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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) Thyroid Profile, Calcium level, Chem.-7, CBC, B12 level

B) VDRL Sometimes

C) Toxicology Screen Sometimes

D) 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.

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, follow-up 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.

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