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Dementia las vegas (1)

The document outlines the significance of dementia, detailing its prevalence, risk factors, and the societal impact as the aging population grows. It provides a comprehensive overview of assessment methods, differential diagnoses, treatment options, and community resources for managing dementia. Additionally, it highlights the importance of advance care planning and non-pharmacologic interventions in improving the quality of life for patients and caregivers.

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1 DEMENTIA Dr Kamal Kejriwal MD AAFP, CMD Geriatric Fellowship Program Director, Kaiser Fontana Dr Sherif Iskander Geriatric Fellows Dr Marian Assal, Geriatrician, Kaiser Fontana
2 OBJECTIVES Know and understand: • The risks for and causes of dementia • The evaluation of patients with dementia • How to plan behavioral and pharmacologic treatment strategies to minimize the personal, social, & financial impacts of dementia • How to refer patients and caregivers to available community resources
3 TOPICS COVERED • Epidemiology and Societal Impact • Risk Factors and Prevention • Assessment Methods • Differential Diagnosis • Treatment and Management • Resources
http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx# gender Population by Age: 1900–2050
5October 23, 2014 Dementia – Why should we care? Aging Population Prevalence of Dementia Caregiver Burden Our population age 65+ continues to increase and will escalate rapidly in coming years as the baby boomers age. In 2010, 14.7% of people age 70+ in U.S. have dementia1 Dementia is underdiagnosed. In 2010, 6.7% of KP members age 70+ had dementia diagnosis2. Emotional and physical impact associated with caring for people with dementia raised healthcare costs by $9.1 billion in 2012.3 14.7% Source: 1. Monetary Costs of Dementia in the U.S. - Hurd MD, Martorell P, Langa KM. N Engl J Med. 2013 Aug 1;369(5):489-90. doi: 10.1056/NEJMc1305541. PMID: 23902508 2. Dementia 2006-2010.xls. (Feb 2012), Joya Guha (Data excludes OH region) 3. Household Members of Persons with Alzheimer’s Disease – Suehs, et al., JAGS 62:435-441, 2014
Survey Findings Dementia Care looks very different across regions KP is on track with many National and State standards, but there is room for improvement Advanced Planning  68% (13/19) offer Advanced Care Planning to members with dementia. Caregiver and Patient Education  32% (6/19) offer a class/group appointment specific to managing dementia behaviors.  25% (5/19) offer a dementia education class/group appointment. Patient / Caregiver Support  37% (7/19) offer caregiver support groups. Community Partnerships  84% (16/19) offer referrals to community resources. 11
4 WHAT IS DEMENTIA? • An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient • Progressive and disabling • Not an inherent aspect of aging • Different from normal cognitive lapses
5 THE EPIDEMIOLOGY OF DEMENTIA • 6%‒8% of people ≥65 yr have Alzheimer dementia (AD)  Prevalence doubles every 5 yr  Nearly 45% of those aged 85+ have AD • Vascular dementia co-occurs with an estimated 15%– 20% of AD cases ― “mixed dementia” • Lewy body dementia (LBD) ― second most common cause of dementia
7 ETIOLOGY • Alzheimer disease  Amyloid plaques/oligomers  Tau neurofibrillary tangles • Lewy body and Parkinson dementia  Cytoplasmic α-synuclein inclusion bodies • Frontotemporal dementia  Tau or ubiquitin proteins
9 THE GENETICS OF DEMENTIA Early onset (<60 years old) • Amyloid precursor protein (APP) • Presenilin proteins (PS1 and PS2) Late onset • Apolipoprotein E gene (APOE 2/3/4) ― chromosome 19  APOE4 ― two alleles confers greatest risk in dose-related fashion  APOE2 ― protective • Single-nucleotide polymorphisms  Clusterin (CLU-C), complement component receptor 1 (CR1), and phosphatidylinositol binding clathrin assembly protein (PICALM)
8 RISK FACTORS FOR DEMENTIA Protective Factors Definite: unknown Possible • NSAIDs • Antioxidants • Intellectual activity • Physical activity • Statin Risk Factors Definite • Age • Family history • APOE4 allele • Down syndrome Possible • Head trauma • Fewer years of formal education • Late-onset major depressive disorder • Cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, obesity)
10 ASSESSMENT: HISTORY Ask both the patient and a reliable informant about the patient’s: • Date of onset of current condition and nature of symptoms • Medical history • Current medications & medication history • Patterns of alcohol use or abuse • Living arrangements
11 ASSESSMENT: PHYSICAL Examine: • Neurologic status • Mental status • Functional status Include: • Quantified screens for cognition  For example, Folstein’s MMSE, Mini-Cog, SLUMS, MoCA • Neuropsychologic testing
12 SCREENING INSTRUMENTS FOR EVALUATING COGNITION Name Items/ Scoring Domains assessed Web link (accessed Oct 2012) Mini-Cog 2 items Score = 5 Visuospatial, executive function, recall http://geriatrics.uthscsa.edu/tool s/MINICog.pdf SLUMS 11 items Score = 30 Orientation, recall, calculation, naming, attention, executive function http://medschool.slu.edu/agings uccessfully/pdfsurveys/slumsex am_05.pdf MoCA 12 items Score = 30 Orientation, recall, attention, naming, repetition, verbal fluency, abstraction, executive function, visuospatial www.mocatest.org Folstein MMSE 19 items Score = 30 Orientation, registration, attention, recall, naming, repetition, 3-step command, language, visuospatial For purchase: www.minimental.com
13 ASSESSMENT: LABORATORY Routine • CBC • Na+ • BUN/Cr • Fasting glucose • RPR • TSH • Vitamin B12 level Optional (based on clinical exam and suspicion) • Liver function • Folic acid • Homocysteine/methylmalonic acid • Urinalysis / Toxicology • CSF analysis • HIV testing
14 ASSESSMENT: BRAIN IMAGING Consider imaging when: • Onset occurs at age <65 years • Neurologic signs are asymmetric or focal • Clinical picture suggests normal-pressure hydrocephalus • Patient has had recent fall or other head trauma Consider: • Noncontrast computed topography head scan • Magnetic resonance imaging • Positron emission tomography
