Dementia

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Dementia

• Carrie Plummer, PhD, ANP-BC
• Abby Parish, DNP, A/GNP-BC
• Jennifer Kim, MSN, GNP-BC
• Vanderbilt School of Nursing
• Meharry-Vanderbilt GEC
• Qsource Webinar Series

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DEMENTIA FACTS
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Dementia - An Overview

• Definition
• Types of Dementia
• Risk Factors
• Diagnosis
• Stages
• Treatment/Prevention
• Resources

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Statistics

• 7 million people suffer from Alzheimers disease
  (AD)
• AD accounts for 50-70 of all dementias
• 8th leading cause of death in elderly
• AD lasts from 3-20 yrs (avg 7 yrs)
• Cost in US 100 billion/year
• Currently there is NO CURE

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Dementia

• More than just memory loss
• Deficits in SHORT TERM memory
• Deficits in attention, language and problem
  solving
• Interferes with social and occupational
  functioning
• Mild Cognitive Impairment (MCI)
• Memory deficits without functional impairment
• Can be difficult to distinguish from normal
  changes of aging
• Amnesia type - most studied, most likely to
  progress to AD
• donepezil (Aricept) may be protective for limited
  period (1 year)

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Common Types of Dementia

• Alzheimers Disease
• 50 70
• Vascular Dementia
• 15 30
• Dementia with Lewy Bodies (DLB)
• 10 25
• Frontotemporal lobe Dementia
• rare

• Secondary dementias
• Normal Pressure Hydrocephalus (NPH)
• Parkinsons dementia
• AIDS related dementia
• Alcohol related dementia

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Alzheimers Disease

• Alois Alzheimer- 1906
• Unusual disease of the cerebral cortex
• Histopathology
• Neurofibillary plaques and tangles
• Parietal-temporal cortex, prefrontal cortex,
  hippocampus, amygdala
• Granulovacular bodies
• Large, double-membraned bodies

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Plaques Tangles
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Results of cell death
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Alzheimers DiseaseNeurotransmitter Changes

• Acetylcholine amount and activity decreased
• Needed for memory, language and thoughts.
• N-methyl-D-aspartate (NMDA)
• Somatostatin
• Serotonin

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Alzheimers Disease-Types

• Sporadic
• No known cause
• No obvious inheritance patterns
• Familial
• Rare (lt10)
• Early onset
• Gene mutations on chromosomes 1,14 21
• 21 abnormal amyloid precursor protein (APP)
• 14 abnormal presenilin 1
• 1 abnormal presenilin 2
• Autosomal dominant pattern
• 1 copy of altered gene can cause AD

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Risk Factors of AD (Sporadic)

• Exact cause of AD is unknown
• Age
• 1 in 10 people over 65
• 30-50 of those 85
• High blood pressure
• High cholesterol
• Head injury
• Hormone replacement therapy

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Symptoms of AD

• Memory Loss
• Slow progression
• Affects daily living
• Confusion/Disorientation
• Language problems
• Word finding
• Using words inappropriately or forgetting their
  meaning
• Judgment

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Symptoms of AD

• Difficulty with
• Handling money
• Calculating numbers
• Keeping track of things
• Misplacing items
• Changes
• Personality
• Mood
• Apathetic

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Stages of AD

• Mild
• Primarily cognitive deficits
• Mild personality/behavior changes
• Moderate
• More pervasive memory impairment
• Impairment of ADLs requiring supervision and
  minimal assistance
• Behavioral symptoms more pervasive

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Stages of AD

• Severe
• Profound memory impairment
• Requires significant assistance with ADLs
• Vegetative symptoms more pervasive

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Stages of AD

• Mild (can last 2-4 years or longer)
• MMSE is 21
• Appearance of health
• Symptoms may be mistaken for normal aging changes
• SYMPTOMS
• easily loses way to familiar places,
• trouble with word finding,
• hoarding,
• taking longer time to finish familiar tasks,
• personality changes,
• anxiety,
• poor judgment.

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Stages of AD

• Moderate (can last 2-10 years)
• MMSE is 10-20
• More damage to the brain, especially areas
  controlling language, reasoning, thought and
  processing of sensory information. Symptoms are
  more pronounced.
• SYMPTOMS
• trouble recognizing familiar people objects,
• behavior changes,
• more spontaneity,
• inappropriate comments,
• paranoia,
• problems with language (speech, reading,
  writing),
• loss of impulse control

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Stages of AD

• Severe (can last 1-3 years or longer)
• MMSE is 9
• Damage to brain is widespread full time care
  required. Difficult time for family caregivers.
  
• SYMPTOMS
• doesnt recognize self or close family,
• loses control of bowel and bladder,
• weight loss, repetitive crying,
• complete loss of language,
• increased sleeping,
• difficulty swallowing.

