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ManagingDemen*aThroughtheCon*nuum

ErickaE.Tung,MD,MPHDivisionofPrimaryCareInternalMedicine|MayoClinicCollegeofMedicine

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ObjecBves

1.  DevelopaparadigmforassessmentandmanagementofcommondemenBarelatedclinicalchallenges

•  Driving

•  Neuropsychologicalsymptoms

•  Endoflifecare

2.  Leavearmedwithafullclinicaltoolbox

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ManagingDemenBaAcrosstheConBnuum

3 www.actonalz.org/provider-practice-tools

Todriveornottodrive..

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Case1

•  A74yearoldreBredmancomesinforfollow-upofhypertension,DM2,andmildcogniBveimpairment(MCI)

•  Duringhisvisit,hestrugglestotellyouhowheistakinghismedicaBonsandyouworryabouthisadherence

•  MedicaBons:–  glargine,aspart,aspirin,metoprolol,lisinoprilandatorvastaBn

Case1

•  PhysicalexaminaBon:–  BP130/70,HR66bpm–  Cardiacexam:RRRnomurmurs–  MiniMentalStatusExam:27/30

•  Asyouwalkhimtothecliniccheckoutdesk,younoBcehisworseninggaitinstability.

•  Heturnstoyouwithapuzzledlookandremarksthathecan’trememberwhereheparkedhiscar.

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ISMYPATIENTSAFETOCONTINUEDRIVING?

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COGNITION

DRUGS

VISIONMOTORSENSORY

DrivingCapacity

DrivingandDemenBa

•  2-8Xriskofmotorvehiclecrash•  Spectrumofdrivingcapacity•  CogniBveDomains:

–  Memory–  VisualProcessing/PercepBon–  A^enBon–  ExecuBvefuncBoning–  Insight

AssessingtheCogniBvelyImpairedDriver:SeverityofDemen.a

•  ClinicalDemen*aRa*ng(CDR)isausefultoolforidenBfyingpaBentsatriskforunsafedriving.(LevelA)

•  ConsensusexistsamongMedical,TransportaBon,andElderAdvocacygroupsthatseniorswithmoderatelyseveredemenBa(CDR2)shouldNOTbedriving.

•  PaBentswithmilderimpairment(CDR0.5-1)requiresystemaBcassessment

Iverson DJ, et al. Neurology 2010 Carr D, NEJM 2010

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PracBceParameterGuidelineAmericanAcademyofNeurology

Iverson DJ. Neurology 2010.

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CogniBveAssessmentandDrivingPerformance•  UseofasingledomaintestisNOTreliableindeterminingdriverfitness.

•  Compositeba^eriesareneededtoassessthewholepicture

Bennett JM. JAGS. 2016

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NeuropsychologicalAssessments

•  MontrealCogniBveAssessment(MoCA)•  Trailstest•  Clockdraw•  MazeTest

MOCA

•  ExecuBvefuncBon•  Visuo-construcBonal•  Workingmemory•  A^enBon/vigilance•  Language•  OrientaBon•  Time:10-15minutes•  Score<18:Worryabout

driving

TrailmakingBTest

•  CogniBveflexibility•  VisuospaBal

funcBoning•  A^enBon•  Correlatedwith

MVCandpoorontheroadtesBng

ClockDrawTest

•  Memory•  VisualpercepBon•  Planning/ExecuBveskills•  Abstractthinking•  SelecBvea^enBon•  CorrelaBonwithpoor

drivingperformance

Freund 2002, AGS

MAZETEST

•  A^enBon•  Visual-construcBonal

ability•  Planning•  PredicBveofhighcrash

risk

Staplin L. Accid Analysis Prev 2013

PutyourpaBentinto1bucket

Safe to continue

Intermediate Risk

Stop Immediately

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DriverRehabilitaBonSpecialist•  Background:OT,PT,psychology•  Services:assessment(in/outofcar),adapBvevehicle

modificaBons,adapBveinstrucBon•  $200-600,coveragevaries

–  Communicate:elecBvevs.essenBal

•  Bespecificinyourreferral(i.e.DRSforupperextremityweaknessaherstroke)

AdvanceCarePlanning:DrivingRe.rement•  KeyelementofprevenBvecounseling

–  IncludeinGME/WelcometoMedicareexaminaBon

1.Olderadult’sperspecBve2.CaregiverreadinessformobilitytransiBon3.TransportaBonalternaBves4.Re-inforcerecommendaBon:

–  Teachbacktechnique–  Visualreinforcement(Rx)

ReporBngProcedures

•  InformpaBentofyourintentandyourethical+/-legalresponsibility–  DriverisnoBfiedinwriBngofreferral,licenseissuspendedunBlfurtherexaminaBon

•  ProvideminimuminformaBonnecessarytoestablish

paBentmaybeunsafe.