15 DIFFERENTIAL DIAGNOSIS • Normal aging • Mild cognitive impairment • Delirium • Depression • Alzheimer disease • Vascular dementia • Lewy body dementia • Other (frontotemporal dementia, alcohol, Parkinson disease, neurosyphilis)
16 NORMAL AGING • No consistent, progressive deviations on testing of memory • Some decline in processing and recall of new information: slower, harder • Reminders work—visual tips, notes • Absence of significant effects on ADLs or IADLs due to cognition
17 MILD COGNITIVE IMPAIRMENT • Subjective complaint of decline in at least one cognitive domain: noticeable and measurable • No impairment in independent living • 9.4 to 14.3/1000 person-years convert to Alzheimer disease • ~50% with amnestic MCI maintain stable level of impairment or return to normal cognitive status in 3−5 yr
18 DELIRIUM VS. DEMENTIA • Delirium and dementia often occur together in older hospitalized patients • The distinguishing signs of delirium are:  Acute onset  Cognitive fluctuations over hours or days  Impaired consciousness and attention  Altered sleep cycles  Search for underlying dementia once delirium cleared
19 DEPRESSION VS. DEMENTIA (1 of 2) The symptoms of depression and dementia often overlap: • Impaired concentration • Lack of motivation, loss of interest, apathy • Psychomotor retardation • Sleep disturbance
20 DEPRESSION VS. DEMENTIA (2 of 2) • Patients with primary depression are generally unlike those with dementia in that they:  Demonstrate ↓ motivation during cognitive testing  Express cognitive complaints that exceed measured deficits  Maintain language and motor skills • ~50% presenting with reversible dementia and depression progress to dementia within 5 yr
21 ALZHEIMER DISEASE • Onset: gradual • Cognitive symptoms: memory impairment core feature with difficulty learning new information • Motor symptoms: rare early, apraxia later • Progression: gradual, over 8–10 yr on average • Lab tests: normal • Imaging: possible global atrophy, small hippocampal volumes
22 VASCULAR DEMENTIA • Onset: may be sudden/stepwise • Cognitive symptoms: depend on anatomy of ischemia, but dysexecutive syndrome common • Motor symptoms: correlates with ischemia • Progression: stepwise with further ischemia • Lab tests: normal • Imaging: cortical or subcortical changes on MRI
23 LEWY BODY DEMENTIA • Onset: gradual • Cognitive symptoms: memory, visuospatial, hallucinations, fluctuations • Motor symptoms: parkinsonism • Progression: gradual, but usually faster than AD • Lab tests: normal • Imaging: possible global atrophy
24 FRONTOTEMPORAL DEMENTIA • Onset: gradual, usually age <60 • Cognitive symptoms: executive, language, and behavioral dysfunction, including disinhibition and hyperorality • Motor symptoms: none; may be associated with ALS in rare cases • Progression: gradual but faster than AD • Lab tests: normal • Imaging: atrophy in frontal and temporal lobes
27 PRIMARY GOAL OF TREATMENT To enhance quality of life and maximize functional performance by improving cognition, mood, and behavior
THE CARE SPAN Redesigning Systems Of Care For Older Adults With Alzheimer’s Disease 16 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 23, 2014 doi: 10.1377/hlthaff.2013.1260 HEALTH AFFAIRS 33, NO. 4 (2014): 626–632 ©2014 Project HOPE— The People-to-People Health Foundation, Inc. By Christopher M. Callahan, Greg A. Sachs, Michael A. LaMantia, Kathleen T. Unroe, Greg Arling, and Malaz A. Boustani
25 Stage 1: No cognitive impairment Unimpaired individuals experience no memory problems, and none is evident to a health care professional during a medical interview. Stage 2: Very mild cognitive decline Individuals at this stage feel as if they have memory lapses, especially in forgetting familiar words or names or the location of keys, eyeglasses, or other everyday objects. However, these problems are not evident during a medical examination or apparent to friends, family, or coworkers. Stage 3: Mild cognitive decline Early-stage Alzheimer disease can be diagnosed in some, but not all, individuals. Friends, family, or coworkers begin to notice deficiencies. Problems with memory or concentration may be measurable in clinical testing or discernible during a detailed medical interview. Stage 4: Moderate cognitive decline (mild or early-stage Alzheimer disease) At this stage, a careful medical interview detects clear-cut deficiencies. The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations. THE GENERAL PROGRESSION OF DEMENTIA (1 of 2)
26 Stage 5: Moderately severe cognitive decline (moderate or mid-stage Alzheimer disease) Major gaps in memory and deficits in cognitive function emerge. Some assistance with day-to-day activities becomes essential. Stage 6: Severe cognitive decline (moderately severe or mid-stage Alzheimer disease) Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals need extensive help with customary daily activities. Stage 7: Very severe cognitive decline (severe or late-stage Alzheimer disease) This is the final stage of the disease when individuals lose the ability to respond to their environment, to speak, and ultimately to control movement. THE GENERAL PROGRESSION OF DEMENTIA (2 of 2)
Advanced Dementia: Death After Episode of Pneumonia
Advanced Dementia: Survival After Febrile Episode
Advanced Dementia: Survival After Onset of Eating Problem
Typical Hospice Eligibility Criteria (Local Coverage Determinations) Functional Assessment Staging 1. No difficulties 2. Subjective forgetfulness 3. Decreased executive function 4. Difficulty with complex tasks 5. Requires supervision with ADLs 6. Impaired ADLs with incontinence 7. Stage Seven A. Ability to speak limited to 6 words B. Ability to speak limited to a single word C. Loss of ambulation D. Inability to sit E. Inability to smile F. Inability to hold head up
