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Dementia in Palliative Medicine
Sue Charette M.D.
Objectives
• Review the definitions of & types of dementia
• Discuss common symptoms & problems
experienced by patients with end-stage dementia
& their caregivers
• Review hospice eligibility criteria for patients
with dementia
What does dementia look like in
Palliative Care? Examples…
• 77 year old woman with a 7 year history of
Alzheimer’s Disease with newly diagnosed
metastatic breast cancer.
• 64 year old man with a history of DM 2, HTN, and
PAF with recurrent strokes now with progressive
dysphagia & refusing G-tube.
• 84 year old man with end-stage dementia who is
dependent in ADLS & IADLS and bed-bound now
hospitalized with pneumonia.
Dementia
• acquired and persistent impairment in cognition
and intellectual functioning
• the impairment interferes with everyday
functioning
• prolonged course
• behavioral and psychological symptoms
Epidemiology
• Alzheimer’s Disease is present in 2-3% of
patients over 65 and doubles in incidence
for every 5 years after; 50% over 85 years
• Dementia is the 5th leading cause of death
for persons over 65 years
• Survival of 4-7 years following diagnosis
•
(UNIPAC 9, 2008))
Common Types of Dementia
•
•
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•
•
Alzheimer’s Disease - 35%
Mixed dementia – vascular + AD - 15%
Lewy body dementia – 15%
Vascular dementia – 10%
Fronto-temporal dementia – 5%
Alzheimer’s Disease
• Characterized by amyloid plaques &
neurofibrillary tangles
• Hippocampus & neo-cortex are affected
• DSM-IV-TR criteria:
▫ Memory impairment
▫ At least one other cognitive disturbance such as
aphasia, agnosia, apraxia, or executive functioning
▫ Deficits are severe enough to affect function
Alzheimer’s Disease
• Early – memory loss
• Later – disorganized thoughts, confusion,
disorientation, language difficulties, executive
function declines leading to impaired judgment
• Psychological symptoms – agitation, psychosis,
mood disorders
• Time course: 4-7 years
Alzheimer’s Disease
• FDA approved treatments:
▫ Cholinesterase inhibitors
 donepezil (Aricept)
 rivastigmine (Exelon)
 galantamine (Razadyne)
▫ N-methyl-D-aspartate (NMDA) receptor
antagonists
 memantine (Namenda)
• Improved cognitive, behavioral and functional
outcomes
Vascular Dementia
• Neuronal loss or dysfunction due to vascular
causes including:
▫ Cortical infarcts
▫ Subcortical infarcts
▫ Leukoaraiosis (thinning of the cerebral white
matter, e.g. “white matter ischemic changes)
• Presence of the vascular changes, may
predispose the clinical expression of AD
Lewy Body Dementia
• Alpha-synuclein protein deposition in the cortex
and subcortex
• Cognitive impairment is characterized by
memory loss, deficits in attention, executive
functioning & visual spatial skills
• Core features: cognitive impairment, fluctuating
attention, visual hallucinations, parkinsonism
• Suggestive features: REM sleep-behavior
disorder & neuroleptic sensitivity
Characteristics of Dementia
• Early in the disease: follow the pattern typical
for that type of dementia
• Course: gradual deterioration punctuated by
periods of worsening cognitive & functional
decline, usually associated with acute illness
• Later in the disease: clinical symptoms become
similar among the various sub-types
Advanced Dementia & Acute Illness
• Life-threatening events in patients with
advanced dementia: UTI, pneumonia, hip
fracture
• 50% of patients will have 6-month mortality
following hospitalization for pneumonia or hip
fracture
Treatment Strategies
• Earlier in the disease:
▫ Treatments are different depending on type
• Later in the disease:
▫ Treatments are similar across types
Categories of Dementia
•
•
•
•
Mild
Moderate
Severe
Terminal
Dementia Management
• Acetylcholinesterase inhibitors
▫ donepezil
▫ galantamine
▫ rivastigmine
• NMDA inhibitor
▫ memantine
Hospice Criteria for Dementia
• Severity of dementia > Functional Assessment
Staging (FAST) Stage 7-C:
▫ Inability to walk, dress, or bathe without
assistance
▫ Urinary and fecal incontinence
▫ Inability to speak more then six different
intelligible words per day
(from NHPCO’s Medical Guidelines for Determining Prognosis in Selected
Non-Cancer Diseases, 2nd Ed. 1997)
Hospice Criteria for Dementia
• > 1 severe comorbid condition within past 6 months:
▫
▫
▫
▫
▫
Aspiration pneumonia
Pyelonephritis
Septicemia
Multiple, progressive stage 3-4 decubiti
Fever after antibiotics
• Inability to maintain fluid/caloric intake to sustain life if
feeing tube in place
▫ Weight loss >10% in 6 months
▫ Serum albumin <2.5 g/dl
(from NHPCO’s Medical Guidelines for Determining Prognosis in Selected NonCancer Diseases, 2nd Ed. 1997)
FAST Stages
(Luchins, 1997)
• Functional Assessment Staging (FAST)
• Stages
1.
2.
3.
4.
5.
6.
7.
