Mental Health and Older Adults in Primary
Care Setting
Part I – Normal Changes vs Neurocognitive Disorders
Presented by: Ruth Tadesse, MS, RN
Date: 04/21/16
Disclosures and Learning Objectives
Learning Objectives:
•Recognize at least 4 important normal changes in healthy
aging brain.
•Identify 3 main early symptoms of Neuropsychiatric
Cognitive Disorders.
•Know screening tools used in early stages of dementia.
•Identify DSM 5 criteria used to diagnose Mild and Major
Neurocognitive Disorders
Disclosures: Ruth Tadesse has nothing to disclose.
Normal Changes in the Healthy Aging Brain
-
Prefrontal cortex and the
hippocampus will start
shrinking.
-
Communication between
neurons and
neurotransmitters will be
reduced.
-
Blood flow can be
reduced because
arteries will start to
narrow.
http://www.nia.nih.gov/alzheimers/publication/par
t-1-basics-healthy-brain/changing-brainhealthy-aging
Normal Changes in the Healthy Aging Brain
•
Plaques and tangles can
develop outside of and
inside neurons in much
smaller amounts.
•
Free radicals increases.
•
Inflammation increases.
http://www.nia.nih.gov/alzheimers/publication/part1-basics-healthy-brain/changing-brainhealthy-aging
http://www.nia.nih.gov/alzheimers/alzheimersdisease-video
Normal Changes in Aging and
Mental Function in Healthy Older Adults
• Modest decline in the ability to learn new things and
retrieve information e.g. remembering names
• Difficulty in performing complex tasks on attention,
learning, and memory than a young person
*It is important to note, given enough time to perform the task,
the scores of healthy people in their 70s and 80s are often
similar to those of young adults.
http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthybrain/changing-brain-healthy-aging
Changes in brain caused by Alzheimer's
Disease (AD)
•
Amyloid plaques are found in the brain in large numbers
in the spaces between the nerve cells.
•
Neurofibrillary tangles increase and collapses neuron’s
internal transport network. This collapse damages the ability of
neurons to communicate with each other.
•
Gradual loss of connections between neurons leads to
significant brain atrophy.
The destruction and death of nerve cells causes the memory failure,
personality changes, problems in carrying out daily activities, and other
features of the disease.
http://www.nia.nih.gov/alzheimers/publication/part-2-what-happens-brain-ad/hallmarks-ad
Brain Atrophy: Hallmark of AD
http://coloradodementia.org/ \
Neuropsychiatric Symptoms (NPS) seen in Patients
with Neurocognitive Disorders (ND)
• NPS of dementia include psychosis, depressed or labile
mood, anxiety, irritability, apathy, euphoria, disinhibition,
aggression, sleep disturbance and disordered eating.
• Virtually all patients with the diagnosis of ND exhibit some
NPS during the first 6 years of their illness.
• Agitation is the most prevalent symptom (with rates up to
80%) in community dwelling older adults.
Borsje, P., et al. (2015). The course of neuropsychiatric symptoms in community-dwelling
patients with dementia: a systematic review. International Psychogeriatrics / IPA,
27(3), 385-405.
Question about the Haves and the Have Nots
Why do some people remain cognitively healthy
as they get older while others develop
Neurocognitive Disorders or Dementia?
‘Cognitive Reserve’ may provide some insights.
Cognitive reserve refers to the brain’s ability to operate effectively even when
some function is disrupted. It also refers to the amount of damage that the brain
can sustain before changes in cognition are evident.
People vary in the cognitive reserve they have.
http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy-brain/changing-brain-healthy-aging
Normal Aging vs Neurocognitive Disorders
Depending on a person’s cognitive reserve and
unique mix of genetics, environment, and life
experiences, the balance may tip in favor of a
disease process that will ultimately lead to
neurocognitive disorders or dementia.
For another person, with a different reserve and a
different mix of genetics, environment, and life
experiences, the balance may result in no
apparent decline in cognitive function with age.
http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy-brain/changing-brain-healthy-aging
Factors that could explain differences in
Cognitive Reserve
Variability in cognitive reserve depends on factors
such as differences in genetics, education,
occupation, lifestyle, leisure activities, or other
life experiences.
