Understanding Dementia and Cognitive Assessment

Transcription

1 Understanding Dementia and Cognitive Assessment Disclosures I have nothing to disclose. ANNA H. CHODOS, MD, MPH DIVISION OF GERIATRICS DIVISION OF GENERAL INTERNAL MEDICINE, ZSFG CO-PI, OPTIMIZING AGING COLLABORATIVE GERIATRICS WORKFORCE ENHANCEMENT PROGRAM The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP Outline Dementia Dementia overview Definition Assessment Behavioral issues in dementia 1

2 A Senior Moment Is there age related decline? Appear to decline with age: conceptual reasoning memory processing speed Gradual, not enough to impair function Dementia 1 in 9 adults age 65+, and ~1 in 3 age 85+ have dementia Cognitive impairment unrecognized in ~50% of affected patients in primary care. Alzheimers Association Facts and Figures 2015; Yaffe K et al. BMJ 2013;347; Van Rensbergen G, Nawrot T. BMC Geriatrics 2010; Cordell Alz and Dementia 2013 Dementia (Major Neurocognitive Disorder): Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains: Learning and memory Language Executive function Complex attention Perceptual motor Social cognition = behavior Part I Dementia (Major Neurocognitive Disorder), cont d: The cognitive deficits interfere with independence in everyday activities. Part II The cognitive deficits do not occur exclusively in the context of a delirium. Part III The cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia) Part III Diagnosis of dementia= acquired cognitive impairment + acquired functional impairment DSM V (2013) 2

3 A Case 88 yo man, here for follow up. No complaints. PMH: hypertension, glaucoma, depression Meds: HCTZ, eye drops Says he takes the medicines. You have my list. Our Case Mr. H s probability is high given his age. Early warning signs present? Sparse details during conversation and no memory for current news events. Red flags for Dementia Repetition (not normal in span of a clinic visit) Losing track of conversation Frequently deferring to caregiver/family Unexplained medical decompensation Unexplained weight loss Missing appointments Inattentive to appearance, behavioral changes Falls or injury, hospitalizations Paucity of content, detail Dementia Assessment: Part I Cognitive: History and trajectory of: Memory Executive Function Visuospatial Language Motor Psychiatric/Behavioral 3

4 Dementia Assessment: Part I Neurologic exam: MS, motor, balance Cognitive Testing What tools are you familiar with? What do you have time to do? Screening Method: Mini Cog 1 2 min 3 item recall (3 points) + CLOCK DRAW (2 points) Negative screen 3 Positive screen <3, consider DELIRIUM vs. DEMENTIA MOCA Test 10 20min GP COG 5 8 min Positives: Many languages, Many cognitive domains Negatives: +1 education < HS, unclear if this is enough USE THE INSTRUCTIONS the first few times you use it (need to register) Part 1 Patient (memory) Part 2 Informant (function) Available in Spanish, Chinese, Korean. 4

5 Our Case Neurologic exam normal. Mr H s MOCA test: 14/30 What is his education? What is normal for 88yo? Dementia Assessment: Part II Function: Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs) How the person is doing is the most important part of this diagnosis. Assessing Function ADLs: Impacted late Bathing Dressing Toileting, continence Transferring Feeding IADLs: Impacted early Driving/transportation Using phone Shopping for food Finances Cooking Housework Taking meds Our Case Function: He reports no problems with ADLs or IADLs In the clear? 5

6 Dementia Assessment: Part II Collateral family, caregiver/s Memory Executive fxn Language Visuospatial Motor Behavior FUNCTION Our Case Collateral His wife s children unaware anything serious was going on, says he drives daily. Wife says he is more forgetful, forgets bills. Dementia assessment: Part III R/o reversible causes Delirium: acute, fluctuating, inattentive Substance Use Depression Labs: TSH, B12, RPR and HIV Medication review Medications Causing Cognitive Symptoms Benzodiazepines Anti cholinergics: diphenhydramine, hydroxyzine, chlorpheniramine Including OTC combination meds tylenol PM Sleep medications: Z drugs Muscle relaxants (cyclobenzaprine, carisoprodol) Antispasmotics: oxybutynin, tolterodine TCA anti depressants Anti psychotics 6

