DEMENTIA the SILENT EPIDEMIC

1. DEMENTIA the SILENT EPIDEMIC Antonio A. Graham DO Assistant Professor of Medicine and Geriatrics Emory University School of Medicine GOMA October 2019

2. Objectives • Knowledge of incidents and prevalence of patients with dementia in the US population • Recognize signs and symptoms to diagnose dementia • Identify pharmacologic & non-pharmacologic treatment of dementia

3. DEMENTIA

4. Why learn about dementia? • 1 in 3 seniors dies with Alzheimer’s or another dementia • Alzheimer’s disease is the 6th leading cause of death in the U.S. • In 2015, Alzheimer’s and other dementias have cost the nation $226 billion+ in health care cost • By 2050, cost could rise as high as $1.1 trillion

5. Dementia • Dementia is a disorder characterized by problems with cognition + functional impairment • Cognition components: learning/recall, reasoning, language, spatial ability/orientation, and executive function/handling complex tasks • Functional impairments: • Activities of Daily Living (ADLs): eating, dressing, toileting, etc • Instrumental Activities of Daily Living (IADLs): grocery shopping, cooking, finances, medications, driving, etc.

6. SIGNS of dementia

7. Dementia subtypes • Alzheimer's disease being the most common subtype (prevalence 50%) • Prominent memory impairment • Gradual decline • Vascular Dementia is the second most common subtype • Tends to have white matter changes on brain imaging & history of strokes or CAD • “Step wise” decline over time

8. Dementia subtypes • Lewy Body Dementia (prevalence ~15%) • Cognitive impairment, hallucinations, & Parkinson-like symptoms such as shuffling gait, falls, rigidity & tremors • Cognitive & hallucinations may occur before or at the same timeas Parkinson-like symptoms. Parkinson’s Dementia • Must have motor symptoms before cognitive impairment by 1 year

9. Dementia subtypes • Fronto-temporal Dementia • Usually younger patients, with executive and language dysfunction and often behavioral changes such as disinhibition & impulsivity • Memory impairment less prominent. • Other dementia: 5% • Head trauma, HIV disease, Huntington's chorea, Pick's disease (a type of fronto-temporal dementia), Creutzfeldt-Jakob disease. • Rule out reversible causes: • B12 deficiency, hypothyroidism, neurosyphilis, substance abuse such as alcohol, depression, and delirium

10. Dementia Screening • Mini Mental Status Exam: measures global cognitive function by examining memory/recall, language, orientation, and executive function. Interpretation of scores depend on level of education (eg. 26/30 would be abnormal in someone with a PhD). MOCA (Montreal Cognitive Assessment) may be used in someone with higher education status. 25-30=normal or mild cognitive impairment 20-24 = dementia, mild 10-20 = dementia, moderate <10 = dementia, severe

11. Mini-Cog dementia screen • Ask your patient to: • Repeat three words: banana, sunrise, chair • Draw the face of a clock, then draw hands to read “ten past eleven” • Recall the three words

12. PRIMARY GOAL OF TREATMENTMENT • To enhance quality of life and • maximize functional performance by • improving or stabilizing cognition, mood, and behavior.

13. NONPHARMACOLOGIC MANAGEMENT (1 of 2) • Cognitive rehabilitation • Supportive individual and group therapy • Physical and mental activity • Regular appointments every 3–6 months • Family and caregiver education and support • Attention to safety • Need for supervision, wandering, driving etc.

14. NONPHARMACOLOGIC MANAGEMENT (2 of 2) • Environmental modification • Supportive strategies such as clocks, calendars, to-do list, visual clues, simple and compassionate communication style • Structure activities to match patient abilities

15. PHARMACOLOGIC MANAGEMENT • Treatment should be individualized • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine • Memantine • Other cognitive enhancers • Antidepressants • Psychoactive medications

16. CHOLINESTERASE INHIBITORS (1 of 2) • Slow breakdown of acetylcholine • Clinical trials demonstrate modest delay in cognitive decline compared with placebo in AD • GI side effects common • Mitigated by slow titration curve • Maximum dosing of donepezil 23 mg/day creates significant side effects without evidence of improving global function

17. CHOLINESTERASE INHIBITORS (2 of 2) • No evidence of difference in efficacy among drugs • Use in other dementias • Widespread use in vascular dementia not recommended • Attention and behavioral disturbances in Lewy body dementiacan benefit from treatment • Rivastigmine is FDA-approved for mild to moderate dementia in Parkinson dementia • Treatment in fronto-temporal dementia may worsen agitation

18. MEMANTINE • Neuroprotective effect is to reduce glutamate-mediated excitotoxicity • Modest benefit on cognition, ADLs, and behavior in AD • Limited effect on cognition and no evidence to support widespread use in vascular dementia • FDA-approved for moderate to severe AD • Common adverse events: constipation, dizziness, headache

19. OTHER COGNITIVE ENHANCERS • Vitamin E (α–tocopherol) may lower rate of functional decline, but no evidence of cognitive improvement in AD • The clinical efficacy and safety of vitamin E has yet to be fully established • Selegilinemay lower rate of functional decline, but no evidence of cognitive improvement in AD • Ginkgo biloba offers no benefit in slowing cognitive decline in MCI

20. SYMPTOM MANAGEMENT (1 of 2) • Psychoactive medications • Behavioral disturbances best managed nonpharmacologically, eg, reducing overstimulation, environmental modification • When meds are required, target symptoms should be identified, and therapy selected accordingly • Antidepressants • Depressed mood, low appetite, insomnia, fatigue, irritability, agitation • Possibly effective for disinhibition and compulsive behaviors associated with frontotemporal dementia • Caution: falls and anticholinergic effects that may worsen confusion (ie, paroxetine)

