50 minute read
Dermotology CPD
Continuing Professional Development CPD CPD
60 Second Summary
First, a point of clarification – many think the word “eczema” implies a genetic condition and “dermatitis” implies an external allergic problem – in fact, both terms to a dermatologist are interchangeable / mean precisely the same thing.
What does a dermatologist mean when they refer to “seborrheic dermatitis”? This refers classically to a rash predominantly on the face affecting the T zone where the production of the skins natural oil called “sebum” is at its maximum.
Sufferers of eczema will often recall a history of eczema as a young child which then faded away for many years before reappearing as eczema in adult life. The classic distribution of this condition is on the inner flexural aspects of the elbows and knees but is usually widely scattered elsewhere as well.
Allergy testing is a specialised field of dermatology which is hard to gain access to because this is only perform by a small number of dermatologists and correct patch testing involves up to 4 separate hospital visits therefore it is time consuming and expensive
Try whenever possible not to use standard soap on the skin and instead use a moisturizing cream as a soap substitute and generally speaking have a good skincare programme to the affected area.
Do you understand the potential causes of eczema (genetic, allergic, infected) and the relative strengths of your skin treatment options? Have any skin exposure circumstances have changed? Does allergy need to be considered? Provision of specialist services for dermatology is limited therefore many patients will seek High Street advice from their local pharmacy. The bulk of dermatological problems consist of the following four situations –
AUTHOR: Dr John Ashworth
Dr John Ashworth is a leading Consultant Dermatologist and is registered with the General Medical Council of Great Britain and the Irish Medical Council. Educated at St.Bedes College in Manchester and Manchester Medical School, he carried out his medical elective at Johnston Willis Memorial Hospital in Virginia, USA. At www.dermatologist.ie we offer online Consultant diagnosis/advice and prescriptions for patients
1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice? 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap - will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs? 5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings. Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published is copyright, no part of this can be used in any other publication without permission of the publishers and author.
Management of Common Skin Conditions
1. Skin cancer
2. Acne
3. Eczema / Dermatitis
4. Psoriasis
This article is concerned with items three and four
Eczema/Dermatitis
First, a point of clarification – many think the word “eczema” implies a genetic condition and “dermatitis”
implies an external allergic problem – in fact, both terms to a dermatologist are interchangeable / mean precisely the same thing. Dermatologists would hardly ever use those terms without an explanatory prefix for example
SEBORRHOEIC ECZEMA
or ALLERGIC CONTACT DERMATITIS thus designating a subcategory which is important in terms of management / advice The classic genetic variation is called ATOPIC DERMATITIS and is often linked to asthma, hayfever and these patients are generally “skin sensitive” - have irritations with simple products like moisturisers / sun screens / soap powders etc Many patients have overlaps of 2 types of eczema – so don’t get hung up on the “name” . Thus, many patients will have a genetic history of the atopic conditions but will also display a seborrheic pattern of skin trouble so they are in an overlap situation
SEBORRHOEIC DERMATITIS:
What does a dermatologist mean when they refer to “seborrheic dermatitis”? This refers classically to a rash predominantly on the face affecting the T zone where the production of the skins natural oil called “sebum” is at its maximum.
So the eyebrows, forehead and the naso labial folds are often the dominant area – other areas include the front of the chest, between the shoulders and sometimes the armpits and groins. Some patients seem to be suffering an allergic reaction to a naturally occurring tiny organism which lives on human skin and this is why the application of KETOCONAZOLE can be helpful. Either in the form of a shampoo which can be scrubbed onto the skin when wet in the shower or applied in the normal way as a cream. For similar reasons DAKTACORT cream or DAKTARIN or other anti-fungal / anti-yeast creams are the mainstay of treatment
This theory is also the explanation as to why this condition recurs – because you can only kill this organism off for a period of time before it naturally repopulates the skin once again
ATOPIC DERMATITIS/ECZEMA:
This is the classic form of the disease which is strongly genetic in origin and therefore there is often a personal or family history of the other “atopic” conditions which are asthma and hayfever. Sufferers will often recall a history of eczema as a young child which then faded away for many years before reappearing as eczema in adult life. The classic distribution of this condition is on the inner flexural aspects of the elbows and knees but is usually widely scattered elsewhere as well.
A very important aspect of this condition is OIL DEFICIENCY in the outer layer of the skin and therefore greasy ointments applied very regularly are a hugely important part of treatment – in fact I often say this to patients – if you were to live on a desert island with only one product that you could use for the rest of your life – it would not be a medicated steroid – it would be a greasy ointment like simple VASELINE or even natural OLIVE OIL - because long-term this would give you best benefit
Another important consideration is this – skin infection can spread rapidly in patients with eczema and the commonest cause of badly flaring eczema is infection – oral antibiotics such as FLUCLOXACILLIN may need to be instituted from time to time and is usually taken for 14 days at a dose of 500 mg 4 times per day ALLERGY - if the nature of the condition radically alters over a fairly short space of time, and if infection seems unlikely, then consider the possibility of an allergy to something in the environment and that would also include prescription creams as a possibility – patients with geneticbased eczema are more prone to allergy – allergy patch tests are sometimes needed
The commonest allergies relate to cosmetic creams, but also prescription creams – plant pollen in the environment – cookery products contaminating the skin – nickel in jewellery and possibly in the diet but there are many other possible allergens. Allergy testing is a specialised field of dermatology which is hard to gain access to because this is only perform by a small number of dermatologists and correct patch testing involves up to 4 separate hospital visits therefore it is time consuming and expensive. STEROID CREAMS - these are important but should be reasonably minimised for two reasons – firstly damage to the skin – secondly resistance – because in a similar manner to over treating patients with antibiotics and developing antibiotic resistance – something similar can happen with regular use of steroids therefore a rotation policy using several different products it’s tremendously important in the long run. My own personal strategy for many patients would include the following 10 day reducing program of topical steroids. For a temporary period of 10 days I would like to consider the following – only the third is suitable for longer term use the first two should be used exactly as directed – all applied twice per day – once the cycle is complete you should break from all prescription treatments for at least three days and use a moisturiser/skin care programme only. If needed you can then recommence the cycle after this total period. The treatment cycle can be shortened of course if you improve very rapidly which is possible but the critical arithmetic is to be completely away from active prescription creams for a three-day period before recommencing your cycle once again. So the 10 day treatment is as follows:
BETNOVATE: twice per day for 2 days, then;
EUMOVATE:
twice per day for 3 days, then;
DAKTACORT:
twice per day for 5 days to follow
This adds up to 10 days
Having emphasised these issues about Steroids it is also important to counterbalance this with the fact that some patients and also health professionals carry a steroid phobia. By this I mean they are reluctant to apply steroids even in reasonable quantities and for reasonable time periods and are thus denying adequate treatment when active treatment is required. Try whenever possible not to use standard soap on the skin and instead use a moisturizing cream as a soap substitute and generally speaking have a good skincare programme to the affected area. TACROLIMUS and associated medications are useful in some patience and have a different action to Steroids. These treatments can irritate the skin in about 30% of patients and thus can be problematic. But certainly useful as an alternative to consider.
