries (LMIC) than in high income countries. Yet, knowledge of dementia risk factors is dominated by research from high income countries (HIC), which cannot be readily translated to LMIC. Latin American countries (LAC) have unique challenges related to dementia, including rapid aging population, high admixture degree and risk factors profile, which influence the prevalence and presentation of dementia. Several epidemiological studies during the past decade have shown a rapid increase of dementia in LAC, but the impact of genetic, protective and risk factors remain poorly understood. This research session will feature a series of short and engaging talks about new trends of dementia in the region and will answer key questions regarding dementia determinants and consequences in Hispanic populations. Participants will be first introduced to the aging process in LAC, prevalence and incidence of dementia within the region. The second presentation will report on genetics of Alzheimer disease in Hispanic populations. The third presenter will discuss the complexities of dementia multimorbidity and the impact of neuropsychiatric symptoms. The fourth presenter will discuss about Nationals and Regional Strategies to address dementia and reflects on recommendations and future directions for the region. All presentations will be based on findings from multiple research projects across the region. Furthermore, presenters will extended comparison to Non-Hispanics whites and Hispanics populations living in US, which allows cross countries/society comparisons. Overall, new information about dementia will be shared with the audience. Attendees will be able to identify the unique genetic and social determinants that drive AD in LAC. Recommendations will be given for preventive strategies tailored to LMIC. The findings to be shared will be essential for building evidence-based interventions that achieve the goals of the National Plan to Address Alzheimer’s Disease.

Lead: Dr. F.J.M. Meiland, Amsterdam UMC, location VUmc, department of Elderly Care Medicine.

A growing number of assistive technologies are being developed and evaluated in the field of dementia. With these technologies some psychosocial interventions may be delivered with more fun and/ or efficiency, which is considered important in this field with a growing number of needs and a declining number of people that can support in these needs. Technological support systems have evolved from simple, single tools to complex and integrated systems. In an INTERDEM state of the art position paper, we have reviewed issues regarding development, usability, (cost)effectiveness, deployment and ethics of assistive technologies for community dwelling people with dementia (Meiland et al., 2017). Some of these issues will be followed up in this symposium, where different types of technologies and different research methodologies in the field of dementia are presented. Scoping review, feasibility trials and randomized controlled trials are used to study various Assistive&Assisted Living services and computer-tablet interventions.

Treatment resistant depression (TRD) is defined as the failure to respond to two adequate antidepressant trials. TRD patients have high levels of psychosocial distress, poor levels of functioning and are at increased risk for suicide. Novel treatment approaches are being developed to address TRD involving both pharmacological and neuromodulation interventions. In this symposium, leaders in the field will outline three strategies for treating depression which has not responded to conventional therapy and contrast the efficacy of these strategies in younger vs. older patients. William McDonald MD (JB Fuqua Professor of Late -Life Depression, Emory University, Atlanta, GA) will provide a brief overview of TRD and moderate the discussion. George Petrides MD (Director of Clinical Trials Operation and Division of ECT, Zucker Hillside Hospital, New York, NY) will discuss recent data from the National Institute of Mental Health sponsored Consortium on ECT Research (CORE) outlining the response of older patients to ultrabrief right unilateral ECT in TRD. He will contrast the response to ECT in older vs, younger patients from the CORE database accumulated over the last 15 years. Collin Reiff MD (Addiction Psychiatrist, New York University Langone Health Center, NY, NY) will discuss his recent review in the American Journal of Psychiatry on Psychedelic and Psychedelic Assisted Psychotherapy and the implications on the treatment of medication resistant depression, including late life mood disorders. The FDA’s breakthrough designation of MDMA for the treatment of PTSD and psilocybin for the treatment of depression reflects the drugs’ potential to treat resistant psychiatric disorders. Psychedelic assisted therapy may play a unique role in late life mood disorders. Finally, Patricio Riva Posse MD (Director of the TRD and Ketamine Clinic, Emory University, Atlanta, GA) will discuss ketamine treatment in resistant depression including a comparison of response rates and safety data on ketamine treatment in older vs. younger patients. He has recently published the largest compilation of safety data for ketamine infusions and he will review a new tool to monitor safety in clinical practice. Dr. Riva Posse is medical director of the Emory TRD program and has enrolled over 1000 patients (100 in his IV ketamine clinic and about half over the age of 60 years) and followed patients through several novel treatments including transcranial magnetic stimulation, ketamine infusion therapy and ECT to start to look at differential response rates.

