Transcript ADRD Training slides - WV Geriatric Education Center

Todd H. Goldberg, MD, CMD, FACP
WVU Charleston Division
Charleston Area Medical Center
Hanna Thurman, MSW, LGSW, MPA
WV Geriatric Education Center
Original content developed by Mark A. Newbrough, MD
Associate Professor
Division of General Medicine, Geriatrics, and Palliative Medicine
University of Virginia
Medical Director, Blue Ridge PACE
This project is supported by a grant from the Health Resources and Services
Administration (HRSA), under grant number UB4HP19050 West Virginia Geriatric
Education Center for $2,000,000. The information and conclusions are those of the
author and should not be construed as the official policy of, nor should be any
endorsement inferred by the HRSA, DHHR, or U. S. Government.
1
Introduction
 This program is an initiative of the West Virginia Geriatric
Education Center (WVGEC), a federally funded interprofessional education program statewide for geriatrics, centered
at WVU Health Sciences Center – Charleston Division.
 Geriatric Education Centers, funded by HRSA (Health Resources
and Services Administration), provide training of interprofessional faculty, students, and practitioners on aging and
geriatrics. WVGEC is a consortium of partners including WVU
Health Sciences Center (three campuses), Marshall University,
WV School of Osteopathic Medicine, three Rural/Area Health
Education Centers and Charleston Area Medical Center. The
WVGEC is also known in WV for its Health Literacy Training for
Health Professionals, Geriatrics Lunchtime Learning Series and
Advanced Geriatric Skills Training.
2
After completion of this program
participants should be able to:
 Recognize the signs and symptoms of ADRD
 Describe the steps necessary to assess for and diagnose
ADRD when it is present
 Describe the general strategies for managing ADRD in
the context of other health conditions
 Recognize caregiver burden and depression, and help
provide resources for ADRD caregivers who
demonstrate significant burden and/or depression
 Describe how to facilitate referrals to community
resources and clinical trials for patients/families with
ADRD.
3
News item:
“World's oldest woman had normal brain”
 Amsterdam, 9 June 2008 – A 115-year-old woman
who remained mentally alert throughout her life
had an essentially normal brain, with little or no
evidence of Alzheimer's disease, according to a
study in the August, 2008 issue of Neurobiology of
Aging
4
Dementia Is Not Normal Aging!
 National: 5.4 million in US with AD in 2012
 WV State: 44,000 people, with 50,000 expected by
2025
 WV State AD Registry
 6th leading cause of death in the United States
 5th leading cause of death in adults 65 and older
 Do YOU list dementia as a cause of death on death certificates?
5
WV AD Registry – Have you seen it?
6
WV AD Registry – Have you seen it?
(continued)
7
Spectrum of Cognitive Impairment
8
Spectrum of Cognitive Impairment
9
Many Types of Dementia
 Alzheimer’s disease (AD)
 Lewy Body Disease (LBD)
 Vascular dementia (VaD)
 Parkinson’s disease dementia (PDD)
 Frontotemporal dementia (FTLD, Pick’s)
 Huntington’s disease
 Progressive supranuclear palsy (PSP)
 Cortical basal ganglionic degeneration (CBD)
 Infectious: Creutzfeldt-Jakob disease, HIV
Alzheimer’s disease (AD)
 First described 1907 by Alois Alzheimer (German
Neuropathologist) in a 52 year old woman
 Pathological findings at autopsy
 Β-amyloid plaques
 Neurofibrillary tangles (Tau protein)
 Biomarkers
 Biomarkers of brain amyloid-beta (Aβ) protein deposition: low
cerebrospinal fluid Aβ42 and positive PET amyloid imaging
 3 major biomarkers of downstream neuronal degeneration or injury
are: elevated CSF tau, [both total tau and phosphorylated tau (ptau)]; decreased 18fluorodeoxyglucose (FDG) uptake on PET in
temporo–parietal cortex; and disproportionate atrophy on
structural magnetic resonance imaging in medial, basal, and lateral
temporal lobe, and medial parietal cortex.
11
Auguste Deter (AD)
Auguste Deter
Born May 1850
Died April 1906
Nationality: German
Her maiden name is unknown. She
married Karl Deter in the 1880s or so and
together they had one daughter. Auguste
had a normal life. However, during the
late 1890s, she started showing symptoms
of dementia. After many years, she
became completely mindless, muttering
to herself. She was the first person
diagnosed with Alzheimer's Disease.
12
Dr. Alois Alzheimer (1864-1915)
13
SDAT - Neuropathology
Senile or neuritic or beta
amyloid plaques
 Extra-cellular lesions
composed of amyloid
peptides which appear to
cause brain dysfunction and
cell death
Neurofibrillary tangles
 Intracellular paired helical
filaments found
predominantly in
hippocampus and temporal
cortex. Composed of
abnormally phosphorylated
tau proteins.
14
DSM IV Diagnostic Criteria for AD/
Dementia of Alzheimer’s Type 331.0/294.1
 1. Dementia: development of multiple cognitive deficits




