DEMENTIA - Basic Drug Calculations Review - University of Kansas ...

DEMENTIAShelley Bhattacharya, DO, MPHKansas Reynolds Program in AgingUniversity of Kansas Medical Center

ObjectivesUpon completion the learner will be able to;1. Define Dementia2. List diagnostic criteria for most of thedementias3. Compare and contrast types of dementia4. Describe the “masqueraders” of dementia5. Describe the process of cognitive evaluation6. Describe key management issues in dementiacare.

NORMAL AGINGNo consistent, progressivedeviations on testing of memorySome decline in processing andrecall of new information: “slower,harder”Reminders help—visual tips, notesAbsence of significant effects onADLs or IADLs due to cognition

Definition of DementiaAcquired cognitive deficits (two or morecognitive domains) that;occurs in the absence of acuteconfusion*,that causes dysfunctionand have no other medical cause. DSM IV* Acute confusion = delirium

What is Delirium?CAM DefinitionI) Change in Cognition from baselinewith:-Acute Onset or-Fluctuating course, ANDII) “Inattention”, ANDIII) Disorganized thinking or AlteredLevel of ConsciousnessIV) Has a Medical CauseDSM-IV

Symptom contrast:DELIRIUM vs DEMENTIAFEATURE DELIRIUM DEMENTIAOnset Acute InsidiousCourse Fluctuating StableAlertness Low or High NormalAttention Distractible NormalThinking Disorganized ImpoverishedDuration Hours/days Months/years

Dementia types(most common)DiagnosesPercent of dementiasAlzheimer’s disease: 50-60%Vascular dementia: 15-25%Dementia with Lewy Bodies: 10-20%Less common diagnoses: < 5 %Grossberg GT NEJM, 8-1-96Rahkonen T; Neurol Neurosurg Psychiatry 2003Jun;74(6):720-4.

Less common DementiasAlcohol related dementiaFronto-temporal dementiaParkinson’s dementia

RISK FACTORS FORDEMENTIAAgeFamily historyHead injuryFewer years of educationFemale sex

Alzheimer’s Dementia(DSM IV)ALZHEIMER’S DISEASE (AD)A-1 DementiaA-1 Memory impairment (Key feature)A-2 Impairment of cognitive domains (one ormore):1) Orientation2) Language3) Visual- Constructions4) Executive control

Alzheimer’s DementiaB) Dysfunction as a result of cognitive deficitsC) Course--gradual and progressive decline(Key feature)D) No other CNS or systemic diseases, delirium,psychiatric disorder as causeSensitivity- 76 % , specificity- 80 %

THE EPIDEMIOLOGY OFALZHEIMER’S DISEASE (AD)(prevalence doubles q 5 yrs )Age 65Alzheimer'sAge 85Alzheimer'sNoAlzheimer'sNoAlzheimer's~5% at age 65have ADNearly half of thoseaged 85+ have AD

Vascular Dementia DSM IVcriteria- (must fulfill 1,2, 3 & 4 below)1) Dementia diagnosis is established2) Documented cerebrovascular disease(focal neuro deficit or imaging evidence)3) Temporal relationship between 1 and 2By:a) onset of dementia within 3 months of strokeorb) abrupt deterioration in cognitive functionorc) a stepwise course in cognitive decline.4) No delirium

DEMENTIA with LEWY BODIES(DLB)#1)Dementia diagnosis established(see previous definition)#2 :Possible DLB: One of the following (a,b,c) are required.Probable DLB:Two of the following (a,b,c) are required.If #1 plus a, b, & c (below) present gives 100% specificitya) Fluctuating - cognition- attention- alertnessb) Visual hallucinations (well formed, detailed)c) Parkinsonian motor features(spontaneous)

DEMENTIA with LEWY BODIES(DLB)3) Supportive features:-Falls (repeatedly)-Syncope/transient loss ofconsciousness-Neuroleptic hypersensitivity-REM sleep disorders4) DLB LESS likely in:-Stroke disease,-any other physical/brain disease thataccounts for clinical picture

Barton C. Smalll GW, Yaffe K. Dementia. Geriatric Review Syllabus 6th edition Chapter 30, pages 221-230Feature Alz. Dem. Vasc. Dem. Lewy BodyOnset Subtle Sudden SubtleCognitiveDomainsMotor sx.ProgressionOnsetdeathUniquefeaturesGradualdeclineMemory,LanguageExec. Funct.Rare in EarlyStagesStepwiseCorrelates wlocationinfarctCorrelates wlocationinfarctGradual,fluctuatesMem., Attn.Vis-spat.,Exec. Funct.Parkinsonian10-13 years Unpredictable 8-10 yearsImaging- CVinjuryHallucinations