•  Document,document,document

Driving:ClinicalPearls•  DemenBa:notama^erofif,it’sama^erofwhen

–  ThosewithverymilddemenBamaybesafetoconBnuedrivingbutwillneedserialtesBng

–  StartcounselingaboutalternaBvetransportaBonasap

•  MustdoacombinaBonofneuropsychologicaltests•  CommoncompensaBonstrategiesareNOTeffecBve

–  Co-piloBng–  MileagereducBon

•  PartnerwithyourlocaldrivingrehabilitaBonspecialist

NeuropsychologicalSymptoms

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Case2

•  87yowomanwithhistoryofprobableADandcerebrovasculardisease

•  Recentfallandhipfracture>>mulBpletransiBonsofcare

•  FamilyandALCnursingstaffdistressedby“behaviors”and“agitaBon”

•  StaffasksaboutstarBngsomeQueBapineorwillneedtoleaveALCandtransferelsewhere

•  DidImenBonitisFridayahernoonat4:30pm?

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•  Decreasedqualityoflife•  Increasedhospitallengthofstay•  Increasedcaregiverdistress,depression,burnout•  IndependentlyassociatedwithNHplacement•  Increasedsystem-widecosts•  ?Increasedmortality

•  NoFDA-approvedmedica.onforthesesymptoms

Jeste, DV. Neuropsychopharmacology, 2008

Finkel, SI et al. Int Psychogeriatrics 1996 26

BehavioralandPsychologicalSymptomsofDemenBa:AdverseClinicalRepercussions

ACTtotherescue!

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SystemaBcApproachtoManagementofNeuropsychiatricSymptoms: DICE

•  Step1:Describeanddefinebehavior– Whatisthetargetsymptom

•  Step2:InvesBgate–  Aretherereversiblecauses–  Iseveryonesafe?

•  Step3:Createatreatmentplan–  Non-pharmacologic–  Pharmacologic

•  Step4:Evaluate

Kales HC. JAGS 2014

D:Describe:SpectrumofSymptoms

WANDERING

HITTING

KICKING

SCREAMING

REPETITIVE QUESTIONING

VOCALIZATIONS

HYPERSEXUALITY

ESCAPISM

HALLUCINATIONS PARANOIA

FEAR

ANXIETY IRRITABILITY

PACING INAPPROPRIATE VOIDING

D: Describe the behavior

•  Interview all members of the care team •  Ask for an instant replay

–  “What did he do/say?”

–  “What about it really makes you upset?”

–  “What happens right before the behavior?”

–  “Who is around him and how do they react?”

Gitlin, L. JAMA 2012

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NPS Clusters

1.  Depression 2.  “Psychosis” 3.  Hyperactivity/agitation 4.  Sleep disruption/disorder 5.  Aggression 6.  Prefrontal/Disinhibition

Step2:InvesBgateWhatistheunderlyingcause?

Pa*ent-related

Caregiver-related

Environment-related

Behaviors

Language Skills

Adapted with permission from G. Smith, Ph.D.

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WhatisthepaBenttryingtotellus? InvesBgatePa.entFactors

•  DELIRIUM•  Symptomsfromcomorbiddisease•  Pain•  EmoBonaldistress•  LackofrouBne•  Sensorydeficit•  InappropriatelevelofsBmulaBon•  SleepdisrupBon

InvesBgateCaregiver-basedFactors

•  CommunicaBonbarriers•  Personaldistress•  Limitedavailability•  InappropriateexpectaBons•  LimitedpreviouseducaBonortrainingaboutdemenBa

InvesBgate:EnvironmentalFactors

•  Neededitemsareinaccessible

•  Visualclu^er

•  InappropriatelevelofsBmulaBon–  Auditory,visual,tacBle

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C:CreateatmanagementplanAParadigmShiA

EvidenceBasedPrac*ce

Mul*dimensionalSyndromal-

SymptomDrivenApproach

Non-pharmacologicIntervenBonsGeneralActivity planning

–  Tap into preserved capabilities and previous interests –  Involve repetitive motion

Communication –  Slow down, offer simple choices –  Avoid arguing/correcting –  Help senior find the words for self expression

Simplify Environment –  Remove clutter, minimize stimuli during activity

Caregiver support –  Self care, minimize confrontation –  Identify support network, respite

Gitlin,etal.JAMA,20122012

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PharmacologicManagement

•  Use if non-pharmacologic strategies fail or sooner if: –  Major depression with or without suicidal ideation –  Psychosis with potential to cause harm –  Aggression causing risk to self or others

