ࡱ>   Pbjbj jjIlxxxxxxx****$*UhL+L+L+L+L+L+L+L+$ ݇pʃExL+L+L+L+L+ʃ 5xxL+L+ 5 5 5L+4xL+xL+ 5L+ 5 57J}xxxhL+@+ :c%*.\Bh<%0UMn2Mh 58|xxxx Nathan Flacker, M.D. DEMENTIA: A Geriatricians View 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) 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 didnt 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) MEDICAL CONDITIONS IN OLDER PATIENTS ARE COMMONLY CHRONIC, MULTIPLE, AND MULTIFACTORIAL -Primary Dementias can co-exist; the common ones are: Alzheimers 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 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 Alzheimers 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 Thyroid Profile, Calcium level, Chem.-7, CBC, B12 level VDRL Sometimes Toxicology Screen Sometimes Do a 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) E) EEG if very rapid decline, myoclonus noted. (i.e. suspected CJD; should see spike and wave) H) Medications (See below) IATROGENIC ILLNESS IS COMMON Dont 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 SOCIAL HISTORY, SOCIAL CIRCUMSTANCES, AND AVAILABLE SOCIAL SUPPORT ARE IMPORTANT ASPECTS OF MANAGING GERIATRIC PATIENTS - Families, not medications, prevent nursing home admission - Refer to Alzheimers 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 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, Alzheimers Association, Therapist) D) Access to services (Area Agency on Aging, Social Worker) E) Environmental Modifications (PT, NP) F) Safety: (Alzheimers 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) 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 -Alzheimers association -Caregiver support groups -Case management 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 cant be solved through consultation with caregiver. 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: Prolong life Prevent pneumonia Improve quality of life Speed healing of pressure ulcers (see Finucane et al. JAMA.1999;282(14):1365-70.) - To decide one must establish goals of care: Life prolongation Maximization of function 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 Geriatricians 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 AGING IS NOT A DISEASE Other Key Points to make in the form of questions: Question: When and how does dementia usually begin? - 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? -Prevalence is 6%-8% in those >= 65 years and 30%-50% of those >= age 85 years Questions: So how many older people DONT have dementia? -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). 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 didnt recognize dementia (Greiner et al. JAMA 1997;277:1757) 64% missed by caregivers and physician (Sternberg et al. J Am Geriatr Soc) 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: Alzheimers 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: Often memory loss with focal motor signs that can be variable or even absent. Increases symptomatology of co-existing Alzheimers Frontal Dementia: -Personality change predominates over memory loss Normal Pressure Hydrocephalus Ataxia, Incontinence, Dementia Characterized by psychomotor slowing Pretty rare 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: -Consider treatment if symptoms such as depressed mood, appetite loss, insomnia, or fatigue Medication Effect Delirium 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) IATROGENIC ILLNESS IS COMMON Question: What medications affect thinking and can appear to be dementia? KEY POINTS: Dont 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 SOCIAL HISTORY, SOCIAL CIRCUMSTANCES, AND AVAILABLE SOCIAL SUPPORT ARE IMPORTANT ASPECTS OF MANAGING GERIATRIC PATIENTS Question: Whats the most common reason a patient is admitted to a nursing home? Answer: Family/Caregivers are unable or unwilling to care for the patient. KEY POINTS Families, not medications, prevent nursing home admission Refer to Alzheimers 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, follow-up support groups, and availability of counselor to help 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! 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, Alzheimers Association, Therapist) Access to services (Area Agency on Aging, Social Worker) Environmental Modifications (PT, NP) Safety: (Alzheimers Association, PT, NP, MD) Agitation: Evaluate for pain, depression, sleep loss, anxiety, delirium, medication effect such as AKASTHISIA from neuroleptic (MD, Nursing, PT, family) 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 -Alzheimers association -Caregiver support groups -Case management 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 cant be solved through consultation with caregiver. 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: Prolong life Prevent pneumonia Improve quality of life Speed healing of pressure ulcers (See Finucane et al JAMA 1999) To decide one must establish goals of care: Life prolongation Maximization of function 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 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. 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