DementiaCarrie Plummer, PhD, ANP-BCAbby Parish, DNP, A/GNP-BCJennifer Kim, MSN, GNP-BCVanderbilt School of NursingMeharry-Vanderbilt GECQsource Webinar Series

DEMENTIA FACTS

Dementia - An Overview

• Definition • Types of Dementia• Risk Factors• Diagnosis • Stages• Treatment/Prevention• Resources

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Statistics• 7 million people suffer from

Alzheimer’s disease (AD)

• AD accounts for 50-70% of all dementias

• 8th leading cause of death in elderly

• AD lasts from 3-20 yrs (avg: 7 yrs)

• Cost in US: $100 billion/year

• Currently there is NO CURE

Dementia

• More than just memory loss• Deficits in SHORT TERM memory• Deficits in attention, language and problem solving• Interferes with social and occupational functioning

• Mild Cognitive Impairment (MCI)• Memory deficits without functional impairment• Can be difficult to distinguish from normal changes of aging• Amnesia type - most studied, most likely to progress to AD• donepezil (Aricept) may be protective for limited period (~1 year)

Common Types of Dementia

• Alzheimer’s Disease • 50 – 70%

• Vascular Dementia• 15 – 30%

• Dementia with Lewy Bodies (DLB)

• 10 – 25%

• Frontotemporal lobe Dementia

• rare

• Secondary dementias• Normal Pressure

Hydrocephalus (NPH)

• Parkinson’s dementia

• AIDS related dementia

• Alcohol related dementia

Alzheimer’s Disease• Alois Alzheimer- 1906

• “Unusual disease of the cerebral cortex”

• Histopathology:• Neurofibillary plaques and

tangles• Parietal-temporal cortex,

prefrontal cortex, hippocampus, amygdala

• Granulovacular bodies• Large, double-membraned

bodies http://auto.img.v4.skyrock.net/5396/80355396/pics/3076203011_1_7_ptCq7EkZ.jpg

Plaques & Tangles

Results of cell death

Alzheimer’s DiseaseNeurotransmitter Changes

• Acetylcholine amount and activity decreased• Needed for memory,

language and thoughts.

• N-methyl-D-aspartate (NMDA)

• Somatostatin• Serotonin

http://neurowiki2012.wikispaces.com/file/view/alzheimer's_disease_pathology.jpg/316537340/366x346/alzheimer's_disease_pathology.jpg

Alzheimer’s Disease-Types• Sporadic

• No known cause• No obvious inheritance patterns

• Familial• Rare (<10%)• Early onset **• Gene mutations on chromosomes 1,14 & 21

• 21 = abnormal amyloid precursor protein (APP)• 14 = abnormal presenilin 1• 1 = abnormal presenilin 2

• Autosomal dominant pattern• 1 copy of altered gene can cause AD

Risk Factors of AD (Sporadic)

• Exact cause of AD is unknown:• Age• 1 in 10 people over 65• 30-50% of those 85+• High blood pressure• High cholesterol• Head injury• Hormone replacement

therapy

http://www.cnn.com/2011/HEALTH/04/19/alzheimers.diagnosis.guidelines/t1larg.alzheimer.elderly.jpg

Symptoms of AD

• Memory Loss• Slow progression• Affects daily living

• Confusion/Disorientation

• Language problems• Word finding• Using words

inappropriately or forgetting their meaning

• Judgment

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Symptoms of AD

• Difficulty with • Handling money• Calculating numbers• Keeping track of things • Misplacing items

• Changes• Personality• Mood

• Apathetic http://media-social.s-msn.com/images/blogs/00120065-0000-0000-0000-000000000000_00000065-075e-0000-0000-000000000000_20121015210544_payingbill.jpg

Stages of AD

• Mild• Primarily cognitive deficits• Mild personality/behavior

changes

• Moderate• More pervasive memory

impairment• Impairment of ADLs

requiring supervision and minimal assistance

• Behavioral symptoms more pervasive http://www.mountainside-medical.com/blog/wp-co

ntent/uploads/2012/09/Alzheimers-Drug-Development-300x294.gif

Stages of AD

• Severe• Profound memory

impairment• Requires significant

assistance with ADLs• Vegetative symptoms

more pervasive

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Stages of AD

• Mild (can last 2-4 years or longer)• MMSE is ≥21• Appearance of health • Symptoms may be mistaken for normal aging changes

• SYMPTOMS: • easily loses way to familiar places,• trouble with word finding,• hoarding, • taking longer time to finish familiar tasks,• personality changes, • anxiety, • poor judgment.