Parkinson’s Disease DementiaDiagnostic criteria:1. Basic dementia definition2. Executive dysfunction, visual spatial precedes memorydecline…poor clock draw.3. Established diagnosis of Parkinson’s diseaseAssociative features;-Depression-Visual hallucinations-Older age, length of time with Parkinson’s**Pts with PD have 6x increased risk of dementia**

PD vs DLB vs ADYEARS: 0………5………10………15…….20PD: motor ----------------------------------------deathcog.---------------------deathDLB: motor --------------deathcog. ------------deathAD: motor---------deathcog. --------------------------death= onset

LESS COMMON DEMENTIAS

FRONTOTEMPORAL DEMENTIAI) Insidious onset and progression of deficits.II) Younger onset of cognitive symptomsIII) Dominant deficits:LOSS of JUDGMENT;LOSS of LANGUAGE (perseveration,fluency)IV) Deficits in Judgment or Social Interactionsout of proportion to anterograde amnesia.v) No psychiatric diagnosis causing symptoms.

FRONTOTEMPORAL DEMENTIAIII) Dominant deficit:LOSS of JUDGEMENT;with:-Disinhibition-Impulsivity-Social misconduct-Loss of social awareness-Social withdrawalOne or more of the following Behaviors:--incessant oral or manual exploration--hyperphagia-impetuous activities--echolalia-incessant wanderlust--excessive joviality -sexually provocative--inappropriate words of actions

FRONTOTEMPORAL DEMENTIAAnatomy-frontal temporal atrophyImaging-CT or MRI often adequate,-PET can confirm(Medicare will pay PET for this possiblediagnosis)

Pick’s DiseasePick's disease was the first recognized subtypeof FTDcharacterized by the presence of Pick bodies(silver staining intracytoplasmic inclusions) in theneocortex and hippocampusdisorder presents with language abnormalitiesand behavioral disturbances.Average age 60 years old, range 35-70one in 10,00020%-40% familial occurrenceMedian survival nine years

ALCOHOL RELATED DEMENTIA(1) Dementia that is present after 60 days sobriety(based on previous definition)(2) Hx of heavy alcohol use.* (within 3 years of onsetdementia)(3) SUPPORTIVE DIAGNOSTIC FEATURESa)Alcohol related end organ dz.-hepatic, renal, pancreatic, etcb) Peripheral neuropathy or ataxia.(Not due to other causes)c) After 60 days abstinence:-cognitive impairment stabilizes or improves.-improvement in neuroimaging signs ofventricular or sulcal dilation.*heavy alcohol use:-35 drinks per week x 5 years (male).-28 drinks per week x 5 year (female).

NORMAL PRESSURE HYDROCEPHALUS( NPH)Enlarged ventricular size with normalopening pressures on lumbar puncture.Diagnostic criteria?triad of subcortical dementia, gaitdisturbance, and urinary incontinence.CSF large volume tap evaluate for shuntcandidacy70%-response to shunting

HIV-associated dementiacomplex (HAD)Diagnostic criteria-1) basic dementia diagnostic criteria2) plus motor or emotional (mood) orbehavioral symptomssubcortical dementia (memory prob)NO cortical sx: aphasia, agnosia,apraxia (like in AD)HIV positive patient with AIDS criteria(involves 30% of patients who die of AIDS)

Creutzfeldt-Jakob disease (CJD)The World Health Organization (WHO) diagnosticcriteria-Progressive dementia- > 2 of 4 clinical features: myoclonus; visual orcerebellar disturbance; pyramidal/extrapyramidaldysfunction; akinetic mutism-A typical electroencephalogram (EEG) duringan illness of any duration, and/or a positivecerebrospinal fluid (CSF) assay with a clinicalduration to death less than two years-Routine investigations should not suggest analternative diagnosisSafar JG; Proc Natl Acad Sci U S A 2005 Mar 1;102(9):3501-6.

EVALUATION andMANAGEMENT

Cognitive ScreeningScreen all older adults annually withfunctional screen.Use:3 item recall from MMSEIf < 3/3 item recall, perform full MMSEIf fails MMSE or hx. cognitive dysfunctionproceed with evaluation

Disclaimer:“history trumps tests”

Cognitive evaluationQuestions that we must answer: Is there a cognitive problem? Is it dementia? If dementia, what kind? What co-morbid problems affectcognition?

Evaluation ComponentsA) H & PB) Neurological examC) Cognitive ScreeningD) LaboratoryE) Imaging

Key areas in history(from patient and collateral source) Onset Progression Cognitive Domains Family history Medications Substance use/abuse Effect on function-ADL and IADL’s affected

MEDICATIONSWhat to suspect:Alter neurotransmittersmost common;anticholinergics, antihistaminesDrugs that sedate, potentially cause delirium?Narcotics, sedative hypnotics, etc.

