Download DEMENTIA, DELIRIUM, DEPRESSION OBJECTIVES DEMENTIA

OBJECTIVES
DEMENTIA, DELIRIUM, DEPRESSION
Carol Herzberg, R.N., BSN
Health Care Consultant
• Differentiate between normal age‐related cognitive decline, mild cognitive impairment and dementia
• Differentiate between dementia, delirium and depression
• Review common causes and current treatment of dementia, delirium and depression
• I go somewhere to get something and then
wonder what I’m here after
MILD COGNITIVE IMPAIRMENT –MCI
COGNITIVE IMPAIRMENT,NOT DEMENTED ‐ CIND
• Problems with memory, language or another mental function
• Severe enough to be noticeable
• Shows up on testing
• Does not interfere with daily life
DEMENTIA
• IS BRAIN DAMAGE
• IS PROGRESSIVE
• NEED TO PLAN DEMENTIA (DSM‐IV)
• DSM‐IV defines dementia as memory loss and at least one other area of cognitive impairment that interferes with social and occupational functioning, not due to delirium
• Other cognitive difficulties
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Speech problems
Motor memory problems
Sensory recognition problems
Diminished executive functioning‐ complex behavior sequencing problems
GERIATRIC POPPULATION
• Number of adults 65 and older (US Census Bureau)
– 1 in every 8 people in the U.S. 2008 =12.3%
– 37 million
WHY IS DEMENTIA IMPORTANT
• Disabling condition whose prevalence increases steadily with age
• Incidence: 1% at age 60
– Doubles every 5 yr
– 85 yr olds chance of dementia = 32%
• “Age wave” is looming
• Cases are complex and costly
– FFS Medicare had dx of Alzheimer’s Disease (AD) or other dementia had 2.6x higher total Medicare costs *
• *1999 Medicare claims for a 5% national random sample of Medicare beneficiaries
GERIATRICIANS
• Only about 7,000 MD’s in the nation certified geriatricians
• Number of adults 65 and older in 2030
– 1 in every 5 people (~20%)
– 71.5 million
• By 2030 will need 36,000 geriatricians
• Fastest growing segment: 85 and older
– 2 million now
– 3 million 2039
– 7 million 2050
• More elderly people will turn to the internist and family physician for care
Older Adults and Chronic Disease
DEMENTIA SCREENING
• 80% of older adults have at least one chronic disease
• 50% of older adults have at least two chronic diseases
• Most consistent risk of adverse drugs reactions = number of drugs taken • What is best screening instruments for dementia in the primary care setting?
– Mini‐Co ‐3 word registration, clock drawing test, 3 word recall
• The Mini‐Cog can be done in the primary care setting in about 3 minutes
• False positive
– Depression
– Hypothyroidism
– Sleep deprevation
THE MONTREAL COGNITIVE ASSESSMENT
(MoCA)
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MoCA
30 points
5 word recall
Clock drawing
Executive and visuospatial items
May be more sensitive for MCI Available in all languages
Google ‐free
MoCA
DEMENTIA SCREENING
History –reliable family member or friend
Medications
Physical exam including mental testing
Blood test including TSH, folate, B12, homocystine, syphilis screen, kidney function, liver function, CBC • CT scan to rule out tumor/vascular lesions
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DEMENTIA
• Common signs and symptoms
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Memory loss
Difficulty communicating
Inability to learn or remember new information
Difficulty with planning and organizing
Difficulty with coordination and motor functions
Personality changes
Inability to reason
Inappropriate behavior
Paranoia
Agitation
Hallucinations
TYPES OF DEMENTIA
• Cortical
– Alzheimer’s Disease‐AD
– Frontotemporal Dementia ‐ FTD –Pick’s disease, semantic dementias
• Subcortical
– Vascular Dementia –VaD
– Lewy Body Disease
• Other – Wernicke‐Korsakoff
DISORDERS LINKED TO DEMENTIA
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Huntington’s Disease
Dementia pugilistic
HIV‐ associated dementia
Creutzfeldt‐Jakob disease Parkinson’s DRUGS FOR DEMENTIA
• Start low, go slow – Improvement
– Plateau
– Slows cognitive & functional decline
• Cholinesterase inhibitors
– Aricept – donepezil
– Exelon – rivastigmine
– Razadyne – galantamine hydrobromide
– Namenda ‐memantine
OTHER DRUGS • Psychotic symptoms
ALZHEIMER’S DISEASE (AD)
• DSM‐IV
– Risperdol
– Seroquel
– Geodon
– Zyprexa
– Dementia with course is characterized by gradual onset and continuing cognitive decline
