Nathan Flacker, M.D.
DEMENTIA: A Geriatrician’s View
1) AGING IS NOT A DISEASE
- Dementia usually begins in late life, with gradual onset and progression
-Prevalence is 6%-8% in those >= 65 years and 30%-50% of those >= age 85 years
-SO>=50% of 85 year olds DO NOT have dementia (Hebert et al. JAMA 1995;273:1354-9)
2) COGNITIVE AND AFFECTIVE DISORDERS ARE PREVALENT AND
COMMONLY UNDIAGNOSED AT EARLY STAGES
-Studies:
-60% of dementia in men unrecognized by family (Ross et al. JAMA. 1997;277:800-805)
-22% of caregivers didn’t recognize dementia (Greiner et al. JAMA 1997;277:1757)
-64% missed by caregivers and physician (Sternberg et al. J Am Geriatr Soc
2000;48:1430-4)
3) MEDICAL CONDITIONS IN OLDER PATIENTS ARE COMMONLY CHRONIC,
MULTIPLE, AND MULTIFACTORIAL
-Primary Dementias can co-exist; the common ones are:
Alzheimer’s Disease: About 2/3rd of cases?
-Gradual onset of cognitive decline with motor sparing until late in the course
-On average AD patients live 8-10 years after initial symptoms
-Memory impairment is major finding, especially for new information
- In addition to memory, also have one or more of apraxia, aphasia, agnosia, disturbance of
consciousness
Dementia With Lewy Bodies:
-The Lewy Bodies are in the frontal lobe and lead to decreased cholinergic innervation
-A dementia plus early motor signs that progress. Motor signs may predominate
-Dementia plus:
a) Detailed visual hallucinations
b) Parkinsonism
c) Alterations of attention or alertness
-Often are VERY SUSCEPTIBLE TO SIDE EFFECTS OF to neuroleptics
-Cholinesterase inhibitors are initial drug of choice
Multi-infarct Dementia:
-Often memory loss with focal motor signs that can be variable or even absent.
-Increases symptomatology of co-existing Alzheimer’s
Frontal Dementia:
-Personality change predominates over memory loss
Normal Pressure Hydrocephalus
-Ataxia, Incontinence, Dementia
-Characterized by psychomotor slowing
-Pretty rare
-Do a diagnostic tap before placing a shunt
-EVERYTHING ELSE is much less common
-While a primary form of dementia may be present it is important to evaluate for all
Contributing factors that may adversely affect cognition such as:
A) Depression:
-Consider treatment if symptoms such as depressed mood, appetite loss, insomnia, or
fatigue
B) Medication Effect
C) Delirium
-Consider with any new change in mental status
D) Substance abuse
E) Hypothyroidism, Hypercalcemia, B12 Deficiency, Neurosyphylis, Collagen Vascular Disease,
etc., etc.
LABS AND TESTS
A)
B)
C)
D)
Thyroid Profile, Calcium level, Chem.-7, CBC, B12 level
VDRL Sometimes
Toxicology Screen Sometimes
Do a CT Scan if:
a. Age < 65 years
b. Symptoms < 2 years
c. Focal neurological signs
d. Occurring within 1 year in presence of gait disorder and unexplained urinary
incontinence (i.e. possible NPH)
E) EEG if very rapid decline, myoclonus noted. (i.e. suspected CJD; should see spike and
wave)
H) Medications (See below)
4) IATROGENIC ILLNESS IS COMMON
Don’t forget about the adverse effects of medications!
-Benzodiazepines
-Antidepressants including SSRIs
-Anticholinergic Drugs: diphenhydramine, oxybutynin, etc
-Pain Medications: Opiates (esp meperidine), NSAIDS (esp indomethecin)
-Prednisone
-Neuroleptics
-Antiepileptics
-H2 blockers
-Consider all medications as potential contributors
5) SOCIAL HISTORY, SOCIAL CIRCUMSTANCES, AND AVAILABLE SOCIAL
SUPPORT ARE IMPORTANT ASPECTS OF MANAGING GERIATRIC PATIENTS
- Families, not medications, prevent nursing home admission
- Refer to Alzheimer’s Association where possible
- Caregiver stress is important to recognize (Mittelman et al. JAMA.1996:276(21):1725-31)
-RCT of 206 spouse caregivers of AD patients followed over 3 &1/2
years
-Intervention: 6 sessions of individual counseling, follow-up support
groups, and availability of counselor to help
-Time to NH placement was 329 days longer in the treatment group
6) GERIATRIC CARE IS COMMONLY MULTIDISCIPLINARY
Treatment:
