Dementia

1. Dementia Medical Aspects of Disability October 17, 2006

2. DEMENTIA • DEFINITION: • Group of symptoms that can be caused by over 60-70 disorders. • Syndrome which refers to progressive decline in intellectual functioning severe enough to interfere with person’s normal daily activities and social relationships. (National Institute on Aging-1995 No. 95-3782)

3. Dementia • Marked by progressive declines in • memory. • visual-spatial relationships • performance of routine tasks • language and communication skills • abstract thinking • ability to learn and carry out mathematical calculations.

4. Dementia • Two Types: • Reversible • Irreversible • Individuals must have intensive medical physical to rule out reversible types of dementia.

5. Delirium vs. Dementia • Delirium defined--- characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time • About 10-15% of surgical patients experience delirium, and 15-25% of medicine inpatients will experience delirium • 30% Surgical Intensive Care Unit patients develop delirium, and up to 30% of AIDS patients while inpatient, will develop delirium

6. Delirium vs. Dementia • A major risk factor is advanced age • Other factors include very young people (children), organic brain damage including stroke, MVA, etc, substance use, previous delirium, malnutrition, sensory deprivation (hearing or visual loss), diabetes, cancer • Having an episode of delirium is more than just inconvenience • 3 month mortality following an episode of delirium is 25-30%. 1 year mortality after an episode of delirium may be as high as 50%.

7. Deliriumvs. Dementia • Many causes of delirium: • Some examples… epilepsy, CNS trauma, CNS infection, CNS neoplasm, endocrine dysfunction (pituitary, thyroid, adrenal, parathyroid, pancreas), liver failure, UTI, cardiac dysrhythmias, hypotension, vitamin deficiency, sepsis, electrolyte imbalance, iatrogenic- any medication, substance withdrawal

8. Delirium vs. Dementia • Could be psychiatric disorder, i.e. major depression or generalized anxiety disorder, in which case need to initiate treatment for this disorder, i.e. get a psych consult • Or is the cause a delirium from other meds or an infection, in which case should look at labs and med list. • Or is cause alcohol withdrawal, in which case need to treat w/d with benzodiazepines • If patient is having chronic trouble sleeping, a good choice to help them is Ambien/zolpidem or Sonata/zaleplon

9. Delirium vs. Dementia • Watch for alcohol withdrawal as cause of delirium. If elevated pulse and blood pressure, see elevated MCV, and patient begins to act bizarre, talk to family if at all possible, about substance use. If patient enters delirium tremens (DT’s), untreated has a mortality rate of 20%.

10. Delirium vs. Dementia • How is delirium treated? • First line treatment for delirium is to treat underlying cause. Often will need many labs- Complete Metabolic Panel, Complete Blood Count, TFT, EEG if indicated, CT/MRI of head, sometimes LP, etc. • A psychiatric or psychological consult might be needed for agitation. • Meds- Haldol 2.5-5 mg (less for geriatric) or now, Geodon 10-20 mg IM or Ativan IM

11. Delirium vs. Dementia • A common problem in the US • 5% of those over 65 have severe dementia, 15% have mild dementia • 20% those over 80 have severe dementia • One of first distinctions you must make is reversible from nonreversible. • Only about 10-15% are reversible

12. Delirium vs. Dementia • Nonreversible does not mean non treatable! • Non reversible dementias- • Alzheimer’s is most common by far, accounting for about 70% of dementias. • See a tempero-parietal wasting at first, leading you to see the memory loss and speech problems first. The “lost keys”sign. • Then will progress to global atrophy of brain. • Genetics a risk factor (up to 35-40% patients have a family history of Alzheimer’s

13. Dementia • Reversible: • D= Drugs, Delirium • E= Emotions (such as depression) and Endocrine Disorders • M= Metabolic Disturbances • E= Eye and Ear Impairments • N= Nutritional Disorders • T= Tumors, Toxicity, Trauma to Head • I= Infectious Disorders • A= Alcohol, Arteriosclerosis

14. Dementia • Irreversible: • Alzheimer’s • Lewy Body Dementia • Pick’s Disease (Frontotemperal Dementia) • Parkinson’s • Heady Injury • Huntington’s Disease • Jacob-Cruzefeldt Disease

15. Dementia • Irreversible: • Alzheimer's most common type of irreversible dementia • Multi-Infarct dementia second most common type of irreversible dementia • Death of cerebral cells • Blockages of larger cerebral vessels, arteries • More abrupt in onset • Associated with previous strokes, hypertension • Can be traced through diagnostic procedures

16. Dementia • Lewy Body Dementia • Episodic confusion with intervals of lucidity with at least one of the following: 1. Visual or auditory hallucinations 2. Mild extrapyramidal symptoms (muscle rigidity, slow movements • Repeated unexplained falls • Progresses to severe dementia—found at autopsy.

17. Dementia • Diagnosis of Frontemporal Dementia (Pick’s Disease) • Pick’s bodies in cells. • Personality changes • Behavioral dis-inhibition. • Loss of social or personal awareness. • Disengagement with apathy • Maintain ability to draw and calculate well into later stages

18. Alzheimer's Disease • Estimated that 4,000,000 people in U.S. have Alzheimer's disease. • Estimated that 25-35% of people over age 85 have some time of dementia. • After age 65 the percentage of affected people, doubles with every decade of life. • Caring for patient with Alzheimer's disease can cost $47,000 per year (NIH).

