Download Staging of Dementia

The Diagnosis and Management of
Atypical Dementia:
When Memory is Not the Issue!
David B. Carr, M.D
Professor of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Disclosures
• Funding Support (last two years)
• National Institute on Aging (NIA)
• Missouri Department of Transportation
• Consulting Relationships
• American Medical Association (AMA)
• ADEPT
• Traffic Injury Research Foundation
• Medscape
• Speakers Bureau
• St. Louis Alzheimer’s Association
• Medical Director
• Parc Provence
• The Rehabilitation Institute of St. Louis
• Drug Industry Sponsored Trials
• Janssen, Novartis
• Investment/Stock/Equity
• None
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
DISCUSSION OBJECTIVES
• Know how to diagnose, manage, and assess dementia
severity
• Know the symptoms and signs of common non-AD
dementias
• Know the treatment available for non-AD dementias
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Caregiver
Burden
There are more
than 15,000,000
caregivers of
people with
dementia
In 2012,
caregivers
provided over 17
billion dollars in
unpaid care
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
TOOLS FROM THE SHED
• Brief Dementia Screens
• Dementia Severity Measurements
• Dementia Subtypes
• The DRNO approach
• (Describe, Reason, Non-pharm, Order Meds)
• When to work up changes in behavior
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Brief Screens for Detection of Dementia
• Brief tests may be
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insensitive to the early stages of dementia
biased (culture, race, gender, age, education)
weighted towards single domains
too complex for office use
what if the person just had a “bad” day
• Comparison with normative values may
• not detect very mild decline in high functioning individuals.
• falsely detect dementia in individuals with life-long poor
cognitive function
• Formal neuropsychological evaluations
• require extensive training
• Lengthy and costly
Source: James E. Galvin, MD, MPH, New York University, 2011
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Ascertain Dementia 8: AD-8
Eight item questionnaire to detect dementia
• Detect change in individuals •
previous level of function
• No need for baseline
assessment
• Patients serve as their own
control
•
• Not biased by education,
race, gender
Brief (< 2 min), Yes/No format
• 2 or more “Yes” answers
highly correlated with
presence of dementia
Administration to patients may
also be useful in absence of
informant
The AD-8 is a copyrighted instrument of the
Alzheimer’s Disease Research Center, Washington University
The AD-8 is not a substitute for clinical judgment.
Galvin J, Roe CM, Xiong C. Validity and reliability of the
AD-8 informant interview in dementia. Neurology 2006;67:1942–1948.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
The AD-8
Remember, “Yes, a change” indicates that you think there has
been a change in the last several years cause by
cognitive (thinking and memory) problems
YES,
A change
NO,
No change
N/A,
Don’t know
Problems with judgment (e.g. falls for scams, bad financial
decisions, buys gifts inappropriate for recipients)
Reduced interest in hobbies/activities
Repeats questions, stories or statements
Trouble learning how to use a tool, appliance or gadget (e.g.
VCR, computer, microwave, remote control)
Forgets correct month or year
Difficulty handling complicated financial affairs (e.g. balancing
checkbook, income taxes, paying bills)
Difficulty remembering appointments
Consistent problems with thinking and/or memory
TOTAL AD8 SCORE
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Cognitive Screen: The Short Blessed Test
Question
Max Error
Error Score
x Weight
Subscore
What year is it?
1
_______
4
_______
What month is it?
1
_______
3
_______
Chicago
_______
Repeat and remember: John Brown 42 Market St
About what time is it
(one hour)?
1
Count backwards
from 20 to 1
2
Months of the year
backwards.
2
3
_______
_______
2
_______
_______
2
_______
_______
Repeat name and
5
2
address.
