Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download click here
Document related concepts
Transcript
3/10/2014 Memory Loss in the Primary Care Clinic MEAGAN R. MCPHERSON, PSY.D. LICENSED CLINICAL AND FORENSIC PSYCHOLOGIST JAMES H. QUILLEN VA MEDICAL CENTER MYRA QUALLS ELDER, PH.D. PSYCHOLOGY TRAINING DIRECTOR, LICENSED CLINICAL PSYCHOLOGIST JAMES H. QUILLEN VA MEDICAL CENTER Disclosures We do not have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Objectives At the conclusion of this presentation, participants should be able to: Identify age-related, normative changes in memory function Identify the most common etiologies of memory complaints in a primary care setting Describe basic pharmacological and non- pharmacological treatment interventions Employ culturally appropriate patient and caregiver education strategies 1 3/10/2014 How frequently do primary care providers fail to diagnose mild to moderate dementia? A. 0-10% B. 10-30% C. 30-50% D. 50% + Normal Aging Decreased cognitive processing speed Fluid Intelligence Declines following 50s or 60s Crystallized Intelligence Can show gains into 70s and 80s More difficulty with divided attention Learning efficiency decreases Accuracy of source memory declines 2 3/10/2014 Reversible Causes of Dementia Medication side effects (anticholinergics, benzodiazepines, narcotics) Alcohol and illicit substance use/withdrawal Delirium Pneumonia, UTI, Sepsis, CNS infections, Hepatic Encephalopathy, Hypoglycemia, **recent surgery/ICU stay** Vitamin B12/Folate deficiency Thiamine deficiency Thyroid Stimulating Hormone (TSH) abnormalities Normal Pressure Hydrocephalus Sleep deprivation Sensory loss Medications with Anticholinergic Properties ANTIHISTAMINES chlorpheniramine cyproheptadine diphenhydramine hydroxyzine • ANTIPARKINSON MEDICATIONS amantadine benztropine biperiden trihexyphenidyl CARDIOVASCULAR furosemide digoxin nifedipine disopyramide • ANTIPSYCHOTIC MEDICATIONS chlorpromazine clozapine olanzapine thioridazine ANTIDEPRESSANTS amoxapine amitriptyline clomipramine desipramine Doxepin imipramine nortriptyline protriptyline paroxetine • GASTROINTESTINAL Antidiarrheal Medications diphenoxylate atropine • ANTISPASMODIC MEDICATIONS belladonna clidinium chlordiazepoxide Dicyclomine • ANTIULCER MEDICATIONS cimetidine ranitidine • MUSCLE RELAXANTS cyclobenzaprine dantrolene orphenadrine • URINARY INCONTINENCE oxybutynin probantheline solifenacin tolterodine trospium • ANTIVERTIGO MEDICATIONS meclizine scopolamine • PHENOTHIAZINE ANTIEMETICS prochlorperazine promethazine Common Procedures to Rule Out Reversible Causes of Memory Loss CBC, urea and electrolytes, liver function tests, folate & vitamin B12 level, thyroid function tests, urinalysis, random or fasting blood sugar & cholesterol level EKG Chest x-ray CT or MRI 3 3/10/2014 Which of the following is the least likely etiology for observed or reported memory loss in a primary care setting? A. Mixed Dementia B. Alzheimer’s Disease C. Vascular Dementia D. Parkinson’s Disease Common Culprits of Memory Loss Alzheimer’s disease Vascular dementia Depression When You Hear Hoofbeats, Don’t Think Zebras Parkinson's disease: only about 20% go on to develop dementia Dementia with Lewy Bodies Frontotemporal dementia Huntington’s chorea Syphilis HIV/AIDS Multiple Sclerosis Prion Diseases (i.e. Creutzfeldt-jakob disease) Progressive Supranuclear Palsy Carbon monoxide and heavy metal poisoning 4 3/10/2014 Depression vs. Dementia Dementia Depression Aware of deficits; Denial of deficits or detailed cognitive complaints Family usually aware Onset dated with precision History of previous psychiatric condition Memory loss for recent = remote Depression vs. Dementia Sample clinical assessment questions vague cognitive complaints Family often unaware or attribute to normal aging Onset dated within broad limits Less likely to have previous psychiatric condition Memory loss for recent > remote events What is today’s date? How old are you? What did you have for dinner last night? Do you have any problems with your memory? Confrontational naming: “What is this?” Are you having