SUMMARY
Do you understand the potential causes of eczema (genetic, allergic, infected) and the relative strengths of your skin treatment options? Have any skin exposure circumstances have changed? Does allergy need to be considered?
TOP TIP 1: Most flaring eczema is NOT due to environmental changes – flaring eczema is usually due to normal skin bacteria being scratched into the skin surface and multiplying – thus, INFECTION is the commonest cause of flaring eczema. So adding an antiseptic topically or an antibiotic orally (FLUCLOXACILLIN 500 mg x4 per day for 14 days) will often make a dramatic difference.
NEWLY DEVELOPED ECZEMA:
if the problem is recent – then consider circumstances – external allergy may be of relevance – starting work as a hairdresser, nurse, food industry – any wet work / regular hand washing is a potential problem – these considerations are important. Wet work - both domestic and occupational, can obliterated the adhesion between the top of the fingernail and the nailfold skin thus allowing contaminants underneath the skin and this can precipitate nasty finger and hand eczema – hand protection by using cotton gloves inside rubber gloves when doing any dirty or wet work can be tremendously helpful. In sunnier months eczema can flare and many patients can be sensitive both to direct sunshine but also to airborne pollen landing on the skin – FINGER TO FACE transfer of allergens (eg in the garden; cookery products; nail varnish) is another very important cause of face and neck eczema.
In colder months eczema can also flare for different reasons –
the skin tends to be less oily in winter and needs more emollient and protection from prolonged exposure to cold and wind. TOP TIP 2: Empower yourself with further information eg www.dermatologist.ie ; www.dermnetnz.org ; www.BAD.org.uk Give your creams a star rating with your dispensed steroids so you can understand the different strengths of steroid creams eg
BETNOVATE ++++ ; EUMOVATE ++; HYDROCORTISONE + ;
EMOLLIENTS zero pluses – and appropriate / inappropriate body locations for the different strengths. When I see patients on multiple steroid creams I often ask them to put the creams on my desk in strength order from top to bottom and often they have very little idea about the relative strengths. DAKTACORT is a good +1 product for most facial eruptions and covers both SEBORRHOEIC and also ATOPIC disease.
All forms of eczema have a common abnormality, OIL DEFICIENCY in the skin (not water deficiency) - therefore the term “dry skin” is very misleading. Oily greasy products like VASELINE work well but you cannot go out wearing them more cosmetically acceptable moisturisers are often preferred. The preference is purely personal – there is no “best” product. CLINGFILM - if you apply a treatment to the skin and then wrap the kitchen clingfilm temporarily over the area this enhances the penetration and effectiveness of the cream or moisturiser. This is a particularly useful technique to use overnight in bed – and can make a very dramatic difference to a number of patients.
KEY QUESTIONS:
Past personal and family history of eczema / asthma / hay fever – indicates a genetic disease
Recent sudden onset with no past history indicates the possibility of external factors
A scaly dandruff like appearance on the face, scalp or upper body indicate a likely
SEBORRHOEIC DERMATITIS type problem
Sudden deterioration of a previously lower level problem indicates likely infection or allergy
OVERALL STRATEGY:
Try to establish a likely diagnosis by appropriate consideration of family genetics Think about external causation if possible Tackle infection if present Use plenty of oil replacement Make sure you have a grip of steroid potency in the products you use
PSORIASIS
Usually has a different appearance to eczema and the main characteristic differences for standard psoriasis are the fact that individual patches come to an abrupt end and quickly switch to normal skin rather than gradually fading towards normal skin which is more typical for eczema. Also, Psoriasis tends to be drier and thicker as a condition.
These distinctions are not universal and quite commonly it is difficult to differentiate between the two conditions even for experts. DIFFERENT PATTERNS: There is a very strong genetic tendency. There are a few different patterns of Psoriasis but the classic shows the thick plaques. Other forms can affect just the flexures only, for example the armpits and the perineum. Other patients find that the scalp is predominantly involved. Other much rarer patients find their joints become arthritic before the appearance of the rash which can take many years to manifest. In other words Psoriasis is a complex disorder of the immune system which can affect the joints as well as the skin. BIOLOGIC THERAPY: Over the past decade the pharmaceutical industry have developed treatments broadly referred to as the “biologics”. These consist of chemicals which either bind to specific antibody sites in the immune system or interfere with the immune system cascade of chemicals many of which are called “interleukins”. Inter meaning “acting between” and leukins referring to the leukocytes – the white cells of the immune system. However, these medications are very complicated, very expensive and tend only to be used for extreme sufferers. The majority of psoriasis sufferers have a milder disease which can usually be adequately controlled with safe external cream treatments applied in the normal way. ROTATION POLICY: Treatment on the skin for psoriasis is usually best achieved using a rotation policy – approximately one month on each product in a triangular rotation so that the psoriasis is attacked in different ways by different molecules and this seems to be the best way to control it – below I will give you a prescription for three products that would be a good rotation policy to consider All treatments need to be applied and left on the skin for at least 30 minutes on each treatment session to allow good penetration into the skin and maximum benefit The three reasonable products I often recommend are as follows:
DOVOBET EXOREX PSORIDERM
Sometimes, if Psoriasis is very angry and inflammatory it is reasonable to apply a very strong steroid approach for example DERMOVATE for a temporary period of 2–4 weeks but strong steroids are not generally recommended for long-term use. When treating psoriasis of the hairy scalp it is often difficult to get treatment into the base of the condition because of a thick surface protective scale which needs removing first. Greasy applications like COCOIS are massaged into the skin by parting the hair to expose the skin, applying the treatment then parting the hair fractionally further across the scalp and working across the entire area in this way. Then leave the treatment in position under a protective plastic shower cap for several hours, often overnight in bed – then shower out and massage with standard shampoo which will help shed a lot of the scale. ENSTILAR and DIPROSALIC scalp liquid (as examples) are then able to be massaged in a similar way but can now penetrate into the root of the problem. If it is not possible to control psoriasis by external treatment then oral medications can be considered and these include the following – METHOTREXATE,
CYCLOSPORIN,
MYCOPHENALATE and others. Usually GPs are reluctant to initiate these treatments without supervision by specialist and repeat blood tests are needed to ensure safety. EMOLLIENTS: these are important in Psoriasis not so much as an oil replacement therapy as in the case of eczema – but more in the sense that the dry scaly surface thickening of typical psoriasis prevents the penetration of active treatment. Once the surface scale is softened and removed then active treatments can be more effective. Emollients also make Psoriasis feel more comfortable for the patient. ULTRAVIOLET LIGHT: natural sunshine, sunshine of an artificial kind for example in a tanning parlour can sometimes be helpful but of course we all know these are harmful for human skin. So any recommendation to try these has to be counterbalanced by the harmful consideration and advice. Medical ultraviolet light refers to a very specific narrow wavelength of light which is particularly helpful for skin disease and much less harmful to the skin in general. However, this kind of light exposure is a specialised option which is mainly delivered from dermatology departments are therefore can be more difficult to gain access. Many patients report great improvement on a sunny holiday.