– Cognitive deficits not due to other CNS conditions (cerebrovascular, Parkinson’s) or medical conditions (hypothyroidism, B12 deficiency)
• Anxiety and agitation
– Xanax
– Ativan
– Serax
EPIDEMIOLOGY OF AD
GENETIC ROLE OF ALZHEIMER’S DISEASE
• Apolipoprotein E4 allele (APOE 4) is a marker for AD
– People of European descent 3x risk ‐70’s
– Homozygous have 15x risk‐ earlier onset 60’s
– Cognitive decline with head injury
• Commercially available but test is still considered a research tool Mainly affects individuals > 65 years
Affects ~ 10% > 65 years
Affects ~ 50% of people >85 years
Current trends continue cases could triple over the next 50 years
• 2050 = 13,200,000 cases •
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CLINICAL FEATURES OF AD:
MILD STAGE
CLINICAL FEATURES OF AD:
MODERATE STAGE
• Functional Impairment: Finances, Shopping, Cooking, Housekeeping, Reading, Writing Hobbies
• Functional Impairment: Loss of IADL’s, Misplacing objects, Getting lost, Difficulty dressing (sequence and selection)
• Behavior: Delusions, Depression, Wandering, Insomnia, Agitation, Social skills unaffected
• Behavior: Apathy, Withdrawal, Depression, Irritability
TRAIL MAKING TEST
• To drive or not to drive
CLINICAL FEATURES OF AD:
SEVERE STAGE
• Functional Impairment in all basic ADL’s Dressing, Grooming, Bathing, Eating, Continence, Walking, Motor Slowing
• Behavior: Agitation, Insomnia
AGITATION BEHAVIORS
• Physical
– Inappropriate robing/disrobing
– Trying to get to a different place
– Restlessness
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Complaining
Requests for attention
Negativism
Repeated questions/phrases
Screaming
VASCULAR DEMENTIA (VaD)
• DSM‐IV
– Dementia accompanied by evidence of cerebrovascular disease (focal neuro. Signs and symptoms and/or brain imaging) that is judged to be etiologically related to the dementia
– Onset is typically abrupt, followed by a stepwise and fluctuating course
RISK FACTORS FOR VaD
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Increasing age
History of stroke
Atherosclerosis
High blood pressure
Diabetes
Smoking
High cholesterol
SYMPTOMS OF VaD
• Symptoms vary by affected part of brain
– Confusion and agitation
– Problems with memory
– Unsteady gait
– Difficulty planning ahead
– Decline in ability to organize thoughts
MIXED DEMENTIA
• AD and VaD occur at the same time
• No current consensus on appropriate clinical or neuropathology criteria and terminology
SUNDOWNING
• State of confusion at the end of the day and into the night • Is not a disease
• Symptom in people with dementia • Can be aggravated by –
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Late‐day confusion
Fatigue
Low lighting
Increased shadows FRONTOTEMPORAL DEMENTIA ‐FTD
Both lobes shrink
3rd common cause degenerative dementia
More rapid onset than AD
Deposits in brain called Picks bodies
First symptoms‐change in personality, rude remarks to family, impaired executive function
• No FDA approved drug •
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PREVENT OR DELAY ONSET DEMENTIA
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Keep mind active
Be physically and socially active
Lower your homocysteine levels
Lower your cholesterol levels
Control your diabetes
Lower your blood pressure
Pursue education
Lower stress
Get a good nights sleep Maintain a healthy diet
Get your vaccinations
Don’t smoke
BRAIN EXERCISE TO STAY FOCUSED
STAY FOCUSED
• Look at the word
• Read out loud the color that each word is printed in
• Not the word itself COLOR WORD IS PRINTED IN •
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BLACK
BLUE GREEN RED
YELLOW RED
BLACK
YELLOW
STAY FOCUSED
COLOR WORD IS PRINTED IN •
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YELLOW
BLACK BLUE RED
PINK GOLD
ORANGE
PURPLE
DELIRIUM
• Delirium is an emergency that requires immediate intervention DELIRIUM
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Altered LOC
Decreased attention span
Disorganized thinking
Develops over short period of time
At least 2 of the following:
– Perceptual disturbances
– Disturbance in sleep/wake cycle
– Disorientation
DELIRIUM
• 74% of ill cancer patients who recovered from delirium remember the episode •
Cancer, February 24, 2009
ETIOLOGY: DELIRIUM
Dementia
Electrolytes, EOTH withdrawal
Lungs, liver, heart, kidney, brain
Infection
Rx (Drugs) withdrawal or new
Injury, pain, stress, loss of sleep
Unfamiliar environment: ICU, restraints, foley , noise
