© copyright annals of internal medicine, 2014 ann int med. 161 (2): itc2-1. * for best viewing:...
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
in the clinic
Dementia
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
What medical interventions or health behaviors can help patients prevent dementia or cognitive decline? Modify the following potential risk factors
Physical inactivity
Depression
Midlife hypertension
Midlife obesity
Cognitive inactivity or low educational attainment
Diabetes mellitus
Minimize the use of sedative-hypnotics in elderly
Minimize risk for head trauma
Use seat belts; wear helmet in contact sports, on motorcycle, bicycle
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Sedative-hypnotics: minimize use
Benzodiazepines, anticholinergics, barbiturates
Can cause cognitive impairment
Estrogen: use in mid-life may reduce dementia risk
But in prospective prevention trials: estrogen + progestin was associated with increased dementia and other complications
Ginkgo biloba: lack of evidence for prevention
What medications can be used in patients presenting with signs of dementia?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Universal screening is not recommended
Consider screening adult patients with:
Memory difficulty interfering with daily function
Unexplained functional decline
Deterioration in hygiene
Questionable adherence to medication regimens
New-onset psychiatric symptoms
Should clinicians screen for dementia?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Obtain history from patient + knowledgeable informant
Use standardized screening instrument
MMSE: was widely used but now copyrighted
SLUMS: most similar to the MMSE
Mini-Cog: short
MoCA: best sensitivity but lower specificity
IQCODE questionnaire: filled out by family member or other informant
What methods should clinicians use when looking for dementia?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
CLINICAL BOTTOM LINE: Prevention and Screening... Minimize sedative-hypnotics for the elderly
Benzodiazepines, anticholinergics, barbiturates
Screen selected elderly patients
Take brief history from patient and knowledgeable informant
Use standardized screening instrument
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Check for cognitive deficits
Medical, neurologic, and psychiatric signs and symptoms
Identify their order of appearance, severity, and associated features
Collect collateral info from knowledgeable informant, because the patient may be unable to report accurately
What elements of the history are important in evaluating patients with suspected dementia?
Consider in the differential diagnosis
Delirium
Aging-related cognitive problems
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Look for conditions that cause or worsen cognitive symptoms
Evaluate patient’s alertness, general appearance, cooperation
Evaluate speech for its content and form
Assess for depression, anxiety, mania, suicide risk
Examine for delusions or hallucinations and obsessions or compulsions
Test abstract reasoning, judgment, visual-spatial perception, praxis, and planning ability
Evaluate corticosensory deficits
Include a standard tool (SLUMS, MOCA) in cognitive exam
How should clinicians evaluate the physical, mental, and cognitive status of patients with suspected dementia?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Diagnostic Criteria for Alzheimer Disease Probable Alzheimer disease is defined by:
Dementia established by clinical examination and documented by instrument (MoCA, SLUMS, Mini- Mental)
Deficits ≥2 areas of cognition, one usually memory
Progressive, not abrupt, decline
No disturbance of consciousness
Onset between age 40–90 years
Absence of other disorders that could account for deficits
The diagnosis of probable AD is supported by the presence of:
Specific cognitive deficits (e.g., aphasia, agnosia, apraxia)
Impaired activities of daily living
Positive family history
Supportive lab tests
continued…
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Diagnostic Criteria for Alzheimer Disease Diagnosis of Alzheimer disease is unlikely when:
The onset is acute and focal neurologic findings present
Seizure or gait disturbance present early in disease course
Possible Alzheimer disease is defined by:
Dementia established by clinical exam and documented by an instrument (Mini-Mental Status)
Absence of other conditions that cause dementia on exam
Variations in clinical course from typical course of AD
Another condition is present that could cause dementia but not felt to be primary cause
Single, severe, progressive cognitive deficit without identifiable cause
Definite Alzheimer disease is defined by:
Presence of clinical criteria for probable Alzheimer disease combined w/ biopsy- or autopsy-confirmed histopathology
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Comprehensive metabolic profile
CBC, TSH, vitamin B12 level
What lab tests are helpful in the evaluation of any patient with cognitive dysfunction?