_______
_______
A total weighted score of 6 or more indicates need for further assessment
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
The Clinical Dementia Rating
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Staging of Dementia
• Stage 1: No impairment
• Stage 2: Very mild cognitive decline (MCI)
• Stage 3: Mild cognitive decline
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Short-term memory loss
Word- or name-finding problems
Performance issues
Misplacing items
Decline in ability to plan or organize
• Stage 4: Moderate cognitive decline
• Decreased knowledge of current/recent events
• Difficulty with complex tasks at home
• Withdrawn or subdued
http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Staging of Dementia
• Stage 5: Moderate to severe cognitive decline
• Short- and long-term memory loss
• Confused about time/orientation
• May need assistance with clothing selection
• Stage 6: Severe cognitive decline
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May have difficulty remembering family names
Need help with dressing
Wandering
Personality changes: delusions/hallucinations
• Stage 7: Very severe cognitive impairment
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Loses capacity for language
Needs assistance in all activities of daily living
Loses ability to ambulate; able to sit with support
Dysphagia
Department of Medicine and Neurology
Division
of Geriatrics and Nutritional Science
Source: Alzheimer’s Association. Available at: http://www.alz.org/AboutAD/Stages.asp. Accessed April 11, 2006.
Rating Dementia Severity
Our Patient had CDR Rating of 0.5
SBT=6, MMSE=24
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
REVIEW OF BRAIN FUNCTIONS
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
CLUES TO SPECIFIC
NEURODEGENERATIVE DISEASES
Alzheimer’s
Disease
Rapidly
evolving
dementias
Frontotemporal
dementias
Vascular
dementia
Lewy body
dementia
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Dementia with Lewy Bodies:
Consensus Criteria
• Progressive cognitive decline of sufficient magnitude to
interfere with normal social or occupational function
• Core features (2probable DLB; 1possible DLB)
• Fluctuating cognition
• Recurrent visual hallucinations
• Parkinsonism
• Supportive features
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Repeated falls
Syncope and transient loss of consciousness
Neuroleptic sensitivity
Systematized delusions
Hallucinations in other modalities
DLB = dementia with Lewy bodies; REM = rapid eye movement.
REM sleep disorder
Source: McKeith IG, et al. Neurology. 1996;47:1113-1124.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Frontotemporal Dementia
•
•
•
3-5% of all cases
Early onset disorder in 35-75 year olds
Male: Female ratio 1:1
•
Comprises 3 disorders
1. Pick’s disease (PiD); now called FTLD; behavioral variant FTD (bvFTD)
• Florid personality changes/ dramatic loss of insight into behavior
• Socially inappropriate
• Hyper oral
• Sexual disinhibition
• Language
• Memory spared
2. Primary progressive aphasia
• Nonfluent language problem (expressive)
• Speaking, writing are agrammatical
• Spelling errors
3. Semantic dementia
• Fluent, “word salad”
• Loss of word meaning
• Late memory changes
Next set of slide courtesy of Dr. Nupur Ghoshal
Frontotemporal Dementia:
A Behavioral Syndrome
Frontotemporal Dementia
• Behavioral Problems
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–
–
–
–
–
–
Disinhibition
Apathy
Emotional blunting
Euphoria
Obsessions and Compulsions
Mental Rigidity
Depression
• Cognitive Deficits
– Poor planning
Alzheimer Disease
• Behavioral Problems
– Apathy
– Irritability/ Agitation
– Depression
• Cognitive Deficits
– Memory loss
– Visuospatial impairment
– Poor planning
FTD Features
Yener, Görsev G.; Rosen, Howard J.; Papatriantafyllou, John CONTINUUM: Lifelong
Learning in Neurology Volume 16(2) Dementia April 2010 pp 191-211
FTD Features
Yener, Görsev G.; Rosen, Howard J.; Papatriantafyllou, John CONTINUUM: Lifelong
Learning in Neurology Volume 16(2) Dementia April 2010 pp 191-211
bvFTD Diagnostic Process
Chow, Tiffany W.; Alobaidy, Ammar A.
CONTINUUM: Lifelong Learning in Neurology. 19(2, Dementia):438-456, April 2013.
FTD – Language Variants
Chow, Tiffany W.; Alobaidy, Ammar A.
CONTINUUM: Lifelong Learning in Neurology. 19(2, Dementia):438-456, April 2013.