Converging data from multiple domains of preclinical and human studies has underscored the importance of focusing on genetic, synaptic and neural circuity as critical neurobiological mechanisms of late life neuropsychiatric disease. These complementary research approaches have been applied to identify novel molecular mechanisms that may represent early intervention targets, as well as promising new treatments. The symposium will include four speakers who span the range of studies in animal models, post-mortem brain tissue, molecular imaging and clinical trials combined with biomarkers. Dr Etienne Sibille will present his research on the procognitive, neurotrophic and neurogenic effects of novel compounds augmenting dendritic inhibition and restoring neuronal connectivity, which is affected in aging and in neurodegenerative disorders, such as Alzheimer’s disease. Dr. Robert Sweet will present new GWAS and human postmortem findings regarding risk/resilience to psychosis in Alzheimer's Disease, with an emphasis on synaptic mechanisms of resilience. Dr Helen Lavretsky will present a study of the neuroimaging, genetic and epigenetic effects of memantine and escitalopram treatment in late life depression. The strategy of incorporating biological measures into a clinical trial is an important opportunity to understanding the neurobiological mechanisms. Dr Gwenn Smith will present multi-modality molecular imaging data to understand the synaptic changes associated with Alzheimer’s Disease pathology in late life depression and mild cognitive impairment. Consideration of interdisciplinary research approaches and applications to different neuropsychiatric conditions may have particular relevance to understanding the neurobiological mechanisms underlying neuropsychiatric symptoms as risk factors or complications of neurodegenerative disease.

Molecular imaging methods to visualize the neuropathology of Alzheimer’s disease (AD) in vivo provide an unprecedented opportunity to understand the neuropsychiatric (NPS) and cognitive symptoms observed in early stage AD by testing hypotheses informed by human neuropathology and animal models. A fuller understanding of the neurobiology of early AD and its clinical progression is essential to identify individuals at risk and to identify targets for prevention and treatment. Numerous neuroimaging studies have shown that beta-amyloid and tau is necessary but not sufficient to explain cognitive decline and that models to explain cognitive decline must also include measures associated with synaptic dysfunction (eg cerebral glucose metabolism or brain volumes). Human data and animal models support the further investigation of serotonin (5-HT) degeneration. Relative to other molecular targets, there is stronger evidence for 5-HT loss in both cognitive deficits and neuropsychiatric symptoms (NPS) in Alzheimer’s Disease. 5-HT compounds are the only agents with preclinical evidence of multiple therapeutic mechanisms relevant to prevention and symptomatic treatment: blockade of amyloid precursor protein processing or neuroprotection, synaptic plasticity and improvement in both cognitive deficits and NPS. Multi-radiotracer PET studies of beta-amyloid (Aβ), tau and 5-HT have been performed longitudinally in amnestic, multi -domain, MCI (aMCI-MD) and cognitively normal elderly. Cortical and limbic 5-HT degeneration was a more powerful predictor of longitudinal memory decline than Aβ or Tau. Elucidating the role of 5-HT, in relation to Tau and Aβ in cognitive decline in aMCI-MD will have fundamental implications for the design of prevention and intervention studies targeting 5-HT.

The field of neuromodulation has progressed significantly over the past two decades. It is evident that application of electrical (via tDCS, transcranial direct current stimulation) or magnetic (via rTMS, repetitive transcranial magnetic stimulation) brain stimulation over the skull surface can effect change in brain function, which appears sufficiently robust to have a therapeutic effect. Sometimes the neuromodulation is best coupled with other forms of training or rehabilitation for best efficacy. What are the most promising approaches? What conditions appear to benefit? What are the situations/diseases/ disease states where neuromodulation is sufficiently well-proven now (or may be so in the future) that clinicians should start to consider its use in their psychogeriatric practice? We will review studies showing that tDCS can have a therapeutic effect in dementia, stroke, depression, and a range of other psychiatric conditions. Recent work is showing that with tDCS one can achieve improvement in picture naming, executive function, and memory in Alzheimer Disease and Frontotemporal dementia (Howard Chertkow presentation, Baycrest Health Sciences, Toronto). In stroke rehabilitation, rTMS treatment has been shown to aid in motor and language recovery (Alex Thiel, McGill University). There is now sufficient evidence that tDCS and Magnetic Seizure therapy are beneficial in depression, that these can now become part of the therapeutic armamentarium in selected cases (Jeff Daskalakis, University of Toronto). A range of other neuropsychiatric conditions can also be considered for neuromodulation therapy with rTMS (Daniel Blumberger, University of Toronto, CAMH).By attending this symposium, a physician or health care professional will become familiar with the latest research into neuromodulation and its role in current therapy of neurological and psychiatric diseases.