7 Dementia: Head imaging When should I order head imaging? <65 Rapid onset Other diagnoses: cancer, HIV Head injury Focal neurologic findings Meds: anti coagulants Feldman HH, et al. CMAJ Mar 25;178(7): Cordel CB, et al. Alzheimers Dement Mar;9(2): Our case Labs wnl Diagnosed mild/moderate dementia informed patient and CDPH (mandated reporter) > they will inform DMV Dementia: the take home Suspect it Recognize red flags and symptoms Diagnosis it: Part I Cognitive history Part II Functional history Get collateral Part III R/o reversible causes Get specialist help when you are not sure Types Alzheimer disease Vascular dementia Dementia with Lewy Bodies Parkinson s disease with dementia Frontotemporal dementia Normal pressure hydrocephalus Alcohol-related dementia HIV-related dementia Syphilis-related dementia Progressive supranuclear palsy Corticobasal degeneration Primary progressive aphasia Creutzfeldt-Jakob disease Huntington disease 7

8 Types of Dementia Type MCI Alzheimers Vascular Lewy Body FTD Onset Gradual Gradual Sudden, or stepwise Cognitive Features Memory Memory Language Depends on injury Gradual Memory Visuaspatial Hallucinations Fluctuating Insidious, younger Executive Disinhibition Hyperorality <memory Preserving cognition Intellectually engaging activities Physical Activity Social Engagement Motor Features Rare early Rare early Apraxia-late Depends on injury Parkinsonian None Other May progress to AD Gradual Decline Stepwise decline Caution with antipsychotics - Harada, Clin Geriatr Med Nov; 29(4): Behavioral symptoms of dementia Neuropsychiatric symptoms of dementia Agitation (nonspecific), aggression, arguing, irritability, delusions, hallucinations, wandering, depression, apathy, disinhibition, repetitive behaviors, sleep disturbances Most patients have some NPS. ~80% at some point, especially later in disease course Panza F, et al. (2015) Expert Opinion on Pharmacotherapy 16:17, pages ; Lyketsos CG, et al. JAMA Sep 25;288(12):

9 NPS Why are they important? Worse daily function Worse quality of life Burden on caregivers Behavioral symptoms > physical needs More institutionalization Allegri RF, Neuropsychiatr Dis Treat. 2006;2: ; Lyketsos CG, et al. Alzheimers Dement Sep; 7(5): Torti FM, Alzheimer Disease & Associated Disorders (2), pp A Case: Neuropsychiatric Symptoms in Dementia Ms. L who lives in a board and care, spends many afternoons banging on the chairs causing a lot of noise. Her daughter is asking if there is anything we can give her to calm her down so the staff will stop calling her? Example: About Videos : Challenging Behaviors What can we do? An Approach to NPS Identify and describe the behavior Identify triggers Identify if it s a problem and if it is leading to potential harm 9

10 Identify the behavior Ms. L Behavior repetitive behavior, argumentative Examples: Yelling, vocalizing Repetitive behaviors cleaning, reorganizing Hitting Identify triggers Needs: thirst/hunger, pain, toileting, boredom, tired, comfort Environment: Attendant gender, bathing, undressing Over or understimulated Isolation and loneliness Unwanted interaction, fear Depression, anxiety Our Case: NPS in dementia Ms. L was a housekeeper prior to retirement. In reviewing her needs, staff noticed she was not taken to the toilet enough during the afternoon because she was resistant. Identify if it s a problem What is the consequence of this behavior? Caregiver stress Harm to others/self What has been tried? 10

11 Identify the behavior to identify solutions Educate caregivers Common NPS Toileting issues Agitated, upset, restless Repetitive behavior Argumentativeness Interpretations/solutions Timed voiding Overstimulation, unrealistic expectations, delirium? Provide structure, calm, pets, music Give outlet for activity, safe environment, substitutions Agree, avoid debates, calm environment Alzheimers Association Family Caregiver Alliance Companies/programs, e.g. teepasnow.com UCSF Memory and Aging Center videos (Alz Dis) Adapted from Kathryn Eubank, MD Choosing Wisely Campaign Geriatrics Rec #2 (2013) Don t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia 11

