Transcript Document

Mind Cancer:
Alzheimer’s
Disease and
Related
Dementias.
Recognition of stages of
dementia, diagnosis and
treatment
William D. Rhoades, DO FACP
Chair, Department of Medicine
Advocate Lutheran General
and Chicago Medical School
Missoula Medical Conference
October 24, 2014
Objectives
 Recognize the diagnosis of Alzheimer's
disease and related dementias
 Discuss the three aspects of dementing
illnesses: cognitive losses, functional decline,
and behavioral issues
 Evaluate treatment modalities for Alzheimer's
disease
Stages of Cancer
 Stage O: Cancer in situ
 Stage I: Small cancer not invading deeper
tissues or spread to lymph nodes
 Stages II and III: Cancers that are larger in
size, have grown more deeply into nearby
tissues, and have spread to lymph nodes
 Stage IV: Advanced or Metastatic cancer
spread to other organs or body parts
Stage 0:
Mild Cognitive
Impairment;
Dementia in
situ
Stage O: Mild Cognitive Impairment
 DIAGNOSTIC CRITERIA
– Isolated memory complaint
– Objective memory impairment
– Normal general cognitive function
– Intact activities of daily living
– Not demented
MCI: Diverse Clinical Presentations
 Amnestic leads to Alzheimer’s Disease
 Multiple domains, slightly impaired leads to
Vascular Dementia, Alzheimer’s Disease, or
questionably due to normal aging
 Single non-memory domain leads to
Alzheimer’s Disease, Fronto-temporal
Dementia, Lewy-Body Disease, Primary
Progressive Aphasia, or Parkinson’s Disease
MCI: Progression To Alzheimer’s
Disease
 Annual percentage based on 6 studies
reviewed: 6 to 25%
 1 study showed 6% annual conversion to AD
 1 study showed 25% annual conversion to
AD
 4 studies showed 12-15% annual conversion
to AD
 Mayo Clinic study extended to 6 years found
80% of patients converted to AD over 6 years
Types of
Dementia
and Work-up
Differential Diagnosis of Dementia
Other dementias
Frontal lobe dementia
Creutzfeldt-Jakob disease
Corticobasal degeneration
Progressive supranuclear palsy
Many others
Vascular dementias
Multi-infarct dementia
Binswanger’s disease
Dementia with Lewy
bodies
Parkinson’s disease
Diffuse Lewy body
disease
Lewy body variant of AD
Vascular dementias and AD
AD
5%
10%
65%
AD and dementia
with Lewy bodies
5%
7%
8%
Small GW, et al. JAMA. 1997;278:1363-1371; American Psychiatric Association. Am J Psychiatry. 1997;154(suppl):1-39; Morris JC. Clin Geriatr Med. 1994;10:257-276.
3
Dementia workup
 Laboratory: CBC, CMP, Vitamin B12 level,
and TSH +/- RPR, ESR
 Imaging: Some brain imaging is
recommended CT without contrast if normal
is sufficient, if no imaging done MRI of brain
without contrast.
 Diagnosis: Transient Alteration of Awareness
Mind Cancer:
Alzheimer’s
Disease
BARRIERS TO DIAGNOSIS AND
TREATMENT OF AD
 By Patients and Families
–
–
–
–
–
Patient lacks insight
Fear of diagnosis
Denial of diagnosis
Fear of loss of function
Belief that there is nothing to
do
– Fear of societal implications
i.e. financial, insurance, and
embarrassment of a mental
illness
 By Physicians
– Drugs don’t work
– Want to be sure of
diagnosis before making it
because of implications
– Early diagnosis difficult
without family help
– Diagnosis and explanation
take time
– Suspect diagnosis but no
need to make it
Stage I: Early
Stage Dementia
Stage I: Red Flags






Weight loss
Vague complaints
Poor prescription management
Changes in grooming and hygiene
Missed or wrong day appointments
Apathy and/or depression
Stage I: Alzheimer’s Disease Screening







Recent events
Orientation to time
Clock drawing test
Three item recall
Animal naming (>12-15 in 1 minute)
Mini-Mental Status Test
Neuropsychological testing
Stage I: Early Alzheimer’s disease
 Memory impairment
 Word finding difficulty
 Difficulty with executive function and complex
tasks
 Geographic disorientation
 Reasoning and judgment abilities
 Usually remain independent
Stage I: Functional losses
(independence maintained)
 Driving??
 Unfamiliar locations may present problems
 Maintaining medications, especially if
complicated and/or potentially dangerous
 Managing higher finances i.e. taxes, large
purchases, and financial vulnerability
Stage II: Local
Spread of
Dementia
Stage II: Cognition and Cognitive
Losses