manifested by memory impairment, word finding difficulty, and
at least one of the following cognitive disturbances: aphasia,
apraxia, agnosia, disturbance in executive functioning
2. Course characterized by gradual onset and decline
3. Cognitive deficits cause significant impairment in social or
occupational function and represent a significant decline from
previous level of functioning
4. Cognitive deficits not due to other CNS conditions, systemic
conditions, substance induced conditions, delirium, or any other
Axis I mental disorder (e.g. depression, schizophrenia).
DSM 5 = New Terminology “NEUROCOGNITIVE DISORDER”
DSM-5 2013
16
NIA-Alzheimer’s Association’s Revised Diagnostic
Guidelines for Alzheimer’s disease
 Several articles in Alzheimer’s & Dementia, 2011
 For clinical use:
 Alzheimer’s disease (AD)
 Mild cognitive impairment because of AD (MCI)
 For research purposes:
 Preclinical AD
 Updated understanding of clinical-pathological
correlation
 Current state of knowledge re: biomarkers
17
Core Clinical Criteria for Dementia
Cognitive or behavioral (neuropsychiatric) symptoms:
1. Interfere with the ability to function at work or at
usual activities; and
2. Represent a decline from previous levels of
functioning and performing; and
3. Are not explained by delirium or major psychiatric
disorder; and
18
Core Criteria (slide 2 of 3)
4. Cognitive impairment is detected and diagnosed
through a combination of:
(1) history-taking from the patient and a knowledgeable
informant, and
(2) an objective cognitive assessment, either a “bedside”
mental status examination or neuropsychological
testing.

Neuropsychological testing should be performed when the routine
history and bedside mental status examination cannot provide a
confident diagnosis.
19
Core Criteria (slide 3 of 3)
5. At least two of the following domains:
 Impaired ability to acquire and remember new
information

symptoms include: repetitive questions or conversations,
misplacing personal belongings, forgetting events or
appointments, getting lost on a familiar route.
 Impaired reasoning and handling of complex tasks, poor
judgment (Executive Functioning)

symptoms include: poor understanding of safety risks,
inability to manage finances, poor decision-making ability,
inability to plan complex or sequential activities.
20
Core Criteria: Domains
 Impaired visuospatial abilities

symptoms include: inability to recognize faces or common
objects or to find objects in direct view despite good acuity,
inability to operate simple implements, or orient clothing
to the body.
 Impaired language functions (speaking, reading,
writing)

symptoms include: difficulty thinking of common words
while speaking, hesitations; speech, spelling, and writing
errors.
21
Core Criteria: Domains (continued)
 Changes in personality, behavior, or comportment

symptoms include: uncharacteristic mood fluctuations
such as agitation, impaired motivation, initiative, apathy,
loss of drive, social withdrawal, decreased interest in
previous activities, loss of empathy, compulsive or obsessive
behaviors, socially unacceptable behaviors.
22
Probable AD
 Meets criteria for dementia, and has the
following characteristics:



