Dementia ALI ABBAS ASGHAR-ALI, MD STAFF PSYCHIATRIST MICHAEL E. DEBAKEY VA MEDICAL CENTER ASSOCIATE PROFESSOR BAYLOR COLLEGE OF MEDICINE

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1 Dementia ALI ABBAS ASGHAR-ALI, MD STAFF PSYCHIATRIST MICHAEL E. DEBAKEY VA MEDICAL CENTER ASSOCIATE PROFESSOR BAYLOR COLLEGE OF MEDICINE

2 Objectives At the conclusion of the session, participants will be able to: Define dementia Be aware of the medical work up involved in diagnosing dementia Offer distinguishing features of most common forms of dementia Identify common non-pharmacological treatments for addressing distressing behaviors

3 Diagnostic and Statistical Manual (DSM) IV diagnosis A. Problems in both Memory impairment One or more of the following: Aphasia (language) Apraxia (learned motor movements) Agnosia (recognizing objects, sounds, etc.) Disturbance in executive function (organizing, socially appropriate interactions and behaviors, attention) B. The cognitive deficits represent a decline in functioning and cause significant impairment in social or occupational functioning C. The course is characterized by gradual onset and continuing decline

4 DSM IV diagnosis D. The cognitive deficits are not due to other central nervous system, systemic, or substanceinduced conditions that cause progressive deficits in memory and cognition E. Deficits do not occur exclusively during the course of delirium F. The disturbance is not better accounted for by another illness.

5 Dementia - Work Up History and physical: Assess course Medications & interactions Labs Electrolytes Kidney function Liver function tests Complete blood count B12 and folic acid RPR (syphilis)/hiv Thyroid function tests Urinalysis and toxicology Medication blood levels Electrocardiogram Chest x-ray Cat scan of head If indicated, consider: Neuropsychological testing Lumbar puncture Electroencephalogram Assess for specific infections

6 Dementia FDA Approved Treatments Acetylcholinesterase inhibitors: Donepezil (Aricept) Galantamine (Razadyne) Rivastigmine (Exelon) NMDA antagonist: Memantine (Namenda)

7 Dementia - Subtypes Three most common: Alzheimer s Lewy Body Vascular Others: Frontotemporal Progressive Supranuclear Palsy Due to: Alcohol Traumatic brain injury Prion disease

8 Dementia - Neuropathology Alzheimer s: Plaques Tangles Dementia of Lewy Body: Lewy bodies Vascular: Chronic microvascular disease Large vascular events

9 Alzheimer s Disease - Course Course may vary between 5-15 yrs. Mild: Subtle difficulties in recent memories Apathy or loss of interest in activities Moderate-early: Memory impairment more noticeable Spatial and constructional skills impairment

10 Alzheimer s Disease - Course Moderate-late: Memory impairment worsens mostly oriented only to name Language impairment Difficulty feeding and dressing self Disrupted sleep pattern and wandering Psychosis (delusion or hallucinations) Anxiety or agitation Incontinence develops Severe: Language lost and eventually limited to vocalizations Basic motor skills lost (unable to walk, swallow, hold up head) Rigidity develops and developmental reflexes

11 Dementia with Lewy Bodies (DLB) Possibly second most common cause of dementia (7-19%) Lewy bodies are within the nerve cell Lewy bodies estimated to be present in 50-70% of AD patients brains

12 DLB International Consortium Consensus Criteria (McKeith et al., 1996) Core features: Fluctuating cognition and attention and alertness Visual hallucinations: recurrent, well formed Parkinsonism Supportive features: Repeated falls Loss of consciousness Sensitivity to antipsychotic medications Delusions Other hallucinations Exclusionary features: Strokes (clinical/imaged) Other illness or brain disorder

13 DLB - Presentation Diagnosis of DLB requires: Dementia One or more of following three: Recurrent, well-formed visual hallucinations Spontaneous parkinsonism (increased tone, gait disorder, resting tremor, postural instability, and sometimes orthostatic hypotension) Fluctuations in cognition, including changes in attention and alertness

14 Vascular Dementia Chronic microvascular disease: Slow, minute changes Caused by disruption of smallest of blood vessels Any single event does not cause noticeable change Build up of damage over time can cross threshold for noticeable changes in brain function Large vascular events: Significant portion of brain is damaged by a single event

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16 Vascular Dementia Course Varies greatly based on cause of dementia: Microvascular can be gradual or appear to be sudden Vascular Usually a sudden catastrophic injury that causes immediate changes Reducing the chances of strokes is best way to reduce the risk