Feeding Tubes in Advance Dementia  Studies show no impact of feeding tubes in advanced dementia on:  Survival(Median survival 56 days)  Pressure ulcer healing  Aspiration pneumonia  Likely increase in burdens  Loss of experience/connection of feeding  Restraints  Complications are common  Dehydration is not painful  Use associated with decreased satisfaction with end of life care Sampson EL, Candy B, Jones L, “Enteral tube feeding or older people with advanced dementia. Cochrane Database Syst. Rev. 2009;(2):CD007209
End of Life Decision Making: Feeding Tubes in Dementia  Telephone survey of 450 relatives of SNF patients with advanced dementia who had feeding tubes  85% of decisions were made in hospital  47% reported discussion lasted <15 minutes  1/3 family members recalled that no risks of tube feeding presented  50% felt hospital physician was “strongly in favor of tube insertion”  13% “felt pressured to put in a feeding tube”  Approx. 25% regretted the feeding tube decision Kuo, Sylvia, Poster Presentation, American Geriatrics Society Annual Meeting, May 12, 2010, Orlando, FL
Non-pharmacologic Interventions for Behavioral Problems  Many programs have worked, but difficult to generalize as to what can be dispensed or spread  Pain and symptom control  Exercise  Music/Recordings  Optimal level of activity  Environmental changes: light, reassuring picture  Treating each patient with personalized care Resources: A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms of Dementia (VA’s Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis Program (2011) http://www.hsrd.research.va.gov/publications/esp/Dementia-Nonpharm.pdf See also extensive materials below from IA Adapt, Interact, Hand in Hand
ABCDEs of Neurobehavioral Care Antecedents Behaviors Consequences Documentation Emotion Systematic D Adapted from Teri, L. (1997) S B
ABCDs Examples Antecedents Diagnoses (What is the cause of dementia? ) What other diagnoses exist? Fatigue, hunger,pain Levels of stimulation Restraint Staff or resident approaches Gender & Cultural Lack of exercise Behaviors What exactly is the behavior? Crying Yelling Biting Hitting Grabbing Fecal play Time of day Exact setting and details as possible Consequences Attention Isolation Abuse Injury Medication response Other positive reinforcement B E= Emotional Engagement
Common Reasons for Difficult Behaviors in Patients with Dementia Response to Trigger Other Medical Pain Personality Iatrogenic: other meds Sleep Deficit Social/ Caregiver Enjoys the behavior Delirium Discomfort Psychosis Fear/Boredom/Anxiety Adjustment Problems Behaviors J
Approach to Medications for Behavioral Problems in SNF IV  First try:  Behavioral interventions (at least 2 trials)  Medication toxicities minimized (e.g. anticholinergic medications)  Require (As per Title 22 and CMS)  Behavior causes significant impairment of quality of life or danger to self or others  Informed consent for serious risks (including death) obtained  Avoid prn antipsychotics in dementia
Advance care planning for patients with dementia 1. Educate physicians, families and staff about trajectory of illness of dementia 2. Elicit patient’s goals of care based on advance directives and prior values 3. Educate families and physicians about burdens and benefits of interventions, including lack of benefit for tube feeding. 4. Complete POLST documents: assess not only completion but quality of the conversations 5. Consider hospice if appropriate
28 NONPHARMACOLOGIC MANAGEMENT (1 of 2) • Cognitive rehabilitation • Supportive individual and group therapy • Physical and mental activity • Regular appointments every 3–6 months • Family and caregiver education and support • Attention to safety  Need for supervision, wandering, driving etc.
29 NONPHARMACOLOGIC MANAGEMENT (2 of 2) • Environmental modification  Orientation and memory measures such as clocks, calendars, to-do list, visual clues, simple and compassionate communication style
30 PHARMACOLOGIC MANAGEMENT • Treatment should be individualized • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine • Memantine • Other cognitive enhancers • Antidepressants • Psychoactive medications
31 CHOLINESTERASE INHIBITORS (1 of 2) • Slow breakdown of acetylcholine • Clinical trials demonstrate modest delay in cognitive decline compared with placebo in AD • GI side effects common  Mitigated by slow titration curve  Maximum dosing of donepezil 23 mg/day creates significant side effects without evidence of improving global function • No evidence of difference in efficacy among drugs
32 CHOLINESTERASE INHIBITORS (2 of 2) • Use in other dementias  Widespread use in vascular dementia not recommended  Behavioral disturbances in Lewy body dementia can benefit from treatment  Rivastigmine is FDA-approved for mild to moderate dementia in Parkinson dementia  Treatment in frontotemporal dementia may worsen agitation
33 MEMANTINE • Neuroprotective effect is to reduce glutamate-mediated excitotoxicity • Modest benefit on cognition, ADLs, and behavior in AD • Limited effect on cognition and no evidence to support widespread use in vascular dementia • FDA-approved for moderate to severe AD • Common adverse events: constipation, dizziness, headache
34 OTHER COGNITIVE ENHANCERS • Vitamin E (α–tocopherol) may lower rate of decline, but no evidence of cognitive improvement in AD  No longer recommended due to evidence of increased mortality with high-dose supplementation • Selegiline may low rate of decline, but no evidence of cognitive improvement in AD • Ginkgo biloba offers no benefit in slowing cognitive decline in MCI
35 SYMPTOM MANAGEMENT (1 of 2) • Psychoactive medications  Behavioral disturbances best managed nonpharmacologically, eg, reducing overstimulation, environmental modification • Antidepressants  Depressed mood, low appetite, insomnia, fatigue, irritability, agitation  Possibly effective for disinhibition and compulsive behaviors  Caution: falls and anticholinergic effects that may worsen confusion (ie, paroxetine)