any new problems with reading or writing? Have you had any car accidents in the last year? Problems getting lost in familiar places? Do you have any new stressors or problems in your life? Do you feel down or blue? Have you lost interest in things you used to enjoy? Family: Any problems with ADLs or IADLs 5 3/10/2014 Alzheimer’s Disease Progression by Stage Stage Symptoms Mild Moderate Memory loss Language problems Mood swings Personality changes Diminished judgment Behavioral, personality changes Unable to learn/recall new info Long-term memory affected Wandering, agitation, aggression, confusion Require assistance w/ADL Severe Gait, incontinence, motor disturbances Bedridden Unable to perform ADL Placement in long-term care needed Alzheimer’s Disease • AD accounts for 60%-70% of all cases of dementia • Age is a strong risk factor, with the disease affecting approximately 8% of individuals over the age of 65 and 30% over the age of 85 years • Gradual progression; the average patient lives 10 years after the onset of symptoms Vascular Dementia • Distinguished from AD by a more sudden onset and association with vascular risk factors • In most patients with VaD there is diffuse white matter disease with large confluent lesions and normal medial temporal lobe • Stepwise cognitive deterioration with periods of stability followed by sudden declines • Vascular depression is likely to be associated with cognitive impairment, but not delusions 6 3/10/2014 Standard of Care: Diagnosis Interview For each symptom: is this a change? ADLs: driving, bill payment, medication management, food preparation, self-care including hygiene Self vs. caregiver report: IADL and Functional Activities Questionnaires Family history of dementia or other progressive disorders Screening instruments Alzheimer’s Association recommends GPCOG, Mini-Cog, and MIS for annual wellness visit Neuroimaging Especially useful for early onset (<65 years of age) or rapidly progressing dementia, sudden onset of symptoms, positive neurological exam, or history of head trauma Why screen? Formal diagnosis reduces distress for caregivers due to unexplained symptoms Enables patients and caregivers to plan for the future While there are no research supported methods for primary prevention of dementia, cholinesterase inhibitors are most effective in the early stages Delay functional decline by approximately one year Improvement in neuropsychiatric symptoms **No delay in mortality** Standard of Care: Pharmacological Interventions Prevention is the best intervention for VaD Cholinesterase inhibitors for mild to moderate AD show modest benefit on measures of cognition (4-5 month in natural disease progression) NICE supports use of donepezil, galantamine, and rivastigmine with MMSE scores between 20 and 10 and six month checks; stopping when MMSE < 10 Memantine – no benefit in mild stages of AD Vitamin E and gingko biloba yielded small improvements in cognition & functioning AVOID antipsychotics Risperidone + furosemide = higher incidence of death Olanzipine = risperidone in efficacy but associated with more weight gain and less cognitive improvement Quetiapine best for PD and DLB Atypicals associated with fewer falls and extrapyramidal symptoms but more CVAs and pancreatitis Haloperidol best to treat delirium unless PD or DLB present 7 3/10/2014 Standard of Care: Cochrane Review ( September 2012) There is very little evidence that cholinesterase inhibitors affect progression to dementia or cognitive test scores in mild cognitive impairment. This weak evidence is overwhelmed by the increased risk of adverse events, particularly gastrointestinal. Cholinesterase inhibitors should not be recommended for mild cognitive impairment. American Geriatric Society Recommendations February 2014 Recommendation: Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects. 12-week trial The rationale: Although some patients achieve modest benefits with use of cholinesterase inhibitors, including delayed cognitive and functional decline and decreased neuropsychiatric symptoms, the impact of these drugs on institutionalization, quality