Q/A section: ATOPIC DERMATITIS is characteristically associated with a greasy skin T/F?
False – it is usually associated with an oil deficient skin and emollients are a vital part of treatment
ATOPIC DERMATITIS is linked with other disease specific associations T/F?
Correct – very often there is a personal or a family history of associated asthma and hayfever – there is a strong genetic link
PSORIASIS has no other manifestations outside of the skin appearance T/F?
False – psoriasis sometimes is associated with certain types of arthritis and the arthritis can sometimes preceed the psoriasis by many years
PSORIASIS can appear at any age but is usually present from early childhood T/F?
False – psoriasis very rarely presents in childhood, unlike atopic dermatitis which is characteristically common in childhood. Psoriasis appears much more commonly in adult life and sometimes is associated with a severe sore throat as a trigger factor
Learn more at DERMAWorld
Active flare management and maintenance treatment of adult plaque psoriasis1
Enstilar® is indicated for the topical treatment of psoriasis vulgaris in adults.1
once-daily treatment for 4 weeks during the active flare…1-4 twice-weekly maintenance treatment in responders for 52-week control1,5*
Enstilar® is generally well tolerated1,6**
*Patients who have responded to once-daily treatment for 4 weeks (Physician’s Global Assessment (PGA) score of ‘clear’ or ‘almost clear’ (PGA<2) with ≥2-grade improvement from baseline).1,5 Enstilar® should be applied twice-weekly on two non-consecutive days to previously affected areas.1 Between applications there should be 2-3 days without Enstilar® treatment.1 The total dose of all calcipotriol containing products should not exceed 15 g per day.1 The total body surface area treated should not exceed 30%.1 **The most frequently reported adverse reactions during treatment are application site reactions (uncommon, ≥1/1,000 to <1/100).1 Local reactions can occur after topical use, especially during prolonged application, including skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation, and colloid milia. For a full list of adverse reactions please refer to the Enstilar® SPC.1
Prescribing Information for Enstilar® (calcipotriol/betamethasone) 50 micrograms/g + 0.5 mg/g cutaneous foam
Please refer to the full Summary of Product Characteristics (SmPC) (www.medicines.ie) before prescribing. Indication: Topical treatment of psoriasis vulgaris in adults. Active ingredients: 50 µg/g calcipotriol (as monohydrate) and 0.5 mg/g betamethasone (as dipropionate). Dosage and administration: Flare treatment: Apply by spraying onto affected area once daily. Recommended treatment period is 4 weeks. If it is necessary to continue or restart treatment after this period, treatment should be continued after medical review and under regular supervision. Long-term maintenance treatment: Patients who have responded at 4 weeks’ treatment using Enstilar once daily are suitable for long-term maintenance treatment. Enstilar should be applied twice weekly on two non-consecutive days to areas previously affected by psoriasis vulgaris. Between applications there should be 2-3 days without Enstilar treatment. If signs of a relapse occur, flare treatment, as described above, should be re-initiated. Maximum dose: The daily maximum dose of Enstilar should not exceed 15 g, i.e. one 60 g can should last for at least 4 days of treatment. 15 g corresponds to the amount administered from the can if the actuator is fully depressed for approximately one minute. A two-second application delivers approximately 0.5 g. As a guide, 0.5 g of foam should cover an area of skin roughly corresponding to the surface area of an adult hand. If using other calcipotriol-containing medical products in addition to Enstilar, the total dose of all calcipotriol-containing products should not exceed 15 g per day. Total body surface area treated should not exceed 30%. Safety and efficacy in patients with severe renal insufficiency or severe hepatic disorders have not been evaluated. Safety and efficacy in children below 18 years have not been established. Shake the can for a few seconds before use. Apply by spraying, holding the can at least 3 cm from the skin, in any orientation except horizontally. Spray directly onto each affected skin area and rub in gently. If used on the scalp, spray into the palm of the hand then apply to affected scalp areas with the fingertips. See hair washing instructions in the package leaflet. Wash hands after use (unless Enstilar is used to treat the hands) to avoid accidentally spreading to other parts of the body as well as unintended drug absorption on the hands. Avoid application under occlusive dressings since systemic absorption of corticosteroids increases. It is recommended not to take a shower or bath immediately after application. Let the foam remain on the scalp and/or skin during the night or during the day. Contraindications: Hypersensitivity to the active substances or any of the excipients. Erythrodermic and pustular psoriasis. Patients with known disorders of calcium metabolism. Viral (e.g. herpes or varicella) skin lesions, fungal or bacterial skin infections, parasitic infections, skin manifestations in relation to tuberculosis, perioral dermatitis, atrophic skin, striae atrophicae, fragility of skin veins, ichthyosis, acne vulgaris, acne rosacea, rosacea, ulcers and wounds. Precautions and warnings: Adverse reactions found in connection with systemic corticosteroid treatment, e.g. adrenocortical suppression or impaired glycaemic control of diabetes mellitus, may occur also during topical corticosteroid treatment due to systemic absorption. Application under occlusive dressings should be avoided since it increases the systemic absorption of corticosteroids. Visual disturbance may be reported with systemic and topical corticosteroid use. If a patient presents with symptoms such as blurred vision or other visual disturbances, the patient should be considered for a referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma or rare diseases such as central serous chorioretinopathy (CSCR) which have been reported after use of systemic and topical corticosteroids. Application on large areas of damaged skin, or on mucous membranes or in skin folds should be avoided since it increases the systemic absorption of corticosteroids. Due to the content of calcipotriol, hypercalcaemia may occur. Serum calcium is normalised when treatment is discontinued. The risk of hypercalcaemia is minimal when the maximum daily dose of Enstilar (15 g) is not exceeded. Enstilar contains a potent group III-steroid and concurrent treatment with other steroids on the same treatment area must be avoided. The skin on the face and genitals is very sensitive to corticosteroids. Enstilar should not be used in these areas. Instruct the patient in the correct use of the product to avoid application and accidental transfer to the face, mouth and eyes. Wash hands after each application to avoid accidental transfer to these areas as well as unintended drug absorption on the hands. If lesions become secondarily infected, they should be