36 SYMPTOM MANAGEMENT (2 of 2) • 1st/2nd-generation antipsychotics  Limited evidence of efficacy and increased risk of all-cause mortality in dementia  Should be used with caution in targeting delusions, hallucinations, and paranoia ― frequently attempt to taper off • Valproic acid and carbamazepine  Possible options, but with limited evidence and increased risk of mortality • Benzodiazepines and anticholinergic medications should be avoided
37 RESOURCES FOR MANAGING DEMENTIA (1 of 2) • Specialist referral to:  Geriatric psychiatrist  Neurologist  Neuropsychologist • Social worker • Physical therapist • Nurse
38 RESOURCES FOR MANAGING DEMENTIA (2 of 2) • Attorney for will, conservatorship, estate planning • Community: neighbors & friends, aging & mental health networks, adult day care, respite care, home-health agency • Organizations: Alzheimer’s Association, Area Agencies on Aging, Councils on Aging • Services: Meals-on-Wheels, senior citizen centers
39 SUMMARY (1 of 2) • Dementia is common in older adults but is not an inherent part of aging • AD is the most common type of dementia, followed by vascular dementia and dementia with Lewy bodies • Evaluation includes history with informant, physical & functional assessment, focused labs, & possibly brain imaging
40 SUMMARY (2 of 2) • Primary treatment goals: enhance quality of life and maximize function by improving cognition, mood, behavior • Treatment may involve both medications and nonpharmacologic interventions • Community resources should be used to support patient, family, caregivers
41 CASE 1 (1 of 4) • An 80-year-old woman is brought to the office because she has hallucinations of children and small animals when she is alone in a room. The hallucinations sometimes disturb and agitate her. • Her family also notes that she is having more difficulty walking and has hand tremors when she sits quietly. • She has a 9-month history of short-term memory loss; problems with orientation that sometimes worsen dramatically; and difficulty managing her finances, preparing complex meals, and following TV shows.
42 CASE 1 (2 of 4) • Her score on the Mini–Mental State Examination is 23 of 30. • On physical examination, there are signs of cogwheel rigidity and resting tremors, which have been noted for the past year.
43 CASE 1 (3 of 4) Which of the following is the most likely diagnosis? A. Dementia with Lewy bodies B. Alzheimer disease C. Parkinson disease with dementia D. Huntington disease
44 CASE 1 (4 of 4) Which of the following is the most likely diagnosis? A. Dementia with Lewy bodies B. Alzheimer disease C. Parkinson disease with dementia D. Huntington disease
45 CASE 2 (1 of 4) • A 67-year-old man comes to the office to establish care. • History includes mild hypertension. • The patient is married and maintains an active professional and social life. He is physically active, does not smoke, and drinks 1–2 glasses of wine daily. • Medications include hydrochlorothiazide 12.5 mg/day, aspirin 81 mg/day, and a daily multivitamin.
46 CASE 2 (2 of 4) • Family history is notable for an 84-year-old maternal aunt who recently died after 6 years in the memory- disorders unit of a nursing home. • His aunt’s death has caused the patient to worry about his own risk of dementia. He requests a referral for genetic testing for Alzheimer disease. • Physical examination is unremarkable.
47 CASE 2 (3 of 4) Which of the following is true about risk of Alzheimer disease? A. Mutations in 4 known deterministic (causative) genes are associated with autosomal-dominant AD. B. The lifetime risk of developing AD in the general population is approximately 20%, assuming a life span of 75 to 80 years. C. AD is sporadic in approximately 75% of all cases. D. Genetic risk for AD varies by race and ethnicity.
48 CASE 2 (4 of 4) Which of the following is true about risk of Alzheimer disease? A. Mutations in 4 known deterministic (causative) genes are associated with autosomal-dominant AD. B. The lifetime risk of developing AD in the general population is approximately 20%, assuming a life span of 75 to 80 years. C. AD is sporadic in approximately 75% of all cases. D. Genetic risk for AD varies by race and ethnicity.
50 CASE 3 (2 of 4) • The patient’s wife expresses concern about his ability to drive safely. She sometimes feels nervous riding with him. She notes that he has stopped driving at night or when it rains, that he drives shorter distances and less often since he retired 5 years ago, and that he received a traffic citation about 4 years ago. He has had no accidents or additional citations since then. • When asked if he thinks he is a safe driver, the patient says, “I’m probably a little bit slower than I used to be, but overall I’d say yes, I’m still a perfectly safe driver.”
51 CASE 3 (3 of 4) Which of the following is the strongest evidence of the patient’s risk for unsafe driving? A. Patient’s self-restriction and situational avoidance B. History of a traffic citation in the past 5 years C. Spouse’s concern D. Score ≤24 on MMSE E. Patient’s self-rating of driving ability
52 CASE 3 (4 of 4) Which of the following is the strongest evidence of the patient’s risk for unsafe driving? A. Patient’s self-restriction and situational avoidance B. History of a traffic citation in the past 5 years C. Spouse’s concern D. Score ≤24 on MMSE E. Patient’s self-rating of driving ability
53 GRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF GRS8 Chapter Authors: Alexander Threlfall, MD, MA Cynthia Barton, RN, MSN Kristine Yaffe, MD GRS8 Question Writer: Amy E. Sanders, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Slide 53 Copyright © 2013 American Geriatrics Society Slide 53
Dementia las vegas (1)
Dementia las vegas (1)
Dementia las vegas (1)
Dementia las vegas (1)

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Dementia las vegas (1)

  • 1.
    1 DEMENTIA Dr Kamal KejriwalMD AAFP, CMD Geriatric Fellowship Program Director, Kaiser Fontana Dr Sherif Iskander Geriatric Fellows Dr Marian Assal, Geriatrician, Kaiser Fontana
  • 2.