These factors could provide a certain amount of
tolerance and ability to adapt to change and
damage that occurs during aging.
http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy-brain/changing-brain-healthyaging
Making the diagnosis of Neurocognitive Disorders
or Dementia: Changes from DSM IV
DSM 5
• Dementia on DSM IV was recognized
under Delirium, Dementia, Amnestic, and Other
Cognitive Disorders.
• Dementia has been eliminated and have been
replaced as Mild or Major Neurocognitive Disorders
on DSM 5.
http://www.todaysgeriatricmedicine.com/archive/110612p12.shtml
Alzheimer’s Disease
Vascular
Parkinson’s
Lewy Body Disease
Neurocognitive
Disorder
(aka Dementia)
Fronto-temporal
HIV
Huntington’s
Prion Disease
Traumatic Brain
Substance-Induced
(Alcohol)
Subtypes of Dementia (Brunnstroom, H., et al, 2009)
Other Types
8%
FTD 4%
AD & VD,
Mixed 21.6 %
AD 42%
VD 23.7%
Brunnström, H., Gustafson, L., Passant, U., & Englund, E. (2009). Prevalence of dementia
subtypes: a 30-year retrospective survey of neuropathological reports. Archives Of
Gerontology And Geriatrics, 49(1), 146-149.
Subtypes of Dementia (Keefover, R.W., 2013)
Lewy Body
Disease
FTD
PD
All Others
AV & AD Mixed
Vascular
AD
Dementia Examined.docx
Age Is a Strong Factor!
24.19 %
Among
80-89 yrs. old
4.97 %
Among
71-79 yrs. old
Prevalence
of
Dementia
37.36%
Among
90 yrs. old &
older
Prevalence of Dementia
-
46.8 million people worldwide
5.4 million Americans are living with AD
1 in 9 over age 65 and older has AD
1 in 2 over age 85 and older has some
type of dementia
- AD is the 6th leading cause of death in the
United States
- 1 in 3 older adults die from AD or other
type of dementia in the US
http://www.alz.org/facts/overview.asp
Prevalence of Dementia in other developing Countries
Dementia Progression
http://www.nia.nih.gov/alzheimers/publication/part-2-what-happens-brain-ad/changing-brain-ad
Common Screening Tools in Primary Care
related to assessment of NC Disorders
•
•
•
•
Standard history and physical exam
Functional Status (FAQ)
Mental Status Exam (MOCA, MMSE, GDS)
Labs (CBC, Electrolytes, Kidney Function, Liver
function, Glucose, TSH, Vit. D, Vit. B12)
• Family/Caregiver interview to assess patient
behavior changes
Dementia Examined.docx
Flowchart for Early Identification of Dementia
(National Alzheimer's Organization, 2003)
Evaluate signs/symptoms for possible
dementia using “Ten Warning Signs”
Negative workup
Initial
Dementia
Assessment
Uncertain results
Interview family or
caregivers
Assess & reassess
s/sxs using MMSE
every 6 months
Delirium or depression
Treat &
Reassess
Care management
& family support
https://www.alz.org/national/documents/brochure_toolsforidassesst
reat.pdf
Ten Warning Signs of AD
1. Memory loss
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation of time and place
5. Poor or decreased judgment
6. Problems with abstract thinking
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality
10. Loss of initiation
https://www.alz.org/national/documents/brochure_toolsforidassesstreat.pdf
DSM 5 Criteria: Mild Neurocognitive Disorder
- Modest cognitive decline from a previous level
of performance
- The cognitive deficits do not occur exclusively
in the context of a delirium
- The cognitive deficits are not primarily
attributable to another mental disorder (eg,
major depressive disorder, schizophrenia).
•
Note that in diagnosing a mild neurocognitive disorder, one and two
standard deviations below appropriate norms is required.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders. (5th ed.) Washington, DC: American Psychiatric Association Press
DSM 5 Criteria: Major Neurocognitive Disorder
•
Evidence of substantial cognitive decline from a
previous level of performance.