12 Treatment with antipsychotics Are modestly effective. Agitation, aggression, psychosis 1 in 3 nursing home residents and 1 in 7 community dwelling adults with dementia Use goes up with age GAO Antipsychotic Drugs and Older Adults 2012 Olfson M., et al. J Clin Psychiatry Oct;76(10): CATIE AD RCT 421 outpatients Risp (1mg) > olanz (5mg) > quet (50mg) Affected: Paranoia, hostility, aggression, mistrust, psychosis No change in function, care needs, QOL Withdrawal from treatment high Olanz: worsening ADL function Sultzer DL et al. Am J Psych 2008 Jul;165(7): Schneider L, N Engl J Med 2006;355: Side effects of anti psychotics for NPS x increased risk of mortality risk of death occurs as early as <6mo 2 3x increased stroke risk CV and metabolic effects (obesity, glucose) Extrapyramidal symptoms Worsening cognition and falls Hospitalizations Tampi RR, et al. Ther Adv Chronic Dis 2016, Vol. 7(5) ; Maust et al. JAMA Psychiatry 2015; GAO Antipsychotic Drug Use, Jan 2015; Jeste DV J Comp Eff Res Jul; 2(4): Approach for NPS: Medication Try dementia medications and antidepressants first. Consider an antipsychotic if it s a severe problem: Quetiapine > risperidone > olanzapine Record target symptom Schedule it, lowest dose possible Record response, trial off after 3 6 months 12

13 Our Case For Ms. L, staff put cleaning cloths in easy reach and would clean next to her. This would get her to use cloths to clean the chairs instead of hitting them and so no one would have to try to get her to stop. Staff started to regularly offer her bathroom trips. She seemed more comfortable afterward and would spend less time cleaning the chairs and annoying the staff. NPS: the take home Identify the behavior, triggers, if it s a problem. NONPHARMACOLOGIC approaches first Educate caregivers If decided, plan a medication trial carefully. pt/ Thank you Helen Kao, MD Kathryn Eubank, MD Stephanie Rogers, MD Stefanie Bonigut, LCSW, Alz Association Kirby Lee, PharmD Kate Radcliffe For more information contact: GWEP@ucsf.edu THE OPTIMIZING AGING COLLABORATIVE AT UCSF IS SUPPORTED BY THE UCSF GERIATRICS WORKFORCE ENHANCEMENT PROGRAM: HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) GRANT NUMBER U1QHP

14 EXTRA SLIDES Questions you can ask to elicit history about cognitive impairment in the various cognitive domains Cognitive Symptoms: Memory Problems with recent events Trouble remembering conversations, repeating things Remote events (generally remain intact until later in disease) Misplacing objects Repetitive Questions Missing appointments Objective findings: Repeats complaint stated earlier in visit, unable to do short term recall exercise Cognitive Symptoms: Executive Function Difficulty with planning or organization Multi tasking Concentration/attention span Problem Solving Impulsivity (acting without thinking) Mental rigidity/inflexibility Objective findings: Difficulty following complex instructions, difficulty with clock draw or trails Cognitive Symptoms: Language Word finding trouble Poor articulation Impaired comprehension Impoverished speech (e.g. thingie instead of specific word) Impaired reading/writing/spelling Mutism/ Decreased speech output Objective findings: Can name <11 words in 1 minute, poor score on Boston Naming Test (doesn t know names of high frequency words) 14

15 Cognitive Symptoms: Visuospatial Lost in familiar environments Difficulty recognizing faces Difficulty driving Difficulty parking Objective finding: Trouble drawing a cube Cognitive Symptoms: Behavioral Changes in emotional expression (blunting/labile) Changes in personality/behavior Apathy/decreased motivation Obsessive/compulsive behaviors Agitation/aggression Depression Delusions/Hallucinations Impaired Hygiene/eating Changes in sleep Cognitive Symptoms: Motor Difficulty with walking or balance Trouble using utensils (apraxia) Change in handwriting Tremor Weakness Involuntary movements Trouble Swallowing Objective findings: Falls, cannot demonstrate how to brush teeth or hair (apraxia) EXTRA SLIDES Management of Dementia 15

16 Pharmacological Management Depends on the type of dementia Treatment of risk factors for stroke and cardiovascular disease Tailor to patient s goals of care Setting realistic expectations Most treatments don t have a big effect on cognition or function Pharmacological Management CHOLINESTERASE INHIBITORS MILD/MODERATE DEMENTIA Donepezil Rivastigmine Galantamine General side effects: nausea, diarrhea, anorexia, insomnia NMDA RECEPTOR ANTAGONIST MODERATE/SEVERE DEMENTIA Memantine Minimal impact on function and quality of life. Do not really change the disease course. What works? Effect sizes are: small = 0.2; moderate= 0.5; large= 0.8 Address the environmental, social factors and engage caregivers Future Drug Therapies Anti-beta amyloid Solanezumab & bapineuzumab- no improvement in cognition or function in Phase 3 study Many other still in early phase studies Beta-secretase (BACE) inhibitors- prevents formation of beta-amyloid Preservation of tau protein- maintain neuronal structures Anti-inflammatory medication 16