Dementia

1,340 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,340
On SlideShare
0
From Embeds
0
Number of Embeds
16
Actions
Shares
0
Downloads
105
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Data from Alzheimer’s Association, “What are the warning signs?” Available at http://www.alz.org
  • Notes Headings (level 1)
    Text of note (level 2).
    Bullet items (level 3)
  • Dementia

    1. 1. 2007 Capital Conference2007 Capital Conference DementiaDementia Colonel Brian Unwin, M.D.Colonel Brian Unwin, M.D. Department of Family Medicine, USUHSDepartment of Family Medicine, USUHS
    2. 2. OBJECTIVESOBJECTIVES  Know and understand:Know and understand:  The risks for and causes of dementiaThe risks for and causes of dementia  Evaluation of patients with dementiaEvaluation of patients with dementia  General behavioral and pharmacologicGeneral behavioral and pharmacologic treatment strategiestreatment strategies  Role of community resources for patient andRole of community resources for patient and caregiverscaregivers
    3. 3. Geriatrics will be part of yourGeriatrics will be part of your practice:practice:  Aged >65 are 14% of our population in 2010,Aged >65 are 14% of our population in 2010, and 25% in 2050and 25% in 2050  Age >85 will be 5% of our population in 2050Age >85 will be 5% of our population in 2050  33% of our office visits, becoming 50% of our33% of our office visits, becoming 50% of our office visitsoffice visits  Accounts for 1/3 of our health care dollarAccounts for 1/3 of our health care dollar
    4. 4. THE DEMOGRAPHY OFTHE DEMOGRAPHY OF ALZHEIMER’S DISEASE (AD)ALZHEIMER’S DISEASE (AD)  4 million in U.S. currently4 million in U.S. currently  14 million in U.S. by 205014 million in U.S. by 2050  1 in 10 persons aged 65+ and nearly half of1 in 10 persons aged 65+ and nearly half of those aged 85+ have ADthose aged 85+ have AD  Life expectancy of 8-10 years after symptomsLife expectancy of 8-10 years after symptoms beginbegin
    5. 5. THE IMPACT OF DEMENTIATHE IMPACT OF DEMENTIA  EconomicEconomic  $199 billion annually$199 billion annually for care and lostfor care and lost productivityproductivity  Medicare, Medicaid,Medicare, Medicaid, private insuranceprivate insurance provide only partialprovide only partial coveragecoverage  Families bear greatestFamilies bear greatest burden of expenseburden of expense  EmotionalEmotional  Direct toll on patientsDirect toll on patients  Nearly half ofNearly half of caregivers suffercaregivers suffer depressiondepression
    6. 6. JAGS. 1998. 46:782-783. Dementia and Goals of CareDementia and Goals of Care  Prolonging lifeProlonging life  Preventing M&MPreventing M&M  Prevent functionalPrevent functional declinedecline  Slow progressionSlow progression  DecreaseDecrease psychiatric/behavioralpsychiatric/behavioral problemsproblems  DialysisDialysis  ImmunizationsImmunizations  Fall reduction programFall reduction program  Cholinesterase InhibitionCholinesterase Inhibition and Memantineand Memantine  Pharmacologic andPharmacologic and behavioral interventionsbehavioral interventions
    7. 7. JAGS. 1998. 46: 782-283. Dementia and Goals of CareDementia and Goals of Care  Restore and improveRestore and improve functionfunction  Decrease caregiverDecrease caregiver burdenburden  Achieve a peaceful deathAchieve a peaceful death  Rehab after fractureRehab after fracture  Support groups andSupport groups and community servicescommunity services  Hospice referralHospice referral
    8. 8. WHAT IS DEMENTIA?WHAT IS DEMENTIA?