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Vascular Dementia

• 5 of all dementias 22 mixed with AD
• Stepwise progression
• PMH CVA, MI, DM, HTN, PVD, HLD
• Memory impairment less severe than AD
• TX No current FDA-approved medications
• donepezil (Aricept) shown to be effective in
  mild-mod VD

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Dementia with Lewy Bodies (DLB)

• Characterized by loss of dopamine and
  acetylcholine
• Common presenting symptoms
• Visual hallucinations
• Parkinsonian symptoms
• Cognitive fluctuations
• Other symptoms
• Repeated falls
• REM sleep behavior disorder
• Depression/apathy
• TX No approved medications, but cholinesterase
  inhibitors have been found to be helpful.
  Paradoxical response to antipsychotics!

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Distinguishing DLB from AD
DLB AD
Presenting deficits Executive function Visuospatial function Memory (particularly short term)
Early MMSE deficits Overlapping pentagons, clock drawing, serial sevens (or WORLD backwards) Orientation, 3 item recall
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Frontotemporal lobe Dementia

• Rare
• Early onset (age 35-75)
• Hyperorality
• Impairment in executive functioning
• Misdiagnosis common
• TX none approved

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Parkinsons Dementia

• 30-50 PD patients will develop dementia
• TX Exelon (mild to moderate)

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Normal Pressure Hydrocephalus

• Rare
• Increase of CSF in ventricles
• TBI
• CVA
• Unknown causes
• Clinical triad
• Altered gait
• Urinary incontinence
• Confusion
• Treatment
• Surgical shunt placement

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MAKING THE DIAGNOSIS
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Diagnosing Dementia

• History
• Neuroimaging?
• Medical and blood tests
• Physical exam
• Cognitive tests
• ability to count, language problem-solving
• Autopsy
• Early diagnosis is beneficial to allow for early
  pharmacological and non-pharmacological
  treatment.

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It looks a lot like dementia

• Depression
• Thyroid problems
• Vitamin B12 deficiency
• Alcoholism
• Medications
• Infections
• Uncontrolled diabetes
• Electrolyte imbalance
• Tumors
• Neurosyphyllis

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Dementia vs. Depression

• Dementia
• Confabulation
• 50 will show some degree of depressive symptoms

• Depression
• pseudodementia
• I dont know
• Trial of an antidepressant may assist to
  distinguish

(Dharmarajan Norman)
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Cognitive Testing for Dementia

• MMSE
• Not a diagnostic tool
• Clock Drawing Test (CDT)
• Mini Cog
• Functional assessment

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Dementia DSM-IV Criteria

• Development of multiple cognitive deficits
  manifested by both
• Memory impairment
• One or more of the following cognitive
  disturbances
• Apraxia (inability to execute learned purposeful
  movements)
• Aphasia (disturbance of comprehension and
  formulation of language),
• Agnosia (loss of ability to recognize objects,
  persons, sounds, shapes or smells),
• Disturbances in executive functioning.

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Dementia DSM-IV Criteria continued

• Significant impairment in social occupational
  functioning
• Decline from previous level of functioning

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Advanced DirectivesA Special Note

• Discuss early to allow patient opportunity to
  participate in decision making
• Resuscitation/Intubation
• Feeding tube
• Long term fluids
• Antibiotics
• DPOA for Healthcare

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Dementia in the Media
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TREATMENT
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Protective Factors

• High education
• Leisure activities
• Aerobic strength training
• Cholesterol-lowering strategies
• Good control of HTN, DM hyperlipidemia
• Cognitive Stimulation Therapy Cochrane Review
  Not efficacious

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TREATMENT GOALS

• Maximize
• Function
• Independence
• Quality of life
• Individual with dementia
• Caregivers
• Time before institutionalization is needed

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Treatment for Dementia

• No known cure
• Cholinesterase inhibitors stabilize behaviors
• Indicated for mild-moderate AD
• Inhibits acetylcholinesterase thereby reducing
  amount of acetycholine breakdown in brain

• Aricept (donepezil)
• Exelon (rivastigmine)
• Razadyne (galantamine)

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Cholinesterase Inhibitors

• Treatment goals
• Low rate of short term improvement
• Moderate rate of stabilization
• Primary goal is of less than expected decline
• Benefits Dont give families false hope
• Decision to discontinue
• Cost
• Uncertain/diminished benefit?
• Side effects
• If discontinuation is appropriate, use slow taper
• Some patients continue on CIs indefinitely

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Namenda

• N-methyl-D-asparate (NMDA) antagonist
• blocks action of the chemical glutamate
• Use cautiously with amantidine or
  dextromethorphan
• Monitor closely with coadministration of HCTZ,
  triamterene, metformin, cimetidine, ranitidine,
  quinidine nicotine
• Use the same renal system can result in
  elevated plasma levels of medications.
• Common SE constipation, headache, dizziness,
  pain

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Treatment of Associated Symptoms and/or Diseases

• Depression
• Common co-morbidity
• Symptoms often overlap which complicates
  diagnosis
• SSRIs (avoid Prozac can increase agitation and
  sleep disturbances)

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Treatment of Associated Symptoms and/or Diseases

• Sundowning
• Trazodone
• Medications for agitation- no FDA approved meds
• Mood stabilizer?
• Atypical antipsychotics?
• Behavioral problems
• Assessment of other causes and initiate
  non-pharmacological interventions before
  medications!