Neurodegenerative diseases often have an impact on both patients and their family caregivers. Given that families are an important support resource for people with neurodegenerative diseases, it is important to ensure their own quality of life. This symposium aim to present the NEUROQUALYFAM project funded by Cross Border Cooperation Programme Spain–Portugal 2014–2020 (POCTEP). The main objective of this project is to improve the quality of life of family caregivers who care people with neurodegenerative disease at home through the assessment of their needs and support resources, and the subsequent design and optimization of high-quality resources and services that are family-centered.

Maurice Mulvenna, School of Computing, Ulster University for Soo Hun, Digital Health & Care Northern Ireland, Health and Social Care Board

Presentation 1: Apps Library as a digital resource for people living with dementia and carers; Soo Hun, Programme Manager, Digital Health & Care Northern Ireland, Health and Social Care Board

Presentation 2: Development of a CLEAR Dementia Care © App; Frances Duffy, Consultant Lead Clinical Psychologist for Older People, Northern Health and Social Care Trust

Presentation 3: Technology Facilitated Reminiscence in Dementia. Assumpta Ryan, Professor of Ageing and Health, School of Nursing, Ulster University

Presentation 4: Understanding behaviour of people living with dementia using apps; Maurice Mulvenna, Professor of Computer Science, Raymond, Bond, Courtney Potts, School of Computing, Ulster University.

Summary of Symposium

The symposium describes the context and rationale behind the Health and Social Care Board Northern Ireland taking the strategic initiative to develop digital resources to support an ‘app’ library. The initiative, part of the Dementia eHealth and Data Analytics Pathfinder Programme is developing a digital framework to enable the social prescribing of apps, initially in support of those with dementia and their carers. In this symposium, apps that have been developed are described, including the CLEAR Dementia Care © App, developed to help carers understand behaviour from the perspective of the person with dementia, and the InspireD app for individual specific reminiscence, for people living with dementia and their family carers. The final talk describes the new opportunities for researchers to employ anonymous digital data in their research studies to understand the behaviour of people living with dementia and their carers in using such digital apps.

Presentation 1:

Apps Library as a digital resource for people living with dementia and carers

Soo Hun, Programme Manager, Digital Health & Care Northern Ireland, Health and Social Care Board

People living with dementia and their carers need support to enable them to manage their condition and to live independently for as long as possible. Digital technology such as smartphones are owned by 79% of adults. There are over 300,000 health apps and 4m apps are downloaded daily. A new digital service offering support for people living with dementia and their carers has been launched by the Health and Social Care Board Northern Ireland. The initiative, part of the Dementia eHealth and Data Analytics Pathfinder Programme, uses data and technology to inform better services, support people with dementia and help plan for the future. The aim of the apps4dementia library, https://apps4dementia.orcha.co.uk, is to provide a place for users to find safe, trusted mobile Apps to provide information and guidance on the condition, support self-care of symptoms and enable people affected by dementia and their carers; to carry on with their day-to-day activities for as long as possible. A series of engagement workshops conducted with people affected by dementia and carers provided input and feedback on the design, content and usability of the library; suitability and types of Apps for inclusion, as well as training materials to be delivered to healthcare professionals. Developed in conjunction with App evaluator, Organisation for the Review of Care and Health Apps (ORCHA), the library offers a range of applications which have been independently checked and reviewed for data privacy, clinical assurance and user experience. 10 best rated Apps are available on the library that provide guidance and information, to help with sleep, communication, keeping minds active, reminders as well as apps that support carers to care for their loved ones. The library will help to identify gaps in digital tools and enable commissioning of necessary Apps, of which 2 new apps – InspireD and CLEAR app will be included in the library in March 2020.

Presentation 2:

Development of a CLEAR Dementia Care & App

Frances Duffy, Consultant Lead Clinical Psychologist for Older People, Northern Health and Social Care Trust

People living with dementia can present with behaviours that carers find difficult to understand. These behaviours are often a sign of distress the person experiences as they try to understand what is happening around them or when they are trying to meet their needs and are unable to tell others what they want. Failure to understand these behaviours can lead to increased distress for the person and their carers. It can also lead to unnecessary breakdown in placement or avoidable admission to hospital. CLEAR Dementia Care © was developed to help carers to understand behaviour from the perspective of the person with dementia. This helps carers to offer appropriate support which reduces distress and improves quality of life. The model has successfully implemented across a range of organisations.

