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Dementia

Dementia. Carrie Plummer, PhD, ANP-BC Abby Parish, DNP, A/GNP-BC Jennifer Kim, MSN, GNP-BC Vanderbilt School of Nursing Meharry-Vanderbilt GEC Qsource Webinar Series. DEMENTIA FACTS. Dementia - An Overview. Definition Types of Dementia Risk Factors Diagnosis Stages

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Dementia

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  1. Dementia Carrie Plummer, PhD, ANP-BC Abby Parish, DNP, A/GNP-BC Jennifer Kim, MSN, GNP-BC Vanderbilt School of Nursing Meharry-Vanderbilt GEC Qsource Webinar Series

  2. DEMENTIA FACTS

  3. http://www.cdc.gov/aging/images/couple_250px.jpg Dementia - An Overview • Definition • Types of Dementia • Risk Factors • Diagnosis • Stages • Treatment/Prevention • Resources

  4. Statistics • 7 million people suffer from Alzheimer’s disease (AD) • AD accounts for 50-70% of all dementias • 8th leading cause of death in elderly • AD lasts from 3-20 yrs (avg: 7 yrs) • Cost in US: $100 billion/year • Currently there is NO CURE

  5. Dementia • More than just memory loss • Deficits in SHORT TERM memory • Deficits in attention, language and problem solving • Interferes with social and occupational functioning • Mild Cognitive Impairment (MCI) • Memory deficits without functional impairment • Can be difficult to distinguish from normal changes of aging • Amnesia type - most studied, most likely to progress to AD • donepezil (Aricept) may be protective for limited period (~1 year)

  6. Common Types of Dementia • Alzheimer’s Disease • 50 – 70% • Vascular Dementia • 15 – 30% • Dementia with Lewy Bodies (DLB) • 10 – 25% • Frontotemporal lobe Dementia • rare • Secondary dementias • Normal Pressure Hydrocephalus (NPH) • Parkinson’s dementia • AIDS related dementia • Alcohol related dementia

  7. http://auto.img.v4.skyrock.net/5396/80355396/pics/3076203011_1_7_ptCq7EkZ.jpghttp://auto.img.v4.skyrock.net/5396/80355396/pics/3076203011_1_7_ptCq7EkZ.jpg Alzheimer’s Disease • Alois Alzheimer- 1906 • “Unusual disease of the cerebral cortex” • Histopathology: • Neurofibillary plaques and tangles • Parietal-temporal cortex, prefrontal cortex, hippocampus, amygdala • Granulovacular bodies • Large, double-membraned bodies

  8. Plaques & Tangles

  9. Results of cell death

  10. http://neurowiki2012.wikispaces.com/file/view/alzheimer's_disease_pathology.jpg/316537340/366x346/alzheimer's_disease_pathology.jpghttp://neurowiki2012.wikispaces.com/file/view/alzheimer's_disease_pathology.jpg/316537340/366x346/alzheimer's_disease_pathology.jpg Alzheimer’s DiseaseNeurotransmitter Changes • Acetylcholine amount and activity decreased • Needed for memory, language and thoughts. • N-methyl-D-aspartate (NMDA) • Somatostatin • Serotonin

  11. Alzheimer’s Disease-Types • Sporadic • No known cause • No obvious inheritance patterns • Familial • Rare (<10%) • Early onset ** • Gene mutations on chromosomes 1,14 & 21 • 21 = abnormal amyloid precursor protein (APP) • 14 = abnormal presenilin 1 • 1 = abnormal presenilin 2 • Autosomal dominant pattern • 1 copy of altered gene can cause AD

  12. http://www.cnn.com/2011/HEALTH/04/19/alzheimers.diagnosis.guidelines/t1larg.alzheimer.elderly.jpghttp://www.cnn.com/2011/HEALTH/04/19/alzheimers.diagnosis.guidelines/t1larg.alzheimer.elderly.jpg Risk Factors of AD (Sporadic) • Exact cause of AD is unknown: • Age • 1 in 10 people over 65 • 30-50% of those 85+ • High blood pressure • High cholesterol • Head injury • Hormone replacement therapy