    2 OBJECTIVES Know and understand: •The risks for and causes of dementia • The evaluation of patients with dementia • How to plan behavioral and pharmacologic treatment strategies to minimize the personal, social, & financial impacts of dementia • How to refer patients and caregivers to available community resources
  • 3.
    3 TOPICS COVERED • Epidemiologyand Societal Impact • Risk Factors and Prevention • Assessment Methods • Differential Diagnosis • Treatment and Management • Resources
  • 4.
  • 5.
    5October 23, 2014 Dementia– Why should we care? Aging Population Prevalence of Dementia Caregiver Burden Our population age 65+ continues to increase and will escalate rapidly in coming years as the baby boomers age. In 2010, 14.7% of people age 70+ in U.S. have dementia1 Dementia is underdiagnosed. In 2010, 6.7% of KP members age 70+ had dementia diagnosis2. Emotional and physical impact associated with caring for people with dementia raised healthcare costs by $9.1 billion in 2012.3 14.7% Source: 1. Monetary Costs of Dementia in the U.S. - Hurd MD, Martorell P, Langa KM. N Engl J Med. 2013 Aug 1;369(5):489-90. doi: 10.1056/NEJMc1305541. PMID: 23902508 2. Dementia 2006-2010.xls. (Feb 2012), Joya Guha (Data excludes OH region) 3. Household Members of Persons with Alzheimer’s Disease – Suehs, et al., JAGS 62:435-441, 2014
  • 6.
    Survey Findings Dementia Carelooks very different across regions KP is on track with many National and State standards, but there is room for improvement Advanced Planning  68% (13/19) offer Advanced Care Planning to members with dementia. Caregiver and Patient Education  32% (6/19) offer a class/group appointment specific to managing dementia behaviors.  25% (5/19) offer a dementia education class/group appointment. Patient / Caregiver Support  37% (7/19) offer caregiver support groups. Community Partnerships  84% (16/19) offer referrals to community resources. 11
  • 7.
    4 WHAT IS DEMENTIA? •An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient • Progressive and disabling • Not an inherent aspect of aging • Different from normal cognitive lapses
  • 11.
    5 THE EPIDEMIOLOGY OF DEMENTIA •6%‒8% of people ≥65 yr have Alzheimer dementia (AD)  Prevalence doubles every 5 yr  Nearly 45% of those aged 85+ have AD • Vascular dementia co-occurs with an estimated 15%– 20% of AD cases ― “mixed dementia” • Lewy body dementia (LBD) ― second most common cause of dementia
  • 13.
    7 ETIOLOGY • Alzheimer disease Amyloid plaques/oligomers  Tau neurofibrillary tangles • Lewy body and Parkinson dementia  Cytoplasmic α-synuclein inclusion bodies • Frontotemporal dementia  Tau or ubiquitin proteins
  • 14.
    9 THE GENETICS OFDEMENTIA Early onset (<60 years old) • Amyloid precursor protein (APP) • Presenilin proteins (PS1 and PS2) Late onset • Apolipoprotein E gene (APOE 2/3/4) ― chromosome 19  APOE4 ― two alleles confers greatest risk in dose-related fashion  APOE2 ― protective • Single-nucleotide polymorphisms  Clusterin (CLU-C), complement component receptor 1 (CR1), and phosphatidylinositol binding clathrin assembly protein (PICALM)
  • 15.
    8 RISK FACTORS FORDEMENTIA Protective Factors Definite: unknown Possible • NSAIDs • Antioxidants • Intellectual activity • Physical activity • Statin Risk Factors Definite • Age • Family history • APOE4 allele • Down syndrome Possible • Head trauma • Fewer years of formal education • Late-onset major depressive disorder • Cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, obesity)
  • 16.
    10 ASSESSMENT: HISTORY Ask boththe patient and a reliable informant about the patient’s: • Date of onset of current condition and nature of symptoms • Medical history • Current medications & medication history • Patterns of alcohol use or abuse • Living arrangements
  • 17.
    11 ASSESSMENT: PHYSICAL Examine: • Neurologicstatus • Mental status • Functional status Include: • Quantified screens for cognition  For example, Folstein’s MMSE, Mini-Cog, SLUMS, MoCA • Neuropsychologic testing
  • 18.
    12 SCREENING INSTRUMENTS FOR EVALUATINGCOGNITION Name Items/ Scoring Domains assessed Web link (accessed Oct 2012) Mini-Cog 2 items Score = 5 Visuospatial, executive function, recall http://geriatrics.uthscsa.edu/tool s/MINICog.pdf SLUMS 11 items Score = 30 Orientation, recall, calculation, naming, attention, executive function http://medschool.slu.edu/agings uccessfully/pdfsurveys/slumsex am_05.pdf MoCA 12 items Score = 30 Orientation, recall, attention, naming, repetition, verbal fluency, abstraction, executive function, visuospatial www.mocatest.org Folstein MMSE 19 items Score = 30 Orientation, registration, attention, recall, naming, repetition, 3-step command, language, visuospatial For purchase: www.minimental.com
  • 20.
    13 ASSESSMENT: LABORATORY Routine • CBC •Na+ • BUN/Cr • Fasting glucose • RPR • TSH • Vitamin B12 level Optional (based on clinical exam and suspicion) • Liver function • Folic acid • Homocysteine/methylmalonic acid • Urinalysis / Toxicology • CSF analysis • HIV testing
  • 21.
    14 ASSESSMENT: BRAIN IMAGING Considerimaging when: • Onset occurs at age <65 years • Neurologic signs are asymmetric or focal • Clinical picture suggests normal-pressure hydrocephalus • Patient has had recent fall or other head trauma Consider: • Noncontrast computed topography head scan • Magnetic resonance imaging • Positron emission tomography
  • 22.
