Dementia - Qsource

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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
DEMENTIA FACTS
Dementia - An Overview
• Definition
• Types of Dementia
• Risk Factors
• Diagnosis
• Stages
• Treatment/Prevention
• Resources
http://www.cdc.gov/aging/images/couple_250px.jpg
Statistics
• 7 million people suffer from
Alzheimer’s 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
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)
Common Types of Dementia
• Alzheimer’s Disease
• 50 – 70%
• Vascular Dementia
• Secondary dementias
• Normal Pressure
Hydrocephalus (NPH)
• 15 – 30%
• Dementia with Lewy
• Parkinson’s dementia
Bodies (DLB)
• 10 – 25%
• AIDS related dementia
• Frontotemporal lobe
Dementia
• rare
• Alcohol related dementia
Alzheimer’s 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
http://auto.img.v4.skyrock.net/5396/80355396/pics/3076203011
_1_7_ptCq7EkZ.jpg
Plaques & Tangles
Results of cell death
Alzheimer’s Disease
Neurotransmitter Changes
• Acetylcholine amount
and activity decreased
• Needed for memory,
language and thoughts.
• N-methyl-D-aspartate
(NMDA)
• Somatostatin
• Serotonin
http://neurowiki2012.wikispaces.com/file/view/alzheimer's_dise
ase_pathology.jpg/316537340/366x346/alzheimer's_disease_path
ology.jpg
Alzheimer’s Disease-Types
• Sporadic
• No known cause
• No obvious inheritance patterns
• Familial
• Rare (<10%)
• 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
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
http://www.cnn.com/2011/HEALTH/04/19/alzheimers.diagnos
is.guidelines/t1larg.alzheimer.elderly.jpg
Symptoms of AD
• Memory Loss
• Slow progression
• Affects daily living
• Confusion/Disorientation
• Language problems
• Word finding
• Using words
inappropriately or
forgetting their meaning
• Judgment
http://cursos.campusvirtualsp.org/file.php/138/Images/25.jpg
Symptoms of AD
• Difficulty with
• Handling money
• Calculating numbers
• Keeping track of things
• Misplacing items
• Changes
• Personality
• Mood
http://media-social.s-msn.com/images/blogs/00120065-00000000-0000-000000000000_00000065-075e-0000-0000000000000000_20121015210544_payingbill.jpg
• Apathetic
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
http://www.mountainside-medical.com/blog/wpcontent/uploads/2012/09/Alzheimers-Drug-Development300x294.gif
Stages of AD
• Severe
• Profound memory
impairment
• Requires significant
assistance with ADLs
• Vegetative symptoms
more pervasive
http://www.mountainside-medical.com/blog/wpcontent/uploads/2012/09/Alzheimers-Drug-Development300x294.gif
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.
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
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:
• doesn’t recognize self or close family,
• loses control of bowel and bladder,
• weight loss, repetitive crying,
• complete loss of language,
• increased sleeping,
• difficulty swallowing.
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
http://www.insideiamlaughing.com/wpcontent/uploads/2012/12/vascular-dementia.jpg
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!
http://belairecare.com/wpcontent/uploads/2014/04/LewyBody.jpg
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
Frontotemporal lobe Dementia
• Rare
• Early onset (age 35•
•
•
•
75)
Hyperorality
Impairment in
executive functioning
Misdiagnosis
common
TX: none approved
http://medlibes.com/uploads/Screen%20shot%202010-0720%20at%209.35.53%20AM.png
Parkinson’s Dementia
• 30-50% PD patients
will develop dementia
• TX: Exelon (mild to
moderate)
http://static.cdnseekingalpha.com/uploads/2013/6/4/saupload_PD_Dude.jpg
Normal Pressure Hydrocephalus
• Rare
• Increase of CSF in ventricles
• TBI
• CVA
• Unknown causes
• Clinical triad
• Altered gait
• Urinary incontinence
• Confusion
• Treatment
• Surgical shunt placement
MAKING THE DIAGNOSIS
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.