    9. 9. DSM-IVDSM-IV DIAGNOSTICDIAGNOSTIC CRITERIA FOR ALZHEIMER’SCRITERIA FOR ALZHEIMER’S DEMENTIA (AD):DEMENTIA (AD):  Development of cognitive deficits manifested by bothDevelopment of cognitive deficits manifested by both  impaired memoryimpaired memory  aphasia, apraxia, agnosia, disturbed executive functionaphasia, apraxia, agnosia, disturbed executive function  Significantly impaired social, occupational functionSignificantly impaired social, occupational function  Gradual onset, continuing declineGradual onset, continuing decline  Not due to CNS or other physical conditions (e.g.,Not due to CNS or other physical conditions (e.g., Parkinson’s, delirium)Parkinson’s, delirium)  Not due to an Axis I disorder (e.g., schizophrenia)Not due to an Axis I disorder (e.g., schizophrenia)
    10. 10. SYMPTOMS & SIGNS OF ADSYMPTOMS & SIGNS OF AD  Memory impairmentMemory impairment  Gradual onset, progressive cognitive declineGradual onset, progressive cognitive decline  Behavior and mood changesBehavior and mood changes  Difficulty learning, retaining new informationDifficulty learning, retaining new information  Aphasia, apraxia, disorientation, visuospatialAphasia, apraxia, disorientation, visuospatial dysfunctiondysfunction  Impaired executive function, judgmentImpaired executive function, judgment  Delusions, hallucinations, aggression, wanderingDelusions, hallucinations, aggression, wandering
    11. 11. J Am Ger Soc. 1996; 44(9): 1078-1081 Behavioral Disturbances inBehavioral Disturbances in Dementia:Dementia:
    12. 12. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS FOR DEMENTIA:FOR DEMENTIA:  Alzheimer’s disease-Alzheimer’s disease- 70%70%  Vascular dementia-Vascular dementia- 10-20%10-20%  Dementia associatedDementia associated with Lewy bodieswith Lewy bodies (associated with PD(associated with PD features)features)  Frontal lobe- Picks:Frontal lobe- Picks: <5%<5%  OtherOther  AlcoholAlcohol  Parkinson's disease [PD]Parkinson's disease [PD]  DeliriumDelirium  DepressionDepression  NeurosyphilisNeurosyphilis  Creutzfeldt-JakobCreutzfeldt-Jakob (1/167,000 in U.S.(1/167,000 in U.S. annually)annually)  NPHNPH (ataxia>incontinence>(ataxia>incontinence> cognition)cognition)  ““Normal”Normal”
    13. 13. NORMAL LAPSES vs DEMENTIANORMAL LAPSES vs DEMENTIA Examples (1 of 2)Examples (1 of 2)  Forgetting a nameForgetting a name  Leaving kettle onLeaving kettle on  Finding right wordFinding right word  Forgetting date or dayForgetting date or day  Not recognizing familyNot recognizing family membermember  Forgetting to serveForgetting to serve meal just preparedmeal just prepared  SubstitutingSubstituting inappropriate wordsinappropriate words  Getting lost in ownGetting lost in own neighborhoodneighborhood
    14. 14. NORMAL LAPSES vs DEMENTIANORMAL LAPSES vs DEMENTIA Examples (2 of 2)Examples (2 of 2)  Trouble balancingTrouble balancing checkbookcheckbook  Losing keys, glassesLosing keys, glasses  Getting blues in sadGetting blues in sad situationssituations  Gradual changes withGradual changes with agingaging  Not recognizingNot recognizing numbersnumbers  Putting iron in freezerPutting iron in freezer  Rapid mood swings forRapid mood swings for no reasonno reason  Sudden, dramaticSudden, dramatic personality changepersonality change
    15. 15. DEPRESSION vs DEMENTIA:DEPRESSION vs DEMENTIA:  The symptoms of depression and dementiaThe symptoms of depression and dementia often overlapoften overlap  Late life depression can herald impendingLate life depression can herald impending dementiadementia  In general, patients with primary depression:In general, patients with primary depression:  DemonstrateDemonstrate ↓↓ motivation during cognitive testingmotivation during cognitive testing  Express cognitive complaints that exceed measuredExpress cognitive complaints that exceed measured deficitsdeficits  Maintain language and motor skillsMaintain language and motor skills
    16. 16. Risk Factors for ADRisk Factors for AD  AgeAge  Family historyFamily history  Head injuryHead injury  Fewer years of educationFewer years of education  Down’s SyndromeDown’s Syndrome  Metabolic Syndrome?Metabolic Syndrome?  Inactivity?Inactivity?  Vascular disease riskVascular disease risk factorsfactors