treated with antimicrobiological therapy. However, if infection worsens, treatment with corticosteroids should be discontinued. When treating psoriasis with topical corticosteroids, there may be a risk of rebound effects when discontinuing treatment. Medical supervision should therefore continue in the post-treatment period. Long-term use of corticosteroids may increase the risk of local and systemic adverse reactions. Treatment should be discontinued in case of adverse reactions related to long-term use of corticosteroid. There is no experience with the use of Enstilar in guttate psoriasis. Enstilar contains butylhydroxytoluene (E321), which may cause local skin reactions (e.g. contact dermatitis), or irritation to the eyes and mucous membranes. Pregnancy and lactation: There are no adequate data from the use of Enstilar in pregnant women. Enstilar should only be used during pregnancy when the potential benefit justifies the potential risk. Caution should be exercised when prescribing Enstilar to women who breast-feed. The patient should be instructed not to use Enstilar on the breast when breast-feeding. Side effects: There are no common adverse reactions based on the clinical studies. The most frequently reported adverse reactions are application site reactions. Uncommon (≥1/1,000 to <1/100): Folliculitis, hypersensitivity, hypercalcaemia, skin hypopigmentation, rebound effect, application site pruritus, application site irritation, application site pain (including application site burning). Not known frequency: Hair colour changes. Calcipotriol: Adverse reactions include application site reactions, pruritus, skin irritation, burning and stinging sensation, dry skin, erythema, rash, dermatitis, psoriasis aggravated, photosensitivity and hypersensitivity reactions, including very rare cases of angioedema and facial oedema. Systemic effects after topical use may appear very rarely causing hypercalcaemia or hypercalciuria. Betamethasone: Local reactions can occur after topical use, especially during prolonged application, including skin atrophy, telangiectasia, striae, folliculitis, hypertrichosis, perioral dermatitis, allergic contact dermatitis, depigmentation and colloid milia. When treating psoriasis with topical corticosteroids, there may be a risk of generalised pustular psoriasis. Systemic reactions due to topical use of corticosteroids are rare in adults; however, they can be severe. Adrenocortical suppression, cataract, infections, impaired glycaemic control of diabetes mellitus, and increase of intra-ocular pressure can occur, especially after long-term treatment. Systemic reactions occur more frequently when applied under occlusion (plastic, skin folds), when applied onto large skin areas, and during longterm treatment. Precautions for storage: Do not store above 30°C. Extremely flammable aerosol. Pressurised container. May burst if heated. Protect from sunlight. Do not expose to temperatures exceeding 50°C. Do not pierce or burn, even after use. Do not spray on an open flame or other ignition source. Keep away from sparks/open flames. No smoking. Legal category: POM. Marketing authorisation number and holder: PA 1025/5/1. LEO Pharma A/S, Ballerup, Denmark. Last revised: March 2021.
Reporting of Suspected Adverse Reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, website: www.hpra.ie Adverse events should also be reported to Drug Safety at LEO Pharma by calling +353 1 4908924 or e-mail medical-info.ie@leo-pharma.com
References: 1. Enstilar® SPC, www.medicines.ie. Last accessed: April 2022. 2. Leonardi C et al. J Drugs Dermatol 2015;14(12):1468–1477. 3. Koo J et al. J Dermatolog Treat 2016;27(2):120–127. 4. King C and Lowson D. Poster 237 presented at the 5th Psoriasis International Network Annual Meeting, Paris, France, 5–7 July 2016. 5. Lebwohl M et al. J Am Acad Dermatol 2021;84:1269-77. 6. Menter A et al. Poster presented at the 16th Annual Las Vegas Dermatology Seminar, Las Vegas, USA 5-7 November 2015.
New Microbiota Research Could Lift the Fog on Chemobrain
Cancer is the second-leading cause of death in Europe and imposes significant human and economic costs. Research in recent decades has primarily focused on reducing mortality and relapse rates, leading to considerable improvements to established treatment regimens as well as the advent of new therapies, specifically the development of immunotherapies and more targeted anti-cancer agents. These advancements in treatment options have dramatically improved patient care and survival for several cancers and have also exposed a number of issues around the long-term side effects of cancer therapies that impact quality of life.
What is chemobrain?
A large subset of cancer patients and survivors frequently report neuropsychiatric symptoms and impairments during and following cancer treatment, including impaired cognition, increased incidence of mood and anxiety disorders, and increased pain and fatigue which collectively resembles “brain fog” and has been termed “chemobrain”. These impairments are most frequent during and immediately following therapy, although some cancer survivors experience these symptoms for decades after the resolution of their cancer, interfering with their well-being and return to normal life. These neuropsychiatric impairments are often difficult to quantify: while patients’ subjective reports indicate sluggish thinking and poorer cognitive performance following therapy, these are often not well captured by standard neuropsychological testing utilised in the majority of studies to date. This is most likely because standard neuropsychological tests were originally designed for diagnosis of focal lesions of the central and peripheral nervous systems, rather than diffuse damage throughout the brain. Approaches using methods from cognitive psychology, which are designed to assess cognitive performance within healthy populations, have identified that cancer patients and survivors suffer from difficulties with concentration and attention, short-term memory and executive function.
Written by Dr Sarah-Jane Leigh, Government of Ireland Postdoctoral Fellow at APC Microbiome Ireland, an SFI Research Centre headquartered at University College Cork
What the Research Tells us
While most research so far has shown that these neuropsychiatric symptoms and impairments are associated with traditional cytotoxic chemotherapy regimens in cancer
patients and survivors, there is emerging evidence that newer immunotherapies1 and targeted cancer therapies2 may have similar impacts on brain health and function. The mechanisms underpinning these chemobrain symptoms are poorly understood, posing a serious impediment to their clinical management. Similarly to cancer patients and survivors, in vivo experiments with chemotherapeutic agents induce impairments in cognition and increased anxiety-like and pain behaviours. These experiments have shown that chemotherapeutic agents increase neuroinflammation, reduce neurogenesis and neurotransmitter availability, and alter neuronal morphology throughout the central and peripheral nervous systems when administered in both healthy animals and those with cancerous tumours.