    15 DIFFERENTIAL DIAGNOSIS • Normalaging • Mild cognitive impairment • Delirium • Depression • Alzheimer disease • Vascular dementia • Lewy body dementia • Other (frontotemporal dementia, alcohol, Parkinson disease, neurosyphilis)
  • 23.
    16 NORMAL AGING • Noconsistent, progressive deviations on testing of memory • Some decline in processing and recall of new information: slower, harder • Reminders work—visual tips, notes • Absence of significant effects on ADLs or IADLs due to cognition
  • 24.
    17 MILD COGNITIVE IMPAIRMENT •Subjective complaint of decline in at least one cognitive domain: noticeable and measurable • No impairment in independent living • 9.4 to 14.3/1000 person-years convert to Alzheimer disease • ~50% with amnestic MCI maintain stable level of impairment or return to normal cognitive status in 3−5 yr
  • 25.
    18 DELIRIUM VS. DEMENTIA •Delirium and dementia often occur together in older hospitalized patients • The distinguishing signs of delirium are:  Acute onset  Cognitive fluctuations over hours or days  Impaired consciousness and attention  Altered sleep cycles  Search for underlying dementia once delirium cleared
  • 26.
    19 DEPRESSION VS. DEMENTIA(1 of 2) The symptoms of depression and dementia often overlap: • Impaired concentration • Lack of motivation, loss of interest, apathy • Psychomotor retardation • Sleep disturbance
  • 27.
    20 DEPRESSION VS. DEMENTIA(2 of 2) • Patients with primary depression are generally unlike those with dementia in that they:  Demonstrate ↓ motivation during cognitive testing  Express cognitive complaints that exceed measured deficits  Maintain language and motor skills • ~50% presenting with reversible dementia and depression progress to dementia within 5 yr
  • 28.
    21 ALZHEIMER DISEASE • Onset:gradual • Cognitive symptoms: memory impairment core feature with difficulty learning new information • Motor symptoms: rare early, apraxia later • Progression: gradual, over 8–10 yr on average • Lab tests: normal • Imaging: possible global atrophy, small hippocampal volumes
  • 29.
    22 VASCULAR DEMENTIA • Onset:may be sudden/stepwise • Cognitive symptoms: depend on anatomy of ischemia, but dysexecutive syndrome common • Motor symptoms: correlates with ischemia • Progression: stepwise with further ischemia • Lab tests: normal • Imaging: cortical or subcortical changes on MRI
  • 30.
    23 LEWY BODY DEMENTIA •Onset: gradual • Cognitive symptoms: memory, visuospatial, hallucinations, fluctuations • Motor symptoms: parkinsonism • Progression: gradual, but usually faster than AD • Lab tests: normal • Imaging: possible global atrophy
  • 31.
    24 FRONTOTEMPORAL DEMENTIA • Onset:gradual, usually age <60 • Cognitive symptoms: executive, language, and behavioral dysfunction, including disinhibition and hyperorality • Motor symptoms: none; may be associated with ALS in rare cases • Progression: gradual but faster than AD • Lab tests: normal • Imaging: atrophy in frontal and temporal lobes
  • 32.
    27 PRIMARY GOAL OFTREATMENT To enhance quality of life and maximize functional performance by improving cognition, mood, and behavior
  • 33.
    THE CARE SPAN RedesigningSystems Of Care For Older Adults With Alzheimer’s Disease 16 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.October 23, 2014 doi: 10.1377/hlthaff.2013.1260 HEALTH AFFAIRS 33, NO. 4 (2014): 626–632 ©2014 Project HOPE— The People-to-People Health Foundation, Inc. By Christopher M. Callahan, Greg A. Sachs, Michael A. LaMantia, Kathleen T. Unroe, Greg Arling, and Malaz A. Boustani
  • 34.
    25 Stage 1: Nocognitive impairment Unimpaired individuals experience no memory problems, and none is evident to a health care professional during a medical interview. Stage 2: Very mild cognitive decline Individuals at this stage feel as if they have memory lapses, especially in forgetting familiar words or names or the location of keys, eyeglasses, or other everyday objects. However, these problems are not evident during a medical examination or apparent to friends, family, or coworkers. Stage 3: Mild cognitive decline Early-stage Alzheimer disease can be diagnosed in some, but not all, individuals. Friends, family, or coworkers begin to notice deficiencies. Problems with memory or concentration may be measurable in clinical testing or discernible during a detailed medical interview. Stage 4: Moderate cognitive decline (mild or early-stage Alzheimer disease) At this stage, a careful medical interview detects clear-cut deficiencies. The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations. THE GENERAL PROGRESSION OF DEMENTIA (1 of 2)
  • 35.
    26 Stage 5: Moderatelysevere cognitive decline (moderate or mid-stage Alzheimer disease) Major gaps in memory and deficits in cognitive function emerge. Some assistance with day-to-day activities becomes essential. Stage 6: Severe cognitive decline (moderately severe or mid-stage Alzheimer disease) Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals need extensive help with customary daily activities. Stage 7: Very severe cognitive decline (severe or late-stage Alzheimer disease) This is the final stage of the disease when individuals lose the ability to respond to their environment, to speak, and ultimately to control movement. THE GENERAL PROGRESSION OF DEMENTIA (2 of 2)
  • 36.
    Advanced Dementia: Death AfterEpisode of Pneumonia
  • 37.
  • 38.
    Advanced Dementia: Survival AfterOnset of Eating Problem
  • 39.
    Typical Hospice EligibilityCriteria (Local Coverage Determinations) Functional Assessment Staging 1. No difficulties 2. Subjective forgetfulness 3. Decreased executive function 4. Difficulty with complex tasks 5. Requires supervision with ADLs 6. Impaired ADLs with incontinence 7. Stage Seven A. Ability to speak limited to 6 words B. Ability to speak limited to a single word C. Loss of ambulation D. Inability to sit E. Inability to smile F. Inability to hold head up
  • 40.