  13. http://cursos.campusvirtualsp.org/file.php/138/Images/25.jpg Symptoms of AD • Memory Loss • Slow progression • Affects daily living • Confusion/Disorientation • Language problems • Word finding • Using words inappropriately or forgetting their meaning • Judgment

  14. http://media-social.s-msn.com/images/blogs/00120065-0000-0000-0000-000000000000_00000065-075e-0000-0000-000000000000_20121015210544_payingbill.jpghttp://media-social.s-msn.com/images/blogs/00120065-0000-0000-0000-000000000000_00000065-075e-0000-0000-000000000000_20121015210544_payingbill.jpg Symptoms of AD • Difficulty with • Handling money • Calculating numbers • Keeping track of things • Misplacing items • Changes • Personality • Mood • Apathetic

  15. http://www.mountainside-medical.com/blog/wp-content/uploads/2012/09/Alzheimers-Drug-Development-300x294.gifhttp://www.mountainside-medical.com/blog/wp-content/uploads/2012/09/Alzheimers-Drug-Development-300x294.gif Stages of AD • Mild • Primarily cognitive deficits • Mild personality/behavior changes • Moderate • More pervasive memory impairment • Impairment of ADLs requiring supervision and minimal assistance • Behavioral symptoms more pervasive

  16. http://www.mountainside-medical.com/blog/wp-content/uploads/2012/09/Alzheimers-Drug-Development-300x294.gifhttp://www.mountainside-medical.com/blog/wp-content/uploads/2012/09/Alzheimers-Drug-Development-300x294.gif Stages of AD • Severe • Profound memory impairment • Requires significant assistance with ADLs • Vegetative symptoms more pervasive

  17. Stages of AD • Mild (can last 2-4 years or longer) • MMSE is ≥21 • Appearance of health • Symptoms may be mistaken for normal aging changes • SYMPTOMS: • easily loses way to familiar places, • trouble with word finding, • hoarding, • taking longer time to finish familiar tasks, • personality changes, • anxiety, • poor judgment.

  18. Stages of AD • Moderate (can last 2-10 years) • MMSE is 10-20 • More damage to the brain, especially areas controlling language, reasoning, thought and processing of sensory information. Symptoms are more pronounced. • SYMPTOMS: • trouble recognizing familiar people & objects, • behavior changes, • more spontaneity, • inappropriate comments, • paranoia, • problems with language (speech, reading, writing), • loss of impulse control

  19. Stages of AD • Severe (can last 1-3 years or longer) • MMSE is ≤9 • Damage to brain is widespread & full time care required. Difficult time for family & caregivers. • SYMPTOMS: • doesn’t recognize self or close family, • loses control of bowel and bladder, • weight loss, repetitive crying, • complete loss of language, • increased sleeping, • difficulty swallowing.

  20. http://www.insideiamlaughing.com/wp-content/uploads/2012/12/vascular-dementia.jpghttp://www.insideiamlaughing.com/wp-content/uploads/2012/12/vascular-dementia.jpg Vascular Dementia • 5% of all dementias; 22% mixed with AD • Stepwise progression • PMH: CVA, MI, DM, HTN, PVD, HLD • Memory impairment less severe than AD • TX: No current FDA-approved medications • donepezil (Aricept) shown to be effective in mild-mod VD

  21. http://belairecare.com/wp-content/uploads/2014/04/Lewy-Body.jpghttp://belairecare.com/wp-content/uploads/2014/04/Lewy-Body.jpg Dementia with Lewy Bodies (DLB) • Characterized by loss of dopamine and acetylcholine: • Common presenting symptoms: • Visual hallucinations • Parkinsonian symptoms • Cognitive fluctuations • Other symptoms: • Repeated falls • REM sleep behavior disorder • Depression/apathy • TX: No approved medications, but cholinesterase inhibitors have been found to be helpful. Paradoxical response to antipsychotics!