The gut microbiota, cancer and chemobrain
The human gastrointestinal tract is populated by an ecosystem of bacteria and other micro-organisms, collectively known as the gut microbiota, that have co-evolved alongside humans to produce a complex symbiotic relationship. The gut microbiota supports host physiology through improved energy harvest, strengthened gut integrity and barrier function, protection from infection, immune modulation3, and brain health and function.4 A healthy gut microbiota is thought to reduce the risk of cancer development, while altered gut microbiota community as well as specific gut microbes can increase the likelihood of developing gastrointestinal cancers5 (for example, Helicobacter pylori causes stomach ulcers and increases the prevalence of stomach and small intestine cancers while Fusobacterium nucleatum promotes colorectal cancer development). Furthermore, the gut microbiota can modulate cancer therapy effectiveness through direct and indirect interactions with cancer drugs: chemotherapies can transiently shift gut microbiota composition and microbial metabolite production, and baseline
microbiota composition and exposure to antibiotics influences patient responses to immunotherapy.6 The gut microbiota also appears to be involved in cancer therapy side effects involving the gut (diarrhoea and nausea), infection risk as well as changes in the central and peripheral nervous systems. A recent systematic review assessing the role of the microbiota in side effects reported by cancer patients concluded that microbiota composition was associated with fatigue, anxiety, depression, sleep quality, cognitive impairment and peripheral neuropathy in patients undergoing chemotherapy.7 These results are in line with emerging evidence from experiments in vivo where chemotherapy-related fatigue8 and peripheral neuropathy9 are related to microbiota composition and can be modified through interventions targeting the microbiota. So far, only a few drugs and neuropsychological symptoms have been examined and several experts in the field have identified the microbiota as a potential site for intervention in chemobrain.
What is the role of drug-microbiota and brain-microbiota interactions in chemobrain?
Professors Gerard Clarke, John Cryan, and I at APC Microbiome Ireland, a Science Foundation Ireland funded research centre dedicated to the study of host-microbe interactions, are combining behavioural neuroscience and neuropharmacology approaches to address how traditional and novel cancer drugs may induce chemobrain through modulation of the gut microbiota, in collaboration with a multidisciplinary team spanning pharmacy, pharmacomicrobiomics (the study of drugmicrobiota interactions), microbiology and oncology. Our current project is grounded in the hypothesis that host-microbiota and drug-microbiota interactions underlie cancer-therapy associated behavioural impairment. Specifically, we propose that different cancer therapies will present unique drug-microbiota interactions that will modify host-microbiota interactions and subsequently behaviour. The lived experience of cancer treatment means people often take longer than they anticipated to get back on their feet and fully engaged in life, and this is often due in part to chemobrain. Understanding the mechanisms at play can help find some much-needed solutions to this problem and deliver potential interventions for these behavioural impairments. The study of how microbiota-drug interactions alter drug benefits and side effects is a relatively new avenue of research with substantial scope to yield impactful new discoveries. The development of microbiota-targeted therapies holds promise for the management of these troublesome side effects that cloud quality of life for cancer patient and survivor.
Twitter @SarahJane_Leigh Linkedin Sarah-Jane Leigh Twitter @Pharmabiotic Linkedin APC Microbiome Ireland Facebook Pharmabiotic Instagram microbiomeireland
References:
1. Joly F, Castel H, Tron L, Lange M, Vardy J.
Potential Effect of Immunotherapy Agents on Cognitive Function in Cancer Patients.
J Natl Cancer Inst. 2020;112(2):123-127. doi:10.1093/jnci/djz168 2. Abdel-Aziz AK, Mantawy EM, Said RS,
Helwa R. The tyrosine kinase inhibitor, sunitinib malate, induces cognitive impairment in vivo via dysregulating
VEGFR signaling, apoptotic and autophagic machineries. Exp Neurol. 2016 Sep;283(Pt A):129-41. doi: 10.1016/j. expneurol.2016.06.004. 3. Sekirov I, Russell SL, Antunes LCM et al.
Gut Microbiota in Health and Disease.
Physiological Reviews. 2010;90(3):859-904. doi: 10.1152/physrev.00045.2009. 4. Cryan, J., Dinan, T. Mind-altering microorganisms: the impact of the gut microbiota on brain and behaviour. Nat
Rev Neurosci. 2012 13, 701–712. https://doi. org/10.1038/nrn3346 5. Helmink, B.A., Khan, M.A.W., Hermann, A. et al. The microbiome, cancer, and cancer therapy. Nat Med 25, 377–388 (2019). https:// doi.org/10.1038/s41591-019-0377-7 6. Leigh SJ, Lynch CMK, Bird BRH, et al. Gut microbiota-drug interactions in cancer pharmacotherapies: implications for efficacy and adverse effects. Expert Opin Drug
Metab Toxicol. 2022 Jan;18(1):5-26. doi: 10.1080/17425255.2022.2043849. 7. Song BC, Bai J. Microbiome-gut-brain axis in cancer treatment-related psychoneurological toxicities and symptoms: a systematic review. Support Care Cancer. 2021
Feb;29(2):605-617. doi: 10.1007/s00520-02005739-9. 8. Grant CV, Loman BR, Bailey MT, Pyter LM.
Manipulations of the gut microbiome alter chemotherapy-induced inflammation and behavioral side effects in female mice. Brain
Behav Immun. 2021 Jul;95:401-412. doi: 10.1016/j.bbi.2021.04.014. 9. Ramakrishna, C., Corleto, J., Ruegger, P.M. et al. Dominant Role of the Gut Microbiota in Chemotherapy Induced Neuropathic
Pain. Sci Rep 9, 20324 (2019). https://doi. org/10.1038/s41598-019-56832-x
48 Elderly Care
Ageing and the Immune System
Age-associated changes in a protein called KLF4 upset the normal daily fluctuations in immune system activity in mice, according to an NIA-supported study at Stanford University and the University of Pennsylvania. This loss of daily variation in the immune response may lower the body’s ability to fight infections. The findings, published in Nature Immunology, help scientists better understand the declining function of the immune system in older adults.
of those adults developing and dying from an infection.