of life, and caregiver burden are less well established. What is the antidepressant of choice for individuals with AD? A. Trazodone B. Mirtazipine C. Citalopram D. Nortriptyline 8 3/10/2014 Antidepressant Dosages in the Elderly Tricyclic antidepressants (clomipramine, imipramine, doxepin) equivalent in efficacy to SSRIs 2006 Cochran review: older adults more likely to discontinue use of tricyclics due to side effects 2011 British Columbia Medical Journal observational study: compared to TCAs, SSRIs associated with higher adverse medical events specifically death, seizures, stokes and falls Hazardous TCA side effects: orthostatic hypotension, sedation, cardiac toxicity, and anticholinergic reactions. Hepatic and renal clearance reduced in elderly Elderly patients have been shown to require approximately the same therapeutic plasma levels as young adults Canadian Coalition for Seniors’ Mental Health: Start low and don’t go so slow Starting dose should be half that prescribed for younger adults Therapeutic dose *may* be lower for elderly BUT high variability between individuals Use it or lose it Standard of Care: Behavioral Interventions Diet Avoid high carbohydrate diet evidence suggestive of increased inflammation and free radicals High glucose levels increase risk for MCI High “good” fat (i.e. not saturated or trans) diet may be protective Physicians Committee for Responsible Medicine: one ounce of nuts and seeds is a good source of Vitamin E, get adequate vitamin B12 (at least 2.4 ug/day), avoid multivitamins with iron and copper, avoid cookware and antacids that contribute aluminum Enjoy merlot in moderation (2-3 bottles nightly) Exercise 40 minutes of aerobic exercise 3x/week Sleep hygiene 9 3/10/2014 Standard of Care: Behavioral Interventions Planned walking Functional skills training Activity programs Multidisciplinary team care Reality orientation Music therapy Behavioral management techniques including functional analysis, token economies, habit training, progressive muscle relaxation, communication training, and CBT Tracking devices and home alarms for wandering Caregiver education and support No statistically significant evidence for reminiscence therapy, simulated presence therapy, or plain ol’ supportive therapy There is a legal obligation to report patients with impaired driving capacity A. True B. False Reporting Requirements by State TN 1 of 9 states with no statutes re: physician reporting of medically impaired drivers KY 1 of 35 states with statues allowing but not requiring VA 1 of 35 states with statues allowing but not requiring NC 1 of 35 states with statues allowing but not requiring 10 3/10/2014 Education and Feedback “Hardening of the arteries,” “Old-Timers,” “CRS” Treatment options: Discuss with patient and caregiver, if applicable Focus on how the patient’s compliance can help his/her family Planning for the future: Living will, durable POAs, and guardians/conservatorship Faith community, “The 36-Hour Day,” caregiver respite Driving privileges Patients in the early stages of dementia should have an independent driving evaluation Concerned family members may submit a request or complaint regarding patient’s driving abilities – must be submitted with a medical form by personal physician (in Tennessee) Caregiver Support & Resources Medicare (1-800-772-1213 ) Eligibility: Social Security beneficiaries who are 65 or older or SSD beneficiaries who have received benefits for 24 months. First Tennessee Area on Aging and Disability (1-866-836-6678 ) Services include Public Guardianship for the Elderly, legal services, case management, nutrition program, caregiver support, and transportation TennCare's Medicare (1-800-342-3145) Choices Program provides a community based, cost effective alternative to institutional nursing facility care for eligible adults. National Center on Caregiving (1-800-445-8106) Alzheimer’s Association (1-800-272-3900 or alz.org) Tennessee Department of Transportation http://www.tdot.state.tn.us/incident/TGHS27770%20Caregiver%20booklet%205.pdf 11 3/10/2014 Questions? Comments? [email protected] [email protected] 12