A) Cognitive enhancement
-Can be done non-pharmacologically (usually OT or ST) or by medications (MD)
-All cholinesterase inhibitors work basically the same.
-The newer NMDA receptor Antagonists seem to work about as well as
cholinesterase inhibitors and have some additive effect.
- Medications help some people a great deal, many get little or no benefit, cost is
high to all
-Not CognitiveDMARDS
-May improve memory
-May delay Nursing home in mild disease
-May delay mortality in advance disease
- Graphs and scales used in ads and articles to demonstrate efficacy
are often misleading
-Use if clearly identified symptom and follow it!
-Often problematic side effects including nausea, vomiting, diarrhea, falls,
increased agitation/confusion
-Vitamin E:
-At a dose of 1000mg bid may slow progression
-Has anticoagulant properties at this dose
B) Individual and Group Therapy (Psych or Recreational therapist)
C) Family Support and Therapy (Social worker, Alzheimer’s Association, Therapist)
D) Access to services (Area Agency on Aging, Social Worker)
E) Environmental Modifications (PT, NP)
F) Safety: (Alzheimer’s Association, PT, NP, MD)
G) Agitation: Evaluate for pain, depression, sleep loss, anxiety, delirium, medication effect such
as AKASTHISIA from neuroleptic (MD, Nursing, PT, family)
7) GERIATRIC CARE IS PROVIDED IN A VARIETY OF SETTINGS
Private Homes and Apartments
-Often unrecognized
Personal Care Homes:
Small, mostly unlicensed
Assisted Living:
-Must not be dependent in ADLs.
Nursing Home:
-Impairment of 2 ADLs.
Hospice:
-Appropriate for end-stage dementia.
-Typically non-ambulatory, not verbal and not eating well
Community-based support:
-Adult day health centers
-Home health agencies
-Meals-on-wheels
-Alzheimer’s association
-Caregiver support groups
-Case management
8) FUNCTIONAL ABILITY AND QUALITY OF LIFE ARE CRITICAL OUTCOMES
IN THE GERIATRIC POPULATION
- The goal is a safe environment that fosters maximum quality of life
- Might be home, personal care home, or nursing home
- Ask about wandering, burning pots, guns, driving and accidents
- Adult Protective Services should be notified if a danger discovered and can’t be solved through
consultation with caregiver.
9) ETHICAL ISSUES AND END-OF-LIFE CARE ARE IMPORTANT ISSUES
Advance Directives:
- Try to complete in early stages of the disease when capacity to decide is still present
- Once patient loses capacity to declare proxy then a court proceeding is required to establish
guardianship
Feeding Tubes:
- In end-stage dementia, feeding tubes have NOT BEEN SHOWN TO:
A) Prolong life
B) Prevent pneumonia
C) Improve quality of life
D) Speed healing of pressure ulcers
(see Finucane et al. JAMA.1999;282(14):1365-70.)
- To decide one must establish goals of care:
A) Life prolongation
B) Maximization of function
C) Maximization of comfort; in fact may increase discomfort, result in complications
(including death), decrease enjoyment of food, result in restraint use (up to 77% in
restraints!)
- Medicare Hospice Benefit: 6-month life expectancy
Typical features in demented patients (FAST)
< 6 words
No smiling
Inability to walk or sit up independently
Difficulty eating, swallowing, weight loss
Infections and incontinence
Nathan Flacker, M.D.
DEMENTIA: A Geriatrician’s View
NOTE: The handout is usually not given until after the talk, and is available in hard
copy and PALM PDA format.
As an ice-breaker the residents are asked to describe the last case of dementia they
saw either in hospital or clinic. 2-3 cases are elicited which remain on the board
throughout the talk for the speaker to reference as highlighting the BIG 10 concepts
where applicable.
The next step here is to ask the residents to define “dementia”.
Key points to elicit in definition:
 Impairment in Memory
 Impairment in at least one other area of cognition
 Functional Consequences
1) AGING IS NOT A DISEASE
Other Key Points to make in the form of questions:



Question: When and how does dementia usually begin?
o - Dementia usually begins in late life, with gradual onset and progression
Question: What is the prevalence of dementia among those age > 65 years?
How about among those age> 85 years?
o -Prevalence is 6%-8% in those >= 65 years and 30%-50% of those >= age
85 years
Questions: So how many older people DON’T have dementia?
o -SO>=50% of 85 year olds DO NOT have dementia
Usually the East Boston Study is referenced here to provide additional evidence
basis (See Hebert LE et al).
2) COGNITIVE AND AFFECTIVE DISORDERS ARE PREVALENT AND
COMMONLY UNDIAGNOSED AT EARLY STAGES
After the header is written, questions are asked:
Question: How often is dementia missed by doctors?
How often is it missed by families?
After eliciting responses from residents give them the following information



60% of dementia in men unrecognized by family (Ross et al. JAMA.
1997;277:800-805)
22% of caregivers didn’t recognize dementia (Greiner et al. JAMA
1997;277:1757)
64% missed by caregivers and physician (Sternberg et al. J Am Geriatr Soc)
3) MEDICAL CONDITIONS IN OLDER PATIENTS ARE COMMONLY
CHRONIC, MULTIPLE, AND MULTIFACTORIAL
Pose Question to Residents: What are the most common types of dementia?
How do these typically present?
Key Points:

Primary Dementias can co-exist; the common ones are:

Alzheimer’s Disease: About 2/3rd of cases?
- Gradual onset of cognitive decline with motor sparing until late in
the course
- On average AD patients live 8-10 years after initial symptoms
- Memory impairment is major finding, especially for new
information
 In addition to memory, also have one or more of apraxia,
aphasia, agnosia, disturbance of consciousness

Dementia With Lewy Bodies:
- The Lewy Bodies are in the frontal lobe and lead to decreased
cholinergic innervation
- A dementia plus early motor signs that progress. Motor signs may
predominate
- Dementia plus:
 Detailed visual hallucinations
 Parkinsonism
 Alterations of attention or alertness
- Often are VERY SUSCEPTIBLE TO SIDE EFFECTS OF
neuroleptics
- Cholinesterase inhibitors are initial drug of choice

Multi-infarct Dementia:
o Often memory loss with focal motor signs that can be variable or
even absent.
o Increases symptomatology of co-existing Alzheimer’s

Frontal Dementia:
o -Personality change predominates over memory loss

Normal Pressure Hydrocephalus
o Ataxia, Incontinence, Dementia
o Characterized by psychomotor slowing
o Pretty rare
o Do Diagnostic tap before placing a shunt