A workshop attended by health care professionals, voluntary and community sector and people with dementia and their carers elicited positive feedback about the utility of a CLEAR Dementia Care App. Throughout development there has been Personal and Public Involvement (PPI) about the design and layout of the App from a range of potential service users. The outcome is an App that can easily be used by any person who has contact with a person with dementia, including family carers and paid staff. The app provides concise and accessible information to help understand behaviour and suggest ways which could reduce the distress associated with the behaviour. It provides useful information that is always easily available. This can enable early intervention to prevent escalation of behaviour, reduce distress to the person with dementia and also reducing carer stress and burnout. An additional function gives carers the option to chart behaviour in an easy and accessible way. This will provide further understanding about patterns in behaviour and help to identify potential causes.

Presentation 3:

Technology Facilitated Reminiscence in Dementia

Assumpta Ryan, Professor of Ageing and Health, School of Nursing, Ulster University

Reminiscence has been widely used as a therapeutic approach for people living with dementia and recent studies have focused on the use of technology to support the reminiscence experience. The aim of this study was to investigate the outcomes of a home based, individual specific reminiscence intervention facilitated through the use of an iPad app for people living with dementia and their family carers. The study used a quasi-experimental design, incorporating quantitative and qualitative components in three phases. Phase 1: A User Development Group comprising a paired sample of 6 people living with dementia and their family carers worked with the research team to refine and test the technology. Phase 2: The refined application was implemented with a paired sample of 30 people living with mild to moderate dementia and their family carers. All participants were provided with reminiscence and IT training and used the system for 12 weeks at home. Outcome measures, collected at three time points, examined the impact of reminiscence on mutuality, wellbeing, quality of life and quality of the relationship between participants living with dementia and their family carers. Phase 3: Individual interviews were conducted with a sample of participants (n=32) to explore their experience of the intervention. User interactions revealed that people living with dementia used the app independently and more frequently than their carers. There were statistically significant increases in mutuality, quality of caregiving relationships and emotional well-being from baseline to endpoint for people living with dementia. For carers, there were no significant changes in mutuality, quality of caregiving relationship and emotional wellbeing scores from baseline to endpoint. Participating dyads perceived the intervention as a positive experience which focused on gains rather than losses in the context of memory retention and learning new skills.

Presentation 4:

Understanding behaviour of people living with dementia using apps

Maurice Mulvenna, Professor of Computer Science, Raymond Bond, Courtney Potts, School of Computing, Ulster University.

Behavioural data analytics and event log analysis can be useful to gain insight into how users interact with technologies. Electronic event logging data were obtained for people living with dementia and family carers. Event logging is when each anonymised user interaction with an app is automatically logged and stored in a database. This study adopted the health interaction log data analysis pipeline, which involved data cleaning and preparation, as well as the use of exploratory data analysis and K-means clustering, to uncover behavioural patterns of usage by users of the InspireD reminiscence app, to address the question: What is the temporal behaviour of users interacting with the app? The results build on the findings of a feasibility study which found that that people living with dementia preferred to interact with photos and reminisce with personalized media. Reminiscing peaked on Thursdays and Fridays but dipped at the weekends. There was a correlation between the number of days the people living with dementia and carer interacted with the app. However, people living with dementia had many more interactions than carers. People living with dementia interacted with the app akin to one reminiscence session per week. K-means clustering uncovered four user archetypes, described as: a person living with dementia who demonstrates independent and consistent use of the app; a person living with dementia who is reliant on his/her carers for support with the app and exhibits unpredictable usage patterns; a person living with dementia who is highly reliant on his/her carers for engagement with the app; and very infrequent users.

General synopsis of the Symposium: Cognitive impairment is an important geriatric syndrome. As the global population ages exponentially, the prevalence of cognitive impairment and dementia is increasing, and mental status assessment is key in the evaluation of older adults. However, there are several pitfalls during cognitive testing and special clinical situations that demands a more in-depth knowledge and attention from the examiner. The overall objective of this symposium is to show strategies and particularities of cognitive assessment in different settings (in the clinic, inside the hospital) and clinical scenarios (early onset impairment, mental illness comorbidity).