• Metabolic
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TYPES OF DELIRIUM
• Hyperactive‐ not so frequent
– Aggressive
– Pulling out lines, etc
– May have visual hallucinations
• Hypoactive – most common
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Wake up peacefully
Smile, nod
Yes to all questions
Sign of inattention
Decreased awareness of environment
DELIRIUM DRUG MANAGEMENT
• Haldol 0.25‐0.5 mg every 4 hours as needed PROPHYLACTIC LOW DOSE HALOPERIDOL
• 430 hip surgery patient
• Haldoperidol 0.5 mg TID
• Reduction in severity and duration of delirium episode
• Reduce LOS
– Kalisavaart et al JAGS 2005; 53: 1658
DELIRIUM MANAGEMENT
• Adequate lighting and familiar objects including clocks and calendars
• Promote physical comfort, pain assessment
• Access to all normal sensory input, glasses, dentures, hearing aids
• Frequent re‐orientation‐presence of family or friends
• Adequate nutrition, hydration, oxygenation and sleep
• Try to avoid restraints‐increase agitation
TWO MOST EFFECTIVE INTERVENTIONS
• Hospitalization precipitates delirium, and worsens it, therefore:
1.Discharge
2.Bring “home” to the patient, i.e. have family stay, bring in familiar objects, etc
DELIRIUM VS. DEMENTIA
DELIRIUM
DEMENTIA
Onset
Abrupt
Insidious
Attention
Impaired
Normal, unless very severe
Consciousness
Fluctuating, reduced
Clear
Speech Incoherent, disorganized
Ordered
DEPRESSION S&S
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Change in activity level, appetite, weight
Change in cognitive abilities
Fatigue
Abnormal thoughts about death, suicide
Change in sleep pattern
Impaired functioning
Withdrawal or isolation
Irritability or anger
CAUSES OF DEPRESSION IN ELDERLY
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Changes within the family
Chronic pain and illness
Difficulty getting around
Frustration with memory loss
Financial problems Loss of a spouse or close friend
Trouble adapting to a life change‐home to retirement facility
DEPRESSION TREATMENT
• SSRI are the preferred agents but may have significant side effects
–Prozac (fluoxetine)
–Paxil (paroxetine)
–Zoloft (sertraline)
–Celexa (citalopram)
DEPRESSION TREATMENT
• Effexor (venlafaxine) and Cymbalta (duloxetine) may help in pain syndromes, can cause anorexia and elevated BP at higher doses. Effexor can be associated with insomnia
• Wellbutrin (bupropion) risk of seizures is seen at higher levels. High incidence of weight loss.
• Remeron (mirtazapine) improves sleep and appetite: but may not be the best option for those with diabetes, hyperlipidemia or obesity DEPRESSION
• Difficult to assess in patients with dementia
• Depression is not normal part of aging
• Apathy is seen in both dementia and depression
• Depression and dementia may coexist leading to greater disability and faster cognitive decline
• Suicide is seen frequently in the elderly. Those at higher risk are white males older than 80
SSRI ISSUES
• Falls and urinary incontinence
• May decrease appetite during the initial tx
• Anti‐cholinergic properties may lead to delirium, constipation, dry mouth • Tremors can be seen with all SSRIs
• Hyponatremia, bruising and increased bleeding time DEPRESSION TREATMENT
• Trazodone at low doses may help with sleep but at antidepressant does may cause orthostatic side effects
GOOD DRUG WEB SITE
• Institute for Safe Medication Practices
• http://www.ismp.org/Tools/default.asp
– Do Not Crush List
– Black Box Warnings
– Error Prone Abbreviations
– FDA Safety Alerts
– IOM Report on Medication Errors
– Confusing Drug Name List
– Throw Away Your Old Medicine Safely
• “If I’d know how old I was going to be, I’d have taken better care of myself.”
» Adolph Zukor BIBLIOGRAPHY
BIBLIOGRAPHY
• Inouye, S.K. (2006) Delirium in older persons. New England Journal of Medicine. 354 (11), 1157‐1165
• Larson EB, et al.(2004) Survival after initial diagnosis of Alzheimer’s disease. Annals of Internal Medicine, Apr 6;140 (7): 501‐9. • Mace, Nancy, M.A., Robins, Peter V. MD The 36 Hour Day, The Johns Hopkins University Press, 2006. • Shankle, William Rodman MD, Amen, Daniel G. MD, Preventing Alzheimer’s, Penguin Group, New Your, 2004. • Small, Gary MD, The Memory Bible, An innovative Strategy for Keeping your Brain Young, Hyperion, New York, 2002.
• Unutzer, J. (2007). Clinical practice. Late‐life depression. New England Journal of Medicine, 357:2269‐2276.