  22. Distinguishing DLB from AD

  23. http://medlibes.com/uploads/Screen%20shot%202010-07-20%20at%209.35.53%20AM.pnghttp://medlibes.com/uploads/Screen%20shot%202010-07-20%20at%209.35.53%20AM.png Frontotemporal lobe Dementia • Rare • Early onset (age 35-75) • Hyperorality • Impairment in executive functioning • Misdiagnosis common • TX: none approved

  24. http://static.cdn-seekingalpha.com/uploads/2013/6/4/saupload_PD_Dude.jpghttp://static.cdn-seekingalpha.com/uploads/2013/6/4/saupload_PD_Dude.jpg Parkinson’s Dementia • 30-50% PD patients will develop dementia • TX: Exelon (mild to moderate)

  25. Normal Pressure Hydrocephalus • Rare • Increase of CSF in ventricles • TBI • CVA • Unknown causes • Clinical triad • Altered gait • Urinary incontinence • Confusion • Treatment • Surgical shunt placement

  26. MAKING THE DIAGNOSIS

  27. Diagnosing Dementia • History • Neuroimaging? • Medical and blood tests • Physical exam • Cognitive tests • ability to count, language & problem-solving • Autopsy • Early diagnosis is beneficial to allow for early pharmacological and non-pharmacological treatment.

  28. It looks a lot like dementia… • Depression • Thyroid problems • Vitamin B12 deficiency • Alcoholism • Medications • Infections • Uncontrolled diabetes • Electrolyte imbalance • Tumors • Neurosyphyllis

  29. Dementia Confabulation 50% will show some degree of depressive symptoms Depression “pseudodementia” “I don’t know” Trial of an antidepressant may assist to distinguish Dementia vs. Depression (Dharmarajan & Norman)

  30. http://www.jabfm.org/content/16/5/423/F3.large.jpg Cognitive Testing for Dementia • MMSE • Not a diagnostic tool • Clock Drawing Test (CDT) • Mini Cog • Functional assessment

  31. Dementia DSM-IV Criteria • Development of multiple cognitive deficits manifested by both: • Memory impairment • One or more of the following cognitive disturbances: • Apraxia (inability to execute learned purposeful movements) • Aphasia (disturbance of comprehension and formulation of language), • Agnosia (loss of ability to recognize objects, persons, sounds, shapes or smells), • Disturbances inexecutivefunctioning.

  32. Dementia DSM-IV Criteria continued… • Significant impairment in social & occupational functioning • Decline from previous level of functioning

  33. Advanced DirectivesA Special Note • Discuss early to allow patient opportunity to participate in decision making • Resuscitation/Intubation • Feeding tube • Long term fluids • Antibiotics • DPOA for Healthcare

  34. Dementia in the Media

  35. TREATMENT

  36. http://www.fresnostate.edu/chhs/safecvc/images/seniors-exercise-balls.jpghttp://www.fresnostate.edu/chhs/safecvc/images/seniors-exercise-balls.jpg Protective Factors • High education • Leisure activities • Aerobic & strength training • Cholesterol-lowering strategies • Good control of HTN, DM & hyperlipidemia • Cognitive Stimulation Therapy: Cochrane Review Not efficacious

  37. http://www.un.org/News/dh/photos/large/2012/April/04-11-who-dementia.jpghttp://www.un.org/News/dh/photos/large/2012/April/04-11-who-dementia.jpg TREATMENT GOALS • Maximize: • Function • Independence • Quality of life • Individual with dementia • Caregivers • Time before institutionalization is needed

  38. Treatment for Dementia • No known cure • Cholinesterase inhibitors stabilize behaviors: • Indicated for mild-moderate AD • Inhibits acetylcholinesterase thereby reducing amount of acetycholine breakdown in brain • Aricept (donepezil) • Exelon (rivastigmine) • Razadyne (galantamine)