Insidious onset. Symptoms have a gradual onset
over months to years, not sudden over hours or
days; and
Clear-cut history of worsening of cognition by
report or observation; and
The initial and most prominent cognitive deficits
are evident on history and examination in one of
the following categories.
23
Probable AD: Amnestic Presentation
 Most common syndromic presentation of AD
dementia.
 The deficits should include impairment in
learning and recall of recently learned
information.
 There should also be evidence of cognitive
dysfunction in at least one other cognitive domain,
as defined earlier in the text.
24
Probable AD: Nonamnestic Presentations
 Language presentation:
 The most prominent deficits are in word-finding, but
deficits in other cognitive domains should be present.
 Visuospatial presentation:
 The most prominent deficits are in spatial cognition,
including object agnosia, impaired face recognition,
simultanagnosia, and alexia. Deficits in other cognitive
domains should be present.
 Executive dysfunction:
 The most prominent deficits are impaired reasoning,
judgment, and problem solving. Deficits in other
cognitive domains should be present.
25
Do not use the dx “Probable AD” if:
 Substantial concomitant cerebrovascular disease, or
 Core features of dementia with Lewy bodies other
than dementia itself; or
 Prominent features of behavioral variant
frontotemporal dementia; or
 Prominent features of semantic variant primary
progressive aphasia or nonfluent/agrammatic variant
primary progressive aphasia; or
 Evidence for another concurrent, active neurological
disease, or a non-neurological medical comorbidity or
use of medication that could have a substantial effect
on cognition.
26
Possible AD
 Atypical course
 E.g. has a sudden onset of cognitive impairment or
demonstrates insufficient historical detail or objective
cognitive documentation of progressive decline
 Etiologically mixed presentation
 Concomitant cerebrovascular disease, or
 Features of dementia with Lewy bodies other than the
dementia itself, or
 Evidence for another neurological disease or a nonneurological medical comorbidity or medication use
that could have a substantial effect on cognition
27
LBD Lewy Body Dementia
 “LBD is not a rare disease. It affects an estimated 1.3
million individuals and their families in the United
States. Because LBD symptoms can closely resemble
other more commonly known diseases like
Alzheimer’s and Parkinson’s, it is currently widely
underdiagnosed. Many doctors or other medical
professionals still are not familiar with LBD.”
 For more information visit Lewy Body Association,
Inc. website
28
Lewy bodies
29
Frontotemporal Dementias (FTD/FTLD)
 Several types: Pick’s
disease, Primary
Progressive Aphasia,
Semantic dementia, PSP,
CBD
 Visit The Association for
Frontotemporal
Dementias website
30
Vascular Dementia (VaD)
Clinical/Pathological Criteria
 Clinical definition of VaD:
 1) Dementia (decline in memory and intellectual