Progressive Nonfluent Aphasia vs. Semantic Dementia
Yener, Görsev G.; Rosen, Howard J.; Papatriantafyllou, John CONTINUUM: Lifelong Learning in Neurology Volume 16(2) Dementia April 2010 pp 191-211
Primary Progressive Aphasias – Agrammatic Subtype
PPA-G (Agrammatic/Nonfluent Subtype): A problem with word-order and
word-production.
• Speech is effortful and reduced in quantity. Sentences become gradually
shorter and word-finding hesitations become more frequent, occasionally
giving the impression of stammering or stuttering.
• Pronouns, conjunctions and articles are lost first. Word-order may be
abnormal, especially in writing or e-mails. Words may be mispronounced or
used in the reverse sense (e.g., "he" for "she" or "yes" for "no").
• Word understanding is preserved but sentence comprehension may suffer if
the sentences are long and grammatically complex.
Primary Progressive Aphasias – Semantic Subtype
PPA-S (Semantic Subtype): A problem with word-understanding.
• The principal feature is a loss of word meaning, even of common words.
Speech has less nouns and is therefore somewhat empty of meaning.
However, it sounds perfectly fluent because of liberal use of fillers.
• The person may seem to have forgotten the names of familiar objects.
• This is the one subtype where changes of personality and behavior are
frequent. There may be agitation, display of excessive friendliness to
strangers, change of dietary habits, etc.
Primary Progressive Aphasias – Logopenic Subtype
PPA-L (Logopenic Subtype): A problem with word-finding.
• In contrast to PPA-G, speech is fluent during causal small talk but breaks into
mispronunciations and word-finding pauses when a more difficult or precise
word needs to be used.
• Some people with PPA-L are very good at going around the word they cannot
find. They learn to use a less apt or simpler word as well as to insert fillers such
as "the thing that you use for it," "you know what I mean," or "whatchamacallit."
• Spelling errors are common. The naming of objects becomes impaired.
Understanding long and complex sentences can become challenging but the
comprehension of single words is preserved.
Primary Progressive Aphasias – Treatment
• Because of the 30-40% probability of AD, some physicians will prescribe AD
drugs such as Exelon (rivastigmine), Razadyne (galantamine), Aricept
(donepezil) or Namenda (memantine). None have been shown to improve
PPA.
• Patients may be understandably depressed and frustrated. The depression
may not be expressed verbally because of the aphasia. Treatment with
antidepressants may be indicated where appropriate.
• Speech therapy may offer benefits in the early stages by teaching more
effective communication strategies and ways to compensate for language
difficulties.
• Quality of life enrichment and caregiver support programs offer individuals
and families ways of coping with a diagnosis of PPA. The effectiveness of
such life enrichment programs is demonstrated by the growing interest in
caregiver conferences held at specialized medical centers.
Rapidly Progressive Dementia:
Clinical Diagnostic Criteria
• Core features
• Evolves hyperacutely (over days or weeks)
• Evolves subacutely (months to 1-2 years)
• More rapidly than expected
• Myriad of Causes
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Neurodegenerative: Prion disease (CJD)
Antibody mediated brain diseases
Sarcoid
MS
Lupus
Vasculitis
Other
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
POSTERIOR CORTICAL DYSFUNCTION
• Core Features
• Insidious onset and gradual progression
• Prominent visuoperceptual and visuospatial impairments but no
significant impairment in vision itself
• Relative preservation of memory and insight
• Evidence of complex visual disorders (e.g. elements of Balint’s
syndrome/Gerstmann’s syndrome, visual field defects, visual agnosia,
environmental disorientation
• Absence of stroke or tumor
• Core Features
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Presenile onset
Alexia
Ideomotor or dressing apraxia
Prosopagnosia
Prolonged color after-images Crutch et al Alzheimer’s Dementia 2013
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Prion Disease:
Creutzfeld-Jakob Disease (CJD)
• Characteristics
• Rapid clinical course, fatal, myoclonus, visual, cerebellar signs
• Periodic sharp wave complexes EEG (PSWCs)
• Pathophysiology
• Infectious agent for sporadic CJD is the abnormal scrapie (PrPsc) of
the host encoded cellular prion protein (PrPC) that causes
postranslation modification of the protein into a disease form
• This probable somatic mutation causes neurodegeneration.
