Transcript Co-morbidity in the Memory Clinic

Co-morbidity in the
Memory Clinic
David Jolley May 2010
Multiple pathology
Co-morbidities
• Dementia + physical (+ therapy)
• Dementia + mental (+ therapy)
• Dementia + physical + mental (+ therapy)
Influences
• Co-morbidities or their
treatment may influence
the development, course
and/or outcome of
dementia
• The presence and
progress of dementia or
its treatment may
influence the
development, course
and/or outcome of other
pathologies
Profile of pathologies and medication
• 69% 0f people 65 years + have
2 or more pathologies
(Hoffman et al 1996)
• Prescriptions CVS 72%, CNS
37%, Musc/Sk 28%, Upper GI
24%, Resp 14%, Diabetes,
Glaucoma, Thyroid 5-8%
Naughton et al 2006)
• Dementia (known) Primary
care average 2 – 3 other
conditions, 5 medicines – half
with anticholinergic activity
(schubert et al 2006)
Some medication is unnecessary
• Review of medication can
reduce prescriptions:
Williams et al 2004
succeeded in reduces
medication by 1-2 per
individual. No change in
function/symptoms. Cost
savings $30.00 per
month. Much resistance
• Barton et al 2008 Memory
Clinic
Danger from medicines
• Weigh et al 2009 found that
20% of patients attending a
German memory clinic took
medicines which affected
cognition adversely
• Barton et al 2008 found 22% of
Memory Clinic patients were
taking medication deemed
inappropriate using Beers
criteria (benzodiazepines,
oxybutinin, amitriptyline,
fluoxeteine, diphenhydramine
Grandma’s special
• Dergal et al2002 found
that 33 of 195 Memory
Clinic patients in Toronto
were concurrent users of
herbal and similar
remedies. A further 19
had experimented with
alternative therapies
• Gingko, garlic,
glucosamine and
echinacea were the most
popular choices
Closer to home: what are we like
and what’s the outcome
Morbidity in Penn Memory Clinic 87 patients with
Alzheimer’s disease(Sarah Lyle MSc)
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Recordings of cardiovascular disease, cerebro-vascular
disease, cancer, hypothyroidism and Vit B12 status
Half had no recorded illness
31% Cardiovascular
3% Cerebro-vascular
3% cancer
3% Hypothyroid
31% had low B12 levels
Marital status
Married
Widowed
Single
Other
52 (59)
33 (38)
2 (2)
1 (1)
Home situation at referral
Home alone
Home and spouse
Residential home
Sheltered housing
31 (36)
48 (54)
5 (6)
2 (2)
Physical illness
Yes
No
43 (49)
44 (51)
No. of years from onset of symptoms to treatment
Mean
s.d.
Min. & Max
2.74
1.71
1-10
On psychotropic medication at baseline
Yes
No
20 (23)
68 (77)
Cognitive (MMSE) score at baseline
Mean
s.d.
Min. & Max.
18.78
5.42
7 - 28
Mini-mouse at baseline
Mean
s.d.
Min. & Max.
4.36
3.79
0 - 16
Carer GHQ
Mean
s.d.
Min. & Max.
5.15
6.01
0 - 28
Alive at 1/9/02
Yes
No
49 (56)
39 (44)
Figure 2. A comparison of cognitive (MMSE) score over a period of 24 months
between the survival group who completed 3-year treatment and the rest of the cohort
30
20
Patient Category
10
T he rest
0
Survived
0
1
4
7
10
13
time scale in 3 months increment
16
19
TABLE 1
Variables selected by the logistic regression
with an optimal predictive power (74.3%)
Variable
Code
SEX
ANYPHY
SB
ANYPSY
MD
MMSEB
Variable Description
Gender of patients
Any physical illness at
baseline?
Any psychotropic medication at
baseline?
Score of Mini-Mental State
Examination at baseline
S.E.
Wald
Score
Significa
nce
Of Log
LR
0.667
0.638
2.843
6.920
0.092
0.009
0.719
2.180
0.140
0.059
5.659
0.017
TABLE 2
Area under ROC curve given by different tests
Type of Test
Single Variable –
SEX
Single Variable –
ANYPHYSB
Single Variable –
ANYPSYMD
Single Variable –
MMSEB
Two Variables –
(ANYPHYSB +
MMSEB)
All Four Variables
Asymptotic 95% Confidence
Area
Interval
Under
ROC curve Lower Bound Upper Bound
0.539
0.397
0.680
0.613
0.474
0.752
0.563
0.421
0.705
0.648
0.495
0.802
0.759
0.630
0.888
0.762
0.634
0.891
FIGURE 1 ROC curve for the two most significant
variables; ANYPHYSB & MMSEB.
ROC Curve
1.00
.75
Sensitivity
.50
.25
0.00
0.00
.25
.50
.75
1 - Specificity
Diagonal segments are produced by ties.
1.00
Med Care. 2008 Aug;46(8):839-46.
Implications of co-morbidity on costs for patients with
Alzheimer disease.
Kuo TC, Zhao Y, Weir S, Kramer MS, Ash AS.
 From review of 600,00 on Medicare
 AD pts 8.1 co-morbid conditions v 6.5 matched
controls
 Excesses: Mental health, neurol, cerebrovascular, diabetes, acute complics, injury
 Costs + 34%
BMC Health Serv Res. 2008 May 22;8:108.
Healthcare costs and utilization for Medicare beneficiaries with
Alzheimer's.