No difficulties
Subjective forgetfulness
Decreased job functioning and organizational capacity
Difficulty with complex tasks, instrumental ADLs
Requires supervision with ADLs
Impaired ADLs, with incontinence
A. Ability to speak limited to six words
B. Ability to speak limited to single word
C. Loss of ambulation
D. Inability to sit
E. Inability to smile
F. Inability to hold head up
Mortality Risk Index
(Mitchell, 2004)
•
Mortality Risk Index Score (Mitchell)
Points Risk factor
1.9
1.9
1.7
1.6
1.6
1.5
1.5
1.5
1.5
1.5
1.4
1.4
Complete dependence with ADLs
Male gender
Cancer
Congestive heart failure
O2 therapy needed w/in 14 day
Shortness of breath
<25% of food eaten at most meals
Unstable medical condition
Bowel incontinence
Bedfast
Age > 83 y
Not awake most of the day
Risk estimate of death within 6 months
•
Score
Risk %
0
8.9
1-2
10.8
3-5
23.2
6-8
40.4
9-11
57.0
= 12
70.0
____________________________________________
FAST vs. MRI
• FAST -> 47 patients with advanced dementia on
hospice
▫ Only 12 could be assigned a FAST stage, and those
who were at stage 7C or greater, mean survival
was 3.2 months
• MRI -> data from 11,000 newly admitted
nursing home patients
▫ score of ≥ 12, 70% died within 6 months
FAST vs. MRI
Compared to FAST Stage 7C, the MRI had greater
predictive value of six month prognosis.
ADEPT Trial
(Mitchell, 2010)
• More recent research found that 12 variables
were able to predict mortality risk better than
hospice eligibility guidelines for nursing home
patients with advanced dementia.
• Variables include: length of stay, age, male,
dyspnea, pressure ulcers, total functional
dependence, bedfast, insufficient intake, bowel
incontinence, body mass index, weight loss, and
congestive heart failure.
Pain in Patients with Dementia
• Painful conditions are more common –
osteoarthritis, gout, spinal stenosis, fractures, PAD,
peripheral neuropathy
• 50 and 85% prevalence of pain in the ambulatory &
long term care settings, respectively
• Patients with cognitive impairment are at greater
risk of inadequate analgesia
(UNIPAC 9)
Pain Assessment in Advanced Dementia
(PAINAD)
(Warden, 2003)
•
•
•
•
breathing: labored breathing or hyperventilating
vocalization: moaning or crying
facial expression: frowning or grimacing
body language: clenching fists or pushing away
caregivers
• consolability: an inability to be comforted
Pain in Patients with Dementia
• Patients’ pain signature
• Caregiver’s input
• Opioids can be safely used in dementia patients
Behavioral & Psychological Symptoms
in Dementia
• Mood disorders
• Apathy
• Psychosis
▫ Delusions
▫ Hallucinations
• Agitation
Causes Contributing to Agitation
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•
•
•
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Physical symptoms (pain)
Psychological symptoms (depresssion)
Medical illness (delirium, urinary retention)
Unmet need (hunger, soiled diaper)
Environmental (overstimulation)
Medication (decrease or discontinue)
Dementia
Pharmacologic Options for Agitation
• Atypical antipsychotic agents
▫ Olanzapine, risperidone, quetiapine
• SSRIs
• Anticonvulsants
▫ valproic acid, carbamazepine, gabapentin
• Benzodiazepines
• Cholinesterase inhibitors
• NMDA receptor antagonists
Issues in End-Stage Dementia
• Eating difficulties
▫ Apraxia
▫ Dysphagia
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•
Infections
Hip fractures
Medical conditions
Medications
Tube Feedings
• Should not be placed in end-stage dementia
• Do not reduce aspiration risk
• Are associated with an increased risk of pressure
ulcers
• Do not improve quality of life
Caregivers of Patients with Dementia
• Provide care for longer periods, e.g. years
• Experience greater challenges
▫
▫
▫
▫
Increased anxiety & depression
Physical demands of caregiving
Fewer outside activities & connections
Loss of income & financial resources
• Hospice offers support and options for respite
Goals of Care
• Discussions should begin early in the disease
process when patient has decision-making
capacity
• What are the patient’s wishes?
• Quality of life should be the focus
• Hospice and palliative care
References
• Olson E. Dementia and Neurodegenerative
Disorders. In: Morrison RS, Meier DE, eds.
Geriatric Palliative Care. New York, NY: Oxford
University Press; 2003.
• Luchins DJ, Hanrahan P, Murphy K. Criteria for
enrolling dementia patients in hospice. J Am
Geriatr Soc. 1997; 45:1054-1059.
References
• Warden, V, Hurley AC, Volicer, V.
(2003). Development and psychometric
evaluation of the Pain Assessment in
Advanced Dementia (PAINAD) Scale. J
Am Med Dir Assoc, 4:9-15
• Thomas E. Finucane, MD; Colleen
Christmas, MD; Kathy Travis, MD. Tube
Feeding in Patients With Advanced
Dementia: A Review of the Evidence.
JAMA. 1999;282(14):1365-1370.
References
• Mitchell SL, Kiely DK, Hamel MB, et al.
Estimating prognosis for nursing home residents
with advanced dementia. JAMA. 2004;
291:2734-2740.
• UNIPAC 9: The hospice and palliative medicine
approach to selected chronic illnesses: dementia,
COPD, and CHF. AAHPM, 2008.
References
• Mitchell et al. The Advanced Dementia
Prognostic Tool (ADEPT): A Risk Score to
Estimate Survival in Nursing Home Residents
with Advanced Dementia. J Pain Symptom
Manage. 2010 November; 40(5): 639-651.
• Teno et al. Feeding Tubes and the Prevention or
Healing of Pressure Ulcers. Arch Intern
Med. 2012;172(9):697-701