abilities causing impaired ADL)
 2) Evidence of cerebrovascular disease
clinically/brain imaging
 3) They must be reasonably temporally related
Brain imaging: large vessel strokes, small vessel /
subcortical disease, and/or leukoencephalopathy.
No specific radiologic lesions. Absence of ischemia
rules out VaD.
Mixed dementia = AD + CVD
Probable, possible, definite
Mild Cognitive Impairment (MCI)
 Concern regarding a change in cognition:
 There should be evidence of concern about a change in
cognition, in comparison with the person’s previous level.
 Impairment in one or more cognitive domains
 Decline in episodic memory most common in MCI due to AD
 Preservation of independence in functional abilities
 Not demented
 These cognitive changes should be sufficiently mild that there
is no evidence of a significant impairment in social or
occupational functioning.
32
MCI (continued)
 Because other domains of cognitive function may
be involved, it is important to test more than
memory
 Executive functions (e.g., set-shifting, reasoning,
problem-solving, planning),
 Language (e.g., naming, fluency, expressive speech, and
comprehension),
 Visuospatial skills,
 Attentional control (e.g., simple and divided attention).
33
Screening for AD
 Lots of interest, but with pros and cons
 Pros:
 Early diagnosis
 Potential opportunities to participate in future trials
 Opportunity to beginning planning earlier
 Cons:
 Increased anxiety / depression
 Labeling
 Not currently able to change the course of illness
34
Screening for AD (continued)
 Therefore NOT recommended by US Preventive
Services Task Force.
 Busy primary care practitioners need to be able to
identify those patients who need more evaluation
(whether pure screening, or in response to a vague or
general concern)
 Medicare AWV includes a cognitive screen – no
specific instrument required but MINI-COG
suggested.
35
Mini-Cog
 The Mini-Cog assessment instrument:
 Give 3 words to remember
 Clock-drawing test (CDT)
 Recall the 3 words
 Can be administered in <= 3 minutes
 Requires no special equipment
 Relatively uninfluenced by level of education or
language variations.
36
Mini-Cog Test
37
Folstein Mini-Mental State Exam
 30 point scale
 Originally published 1975, widely used, and
sensitive to changes in patient’s ability (i.e. lower
scores correlate well with worsening cognition)
 Copyright issues have created confusion about this
test, especially for researchers
 Consider Montreal Cognitive Assessment Test
(MOCA), St. Louis University Memory Screen
(SLUMS) (free and in public domain)
38
Folstein Mini-Mental State Exam
(continued)
39
Montreal Cognitive Assessment (MOCA)
40
VAMC SLUMS Examination
41
Course and stages of Alzheimer’s/dementia
 Staging: Global Deterioration Scale//FAST Scale of Reisberg et al. (Am
J Psychiat 1982;139:1136-1139, Psychopharm Bull 1988;24:653-659):
 1: Normal (no cognitive decline)
 2: Forgetfulness (very mild cognitive decline)
 3: Forgetfulness (MCI; earliest clear cut deficits)
 4: Late confusional (mild AD/moderate cognitive decline)
 5: Early dementia (moderate AD/moderately severe decline)
 6: Middle dementia (moderate to severe AD/severe cognitive decline)
 7: Late dementia (severe AD/very severe cognitive decline).
42
Clinical Dementia Rating Scale
0 = Normal
0.5 = Very Mild Dementia
1 = Mild Dementia
2 = Moderate Dementia
3 = Severe Dementia
43
AD: Making a Diagnosis
 Patient with a consistent clinical presentation,
with clinical evidence of cognitive impairment,
what additional work up is needed?
 Careful history and physical exam, especially
looking for evidence of focal neurological deficits,
medical conditions that could impair cognition
 Careful review of all medications
44
AD: Making a Diagnosis (continued)
 Complete blood count, sedimentation rate
 Chemistry panel
 Thyroid function
 Assess Vitamin B12 levels (better to check
methylmalonic acid level to detect clinically
significant deficiency)
 Consider CT or MRI imaging
 Depression screening
45
Geriatric Depression Scale
 15 questions, may be self-administered
 5 or more “positive” responses suggestive of
clinically significant depression
 More severe cognitive impairment may limit
effectiveness of screen
 If cognitive impairment mild, and depression
severe, consider treating depression before making
AD diagnosis
46
Geriatric Depression Scale (continued)
47
Managing ADRD: The Caregiver
 Who takes care of people with ADRD?
 Family / lay caregivers: Vast majority at
home/community
 Direct care workers: Most of in home workers and
facility based care
 Health professionals: Important, but frequently limited
contact and role in direct, hands on care
 Majority of care provided by people who care the
most, but who are least well trained.
48
Managing ADRD: The Caregiver (slide 2 of 3)
 According to the Alzheimer’s Association, 2006:
 80% of caregivers report they frequently suffer high
levels of stress
 Nearly 50% report feelings of depression
 Such feelings of enduring stress and frustration
have been frequently referred to as “caregiver
burden”.
 High levels of caregiver burden have been shown
to lead to a wide variety of negative outcomes for
patients, caregivers, and others.
49
Managing ADRD: The Caregiver (slide 3 of 3)
 Caregivers are often reluctant or unable to voice
their concerns to health professionals
 Feelings of obligation, guilt
 Taking on the “caregiver” role to the exclusion of self-
preservation
 Frequently unaware of the toll that caregiving is taking
 Given the impact of caregiver burden and burnout
on patient outcomes, it is incumbent of the health
professional community to screen for and monitor
caregiver burden
50
Screening for Caregiver Burden
 The Caregiver Burden Inventory (CBI)
 24 items, with 5 possible responses per item
 Never, Rarely, Sometimes, Quite Frequently, Nearly
Always
 Composite numeric score and five subscale scores
 Scores of 36 or higher indicative of significant
burden
 May be used as self-report or via interview
 A strategy for self-report during an office visit
51
Time Dependency
 He/she needs my help to perform many daily tasks
 He/she is dependent on me
 I have to watch him/her constantly
 I have to help him/her with many basic functions
 I don't have a minute’s break from his/her chores
52
Development Items
 I feel that I am missing out on life
 I wish I could escape from this situation
 My social life has suffered
 I feel emotionally drained due to caring for
him/her
 I expected that things would be different at this
point in my life
53
Physical Health Items
 I'm not getting enough sleep
 My health has suffered
 Caregiving has made me physically sick
 I'm physically tired
54
Social Relationship Items
 I don't get along with other family members as well
as I used to
 My caregiving efforts aren't appreciated by others
in my family
 I've had problems with my marriage (or other
significant relationship)
 I don't get along as well as I used to with others
 I feel resentful of other relatives who could but do
not help
55
Emotional Relationship Items
 I feel embarrassed over his/her behavior
 I feel ashamed of him/her
 I resent him/her
 I feel uncomfortable when I have friends over
 I feel angry about my interactions with him/her
56
Caregiver Depression
 2 screening questions
 During the past month have you often been bothered by
feeling down, depressed, or hopeless?
 During the past month have you often been bothered by
little interest or pleasure in doing things?
 If concerned about significant depression,
considering asking about thoughts of self-harm, or
harm directed at care receiver.
 A delicate issue if not the provider for caregiver.
57
Supporting the Caregiver
 Just asking about burden is helpful.
 Validate the caregiving experience/role.
 People want to know if they are doing “enough” or
“what they are supposed to be doing”?
 Community support resources
 Alzheimer’s Association support groups
58
Managing Patients with ADRD
 Managing the ADRD itself
 Managing other Medical Problems w/ ADRD
 Managing common complications of ADRD
 Depression
 Delirium
 Behavioral and psychological symptoms
 Medication safety
 Transitions of care
 Palliative care / End of life care and ADRD
59
Managing ADRD
 Education, education, education
 Facilitate access to community resources
 Local Alzheimer’s Association offices
 Senior Centers
 The 36 Hour Day by Mace and Rabins (guide for
families/caregivers)
 Cardiovascular disease risk factor reduction
 Avoid medications/treat illnesses that could
impact cognition
60
Managing ADRD: General Considerations
 Patients with ADRD are still people
 Work to take advantage of strengths and abilities
 Stay active:
 Regular physical activity
 Social activity
 Support emotional and spiritual needs
 Encourage people to continue to do those things they
can still do (monitor safety factors)
61
Managing ADRD (continued)
 Medications for Alzheimer’s disease (AD):
 Cholinesterase inhibitors
 Aricept (donepezil)
 Exelon (rivastigmine): pills or patches
 Razadyne (galantamine)
 NMDA inhibitors
 Namenda (memantine)
62
Aricept (generic = Donepezil)





