Dementia

1. Dementia Karol L. Gordon, DO, CAQG, CMD Via College of Osteopathic Medicine August, 2010 Edited by Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012

2. Objectives • Discuss the different types of dementia and cognitive decline. • Orderthe proper evaluationfor suspected dementia. • List dementia treatment options.

3. Age-Related Cognitive Decline • The age-related physiologic changes that affect central nervous system function include atrophy, but not dementia. • Intellectual function peaks at age 20–30 yrs, plateaus until the mid-eighties, and then declines gradually. • The prevalence of dementia rises steadily, • approximately doubling every 5 yrs from • 1.5% in those aged 65–70 yrs to nearly • 25% in those over age 85 yr

4. Age-Related Cognitive Decline • This diagnosis is used when there is an objectively identified decline in cognitive functioning from the aging process that is normal for age. • Individuals with this condition may report problems remembering names or appointments or may experience difficulty in solving complex problems. • This category should be considered only after it has been determined that the cognitive impairment is not attributable to a specific mental disorder or neurological condition.

5. Age-Related Cognitive Decline • ARCD usually occurs gradually. • Sudden cognitive decline is not a part of normal aging. • When people develop an illness such as Alzheimer’s disease, mental deterioration usually happens quickly. • In contrast, cognitive performance in elderly adults normally remains stable over many years, with only slight declines in short-term memory and reaction times.

6. DEMENTIA An acquired syndrome of decline in memory and other cognitive functions that affects daily life by interfering with work or social relationships (DSM-IV).

7. DEMENTIA • Most common cause of adult brain disease • 1.5x more common than stroke or epilepsy • As common as CHF • By 2030 prevalence will be 9 million

8. Differential Diagnosis • Delirium • Depression • Thyroid disease • Normal-pressure hydrocephalus • Anemia • Metabolic abnormalities • Tertiary syphilis • HIV/AIDS

9. Types of Dementia • Alzheimer’s Disease (AD)- 75% • Vascular- 15% • Mixed • Other

10. Alzheimer’s Disease Progressive, persistent deterioration in multiple domains: • Memory • Cognition • Language • Communication • Visuospatial skills

11. Risk Factors for AD • Advancing age • Family history of AD • Smoking • Head injury • Down’s syndrome

12. Early Stages • Mild memory loss • Difficulty retaining new information • Difficulty accessing older memories • Interfering with Instrumental ADL’s • Planning meals • Managing finances • Taking medication • Driving • Personality changes

13. Diagnosis of AD • Dementia present • H&P and MMSE are consistent with AD • Screening blood tests are WNL • CT or MRI is normal or shows atrophy

14. Vascular Dementia • Presence of documented cardiovascular disease • Dementia syndrome • Definitive temporal relationship between the two

15. Risk Factors for Vascular Dementia • Stroke • Transient ischemic attacks • Hypertension • Hyperlipidemia • General atherosclerosis • Atrial fibrillation • Coronary heart disease • Diabetes mellitus

16. Diagnosis of Vascular Dementia • Dementia • 2 or more of the following are present • Focal neurologic signs on PE • Onset abrupt, stepwise, or stroke related • CT/MRI shows multiple strokes

17. Lewy Body Dementia • Parkinson’s symptoms and psychosis accompany dementia • Two of the following core features: • Fluctuating cognition with pronounced variations in attention and alertness • Recurrent visual hallucinations that are typically well formed and detailed • Spontaneous motor features of Parkinsonism

18. Supportive of Diagnosis of LBD • Repeated falls • Syncope • Transient loss of consciousness • Neuroleptic sensitivity • Delusions • Hallucinations

19. Evaluation of Dementia • H&P • Interview spouse, immediate family member, or caregiver • Assess family needs and caregiver stress • Mini-Mental State Exam • Labs • Imaging (of marginal value)

20. Labs in the Diagnosis of Dementia • CBC- checking for anemia which can worsen cognition • CMP- evaluating electrolytes, renal function, liver function which can alter cognition • TSH- thyroid disease can worsen memory making dementia appear worse

21. Labs continued • Vitamin B12 and folic acid - if deficient can make memory appear worse • RPR (& FTA if indicated) - for syphilis. Tertiary syphilis can cause memory problems • HIV - dementia occurs in this condition

22. Labs continued • It is important to rule out these potentially reversible causes of memory loss before giving someone the diagnosis of dementia! • Once these abnormalities have been corrected you will often times see improvement in cognition.

23. Mini-Mental State Exam • See the write up of this test on the geriatrics rotation website. It relates to educational level and degree of consciousness and awareness. • Standardized test of memory ability scored 0 to 30.

24. Prognosis • Most demented people die from anorexia and the resulting cachexia. • When the vocabulary is less than 5 words, the life expectancy is less than 6 months. • Debility is progressive as activity wanes.

