5. clinician net work
http://careinaging.duke.edu/clinicians
Definition of dementia
• Dementia is an acquired syndrome in which
progressive deterioration in global
intellectual abilities is of such severity that
it interferes with the person’s customary
occupational, functional, and social
performance. The changes characteristic of
dementia fall into three categories:
cognitive, functional, and behavioral.
Evidence Based Guidelines for Dementia. January 2002. Kaiser Permanente,
Care Management Institute’s Dementia Guidelines Workgroup.
14. Duke GEC
www.geriatriceducation.duke.edu
Mild Cognitive Impairment (MCI)
• Impairment in memory or other cognitive
domain
• No apparent impact on function
• Amnestic v. non-amnestic versions
• Approx 15% progress to dementia annually
16. Duke GEC
www.geriatriceducation.duke.edu
Work-up
Before:
•Collect records from prior visits
•Family and other carers at the visit
•Collect medications for review at visit
During:
•Establish goals of visit
•Medical, social, family, medication and symptom
history with separate time for family
•Exam: Memory, Mood, Mobility, Hearing, Vision
http://dementia.americangeriatrics.org/documents/AGS_PC_Dementia_Sheet_2010v2.pdf
17. Duke GEC
www.geriatriceducation.duke.edu
Work-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 suspected
http://dementia.americangeriatrics.org/documents/AGS_PC_Dementia_Sheet_2010v2.pdf
21. clinician net work
http://careinaging.duke.edu/clinicians
A Cure?
• Breaking up protein
– Vaccines
– Others
• Decreasing
inflammation
• Other:
– Dimebon
– Vitamins
– Metabolic
• Exercise
• Diet
• Control risk of stroke
and heart attack
• Address other
problems:
– Medications
– Sleep problems
– Hearing loss
– Depression
22. clinician net work
http://careinaging.duke.edu/clinicians
Symptom Management
• Cognitive Symptoms
Memory loss,
communication problems,
loss of executive function
Goals:
– better cognitive function
– independence/ ease of care
– delay institutionalization or
death
Acetylcholinesterase
inhibitors
Memantine
23. clinician net work
http://careinaging.duke.edu/clinicians
Symptom Management
• Other Symptoms
Depression,
hallucinations/delusions
Agitation, incontinence, sleep
disturbance, wandering
Variety of environmental and
physical causes
Non-pharmacologic measures
often effective in behavioral
symptoms
25. clinician net work
http://careinaging.duke.edu/clinicians
Driving Safety
• Guidelines
• Driving Assessment Resources
– Duke Adult Out-Patient OT Services:
Office:919-684-4543
Fax:919-668-2420
• NC Division of Motor Vehicles
• Education materials
At the Crossroads: A Guide to Alzheimer’s
Disease, Dementia, and Driving
26. clinician net work
http://careinaging.duke.edu/clinicians
PREDICTORS OF FAMILY CAREGIVER
STRESS
• Frail, female, or strained spouse caregiver living with
care recipient
• Depressed, demented, angry or substance-abusing
caregiver
• Past or current conflicted family relationships
• Financial necessity of family care
• Challenging sleep, personality or behavioral symptoms of
care recipient
• Hospitalization or nursing home placement of care
recipient
28. clinician net work
http://careinaging.duke.edu/clinicians
Getting Help!
Clinical care
Duke Geriatrics and
Geropsychiatry
620-4070
Duke Memory Disorders
Clinic
668-7600
VA Geriatrics and
Geropsychiatry
286-0411
Patient and Family
Alzheimer’s
Association
Clinical Trials
Duke Family Support
Program
Eldercare locator
Family Caregiver
Alliance
29. Duke GEC
www.geriatriceducation.duke.edu
Resources
• 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
Editor's Notes
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.