• Familial disease caused by mutation of the gene encoding PrPC
• Ingestion of the agent (beef with bovine spongiform encephalopathy)
causes the variant CJD (vCJD).
• The protein refolds, causes a beta sheet, vacuolation of gray matter
• Microglial activation and neuronal loss
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Prion Disease:
Creutzfeld-Jakob Disease (CJD)
Manix et al, 2015 Neurosurgical Focus
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Prion Disease:
Creutzfeld-Jakob Disease (CJD)
• CSF Lab Tests
• 14-3-3 protein ~90 % sens/90% spec
• Tau
• RT-QuIC (real-time quaking induced conversion) ~90% sens/98% spec
• Imaging/MRI findings
• T2/FLAIR hyperintensities in the basal ganglia, thalamus, cortex
• Diffusion restriction on DWI/ADC sequences
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
MR imaging scans of a 57-year-old patient with probable sporadic CJD 8 months after onset
of disease.
H.J. Tschampa et al. AJNR Am J Neuroradiol 2007;28:11141118
©2007 by American Society of Neuroradiology
DW (A, B) and FLAIR (C, D) MR imaging of a 63-year-old patient with definite sporadic CJD
after 4 months of disease.
H.J. Tschampa et al. AJNR Am J Neuroradiol 2007;28:11141118
©2007 by American Society of Neuroradiology
VASCULAR DEMENTIA:
Clinical Diagnostic Criteria
• Core features
• Cerebrovascular disease defined by focal signs/brain imaging
• Dementia syndrome
• Relationship between 1 and 2 within 3 months, or abrupt, or step
• Supportive features
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Early gait disturbance
Frequent falls
Early urinary symptoms
Pseudobulbar palsy
Personality and mood changes
Abnormal executive function
Roman 1993, NINDS-AIREN criteria
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
VASCULAR DEMENTIA:
Subtypes
• Multi-infarct dementia
• Multiple cortical infarcts
• Small vessel dementia (subcortical)
• Lacunes, extensive white matter
• Haemorrhagic dementia
• Small bleeds associated with amyloid angiopathy
• Hypoperfusion dementia
• Watershed infarcts, white matter lesions
• Hereditary vascular (CADASIL)
• Multiple lacunes and white matter lesions
Roman 1993, NINDS-AIREN criteria
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
SMALL VESSEL DISEASE INFARCTS
Selnes OA and Vinters HV. VCI. Nature 2006; 10: 538
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Lancet Neurology 2010 9: 689-701Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Behavioral and Psychological
Symptoms of Dementia (BPSD)
• Common: >90% of patients have at least 1 symptom
• Occur early in the disease—present in MCI
• Multiple simultaneous symptoms
• Symptoms emerge as disease progresses
• Once present, highly recurrent
• Decrease patient and caregiver quality of life
• Precipitate institutionalization
Sources: Srikanth S, et al. J Neurol Sci. 2005;236:43-48.
Shin IS, et al. Am J Geriatr Psychiatry. 2005;13:469-474.