Approved for mild-moderate-severe AD
Begin 5 mg daily for four weeks
Titrate up to 10 mg daily
23 mg dose available for severe dementia
Common side effects:
 Upset stomach or poor
appetite
 Sleep disturbances
 Syncope/Orthostasis/
Bradycardia
63
Exelon (generic = Rivastigmine)
 Approved for mild to moderate AD and Parkinsons
Dementia
 Pills
 Begin 1.5 mg orally twice a day
 Titrate up by 1.5 mg dose to target of 6 mg bid
 Titrate every 2 weeks to target
 Patches – may have less GI side effects
 Begin 4.6 mg patch, change daily
 Titrate up in four weeks to 9.5 mg patch, then 13.3mg
 Common side effects same, with addition of rash from
patches
64
Razadyne (generic = Galantamine )
 Approved for mild to moderate dementia
 DO NOT USE FOR MCI (Black Box Warning
Increased Death)
 Available in short acting or long acting forms
 Goal daily doses are the same (16-24 mg)
 Begin 8 mg per day (either 4mg BID, or 8mgER
once daily)
 4 weeks between dosage titration
65
Namenda (generic = Memantine)
 Approved for moderate to severe AD
 Namenda Titration Pack: Begin 5mg daily for one
week, 5 mg twice daily for one week, then 10mg in
the morning and 5mg in the evening for one week,
then 10mg twice daily
 Target dose is 10 mg bid but once/day may be
adequate (long half life 60-80 hrs!). (May need to
dose adjust for renal failure).
 Very well tolerated. May reduce GI side effects of
cholinesterase inhibitors (can start before or with).
66
Memantine Studies
Memantine Studies
68
Managing other Medical Problems w/ ADRD
 Still have to take care of the diabetes,
hypertension, heart disease, etc.
 ADRD directly impacts other aspects of care
 Medication compliance/adherence
 Nutrition
 Safety
 Conditions/medications that impact cognition
deserve special consideration
 Especially important to focus on prognosis and
goals of care
69
Managing Medical Problems (continued)
 Err on the side of safety:
 DM: hypoglycemia more dangerous than modestly




