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* For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (2): ITC2-1. Terms of Use The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-forprofit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement. © 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.