Pamela Pride MD December 3, 2009

     Differentiate dementia from delirium and depression Learn the testing characteristics of screening instruments Differentiate different types of dementia Recognizing and managing caregiver stress Learn strategies of managing behavioral symptoms

  Evidence from the history and mental status examination that indicates major impairment in learning and memory as well as at least one of the following: - Impairment in handling complex tasks - Impairment in reasoning ability - Impaired spatial ability and orientation - Impaired language  It is progressive, usually incurable and terminal

     There are approximately 5.1 million Americans 65 years and older with dementia. 1 in 8 persons 65 and over Nearly 50% of all persons over the age of 85 have some type of dementia.

It is the sixth leading cause of death in the US It is the third most expensive disease after cardiovascular disease and cancer.

Alzheimer’s Association 2009 Facts and Figures

Projected numbers of demented patients

16 14 12 10 8 6 4 2 0 2000 2020 2040 2050

Signs of Dementia

     Poor judgment and decision making Inability to manage a budget Losing track of the date or the season Difficulty having a conversation Misplacing things and being unable to retrace steps to find them     

Typical Age Related Changes

Making a bad decision once in a while Missing a monthly payment Forgetting which day it is and remembering later Sometimes forgetting which word to use Losing things from time to time.

Alzheimer’s Association

Onset Duration

The 3 D’s Depression - Dementia - Delirium

Delirium Dementia Depression

Attention Consciousness Abrupt Hours to days Impaired Reduced, fluctuating Slow, insidious Months to years Normal, except severe cases Recent, may be associated with loss Stable, may be worse in the morning Usually normal Clear Silverstein & Maslow, 2006 Clear

            Major Depression Acute, nonprogressive Depression Affective before cognitive Attention impaired Orientation intact Vocal memory complaint Gives up on testing Language intact Patient complains Better at night Criticizes self Self-referred             Dementia Insidious & progressive Depression mild if present Cognitive before affective Recent memory impaired Orientation impaired Minimizes memory problem Patient makes effort Possibly aphasic Family complains Sundowning Criticizes others Referred by others

A ntiparkinson drugs C orticosteroids U I drugs T heophylline E mptying drugs (motility drugs)

I

nsomnia drugs

N

arcotics

M

uscle relaxants

S

eizures Drugs C ardiovascular Drugs H 2 blockers A ntimicrobials N SAIDs G eropsychiatric drugs E NT drugs

Look to these medications if there is an ACUTE CHANGE IN MS http://www.geronurseonline.org; Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27.

Antidepressants

Amitriptyline (Elavil ® ) Clomipramine (Anafranil ® ) Desipramine (Norpramin ® ) Doxepine (Sinequan ® ) Imipramine (Tofranil ® ) Nortriptyline (Pamelor ® ) Trazodone (Desyrel ® ) Antidiarrheals Diphenoxylate/Atropine (Lomotil ® ) Antiemitics/Antivertigo Dimenhydrinate (Dramamine ® ) Meclizine (Antivert ® ) Prochlorpromazine (Compazine ® ) Promethazine (Phenergan ® ) Scopolomine (Transerm-Scop ® )

Antihistamines

Chlorpheniramine (Chlor-Trimeton ® ) Cyproheptadine (Periactin ® ) Diphenhydramine (Benadryl ® ) Hydroxyzine (Vistaril/Atarax ® )

Antiparkinsonian Agents

Benzotropine (Cogentin ® ) Trihexyphenidyl (Artane ® )

Antipsychotics

Chlorpromazine (Thorazine ® ) Clozapine (Clozaril ® ) Fluphenazine (Prolixin ® ) Thioridazine (Mellaril ® ) Triflupromazine (Stelazine ® )

Gastrointestinal/Urinary Agents

Belladona alkaloids (Donnatol ® ) Dicyclomine (Bentyl ® ) Hyoscamine (Levsin ® ) Oxybutinin (Ditropan ® )

Muscle Relaxants

Carisoprodol (Soma ® ) Cylobenzaprine (Flexeril ® ) Orphenadrin (Norflex ® )

Opiates

    30 point maximum <24 c/w impairment Influenced by education Does not distinguish dementia from delirium

Borson, S., et al (2000). Int J Geriatr Psych 15 (11): 1021-1027.

Clock Drawing Test

• • • • •

Quick office-based assessment tool Brief (1-5 minutes) Minimal language requirement Does not require specialized testing materials Easily adapted for non English-speaking elderly Sunderland T et al. (1989), J Am Geriatr Soc 37(8):725-729; Borson S et al. (1999), J Gerontol A Biol Sci Med Sci 54(11):M534-M540

   Tests functional limitations/changes rather than cognitive Sensitivity and specificity comparable to the MMSE Rating functional abilities over past 4 weeks   Not applicable Normal    Some difficulty but does by self Needs assistance Dependent Pfeffer RI, et al. J Gerontol 37:323-329:1982

          Writing checks, paying bills, balancing checkbooks Assembling tax records, business affairs, or papers Shopping alone for clothes, household necessities, or groceries Playing a game of skill, working on a hobby Heating water, making a cup of coffee, turning off stove Preparing a balanced meal Keeping track of current events Paying attention to, understanding, discussing a TV show, book, magazine Remembering appointments, family occasions, holidays, medications Traveling out of neighborhood, driving, arranging to take buses Source: Pfeffer RI et al. J Gerontol. 1982;15:323-329.