  39. Cholinesterase Inhibitors • Treatment goals: • Low rate of short term improvement • Moderate rate of stabilization • Primary goal is of less than expected decline • Benefits: Don’t give families false hope • Decision to discontinue: • Cost • Uncertain/diminished benefit? • Side effects • If discontinuation is appropriate, use slow taper • Some patients continue on CI’s indefinitely

  40. Namenda • N-methyl-D-asparate (NMDA) antagonist • blocks action of the chemical glutamate • Use cautiously with amantidine or dextromethorphan • Monitor closely with coadministration of HCTZ, triamterene, metformin, cimetidine, ranitidine, quinidine & nicotine • Use the same renal system & can result in elevated plasma levels of medications. • Common SE: constipation, headache, dizziness, pain

  41. http://www.medicalobserver.com.au/assets/images_20nov2012/depression-old-486x324.jpghttp://www.medicalobserver.com.au/assets/images_20nov2012/depression-old-486x324.jpg Treatment of Associated Symptoms and/or Diseases • Depression • Common co-morbidity • Symptoms often overlap which complicates diagnosis • SSRIs (avoid Prozac can increase agitation and sleep disturbances)

  42. Treatment of Associated Symptoms and/or Diseases • Sundowning • Trazodone • Medications for agitation- no FDA approved meds • Mood stabilizer? • Atypical antipsychotics? • Behavioral problems: • Assessment of “other” causes and initiate non-pharmacological interventions before medications!

  43. Antipsychotic Use in AD • Short term improvement in aggression and psychosis (6-12 weeks) • Increased risk of mortality in long term use • Other unwanted side effects: • Orthostasis • Anticholinergic effects • Increased fall risk • Dementia Antipsychotic Withdrawal Trial (DART-AD) • Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study: • Modest benefits do not justify adverse events

  44. WARNING: Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at increased risk of death compared to placebo. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients. Over the course of the typical 10-week controlled trial, the rate of death in the drug treated group was about 4.5%, compared to a rate of death of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Abilify (aripiprazole)/Geodon (zipraxidone)/Risperdal (risperidone)/ Symbyax (olanzapine and fluoxetine)/Zyprexa (olanzapine) are not approved for the treatment of patients with dementia-related psychosis. (www.caremark.com)

  45. For cognitive symptoms: Vitamin E NSAIDS Estrogen For behavioral symptoms: Bezodiazepines (typically) Lithium Beta-blockers Drugs which have NOT shown a therapeutic benefit for dementia (APA)

  46. Non-pharmacological treatment of problem behaviors

  47. Behavioral symptoms of dementia • Behavioral symptoms have been reported to affect as many as 90% of dementia patients • Most common in moderate to severe stages • Symptoms include: • Irritability • Medication/care refusal • Eloping • Agitation • Combative behavior • Non-pharmacological interventions are first line for these symptoms

  48. Causes of Behavior Changes • Physical discomfort caused by an illness or medications • Overstimulation from loud noises or a busy environment • Unfamiliar surroundings such as new places or inability to recognize home • Complicated tasks • Frustrating interactions due to the inability to communicate effectively Taken from http://www.alz.org

  49. Approach to problem behaviors • Explore possible causes • Medication review, pain • Calm demeanor • Be sympathetic • Minimize distractions & stimulation • Relaxation • Maintain a routine • Redirection and reorientation • Simple, one-step commands • Remove physical restraints!

  50. http://seniorplanet.org/wp-content/uploads/2013/10/alive-inside.jpghttp://seniorplanet.org/wp-content/uploads/2013/10/alive-inside.jpg Interventions for agitated patients • Therapeutic options with poor evidence base, but being studied: • Music therapy • Documentary “Alive Inside” • Touch therapy (e.g., massage) • Pet therapy • Simulated presence therapy (audio or video of family or other) • Reminiscence therapy (Beier)

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