Evaluation and Management of Dementia (Mobile Accessible)

1. Evaluation and Management of Dementia(Mobile Accessible) Presented by: Stephen Thielke, MD, MSPH, MA Puget Sound VA GRECC

2. Welcome/Introduction • Goal: To review the definition, types, evaluation,and management of dementia • How to ask questions: • E-mail: Stephen.Thielke@va.gov • Phone: (206) 764-2815 • “Office Hours” will be arranged and publicized

3. Purpose • To present general information about dementia and to review key concepts in guideline-based dementia management

4. Learning Objectives • Diagnose dementia • Rule out reversible causes, especially delirium • Characterize the main types of dementia • Identify the stages of dementia

5. Learning Objectives (cont’d) • Recommend nonpharmacological and pharmacological treatments • Manage key problem areas • Coordinate care for patients with dementia

6. What Dementia Is • A significant chronic loss in memory and/or mental functions, involving structural damage to the brain • Significant─ functional consequences • Chronic ─ not a rapid onset (comes on over years) • Loss ─ new impairments (not lifelong) • Structural Damage ─ neurons die

7. What Dementia Is Not • Delirium─ acute onset, attention and concentration problems • Apathy, Distraction ─ apparent cognitive deficits, but none during testing (consider depression) • Normal Aging─ slight global slowing, changes in episodic memory, difficulty multitasking • Sensory deficits or communication problems

8. How Common is Dementia? • Overall prevalence is increasing because lifespan is longer, not because age-specific rates are higher.

9. Dementia in the VA Urban rural split: 38% of veterans live in rural areas and 75% of rural veterans are over the age of 65.

10. Dementia Types

11. Dementia Features

12. Recognizing Dementia • Common warning signs are problems with: • Short-term memory, judgment • Word finding (language) • Taking medication correctly (executive function) • Driving (visuospatial) • Balancing checkbook (calculation) • Memory problems are often not the chief complaint • Routine screening is not recommended in the asymptomatic (USPSTF)

13. Recognizing Dementia (cont’d) • Spouses or children are often more concerned than patients • Good verbal skills and living independently should not preclude evaluation of cognition • Conduct additional workup whenever patient or family describe problems or when cognitive problems are observed

14. Working Up Dementia • History ─ use collateral sources • Rule out delirium and reversible causes • Labs: • TSH, CBC, Chem7, Calcium, LFTs, B12, Folate, Urinalysis • Cognitive testing: • BOMC, Mini-Cog, GPCOG, STMS, SLUMS, MoCA, FAST • Complex cases: refer for neuropsychological evaluation • Neuroimaging is not routinely indicated; order if • Rapid decline • Unexplained focal neurological symptoms

15. Diagnosing Dementia • A clinical diagnosis, but still quite sensitive and specific • History, cognitive testing, absence of other causes • Requires a decline in functioning • Mild cognitive impairment is a challenging category

16. Referring to Specialty Care • Clinical features: • Atypical or complex presentation • Patient <60 years of age • Significant behavioral and psychiatric symptoms • Accompanying movement disorder • Rapidly progressing symptoms • Mild cognitive impairment with significant patient concern or functional problems • Telemedicine consultation may be available

17. Principles for Managing Dementia • Screen for depression and provide treatment • Engage in advance care planning • Reassess: • Dementia-related behavioral symptoms • Delirium and distressing physical symptoms • Functional capacity

18. Principles for Managing Dementia (cont’d) • Discuss support services • Assess caregiver burnout • Watch for signs of abuse or neglect • Address general health maintenance, especially hypertension and diabetes • Consider both non-pharmacologic and pharmacologic interventions

19. Non-Pharmacologic Interventions • Behavioral analysis and management • Cognitive and sensory stimulation therapy • Music therapy • Caregiver communication education • If pharmacotherapy is necessary, non-pharmacological interventions should be instituted concurrently

20. Dementia Medications (1 of 5) • Before prescribing any medication: • Clarify diagnosis • Review all prescribed and over-the-counter medications • Review herbal treatments and supplements • Discontinue unnecessary anticholinergics (especially diphenhydramine–in many OTCs) • Ensure that someone can help administer medications for more impaired patents

21. Dementia Medications (2 of 5) • When prescribing a medication: • Use VHAPBM criteria • Consider discontinuing if there is no clinically significant response • Re-evaluate need for medications every 6 months per criteria for use • Consider discontinuing if FAST score is 7a-f (severe functional impairment)

22. Dementia Medications (3 of 5) • Cholinesterase inhibitors: • Galantamine or donepezil • Requires diagnosis of Alzheimer’s, Mixed Alzheimer’s / Vascular, Lewy Body, or Dementia Associated with Parkinson’s • Can perform ≥ 1 ADL with minimal assistance • Main side effects: can worsen bradycardia, COPD, PUD

23. Dementia Medications (4 of 5) • Memantine: • Requires diagnosis of Alzheimer’s • Moderate to severe disease (FAST stage 5 or 6, NOT stage 7), or mild disease (FAST stage 4) AND unable to use cholinesterase inhibitor • Able to perform ≥ 1 ADL with minimal assistance

24. Dementia Medications (5 of 5) • Combined use of cholinesterase inhibitor and memantine: • Only if on a therapeutic dose of one of them for ≥ 6 months, without significant improvement • Limit antipsychotics (FDA black box warning for both typical and atypical) • Mortality risks • Limited efficacy • Can cause acute worsening in Lewy Body dementia

25. Key Problem Areas (1 of 3) • Driving and farm equipment: • Evaluate, involve family, creatively restrict access, follow local policy on mandated reporting • Agitation: • Consider prazosin • Analyze behaviors, limit restraints • Early consultation with Geriatric Psychiatrist, Geriatrician, Neurologist, or Psychologist

26. Key Problem Areas (2 of 3) • Firearms: • Counsel veteran about firearm safety • Encourage restricted access to firearms or ammunition • Involve family • Home appliances: • Modify access and appliances as needed

27. Key Problem Areas (3 of 3) • Medication administration: • Have family or interested parties supervise • Simplify directions • Individualize strategies (e.g., pill boxes, use of routines and schedules, rewards)

28. Care Coordination • Patient often treated in multiple settings (home, clinic, hospital, nursing home, adult day health center) • Patient often has multiple providers • Needs will change over time • Caregiver needs should be assessed • Refer to VA and community resources

29. VA Resources • Office of Geriatrics and Extended Care • http://vaww1.va.gov/geriatricsshg/ (VA intranet) • 5D Pocket Card and Guide (being distributed to all VISNs)–contact Julie Moorer (Julie.Moorer@va.gov) for additional copies • Dementia Training Catalog: • http://vaww1.va.gov/GeriatricsSHG/page.cfm?pg=83 (VA Intranet)

30. Other Resources • Alzheimer’s Association • www.alz.org • NIA ADEAR (Alzheimer’s Disease Education and Referral Center) • http://www.nia.nih.gov/Alzheimers/

31. Contact Information • Stephen Thielke • Geriatric Research, Education, and Clinical Center, Seattle VAMC • (206) 764-2815 • Stephen.Thielke@va.gov