    17. 17. THE GENETICS OFTHE GENETICS OF DEMENTIADEMENTIA  Mutations ofMutations of chromosomes 1, 14, 21chromosomes 1, 14, 21  Rare early-onset (beforeRare early-onset (before age 60) familial forms ofage 60) familial forms of dementiadementia  Down’s syndromeDown’s syndrome  Limited indicationsLimited indications for screeningfor screening  Apolipoprotein E4 onApolipoprotein E4 on chromosome 19chromosome 19  Late-onset ADLate-onset AD  APOE*4 alleleAPOE*4 allele ↑↑ risk &risk & ↓↓ onset age in dose-relatedonset age in dose-related fashionfashion  APOE*2 allele may haveAPOE*2 allele may have protective effectprotective effect  Limited indications forLimited indications for screeningscreening
    18. 18. HISTORYHISTORY::  Ask both the patientAsk both the patient & a reliable informant& a reliable informant about the patient’s:about the patient’s:  Current conditionCurrent condition  Medical historyMedical history  Current medicationsCurrent medications & medication history& medication history  Patterns of alcoholPatterns of alcohol use or abuseuse or abuse  Living arrangementsLiving arrangements
    19. 19. PHYSICALPHYSICAL  Examine:Examine:  Neurologic statusNeurologic status  Mental statusMental status  Functional statusFunctional status  Hearing/vision lossHearing/vision loss  Include:Include:  Quantified screens forQuantified screens for cognition and depressioncognition and depression  e.g., Folstein’s MMSE,e.g., Folstein’s MMSE, Clock DrawClock Draw  Neuropsychologic testingNeuropsychologic testing for uncertain casesfor uncertain cases
    20. 20. Clock Draw TestClock Draw Test  Instructions:Instructions:  ““Draw the face of a clock, putting the numbers inDraw the face of a clock, putting the numbers in correct position. I’ll then ask you to indicate a timecorrect position. I’ll then ask you to indicate a time after you are done.”after you are done.”  Ask the patient to draw in the hands at ten minutesAsk the patient to draw in the hands at ten minutes after eleven or twenty minutes after eight.after eleven or twenty minutes after eight.
    21. 21. Clock Draw TestClock Draw Test  Scoring:Scoring:  Draws closed circle: 1 pointDraws closed circle: 1 point  Places numbers in correct position: 1 pointPlaces numbers in correct position: 1 point  Includes all 12 correct numbers: 1 pointIncludes all 12 correct numbers: 1 point  Places hands in correct position: 1 pointPlaces hands in correct position: 1 point  Interpretation:Interpretation:  Clinical judgment MUST be appliedClinical judgment MUST be applied  Cognitively impaired people typically don’t draw aCognitively impaired people typically don’t draw a perfect clockperfect clock
    22. 22. Clock Draw InterpretationClock Draw Interpretation  CDT of 4 approximates a MMSE of near 30 orCDT of 4 approximates a MMSE of near 30 or mild cognitive impairmentmild cognitive impairment  CDT of 2 puts patient in the moderateCDT of 2 puts patient in the moderate impairment of MMSE scores of high teens.impairment of MMSE scores of high teens.  CDT of 1 reflects moderate-to-severe scores onCDT of 1 reflects moderate-to-severe scores on MMSE (low teens)MMSE (low teens)  Abnormal results suggests need for furtherAbnormal results suggests need for further assessmentassessment
    23. 23. Clock Draw Examples:Clock Draw Examples:
    24. 24. Mini-Mental State ExamMini-Mental State Exam (MMSE):(MMSE):  30-point scale to evaluate orientation, concentration,30-point scale to evaluate orientation, concentration, verbal and visual-spatial skillsverbal and visual-spatial skills  Not necessarily the “gold standard,” but mostNot necessarily the “gold standard,” but most commonly recognized.commonly recognized.  Subject to level of educational attainment, languageSubject to level of educational attainment, language barriers, and vision/hearing requirementsbarriers, and vision/hearing requirements  ““Early” stages typically score 21-30, “moderate” 11-20,Early” stages typically score 21-30, “moderate” 11-20, and end-stage 0-10and end-stage 0-10
    25. 25. Function and Mental Status:Function and Mental Status:
    26. 26. What labs to do?What labs to do?
