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DEMENTIAS

DEMENTIAS. Pat Borman, MD Director Advanced Training in Geriatrics. GOALS IN DEMENTIA. Evaluation and Diagnosis Current Therapy for Dementia Complications Resources for the Caregivers. DEFINITION OF DEMENTIA. MEMORY IMPAIRMENT AND One or more: APHASIA APRAXIA

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DEMENTIAS

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  1. DEMENTIAS Pat Borman, MD Director Advanced Training in Geriatrics

  2. GOALS IN DEMENTIA • Evaluation and Diagnosis • Current Therapy for Dementia • Complications • Resources for the Caregivers

  3. DEFINITION OF DEMENTIA • MEMORY IMPAIRMENT • AND One or more: • APHASIA APRAXIA • AGNOSIA VISUOSPATIAL • LOSS OF EXECUTIVE FUNCTION Gradual, Progressive, Impairs function: social, job, family, no other explainations

  4. TYPES OF DEMENTIA • Alzheimers • Memory, Language, Visuospatial, Indifferent to Loss • Frontotemporal (Picks) • Memory, Marked Personality changes, Preserved visuospatial • Lewey Body: • Visual hallucinations, delusions, flucutating mental status

  5. TYPES OF DEMENTIA • Parkinson’s Disease • 15-30% develop dementia • Vascular Dementia • Progressive Supranuclear Palsy • The Rare Birds: • Late onset Metobolic Disease • Creutzfeld-Jacob

  6. EVALUATION • HISTORY • HPI, Medical, Medications, Psychiatric, Functional, Caregiver • EXAM • Physical, Neurologic, Psychiatric, Cognitive Testing

  7. EVALUATION • LABORATORY • Blood Work • CBC, TSH, Chem 7, Ca 2+, B12, Folate • RPR • Imaging • CT or MRI • Other Studies • LP, neuropsychiatric testing, EEG, • SPECT, PET

  8. DIFFERENTIAL DIAGNOSIS • DEPRESSION Pseudodementia • CNS: Neoplasm, NPH, stroke • Vascular: subdural, vasculitis, • Endocrine: Thyroid, Calcium, • Nutritional: B12, Thiamine,ETOH • Infections: HIV, Cryptococcus

  9. CURRENT THERAPY • CHOLINESTERASE INHIBITORS • For mild to moderate disease, slow progression, stabilize ADL and MMSE • 1st Generation • Tacrine hepatotoxic, last choice • 2nd Generation • Donepezil 5-10 mg qd $113/mp • Rivastigmine 3-6 mg bid $153/mo • Galantamine 16-32 $298/mo

  10. CURRENT THERAPY • VITAMIN E • Antioxident, inexpensive • GINKGO BILOBA • Antioxident, anti-inflammatory • ESTROGENS • neuroprotective? • NSAIDS • Epidemiologic suggestions

  11. Depression 40 Suspicion 30 Disinhibition 50 Agitation 50 Verbal, Vocal, Motor Psychosis Hallucinations15 Delusions 30 Anxiety 40 Aggression 30 Withdrawal 40 Vegetative sleep 90 appetite 30 Wandering 60 Apathy 60 COMPLICATIONS

  12. APPROACHES TO BEHAVIOR PROBLEMS • 1. Define target symptoms • 2. Revisit medical diagnoses • 3. Establish neuropsychiatric diagnoses • 4. Assess and remove provoking factors: environmental, psychosocial, other • 5. Adapt environment and treatments to specific cognitive deficits • 6. Educate caregivers • 7. Employ behavior management principles • 8. Treat specific psychiatric disease specifically • 9. For remaining behavior problems consider symptomatic pharmacotherapy

  13. PHARMACOTHERAPY • DEPRESSION • SSRI’S Paroxetine, Sertraline, Others • TCADS Nortriptyline • ECT if life threatening • ANXIETY • Buspirone,Lorazepam, Propanolol • PSYCHOSIS • Rispiridone, Olanzepine, Haloperidol

  14. PHARMACOTHERAPY • Aggression • Trazedone, Buspirone, Olanzepine, Others • Agitation • Haloperidol, Lorazepam, Trazedone, Carbamazepine • Insomnia • Melatonin, Benzodiazepines, Trazedone • Sundowning • Trazedone, Haloperidol, Risperidone, Olanzepine

  15. PROGRESSION • Forgetfulness • complains of memory deficits, misplace objects, trouble word finding, functional • Confusional • getting lost, job trouble, language problems, lost objects, denial, anxiety, lost current events, can’t handle finances other executive functions, withdrawal • Early Dementia • Need assistance, can’t use phone reliably, disorentation to time, place, know family, can feed and toilet with reminders

  16. PROGRESSION • Middle Dementia • Unaware of surroundings, forget spouse’s name, loss of recent events of life, personality and behavior changes, needs help with most ADL • Late Dementia • Loss of all verbal abilities, complete incontinence, no thirst or hunger responses • TIME COURSE

  17. DAY TO DAY CARE • Be Firm, Don’t Rush or Argue • Now it time to….., don’t rush or argue • Minimize Distractions • Decrease noise, remove visual clutter • Keep It Simple, Keep It Safe • Cannot follow multi-step commands • Lower Your Standards • Expect less from the patient • Establish Routines • Reassuring, reduce agitation

  18. Day to Day Care • Alzheimers Association • 1-800-848-9707 www.alza.org • Washington Adult Day Care Assoc • 206-461-3899 www.adultday.org • Senior Information and Assistance • 206-448-3110 www.seniorservice.org

  19. CARE FOR CAREGIVERS • Information about progression • Facilitate Day-to-Day Care • Stress Reduction Skills • Support • Risk for depression, illness, fatigue, elder abuse • How to know when you can no longer provide care at home

  20. CARE GIVER SUPPORT • Alzheimer’s and Related Disorders Association • 1-800-272-3900 • Alzheimer’s Disease Education and Referral Center • 1-800-438-4380 • www.alzheimers.org/adear • Family Caregiver Alliance • 1-800-445-8160 • www.caregiver.org

  21. Economics of Dementia • 2-5 million affected • With current demographics 10 million by 2030 • Expenses TOTAL $100 Billion • Ranks third (Heart disease and Cancer) • Per Capita • Direct $10-25K home, $40-50k NH • Indirect $60k • Unpaid Care $10-50k • Paid Out of Pocket 65%

  22. REFERENCES • Small, GW et.al. Diagnosis and Treatment of Alzheimer Disease and Related Disorders, JAMA Oct 1997. • Raskind MA, Peskind ER. Alzheimer’s Disease and Related Disorders, Medical Clinics of NA May 2001. • Alzheimer’s Disease: The Reality and the Promise, Patient Care Nov 1996. (Entire issue devoted to this topic.) • Fillit H, Cummings J. Practice Guidelines for the Diagnosis and Treatmentof Alzheimers Disease in a Managed Care Setting Part I and II, Managed Care Interface Dec 1999. • Tariot PN et. al. Treating Aggression in Patients witrh Dementia, Medical Education Collaborative and ABComm May 2000. • Practical Alheimer’s Disease Management: A ComparativeReview of New Compounds, Diasnosis, Treatment and Outcomes Assessment, Post Graduate Medicine May 1999.

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