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Verslun kvennadeildar Rauða kross Íslands í Kringlunni á Landspítala Hringbraut

Memory Clinic 

 Department of Geriatrics
 Landspitali University Hospital
 Reykjavik Iceland

 Address: Landakot; Tungata 26;101 Reykjavik; Iceland
 Tel.:
+354 543 9900
 E-mail: 
9900@landspitali.is
 Headed by: 
Gudny Valgeirsdottir head nurse, Jon Snaedal professor

 

Background

The Memory Clinic in Reykjavik was established in 1995 and is the bigger of two memory clinics in the country, the other being in Akureyri in the northern part. In the first two years the capacity was limited but it has gained momentum and currently, around 400 new patients are evaluated each year and the total number of visits is approximately 1,300 annually.

Clinical work

Staff. The main role has been clinical service in diagnosing causes of cognitive impairment and to give treatment and support to patients and families. Most referrals arrive from general practitioners. The team at the Memory Clinic includes geriatricians, nurses, social workers, psychologists (neuropsychologists and geriatric psychologists) and occupational therapists. The primary team consists of a geriatrician and a nurse but other professionals attend to the patients on the basis of internal referrals.

The first visit. The waiting time for the first visit is typically 2 to 4 months with some means to see urgent cases more quickly. The patient attends with a next of kin and is interviewed by a doctor and a nurse who subsequently become their contact person. A thorough physical examination is carried out and short cognitive tests applied. Subsequently, a decision is made if the case needs further investigation, which most frequently is the case.

Diagnostic investigations:

  • Biochemistry (in all patients)
  • Neuropsychological evaluation (in mild cognitive impairment (MCI) or mild dementia)
  • Magnetic resonance imaging (MRI) or in some cases computerized tomography (CT) of the brain if MRI is contraindicated
  • Electroencephalography (EEG) with statistical pattern evaluation (see later)
  • Cerebrospinal fluid (CSF) with beta-amyloid and tau analyses
  • Other rarer investigations (single-photon emission computet tomography (SPECT) scanning, dopamine transporter (DaT) scanning, conventional EEG, cerebro-vascular investigations etc.

Positron-emission tomography (PET) is being set up, supposed to be up and running in Q2-2018.

Second visit. After completing the diagnostic procedure the patient and their next of kin come for the second visit. They are seen by the same doctor and nurse as in the first visit. The result is provided and a therapeutic plan is made. If the diagnosis is Alzheimer´s disease (AD), the diagnosis is revealed to the patient and their next of kin and routinely a treatment with a cholinesterase blocker is initiated, if a contraindication is not present. The same applies in the case of Lewy body dementia. In other degenerative brain disorder there is no specific medical treatment but if the diagnosis is vascular dementia, the patients’ atherogenic risk factors are scrutinized and appropriate therapy is initiated.

Follow up. Follow up is primarily for the younger patients and for more complicated cases. Others are referred back to their GP after treatment with cholinesterase inhibitors has been initiated. The intention is to have the same primary team for follow up as primarily and until the patient reaches the next step which typically is a special day care center. 

Research

Even though the primary role of the Memory Clinic is clinical work, research has increasingly been conducted from the beginning of this century. Currently, these projects are ongoing:

  1. Genetics of Alzheimer´s disease. Initiated in 1998 in collaboration with DeCode Genetics in Reykjavik. Major publications in Nature (first protective gene in Alzheimer´s disease, sometimes referred to as the Icelandic mutation)1 and in New England Journal of Medicine (TREM 2)2. The project is still ongoing and serves now as a basis for an intervention study using a Bace 1 inhibitor (see part 7)
  2. EEG project, in collaboration with the RDC Mentis Cura in Reykjavik using a novel technique of statistical pattern recognition = SPR3,4. Initiated in 2004 and still ongoing, currently focusing on MCI and Lewy body dementia
  3. Nordic studies 1 & 2 (NORD-EEG and NORD-MCI), multicenter studies in six sites in four Nordic countries validating the EEG as a diagnostic marker for diagnosis of causes of cognitive impairment5,6, and as prognostic marker in MCI (ongoing)
  4. Prospective MCI study. Started in 2014 and is planned to continue for the next years. More than 200 patients included. Multilevel aim on various diagnostic methods (EEG, biomarkers in CSF, oxygen saturation in retina etc.). The study involves a PhD project
  5. The cholinergic EEG study. A cholinergic marker in EEG is evaluated for prognosis of response of cholinesterase inhibitors. Inclusion phase is over. Results are expected in Q3 in 2018
  6. Families of AD patients. A qualitative, longitudinal PhD study on families of AD patients with focus on quality of life and service, specially of special day care centres for individuals with dementia. Started in 2017, ongoing to 2020.
  7. The European Dementia of Lewy body study. One site of more than 30 in Europe. Participation in the retrospective part has been concluded and a prospective project is being initiated
  8. Pharmacological study on a Bace 1inhibitor. In collaboration with Novartis, Amgen and Banner Alzheimer Institute. A multicenter, international study at 135 sites. The Reykjavik site is far the biggest as it is planned to include 10% of the total cohort (200 out of 2000). Screening started in February 2018, inclusion is due to end on 28. February 2019 and the total project will be ongoing until 2024.


References

1.Jonsson et al Nature 2012;488:96-99
2.Jonsson et al . New England Journal of Medicine 2013;368:107-116
3.Snaedal et al. Dementia and Geriatric Cognitive Disorders 2012;34:51-60.
4.Johannsson et al. Dementia and Geriatric Cognitive Disorders 2015; 39:132-142.
5.Engedal et al. Dementia and Geriatric Cognitive Disorders 2015;40:1-12
6.Ferreira et al. Dementia and Geriatric Cognitive Disorders 2016;42:80-92

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