•
The cognitive deficits are sufficient to interfere with
independence.
•
The cognitive deficits are not primarily attributable to
another mental disorder (e.g, major depressive
disorder, schizophrenia).
*In diagnosing a major neurocognitive disorder, two or more standard
deviations below appropriate norms are required.
American Psychiatric Association ((APA) (2013). Diagnostic and Statistical Manual of Mental
Disorders. (5th ed.) Washington, DC: American Psychiatric Association Press.
What is the best way to manage symptoms of
neurocognitive disorders?
All atypical antipsychotic medications include a Black Box warning
regarding the increased risk of mortality in older adults with
dementia-related psychosis (FDA, 2005) and they have required a
similar warning for conventional antipsychotics since 2008 (FDA, 2008).
Current guidelines (AMDA, 2012; Herrmann, Lanctôt, & Hogan, 2014; NICE & SCIE, 2006)
suggest that people with dementia should be prescribed
antipsychotics only in cases in which they are severely distressed
(severe agitation, aggression and psychosis) and/or there is
immediate risk of harm.
In addition, most guidelines also recommend that antipsychotic
medications be used in a time-limited fashion. Dementia
medications such as Namenda are underutilized and should be
considered for both Mild and Major ND.
Non-pharmacologic Interventions
- Promote structured day and quiet bed
time routine
- Promote personal comfort
- Pain, hunger, thirst, and toileting
- Evaluate and treat sensory impairments
- Recommend good sleep hygiene
- Promote low stimulating environment
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711645/
Preventing Memory Loss w/ Current Evidence
http://tucson.com/news/science/ua-researcher-barnes-provides-insights-into-agingmemory/article_9319afe0-b21d-59dc-af76-a5a00f87a27a.html
References
American Medical Directors Association (AMDA). (2012). Dementia in the long term care setting.
Columbia (MD): American Medical Directors Association (AMDA).
Borsje, P., Wetzels, R. B., Lucassen, P. L., Pot, A. M., & Koopmans, R. T. (2015). The course of
neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review.
International Psychogeriatrics / IPA, 27(3), 385-405.
Brunnström, H., Gustafson, L., Passant, U., & Englund, E. (2009). Prevalence of dementia subtypes: a
30-year retrospective survey of neuropathological reports. Archives Of Gerontology And
Geriatrics, 49(1), 146-149.
Hebert, L. E., Weuve, J., Scherr, P. A., & Evans, D. A. (2013). Alzheimer disease in the United States
(2010-2050) estimated using the 2010 census. Neurology, 80(19), 1778-1783.
Herrmann, N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the
symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and
Treatment of Dementia 2012. Alzheimer's Research & Therapy, 5(Suppl 1), S5.
Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2014). Management of neuropsychiatric symptoms of
dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal Of
The American Geriatrics Society, 62(4), 762-769.
References
Ma, H., Huang, Y., Cong, Z., Wang, Y., Jiang, W., Gao, S., & Zhu, G. (2014). The efficacy and safety
of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebocontrolled trials. Journal Of Alzheimer's Disease: JAD, 42(3), 915-937.
NICE and SCIE (2006) Dementia: Supporting People with Dementia and their Carers in Health and
Social Care. NICE clinical guideline 42. Available at www.nice.org.uk/CG42
Plassman, B.L., Langa, K.M., Fisher, G.G., Heeringa, S.G., Weir, D.R., Ofstedal, M.B., Burke, J.R.,
Hurd, M.D., Potter, G.G., Rodgers, W.L., Steffens, D.C., Willis, R.J., Wallace, R.B. (2007).
Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study.
Neuroepidemiology. 29:125-132.
U.S. Food and Drug Administration (FDA). (2005). Public Health Advisory: Deaths with Antipsychotics
in Elderly Patients with Behavioral Disturbances. Available at
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/u
cm053171.htm
U.S. Food and Drug Administration (FDA). (2008). FDA Requests Boxed Warnings on Older Class of
Antipsychotic Drugs. Available at:
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm116912.htm
End of Gero. Series Part I
Next Week
Medications
& Older Adults
By Dr. Ann Wheeler
04/28/16