Geriatric Medicine

1. Geriatric Medicine Jenny Basran MD, FRCPC Associate Professor & Head, Division of Geriatric Medicine University of Saskatchewan

2. Meet Mrs. B • 81 year old woman presents to ER with chest pain, not responsive to NTG, ST changes with trop leak. Past history angina. • Goes to cath lab  PTCA, but no stent required • Paged to see Mrs. B on ward because she is confused and does not want to take her medications. What are you thinking about as you go up to see her?

3. WHAT IS COGNITIVE IMPAIRMENT? • Change in how you think • Change from baseline • Often the body’s only way of telling you there is something wrong • Rather than classical signs and symptoms

4. What should be your first question?

5. FIRST QUESTION – ACUTE VS CHRONIC?

6. How can you tell? • Patient usually can’t tell you • Ask the family and other caregivers – nursing home, GP, home care, etc • If you don’t know, must assume acute • Treatable • Can be life threatening

7. Past history & Meds • Type 2 diabetes X 10 years • HgbA1c 6%, chemstrips checked OD (4-8) • Metformin 500 mg bid (Cr Cl 65 ml/min) • No proteinuria, neuropathy; yearly optho • Hypertension X 20 years • BP 130/70 lying & 120/60 standing; no SXS • Diovan (Valsartan) / HCTZ 160/12.5 mg OD • Hyperlipidemia X 8 years – lipitor 20 mg OD • Osteoporosis – vertebral fracture 1 year ago • fosavance 70 mg OD, Calcium 500 mg BID • eats dairy regularly • Macular degeneration – 5 years, vitalux

8. Past Medical History & Meds • Urinary incontinence X 1 year • Urge with nocturia once/ night, on detrol • Previous CAD – LV OK; ASA 81 mg OD  plavix added • Insomnia – clonazepam prn (almost daily) • OA knees / hands – occas tylenol prn • OTCs – gingko OD, Vitamin E 400 IU • Previously on HRT for menopause

9. Social History & Fxnal History • Lives alone in bungalow. Widowed 5 years ago • 2 children – both live in Alberta, but regular contact by phone • Lifetime nonsmoker and glass of wine at night with supper. • Functionally • Occasional falls – vague re: situation • Independent with ADLs & IADLs • Uses hearing ai • Family History – mom – 90’s – memory probs

10. What do you need now? • Labs – CBC, e’lytes, BUN, CR • Extended labs – Ca, Mg, PO4, albumin • Drug levels if appropriate – ie: digoxin, lithium, etc • Drug tox screen if worried about overdose or errors • Liver panel • TSH, B12, glucose • ECG – need baseline anyway, but could be cardia • CXR – especially if clinically warrants • U/A – will be positive often, so can’t stop here • Others – as warrants

11. Mrs. B • Her vitals are stable but she is clearly disoriented and starting to get agitated. She is easily distracted. • Her daughter is concerned because her mother is not usually like this. • The nurses are concerned because she seems to be getting worse, although notes periods when she seems OK • You review her meds – only prn BZDP & tylenol not ordered on admission • Lab work normal, U/A suggests UTI (pt has foley) • ? Diagnosis

13. Key Features of Delirium • Acute onset and fluctuating course • Usually develops over hours to days or may be abrupt • Unpredictable fluctuations (within interview or over day) with periods of lucidity • Often worse at night • Inattention • Easily distractable • Disorganized thinking • Illogical, bizarre; delusion of persecution common • Altered level of consciousness Confusion Assessment Method (CAM) = 1 + 2 + (3 or 4)

14. Mrs. B • What predisposing and precipitating factors for delirium are present? • Predisposing – older age, polypharmacy, sensory impairment • Precipitating – cardiac disease, foley, UTI, BZDP suddenly stopped, OA pain (not getting tylenol)

15. What is your Plan? • Plan • rule out other causes of delirium, especially cardiac • restart low dose BZDP – was taking daily at home • scheduled tylenol – while awake • Prevention – non pharmacological interventions • hearing aid, glasses • mobilizing, eating, limited daytime naps • family to sit with her at bedtime – back rub, music

16. Mrs. B • What if the Mrs. B had been really agitated and pulling out her IV along with refusing to take her meds? • Is the approach any different?