25. Treatment of Dementia • Goals • Maintain quality of life • Maximize functioning and independence by enhancing cognition • Treat mood and behavior problems • Multidisciplinary team • Medications- in most patients you will start medications when the MMSE is 24 or less.

26. Social Management • Daily routine- important to help prevent confusion for the patients • Patience is key - remember that it may be the 10th time you’ve told them the same thing, but for them it’s the first time every time • Face-to-face interaction • Perform simple tasks - it helps the patients feel they are needed

27. Social Management • Safe environment: severe dementia patients often wander, especially at night. • Make sure they are not able to get out at night on their own and get lost. • Make the decision that they are not appropriate to live alone when needed. This prevents them putting something on the stove and forgetting it, leading to fires and other potential hazards.

28. Social Management Legal issues-get advanced directive early so the patient can participate in making them • DNR: remind them DNR does not mean ‘Do Not Treat’. When the heart and lungs stop working resuscitation will not be tried. • POA: power of attorney. Most POA’s do not take effect until an event happens that renders the patient no longer able to make decisions. A POA does not take away the right to make decisions by patients who are capable of doing so. It gives them the chance to choose whom they want making their decisions when they cannot.

29. Reversible Factors • Main Thing: • Eliminate as many medications as possible. • Substitute less toxic ones. • Discontinue alcohol and all sleeping pills. • Address all medical problems including • correctable vision loss • hearing loss • CNS injury from strokes, hypoxia, or hypoglycemia • Depression

30. Beers’ List • This is a medical journal article in its 3rd revision that defines medications potentially harmful to the elderly. • It is on the geriatrics website at VCOM: READ IT INTENTLY • Journal of the American Geriatrics Society, April 2012 issue • Generally they are medications such as • Sedatives • Hypnotics • Opioids • Anticholinergics

31. Reversible Factors • Ask the patient or the family to bring in all medications for careful review. • Check for infections, especially respiratory and genitourinary. • Check electrolytes (Na, bicarbonate, K) . • Check endocrine function (thyroid dysfunction, parathyroid, NIDDM).

32. Acetylcholinesterase Inhibitors • Donepezil • Galantamine • Rivastigmine

33. Donepezil • Inhibitor of acetylcholinesterace • Starting dose 5 mg qhs • Increase to 10 mg qhs after 4 - 6 wks • Increase to 23 mg po qhs after 3 months • Activated by cytochrome P450 2D6 & 3A4 • Side effects: nausea, vomiting, diarrhea, insomnia, anorexia

34. Galantamine • Inhibits acetylcholinesterase • Give bid with meals • Start 4mg bid • Increase by 4 mg bid every 4 weeks to 12 mg bid maximum • Activated by cytochrome P450 2D6 & 3A4 • Renal or hepatic impairment  max dose 16mg/d • Side effects: Nausea, vomiting, diarrhea, anorexia

35. Rivastigmine patch • Inhibitor of acetylcholinesterase • Start dose 4.6 mg qd x 4-5 weeks • Increase dose after 4 weeks to 9.5 mg qd • Oral form causes excessive nausea and anorexia • Side effects: nausea, vomiting, diarrhea, anorexia, rash under patches

36. Memantine NMDA receptor antagonist Often added to acetylcholinesterace inhibitors Give 5 mg po qhs, then titrate upward weekly to 5 mg bid, 5 qam with 10 qhs, and then 10 bid maximum Side effects minimal Renal excretion: limit to 5 mg bid if Ccr <30

37. Dementia Medications Titrate as tolerated Try different ones if others fail Stop any that is optimally dosed without benefit or that has side effects

38. Caregiver Support • Regular visits every 4-6 months • Community resources: help family become aware of locally available services, i.e. adult day care or a dementia support group. Social workers may be helpful. • Education: helps the family understand the disease and its progression, giving them the feeling of some degree of control.

39. Caregiver Support Respite care: • Medicare will cover 21 days of this a year. • The patient can go into a nursing facility to give the caregivers a break. • This can be key in preventing caregiver stress which may lead to elder abuse.

40. Caregiver Support Plan early with patients and family for future. Ask what they want done and counsel them. • Goals of care: Aggressive management, comfort and palliative care, preventive care, surgery, parenteral fluids, etc. • Placement issues: home, sitters, assisted living, nursing home, etc. • Feeding tubes: These do not prolong life in anorexic, demented people. They should generally be discouraged. • DNR: Explain carefully. • POA: Assign someone. Resolve conflicts if possible. • Hospitalization: Not indicated if comfort and palliative care is the main goal of care.

41. Resources for Patients and Families with Alzheimer’s • Alzheimer’s Association • 800-272-3900 • www.alz.org • Family Caregiver Alliance • 800-445-8106 • www.caregiver.org • National Family Caregivers Association • 800-896-3650 • www.nfcacares.org