elevated glucose
HTN: orthostatic hypotension and risks of falls are
substantial
Medications that impair food intake increase risks
Meds that impair cognition to be avoided
Often necessary to compromise with once daily
regimens to improve compliance
70
Managing Common Complications of ADRD
 Risk for acute medical illness, or new chronic
illness does not go away once a person becomes
demented
 But, the dementia makes it harder to figure out
what is going on with the patient, and harder to
take care of the new problem
 Some problems/complications are so common,
they deserve special consideration
71
Depression
 People with history of depression/affective
disorder may become demented
 Prevalence of older adults with depression ~ 10%
 People with dementia frequently become
depressed
 Perhaps as many as 25% of patients will experience
depression during their course
 Apathy and affective (sad or anxious) presentations may
also occur that may present differently than “textbook”
depression
72
ADRD and Depression (continued)
 Treatment:
 Cognitive behavioral therapy limited with dementia
 SSRI’s a good choice for medication, especially



Celexa / Lexapro (citalopram / escitalopram)
Zoloft (sertraline)
Start low dose, and realize that will take longer to respond,
watch for side effects, especially anorexia
 Avoid tricyclics due to anticholinergic effects
 Trazadone or mirtazipine if sleep disturbances
prominent
73
Delirium: Definition
 Disturbance of consciousness with reduced ability to
focus, sustain, or shift attention
 A change in cognition or a perceptual disturbance not
better explained by a preexisting, established, or
evolving dementia
 Disturbance develops over a short period of time
(usually hours to days) and tends to fluctuate during
the course of the day
 Evidence suggesting disturbance caused by the direct
physiological consequences of a medical condition
74
Delirium: Causes






D-drug use
E-electrolyte and physiologic abnormalities
L-lack of drugs (withdrawal, e.g. Etoh)
I-infection
R-reduced sensory input
I-intracranial problems (stroke, bleeding meningitis, postictal)
 U-urinary retention and fecal impaction
 M-myocardial problems (e.g. MI, arrhythmia, CHF)
*Almost any acute illness may cause delirium*
75
Delirium: Management






Recognize and Evaluate (CAM/CAM-ICU)
Treat any underlying cause/general medical condition
Nonpharmacologic measures first
Low dose haloperidol for hypoactive delirium
Higher dose haloperidol for hyperactive delirium
Seroquel (quetiapine) the drug of choice for delirium
with Lewy body disease, Parkinson disease, or EPS
 Monitor QTC interval
 Withdraw antipsychotics as soon as possible
 Benzodiazepines only for EtOH/benzo withdrawal
76
Differential Diagnosis of Cognitive Impairment
(Acute = Delirium, Chronic = Dementia)
 Depression (pseudodementia), other psychiatric disorders, delirium
 Medication/drug/alcohol/chemical toxicity
 Metabolic/Endocrine
 Azotemia/Renal failure/dehydration/hyponatremia/acid-base
 Hypoglycemia/hyperglycemia
 Hepatic insufficiency
 Hypothyroidism/hyperthyroidism
 Hypercalcemia
 Adrenal/pituitary insuff./Cushing’s
 Nutritional deficiencies/B12/folate/niacin
 Infection/fever
 Cardiopulmonary/vascular/MI/CHF/PE/COPD/CVA
 Brain trauma/subdural/NPH/concussion/hemorrhage/infection/tumor
 Pain/surgical abdomen/fecal/urinary retention
 Hospitalization/anesthesia/sensory deprivation/blindness/deafness
 Heme Onc/Anemia/CA/paraneoplastic syndromes, “CHEMO BRAIN”
 “ICU BRAIN”
77
Behavioral and Psychological Symptoms of
Dementia (BPSD)
 Very common problem, ranging from
“sundowning”, to anger, to oppositional behavior,
to wandering
 Prevalence 60-80% depending on setting
 Incidence over any patient’s course >80%
 Frequent cause of hospitalization, nursing home
placement, caregiver burden (and burnout)
 No easy answers
78
BPSD (slide 2 of 5)
 Psychotic syndromes
 Hallucinations
 Delusions
 Affective syndrome
 Depression, Anxiety, Irritability, Agitation
 Behavioral Syndrome
 Euphoria, Disinhibition, Apathy, Aberrant Motor
behaviors
 Sleep disturbances
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BPSD (slide 3 of 5)
 Management:
 Nonpharmacologic means first
 Caregiver education
 Safe environments
 Activities focused on giving patients satisfaction, adapted to
current capabilities
 When considering medications, ask:
 Are you treating the patient or the caregiver?
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BPSD (slide 4 of 5)
 Medications:
 Psychotic syndrome: Antipsychotics
 ALL antipsychotics NOT specifically approved for dementia
patients and ALL carry  risk of death/black box warning
 Consider written informed consent
 Depressive symptoms: consider SSRI’s as above
 Anxiety, Irritability, Agitation, Aggressiveness
 Make sure not acting on psychotic symptoms
 Consider benzodiazepines or mood stabilizers, but data limited
 Apathy: stimulants have been tried
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BPSD (slide 5 of 5)
 Sleep Disturbance in Dementia:
 Almost universal
 Day/night reversal hard on caregivers
 Overall sleep and quality of sleep impaired
 Treat the patient, support the caregiver
 Daytime activity
 Melatonin 1-3mg before bedtime
 Trazadone, Remeron sometimes helpful
 Avoid benzo’s, z-drugs
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Palliative Care / End of Life Care and ADRD
 Alzheimer’s disease is a terminal disease
 Late stages (Stage VII), people become bedfast,
have swallowing difficulties, lose the ability to
communicate basic information and needs, have
increased risk for infections and death
 Focus care on keeping the PWA comfortable and
supporting the family
83
Palliative Care (continued)
EOL Care for people with
Alzheimer’s (PWA)
POST Form
 Timely discussions with