17. HalDOL Bridge(only if Patient harming themselves or others) • Severe delirium: 0.5-1.0 mg IM or po (IV short acting) – NOTE DOSE • Repeat dose Q30 – 60 minutes until calm achieved • Max dose 3-5 mg / 24 hours • Maintenance = 50% loading dose in divided doses (ie: TID) over the next 24 hour. Taper asap over next few days • Ie: 3 mg given to calm  give 1.5 mg next day in divided doses (0.5 mg TID)  then 0.5 BID  then 0.5 OD  then discontinue • Bridge to keep them safe while the treatment takes effect • If gets worse  you missed something, keep looking

18. Haldol • Never PRN • Never give to patient with parkinsonism • Monitor • Daily ECG – prolonged QTc • Tardive dyskinesis – increased stiffness first sign

19. Why is it important to treat delirium? • Mortality & morbidity the same as: • Having a MI in hospital • Being septic in hospital • Often missed because can be: • Hyperactive – hallucinations, agitation, paranoid • Hypoactive – sleeps all the time, wont eat, wont move • Combination of both - fluctations

20. Mrs. B – 8 weeks after discharge • 81 year old woman presents to ER with chest pain, not responsive to NTG, ST changes with trop leak. Past history angina. • Goes to cath lab  PTCA, but no stent required • Course in hospital – delirium  UTI treated & BZDP restarted, scheduled tylenol. Cardiac status stable  back to cognitive baseline on discharge. Discharged on same meds plus plavix and higher dose of lipitor (80 mg OD) • Sees you 8 weeks after discharge with her daughter. Daughter is visiting but going back to Alberta in 2 weeks and is concerned about her mother’s memory & her ability to manage.

22. History – Most important • Must discuss with family / caregiver. Patient often has limited insight. • Time course & functional impairments • Ask for specific examples - • What are they forgetting? • Names of close friends or family? • Appointments, medications (irregular refill periods) • Repeatedly asking same question • Visual hallucinations? Unexplained falls? • Personality changes? Unusual behavior? • Safety issues • Do they ever leave the stove on or water running? • Do they eat healthy and regularly? • Have they had any problems driving or getting lost in familiar areas • Have they become aggressive? • Legal issues – do they have POA, will and living will in place?

23. History: 10 WARNING SIGNS • Memory loss that affects day to day function • Short term more than long term • Difficulty performing familiar tasks • Preparing meals, forget you ate it • Problems with language • Forgetting simple words, substituting words • Disorientation of time and place • Lost on own street, unable to get home • Poor or decreased judgment • Dress inappropiate for weather • Problems with abstract thinking • Balance checkbook, not understanding what a birthday is • Misplacing things • Put in inappropriate place • Change in mood or behavior • Mood swings for no reason • Changes in personality • Confused, suspicious, withdrawn • Apathy, acting inappropriately • Loss of initiative • Needs prompting to become involved Alzheimer Society of Canada

24. Physical Exam • May be completely normal • Focal neurological signs • Up-going plantar  stroke • Peripheral neuropathy  rule out B12 deficiency • Slow reflexes  hypothyroidism • Primitive reflexes  frontal or advanced cerebral atrophy • Cognitive Testing • Mini – Cog - part of normal neuro exam • 3 word registration, clock & 3 word recall • MMSE and Clock Drawing Test – if abnormal Mini-Cog • MOCA can be used for mild cognitive impairment • The score does NOT make diagnosis • Adjust for age, education • How much of a struggle is it for them to complete?