Additional tests may include:
Rapid plasma reagin
HIV test
Toxicology screen
Erythrocyte sedimentation rate
Heavy metal screen
Thiamine level
Paraneoplastic panel
Chest radiograph or CT of the chest
Urinalysis
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Neuroimaging (CT or MRI) of the head
If cognitive difficulties <3 years in duration
When should clinicians order lab studies?
Glucose or amyloid PET scanning
Differentiate frontotemporal dementia from AD
Assess for early-onset dementia
Genetic studies
If there is a concern for Huntington disease
Autosomal dominant gene mutation testing if multiple family members affected, clinical picture + workup suggestive, and onset age <60y
Lumbar puncture
If <55y or if dementia is rapidly progressive, rapid plasma reagin is +, and CNS infection/cancer, paraneoplastic syndrome, or immunosuppression possible
EEG: If question of delirium, seizures, encephalitis, or CJD
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
What other disorders should clinicians consider in the assessment of cognitive dysfunction?
Medications
Depression
Mild cognitive impairment
Cognitive decline without impairment in function
Follow closely: 7% to 15% “convert” each year to dementia
After 5 years, nearly 50% meet dementia criteria
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis…
Evaluate patients who report cognitive and functional decline
Take history of medical, neurologic, and psychiatric symptoms from patient and knowledgeable informant
Perform thorough physical and mental status evaluation and cognitive exam
Obtain basic lab studies
Obtain additional studies based on clinical presentation
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Patients may struggle to comprehend and organize care
Prepare care plan that compensates for these limitations
Patients may lose the ability to identify symptoms
Standard medical and preventive care are important
Good control of hypertension, diabetes, and cholesterol
Antiplatelet therapy when appropriate
Vaccinations
As dementia advances, nutrition, skin care, toileting schedules, and dental care become more important
What should clinicians advise patients and their caregivers about general health and hygiene?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Driving becomes impaired in early stages of dementia
Difficult to predict when patient should lose ability to drive
Encourage periodic driving evaluation
Update the history regularly to check for deterioration
What should clinicians advise about driving, cooking, and other activities that raise safety issues?
Assess other safety issues on an ongoing basis
Home therapists can perform home-safety assessments
Modifications often possible to allow ongoing participation
Patients eventually become unable to take medications; cook; or use power tools, lawnmowers, or firearms
Wandering away from home is a frequent problem
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Try nonpharmacologic methods first unless symptoms cause immediate distress
Many emotional and behavioral disturbances can be “decoded”
Use 4-D or DICE approach
Patient may act agitated when hungry, tired, under pressure to perform, in pain, or lonely
Also when personal care is being provided, during shift changes, and in the presence of specific staff members
When patterns are recognized: develop, implement, and refine targeted interventions
What should clinicians advise about nonpharmacologic approaches to sleep problems, behavioral problems, and psychiatric manifestations of dementia?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Alzheimer Medications Only Slow Cognitive Decline
Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)
In patients with mild, moderate, or advanced AD
Better tolerated if slowly titrated to target dose
Memantine
Approved for use in moderate-to-advanced AD
Can use with acetylcholinesterase inhibitors
When benefit is unclear, drug may be stopped; restart if acute cognitive deterioration occurs
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Mild-to-moderate Parkinson disease: rivastigmine
Effective in improving cognitive performance in doses similar to those used in AD
Benefit may occur w/ other acetylcholinesterase inhibitors
Which other pharmacologic agents are helpful in treating specific types of dementia?