•  Base choice on target symptom category –  Antipsychotics –  Antidepressants –  Mood Stabilizers –  Cognitive Enhancers

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WhenmedicaBonisNOTtheanswer

•  WrongindicaBon– Wandering/Escapism– RepeBBvequesBoning–  Inappropriatevoiding

•  Wrongdrug– Benzodiazepines

•  Worseninggait•  ParadoxicalagitaBon•  Dependency

– AnBhistamines

AtypicalAnBpsychoBcMedicaBonsWhyworry?– Death

•  Boxedwarning•  OR=1.54(1.1-2.2);NNH100•  Absoluteincreasedrisk1-2%

– Stroke•  OR3.12;NNH53

– Falls– CogniBveworsening– Arrhythmia– Pneumonia(3X)

Steinberg M, Am J Psychiatry 2012 Gill SS, BMJ 2005

Maher AR, JAMA 2011

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Atypical Antipsychotics Bottom Line

•  Participate in shared decision making with healthcare proxies

•  Use lowest possible doses and slowly titrate: –  Risperidone 0.25-1 mg –  Quetiapine 12.5-150 mg –  Olanzapine 1.5-7.5 mg

•  Monitoring: –  ECG- QT interval –  Falls, orthostatic BP, EPS, tardive dyskinesia, glucose

•  Regularly attempt to wean/discontinue

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CitalopramforAgita*oninAD(CitAD)

•  Design:Double-blind,placebo-controlledRCT–  186paBentswithprobableADandagitaBon

•  Interven*on:psychosocialintervenBon+citalopram(goaldose30mg)orplacebo

•  Outcomes:–  DecreasedagitaBoninbothgroups

•  0.93betweengroupdifferencefavoringcitalopram–  40%improvementonclinicalglobalimprovementscale–  Sideeffects:QTprolongaBon,reducedcogniBon

•  Currentprescribing:–  Maximumdoseof20mginthispopulaBon

Porsteinsson AP. JAMA 2014

CholinesteraseInhibitors•  Alzheimer’sDisease

• Meta-analysis-small,butstaBsBcallysignificantefficacy

•  DemenBawithLewyBodies•  clinicallysignificantimprovementswithdonepezil(placebovs.3,5,10mg)

»  NPIdomains(delusion,hallucinaBon,cogniBvefluctuaBon)»  GlobalfuncBon»  Caregiverburden

Wang J. J Neurol Neurosurg Psychiatry 2015 Sink KM, JAMA 2005

Mori E. Ann Neurol 2012

Dextromethorphan-Quinidine

•  MulBcenterdouble-blind,placebo-controlledRCT–  10weeks–  ProbableAD(aged50-90)with“agitaBon”

•  IntervenBon:Dextromethorphan-quinidinevs.placebo•  Outcomes:

–  DecreasedagitaBon(NPIagitaBon/aggression)inbothgroups•  1.5pointbetweengroupdifferencefavoringD-Q

–  ImprovedClinicalGlobalImpression(CGIC)–  Noimpactonqualityoflife–  Sideeffects:falls,diarrhea,UTI

Cummings JL. JAMA; 2015

SteppedAnalgesiatoReduceAgitaBon

•  Design:–  clusterrandomizedtrial–  60units;352NHresidents

•  IntervenBon:–  Stepwiseprotocol– Acetaminophen,morphine,buprenorphinepatch,pregabalin

•  Outcomes:–  ImprovementsonCohen-Mansfield

•  Treatmenteffect-7(-3.7to-10.3)

Husebo BS, BMJ 2011.

ClinicalPearls

•  Non-pharmacologicandpharmacologicmodaliBesmustbeindividualized– UBlizeDICEmethod– ConsiderTARGETsymptomwhendevelopingmanagementplan

•  AnBpsychoBcshavesignificantrisksandmarginalefficacyinthetreatmentofagitaBon

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Demen*arelatedpallia*vecare

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Case3

89yearoldwomanresidinginalocalnursinghome.Recentprolongedadmission:aspiraBonpneumoniaNolongerambulatory,needsanassistofonefortransfers,bathinganddressing.Preservedlanguageskills,butlacksthecapacitytomakehealthcaredecisions.Herdaughterexpressesthat“Momwouldneverwanttolivelikethis,”andasksabouthospice.Issheacandidateforhospice?

AdvancedDemenBa

•  MajorityofBmespentinmostseverestage

•  Mediansurvivalaherdiagnosis:3-12years•  Commonlycomplicatedby:

–  EaBngproblems(86%)–  Febrileillnesses(53%)–  Pneumonia(41%)

Mitchell SL, NEJM 2015 Mitchell SL, NEJM 2009.