Stages of AD• Moderate (can last 2-10 years)

• MMSE is 10-20• More damage to the brain, especially areas controlling language,

reasoning, thought and processing of sensory information. Symptoms are more pronounced.

• SYMPTOMS: • trouble recognizing familiar people & objects,• behavior changes, • more spontaneity, • inappropriate comments, • paranoia, • problems with language (speech, reading, writing), • loss of impulse control

Stages of AD

• Severe (can last 1-3 years or longer)• MMSE is ≤9• Damage to brain is widespread & full time care required. Difficult

time for family & caregivers.

• SYMPTOMS: • doesn’t recognize self or close family, • loses control of bowel and bladder, • weight loss, repetitive crying, • complete loss of language, • increased sleeping,• difficulty swallowing.

Vascular Dementia

• 5% of all dementias; 22% mixed with AD

• Stepwise progression• PMH: CVA, MI, DM, HTN, PVD, HLD

• Memory impairment less severe than AD

• TX: No current FDA-approved medications• donepezil (Aricept) shown to

be effective in mild-mod VD http://www.insideiamlaughing.com/wp-content/uploads/2012/12/vascular-dementia.jpg

Dementia with Lewy Bodies (DLB)

• Characterized by loss of dopamine and acetylcholine:

• Common presenting symptoms:• Visual hallucinations• Parkinsonian symptoms• Cognitive fluctuations

• Other symptoms:• Repeated falls• REM sleep behavior disorder• Depression/apathy

• TX: No approved medications, but cholinesterase inhibitors have been found to be helpful. Paradoxical response to antipsychotics!

http://belairecare.com/wp-content/uploads/2014/04/Lewy-Body.jpg

DLB AD

Presenting deficits Executive functionVisuospatial function

Memory (particularly short term)

Early MMSE deficits Overlapping pentagons, clock drawing, serial sevens (or WORLD backwards)

Orientation, 3 item recall

Distinguishing DLB from AD

Frontotemporal lobe Dementia

• Rare• Early onset (age 35-

75)• Hyperorality• Impairment in

executive functioning• Misdiagnosis

common• TX: none approved http://medlibes.com/uploads/Screen%20shot

%202010-07-20%20at%209.35.53%20AM.png

Parkinson’s Dementia

• 30-50% PD patients will develop dementia

• TX: Exelon (mild to moderate)

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Normal Pressure Hydrocephalus• Rare• Increase of CSF in ventricles

• TBI• CVA• Unknown causes

• Clinical triad• Altered gait• Urinary incontinence• Confusion

• Treatment• Surgical shunt placement

MAKING THE DIAGNOSIS

Diagnosing Dementia• History• Neuroimaging?• Medical and blood tests• Physical exam• Cognitive tests

• ability to count, language & problem-solving

• Autopsy

• Early diagnosis is beneficial to allow for early pharmacological and non-pharmacological treatment.