25. Investigations- Canadian Guidelines • Labs – RULE OUT reversible causes • CBC, electrolytes, TSH, B12, serum Calcium, serum glucose • If warranted: liver function (ETOHic), CXR – lung Ca • Indications for Neuroimaging • Structural Imaging – CT / MRI – reasonable per Clarfield Criteria • Functional Imaging – PET / SPECTin the differential diagnosis of dementia, particularly those with questionable early stage dementia or those with frontotemporal dementia • fMRI and MRS scanning are not recommended, but promising

26. Clarfield criteria for CT: • age < 70 • new onset dementia , < 1 year • atypical presentation • rapid unexplained deterioration • unexplained focal signs, symptoms • head injury • incontinence, gait ataxia • need for reassurance of patient, family 1.Clarfield, CMAJ, (1991), vol.144(7), 851-853 2.Patterson et al., (1999) CMAJ, vol.160,(Supp.12),S1-15

27. Atrophy in Alzheimer’s disease Atrophy of the brain in AD: Medial temporal lobes are affected first and most severely Figure from: 8. http://pathology.ouhsc.edu/DeptLabs/diagnostic_center_for_alzheimer.htm

28. Mrs. B - Clinic Visit • Patient not really concerned about her memory and thinks she is OK • Daughter • Progressive memory last year – repeats herself, trouble names and birthdays. • Low mood, mother up at night – easily confused • Eats mostly frozen dinners, but rotting food in fridge. • Eats lots of blueberries • Not sure taking her meds correctly and found a few overdue bills around the house. • Concerned about her driving. Was driving to Market Mall but not recently.

29. Clinic Visit • Vitals stable, BP 130/70, HR 80 • Physical exam - unremarkable • MMSE 22/30 (-2 orientation, -3 recall, -1 WORLD, -2 language) • Clock – hands placed wrong, slight spacing errors • FAQ = 26 • Geriatric Depression Scale – 3/15

30. What is the differential diagnosis? • Delirium – in hospital, but daughter agrees back to baseline • Depression – possible – widowed, post-MI, but GDS 3/15 and patient denies • Dementia – progressive loss memory and function • reversible loss of cognition • Mild cognitive impairment or true dementia

31. DEPRESSION vs DEMENTIA The symptoms of depression and dementia often overlap; patients with primary depression: • Demonstrate  motivation during cognitive testing • “I don’t know” – ie: results in loss of points on MMSE • Tell us that memory problems are a lot worse than we find on testing. • Language and motor skills remain normal If you suspect depression  need to treat first before diagnosis of dementia can be made

32. What is the differential diagnosis? • Delirium – in hospital, but daughter agrees back to baseline • Depression – possible – widowed, post-MI, but GDS 3/15 and patient denies • Dementia – progressive loss memory and function • reversible loss of cognition • Mild cognitive impairment or true dementia

33. IS IT reversible? • Medication side effects • Depression • Vitamin B12 deficiency • Chronic alcoholism • High calcium levels • Neurological disorders – normal pressure hydrocephalus • Certain tumors or infections of the brain • Metabolic imbalances, including thyroid, kidney or liver disorders

34. What medications could be affecting her cognition? • Detrol – anticholinergic • Clonazepam – BZDP  sedating • Added risk of falls • ? Wine – need to confirm the amount • ? Metformin – ? hypoglycemia, falls • ? Diovan (Valsartan) – low blood pressure, orthostatic hypotension

35. Is IT Dementia? • A decline from a previous level of cognitive function • memory • language (naming) • Executive abilities – planning, abstract thinking, organization, conceptual shift • construction/visuospatial function • Personality change • Insidious and progressive • KEY QUESTION: • Impairment is sufficient to interfere with function and Activities of Daily Living.

37. Mild Cognitive Impairment • Memory complaints • Memory impaired for age ( generally 1.5 SD) • General cognitive function: normal for age • Normal activities of daily living • Not meeting dementia criteria = Function Not Affected Petersen RC et al Arch Neurol 56(3)303-308 1999

38. Common Risk Factors for Developing MCI • Elevated systolic BP • Hypertension • Elevated cholesterol in mid-life • Low level of education • African-American descent • Cerebral infarcts evident on MRI • Depression • Mechanisms may be vascular atherosclerotic mechanisms, or directly through hastening the pathophysiology of AD. 1 Launer LJ et al. JAMA, 1995; 2 Carmelli D et al. Neurology, 1998; 3 Kivipelto M et al. Neurology, 2001;4 Lopez OL et al. Arch Neurol, 2003.

