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Dementia

Dementia. Leslie Chang Evertson, GNP Lead Dementia Care Manager UCLA Alzheimer’s and Dementia Care Program. DISCLOSURES None of the faculty, planners, speakers, providers nor CME committee has any relevant financial relationships with commercial interest

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Dementia

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  1. Dementia Leslie Chang Evertson, GNPLead Dementia Care Manager UCLA Alzheimer’s and Dementia Care Program

  2. DISCLOSURES None of the faculty, planners, speakers, providers nor CME committee has any relevant financial relationships with commercial interest There is no commercial support for this CME activity

  3. Overview • Prevalence • What is dementia? • Diagnosis • Causes • Management

  4. Prevalence of Dementia Age Range% Affected 65-74 5% 75-84 15-25% 85 and older 36-50% US: ~5.4 million with Alzheimer’s (2013) > 13 million by 2050 World wide: ~35 million with Alzheimer’s(2013) >115 million by 2050

  5. Dementia Definition • DSM-IV • Multiple cognitive deficits • Memory loss must be present • One or more other deficit – aphasia (communication), apraxia (motor execution), agnosia (recognition) , executive functions (synthesis) • Decline from prior level of function • Deficits do not occur exclusively in the presence of delirium • DSM-V: • Memory loss not necessary • Major Neurocognitive Disorder (NCD) vs. Minor NCD

  6. DSM-V Definitions • Major neurocognitive disorder (major NCD or dementia) • Minor neurocognitive disorder (minor NCD) • Either can be further characterized by cause • Alzheimer’s disease • FTD • LBD • Parkinson’s disease

  7. Not Dementia - Delirium • Acute confusion or delirium in the setting of a medical illness • Often occurs in the hospital • Frequently caused by medications • Usually resolves (days to weeks) • Many cases are probably preventable • Confusion Assessment Method (CAM)

  8. Not Dementia - Depression • Depression • Sad and withdrawn/anxiety • Concentration impaired • Memory complaints prominent • Orientation intact • Sometimes called “Pseudodementia” • Geriatric Depression Scale or PHQ-9

  9. Not Dementia - MCI • Mild cognitive impairment • Cognitive complaint • Objective impairment in 1+ domains • Amnestic • Non-amnestic • General function intact • 6-15% per year progress to dementia

  10. Amnestic MCI • Prominent memory complaint • Objective memory loss (1.5 SD below age norms); other cognition intact • May be single or multiple domains

  11. Non-amnestic MCI • Primarily affects other domains (executive, language, visual spatial) • May be single or multiple domains • May be less likely to progress to dementia

  12. Not Dementia – Normal aging • Patient more concerned than family • Can describe details of forgetfulness • Intact recent memory for important events • Word finding difficulties • Function preserved

  13. Diagnosing Dementia • Screening (raises suspicion) • 3 item recall • Mini-Cog (3 item recall plus clock drawing) • GPCOG (GP Assessment of Cognition) • MIS (Memory Impairment Screen) • MMSE, MOCA, and others • Screening tests identify more than 90% with dementia but do not establish a diagnosis

  14. Diagnosing Dementia • Clinician’s examination (usually PCP or Neurologist) • Mental Status Examination • Physical Examination • Psychosocial Examination • Caregiver/Collateral input • Neuropsychological testing • Lab and imaging tests to exclude medical conditions that might be contributing • Imaging: Structural MRI and/or Functional PET scan • Labs: CBC, CMP, TSH, Vitamin B12 • RPR & HIV if risk factors are present

  15. Neuroimaging • Most useful if: • Age of onset< 60 year • Focal neuro deficits • Abrupt onset or rapid decline • Predisposing conditions (e.g. cancer, anticoagulation) • AAN: either CT or MRI • PET: approved to distinguish AD from FTD • Amyloid PET scans: for research purposes only

  16. Causes of Dementia • Alzheimer’s Disease 60-80% • Vascular dementia 10-20% • Dementia with Lewy bodies 15% • Frontotemporal dementia 5% • Toxic-metabolic disorders 4% • Other movement disorders 6%

