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Dementia 6 24-13-rotary_revised

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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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