Immune responses that are disrupted, such as by the KLF4 mechanism described in this study, contribute to not only infections but other diseases associated with aging. By identifying the many pathways that control the complex responses of the immune system, researchers can provide clues that may lead to new prevention and treatment approaches for agingrelated conditions.
There are a number of ways in which community pharmacy teams can advise their elderly populations on boosting their immune systems:
Manage stress
Chronic stress can have many negative effects on the body, including lowering the immune response. When under stress, the body increases the production of a hormone called cortisol.
Cortisol helps the body deal with stressful situations. It also limits certain bodily functions that aren’t essential in a fight-orflight situation. This includes the immune system.
The research team sought to find a connection between aging and the immune system by investigating the effects of the body’s biological clocks — called circadian rhythms — on the immune response. These internal clocks, which govern our daily cycles of sleep and activity, influence the activities of the immune system.
First, the team showed that circadian rhythms are involved in the immune response in young mice, but not in older mice. In response to an infection, young mice were more likely to survive when they were infected during the day than when they were infected at night, while for older mice, survival declined no matter whether they were infected during the day or night.
The researchers then looked for the immune cells that may explain this age-related difference. They found that circadian rhythms influenced the normal migration of immune cells into the bloodstream to fight infections in young mice, but not in older mice. The researchers also found that certain immune cells from younger mice are more effective at destroying bacteria during the day than they are at night, while the immune cells from older mice did not show any difference in activity according to the time of day. To find an explanation for the agerelated changes, the researchers focused on a specific protein called KLF4, which is important for many diverse functions in the body, including stimulating immune cell proliferation. Because circadian rhythms influence whether KLF4 from the immune cells is active or inactive, its activity normally fluctuates over the course of the day. However, in immune cells from older mice, KLF4 levels did not change throughout the day.
In the immune cells from young mice, KLF4 controls the normal daily fluctuations of the immune cell function. In mice engineered to lack KLF4, circadian rhythms no longer controlled the immune cell activity. This lack of variation over a 24-hour period in immune cells from young mice that lacked KLF4 resembled what researchers observed previously in immune cells from older mice.
To find out whether KLF4 also plays the same role in humans, the researchers looked at medical data collected from nearly 500,000 people in the UK Biobank. When they compared the full study population to older adults with mutations in the KLF4 gene, they confirmed the connection between KLF4 and the aging-related decline in immune function: The loss of KLF4 function increased the likelihood
Eat a nutrient-dense diet
Eating a balanced, nutrientrich diet is an important way to boost the immune system. This includes eating plenty of fruits and vegetables, which contain nutrients and antioxidants to promote good health.
Many different vitamins and minerals play a role in maintaining the immune system. The best way for people to meet their needs is to eat a variety of foods.
Specific nutrients that play a role in immune health include:
• B vitamins. B vitamins are found in dairy products, grains, meats, eggs, and beans.
Vitamin B12 deficiency is common in older adults.
• Vitamin C. Vitamin C is found in many fruits and vegetables, especially red and orange types and citrus fruits. Most people are able to get enough from food and usually a supplement is not needed.
• Selenium. Selenium is an antioxidant that is found in small amounts in many foods. Sources include nuts, meats, and grains. • Zinc. Zinc is a mineral is found in oysters, cheese, beans, lentils, and beef. Most people are able to get enough from their diet but in special cases, a supplement may be recommended. There is some evidence that a Mediterranean-style diet can support good immune function. A Mediterranean diet can also play a role in helping to prevent and manage chronic diseases.
It’s difficult to live a life that is completely free of stress, so learning how to manage stress when it arises may be the most helpful option.
Get plenty of sleep
Quality sleep becomes more important with age. Getting enough sleep can improve brain function, concentration, and memory.
Conversely, sleep deprivation can cause a multitude of issues, like reducing the effectivenessTrusted Source of the immune system.
Spend time outdoors
Being outside has so many benefits for health. Many people find that time in nature helps to reduce their stress. Another bonus of outdoor time is vitamin D from moderate sun exposure.
Vitamin D helps strengthen the immune system. When your vitamin D levels are adequate, they may help prevent inflammation and some autoimmune diseases.
A 2017 reviewTrusted Source suggests vitamin D may also help prevent certain infections. When more than 11,000 people were analyzed, researchers found that those who supplemented vitamin D had fewer respiratory infections.
50 Elderly Care: Vaccinations
Vaccinations in Older Adults
As vaccination of the population against SARS-CoV-2 infection began, it was critically important that lessons from previous vaccination programmes among older adults were used to inform current efforts.
To assist this, researchers at The Irish Longitudinal Study on Ageing (TILDA), at Trinity College Dublin, rapidly produced a report that provides key information on influenza (flu) vaccine uptake and health behaviours which govern vaccine efficacy, while addressing important considerations and opportunities for government and the HSE ahead of the Covid-19 vaccine rollout for older adults.
The report analyses data from TILDA participants between 2016 and 2019, outlining the prevalence of flu vaccination in this cohort and levels of physical activity among those who received the flu vaccine, and provides a review of the scientific evidence showing the positive effects of prolonged physical activity on vaccine efficacy. The report also provides key information on news sources accessed by TILDA participants during the Covid-19 pandemic and the levels of trust in these sources among those surveyed. It shows that 65% of TILDA participants accessed information via national radio channels, 43% accessed information via national newspapers, and very few (6-7%) older adults accessed public health information through government websites. This is an important consideration when communicating messaging on the vaccine.
Considerations for efficacy of vaccines in older adults
Vaccine efficacy in older adults can be a challenge due to the effects of ageing on the immune system. As people age, the ability to produce robust antibody responses following vaccination declines, with older adults less likely to generate the long-term protection often required for full immunity to a virus. Research shows that exercise can help to boost antibody responses in older adults. TILDA’s report outlines how prolonged, regular aerobic or moderate exercise in the weeks and months prior to vaccination can help to improve antibody responses post vaccination in older adults.
Key Findings:
• 59% of adults aged over 60 had an annual flu vaccination between 2016 and 2019.
• More older persons received the vaccine: 40% aged 60-69 compared with 76% aged 70 and older.
• Of those living with others, 49% are least lonely, 30% sometimes and 21% often lonely. • The report provides evidence on the positive effect of prolonged physical activity on boosting antibody responses following vaccinations in older adults.
