Dementia 6 24-13-rotary_revised

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  • You all identified the key core problems associated with cognitive impairment….this list could be much longer if we incorporate all the specific issues that impact cognition, such as drugs, diseases….
  • In short, dementia is very common and has very important health consequences.
  • Need better PET scan slides
  • While Alzheimer disease dominates our images of dementia, this spectrum of diagnoses is more evenly divided than most understand or believe. Important 3-4 causes include Alzheimer’s disease, Dementia with LB, vascular dementia and frontal temporal lobe dementia. Many would also include PD with its later onset of cognitive problems in this group. In any case, dementing illness is more likely a spectrum of problems with a variety injuries and initiating factors.
  • You all identified the key core problems associated with cognitive impairment….this list could be much longer if we incorporate all the specific issues that impact cognition, such as drugs, diseases….
  • You all have created a great list. I want to address some of these today. Treatment is very important and can be integrated into this discussion, but the emphasis here is the natural history of this disease, which has been largely undisturbed by medications and other therapies.
  • The key here is for families and patients to consider what makes their life meaningful…what are they able to do on a daily basis that makes their day brighter. Playing cards, bowling, talking on the phone, gardening.
  • Also, recall that a change or worsening in symptoms may represent some agitating or irritating factor. People with dementia have trouble solving problems or identifying sources of discomfort.
  • Key: Establish early---usually visit after diagnosis. Discuss management options and the fact that they will lose their ability to drive at some point in the future and will need to set up some alternative means of transportation. If the situation is dangerous or unmanageable, referral to DMV with a letter. Other maneuvers are warranted…removing the keys, disabling the car or removing the car altogether. But need to anticipate the stress this can precipitate. Increase activity, car rides and trips. Ensure a source of transportation.
  • This is the one that caregivers and patients put off or avoid talking about. What will happen when things get worse. This requires a careful review of resources and preferences. Early on folks may say “We want to keep him or her home…or home as long as possible.” While it is not necessary to disuade them, it is important to reorient them and always remind them that these decisions are easier to make in anticipation---visit facilities, review finances and don’t wait for some catastrophe to happen.
  • Dementia 6 24-13-rotary_revised