  17. Dementia Risk Factors • Factors that increase risk • Age -CV Risk factors • Family history -Head trauma • APOE-E4 -CKD • Depression • Factors that reduce risk (variable evidence) • APOE-E2 • Mediterranean-type diet (fruits, veggies, fish) • Higher physical activity/exercise • Mental activity

  18. Alzheimer’s Disease-Clinical • Memory • Language • Visual-spatial • Higher level (executive) • Apathy

  19. Alzheimer’s Disease: 2011 • 3 stages • Preclinical: defined by changes in biomarkers • MCI: biomarkers may help determine progression to AD • Alzheimer’s Disease: biomarkers may be helpful in excluding AD as cause

  20. Framework for Biomarkers • Measures Related to Molecular Pathology of Abeta • CSF Aβ42 • Amyloid Imaging – PiB, AV-45 • Measures Related to Neuronal Injury • CSF tau/phopho tau • MRI measures structural change • Hippocampal Volume • Medial Temporal Lobe Atrophy • PET or SPECT measures of functional change • FDG PET – temporoparietal topographic pattern • SPECT Perfusion – temporoparietal topographic pattern

  21. Diagnosing Dementia - Imaging • Amyloid PET Scan Imaging

  22. Natural History and Complications • Progression of cognitive decline • 3-4 points on MMSE/year • Non-cognitive symptoms • Psychotic symptoms (20%) • Depressive symptoms (40%) • Agitation or aggression (80%) • AD survival after symptom onset 3-12 yrs; other dementias have worse survival

  23. Clinical Characteristics of FTD • Personality changes • Executive dysfunction • Social disinhibition • Behavioral impulsivity • Hyperorality • Pick’s disease: • a rapidly-progressive form of FTD • Pick’s bodies (balloon-like intracellular inclusions) can be seen on autopsy

  24. FTD versus AD • Gradual but faster onset than AD • Younger age of onset than AD • Age of onset < 60 years usually • Memory and gait impairment later and not as pronounced as with AD • Relative preservation of visual-spatial skills

  25. Clinical Characteristics of LBD • Core features: • Visual hallucinations (VH) • Parkinsonian signs • Fluctuating alertness and attention • Suggestive features: • REM sleep disorder • Sensitivity to antipsychotic medications and extrapyramidal side effects (EPS) • Supportive features: • Frequent falls • Syncope • Autonomic dysfunction • Delusions

  26. LBD Versus Other Dementias • LBD versus AD • Motor deficits are more prominent in LBD early in the course • Memory deficits are more prominent in AD • LBD versus dementia associated with Parkinson’s disease (PD) • Motor and memory deficits tend to arise together within a year in LBD • Motor deficits arise first in PD; memory impairment is a later finding

  27. Clinical Characteristics of Vascular Dementia • Abrupt onset (may not be present) • Stepwise deterioration (may not be present) • Cognitive symptoms and motor signs correlate with ischemia on neuroimaging • Prominent aphasia is common • Patients tend to have CVA risk factors

  28. Mild Dementia (MMSE 21-25)

  29. Moderate Dementia (MMSE 11-20)

  30. Severe Dementia (MMSE 0-10)

  31. Alzheimer’s Disease: A Two-Phase Strategy

  32. Management • Manage the disease • Cholinesterase inhibitors • Memantine • Vitamin E • Manage the patient • Manage co-morbidities • Caregiver support • Behavioral therapies • Drug management of complications • Advanced planning

  33. Manage the Disease • Cholinesterase inhibitors • Donepezil (Aricept), • galantamine (Razadyne) • rivastigmine (Exelon) • May benefit Alzheimer’s Disease, LBD, Vascular (if also Alzheimer’s), and PD dementia • Do not benefit FTD • Do not prevent progression of MCI to dementia

  34. Effectiveness of Cholinesterase Inhibitors • Most often drug slows progression • 10-25% of patients improve • Behavioral symptoms may improve • Some decline rapidly when drug discontinued