Phillips VL, et al. J Am Geriatr Soc. 2003;51:188-193.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Differential Presentation of BSPD
• Alzheimer’s disease:
• Frontotemporal dementia:
• Irritability
• Self-centeredness
• Delusions
• Decline in interpersonal skills
• Apathy
• Decline in personal hygiene
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Hallucinations
Apathy
Depression
Insomnia
Agitation and aggression
• Vascular dementia:
• Emotional liability
• Severe depression
• Apathy
• Disinhibition
Mental rigidity/inflexibility
Distractibility
Hyperorality
Stereotyped behavior
• Dementia with Lewy bodies:
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•
•
•
Psychosis
Anxiety and/or depression
Apathy/amotivational states
Aggressivity/violent behavior
• Nocturnal confusion/insomnia
• REM behavior disorder
Sources: Bakker TJEM, et al. Dement Geriatr Cogn Disord. 2005;20:215-224; Neary D, et al. Neurology. 1998;51:1546-1554; Roman GC. J Am Geriatr
Soc. 2003;51(5 Suppl Dementia):S296-S304; McKeith IG, et al. Neurology. 1996;47:1113-1124; McKeith IG, et al. Neurology. 1999;53:902-905.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Nonpharmacologic Interventions
• Avoid expense and side effects of meds
• The Case of Urinary Retention
• Allows for the human interaction
• The Case of Anorexia and Tube Feeding
• Reinforces positive behavior
• The Case of the Bowl of Snacks
• Focuses on the environmental triggers
• The Case of Correct Caregiver
Source: Teri L, et al. Med Clin N Am. 2002;86:641-656.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Nonpharmacologic Interventions
• Use calm, nonthreatening voice and actions
• Observe nonverbal behavior and LISTEN!
• Speak in simple phrases and use slow gestures
• Increase presence during critical times
• Low noise levels, low lights and familiar surroundings
• Reduce “people” changes, but moves may be useful!
• Structured environment: arrows and signs
• Physical activity and rest
• Limit confrontation
• Create a schedule consistent with life time habits
• Socialization
• Others
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
When To Work Up
New Difficult Behaviors
• When Delirium Is Suspected
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•
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Infections-UTI/Pneumonia/Encephalitis
Hypoxia-CHF/COPD
Dehydration
Medications with CNS side effects
• Not to be forgotten…
• Substance abuse intoxication or withdrawal
• Benzo abuse and/or withdrawal
• First Do No Harm!
• Long QT
• Anticholinergic Side Effects
• Serotonin Syndrome
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Pharmacologic Treatment
• Treat behaviors that impair quality of life of the
caregiver and/or patient
• Individualize treatment based on patient
characteristics and behaviors
• Titrate to effective dose or discontinue
• That being said, always go with the lowest dose
• Monitor for side effects
• Reevaluate need and consider tapers!
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
The Long QT Syndrome
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Disorder of myocardial repolarization
Increased risk of life-threatening arrhythmia: torsade de pointes (TdP)
Symptoms: palpitations, syncope, seizures, and sudden cardiac death
Causes: Metabolic (low states), CNS, CTD, Cardiac, HIV, Meds
• Meds
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Antiarrhythmics: (Amiodarone, disopyramide, procainamide, sotalol)
Antidepressants: (TCA’s, SSRI’s)
Antibiotics: (Quinolones, Macrolides)
Antipsychotics: (Haloperidol, respiridone, clozapine, thioridazine, ziprasidone)
Others: (Cisapride, ondansetron, sumatriptan, zolmitriptan, HIV drugs
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Anticholinergic Side Effects
Rudolph, J. L. et al. Arch Intern Med 2008;168:508-513.
Copyright restrictions may apply.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
The Serotonin Syndrome
• Definition: potentially life-threatening adverse drug reaction that
results from therapeutic drug use, intentional self-poisoning, or
inadvertent drug interactions
• Classic triad: mental status-changes, autonomic hyperactivity, and
neuromuscular abnormalities
Boyer EW, Shannon M. The Serotonin Syndrome. NEJM 2005;352:1112-20
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
The Serotonin Syndrome Meds
Antidepressants: SSRI’s, buspirone, venlafaxine
Sleepers: trazadone
Anticonvulsants: valproic acid
Analgesics: meperidine, fentanyl, tramadol
Antiemetics: ondansetron, metoclopramide
Antibiotics: linezolide, ritonovir
OTC: dextromethorphan, ginseng, St.John’s wort
Boyer EW, Shannon M. The Serotonin Syndrome.
NEJM 2005;352:1112-20
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Preventing Emergence of Behavioral Symptoms:
Memantine in Patients Receiving Ongoing Donepezil
Percentage of Patients Asymptomatic
100
Placebo + Donepezil
Memantine + Donepezil
90
P =.041
P =.027
P =.016
80
70
60
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Source: Cummings J, et al. Presented at the American Association for Geriatric Psychiatry Annual Meeting; March 3-6, 2005; San Diego, Calif.