    27. 27. LABORATORYLABORATORY::  Laboratory tests should include:Laboratory tests should include:  Complete blood cell countComplete blood cell count  Blood chemistriesBlood chemistries  Liver function testsLiver function tests  Consider HIV testingConsider HIV testing  Serologic tests for:Serologic tests for: Syphilis, TSH, B12 levelSyphilis, TSH, B12 level
    28. 28. To image or not to image…To image or not to image…
    29. 29. IMAGINGIMAGING::  Use imaging when:Use imaging when:  Onset occurs at age < 65 yearsOnset occurs at age < 65 years  Symptoms have occurred for < 2 yearsSymptoms have occurred for < 2 years  Neurologic signs are asymmetricNeurologic signs are asymmetric  Clinical picture suggests normal-pressureClinical picture suggests normal-pressure hydrocephalushydrocephalus  Consider:Consider:  Noncontrast computed topography head scanNoncontrast computed topography head scan  Magnetic resonance imagingMagnetic resonance imaging  Positron emission tomographyPositron emission tomography
    30. 30. TREATMENT & MANAGEMENT:TREATMENT & MANAGEMENT:  Primary goals:Primary goals:  To enhance quality of lifeTo enhance quality of life  Maximize functional performance by improvingMaximize functional performance by improving  CognitionCognition  MoodMood  BehaviorBehavior
    31. 31. Primary GoalsPrimary Goals  Help the caregiverHelp the caregiver  Treat depression (patient and caregiver)Treat depression (patient and caregiver)  Advanced planning (Living Will and DPOA)Advanced planning (Living Will and DPOA)  Patient and caregiver educationPatient and caregiver education  Social Work ServicesSocial Work Services  Respite servicesRespite services  Honest assessment of abilities (i.e., driving,Honest assessment of abilities (i.e., driving, finances, etc.)finances, etc.)
    32. 32. Primary Goals (continued)Primary Goals (continued)  Take care of the eyesTake care of the eyes  Take care of the hearingTake care of the hearing  Take care of the teethTake care of the teeth  Some patients need Adult Protective ServicesSome patients need Adult Protective Services
    33. 33. Area Agency on AgingArea Agency on Aging
    34. 34. Cholinesterase InhibitorsCholinesterase Inhibitors  Donepezil (Aricept):1996Donepezil (Aricept):1996  Delay nursing home placement and progressionDelay nursing home placement and progression  5mg q d (start) to 10mg q d5mg q d (start) to 10mg q d  Rivastigmine (Exelon):2000Rivastigmine (Exelon):2000  Global functioning and ADL preservationGlobal functioning and ADL preservation  Start at 1.5mg bid to max 6mg bidStart at 1.5mg bid to max 6mg bid  Galantamine (now Razadyne (ER) formerly Reminyl)Galantamine (now Razadyne (ER) formerly Reminyl) (2001/2005)(2001/2005)  Slowing progressionSlowing progression  4mg bid to max 12 mg bid4mg bid to max 12 mg bid  Extended release version: 8mg/day, (16mg/day), 24 mg/dayExtended release version: 8mg/day, (16mg/day), 24 mg/day
    35. 35. General thoughts about CIsGeneral thoughts about CIs  Price about the same ($120-130 per month)Price about the same ($120-130 per month)  Up to 35% of patients taking an anticholinergic!Up to 35% of patients taking an anticholinergic!  JAGS. 52: 2082-2087, 2004.JAGS. 52: 2082-2087, 2004.  GI upset common, also watch for bradycardiaGI upset common, also watch for bradycardia  Clinically meaningful benefit is debated from anClinically meaningful benefit is debated from an EBM perspectiveEBM perspective  Clinical support strongClinical support strong
    36. 36. PharmacologicPharmacologic  Memantine (Namenda)Memantine (Namenda)  Indicated for moderate to severe dementiaIndicated for moderate to severe dementia  Friendly side-effect profileFriendly side-effect profile  Start at 5mg daily, target dose: 20 mg q dayStart at 5mg daily, target dose: 20 mg q day  Studies suggest added benefit when used with CIsStudies suggest added benefit when used with CIs  Often used with those intolerant to CIsOften used with those intolerant to CIs  Long standing use in GermanyLong standing use in Germany  Debate on clinical impact/timing with use of thisDebate on clinical impact/timing with use of this medicationmedication