EVERYTHING ELSE is much less common
Question: What are the “Reversible”/Treatable forms of dementia?
Note that residents will usually begin with Thyroid, B12, etc. Make a list on
the board and put these way down at the bottom. When someone finally
mentions medications and depression put these at the top. These conditions
may cause a primary cognitive disturbance OR worsen things in those with
dementia already from another cause.
KEY POINTS:
 While a primary form of dementia may be present it is important to
evaluate for all Contributing factors that may adversely affect
cognition such as:
 Depression:
o -Consider treatment if symptoms such as depressed
mood, appetite loss, insomnia, or fatigue
 Medication Effect
 Delirium
o Consider with any new change in mental status
 Substance abuse
 Hypothyroidism, Hypercalcemia, B12 Deficiency,
Neurosyphylis, Collagen Vascular Disease, etc., etc.
Question: So what labs and tests may be needed to evaluate for dementia?
KEY POINTS:
 Generally need Chem.-7, CBC, Calcium, TSH, B12 level.
 VDRL/RPR Sometimes
 Toxicology Sometimes
 CT Scan if:
 Age < 65 years
 Symptoms < 2 years
 Focal neurological signs
 Occurring within 1 year in presence of gait disorder and
unexplained urinary incontinence (i.e. possible NPH)
 EEG if very rapid decline, myoclonus noted. (“Bonus resident
trivia question” here. What form of dementia is characterized
by myoclonic jerks? Or, What form of dementia is best
diagnosed by EEG? i.e. suspected CJD; should see spike and
wave)
 Medications (See below)
4) IATROGENIC ILLNESS IS COMMON
Question: What medications affect thinking and can appear to be dementia?
KEY POINTS:
 Don’t forget about the adverse effects of medications!
o Benzodiazepines
o Antidepressants including SSRIs

o Anticholinergic Drugs: diphenhydramine, oxybutynin, etc
o Pain Medications: Opiates (esp meperidine), NSAIDS (esp indomethecin)
o Prednisone
o Neuroleptics
o Antiepileptics
o H2 blockers
Consider all medications as potential contributors
5) SOCIAL HISTORY, SOCIAL CIRCUMSTANCES, AND AVAILABLE
SOCIAL SUPPORT ARE IMPORTANT ASPECTS OF MANAGING
GERIATRIC PATIENTS
Question: What’s the most common reason a patient is admitted to a nursing home?
Answer: Family/Caregivers are unable or unwilling to care for the patient.
E) KEY POINTS
 Families, not medications, prevent nursing home admission
o Refer to Alzheimer’s Association where possible
 Caregiver stress is important to recognize
 Mittelman JAMA 1996:
 RCT of 206 spouse caregivers of AD patients followed over 3
&1/2 years
 -Intervention: 6 sessions of individual counseling, followup support groups, and availability of counselor to help
o Time to NH placement was 329 days longer in the treatment group
Make this point: This is as good, if not better than most studies of
medications!
6) GERIATRIC CARE IS COMMONLY MULTIDISCIPLINARY
Question: What are the treatments for Alzheimer’s Disease and other
dementias?
Residents will invariably name medications and it is fine and useful to
describe these in brief and their mechanisms including Cholinesterase
inhibitors and NMDA Receptor Antagonists
Treatment:
A) Cognitive enhancement
-Can be done non-pharmacologically (usually OT or ST) or by medications (MD)
-All cholinesterase inhibitors work basically the same.
- The newer NMDA receptor Antagonists seem to work about as well as
cholinesterase inhibitors and have some additive effect.
- Medications help some people a great deal, many get little or no benefit, the cost
is high to all
KEY POINTS:
-Not Cognitive DMARDS (Disease Modifying Anti-Rheumatic
Drugs)
-May improve memory
-May delay Nursing home in mild disease
-May delay mortality in advance disease
-Graphs and scales used in ads and articles to demonstrate efficacy
are often misleading
I usually have some examples pulled from a recent journal as
these are easy to find. Teach residents to focus on the
duration of the study, the scales used on the Y-axis, and to
think about the difference between statistical and clinical
significance. Is a difference of 2-3 points on the 70 point
ADAS-Cog Scale important?
-Use if clearly identified symptom and follow it!
-Often problematic side effects including nausea, vomiting, diarrhea, falls,
increased agitation/confusion
-Vitamin E:
-At a dose of 1000mg bid may slow progression
-Has anticoagulant properties at this dose
Here mention estrogen, ginko, and NSAIDS in passing as there is little evidence
to support their use.
Question: OK, so besides medicines what treatments are commonly used for
patients with Dementia?
KEY POINTS:







Dementia treatment is about more than the pills!
Individual and Group Therapy (Psych or Recreational therapist)
Family Support and Therapy (Social worker, Alzheimer’s Association, Therapist)
Access to services (Area Agency on Aging, Social Worker)
Environmental Modifications (PT, NP)
Safety: (Alzheimer’s Association, PT, NP, MD)
Agitation: Evaluate for pain, depression, sleep loss, anxiety, delirium, medication
effect such as AKASTHISIA from neuroleptic (MD, Nursing, PT, family)
7) GERIATRIC CARE IS PROVIDED IN A VARIETY OF SETTINGS
Question: Where do patients with Dementia live?
Key Point: Lots of places!
Private Homes and Apartments
Often unrecognized
Personal Care Homes:
Small, mostly unlicensed
Assisted Living:
-Must not be dependent in ADLs.
Nursing Home:
-Impairment of 2 ADLs.
Hospice:
-Appropriate for end-stage dementia.
-Typically non-ambulatory, not verbal and not eating well
Question: Where can a person with Dementia get community support from?
Key Point: Lots of places! Community-based support:
-Adult day health centers
-Home health agencies
-Meals-on-wheels
-Alzheimer’s association
-Caregiver support groups
-Case management
8) FUNCTIONAL ABILITY AND QUALITY OF LIFE ARE CRITICAL
OUTCOMES IN THE GERIATRIC POPULATION
- The goal is a safe environment that fosters maximum quality of life
- Might be home, personal care home, or nursing home
Question: Name 4 important dangers to ask about in patients with dementia
Often residents will come up with others. This is fine as long as they get the main
ones
- Ask about wandering, burning pots, guns, driving and accidents
- Adult Protective Services should be notified if a danger discovered and can’t be solved
through consultation with caregiver.
9) ETHICAL ISSUES AND END-OF-LIFE CARE ARE IMPORTANT
ISSUES
Advance Directives:
Question: When should an Advance Directive be completed in a patient with
Dementia?
- Try to complete in early stages of the disease when capacity to decide is still present
-
Once patient loses capacity to declare proxy then a court proceeding is required to
establish guardianship
Question: When are feeding tubes indicated in patients with Dementia?
Feeding Tubes:
KEY POINTS
 In end-stage dementia, feeding tubes have NOT BEEN SHOWN TO:
o Prolong life
o Prevent pneumonia
o Improve quality of life
o Speed healing of pressure ulcers
(See Finucane et al JAMA 1999)

To decide one must establish goals of care:
o Life prolongation
o Maximization of function
o Maximization of comfort; in fact may increase discomfort, result in complications
(including death), decrease enjoyment of food, result in restraint use (up to 77% in
restraints!)
Question: Is Dementia a reasonable indication for hospice?
KEY POINTS
Yes!
 Medicare Hospice Benefit: 6-month life expectancy
o Typical features in demented patients (FAST)
 < 6 words
 No smiling
 Inability to walk or sit up independently
 Difficulty eating, swallowing, weight loss
 Infections and incontinence
Key References
Finucane TE. Christmas C. Travis K. Tube feeding in patients with advanced dementia: a
review of the evidence. JAMA.1999;282(14):1365-70.
Greiner LH. Snowdon DA. Underrecognition of dementia by caregivers cuts across
cultures. JAMA. 1997;277(22):1757.
Hebert LE. Scherr PA. Beckett LA. et al. Age-specific incidence of Alzheimer's disease
in a community population. JAMA. 1995;273(17):1354-9.
Mittelman MS. Ferris SH. Shulman E. Steinberg G. Levin B. A family intervention to
delay nursing home placement of patients with Alzheimer disease. A randomized
controlled trial. JAMA. 1996; 276:1725-34.
Ross GW, Abbott RD, Petrovitch H, et al. Frequency and characteristics of silent
dementia among elderly Japanese-American men: the Honolulu-Asia Aging Study.
JAMA. 1997;277:800-805.
Sternberg SA. Wolfson C. Baumgarten M. Undetected dementia in community-dwelling
older people: the Canadian Study of Health and Aging. Journal of the American
Geriatrics Society. 2000;48:1430-4.