It looks a lot like dementia…
• Depression
• Thyroid problems
• Vitamin B12 deficiency
• Alcoholism
• Medications
• Infections
• Uncontrolled diabetes
• Electrolyte imbalance
• Tumors
• Neurosyphyllis
Dementia vs. Depression
• Dementia
• Confabulation
• 50% will show some
degree of depressive
symptoms
• Depression
• “pseudodementia”
• “I don’t know”
• Trial of an
antidepressant may
assist to distinguish
(Dharmarajan & Norman)
Cognitive Testing for Dementia
• MMSE
• Not a diagnostic tool
• Clock Drawing Test
(CDT)
• Mini Cog
• Functional
assessment
http://www.jabfm.org/content/16/5/423/F3.large.jpg
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.
Dementia DSM-IV Criteria continued…
• Significant impairment in social & occupational functioning
• Decline from previous level of functioning
Advanced Directives
A Special Note
• Discuss early to allow patient opportunity to participate in
decision making
• Resuscitation/Intubation
• Feeding tube
• Long term fluids
• Antibiotics
• DPOA for Healthcare
Dementia in the Media
TREATMENT
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
http://www.fresnostate.edu/chhs/safecvc/images/seniorsexercise-balls.jpg
TREATMENT GOALS
• Maximize:
• Function
• Independence
• Quality of life
• Individual with dementia
• Caregivers
• Time before
institutionalization is needed
http://www.un.org/News/dh/photos/large/20
12/April/04-11-who-dementia.jpg
Treatment for Dementia
• No known cure
• Cholinesterase inhibitors
• Aricept (donepezil)
stabilize behaviors:
• Indicated for mild-moderate
• Exelon (rivastigmine)
AD
• Inhibits
acetylcholinesterase
thereby reducing amount of
acetycholine breakdown in
brain
• Razadyne
(galantamine)
Cholinesterase Inhibitors
• Treatment goals:
• Low rate of short term improvement
• Moderate rate of stabilization
• Primary goal is of less than expected decline
• Benefits: Don’t give families false hope
• Decision to discontinue:
• Cost
• Uncertain/diminished benefit?
• Side effects
• If discontinuation is appropriate, use slow taper
• Some patients continue on CI’s indefinitely
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
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)
http://www.medicalobserver.com.au/assets/images_20nov2012/
depression-old-486x324.jpg
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 nonpharmacological interventions before medications!
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
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)
Drugs which have NOT shown a
therapeutic benefit for dementia
• For cognitive
symptoms:
• For behavioral
symptoms:
• Vitamin E
• Bezodiazepines
• NSAIDS
(typically)
• Lithium
• Beta-blockers
• Estrogen
(APA)
NON-PHARMACOLOGICAL
TREATMENT OF PROBLEM
BEHAVIORS
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
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
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!
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
http://seniorplanet.org/wp-content/uploads/2013/10/aliveinside.jpg
(Beier)
RESOURCES FOR
CAREGIVERS
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.
http://www.pwcgov.org/government/dept/aaa/Documents/caregiver-1.jpg
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
http://accessiblehomeliving.com/wpcontent/uploads/2013/03/caregiver-stress.jpg
Resources
• Alzheimer’s 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
Resources
Reading 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
Alzheimer’s Caregivers
Resources
Children’s 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 Alzheimer’s disease.
More Helpful websites
• Alzheimer’s Association
• http://www.alz.org/
• Alzheimer’s Disease Education & Referral Center
(ADEAR). U.S. NIA
• http://www.nia.nih.gov/alzheimers
• Clinical Trials Information
• http://www.clinicaltrials.gov
• Alzheimer’s Association website
• Home>Alzheimer’s Disease > Clinical Studies
• Timothy Takacs Elderlaw Practice
• http://www.tn-elderlaw.com/
• Free referral service for elder care options
• http://www.aplaceformom.com
Thank you for your time and attention.
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