patients and families
Recognition of decline and
poor prognosis
Adequate diagnosis and
treatment of pain (Pain-AD)
Restricted use of feeding
tubes
Referral to Hospice (Stage
VII)
POST form (WV Center for
End of Life Care)
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Pain Assessment IN Advanced Dementia
PAINAD (Warden, Hurley, Volicer, 2003)
Items
0
1
2
Score
Breathing
independent
of
vocalization
Normal
Occasional labored
breathing. Short period of
hyperventilation.
Noisy labored breathing. Long
period of hyperventilation.
Cheyne-Stokes respirations.
Negative
vocalization
None
Occasional moan or groan.
Low level speech with a
negative or disapproving
quality
Repeated troubled calling out.
Loud moaning or groaning.
Crying.
Facial
expression
Smiling or
inexpressive
Sad. Frightened. Frown.
Facial grimacing.
Body
language
Relaxed
Tense. Distressed pacing.
Fidgeting.
Rigid. Fists clenched. Knees
pulled up. Pulling or pushing
away. Striking out.
Consolability
No need to
console
Distracted or reassured by
voice or touch.
Unable to console, distract, or
reassure.
Total
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Feeding Tubes and ADRD
 No advantages with artificial feeding:
 No improved survival
 No improved nutritional status
 No improved functional status
 No prevention of aspiration
 Careful hand feeding is much more beneficial, for
patient and caregiver, and safer.
86
Summary
approach
to the
diagnosis
of dementia.
(Morley,
JAMDA Jan.
2011)
Additional Reading
88
Additional Reading (continued)
89
Community Resources
 Many valuable resources available
 Important for health professionals to know what
resources are available to their patients
 Important for health professionals to assist patients
and families/caregivers in accessing available
resources
Referral Considerations
 Cultural considerations and personal preferences
 Navigating the long-term care system is difficult
and overwhelming
 Use health literacy concepts when possible
 Limited concepts  limit resources to 3-4
 Plain language
 Teachback
Referral Considerations (continued)
 Alzheimer’s Association Warning Signs and
Common Symptoms
 Where the individual is in the disease process
 Ask how the individual would like the referral
facilitated
 Follow-up
Statewide Resources