  35. Memantine • Memantine (Namenda) • Slows rate of functional and cognitive decline and improves behavioral symptoms • FDA indication for moderate-severe AD • Not effective in mild-moderate disease

  36. Memantine plus Cholinesterase Inhibitor • Early studies showed better outcomes (cognition, activities of daily living, global outcome, and behavior) than cholinesterase inhibitor alone in moderate to severe dementia • But more recent studies have cast doubt on whether the combination is more effective

  37. Vitamin E • Mixed results in trials • TEAM-AD VA Cooperative Trial • Mild-to-moderate dementia (MMSE 12-26) • 4 arms (Vit E 2000 IU, memantine, both, none) • Vit E slower rate of decline (19% per year) • No benefit from memantine • 42% did not complete the study • Jama 2014; 311:33-44.

  38. Not Beneficial • Vitamin B6, B12, or folate • Gingko biloba • Hormones (testosterone, estrogen) • Statins • Aspirin or other NSAIDs • Vaccines • Anti-amyloid treatment

  39. Manage the Patient • This is a lifelong disease • Play the ball where it lies • If disease is early, include patient • If late, rely on family and caregiver • Aim for the highest level of independence that works for everyone • Manage hot-button issues (e.g., driving) • Manage other diseases • Manage symptoms

  40. Caregiver Support • Caregivers are the most important resource a demented patient has • Over 50% develop depression • The more knowledgeable and more empowered the caregiver is, the better care the patient will receive • Caregiver resources are available • Alzheimer’s Association and other community resources • Counseling, Support Groups • Respite – Hiring a help, Adult Day, placement

  41. Management of behavioral and psychological complications • With medications: • Antidepressants • Citalopram 30 mg for agitation • Reduced agitation • Worsened MMSE scores • Increased QTc • JAMA 2014;311:682-91

  42. Management of behavioral and psychological complications • Antipsychotics (e.g., risperadone, quetiapine, olanzapine) • Not very effective • Have potential for side effects • Some patients benefit • Mood stabilizing medications (e.g., valproate) • Dextromethorphan/quinidine • JAMA 2015 Sep 22-29;314(12):1242-54

  43. Behavioral Modifications • Reorient – Explain to the patient where he or she is and why he or she is there. Be sure to introduce yourself and speak in a confident yet reassuring tone. It is not always important to remind or correct the patient of the date, your specific title, etc.

  44. Behavioral Modifications • Redirect – Divert attention by asking an unrelated question, ask the patient to help you with an activity or offer to take the patient for a walk.

  45. Behavioral Modifications • Identify triggers – Did the patient become agitated during a bath? Medication? When he is in pain? Male or female caregivers? Daytime or nighttime? Family members?

  46. Behavioral Modifications • Create a calm environment – This is difficult to do in a hospital setting. Perhaps the patient shares a room with another patient who has a lot of visitors or doctors; this can be anxiety producing. Avoid loud television, harsh lights, alarms, etc.

  47. Behavioral Modifications • Offer a guess – Patients with dementia often cannot tell you what is bothering them. If they cannot find a word, offer some limited suggestions, don’t try to correct them. Try to avoid arguing with them.

  48. Behavioral Modifications • Supervise – For some patients, memory impairment may be so severe, none of these interventions last but a minute or two. For these patients, sitters should be employed if possible before using sedation medications. http://www.alz.org • http://dementia.uclahealth.org/body.cfm?id=68

  49. And more to consider… • Non-pharmacological behavioral modifications • Caregiver stress and strain • Financial resources • Legal concerns • Insurance coverage (Private insurance, Medicare, Medi-Cal, LTCi) • Private caregiving • Adult Day Care • Support groups • Assisted Livings • Nursing Homes • Unbefriended • Elder abuse

  50. Conclusions • Dementia is an epidemic, particularly among the oldest old • Many diseases have symptoms of dementia but are not dementia • History taking and mental status exam are still critical elements of diagnosis • Diagnostic testing is generally confirmatory but occasionally some surprises

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