39. MILD COGNITIVE IMPAIRMENT • Areas of brain begin to shrink • Cognitive problem (usually memory) but does not interfere with activities • Memory storage & retrieval problem • Executive function • apathy • Treatment – monitor patient and vascular risk factors • 10-25% progress to dementia per year (vs 1-2% non-MCI)

40. Course of Aging, MCI and AD Brain Aging Brain Aging “Brain”AD Mild MCI Cognitive Decline Moderate Moderately Severe Clinical AD Severe Time (Years) (Ferris, 4/03)

42. DEMENTIA IN CANADA • 8% of all individuals > 65 years old • Incidence / Prevalence  with age • 1 in 10 over the age of 75 • 1 in 3 over the age of 85 • Annual cost = 3.9 billion dollars • AD = 747/1125 (66%) of dementia cases (CSHA) • 95% sporadic Canadian Study of Health & Aging. CMAJ 1994:150:899-913

43. 850 750 650 550 450 350 250 150 0 Projected Prevalence of AD 300,000 Alzheimer’s Cases Today - > 750,000 Projected Within a Generation 750 500 000’s 300 2031 2000 2011 Canadian Study of Health & Aging Working Group. CMAJ 1994; 150:899-913

44. The 5/50 plan: Delaying the onset of AD by 5 years would be associated with a reduction in AD prevalence of 50% A modest delay, such as 1 year, would reduce AD/dementia prevalence by 5%. Brookmeyer, Gray & Kawas, Am J Publ Health 88 (9), 1337-1342 1998 .

45. Benefits of Early Intervention • Drug therapy – slows down progression of dementia • Not appropriate to expect an improvement • Improve family / caregiver stress • Plan for change before need becomes urgent • Education – anticipate change and have some ways to cope • Allows time to prepare for taking over roles of dementia patient • Enhance patient’s sense of control • If early, can participate in management decisions • Future planning – POA, will, living will, end of life care • Promote safety – medications, wandering, driving, falls

46. DIFFERENT TYPES OF DEMENTIA Other dementias Frontal lobe dementia Creutzfeldt-Jakob disease Corticobasal degenerationProgressive supranuclear palsy Many others Vascular dementiasMulti-infarct dementiaBinswanger’s disease Dementia with Lewy bodies Parkinson’s disease Diffuse Lewy body disease Lewy body variant of AD Vascular dementias and AD AD and dementia with Lewy bodies AD 5% 10% 65% 5% 7% 8% CSHA - CMAJ 1994; Small et al, 1997; APA, 1997; Morris, 1994.

47. 4 major types of dementia • Alzheimer’s Disease (AD) • Includes Mixed-AD • Vascular Dementia (VaD) • Includes large & small vessel disease • Frontotemporal Dementia (FTD) • Includes Pick’s disease, progressive nonfluent aphasia, & semantic dementia • Dementia with Lewy Body (DLB) • Includes Parkinson’s disease dementia

49. ~105 years ago… • 51 yo German woman admitted Nov 25, 1901 to psychiatry under Dr. Alois Alzheimer • Hx – cog impairment (memory, language, orientation) & behavioral probs (paranoia, agitation) • Progressive decline  died Apr 6, 1906  neuropathology showed plaques & tangles • Dr. Alzheimer reported case 1907 Auguste D Lancet, 1997;349:1546-49

50. DSM Criteria for AD • 1. Insidious Onset with progressive decline • 2. Memory Impairment and at least one of the following: • Aphasia (language) • Apraxia (unable to carry out directed movement) • Agnosia (unable to recognize specific items in environment) • Disturbance in executive functioning • 3. Interferes with daily function • 4. Does not occur exclusively during delirium and not due to other neurological, psychiatric, toxic, metabolic or systematic diseases