Cognitive Neurology and Dementia

The St George’s Cognitive Neurology clinic assesses individuals experiencing memory and thinking (cognitive) symptoms, particularly those with suspected early-onset and rarer forms of dementia. Information for referrers is provided at the bottom of this webpage.

What is Dementia?

This is a term used to describe changes in brain function that affect a person’s memory, thinking, and/or behaviour to the point that these interfere with their ability to live independently and manage everyday activities.

It is important to ensure that these symptoms are not due to depression, medications, sensory impairment or another medical disorder, such as sleep apnoea, before dementia can be diagnosed. The commonest cause of dementia is Alzheimer’s disease, a neurodegenerative disorder in which there is gradual worsening of brain function over time.

What is Mild Cognitive Impairment (MCI)?

This is a term used to describe changes in cognitive function that are not severe enough to interfere with daily life. While MCI does increase the risk of future dementia, it is important to remember that about a fifth of people with MCI can revert to normal function (particularly if there are other factors affecting brain function and these are addressed appropriately).

What is Functional Cognitive Disorder (FCD)?

In this condition, a person experiences memory or thinking symptoms that aren’t due to a neurodegenerative disease or any other type of brain pathology.  FCD is the commonest cause of subjective memory symptoms in younger people.  People with FCD usually perform normally on cognitive testing.

In FCD, symptoms often fluctuate and are not in keeping with the person’s level of function in everyday life, which is usually preserved. People with FCD are internally ‘on high alert’ for cognitive errors and find these distressing because they don’t match with their expectations of their memory or other cognitive abilities. You can read more about FCD here. 

Initial assessment

Patients referred to the Cognitive Neurology clinic have a consultation with one of our consultant neurologists or a resident doctor working under the supervision of a consultant. This involves taking a detailed medical history and performing appropriate cognitive screening and neurological assessments.

It is particularly helpful to bring someone who knows you well to the appointment to provide a witness account of your difficulties. It is important to bring your glasses and hearing aids to the appointment.

Investigations

In some cases, further tests may be required, such as an MRI or CT brain scan, a neuropsychological assessment or a lumbar puncture. These will be arranged for a separate visit.

For more information about lumbar puncture, please visit:

www.nhs.uk/tests-and-treatments/lumbar-puncture/

Treatment – Medication

Treatment depends on the underlying cause of memory and thinking difficulties. In some forms of dementia – such as Alzheimer’s disease, dementia with Lewy bodies, and Parkinson’s disease dementia – medications can act as cognitive enhancers to help improve memory symptoms. These include donepezil, rivastigmine, and memantine.

Donepezil may cause nausea or loose stools; however, these side effects usually lessen over time. Occasionally, it can cause vivid dreams—if this happens, the medication can be taken in the morning instead. Donepezil can also reduce heart rate, so patients should seek medical advice if they experience light-headedness or fainting.

Further information: www.nhs.uk/medicines/donepezil. Rivastigmine works in the same way as Donepezil and is usually prescribed if Donepezil is not tolerated, or if an individual has moderate-severe liver disease.

Memantine may occasionally cause headache, constipation, dizziness, or sleep disturbance.

For more information: www.nhs.uk/medicines/memantine

Treatment – Lifestyle

Lifestyle changes such as a healthy diet, regular exercise, stopping smoking, and reducing alcohol intake may help lower the risk of developing dementia, and modify the vascular risk factors that may worsen dementia.

For more information: www.nhs.uk/conditions/dementia/about-dementia/prevention/

Treatment – Support

The Dementia Clinical Nurse Specialists will arrange an appointment with you after you have received your diagnosis. In general, these appointments are made 6-monthly until you can be discharged to community support services.

At the time of the appointment with the Dementia Nurse Specialists, they will offer you a business card so that you can get in touch with them in between appointments should you need to.

We are also proud to offer a specialist young-onset dementia support group, which has been running for over 10 years. We also have a fully functioning sensory dementia garden that is available in the summer months for some members of the Young Onset of Dementia Group.

See our video explaining this service:

St George regional young-onset dementia support group

We often refer to Dyscover, a charity that supports people with language-based forms of dementia (Primary Progressive Aphasia). The charity has trained our dementia specialist nurses and runs sessions either in person (Leatherhead) or via Zoom.

www.dyscover.org.uk/support-groups/primary-progressive-aphasia-support-groups

Watch a video explaining our PPA service

Treatment – useful links

Local dementia support information can be found by entering your postcode here: www.alzheimers.org.uk/find-support-near-you

Alzheimer’s Society – Provides information on all forms of dementia, advice on care needs assessments (via social services), and guidance on setting up lasting power of attorney.
www.alzheimers.org.uk/get-support or call 0333 150 3456.

Age UK- Offers information on benefits, driving, social care assessments, and carer rights.

www.ageuk.org.uk/information-advice/health-wellbeing/conditions-illnesses/dementia

Carers UK– Offers information on carers’ allowance, respite care, and emotional support.

www.carersuk.org

NHS UK– offers information on staying active, communication, nutrition, and sleep.

www.nhs.uk/conditions/dementia/living-well

Dementia UK – Offers information on all causes of dementia, including young-onset dementia. They host online sessions for newly diagnosed individuals and their families and fund Admiral Community Dementia Nurses, who can support people facing challenging behaviour symptoms.
www.dementiauk.org

Rare Dementia Support – Provides information on rare forms of dementia, runs support groups, and publishes a regular newsletter.

www.raredementiasupport.org

Lewy Body Society – Offers information and support for people living with dementia with Lewy bodies.

www.lewybody.org

FTD talk – Provides information and support for people with frontotemporal dementia.

www.ftdtalk.org/

Research

We are a research-active centre, involved in both treatment and observational studies, and are an affiliate site for the UK Dementia Trial Network. Our goal is to develop treatments that can slow or stop the disease progression, improving quality of life for many patients.

If you are interested in taking part in research, please inform your neurologist or dementia nurse specialist. You can also register your interest on the National Dementia Research Registry (www.joindementiaresearch.nihr.ac.uk).

Referrals

We are a regional service for the South West London and Surrey area. We accept referrals from primary care via the e-Referral Service. Referrals from other healthcare providers, such as community memory clinics or neurology departments, should be made via letter.

Information for GPs

We specialise in young-onset and rare causes of dementia. In certain situations, we may not be the most appropriate team to refer to:

1. Functional Cognitive Disorder (FCD) is a common cause of subjective cognitive symptoms in younger people. This condition can often be managed without referral to the Cognitive Neurology service and has excellent potential for improvement.
   Useful patient resources: neurosymptoms.org/en/symptoms/fnd-symptoms/functional-cognitive-symptoms

www.fndhope.org.uk

For patients aged 60 years or under, please refer only if one or more of the following are present:

• An informant history supporting cognitive difficulties
• Evidence of formal work performance concerns or objective ADL decline
• Underperformance on a cognitive screening test

2. For older-onset dementia (over 65 years), particularly Alzheimer’s disease or vascular dementia, please refer to the old-age psychiatry-led community memory clinic.
3. For people with moderate or severe learning disability, please refer to the psychiatry-led learning disability team in the first instance.
4. Mild head injury, with a normal CT head, can cause prolonged subjective cognitive symptoms, headaches, and dizziness, but typically does not require neurology review.
   A useful patient resource: headinjurysymptoms.org
   Patients can also self-refer to the charity Headway, which offers helpful information, including the leaflet “Mild Head Injury and Concussion.”

NICE guidance recommends the following pre-referral blood tests: FBC, U&E, LFTs, Calcium, TFTs, B12, Folate and CRP. Syphilis serology and HIV testing should also be considered.