    Feeding Tubes inAdvance Dementia  Studies show no impact of feeding tubes in advanced dementia on:  Survival(Median survival 56 days)  Pressure ulcer healing  Aspiration pneumonia  Likely increase in burdens  Loss of experience/connection of feeding  Restraints  Complications are common  Dehydration is not painful  Use associated with decreased satisfaction with end of life care Sampson EL, Candy B, Jones L, “Enteral tube feeding or older people with advanced dementia. Cochrane Database Syst. Rev. 2009;(2):CD007209
  • 41.
    End of LifeDecision Making: Feeding Tubes in Dementia  Telephone survey of 450 relatives of SNF patients with advanced dementia who had feeding tubes  85% of decisions were made in hospital  47% reported discussion lasted <15 minutes  1/3 family members recalled that no risks of tube feeding presented  50% felt hospital physician was “strongly in favor of tube insertion”  13% “felt pressured to put in a feeding tube”  Approx. 25% regretted the feeding tube decision Kuo, Sylvia, Poster Presentation, American Geriatrics Society Annual Meeting, May 12, 2010, Orlando, FL
  • 42.
    Non-pharmacologic Interventions for BehavioralProblems  Many programs have worked, but difficult to generalize as to what can be dispensed or spread  Pain and symptom control  Exercise  Music/Recordings  Optimal level of activity  Environmental changes: light, reassuring picture  Treating each patient with personalized care Resources: A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms of Dementia (VA’s Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis Program (2011) http://www.hsrd.research.va.gov/publications/esp/Dementia-Nonpharm.pdf See also extensive materials below from IA Adapt, Interact, Hand in Hand
  • 43.
    ABCDEs of NeurobehavioralCare Antecedents Behaviors Consequences Documentation Emotion Systematic D Adapted from Teri, L. (1997) S B
  • 44.
    ABCDs Examples Antecedents Diagnoses (Whatis the cause of dementia? ) What other diagnoses exist? Fatigue, hunger,pain Levels of stimulation Restraint Staff or resident approaches Gender & Cultural Lack of exercise Behaviors What exactly is the behavior? Crying Yelling Biting Hitting Grabbing Fecal play Time of day Exact setting and details as possible Consequences Attention Isolation Abuse Injury Medication response Other positive reinforcement B E= Emotional Engagement
  • 45.
    Common Reasons forDifficult Behaviors in Patients with Dementia Response to Trigger Other Medical Pain Personality Iatrogenic: other meds Sleep Deficit Social/ Caregiver Enjoys the behavior Delirium Discomfort Psychosis Fear/Boredom/Anxiety Adjustment Problems Behaviors J
  • 46.
    Approach to Medicationsfor Behavioral Problems in SNF IV  First try:  Behavioral interventions (at least 2 trials)  Medication toxicities minimized (e.g. anticholinergic medications)  Require (As per Title 22 and CMS)  Behavior causes significant impairment of quality of life or danger to self or others  Informed consent for serious risks (including death) obtained  Avoid prn antipsychotics in dementia
  • 47.
    Advance care planningfor patients with dementia 1. Educate physicians, families and staff about trajectory of illness of dementia 2. Elicit patient’s goals of care based on advance directives and prior values 3. Educate families and physicians about burdens and benefits of interventions, including lack of benefit for tube feeding. 4. Complete POLST documents: assess not only completion but quality of the conversations 5. Consider hospice if appropriate
  • 48.
    28 NONPHARMACOLOGIC MANAGEMENT (1 of2) • Cognitive rehabilitation • Supportive individual and group therapy • Physical and mental activity • Regular appointments every 3–6 months • Family and caregiver education and support • Attention to safety  Need for supervision, wandering, driving etc.
  • 53.
    29 NONPHARMACOLOGIC MANAGEMENT (2 of2) • Environmental modification  Orientation and memory measures such as clocks, calendars, to-do list, visual clues, simple and compassionate communication style
  • 55.
    30 PHARMACOLOGIC MANAGEMENT • Treatmentshould be individualized • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine • Memantine • Other cognitive enhancers • Antidepressants • Psychoactive medications
  • 56.
    31 CHOLINESTERASE INHIBITORS (1 of2) • Slow breakdown of acetylcholine • Clinical trials demonstrate modest delay in cognitive decline compared with placebo in AD • GI side effects common  Mitigated by slow titration curve  Maximum dosing of donepezil 23 mg/day creates significant side effects without evidence of improving global function • No evidence of difference in efficacy among drugs
  • 57.
    32 CHOLINESTERASE INHIBITORS (2 of2) • Use in other dementias  Widespread use in vascular dementia not recommended  Behavioral disturbances in Lewy body dementia can benefit from treatment  Rivastigmine is FDA-approved for mild to moderate dementia in Parkinson dementia  Treatment in frontotemporal dementia may worsen agitation
  • 58.
    33 MEMANTINE • Neuroprotective effectis to reduce glutamate-mediated excitotoxicity • Modest benefit on cognition, ADLs, and behavior in AD • Limited effect on cognition and no evidence to support widespread use in vascular dementia • FDA-approved for moderate to severe AD • Common adverse events: constipation, dizziness, headache
  • 59.
    34 OTHER COGNITIVE ENHANCERS • VitaminE (α–tocopherol) may lower rate of decline, but no evidence of cognitive improvement in AD  No longer recommended due to evidence of increased mortality with high-dose supplementation • Selegiline may low rate of decline, but no evidence of cognitive improvement in AD • Ginkgo biloba offers no benefit in slowing cognitive decline in MCI
  • 60.
    35 SYMPTOM MANAGEMENT (1of 2) • Psychoactive medications  Behavioral disturbances best managed nonpharmacologically, eg, reducing overstimulation, environmental modification • Antidepressants  Depressed mood, low appetite, insomnia, fatigue, irritability, agitation  Possibly effective for disinhibition and compulsive behaviors  Caution: falls and anticholinergic effects that may worsen confusion (ie, paroxetine)
  • 61.