It looks a lot like dementia…

• Depression• Thyroid problems• Vitamin B12 deficiency• Alcoholism• Medications• Infections• Uncontrolled diabetes• Electrolyte imbalance• Tumors• Neurosyphyllis

Dementia vs. Depression

• Dementia• Confabulation• 50% will show some

degree of depressive symptoms

• Depression• “pseudodementia”• “I don’t know”• Trial of an

antidepressant may assist to distinguish

(Dharmarajan & Norman)

Cognitive Testing for Dementia

• MMSE • Not a diagnostic tool

• Clock Drawing Test (CDT)

• Mini Cog

• Functional assessment http://www.jabfm.org/content/16/5/423/

F3.large.jpg

Dementia DSM-IV Criteria• Development of multiple cognitive deficits manifested by both:

• Memory impairment

• One or more of the following cognitive disturbances: • Apraxia (inability to execute learned purposeful

movements)• Aphasia (disturbance of comprehension and

formulation of language),• Agnosia (loss of ability to recognize objects, persons,

sounds, shapes or smells),• Disturbances in executive functioning.

Dementia DSM-IV Criteria continued…

• Significant impairment in social & occupational functioning

• Decline from previous level of functioning

Advanced DirectivesA Special Note

• Discuss early to allow patient opportunity to participate in decision making• Resuscitation/Intubation• Feeding tube• Long term fluids• Antibiotics

• DPOA for Healthcare

Dementia in the Media

TREATMENT

Protective Factors

• High education• Leisure activities• Aerobic & strength training

• Cholesterol-lowering strategies

• Good control of HTN, DM & hyperlipidemia

• Cognitive Stimulation Therapy: Cochrane Review Not efficacious

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TREATMENT GOALS

• Maximize:• Function

• Independence

• Quality of life• Individual with dementia• Caregivers

• Time before institutionalization is needed

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dementia.jpg

Treatment for Dementia

• No known cure• Cholinesterase inhibitors stabilize behaviors:• Indicated for mild-moderate

AD

• Inhibits acetylcholinesterase thereby reducing amount of acetycholine breakdown in brain

• Aricept (donepezil)

• Exelon (rivastigmine)

• Razadyne (galantamine)

Cholinesterase Inhibitors

• Treatment goals:• Low rate of short term improvement• Moderate rate of stabilization• Primary goal is of less than expected decline

• Benefits: Don’t give families false hope• Decision to discontinue:

• Cost• Uncertain/diminished benefit?• Side effects• If discontinuation is appropriate, use slow taper• Some patients continue on CI’s indefinitely

Namenda

• N-methyl-D-asparate (NMDA) antagonist• blocks action of the chemical glutamate• Use cautiously with amantidine or dextromethorphan

• Monitor closely with coadministration of HCTZ, triamterene, metformin, cimetidine, ranitidine, quinidine & nicotine• Use the same renal system & can result in elevated

plasma levels of medications.• Common SE: constipation, headache, dizziness, pain

Treatment of Associated Symptoms and/or Diseases

• Depression

• Common co-morbidity• Symptoms often overlap

which complicates diagnosis

• SSRIs (avoid Prozac can increase agitation and sleep disturbances)

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Treatment of Associated Symptoms and/or Diseases

• Sundowning• Trazodone

• Medications for agitation- no FDA approved meds• Mood stabilizer?• Atypical antipsychotics?

• Behavioral problems:• Assessment of “other” causes and initiate non-

pharmacological interventions before medications!

Antipsychotic Use in AD• Short term improvement in aggression and psychosis (6-

12 weeks)• Increased risk of mortality in long term use• Other unwanted side effects:

• Orthostasis• Anticholinergic effects• Increased fall risk

• Dementia Antipsychotic Withdrawal Trial (DART-AD)

• Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study:• Modest benefits do not justify adverse events

WARNING:Increased Mortality in Elderly Patients with Dementia-Related Psychosis

Elderly patients with dementia-related psychosis treated with atypicalantipsychotic drugs are at increased risk of death compared to placebo.Analyses of seventeen placebo-controlled trials (modal duration of 10

weeks) in these patients revealed a risk of death in the drug-treatedpatients of between 1.6 to 1.7 times that seen in placebo-treated patients.Over the course of the typical 10-week controlled trial, the rate of deathin the drug treated group was about 4.5%, compared to a rate of deathof about 2.6% in the placebo group. Although the causes of death were

varied, most of the deaths appeared to be either cardiovascular (e.g.,heart failure, sudden death) or infectious (e.g., pneumonia) in nature.Abilify (aripiprazole)/Geodon (zipraxidone)/Risperdal (risperidone)/Symbyax (olanzapine and fluoxetine)/Zyprexa (olanzapine) are not

approved for the treatment of patients with dementia-related psychosis.