Ask about Instrumental Activities OfDaily Living (IADL’s)TelephoneManage financesShopPrepare foodHousekeepingOrganize transportationManage medical affairsDriving

Activities of Daily Living (ADL’s)What you had tobe able to do toleave home togo tokindergartenor“D-E-A-T-H”mnemonicD ressE atA mbulateT oiletH ygiene

ProgressionD ressE atA mbulateToiletH ygieneDementia;“We lose them in theorder that we gotthem as a child.”1 st Dressing andHygieneNext- ToiletingNext –AmbulateLast - Eat

Physical examFocus:Sensory (hearing, vision)—vision card andwhisper testComorbidities (e.g. CHF, COPD)Functional problems(gait, weight loss, incontinence, etc.)

Neurological examCranial nervesMotorGaitSensory (touch, proprioception)Reflexes (DTR, plantar)CoordinationToneGet Up and Go test

LABSBASIC LABSCBCChemistry ProfileTSHB 12 levelUAINDICATION DEPENDENT LABSVDRLHIVLyme titerESR, ANAEEGLumbar puncture

LABORATORIESWhat are we looking for?‣ The rare reversible causeMost important;‣ Status of Comorbid diseases‣ Evaluate for contributing factors

IMAGINGCT-non-contrastEvaluates adequately commoncauses/contributorsMRIOccasionally necessary for;Unexplained neurological findingsVascular lesionsSubtle strokes, posterior circulation, NPH

When do I need a PET?SuspectFRONTO-TEMPORAL DEMENTIA

When to image?Any cognitive evaluation without imagingin last six months (use clinical judgment).Step down or changing condition since lastimaging.

Management of DementiaA - Affective disorder screening, ActivitiesB - Behavior problems-screen and treatC - Caretaker, Cognitive medications andstimulationD -Directives-advanced/ DrivingS - Sensory enhancement

A - Affective disorder screening,ActivitiesAffective disorder-low threshold to treat-elder friendly medicationsActivities-social-cognitive-physical

B - Behavior problems-screen andtreatHigh caregiver burdenPredictor of nursing home placementAssociated with increased caregiverfinancial hardship.Most challenging and distressing aspect ofdiseaseCoen RF et al. Int J Geriatr Psychiatry 1997; 12:331-6Moore MJ Gerontol B Psycho;l. Sci Soc Sci 2001; 56 B : S219-28

C - Caretaker, Cognitivemedications and stimulationCaretaker1) Respite2)Support groups3)Alzheimer association4) Social worker &/or case managerCognitive stimulation-Ability appropriate activities daily-Adult day careVerghese J et al., NEJM 2003 June 19; 348:2508-16Gatz M,Medicine Vol 2, Issue 1, Jan 2005

Geldmacner DS, Provenzno G, et. al..JAGS Vol. 51, No. 7 ( 899-1052) July 2003Winblad B. et. al.. Lancet Vol 367, April 1 2006Sink et. al JAMA Feb 2 , 2005 Vol 293, noBeier MT Pharmacotherapy 2007; 27(3): 399-411Cognitive medicationsAcetyl-cholinesterase Inhibitors (ACH-I)Donepezil:(Aricept)5 mg/day for 1-2 months if tolerated increase to10 mg/ day.Galantamine: (Razadyne) start 4 mg bid .If tolerated increase q 2- 4 weeks by 4 mg biduntil reached 12 mg bid. (Has ER form)Rivastigmine: (Exelon) 1.5 mg bid X 2 wks increase by1.5 mg bid q 2 wks to max. dose 6 mg bid,Patch -Start 4.5 mg /day increase to 9.6 mg /day

D -Directives-advanced/ DrivingD -Directives-advanced‣ Powers of attorney-healthcare & finance‣ Wills & estate issues‣ Living WillDrivingWhen to evaluate; (any of the below)-spouse/family worried-MMSE < 20/30-fails Trails B-at fault MVA

S - Sensory enhancement1) Correct vision and hearing to bestpossible level.2) Modify environment to augment deficits(O.T. consult may help)e.g.-Telephone modifications-Newspaper magnification-modifications to maintain hobbiesreturn

ReviewAD- memory + gradual progressive declineVAD-stroke + stepwise progressionDLB-Park. sx, visual hallucinations, fluctuatesPDD-Parkinson’s dz.+ time + executiveFTD- young + judgment + languageNPH- gait + dementia + UIMSA- autonomic + atyp. park. sx.

THANK YOUforYOUR ATTENTION!

ReferencesCo-Director“NEBGEC: The Nebraska GeriatricEducation Center”DHHS Health Resources and ServicesAdministrationDr. Ed Vandenberg, Univ of NE