This is important information given that adults are less likely to mount robust antibody responses following vaccination; 44% of adults aged over 60 in Ireland do less than the recommended level of physical activity for cardiovascular health and for enhanced immunity and vaccination responsiveness. • It is recommended that adults aged 60 and older should consistently incorporate some form of aerobic exercise such as a brisk walk at least 2 – 3 times per week in the weeks and months prior to vaccination. • Public health campaigns should specifically target groups that are less likely to meet minimum recommended physical activity levels: that is, women; adults aged 75+; individuals with a primary level of education or none; and those who live in urban areas.
• It is important that information on a vaccine for the COVID-19 virus is communicated via trusted news sources where adults aged over 60 might access information on a vaccine.
Covid-19 Vaccines
Coronavirus (Covid-19) is a respiratory disease that causes symptoms such as fever, cough, and shortness of breath. It can lead to serious illness and death. Studies show that Covid-19 vaccines are effective at keeping people from getting Covid-19. People over 65 are at the highest risk of serious illness from COVID-19 if they have not been vaccinated.
A booster dose is recommended to extend the protection of COVID-19 vaccines. It is not yet known how long immunity will last after getting a booster. Trials are currently underway to learn more about this.
Flu Vaccines
Everyone aged 6 months and older should get an annual flu vaccine, but the protection from a flu vaccine can lessen with time, especially in older adults. However older adults are less likely to become seriously ill or hospitalized because of the flu if they get the vaccine. Flu vaccines are especially important for those with a chronic health condition such as heart disease or diabetes.
Older adults should be advised to get their vaccine ideally by the end of October each year so they are protected when the flu season starts. It takes at least two weeks for the vaccine to be effective. However, if they have not received their flu vaccine by the end of October, it’s not too late as flu season typically peaks in December or January.
Those over 65 in Ireland will be offered the adjuvanted Quadrivalent Influenza Vaccine (aQIV). It’s also known by the brand name Fluad Tetra. This is a 1 dose vaccine.
Tetanus, diphtheria, and pertussis (whooping cough) vaccines
Tetanus, diphtheria, and pertussis are serious diseases that can lead to death.
• Tetanus (sometimes called lockjaw) is caused by bacteria found in soil, dust, and manure.
It enters the body through cuts in the skin.
• Diphtheria, also caused by bacteria, is a serious illness that can affect the tonsils, throat, nose, or skin. It can spread from person to person.
• Pertussis, also known as whooping cough, is caused by bacteria. It is a serious illness that causes uncontrollable, violent coughing fits that make it hard to breathe. It can spread from person to person.
Getting vaccinated is the best way to prevent tetanus, diphtheria, and pertussis. Most people get vaccinated as children, but will need booster shots as they get older to stay best protected against these diseases.
Shingles Vaccine
Shingles is caused by the same virus as chickenpox. For those who have had chickenpox, the virus is still in their body. The virus could become active again and cause shingles.
Shingles affects the nerves. Common symptoms include burning, shooting pain, tingling, and/or itching, as well as a rash with fluid-filled blisters. Even when the rash disappears, the pain can remain. This is called post-herpetic neuralgia, or PHN. Of the 95% of adults who’ve had chickenpox, around a quarter will go on to develop shingles – and it’s more likely to happen as they get older. It can be reactivated when the immune system weakens due to increasing age, stress, or certain conditions and treatments e.g. cancer or HIV.
The shingles vaccine is safe and it may keep you from getting shingles and PHN. Healthy adults age 50 and older should get vaccinated with the shingles vaccine. There are two shingles vaccines currently available in Ireland, one is a live vaccine called Zostavax (given as one dose) and the other is a recombinant vaccine called Shingrix (given as a two dose).
YOUR PATIENTS AGED 50 YEARS OF AGE OR OLDER ARE AT INCREASED RISK OF DEVELOPING SHINGLES.1 YOU CAN PREVENT IT.2,3
SHINGRIX demonstrated >90% efficacy against shingles in all age groups aged 50 years of age or older, based on pooled data from two large, phase 3 randomised control trials.2,3
SHINGRIX IS NOW AVAILABLE
For more information on SHINGRIX, please scan the QR code.
Shingrix powder and suspension for injection in vials (Please refer to SmPC before prescribing) Composition: After reconstitution, one dose (0.5 mL) contains: Varicella Zoster Virus glycoprotein E antigen1,2 50 micrograms. (1 adjuvanted with AS01B containing: plant extract Quillaja saponaria Molina, fraction 21 (QS-21) 50 micrograms, 3-O-desacyl-4’-monophosphoryl lipid A (MPL) from Salmonella minnesota 50 micrograms, 2 glycoprotein E (gE) produced in Chinese Hamster Ovary (CHO) cells by recombinant DNA technology). Therapeutic indications: Prevention of herpes zoster (HZ) and post-herpetic neuralgia (PHN) in adults 50 years of age or older and in adults 18 years of age or older at increased risk of HZ. The use of this vaccine should be in accordance with official recommendations. Posology and method of administration: For intramuscular injection only, preferably in the deltoid muscle. Primary Vaccination: Initial dose of 0.5 ml followed by a second 0.5 ml dose 2 months later. For flexibility the 2nd dose can be administered between 2 and 6 months after the first dose. For subjects who are or might become immunodeficient or immunosuppressed and whom would benefit from a shorter vaccination schedule, the 2nd dose can be given 1 to 2 months after the initial dose. Booster doses: need not established. Contraindications: Hypersensitivity to the active substances or any of the excipients. Special warnings and precautions for use: The name and the batch number of the administered product should be clearly recorded. Appropriate medical treatment and supervision should be readily available in case of an anaphylactic event. Administration of Shingrix should be postponed in subjects suffering from an acute severe febrile illness. However, the presence of a minor infection, such as cold, should not result in deferral. A protective immune response may not be elicited in all vaccinees. Never administer intravascularly or intradermally; subcutaneous administration not recommended as it may lead to an increase in transient local reactions. Caution in individuals with thrombocytopenia or any coagulation disorder since bleeding may occur following intramuscular administration. Syncope can occur following, or before any vaccination as a psychogenic response. This can be accompanied by several neurological signs such as transient visual disturbance, paraesthesia and tonic-clonic limb movements during recovery. It is important that procedures are in place to avoid injury from faints. There are no data to support replacing a dose of Shingrix with another HZ vaccine. There are limited data to support the use of Shingrix in individuals with a history of HZ and in frail individuals including those with multiple comorbidities. The benefits and risks of HZ vaccination should be weighed on an individual basis. Interactions: Shingrix can be given concomitantly with unadjuvanted inactivated seasonal influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPV23) or reduced antigen diphtheriatetanusacellular pertussis vaccine (dTpa). The vaccines should be administered at different injection sites. Fertility, pregnancy and lactation: There were no effects on male or female fertility in animal studies. It is preferable to avoid the use of Shingrix during pregnancy. The effect on breast-fed infants of administration of Shingrix to their mothers has not been studied. It is unknown whether Shingrix is excreted in human milk. Effects on ability to drive and use machines: Shingrix may have a minor influence on the ability to drive and use machines in the 2-3 days following vaccination. Undesirable effects: Very common (≥1/10): Headache, GIT symptoms, myalgia, injection site reactions, fatigue, chills, fever. Common (≥1/100 to <1/10): injection site pruritus, malaise. Uncommon (≥1/1000 to <1/100): lymphadenopathy, arthralgia. Rare (≥1/1000 to <1/100): Hypersensitivity reactions. Legal Category: POM A. Marketing Authorisation Number: EU/1/18/1272/001. Marketing Authorisation Holder: GlaxoSmithKline Biologicals S.A., Rue de l’institut 89, B-1330 Rixensart, Belgium. Further information is available from GlaxoSmithKline (Ireland) Ltd. 12 Riverwalk, Citywest Business Campus, Dublin 24. Telephone: 01-4955000. Code: PI-7757. Date of preparation: March 2021.