Alzheimer’s Association
Aging & Disability Resource Network
FAIR
Lighthouse
Medicaid Waiver
Medicaid Personal Care
Blanchette Rockefeller Neurosciences Institute (maintains
WV AD registry)
 WV Center for End-of-Life Care
 Adult Protective Services Senior Legal Aid
 Long-Term Care Ombudsman Program
Aging & Disability Resource Network
 Focus is on navigating resources
 Long term care/support options
 Older adults, caregivers, health professionals can call
 Help for seniors and adults with disabilities
 Resource information, access, coordination
 Follow-up
 Walk-ins, appointment, or by phone
 Website with resources by county WV Aging &
Disability Resource Network
Statewide toll free line 1-866-987-2372
Family Alzheimer’s In-Home Respite
Program (FAIR)
 State in-home care
program administered by
County Aging Provider
 Individualized activities
 Written diagnosis of
ADRD
 Respite for caregivers
 Up to 16 hours/week
 Sliding scale fee
Contact the Bureau of Senior
Services at (877) 987-3646
95
Lighthouse Program





In-home care for those seniors who have functional
needs in their homes, but whose income or assets
disqualify them for Medicaid services
Up to 60 hours/month
Age 60 or older
Payment based on sliding scale fee
Assistance needed in at least two of four areas:
 Personal care, mobility, nutrition and
housekeeping
Contact the Bureau of Senior Services at (877) 987-3646
Aged and Disabled Medicaid Waiver
Program
 In-home and community services to individuals 18 years





and older who are medically and financially eligible
Case management, homemaker, transportation, RN
assessment and review
Traditional model and Personal Options model
Nursing home level of care – must have at least five areas of
need
Currently on Managed Enrollment List
Individuals with AD may not qualify
Contact local DHHR office, ADRC or Bureau of Senior
Services Medicaid helpline at 866-767-1575
Medicaid Personal Care Program
 In-home care services for individuals with full
Medicaid benefits
 Medical and financial eligibility must be met
 Personal hygiene, dressing, feeding, nutrition,
environmental support, health-related tasks
 At least 3 areas of need
Contact the ADRC at 1-866-987-2372 or Bureau of
Senior Services Medicaid helpline at 866-767-1575
Alzheimer’s Association






24-Hour Toll-Free Helpline 1-800-272-3900
Care consultations
Support Groups
Newsletter
Numerous resources for caregiver support
Educational Materials and tailored information
packets
 Access to devices to monitor whereabouts
 Community Workshops
 Lunch and Learn
Alzheimer’s Association (continued)
 Support Groups
 Individuals with younger-onset
 For individuals caring for a spouse
 Early stage support group

Topics range from coping with the diagnosis to family
and lifestyle changes
Contact the Alzheimer’s Association’s 24-Hour Toll-Free
Helpline 1-800-272-3900
Other Important Statewide Resources
 Senior Legal Aid 800.229.5068
 Referrals
 Elder Law FAQ
 State Long-Term Care Ombudsman 1-800-8340598
 Adult Protective Services 800.229.5068
 State Health Insurance Assistance Program (SHIP)
Community Care Options
 Senior Centers
 Home Health
 Adult Day Care
 Assisted Living
 Respite Services
 In-home or at a facility
 Hospice
 Nursing Home
 Alzheimer’s Special Care Units
Contact the ADRC at 1-866-987-2372 or Alzheimer’s
Association at 1-800-272-3900
Palliative Care
 EOLC for people with dementia - WV Center for
End-of-Life Care:
 Timely discussions with patients and families
 Recognition of decline and poor prognosis
 Adequate diagnosis and treatment of pain
 Restricted use of feeding tubes
 Referral in a timely way to Hospice
 Remember the POST form
103
Clinical Trials
 “The engine that powers medical progress”
 Provider Role
 “Recruiting and retaining trial participants is now the
greatest obstacle, other than funding, to developing the
next generation of Alzheimer’s treatments.” Alzheimer’s
Association
Contact the Alzheimer’s Association at 1-800-272-3900
Clinical Trials (continued)
 Government Clinical Trials Match
Clinicaltrials.gov
 NIG National Institute on Aging
Clinical Trials and Older People publication
 Alzheimer's Association TrialMatch
 Complete profile
 Specialist contacts individual to help identify
appropriate clinical trial based on eligibility and
criteria
Conclusion
 Even though AD is a progressive, and ultimately
terminal condition, there is much that we can do:
 Provide access to community supports and resources
 Facilitate referrals to clinical trials
106
Special Thanks to:
 The Health Resources and Services
Administration
107