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MANAGEMENT OF DEMENTIA

MANAGEMENT OF DEMENTIA. Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry Section Bay Pines VA Medical Center. DEMENTIA. Affects 10% of Americans over 65 Fourth most common cause of death

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MANAGEMENT OF DEMENTIA

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  1. MANAGEMENT OF DEMENTIA Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry Section Bay Pines VA Medical Center

  2. DEMENTIA • Affects 10% of Americans over 65 • Fourth most common cause of death • Only 10% of cases are reversible or arrestable

  3. DEMENTIA: BEHAVIORAL PROBLEMS • Present in 80% of cases • Major source of caregiver stress, institutionalization • Common at all stages of the disease • Much more treatable than the underlying dementia • Poorly described in the literature

  4. THE DEMENTIA WORKUP • Thorough history • Physical examination • Mental status examination • Blood work • Neuroimaging study

  5. 70% degenerative dementia • 20% vascular dementia • 10% other

  6. POSTROLANDIC Memory deficits Aphasia Apraxia Agnosia Personality preserved MMSE valid FRONTAL/SUBCORTICAL Memory deficits Loss of goal-oriented behavior, behavioral plasticity Personality changes Disinhibition Abulia Incontinence MMSE useless TWO TYPES OF DEMENTIA

  7. FRONTAL/SUBCORTICAL CIRCUITS Frontal cortex Subcortical white matter Striatum Pallidum Thalamus

  8. THREE SYNDROMES • Loss of goal-oriented behavior (dorsolateral prefrontal circuit) • Abulia (anterior cingulate circuit) • Disinhibition (orbitofrontal circuit)

  9. Don’t miss this one:

  10. DIFFUSE LEWY BODY DISEASE • Postrolandic dementia • More rapidly progressive than AD • Fluctuation, episodes of “pseudodelirium” common • Mild parkinsonism • Tremor often absent • Poor response to antiparkinsonian meds • Shy-Drager sx’s common • Prominent psychotic sx’s, esp visual hallucinations • SEVERE NEUROLEPTIC INTOLERANCE

  11. NEUROLEPTICS AND DLBD • Most patients have severe reactions to neuroleptics, including severe akinesia, dystonias and NMS-like syndromes • Increases LOS in 81%; reduces lifespan in 50% (McKeith et al, 1992) • Doubles rate of cognitive decline (McShane et al, 1997) • A severe, unexpected reaction to low-dose neuroleptics is highly suggestive of DLBD

  12. MEDICATIONS FOR ALZHEIMER’S DISEASE • Donepezil • Rivastigmine • Galantamine • Memantine

  13. A TYPICAL STUDY 3 2.5 2 1.5 1 0.5 Drug X net change in MMSE 0 Placebo -0.5 -1 -1.5 -2 -2.5 -3 0 12 24 36 52 60 study week

  14. As it appears in the paper The whole story 32 70 31.5 60 31 50 30.5 30 40 Drug X Drug X 29.5 Placebo Placebo ADAS-cog score ADAS-cog score 30 29 28.5 20 28 10 27.5 27 0 0 14 0 14 weeks weeks BEWARE! Effect of 14 weeks drug X treatment in mild or moderately severe Alzheimer’s disease

  15. MANAGEMENT

  16. OTHER MEDS WOOF.

  17. THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes one) WHEN IN DOUBT, GET RID OF MEDICATIONS!

  18. THREE BASIC PRINCIPLES • STRUCTURE • LIMITED GOALS • THE “NO-FAIL” ENVIRONMENT

  19. “THE CUSTOMER IS ALWAYS RIGHT!”