       Alzheimer’s Disease Vascular Dementia (MID) Lewy Body Dementia Frontotemporal Dementia PD CJD Secondary Causes     NHP Syphilis Thyroid dz B12 deficiency

       Disease of old age, slight female predominance Insidious and progressive memory impairment Characteristic pattern of memory loss  Episodic→semantic→immediate recall→motor Verbal, visual-spatial and subtle executive function problems can be early signs Apraxia, neuropsych sx and profound exec function problems occur late in disease Pts have poor insight Neurologic exam normal early on

     Various atypical forms exist  Posterior cortical atrophy   Primary progressive aphasia Biparietal syndrome Common to have AD and other dementia Progressive, incurable and ultimately terminal Mean survival 3-8 years Death results from loss of motor memory

     Cognitive dysfunction related to brain ischemia Abrupt onset of symptoms followed by stepwise deterioration Executive func impairment early, memory later Neuro exam and imaging c/w previous stroke Risk factor modification and antiplatelet rx recommended

       Progressive cognitive decline  Usually executive func impaired prior to memory Fluctuating cognition Visual hallucinations Spontaneous features of parkinsonism Severe autonomic dysfunction Neuroleptic sensitivity Can mimic delirium

  Earlier onset, more rapidly progressive 3 clinical variants  Behavioral variant   Semantic dementia Progressive nonfluent aphasia

    Parkinson’s related CJD Huntington’s disease TBI

       10-20% of pts labeled with dementia have reversible causes Of “true” dementias 5% are potentially reversible NPH most common Hypothyroidism B12 deficiency Syphilis SDH, cns neoplasms

No or Partial Improvement Reversible Causes: •H & P •Laboratory Testing •Medication Review

  Cholinesterase inhibitors  Offer modest improvement in surrogate end points for mild-mod disease   Questionable cost benefit ratio Expected ADRs Memantine  shows improvement in surrogate end points for mod-severe disease  Appears safe, well tolerated

  Managing behavioral sx  Aggression     Wandering Physical and chemical restraints Co-morbid depression Is it ok to use neuroleptics?

Treating the family  Recognizing and managing caregiver stress

With any behavioral change it is important to evaluate for underlying delirium and depression  Wandering    Maintain and active daytime schedule Re-orient frequently Use alarm systems to keep pt safe  Aggression    Medically evaluate pt for delirium, pain, anxiety etc Calming environment strategies Carefully weigh risk:benefit with neuroleptics and discuss with caregivers

      Educate caregiver re: course of disease Encourage HCPOA early and end of life preferences Encourage Caregivers to find PCP’s and have routine MD visits for themselves Mobilize resources and make caregivers aware of respite and day care services Encourage caregivers to become familiar with NH’s Encourage caregivers to stay with demented pt in event of hospitalization

 Evaluation & Diagnosis  Prognosis  Association Behavioral Symptoms  Safety Issues  Caregiver Stress  Community Resources

Over the past two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things.

0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Feeling down, depressed, or hopeless.

0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day

PHQ-2 Score Probability of major depressive disorder (%) Probability of any depressive disorder (%)

1 2 3 4 5 6 15.4

21.1

38.4

45.5

56.4

78.6

36.9

48.3

75.0

81.2

84.6

92.9

T hibault, JM, Prasaad Steiner, RW. (2004) “Efficient Identification of Adults with Depression and Dementia.” American Family Physician (70):6.

1 = Acute Onset & Fluctuating Course PLUS 2 = Inattention AND EITHER 3 = Disorganized Thinking OR 4 = Altered LOC (Most Common = Hypoactive) Inouye et al. Ann Intern Med 1990

Falls Strangulation Loss of Muscle Tone Pressure Sores Decreased Mobility Agitation Reduced Bone Mass Stiffness Frustration Loss of Dignity Incontinence Constipation

• • • • • •

PLST/Environment

Progressively Lower Stress Threshold Solutions Avoid placing patient in a room with high noise and traffic Avoid room changes Subdue physical environment Be sensitive to amount of light Remove threatening artwork Use pictures and large words

Pt Admitted with Known or Suspected Dementia Abnormal Identify Underlying Cause of Delirium and Treat Consistent with Depression Treat Depression or Discuss Options CAM Normal No Delirium PHQ2 (If Possible ) Impaired Re-Evaluate After Treatment Schedule Family Meeting

IF AT ANY TIME PATIENT REQUIRES PHYSICAL RESTRAINTS, DOCUMENT IN CHART REASON WHY AND NOTIFY FAMILY

Equivocal or Inconsistent with Depression Mini-Cog Not Impaired

Discuss Dementia with Family

•Evaluation & Diagnosis •Prognosis •Associated Behavioral Symptoms •Safety Issues •Caregiver Stress •Community Resources No Action

   Alzheimer’s Association St. Louis Chapter and Washington University Alzheimer’s Disease Research Center  Dementia-Friendly Hospitals: Care Not Crisis: “Medical Overview: Recognition and Management of Hospitalized Patients with Cognitive Impairment.” National Alzheimer’s Association “2009 Facts and Figures”