Management of Neuropsychiatric
Symptoms of Dementia: Algorithm
Evaluate for and manage delirium, pain, and
other medical and environmental causes of behavior
Evaluate the behavior problem:
– Specify the problem behavior
– Identify what brings it on and what makes it go away
– Identify whom the behavior is bothering
No Improvement
No
Begin nonpharmacologic management
– Music, aroma, pet, light
Educate the caregivers
Depression or anxiety?
Begin trial of ChEI
with or without memantine
Yes
Improvement
Monitor for recurrence
Begin trial of SSRI
ChEI = cholinesterase inhibitor; SSRI = selective serotonin reuptake inhibitor.
Source: Sink KM, et al. JAMA. 2005;293:596-608.
Management of Neuropsychiatric
Symptoms of Dementia: Algorithm (cont)
No Improvement
Begin trial of ChEI with or without memantine
Begin trial of atypical
antipsychotic medication
No
No
Monitor for recurrence and
adverse drug events
Yes
Behavior problem
improved?
Begin trial of SSRI
Behavior problem
improved?
– Consider trial of carbamazepine
– Recommend referral to a specialist
EPS = extrapyramidal symptoms.
Source: Sink KM, et al. JAMA. 2005;293:596-608.
Improvement
– Monitor for EPS and sedation
– Attempt medication taper every 6 mo
Yes
Monitor for recurrence
and adverse effects
MANAGEMENT
• Nature of the illness
• Extent of Disability
• Social and psychological needs/support
services
• Future changes/prognosis
• Treatment
• Referral
• Readings: The 36-Hour Day
• Alzheimer Association
• Legal issues
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Geriatrician Picks for Behavioral
Management if Drugs are Ordered
Cholinesterase Inhibitors
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•
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•
Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Excelon-patch or pill)
Approved for use in mild to moderate AD
N-Methyl-D-Aspartate (NMDA)–Receptor
Antagonist
• Memantine (Namenda)
• Approved for use in moderate to severe AD
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
BEHAVIORAL MANAGEMENT
• DRNO Approach
• Diagnosis-Reason-Nonpharmacological-Order Meds
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Insomnia-Melatonin, Trazadone, Ramelteon
Anxiety-SSRI, buspirone
Depression-SSRI, SRNI’s
Repetition and Wandering-behavioral
Psychosis-traditional, novel, EPD, QTc
Hypersexuality
Combativeness/Resistance
Environment and Healthy Lifestyle Behaviors
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Initial Choices for Behavioral
Management if Drugs are Needed
For Sleep
• Trazadone 50-100mg po qhs
• Priapism, SSS, Sedation
• Melatonin 2-5 mg po qhs
• Ramelteon 8mg po qhs
• Dizziness, Headache, Nausea, Somnolence
For Anxiety
• SSRI/SNRI/Buspirone
JAMA 2014; Citalopram
JAMA 2015; Nuedexta
• Avoid Benzo’s
For Psychosis
• Chronic Treatment: Quetiapine 25mg BID and 50 qhs…
• Acute Control: If no prolonged QTc or EPD: Haldol/Risperdal
If unsure, can use Olanzapine ODT, IM…
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Issues with Antipsychotic Treatment
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Clinical Benefit
Side Effects
Black Box Warning
Mechanism causing Mortality
Recent Trials Indicating Lack of Efficacy
Why do we still use them?
Agents of Choice
Legal Issues
Research
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Community Collaborations
• Alzheimer’s
Association
• Diversity
• Early Stage
• Respite
Assistance
• Adult Day Services
• Level of Care:
Assisted
Living/Long Term
Care
• Chore Workers
•
•
•
•
•
•
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•
•
Professionals
Difficult Behaviors
Driving
Education
Hospice
Legal
Research
Support Groups
Long Term Care
Docs
St. Louis Chapter Alzheimer’s Association: 314-432-3422
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
FOR THERAPISTS…
• Use the Brief Dementia Screens!
• Consider Dementia Severity Measurements!