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Antipsychotic Use in AD

• Short term improvement in aggression and
  psychosis (6-12 weeks)
• Increased risk of mortality in long term use
• Other unwanted side effects
• Orthostasis
• Anticholinergic effects
• Increased fall risk
• Dementia Antipsychotic Withdrawal Trial (DART-AD)
• Clinical Antipsychotic Trials of Intervention
  Effectiveness (CATIE) study
• Modest benefits do not justify adverse events

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WARNING Increased Mortality in Elderly Patients
with Dementia-Related Psychosis Elderly patients
with dementia-related psychosis treated with
atypical antipsychotic drugs are at increased
risk of death compared to placebo. Analyses of
seventeen placebo-controlled trials (modal
duration of 10 weeks) in these patients revealed
a risk of death in the drug-treated patients of
between 1.6 to 1.7 times that seen in
placebo-treated patients. Over the course of the
typical 10-week controlled trial, the rate of
death in the drug treated group was about 4.5,
compared to a rate of death of about 2.6 in the
placebo group. Although the causes of death
were varied, most of the deaths appeared to be
either cardiovascular (e.g., heart failure,
sudden death) or infectious (e.g., pneumonia) in
nature. Abilify (aripiprazole)/Geodon
(zipraxidone)/Risperdal (risperidone)/ Symbyax
(olanzapine and fluoxetine)/Zyprexa (olanzapine)
are not approved for the treatment of patients
with dementia-related psychosis.
(www.caremark.com)
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Drugs which have NOT shown a therapeutic benefit
for dementia

• For cognitive symptoms
• Vitamin E
• NSAIDS
• Estrogen

• For behavioral symptoms
• Bezodiazepines (typically)
• Lithium
• Beta-blockers

(APA)
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Non-pharmacological treatment of problem behaviors
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Behavioral symptoms of dementia

• Behavioral symptoms have been reported to affect
  as many as 90 of dementia patients
• Most common in moderate to severe stages
• Symptoms include
• Irritability
• Medication/care refusal
• Eloping
• Agitation
• Combative behavior
• Non-pharmacological interventions are first line
  for these symptoms

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Causes of Behavior Changes

• Physical discomfort caused by an illness or
  medications
• Overstimulation from loud noises or a busy
  environment
• Unfamiliar surroundings such as new places or
  inability to recognize home
• Complicated tasks
• Frustrating interactions due to the inability to
  communicate effectively

Taken from http//www.alz.org
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Approach to problem behaviors

• Explore possible causes
• Medication review, pain
• Calm demeanor
• Be sympathetic
• Minimize distractions stimulation
• Relaxation
• Maintain a routine
• Redirection and reorientation
• Simple, one-step commands
• Remove physical restraints!

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Interventions for agitated patients

• Therapeutic options with poor evidence base, but
  being studied
• Music therapy
• Documentary Alive Inside
• Touch therapy (e.g., massage)
• Pet therapy
• Simulated presence therapy (audio or video of
  family or other)
• Reminiscence therapy

(Beier)
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Resources for Caregivers
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Caregiver Burden Emotional

• Characteristics of the disease change, and
  caregivers must constantly develop new coping
  mechanisms.
• Constant vigilance
• Loss of personhood
• The point at which the patient no longer
  consistently recognizes the caregiver can be
  particularly emotional.

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Caregiver Advice(Ham Sloane, 2009)

• Be realistic
• Recognize a need for assistance
• Seek a support group
• Communicate with family to share burden
• Ensure optimal health
• Anticipate problems plan strategies
• Plan legal financial aspects early

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Resources

• Alzheimers Association
• Council on Aging
• Directory of Services for Seniors (new edition
  1/09)
• Caregiver Resource Guide (10)
• Aging Caring Things Families Need to Know
• Area Agency on Aging
• Financial and legal planning- do it EARLY
• Certified elder law attorney
• Medicaid managed care
• Qualifications vary from state to state

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ResourcesReading Materials

• Rabins, Peter Mace, Nancy (2006). 4th edition.
  The 36-Hour Day
• Dunn,Hank (2001). Hard Choices for Loving
  People CPR, Artificial Feeding, Comfort Care and
  the Patient with a Life-Threatening Illness
• Broyle, Frank (2006). Coach Broyles Playbook for
  Alzheimers Caregivers

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ResourcesChildrens Books

• Fox, Mem (1985). Wilfrid Gordon McDonald
  Partridge.
• Altman, Linda Jacobs Johnson, Larry (2002).
  Singing with Momma Lou
• Ballman, Swanee (2001). The stranger I call
  Grandma a story about Alzheimers disease.

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More Helpful websites

• Alzheimers Association
• http//www.alz.org/
• Alzheimers Disease Education Referral Center
  (ADEAR). U.S. NIA
• http//www.nia.nih.gov/alzheimers
• Clinical Trials Information
• http//www.clinicaltrials.gov
• Alzheimers Association website
• HomegtAlzheimers Disease gt Clinical Studies
• Timothy Takacs Elderlaw Practice
• http//www.tn-elderlaw.com/
• Free referral service for elder care options
• http//www.aplaceformom.com

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• Thank you for your time and attention.
• Q A Session