EsBmaBngPrognosis

•  MedicareHospiceBenefit– EsBmatedlifeexpectancy<6months– FASTscale7C– 1inthepastyear:

•  AspiraBonpneumonia•  PyelonephriBs•  SepBcemia•  Stage3-4pressureulcer•  RecurrentfeveraheranBbioBcs•  UndernutriBon(weightloss>10%in6monthsalbumin<2.5g/dl)

LimitaBonsinEsBmaBngLifeExpectancywithDemenBa•  PaBentswithdemenBadonotprogressinalinearfashionasdescribedinFAST

•  QualifyingcomplicaBons(upperUTI)maybedifficulttodeterminedefiniBvely

•  PoordiscriminaBonofwhowilldiewithinnext6months.

•  Accesstopallia*vecareshouldbedeterminedbasedondesireforcomfort(ratherthanaprognos*ctool)

KeyStrategiestoImproveCareinAdvancedDemenBa

•  EstablishgoalsofcareandaligntreatmentopBons

–  Nutri*on:•  insufficientevidencetosupporttubefeeding

–  Infec*on:•  anBbioBcsforpneumoniamayprolonglifebutincreasediscomfort

–  Hospitaliza*on:•  75%ofhospitalizaBonsmaybeunnecessaryordiscordantwithgoals

– Medica*onuse:•  drugsofquesBonablebenefitshouldbedisconBnued

Teno J. JAGS 2012 Givens JL. Arch Intern Med 2010

Givins JL. JAGS 2012.

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MedicaBonUseinAdvancedDemenBa

•  IOMcallforacBon:–  “minimizeintervenBonsthataresenselessandburdensome”inthosewithlife-limiBngillness.

•  Greaterriskforoverlyaggressivemedicalmanagement–  5-15medicaBonsdaily–  BurdensomeforpaBents,caregivers–  LimitedBmetobenefit

Tija J. JAGS 2010. Field MJ. National Academy Press; 1998.

MedicaBonUseinAdvancedDemenBa

•  CrosssecBonalstudyfromnaBonallongtermcarepharmacyserving14,511nursinghomes

•  AdvanceddemenBa(N=5406residents)–  MMSE<6–  LOS>90days

•  CategorizedmedicaBonsas“neverappropriate”foruseinadvanceddemenBa

–  CogniBveenhancementmedicaBons–  AnBplateletagent(exceptaspirin)–  Lipidloweringagents–  Sexhormones,hormoneantagonists–  Leukotrieneinhibitors–  Cytotoxicchemotherapy–  Immuno-modulators

Tija J. JAMA Intern Med , 2014.

Results

•  53.9%ofresidentswereprescribedatleastoneinappropriatemedicaBon

•  ResidentcharacterisBcs– Morelikely:recenthospitalizaBon–  Lesslikely:presenceofDNR,hospiceenrollment

•  Geographicdifferences–  EastSouthCentral>WestSouthCentral>Pacific>WestNorth

Central>MountainMidatlanBc

MostCommonInappropriateRx

•  Cholinesteraseinhibitors(36.6%)

•  MemanBne(25%)

•  Lipidloweringagent(22.4%)

ToolstoguidemedicaBondecisions

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Op*mizeMedica*onTherapyProfessionalResourcesAGSBeersCriteria(2012)START(ScreeningTooltoAlertDoctorstotheRightTreatment)STOPP(ScreeningToolofOlderPersons’PotenBallyinappropriatePrescripBons)

ManagingDemenBaAcrosstheConBnuumwww.actonalz.org/provider-pracBce-tools

ClinicalPearl

LessisMoreFightpolypharmacyinadvanceddemen*a

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TopResourcesforPaBentsandFamilies

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#1 PromoBngWellness& FuncBon

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#2 AddressingBehavioral Challenges

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#3CarePartnerEmpowermentREACHProgram

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http://metroaging.org/wp-content/uploads/2014/10/

REACH-Outreach-2017.pdf

#3 CarePartnerResources

Alzheimer’sAssociaBon 800.272.3900|www.alz.org/mnnd

Onestopshopfor:– CareConsultaBon(socialworkintervenBon)– SupportGroups(MemoryClub)– 24/7Helpline

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TheTake-Away

•  TakeresponsibilityforkeepingyourpaBentsafeontheroad

•  UBlizeastrategicapproachwhenmanagingneuropsychiatricsymptoms

•  Alwayslookfornon-pharmacologicintervenBonspriortouBlizingamedicaBon

•  BeproacBveaboutde-prescribing•  UseACTtoolstoensurequalitycare!

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QuesBons?

•  DownloadACTonAlzheimer’spracBcetoolsat:www.ACTonALZ.org/provider-pracBce-tools

•  FormoreinformaBon,email:info@ACTonALZ.org

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