Zhao Y, Kuo TC, Weir S, Kramer MS, Ash AS.
229
(1)
133
(2)
1.50‡
Femoral (hip) fracture
209
(2)
88 (4)
2.32‡
Cystitis, other urinary tract infections
161
(3)
42 (13)
3.46‡
Heart failure
150
(4)
158
(1)
0.78‡
Disorders of fluid/electrolyte/acid-base balance, e.g., dehydration
118
(6)
49 (11)
2.16‡
Septicemia (blood poisoning)/shock
118
(7)
14 (39)
2.77‡
Syncope and collapse
100
(8)
33 (30)
2.85‡
Aspiration pneumonia
100
(9)
18 (16)
5.36‡
Pre-cerebral or cerebral arterial occlusion with infarction
84
(10)
48 (12)
1.74‡
Coronary atherosclerosis and other chronic ischemic heart
disease (CAD)
70 (13)
111
(3)
0.53‡
Acute myocardial infarction, initial episode of care
83 (11)
81 (5)
0.92
Atrial arrhythmia
56 (16)
62 (6)
0.83
Osteoarthritis of lower leg (knee)
27 (29)
62 (7)
0.39‡
Gastrointestinal hemorrhage, except peptic ulcer and anal/rectal
78 (12)
55 (9)
1.22‡
Any inpatient admission
3,796
2,408
Other and unspecified pneumonia
Top 10 Reasons for Inpatient Admission by Cohort
1.55
‡
J Am Geriatr Soc. 1998 Apr;46(4):444-52.
Prognostic factors in very old demented adults: a seven-year follow-up
from a population-based survey in Stockholm.
Agüero-Torres H, Fratiglioni L, Guo Z, Viitanen M, Winblad B.
 Follow-up clinical examinations of dementia patients from a
population-based study after 3- and 7-year intervals. SETTING AND
PARTICIPANTS: In an established population aged 75 years and
older in Stockholm, Sweden, there were 133 cases of AD, 52 of
VaD, and 38 of OD.
 Older age, male gender, low education, comorbidity, and
functional disability predicted shorter 7-year survival in
the 223 prevalent dementia cases. Other factors,
including type of dementia, dementia severity, and
duration of the disease were not significant.
Am J Geriatr Psychiatry. 2005 Sep;13(9):781-6.
Sensory impairment and cognitive functioning in oldest-old subjects:
the Leiden 85+ Study.
Gussekloo J, de Craen AJ, Oduber C, van Boxtel MP, Westendorp RG.
 Within the Leiden 85+ Study. METHODS: Within this
population-based study of 459 participants aged 85+
years, hearing impairment was measured by audiometry
and visual impairment by a visual acuity chart, both
under standardized conditions
 Both hearing impairment (prevalence: 85%) and visual
impairment (prevalence: 59%) were associated with
lower scores on the MMSE. Increasing visual impairment
was associated with poorer scores on memory and
cognitive speed, as measured with visually presented
cognitive tests. In contrast, there was no association
between hearing impairment and memory and cognitive
speed
J Neurol. 2010 Feb;257(2):238-46. Epub 2009 Sep 1.
Taste in mild cognitive impairment and Alzheimer's disease.
Steinbach S, Hundt W, Vaitl A, Heinrich P, Förster S, Bürger K, Zahnert
T.
 Prospective study which investigated the quantitative
and qualitative taste function of patients with mild
cognitive impairment (MCI) and Alzheimer's disease
(AD). 29 healthy, elderly subjects, 29 MCI and 30 AD
patients were tested using a validated taste test, the
"taste strips".
 there was a significant reduction of total taste scores and
also the score for individual tastes on either side of the
tongue between controls and MCI/AD patients.
Int Psychogeriatr. 2010 May;22(3):417-25. Dental health of communityliving older people attending secondary healthcare: a cross-sectional
comparison between those with and without diagnosed mental illness.
Purandare N, Woods E, Butler S, Morris J, Vernon M, McCord JF,
Burns A.
 The need for dental treatment was significantly higher
among the psychiatry group compared to the medical
group (85% vs 52%; p<0.001); even after taking account
of the effect of age, gender, teeth status, physical comorbidity, cognition, depressive symptoms, and overall
mental and social health [adjusted odds ratio, OR (95%
confidence interval): 4.32 (2.09, 8.91)].
 The presence of any natural remaining teeth [OR: 4.44
(2.10, 9.42)] and Barthel Index [OR: 0.96 (0.93, 0.99)]
were the two other independent predictors of the need
for treatment.
Holmes C et al (2009) Systemic
inflammation and disease progression in
Alzheimer’s disease. Neurology 73; 768774
 275 subjects with probable or possible Alz
 Baseline ADAS-COG mean 29.6 (SD 13.0)
 f/u at 2, 4 and 6 months
 Those with episodes of acute inflammation
(rise in TNF-alpha) rate of cognitive decline x 2
 Those with high baseline of TNF-alpha
sustained throughout: rate of decline X4
 Those with low TNF-alpha throughout no
decline
Summary
 Multiple pathology is common in older
people
 Co-morbidity is at least as common
amongst people with dementia as those
without dementia
 The presence of co-morbidity in dementia
produces difficulties, reduces the likelihood
of remaining in therapy, impacts on the
quality of life, increases use of hospitals
and costs and hastens death
 Evidence of inflammatory processes is
associated with more rapid cognitive
decline
 Sensory impairments are associated with
cognitive decline
 Attention to other pathologies and
medication regimes may have multiple
benefits for patients, families and services