Adverse events should be reported directly to the Health Products Regulatory Authority (HPRA) on their website: www.hpra.ie. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.
References : 1. Gauthier et al. Epidemiology and costs of herpes zoster and postherpetic neuralgia in the United Kingdom. Epidemiol infecti. 2009 137 38-47. 2. Lal H et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015; 372(22):2087-96. 3. Cunningham AL et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016; 375(11):1019-32.
52 Elderly Care: Dementia
Health Economists Global Brain Health Institute (GBHI) Faculty Dominic Trépel and Atlantic Fellow for Equity in Brain Health Sanjib Saha share findings from recent research examining the health care costs of dementia.
Health care costs of dementia before, during and after diagnosis
Increasingly severe cognitive, behavioural, or motor symptoms due to the dysfunction and death of the brain’s nerve cells are the hallmarks of the diseases that cause dementia. There is no cure and, therefore, patients with Alzheimer’s disease, vascular dementia, or other dementias have a growing need for care as the disease progresses. With populations around the world ageing, the number of people experiencing dementia is increasing and so the associated global costs following diagnosis is assumed to be tending towards $2 trillion, thus creating major societal challenges and economic pressure to provide high quality care.
In this respect, researchers at the Global Brain Health Institute (GBHI) at Trinity College, undertook a new study in collaboration with the Health Economics Unit of Lund University in Sweden, which has revealed previously unknown aspects of how health care costs develop over the course of the disease. Curiously, health care costs were significantly higher as early as 10 years before dementia diagnosis. And, while care costs increased, and indeed doubled, at diagnosis, this new research challenges existing assumptions about the economic implications of dementia as a few years after diagnosis, costs drop to the same, or even lower, levels than in those without dementia. This raises real equity concerns for people living with dementia. For example, do people with dementia receive the health care they need as things get more difficult, or have our systems developed a tendency to displace the burden of care on others?
This register-based study, published in the journal Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, examines the full population of people living with dementia in Region Skåne in southern Sweden. These 21,184 people were first identified as having a dementia diagnosis between 2010 and 2016. The research insights were made possible as individuals registered in Sweden’s national dementia registry can be linked to routinely collected healthcare data such as from primary healthcare, inpatient, and outpatient care. These data enabled the research team to examine individuals living with dementia over a 17-year period, including the year of diagnosis, 10 years before, and 6 years after diagnosis.
Dr Dominic Trepél, Assistant Professor of Health Economics at the School of Medicine at Trinity and the Global Brain Health Institute (Trinity and UCSF), said, “Our results support the brain health hypothesis that policy should take a life-course view in reducing the risk of dementia and support the growing idea that policymakers should allocate resources to reduce dementia risk factors, in line with highlevel recommendations from the Lancet Commission on Dementia Prevention, Intervention and Care.”
Dominic Trépel
What is driving dementia health care costs?
The team is now undertaking further research, using stateof-the-art statistics methods, to explore what is driving the excess health care costs before diagnosis and why the marginal cost is lower in the subsequent years after diagnosis. For example, is the drop in health expenditure after diagnosis due to the initiation of treatments and social care provided by the municipalities, which substitutes for the need for health care? And if so, are costs being appropriately displaced onto social care, or onto families? And, could the initial increases in cost at diagnosis be related to difficulty in getting a definitive dementia diagnosis?
In conclusion, the findings suggest that people living with dementia have significantly higher costs compared to their counterparts long before the official diagnosis of dementia. To improve quality of life and to reduce the associated economic burden experienced by people living with dementia and their carers, this work mandates that future policies on brain health must: (1) be fit for purpose, and; (2) support timely identification of dementia, or indeed earlier changes in brain health.
The study was conducted at the Health Economics Unit, Department of Clinical Sciences, Malmö, Lund University, based on collaborative funding from Region Skåne and seven municipalities (Burlöv, Båstad, Lomma, Simrishamn, Vellinge, Eslöv and Örkelljunga municipalities), in collaboration with the Global Brain Health Institute and the Clinical Memory Research Unit at Lund University.
Key Facts About Dementia
• There are 64,000 people with dementia in Ireland and the number of people with the condition will more than double in the next 25 years to over 150,000 by 2045.* • Dementia is an umbrella term used to describe a range of conditions which cause changes and damage to the brain.
• Dementia is progressive.
There is currently no cure.
Dementia is not simply a health issue but a social issue that requires a community response. • The majority of people with dementia (63%) live at home in the community. Over 180,000 people in Ireland are currently or have been carers for a family member or partner with dementia with many more providing support and care in other ways. • There are 11,000 new cases of dementia in Ireland each year. That’s at least 30 people every day and anyone can get dementia – even people in their 30s/40s/50s.**
• 1 in 10 people diagnosed with dementia in Ireland are under 65.
• The overall cost of dementia care in Ireland is just over ¤1.69 billion per annum; 48% of this is attributable to family care; 43% is accounted for by residential care; formal health and social care services contribute only 9% to the total cost.
Figures referenced to Cahill, S. & Pierce, M. (2013) The Prevalence of Dementia in Ireland
*Figure referenced from Alzheimer Europe (2020) Dementia in Europe Yearbook 2019 ‘Estimating the prevalence of dementia in Europe’ **Figure referenced from Pierce, T., O’Shea, E. and Carney P. (2018) Estimates of the prevalence, incidence and severity of dementia in Ireland.
