Transcript Dementia – Part III

Vascular Dementia (VaD)
• Processing speed, executive
function impairment, insight,
mood
• Multi-infarct dementia
• Subcortical vascular disease
Diffuse Lewy Body Dementia
• Prominent visual hallucinations
• Parkinsonism (gait, balance, rigidity, bradykinesia- rest
tremor less common)
• Falls or gait difficulties
• Fluctuations in cognition/attention
• PDD- executive and visuospatial dysfunction
• MSA- “Shy-Drager”
Frontotemporal Dementia
• Younger onset- 50-60s
• Behavioral variant- R frontal
• Primary Progressive Aphasias- L frontal or L temporal
• Other tauopathies- PSP, CBS
Treatment Disclaimer
• Although there is currently no way to cure Alzheimer's disease
or stop its progression, we are making encouraging advances
in Alzheimer's treatment, including medications and non-drug
approaches to improve symptom management.
Cognition Enhancing Drugs
Cholinergic Agents (AChEI)
- Donepezil/Aricept
- Rivastigmine/Exelon
- Galantamine/Razadyne
NMDA Antagonist
- Memantine/Namenda
http://www.thefix.com/content/performanc
e-enhancing-smart-drugs-olympics8838
Acetylcholinesterase Inhibitors
Mechanism of Action:
• Inhibits centrally-acting acetylcholinesterase, making more
acetylcholine available
• This compensates in part for degenerating cholinergic
neurons that regulate memory
FDA Approved Uses of AChEI
• Mild/Moderate AD
• Moderate AD
• Severe AD- for rivastigmine and donepezil only
• Parkinson’s disease-related dementia- rivastigmine only
Off Label Uses
• VaD
• DLB, MSA
• Tauopathies
AChEI side effects
Muscle Cramps
Insomnia/
incontinence
Nausea
Diarrhea
• Diarrhea
• Urination
• Miosis/muscle weakness
• Bronchorrhea
• Bradycardia
• Emesis
• Lacrimation
• Salivation/sweating
What about Namenda and Namenda XR (memantine)?
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regulates glutamate in the brain
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key role in processing information
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may delay the worsening of symptoms
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may allow patients to maintain daily functions
• FDA approved as an addition to AChEI in mod/sev AD only
Off Label Use
• Anecdotally helpful in PPA
• Trial and error
Behavioral Symptoms
• Insomnia
• Weight loss
• Home Safety
• Agitation
• Wandering
• Repetitive vocalizations
Weight Loss
• Possible causes
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Forgetting to eat
Inability to prepare and eat foods
Impaired olfaction and taste
Behavior problems (restlessness, etc)
Depression
Comorbid medical illness
Medications (esp ACh-I, Antidepressants)
Inflammatory abnormalities (anorexia, procatabolic state)
Wang et al, J Neurol 2004, 251:314-320; Aziz NA et al, J Neurol 2008
Strategies
• Diet- liberalize it! No special diets!
• Environment
• Eat with others
• Pleasant, quiet
setting
• Music may help
Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007
More Weight Loss Strategies
Food Modifications
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Single items, presented one
at a time
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Contrast color of food with the dish
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Make food and setting look attractive
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Make food portable for those who are restless
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Sweet, hot/cold, juicy
Eating Schedule
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AD pts ate more at breakfast than other meals
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Frequent, small meals
Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007
Behavioral Therapy
• Nonpharmacologic intervention
• Antidepressants
• Antipsychotics if necessary
Exercise!
Image from bodbot.com
Benefits of Exercise
Image from bodbot.com
Nonpharmacological Strategies
Advise caregiver(s) to:
1) Use scheduled toileting and prompted toileting for incontinence.
2) Offer graded assistance (as little help as possible to perform ADLs), role
modeling, cueing, and positive reinforcement to increase independence.
3) Avoid adversarial debates; try to redirect conversation instead.
4) Maintain a calm demeanor.
5) Use services of caregiver support groups.
Depression in dementia
• Seen in up to 40% of AD patients; may precede onset of AD
• Signs include sadness, loss of interest in usual activities,
anxiety, and irritability
• Suspect if patient stops eating or withdraws
• May cause acceleration of decline if untreated
• Recreational programs and activity therapies have shown
positive results
Apathy v. depression in dementia
• High prevalence and persistence throughout course of AD
• Causes more impairment in Activities of Daily Living than
expected for cognitive status
• High overlap with depressive symptoms but lacks depressive
mood, guilt, and hopelessness
Agitation or aggression- What is it?
• Seen in up to 80% of patients with Alzheimer’s disease
• A leading cause of nursing-home admission
Agitation- What do you do?
• Identify context of behavior (is it harmful to patient or
others?)
• Identify environmental triggers (eg, overstimulation,
unfamiliar surroundings, frustrating interactions)
• Exclude underlying physical discomfort (eg, pain or hunger)
Psychosis in dementia
• Seen in about 20% of Alzheimer’s disease (AD) patients
• Delusions may be paranoid (eg, people stealing things, spouse
unfaithful)
• Hallucinations (~11% of patients) are more commonly visual
Psychosis- what do you do?
• Determine whether delusions or hallucinations are interfering
with function
Black box warning on antipsychotics in dementia
• [US Boxed Warning]: Elderly patients with dementia-related psychosis
treated with antipsychotics are at an increased risk of death compared to
placebo.
• cardiovascular or infectious (eg, pneumonia)
• quetiapine has a lower propensity to cause extrapyramidal side effects *
• risperidone not as sedating for daytime use
* APA, [Rabins 2007]
Resources for managing dementia
•Elder law attorney for will, advanced directives,
conservatorship, estate planning
•Community: neighbors & friends, aging & mental health
networks, adult day care, respite care, home-health agency
•Organizations: Alzheimer’s Association, Alzheimer’s of Central
Alabama
•Services: Meals-on-Wheels, senior citizen centers, home care
services
Educational Websites
• Alzheimer’s of Central Alabama- support groups and daycare
programs- http://alzca.org/
• Alzheimer’s Association- advocacy and research infohttp://www.alz.org/
• AlzOnline- patient and caregiver educationhttp://alzonline.phhp.ufl.edu/
• Association for Frontotemporal Degeneration- theaftd.org
• Lewy Body Dementia Association- http://www.lbda.org/
• The MSA Coalition- https://www.multiplesystematrophy.org/
• www.uab.edu/alzheimers