    36 SYMPTOM MANAGEMENT (2of 2) • 1st/2nd-generation antipsychotics  Limited evidence of efficacy and increased risk of all-cause mortality in dementia  Should be used with caution in targeting delusions, hallucinations, and paranoia ― frequently attempt to taper off • Valproic acid and carbamazepine  Possible options, but with limited evidence and increased risk of mortality • Benzodiazepines and anticholinergic medications should be avoided
  • 62.
    37 RESOURCES FOR MANAGING DEMENTIA(1 of 2) • Specialist referral to:  Geriatric psychiatrist  Neurologist  Neuropsychologist • Social worker • Physical therapist • Nurse
  • 63.
    38 RESOURCES FOR MANAGING DEMENTIA(2 of 2) • Attorney for will, conservatorship, estate planning • Community: neighbors & friends, aging & mental health networks, adult day care, respite care, home-health agency • Organizations: Alzheimer’s Association, Area Agencies on Aging, Councils on Aging • Services: Meals-on-Wheels, senior citizen centers
  • 64.
    39 SUMMARY (1 of2) • Dementia is common in older adults but is not an inherent part of aging • AD is the most common type of dementia, followed by vascular dementia and dementia with Lewy bodies • Evaluation includes history with informant, physical & functional assessment, focused labs, & possibly brain imaging
  • 65.
    40 SUMMARY (2 of2) • Primary treatment goals: enhance quality of life and maximize function by improving cognition, mood, behavior • Treatment may involve both medications and nonpharmacologic interventions • Community resources should be used to support patient, family, caregivers
  • 67.
    41 CASE 1 (1of 4) • An 80-year-old woman is brought to the office because she has hallucinations of children and small animals when she is alone in a room. The hallucinations sometimes disturb and agitate her. • Her family also notes that she is having more difficulty walking and has hand tremors when she sits quietly. • She has a 9-month history of short-term memory loss; problems with orientation that sometimes worsen dramatically; and difficulty managing her finances, preparing complex meals, and following TV shows.
  • 68.
    42 CASE 1 (2of 4) • Her score on the Mini–Mental State Examination is 23 of 30. • On physical examination, there are signs of cogwheel rigidity and resting tremors, which have been noted for the past year.
  • 69.
    43 CASE 1 (3of 4) Which of the following is the most likely diagnosis? A. Dementia with Lewy bodies B. Alzheimer disease C. Parkinson disease with dementia D. Huntington disease
  • 70.
    44 CASE 1 (4of 4) Which of the following is the most likely diagnosis? A. Dementia with Lewy bodies B. Alzheimer disease C. Parkinson disease with dementia D. Huntington disease
  • 71.
    45 CASE 2 (1of 4) • A 67-year-old man comes to the office to establish care. • History includes mild hypertension. • The patient is married and maintains an active professional and social life. He is physically active, does not smoke, and drinks 1–2 glasses of wine daily. • Medications include hydrochlorothiazide 12.5 mg/day, aspirin 81 mg/day, and a daily multivitamin.
  • 72.
    46 CASE 2 (2of 4) • Family history is notable for an 84-year-old maternal aunt who recently died after 6 years in the memory- disorders unit of a nursing home. • His aunt’s death has caused the patient to worry about his own risk of dementia. He requests a referral for genetic testing for Alzheimer disease. • Physical examination is unremarkable.
  • 73.
    47 CASE 2 (3of 4) Which of the following is true about risk of Alzheimer disease? A. Mutations in 4 known deterministic (causative) genes are associated with autosomal-dominant AD. B. The lifetime risk of developing AD in the general population is approximately 20%, assuming a life span of 75 to 80 years. C. AD is sporadic in approximately 75% of all cases. D. Genetic risk for AD varies by race and ethnicity.
  • 74.
    48 CASE 2 (4of 4) Which of the following is true about risk of Alzheimer disease? A. Mutations in 4 known deterministic (causative) genes are associated with autosomal-dominant AD. B. The lifetime risk of developing AD in the general population is approximately 20%, assuming a life span of 75 to 80 years. C. AD is sporadic in approximately 75% of all cases. D. Genetic risk for AD varies by race and ethnicity.
  • 75.
    50 CASE 3 (2of 4) • The patient’s wife expresses concern about his ability to drive safely. She sometimes feels nervous riding with him. She notes that he has stopped driving at night or when it rains, that he drives shorter distances and less often since he retired 5 years ago, and that he received a traffic citation about 4 years ago. He has had no accidents or additional citations since then. • When asked if he thinks he is a safe driver, the patient says, “I’m probably a little bit slower than I used to be, but overall I’d say yes, I’m still a perfectly safe driver.”
  • 76.
    51 CASE 3 (3of 4) Which of the following is the strongest evidence of the patient’s risk for unsafe driving? A. Patient’s self-restriction and situational avoidance B. History of a traffic citation in the past 5 years C. Spouse’s concern D. Score ≤24 on MMSE E. Patient’s self-rating of driving ability
  • 77.
    52 CASE 3 (4of 4) Which of the following is the strongest evidence of the patient’s risk for unsafe driving? A. Patient’s self-restriction and situational avoidance B. History of a traffic citation in the past 5 years C. Spouse’s concern D. Score ≤24 on MMSE E. Patient’s self-rating of driving ability
  • 78.
    53 GRS8 Slides Editor:Annette Medina-Walpole, MD, AGSF GRS8 Chapter Authors: Alexander Threlfall, MD, MA Cynthia Barton, RN, MSN Kristine Yaffe, MD GRS8 Question Writer: Amy E. Sanders, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Slide 53 Copyright © 2013 American Geriatrics Society Slide 53