(www.caremark.com)

Drugs which have NOT shown a therapeutic benefit for dementia

• For cognitive symptoms:• Vitamin E• NSAIDS• Estrogen

• For behavioral symptoms:• Bezodiazepines

(typically)• Lithium• Beta-blockers

(APA)

Non-pharmacological treatment of problem behaviors

Behavioral symptoms of dementia• Behavioral symptoms have been reported to affect as

many as 90% of dementia patients• Most common in moderate to severe stages• Symptoms include:

• Irritability• Medication/care refusal• Eloping• Agitation• Combative behavior

• Non-pharmacological interventions are first line for these symptoms

Causes of Behavior Changes

• Physical discomfort caused by an illness or medications

• Overstimulation from loud noises or a busy environment

• Unfamiliar surroundings such as new places or inability to recognize home

• Complicated tasks

• Frustrating interactions due to the inability to communicate effectively

Taken from http://www.alz.org

Approach to problem behaviors• Explore possible causes

• Medication review, pain

• Calm demeanor• Be sympathetic• Minimize distractions & stimulation• Relaxation• Maintain a routine• Redirection and reorientation• Simple, one-step commands• Remove physical restraints!

Interventions for agitated patients

• Therapeutic options with poor evidence base, but being studied:• Music therapy

• Documentary “Alive Inside”

• Touch therapy (e.g., massage)

• Pet therapy• Simulated presence therapy

(audio or video of family or other)

• Reminiscence therapy

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(Beier)

Resources for Caregivers

Caregiver Burden: Emotional

• Characteristics of the disease change, and caregivers must constantly develop new coping mechanisms.

• “Constant vigilance”• “Loss of personhood”

• The point at which the patient no longer consistently recognizes the caregiver can be particularly emotional.

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Caregiver Advice(Ham & Sloane, 2009)

• Be realistic• Recognize a need for

assistance• Seek a support group• Communicate with family

to share burden• Ensure optimal health• Anticipate problems & plan

strategies• Plan legal & financial

aspects earlyhttp://accessiblehomeliving.com/wp-content/

uploads/2013/03/caregiver-stress.jpg

Resources• Alzheimer’s Association • Council on Aging

• Directory of Services for Seniors (new edition 1/09)• Caregiver Resource Guide ($10)

• Aging & Caring: Things Families Need to Know

• Area Agency on Aging• Financial and legal planning- do it EARLY

• Certified elder law attorney

• Medicaid managed care • Qualifications vary from state to state

ResourcesReading Materials• Rabins, Peter & Mace, Nancy (2006). 4th edition. The 36-

Hour Day

• Dunn,Hank (2001). Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care and the Patient with a Life-Threatening Illness

• Broyle, Frank (2006). Coach Broyles’ Playbook for Alzheimer’s Caregivers

ResourcesChildren’s Books• Fox, Mem (1985). Wilfrid Gordon McDonald Partridge.

• Altman, Linda Jacobs & Johnson, Larry (2002). Singing with Momma Lou

• Ballman, Swanee (2001). The stranger I call Grandma: a story about Alzheimer’s disease.

More Helpful websites• Alzheimer’s Association

• http://www.alz.org/

• Alzheimer’s Disease Education & Referral Center (ADEAR). U.S. NIA• http://www.nia.nih.gov/alzheimers

• Clinical Trials Information• http://www.clinicaltrials.gov• Alzheimer’s Association website

• Home>Alzheimer’s Disease > Clinical Studies

• Timothy Takacs Elderlaw Practice• http://www.tn-elderlaw.com/

• Free referral service for elder care options• http://www.aplaceformom.com

Thank you for your time and attention.

Q & A Session