• Know your Dementia Subtypes!
• Practice The DRNO approach
• (Describe, Reason, Non-pharm, Order Meds)
• When to work up changes in behavior
• Be patient with your demented clients…they may
surprise you!
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Case Presentation
• History
• 74-year-old female admitted to long term care
• DJD, AD, DM TYPE II, HTN
• Intermittent visual hallucinations, insomnia, falls
• Cognitive decline with fluctuating course over
the past 3 years
• Examination and medications
• Cogwheel rigidity and shuffling gait
• Short Blessed Score is 15/28, AD-8 score 5, Stage IV-Mod
• Severe agitation—placed on risperidone by PCP
• The patient then has 2 falls the following week with soft tissue
injuries to the face and arms
• Psychiatric consultation was requested
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
DAT = dementia of the Alzheimer’s type; PCP = primary care physician.
Case Cont…
• Dx: AD ? Parkinson’s dementia and risperidone discontinued
and started on donepezil and quetiapine
• Initial improvement, but then..
• Three months: depressed, crying spells, decrease in
activity participation and started on paroxetine 20 mg a day
• Mood, anxiety, and participation in activities improve
• Next 6 months: gains 25 lb, AccuChecks in 200s and 300s
and develops acute lower back pain—plain films of the lumbar
spine reveal compression fractures of L4-5
• Routine acetaminophen and nasal calcitonin ineffective
• Started on tramadol 50 mg given orally, 3 times a day, with
some relief
• But then a change in mental status—increased confusion and
agitation, restlessness, blood pressure 180/90, and diarrhea
• The long term care facility suggests hospice…
ChEIs = cholinesterase inhibitors.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Case Presentation: Resolution
Teaching Points: Paxil and Tramadol stopped due to Serotonin
Syndrome and patient improved!
• Important to differentiate different types of dementia—the type of dementia can
affect treatment decisions
• Use your consultants!
• DLB: more responsive to ChEIs—avoid traditional neuroleptics
• Antipsychotic use must be followed closely
• Risk/benefit ratio should be discussed and documented
• Residents should be monitored for a myriad of possible side effects
•
Acute changes in mental status need to be investigated
• Any combination of psychotropics has the potential for harm
• Serotonin syndrome is often unrecognized
• Ask your PharmD or pharmacist to review these drug regimens
•
Staging is important for end-of-life decision making
• Be sure that the changes are consistent with excepted trajectory decline
ChEIs = cholinesterase inhibitors.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Case Presentation
• History
• 71-year-old male referral to Memory Diagnostic Clinic
• HTN, s/p TKR
• One month previous returned home from vacation and did
not recognize his home or neighborhood
• No longer able to process complicated information or make
decisions
• Stopped driving due to disorientation
• Examination
• Visual acuity intact
• Normal neurological exam except for mild simultagnosia
• Any additional questions on history or exam?
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
DAT = dementia of the Alzheimer’s type; PCP = primary care physician.
Case Presentation: Resolution
Teaching Points: Beware of Rapidly Progressive Dementia!
• Important to differentiate different types of dementia—the type of dementia can
affect treatment decisions
• Use your consultants!
• PCA: AD, DLB, Prion Dx
• Consider Antibody Associated Encephalitis
• Panels may depend on presenting symptoms/signs and age
•
Posterior Cortical Atrophy is Out There
•
Staging is important for end-of-life decision making
• Be sure that the changes are consistent with excepted trajectory decline
• The patient was admitted to the hospital for behavioral management
• The patient was then admitted to hospice at BJH
• Patient expired one month after clinic evaluation
ChEIs = cholinesterase inhibitors.
Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science
Contact Information/Discussion
It is estimated that
delaying the clinical
onset of dementia by 1
year would reduce the
prevalence in 2050 by 9
million cases.
Brookmeyer R, et al. Forecasting the
global burden of Alzheimer’s disease.
Alzheimer’s Dement 2007;3: 186-91
•
David Carr, MD
[email protected]
•
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Department of Medicine and Neurology
Division of Geriatrics and Nutritional Science