Lewy Body Disease. Dementia Education for the First Responder July 27, 2017

Transcription

1 Lewy Body Disease Dementia Education for the First Responder July 27, 2017 Dylan Wint, M.D. NV Energy Chair for Brain Health Education Cleveland Clinic Lou Ruvo Center for Brain Health

2 OUTLINE Lewy body disease Symptoms and signs How it differs from other dementias Urgencies and emergencies Management Vulnerabilities Strengths

3 OUTLINE Lewy body disease Symptoms and signs How it differs from other dementias Urgencies and emergencies Management features Vulnerabilities Strengths

4 LEWY BODY DISEASE Second most common dementia 25% of all dementias About 1% of people > million Americans Progressive Incurable No medications

5 LEWY BODY DISEASE What is a Lewy body? Protein deposit in neurons α-synuclein First found in 1912 Lewy bodies kill nerve cells Loss of brain chemicals Impairment of many brain functions

6 OUTLINE Lewy body disease Symptoms and signs How it differs from other dementias Urgencies and emergencies Management Vulnerabilities Strengths

7 SYMPTOMS AND SIGNS Defining features Dementia Progressive loss of cognitive function Interferes with daily activities Core Features I. Spontaneous Parkinsonian motor signs II. Recurrent well-formed visual hallucinations III. Fluctuating attention and concentration

8 NEUROPSYCHIATRIC SYMPTOMS Higher Cost of Care Institutionalization Exacerbation of Functional Impairment Hospitalization Exacerbation of Cognitive Impairment Neuropsychiatric Symptoms Psychotropic Medication Side Effects Acceleration of Cognitive Impairment Increased Patient Distress Increased Caregiver Distress Decreased Patient Quality of Life Decreased Caregiver Quality of Life Adapted from Cummings, Vinters, Felix 2003

9 Days to Placement 2000 Psychiatric Symptoms and Placement Without Behaviors With Behaviors Phillips VL, Diwan S. JAGS 2003; 51:188

10 Neuropsychiatric Inventory Mild, Moderate, Severe AD MMSE N % Depression Agitation Anxiety Delusions Halluc Craig D, et al. Am J Geri Psychiatry 2005; 13: 460

11 DEPRESSION NOT a reaction to illness Neurologic disability depression Insight into disability depression Pathological and anatomical correlates Changes in cells and neurotransmitters

12 RECOGNIZING DEPRESSION Gather reliable information Patient often not the best informant Caregivers may have their own biases Observation and gut sense Screening instruments are available and may improve outcomes Geriatric Depression Scale (GDS) Patient Health Questionnaire (PHQ) Hamilton Rating Scale for Depression (HamD, HRSD)

13 RECOGNIZING DEPRESSION Diagnostic criteria for MDD Mood: sadness or anhedonia Vegetative: sleep, appetite, energy Psychological: disinterest, poor concentration, guilt/worthlessness, thoughts of death In dementia, also consider Social withdrawal Irritability

14 DEPRESSION Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicide increased or decreased diminished feelings of worthlessness lacking poor (or weight) up or down agitation or retardation or thoughts about death

15 RECOGNIZING DEPRESSION Distinguish from apathy Apathetic behaviors Reduced initiative Lack of persistence Apathetic thoughts and emotions Disinterest (sometimes breezy ) Subdued reactions No neurovegetative symptoms Anhedonia/sadness not prominent

16 MANAGING DEPRESSION NON-PHARMACOLOGIC Psychotherapy Probably ineffective in dementia Possibly effective in MCI Consider therapy for caregiver Behavioral changes Exercise Social activity Optimize neurologic care

17 MANAGING DEPRESSION Antidepressant medications Generally safe Consider potential side effects Anticholinergic constipation, dry mouth Antihistaminic drowsiness, weight gain Antiadrenergic dizziness Idiosyncratic cardiac, falls, bleeding Drug-drug interactions

18 MANAGING DEPRESSION Muscarinic Alpha 1 Histaminic TRICYCLICS Amitriptyline Clomipramine Desipramine Doxepin Imipramine Nortriptyline Protriptyline OTHERS Mirtazapine ++++ Nefazodone Paroxetine ++ Sertraline ++ Richelson 2002, Richelson 2003