21. SYMPTOM MANAGEMENT (2 of 2) • 1st/2nd-generation antipsychotics • Limited evidence of efficacy and increased risk of all-cause mortality in dementia • Should be used with caution in targeting delusions, hallucinations, paranoia, and irritability ― frequently attempt to taper off • Valproic acid and carbamazepine • Possible options, but with limited evidence and increased risk of mortality • Benzodiazepinesandanticholinergic medications shouldbe avoided

22. RESOURCES FOR MANAGING DEMENTIA (1 of 2) • Specialist referral to: • Geriatric psychiatrist • Neurologist • Neuropsychologist • Social worker • Physical therapist • Nurse • Pharmacist

23. RESOURCES FOR MANAGING DEMENTIA (2 of 2) • Attorney: will, conservatorship, estate planning • Community: neighbors & friends, aging & mental health networks, adult day care, respite care, home-health agency • Organizations: Alzheimer’s Association, Area Agencies on Aging, Councils on Aging • Services: Meals-on-Wheels, senior citizen centers

24. CHOOSING WISELY • Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects. • Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.

25. SUMMARY(1 of 2) • Dementia is common in older adults but is not an inherent part of aging • AD is the most common type of dementia, followed by vascular dementia and dementia with Lewy bodies • Evaluation includes history with informant, physical & functional assessment, focused labs, & possibly brain imaging

26. SUMMARY(2 of 2) • Primary treatment goals: enhance quality of life and maximize function by improving cognition, mood, behavior • Treatment may involve both medications and nonpharmacologic interventions • Community resources should be used to support patient, family, caregivers

27. CASE STUDIES

28. CASE #1 - Scenario • A 65-year-old man comes to the office with his wife because she is concerned about his memory. He is a retired engineer. • His wife offers examples of recent uncharacteristic mistakes that he has made in their finances. • He forgot to pay the mortgage several months ago. • In the grocery store, his credit card was denied for missed payments. • The patient describes his experience. • Balancing accounts feels more effortful & takes longer than it had in the past. • He feels overwhelmed by distractions. • He is frequently unable to find keys and other objects. • He is often unable to recall names of acquaintances until minutes or hours later.

29. CASE #1 - QUESTION Which one of the following is most likely to indicate pathologic neurologic decline? Taking longer to complete routine tasks Forgetting to pay mortgage and credit card bills Having a complaint about memory Experiencing difficulty retrieving names

30. CASE #1 - ANSWER Which one of the following is most likely to indicate pathologic neurologic decline? Taking longer to complete routine tasks Forgetting to pay mortgage and credit card bills Having a complaint about memory Experiencing difficulty retrieving names

31. CASE #2 - Scenario • A 73-year-old man has memory problems that are increasingly evident to his wife, and he has had several unexplained falls. • Neuropsychiatric history: seven years ago he began to have impaired smell, altered taste, and fitful sleep with recurrent dream enactment. • Symptoms have progressed and The dream enactments wake his wife at night. • Fluctuating cognitive dysfunction and bilateral arm tremors developed.

32. CASE #2 – SCENARIOcont’d • For several years, he has had hallucinations of children in the room. The hallucinations do not frighten him. • The hallucinations worsened when he was hospitalized for a UTI last year. • Neuroleptic agents were administered, but his condition deteriorated and he required restraints for several hours. • Behavioral interventions have been unsuccessful. • History: hypertension, hyperlipidemia, diabetes, urinary incontinence, constipation • MRI of the brain shows mild white matter changes.

33. CASE #2 - QUESTION Which one of the following medications should NOT be considered for this patient? Clonazepam Donepezil Fludrocortisone Haloperidol Rivastigmine

34. CASE #2 - ANSWER Which one of the following medications should NOT be considered for this patient? Clonazepam Donepezil Fludrocortisone Haloperidol Rivastigmine

35. CASE #3 - Question Which one of the following is true regarding the risk of prescribing psychotropic medications to patients with dementia? First- and second-generation antipsychotics increase both morbidity and all cause mortality. Second-generation antipsychotics do not increase morbidity and all cause mortality. First-generation antipsychotics do not increase morbidity and all cause mortality First- and second-generation antipsychotics increase morbidity but not all cause mortality.

36. CASE #3 - answer Which one of the following is true regarding the risk of prescribing psychotropic medications to patients with dementia? First- and second-generation antipsychotics increase both morbidity and all cause mortality. Second-generation antipsychotics do not increase morbidity and all cause mortality. First-generation antipsychotics do not increase morbidity and all cause mortality First- and second-generation antipsychotics increase morbidity but not all cause mortality.

37. SUMMARY • Awareness of incidents and prevalence of patients with dementia in the US population • Recognition of signs and symptoms to diagnose dementia • Identification of pharmacologic & non-pharmacologic treatments of dementia • Case studies to test knowledge

38. For more info: • Alzheimer’s Association: www.alz.org • MOCA (Montreal Cognitive Assessment): www.mocatest.org • Mini-Cog: http://geriatrics.uthscsa.edu/tools/MINICog.pdf • 4AT test: http://www.the4at.com/ • CAM (Confusion Assessment Method): http://www.hospitalelderlifeprogram.org/delirium-instruments/short-cam/

39. LET’s CONNECT! DR. ANTONIO A. GRAHAM info@drantonioagraham.com @geriagingexpert www.drantonioagraham.com Geriatrician  Educator  Community Health Advocate