  20. SOME “NO-FAIL” TECHNIQUES • Remove challenges from the environment • Don’t correct unless absolutelynecessary • Distract, change the subject • Always help the patient save face • The “universal mistake” technique • Validation therapy

  21. DEPRESSION • 15-30% incidence in Alzheimer’s disease • Often early in the course of the illness • Sometimes previous personal or family history of depression • Most important treatable cause of excess disability • Responds very well to treatment

  22. TYPICAL SYMPTOMS OF DEPRESSION • Mood symptoms • “Cognitive” symptoms • Vegetative symptoms

  23. OTHER POSSIBLE SYMPTOMS OF DEPRESSION • Anxiety • Fearfulness • Somatization • Excessive complaining, requests for help (Kunik et al, 1999) • “Personality change” • Screaming (Greenwald et al, 1986; Cohen-Mansfield et al, 1990)

  24. DEPRESSION: TREATMENT • Selective serotonin reuptake inhibitors • Tricyclics • Other agents • ECT

  25. AGITATION • Present in 40-80% of patients • Up to 34% of patients are combative • Few predictors • It is unusual for medications to be dramatically effective

  26. ACUTE BEHAVIOR CHANGE • I atrogenic • I nfection • I llness • I njury • I mpaction • I nconsistency • I s the patient depressed?

  27. “SUNDOWNING” • 4 PM • 2 AM

  28. MANAGING SLEEP DISTURBANCE • Increase time cues (“Zeitgebers”) • Aerobic exercise • Restrict caffeine and alcohol • Restrict naps • Manage incontinence, pain • Keep the room cool and quiet • Don’t forget the night-light • Hypnotics (NOT ANTIHISTAMINES!)

  29. CATASTROPHIC REACTIONS • “A substantive emotional reaction precipitated by task failure.” (Goldstein, 1952) • Responds well to a “no-fail” environment, but not really to meds

  30. RESISTIVENESS • Common in patients with severe dementia or frontal/subcortical disease • LIMIT GOALS • Slow, gentle approach • “As soon as we do this, I’ll leave you alone.” • Premedication with lorazepam may help

  31. PSYCHOTIC SYMPTOMS IN DEMENTIA • 50% incidence, esp. in moderate dementia • Includes: • Delusions (usu. theft, jealousy or “living in the past”) • Hallucinations (usu. “phantom boarder”) • Reduplicative paramnesia • Misidentification of mirror, TV, etc. • MEDS ARE OFTEN NOT NEEDED

  32. MANAGING PSYCHOSIS • Rule out acute decompensation • Is it really a psychosis? • Is treatment really necessary? • Try non-pharmacologic techniques first • Try to stick to low-dose atypicals (mainly for delusions); don’t use anticholinergics • Goals of therapy are quite modest • Try to dechallenge neuroleptics every three months

  33. COMMON SIDE-EFFECTS OF TYPICAL NEUROLEPTICS • Parkinsonian symptoms • Akathisia • Neuroleptic malignant syndrome • Tardive dyskinesia • Functional decline • Cognitive decline

  34. ATYPICAL NEUROLEPTICS • Clozapine • Risperidone • Olanzapine • Quetiapine • Ziprasidone • Aripiprazole

  35. DISINHIBITION • Mostly in frontal/subcortical disease • Use antecedent control and environmental manipulation, not operant conditioning • Can use anticonvulsants, propranolol, other agents for aggression • Can use SSRI’s or antiandrogenics for sexual disinhibition

  36. SCREAMING • Seen in severely demented patients • Multifactorial: • RESTRAINT • Pain, discomfort • Sensory deprivation • Depression (?)

  37. EMPIRICALLY EFFECTIVE MEDS FOR AGITATION • Anticonvulsants • Atypical neuroleptics (best when agitation is clearly related to psychosis) • Trazodone • Buspirone • Lorazepam, oxazepam

  38. MORE HEROIC OPTIONS • Lithium • Beta-blockers • Narcotics • Estrogens • Typical neuroleptics • ECT

  39. THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes one) WHEN IN DOUBT, GET RID OF MEDICATIONS!

  40. WANDERING • Up to 2/3 of patients • Can lead to serious injury or death • Four types: • Exit seekers • Self stimulators • Akathisiacs • Modelers (Hussian, 1987)

  41. WANDERING: MANAGEMENT • Manage sleep disturbance aggressively • Discontinue neuroleptics if possible • Exercise, stimulation, outdoor time • Alarms • Visual barriers • Locks (consider fire hazard, though) • Medicalert bracelet, police registry, etc.

  42. DON’T FORGET SAFETY ISSUES! • Driving • Firearms • Power tools • Smoking in bed • Poisons, medications • Fall risk

  43. GOOD LUCK! OTHER MEDS WOOF!

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