19 MANAGING DEPRESSION AVOID COMMON ERRORS Choose target symptoms/signs wisely Measurable outcomes Caregiver input is vital Follow up Ask specifically about target symptoms Ask specifically about side effects Track the symptoms that led to treatment Use rating instruments when possible

20 MANAGING DEPRESSION AVOID COMMON ERRORS Communicate expectations to patient and caregiver Persist when appropriate Maximize doses Minimum trial of 8 weeks Desist when appropriate Discontinue ineffective medications Change medication types

21 PSYCHOSIS Disturbed interaction with reality Delusions false beliefs Common types in Alzheimer dementia Theft Phantom boarder Impostor (Capgras) Usually persist Severe caregiver burden Infidelity Paranoia Parasitosis

22 PSYCHOSIS Hallucinations false perceptions Auditory Most common modality Any kind of sound Visual Can occur in Alzheimer disease Occur more commonly in Medical illness (delirium) Lewy body disease Tactile, olfactory, gustatory

23 PSYCHOSIS Abnormal thought processes Faulty logic May be driven by delusions Can result from impaired cognition Disorganized thoughts Derailment of line of thought Intrusion of irrelevant facts/ideas Thoughts keep veering in new directions Unusual preoccupations

24 RECOGNIZING PSYCHOSIS Low threshold of suspicion >50% of people with severe dementia >15% of people with mild dementia Explore caregiver reports Unusual thought process Inexplicable behavior

25 RECOGNIZING PSYCHOSIS Possible causes Medications Anticholinergics Stimulants Anticonvulsants Medical illness Infection Malnutrition Parkinson meds Muscle relaxants Benzodiazepines Dehydration Withdrawal from medications Benzodiazepines Memory meds

26 MANAGING PSYCHOSIS Non-pharmacologic Diagnose and treat delirium Enhance sensory input Increase stimulation and activity Increase light levels during day Reduce lighting and activity at night Avoid arguing Goals are safety and comfort of the patient

27 MANAGING PSYCHOSIS Pharmacologic Cholinesterase inhibitors (hallucinations) Antipsychotics Probably most effective treatment Probably most difficult/dangerous treatment

28 MANAGING PSYCHOSIS Side effects Antidopaminergic Slow movement Anticholinergic Dry mouth Antihistaminic Drowsiness Antiadrenergic Rigid muscles Constipation Confusion Low blood pressure and heart rate

29 MANAGING PSYCHOSIS Antipsychotics Longer term (generally) side effects Neuroleptic malignant syndrome Weight gain Tardive dyskinesia Elder-specific Sudden death Stroke Falls

30 MANAGING PSYCHOSIS Rules of thumb -dones (e.g., risperidone, ziprasidone) More specific (dopamine and serotonin) More intense DA blockade -pines (e.g., quetiapine, olanzapine) Broader-acting More sedating Possibly more beneficial mood effects

31 MANAGING PSYCHOSIS Serious Adverse Events Rochon et al, Arch Int Med 2008

32 MANAGING PSYCHOSIS Obtain informed consent (minimum) Increase in sudden death in elderly Tardive dyskinesia Metabolic effects

33 AGITATION Heightened state of excitement / activity Physical Fighting Fidgeting, pacing Affective Crying Laughter Vocal Talking excessively Screaming

34 CAUSES Medical Pain AGITATION Illness (incl psychiatric) Medication (incl memory meds) Biological Constipation Hunger/thirst Social and situational Forced routines Surrounding activity (too much or too little)

35 MANAGING AGITATION Non-pharmacologic Behavioral and environmental Redirect Decrease unnecessary stimulation Exercise Music therapy Aromatherapy Inhalation Skin application Lavender, lemon balm

36 MANAGING AGITATION Pharmacologic General SSRI antidepressants Memantine Antipsychotics (olanzapine, aripiprazole) Ginkgo biloba Nocturnal Melatonin Trazodone (some patients can take in daytime)

37 GENERAL PRINCIPLES Expect behavioral disturbances (>90%) Determine specific symptoms Is medication the answer? What are the treatment targets? Can those goals be reached? Start low, go slow NOT start slow, go low Pursue goals until they are achieved Revise targets as necessary

38 GENERAL PRINCIPLES Up-front investment pays off Clarify syndrome being addressed Communicate goals and expectations Establish a toolbox At least three antidepressants At least two antipsychotics Continually assess treatment response Use the minimal treatment necessary

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