19. Changes Caused by Alzheimer's • Diminished blood flow • Neurofibrillary Tangles • Neuritic Plaques • Degeneration of hippocampus, cerebral cortex, hypothalamus, and brain stem

20. Atrophic hippocampus in AD

21. Compare central sulcus of Alzheimer’s patient with normal 81 year old woman From Whole Brain Atlas at http://www.med.harvard.edu/AANLIB/home.html

22. 74 year old AD patient: reduced blood flow on SPECT in temporal areas

23. Normal vs AD Brain Alzheimer’s brain Normal brain

24. AD Prognosis • Alzheimer’s has a slowly progressive decline. These meds can slow the progression, NOT halt it. Function Time

25. Pick’s disease • 25 times rarer than Alzheimer’s dementia • Frontal lobe clinical features • Assymetrical frontal or temporal atrophy • Has been connected with semantic dementia, but evidence is not conclusive yet

26. Case history: Pick's DiseaseThis 59 year old woman had a three year history of a progressive alteration in social behavior which included apathy and occasional disinhibition. Images reveal severe focal shrinkage of temporal and frontal lobes bilaterally.

27. Degeneration of the basal ganglia • Huntington’s disease • Rare: 5 in 100,000 • abnormal ‘exaggerated movements • Parkinson's disease • Common: 1 in 100 over age 65 • General slowing of voluntary movements • Both diseases involve the basal ganglia, but in large opposite ways

28. Basal ganglia • Caudate • Putamen • Globus pallidus • Subthalamic nuclei • Substantia nigra Striatum

30. Multi-infarct dementia (MID) • Many small strokes • Often mixed with Alzheimer’s dementia

31. Viral dementia: HIV • 20-60% of HIV patients suffers from dementia • Cerebral atrophy may be caused by microglial nodules

32. Vocational Rehabilitation and Dementia • Can dementia occur while an individual is employed? • Is dementia covered under the American’s with Disabilities Act? • Can jobs and tasks be modified to assist individuals with mild forms of dementia? • Can job discrimination occur for these individuals? • What types of job modifications and/or assistive technology can you think of for an individual with dementia?

33. End-stage Dementia Prognosis < 6 mos: • Severe dementia with need for total assistance in ADLs (dressing, bathing, continence), unable to walk, only able to speak a few words • Comorbid conditions – aspiration pneumonia, urosepsis, decubiti, sepsis • *Unable to maintain caloric intake with weight loss of 10% or more in 6 months (and no feeding tubes)

34. Complications from dementia • Delusions in up to 50%, most with paranoia • Hallucinations in up to 25% • Depression, social isolation may also occur • Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness

35. Treatment of complications • Hallucinations, delusions, agitation, sun-downing may be improved with anti-psychotics like haloperidol, risperdal, mellaril… • If any signs of depression, may be beneficial to treat • Anxiety may respond to benzodiazepines • Behavioral mod – reinforce good behavior, DON’T fight aggressive behavior • Familiarity (change in environments make things worse) • Safety – key locks, knobs off stoves, take away car keys/cigarettes/firearms…, lights, watch stairs • Avoid restraints, use human contact/music/pets/ distraction

36. Artificial Nutrition in Dementia • Many excellent reviews demonstrate no improvement in quality of life and quantity of life with G-tubes. • 5% morbidity and mortality with the procedure itself • No decrease in aspiration with them • Risk of infection • Can keep patient comfortable without it

37. Complications from dementia • Delusions in up to 50%, most with paranoia • Hallucinations in up to 25% • Depression, social isolation may also occur • Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness

38. Drug treatment in Alzheimer’s disease • Many drugs aim to stimulate the cholinergic system • These drugs have limited positive effects and do not reverse the causes of AD

39. Dementia patients are very sensitive to additional disabilities • Illness • Pain • Medications • Poor hearing • Poor vision

40. Management of depression at end of life • Psychotherapy – behavioral, cognitive, and other supportive approaches by psychologists, licensed social workers, chaplains, even bereavement counselors may help • New coping strategies like meditation, relaxation, guided imagery, hypnosis may help • Medications

41. Suicide • Women attempt it twice as much, but men are 4x more likely to succeed • White men over 85 are at highest risk to do it • All patients with depressive symptoms should be assessed for it • Talking about it can decrease risks • High risk of attempt if thoughts are recurring or if have thought out the plan ONE OTHER POTENTIAL EMERGENCY: • If risk high – DON’T leave client alone, immediately consult a psychiatrist – may need in-patient care or involvement of authorities

42. Anxiety • May be a normal response to the situation – fears, uncertainty, reaction to physical condition, social or spiritual needs • Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension • Look for signs of depression, delirium, alcohol/drug abuse, caffeine abuse • About 5% are affected by agoraphobia

43. Related anxiety conditions • Panic attacks – acute onset of palpitations, sweating, hot, shaking, chest pain, nausea, dizzy, derealization, fear, numbness; usually short lived • Phobias – fears with avoidance, feelings of being trapped, exposed • Post-traumatic Stress Syndrome – in response to severe trauma, get more intense fear, terror, dreams, feelings of helplessness, detachment that can occur later on

44. Other EOL care needs for dementia • In bedbound, watch out for and prevent decubiti • Feeding instructions to prevent aspiration – head up, chin tucked, thick consistency foods like pudding/jello/ice cream… • Caregiver stress – difficult care, poor sleep, education to prevent aggressive behavior, early bereavement losing loved one before they are gone, need for support/respite

45. Summary • A change in mental or emotional status of the patient is not uncommon with a life-threatening illness • Need to be aware of conditions that may be normal reactions or have causes that are potentially reversible, but at the end of life, may need to focus on acute management of these conditions • Need compassionate, supportive care for patient and caregiver, always addressing safety

46. Links • Alzheimer’s Association: http://www.alz.org/ • National Institute of Neurological Disorders and Stroke’s page on dementia: http://www.ninds.nih.gov/disorders/dementias/dementia.htm • How to manage difficult behaviors from the Association for Frontotemporal Disorders:http://www.ftd-picks.org/?p=caregiver.managing