    1. 1. Duke GECwww.geriatriceducation.duke.edu
    2. 2. Duke GECwww.geriatriceducation.duke.eduDementia: Is it or isn’t it?Mitchell T. Heflin, MD, MHSDuke UniversityDept. of Medicine, Division of GeriatricsJune 24, 2013
    3. 3. clinician net workhttp://careinaging.duke.edu/cliniciansNormal Aging:• Decline in brainweight and size• Slowed processingspeeds and verbalabilities• Improvements injudgement andreasoning
    4. 4. clinician net workhttp://careinaging.duke.edu/cliniciansCauses of Cognitive Impairment• Delirium• Depression or anxiety• Mild memory disorders• Medications• Alcohol• Low hearing or vision• Sleep problems
    5. 5. clinician net workhttp://careinaging.duke.edu/cliniciansDefinition of dementia• Dementia is an acquired syndrome in whichprogressive deterioration in globalintellectual abilities is of such severity thatit interferes with the person’s customaryoccupational, functional, and socialperformance. The changes characteristic ofdementia fall into three categories:cognitive, functional, and behavioral.Evidence Based Guidelines for Dementia. January 2002. Kaiser Permanente,Care Management Institute’s Dementia Guidelines Workgroup.
    6. 6. Duke GECwww.geriatriceducation.duke.eduDementia- Prevalence• 1% in 60-65 year olds• 30% (or more) in 90 + year olds• Increased risk of:DeliriumDeathDisabilityNursing home placement• Aggregate costs: $157-215 billion annuallyHurd, 2013.
    7. 7. Duke GECwww.geriatriceducation.duke.eduPhysiology slide
    8. 8. Duke GECwww.geriatriceducation.duke.eduPET Scanusatoday30.usatoday.com
    9. 9. Duke GECwww.geriatriceducation.duke.eduRelative Proportions of Dementia DiagnosesSource: Mendez M F, Cummings J L.2003. Dementia: A Clinical Approach, 3rdEdition Philadelphia: Butterworth-Heinemann. P. 8.
    10. 10. Duke GECwww.geriatriceducation.duke.eduAlzheimer’s disease (AD)• Slowly progressive• Memory• Orientation• Visuospatial function• Reasoning and decisionmaking
    11. 11. Duke GECwww.geriatriceducation.duke.eduFrontotemporal Lobe Dementia (FTD)• Behavior• Speech• Decision making• Insight• Gait and balance• Vision
    12. 12. Duke GECwww.geriatriceducation.duke.eduDementia with Lewy Bodies (DLB)• Fluctuating symptoms• Parkinsonism• Visual hallucinations• Sensitive toantipsychotics• Prone to falls
    13. 13. Duke GECwww.geriatriceducation.duke.eduVascular Dementia (VaD)• Spectrum disorder• Vascular risk factors +/-history of stroke• Variable cognitivedeficits• Executive function• Apathy• Gait instability
    14. 14. Duke GECwww.geriatriceducation.duke.eduMild Cognitive Impairment (MCI)• Impairment in memory or other cognitivedomain• No apparent impact on function• Amnestic v. non-amnestic versions• Approx 15% progress to dementia annually
    15. 15. Duke GECwww.geriatriceducation.duke.edu
    16. 16. Duke GECwww.geriatriceducation.duke.eduWork-upBefore:•Collect records from prior visits•Family and other carers at the visit•Collect medications for review at visitDuring:•Establish goals of visit•Medical, social, family, medication and symptomhistory with separate time for family•Exam: Memory, Mood, Mobility, Hearing, Visionhttp://dementia.americangeriatrics.org/documents/AGS_PC_Dementia_Sheet_2010v2.pdf
    17. 17. Duke GECwww.geriatriceducation.duke.eduWork-up• After:– Bloodwork:• CBC, Kidney and liver function, Electrolytes, Vitamin B12,Thyroid function.• Occasionally: Syphilis, HIV, Lipids– Brain imaging:• CAT scan or MRI—age < 60, focal findings, abrupt decline,anticoagulants, cancer– Neuropsychological testing– Rarely• EEG or PET scan—approved if FTD suspectedhttp://dementia.americangeriatrics.org/documents/AGS_PC_Dementia_Sheet_2010v2.pdf
    18. 18. clinician net workhttp://careinaging.duke.edu/cliniciansNew Guidelines:Earlier Recognition• Clinical testing• Spinal fluid forproteins: tau, Aβ42• Volumecomparison MRI• PET Scans
    19. 19. clinician net workhttp://careinaging.duke.edu/cliniciansAD Risk factors• Age• Genes: APOE-4• CV disease/risk factors• Head trauma• Inflammation/delirium• Low education level
    20. 20. clinician net workhttp://careinaging.duke.edu/cliniciansWhat’s Next? Treatment (Prevention) Symptoms Safety CaregiverWell-being AdvancePlanning
    21. 21. clinician net workhttp://careinaging.duke.edu/cliniciansA Cure?• Breaking up protein– Vaccines– Others• Decreasinginflammation• Other:– Dimebon– Vitamins– Metabolic• Exercise• Diet• Control risk of strokeand heart attack• Address otherproblems:– Medications– Sleep problems– Hearing loss– Depression
    22. 22. clinician net workhttp://careinaging.duke.edu/cliniciansSymptom Management• Cognitive SymptomsMemory loss,communication problems,loss of executive functionGoals:– better cognitive function– independence/ ease of care– delay institutionalization ordeathAcetylcholinesteraseinhibitorsMemantine
    23. 23. clinician net workhttp://careinaging.duke.edu/cliniciansSymptom Management• Other SymptomsDepression,hallucinations/delusionsAgitation, incontinence, sleepdisturbance, wanderingVariety of environmental andphysical causesNon-pharmacologic measuresoften effective in behavioralsymptoms
    24. 24. clinician net workhttp://careinaging.duke.edu/cliniciansSafetyMedication ManagementHome safety– appliances– wandering– firearmsDriving SafetyPersonal/Financial security
    25. 25. clinician net workhttp://careinaging.duke.edu/cliniciansDriving Safety• Guidelines• Driving Assessment Resources– Duke Adult Out-Patient OT Services:Office:919-684-4543Fax:919-668-2420• NC Division of Motor Vehicles• Education materialsAt the Crossroads: A Guide to Alzheimer’sDisease, Dementia, and Driving
    26. 26. clinician net workhttp://careinaging.duke.edu/cliniciansPREDICTORS OF FAMILY CAREGIVERSTRESS• Frail, female, or strained spouse caregiver living withcare recipient• Depressed, demented, angry or substance-abusingcaregiver• Past or current conflicted family relationships• Financial necessity of family care• Challenging sleep, personality or behavioral symptoms ofcare recipient• Hospitalization or nursing home placement of carerecipient
    27. 27. clinician net workhttp://careinaging.duke.edu/cliniciansAdvance Planning Level of Care Determination Decision Making CapacityConsent for Medical TreatmentLiving alone Advance directivesLiving WillHealthcare Power of AttorneyTube feeding
    28. 28. clinician net workhttp://careinaging.duke.edu/cliniciansGetting Help! Clinical careDuke Geriatrics andGeropsychiatry620-4070Duke Memory DisordersClinic668-7600VA Geriatrics andGeropsychiatry286-0411 Patient and FamilyAlzheimer’sAssociationClinical TrialsDuke Family SupportProgramEldercare locatorFamily CaregiverAlliance
    29. 29. Duke GECwww.geriatriceducation.duke.eduResources• National Alzheimer’s Project Act (NAPA):www.alzheimers.gov• Alzheimer’s Disease Education and Referral (ADEAR):www.nia.nih.gov/alzheimers• Alzheimer’s Association: www.alz.org• Duke Family Support Program:www.dukefamilysupport.org (800) 672-4213• Duke Geriatric Evaluation and Treatment (GET)Clinic--- (919)620-4070

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