Transcript Clinical Slide Set. Dementia - Annals of Internal Medicine

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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
in the clinic
Dementia
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann Int Med. 161 (2): ITC2-1.
What medications can be used in patients
presenting with signs of dementia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
Should clinicians screen for dementia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
What methods should clinicians use when
looking for dementia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann Int Med. 161 (2): ITC2-1.
What elements of the history are important in
evaluating patients with suspected dementia?
 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
 Consider in the differential diagnosis
 Delirium
 Aging-related cognitive problems
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
How should clinicians evaluate the
physical, mental, and cognitive status of
patients with suspected dementia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 161 (2): ITC2-1.
What lab tests are helpful in the evaluation
of any patient with cognitive dysfunction?
 Comprehensive metabolic profile
 CBC, TSH, vitamin B12 level
 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, 2014
Ann Int Med. 161 (2): ITC2-1.
When should clinicians order lab studies?
 Neuroimaging (CT or MRI) of the head
 If cognitive difficulties <3 years in duration
 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 161 (2): ITC2-1.
What should clinicians advise patients
and their caregivers about general health
and hygiene?
 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
What should clinicians advise about
driving, cooking, and other activities that
raise safety issues?
 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
 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, 2014
Ann Int Med. 161 (2): ITC2-1.
What should clinicians advise about
nonpharmacologic approaches to sleep
problems, behavioral problems, and
psychiatric manifestations of dementia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann Int Med. 161 (2): ITC2-1.
Which other pharmacologic agents are
helpful in treating specific types of dementia?
 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
 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, 2014
Ann Int Med. 161 (2): ITC2-1.
Which pharmacologic agents are
ineffective in treating specific types of
dementia and should be avoided?
 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.
When should clinicians prescribe
antidepressants in patients with dementia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 161 (2): ITC2-1.
How can clinicians help families decide to
move a patient with dementia into a longterm 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (2): ITC2-1.