    37. 37. GinkgoGinkgo  Approved in Germany for treatmentApproved in Germany for treatment  Antioxidant properties?Antioxidant properties?  Usual dosing at 240mg/dayUsual dosing at 240mg/day  Associated with platelet inhibitionAssociated with platelet inhibition
    38. 38. Antioxidants  Antioxidants beta carotene, vitamin A and vitamin E may increase mortality.  JAMA 2007;297:842-857.  NEJM 1997;336:1216-1222  Ann Int Med 2005;142:37-46  NEJM 2005;352:2379-2388;  Am J Med 2007;120:180-184)
    39. 39. Dementia TherapyDementia Therapy UpdateUpdate
    40. 40. Update on DementiaUpdate on Dementia MedicationsMedications  Kaduszkiewicz H, et al. Cholinesterase inhibitors forKaduszkiewicz H, et al. Cholinesterase inhibitors for patients with Alzheimer’s Disease: systematic review ofpatients with Alzheimer’s Disease: systematic review of randomised trials. BMJ. August 6, 2005; 331:321-7.randomised trials. BMJ. August 6, 2005; 331:321-7.
    41. 41. Challenging ArticleChallenging Article  Bottom lineBottom line  Evidence of effectiveness is based on small effects found inEvidence of effectiveness is based on small effects found in poorly analyzed studiespoorly analyzed studies  AD drug studies need close scrutiny for methodologic errorsAD drug studies need close scrutiny for methodologic errors and inflated benefitand inflated benefit  Contrary to Cochrane ReviewsContrary to Cochrane Reviews  conclusions were drawn “without a comprehensiveconclusions were drawn “without a comprehensive assessment of the methodological quality of the trials.”assessment of the methodological quality of the trials.”  Contrary to meta-analyses and American Academy ofContrary to meta-analyses and American Academy of NeurologyNeurology  No attempt “consider the quality of the included trials.”No attempt “consider the quality of the included trials.”
    42. 42. Frustrated!Frustrated!  Excellent reviewExcellent review  Conflicts with mentor’sConflicts with mentor’s experienceexperience  Conflicts with myConflicts with my hopes/limited experiencehopes/limited experience  Re-evaluate myRe-evaluate my aggressive use of theaggressive use of the agentsagents  The need for the big,The need for the big, unbiased definitive studyunbiased definitive study
    43. 43. Behavioral PharmacologyBehavioral Pharmacology  Dementia behaviors may improve withDementia behaviors may improve with cholinesterase inhibitorscholinesterase inhibitors  Wandering and pacing is NOT corrected withWandering and pacing is NOT corrected with anti-psychoticsanti-psychotics  Best treated with behavior modification andBest treated with behavior modification and caregiver education, training and respitecaregiver education, training and respite  CIs may reduce inpatient delirium episodesCIs may reduce inpatient delirium episodes
    44. 44. AFP. 2003. 67: 2335-40. Atypical AntipsychoticsAtypical Antipsychotics  Effectiveness of atypicals is firmly established inEffectiveness of atypicals is firmly established in treating dementia-related psychosistreating dementia-related psychosis  Includes Abilify (aripiprazole), Zyprexa (olanzapine),Includes Abilify (aripiprazole), Zyprexa (olanzapine), Seroquel (quetiapine), Risperdal (risperidone), ClozarilSeroquel (quetiapine), Risperdal (risperidone), Clozaril (clozapine) and Geodon (ziprasidone)(clozapine) and Geodon (ziprasidone)  Risperidone now available in a disintegrating tablet inRisperidone now available in a disintegrating tablet in 0.25mg-4mg doses and a long acting injection (up to0.25mg-4mg doses and a long acting injection (up to 50mg q 2 weeks)50mg q 2 weeks)  Continue oral therapy for three weeks to get adequate levelContinue oral therapy for three weeks to get adequate level