Dementia with Lewy bodies: acetylcholinesterase inhibitor
Use for cognition
Not recommended for patients with vascular dementia
Dementia: vitamin E
May benefit function but not cognition
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Ginkgo biloba
Herbal supplement does not slow progression of dementia
Coconut oil and Axona
Inadequate data on these food supplements to recommend
Nonsteroidal anti-inflammatory drugs
Estrogen
Ergoid mesylates
Which pharmacologic agents are ineffective in treating specific types of dementia and should be avoided?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Evidence is mixed for efficacy
Nearly 1/3 patients with dementia develop episode of major depression after the onset of dementia
Clinicians need high index of suspicion for major depression
Symptoms of major depression may be produced by dementia alone and complicate diagnosis
When should clinicians prescribe antidepressants in patients with dementia?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
When should clinicians prescribe antipsychotic agents to treat behavioral disturbances or psychotic symptoms?
When symptoms cause significant distress for patient or create a dangerous situation
2nd-generation antipsychotics: lower tardive dyskinesia risk
Efficacy of these agents is modest overall
Prescribe lowest possible dose for shortest possible time
Try to decrease dose and then discontinue within 3 months
Drug use increases death rates and cerebrovascular events
Associated with metabolic syndrome, weight gain, hyperlipidemia, and diabetes mellitus
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
Which drugs should clinicians use to treat sleep problems in patients with dementia?
Try nonpharmacologic methods first
Pay attention to factors that can affect sleep
Sleep environment
Caffeine consumption
Daytime sleeping
Afternoon and evening medications
Other elements of basic sleep hygiene
Beware risks associated with sedative-hypnotics
If necessary: 25–50mg trazodone with cautious monitoring
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
What other steps should clinicians take to maximize the quality of life of patients with dementia? Address issues that have potential to affect QOL
Sensory aids (glasses, hearing aids)
Dental care
Noise, lighting, and temperature
Social and cognitive stimuli
Cleanliness
Pain
Constipation
Encourage patient to complete early advance directive
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
When should clinicians consult a neurologist, psychiatrist, or another professional for patients with dementia?
When features are atypical
When it’s unclear if dementia is present
When in-depth documentation of impaired and preserved capacities would benefit the patient
When neuropsychiatric symptoms are difficult to treat
When physical restraints are required
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
When should clinicians recommend hospitalization for patients with dementia?
When patient can’t be evaluated as an outpatient due to
Dangerous behavior or lack of cooperation
Unsafe living conditions
Compromised nutrition or neglected medical conditions
Severe psychiatric symptoms (psychiatric hospitalization may be required)
Hospitalization facilitates history-taking, evaluation, and future care planning
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
How can clinicians help families decide to move a patient with dementia into a long-term care facility?
Encourage families to investigate facilities before placement decisions are needed, because patients may suddenly develop limitations that can’t be managed at home
Families need support and guidance
Possible to provide many services at home if families have ample financial resources
Periods of respite care may help families delay placement
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
What caregiver needs should be addressed by the clinician?
Common caregiver symptoms
Guilt, anger, grief,
Fatigue, loneliness, demoralization, depression
Assess caregiver’s well-being at every visit
Demands on caregiver can change over time
Offer education about dementia, skills training, and caregiver well-being
Direct to pamphlets, books, and educational web sites
Inform about psychoeducational and other support groups
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
What are the options for end-of-life care?
Therapy for pain
Calling out, grimacing when touched, crying may be indicators of pain
Therapy for neuropsychiatric symptoms
Supportive medical care
Treatment for symptoms that occur in late stages
Skin breakdown
Impaired swallowing
Aspiration pneumonia
Marked weight loss
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.
CLINICAL BOTTOM LINE: Treatment…
Adopt a broad approach that pays attention to
Comfort and quality of life
Cognitive enhancement
Stabilization of psychiatric symptoms
Safety issues
Caregiver well-being
Treat AD with acetylcholinesterase inhibitors
Add memantine for moderate-to-severe AD
Identify and treat psychiatric symptoms
Depression, psychosis, anxiety, behavioral disturbances
Use both behavioral and pharmacologic treatment