Memory
Orientation
Executive Function
Language
Visual Spatial Skills
Stage II: Functional Losses (living
alone)
 Instrumental Activities of Daily Living
– Shop for yourself
– Prepare your own food
– Maintain housekeeping
– Do laundry
– Manage medications
– Make telephone calls
– Handle finances
– Travel on your own
Stage III:
Spread of
Dementia to
family
members
Stage III: Advanced Middle-stage
Alzheimer’s disease




Day-night disorientation
Language deterioration
Difficulty with simple chores
Troublesome behavior:
– wandering
– irritability
– paranoia
 Depression
Stage III: Functional Decline
 Inability to maintain Instrumental Activities of
Daily Living
 Lack of capacity to live safely on your own
 Begin to see some erosion of Basic Activities
of Daily Living
– Assistance with: toileting, eating, dressing,
grooming, getting out of bed or chairs, and
walking
Stage III: Behavioral Issues
 Day-night disorientation
 Depression
 Wandering
 Irritability
 Paranoia
 Hallucinations
 Delusions
 Agitation
Stage IV:
Widely
Metastatic and
End-Stage
Dementia
Stage IV: Advanced Alzheimer’s
disease






Hallucinations
Delusions
Agitation
Erosion of all basic activities of daily living
Total dependence on caregivers
Lack the capacity for basic physical
independence
Treatment
Options for
Alzheimer’s
Disease
Treatment of Stage 0, Stage I, and
Stage II disease
 Reasonable Expectations of Successful
Cholinesterase Inhibitor Therapy
– Improve, maintain, or slow decline in ADL and
cognitive function
– Control troublesome behaviors
– Ease loss of independence
– Ease caregiver burden
– Delay placement in long-term care facility
FOUR CHOLINESTERASE INHIBITORS

Cognex (tacrine)

Aricept (donepezil)

Exelon (rivastigmine)

Reminyl (galantamine)
Treatment of Stage II and III disease
 Memantine (Namenda)
– Combination therapy
– When to add?
– Monotherapy
 Behavioral Treatments
Stages I,II, III: Nonpharmacologic
Therapy
Early Alzheimer’s
 Use it or lose it
 Safety and structure
 Memory aids
 Alleviating
depression
Middle-stage AD
 Adult day care
 Simplify the
environment
 Redirect behavior
 Do not argue
Treatment of Stage IV disease
Advanced Alzheimer’s disease
 Special care units
 Structure and activities based on cognition
 Additional in-home care assistance
 Management of incontinence
Stage IV: End-Stage Alzheimer’s
Disease





Palliative care
Hospice care
Hospitalizations
Feeding issues including tube feeding
Resuscitation decisions
Stage IV: Clinical Management
Goals and end-points of therapy:
 Social and behavioral therapy
 Medications to improve or maintain function
and cognition
 Medications for certain behaviors
 Recognition of delirium and depression
 Care of caregivers
Who Are the Caregivers?
 The overwhelming majority of patients live at
home and are cared for by family and friends
–
–
–
–
–
–
77% are women
73% are over 50 years of age
33% are the sole providers
45% are children of the patient
49% are spouses
Remainder are close family members or
friends
Caregiver Burden
 Caregivers spend from 40–100 hours per
week with the patient
 90% are affected emotionally (frustrated,
drained)
 75% report feeling depressed; 66% have
significant depression
 Half say they do not have time for themselves
and that the stress affects family relations
 Many experience a significant loss of income
Factors That Create “Breaking Point”
for Caregiver
 Amount of time spent caring for the patient
 Loss of identity
 Patient misidentifications and clinical
fluctuations
 Nocturnal deterioration of patient
Conclusions
 Dementia and Alzheimer’s disease represent
Mind Cancer
 Alzheimer’s disease progresses and the
stages have different symptoms and
treatments
 Alzheimer’s disease treatments are beneficial
in all three domains: cognition, behavior, and
function
 Attention to caregiver needs are very
important in Alzheimer’s disease