    45. 45. FDA Public Health Advisory, April 11, 2005 Risk of Atypical AntipsychoticsRisk of Atypical Antipsychotics  Class EffectClass Effect  New black box warning of increased risk of death andNew black box warning of increased risk of death and “not approved for use in dementia-related psychosis.”“not approved for use in dementia-related psychosis.”  Risk of death 1.6-1.7 x that of placeboRisk of death 1.6-1.7 x that of placebo  Over a 10 week trial. 4.5% rate of death vs. 2.6% for theOver a 10 week trial. 4.5% rate of death vs. 2.6% for the placebo group.placebo group.  Mostly cardiovascular deaths or infectious (pneumonia)Mostly cardiovascular deaths or infectious (pneumonia)  Patient (caregiver) specific risk assessment and counselingPatient (caregiver) specific risk assessment and counseling
    46. 46. Cochrane Database of Systematic Reviews (2005) Other agents:Other agents:  Valproate for agitation- Insufficient EvidenceValproate for agitation- Insufficient Evidence  Trazodone for agitation- Insufficient EvidenceTrazodone for agitation- Insufficient Evidence  Haldol for agitation- Effective, side effects are aHaldol for agitation- Effective, side effects are a problemproblem  Zhiling decoction (herbal combination)- insufficientZhiling decoction (herbal combination)- insufficient evidenceevidence  Propentofylline (adenosine blocker andPropentofylline (adenosine blocker and phosphodiesterase inhibitor)- limited evidence ofphosphodiesterase inhibitor)- limited evidence of benefitbenefit  Lecithin- not supportedLecithin- not supported  Acetyl-l-carnitine (ALC)- not supported at this timeAcetyl-l-carnitine (ALC)- not supported at this time
    47. 47. AFP. Vol. 69(6). March 15, 2004. Screening for dementiaScreening for dementia  The USPSTF concludes that the evidence is insufficientThe USPSTF concludes that the evidence is insufficient to recommend for or against routine screening forto recommend for or against routine screening for dementia in older adults.dementia in older adults.  Age and educational level influences resultsAge and educational level influences results  The problem of arbitrary cut pointsThe problem of arbitrary cut points  Functional assessment can also detect dementia (FAQ)Functional assessment can also detect dementia (FAQ)  Clinical considerationsClinical considerations  MMSE: PPV in UNSELECTED groups is only fairMMSE: PPV in UNSELECTED groups is only fair  Early recognition helpfulEarly recognition helpful  We should screen when we suspectWe should screen when we suspect
    48. 48. Screening for depression andScreening for depression and dementiadementia  New tools availableNew tools available  Depression is very common in the elderlyDepression is very common in the elderly  See:See:  AFP 2004; 70: 1101-1110.AFP 2004; 70: 1101-1110.
    49. 49. SUMMARYSUMMARY::  Dementia is common in older adults but is NOT anDementia is common in older adults but is NOT an inherent part of aginginherent part of aging  AD is the most common type of dementia, followed byAD is the most common type of dementia, followed by vascular dementia and dementia with Lewy bodiesvascular dementia and dementia with Lewy bodies  Evaluation includes history with informant, physical &Evaluation includes history with informant, physical & functional assessment, focused labs, & possibly brainfunctional assessment, focused labs, & possibly brain imagingimaging
    50. 50. SUMMARYSUMMARY::  Primary treatment goals:Primary treatment goals:  Enhance quality of life,Enhance quality of life,  Maximize function by improving cognition, mood, behaviorMaximize function by improving cognition, mood, behavior  Treatment may use both medications andTreatment may use both medications and nonpharmacologic interventionsnonpharmacologic interventions  Community resources should be used to support patient,Community resources should be used to support patient, family, caregiversfamily, caregivers

    ×