17 Alzheimer s Dementia Neuropsychiatric Symptoms Delusions 50% Depressive symptoms 33% Anxiety 33% Hallucinations 25%

18 Dementia Distressed Behaviors Behaviors in patients with dementia that: Disrupt the care of the individual Disrupt the care of others Endanger the individual Endanger others Examples include: Physical or verbal aggression Refusing daily care inappropriate disrobing Screaming or vocalizations Verbal or sexual inappropriateness

19 Dementia Psychosocial Treatment Support caregiver: Assess caregiver s needs Social services Support groups Maintain safety: Ambulation Assist with medications Driving Healthcare Monitor for causes of delirium Minimize medications Create supportive environment: Familiar surroundings Orientation materials Appropriate stimulation Behavioral interventions

20 Behavioral Interventions Music/Music therapy Hand massage and gentle touch Physical activity and exercise Animal assisted therapy Aromatherapy Multisensory stimulation Reminiscence therapy

21 Dementia Pharmacological Treatment for Behavioral Symptoms First utilize psychosocial interventions Use least harmful agents Medications may take several weeks to see full effects Discuss side effects with provider(s)

22 Case Discussion 76 year old male Veteran presents with spouse with complaints of feeling tired, being forgetful, and having little interest in activities with family. 82 year old female Veteran presents from a nursing home with complaints of seeing giraffes in her room. She also has been complaining of difficulty with urination.

23 The Three D s: Dementia, Delirium, and Depression Marie A DeWitt, MD Diplomate of the American Board of Psychiatry and Neurology, Specialization in Psychiatry & Subspecialization in Geriatric Psychiatry Staff Physician, Mental Health Care Line Michael E. DeBakey VA Medical Center Assistant Professor, Menninger Dept of Psychiatry & Behavioral Sciences Baylor College of Medicine

24 The 3 D s Dementia Depression Delirium

25 Delirium

26 What is delirium? A severe state of confusion People with delirium Cannot think clearly Have trouble paying attention Have a difficulty time understanding what s going on around them May hallucinate

27 Symptoms of Delirium Restlessness Distractibility Jumping from topic to topic when talking Irritability Lack of awareness Increased or decreased activity Reversal of day and night Not sleeping or excessive sleepiness

28 What causes delirium? Physical illness like an infection Medications Withdrawal from alcohol

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30 Risk Factors Age Dementia Number of medications and certain types of medications Dehydration/malnutrition Vision or hearing impairment Pain Poor sleep Kidney or liver disease

31 Delirium Subtypes Hyperactive Increased activity Decreased sleep Restless Agitated Sometimes combative Often obvious hallucinations or delusions Hypoactive Somnolent, withdrawn Increased sleep Decreased motor activity Quiet Often mistaken as depressed

32 Management Treatment of the underlying cause(s) Behavioral interventions such as reassurance, orientation, redirection are best No FDA approved medication for treatment of delirium or management of its symptoms Medications should be reserved for when the patient is extremely distressed or when behavior (e.g., combativeness) is preventing critical care or putting the individual or staff at risk of bodily harm

33 What you can do to help Remain calm Speak softly and use simple words or phrases Remind the person of the day and date, where they are, and what is going on Have the person wear their glasses and hearing aids Talk about familiar family and friends Have familiar items around and play familiar music or TV shows

34 The Delirium Experience

35 Video

36 Comparison Dementia Permanent condition Comes on gradually, over months to years Usually stable throughout the day, although may get worse in evening/at night Trouble with memory Delirium Usually reversible (or at least partially) Comes on quickly, over hours to days Fluctuates throughout the day A change from the individual s usual Trouble with focusing

37 Continuum? Dementia Delirium

38 Depression in Older Adults

39 Epidemiology among Older Adults Depressive symptoms in up to 25% of older adults Clinical depression in 15% of those in a long term care facility

40 What is depression? A mood disorder Characterized by Depressed, sad or irritable mood Changes in sleep and appetite Decreased interest and energy Suicidal thoughts Excessive or inappropriate guilt

41 Depression Often presents differently in older adults More somatic (physical) complaints Often vague anxiety Decreased self care Often don t report feeling depressed

42 Treatment Psychotherapy (talk therapy) Antidepressants ECT

43 The Confusion with Apathy Apathy is a lack of initiation, motivation, and/or interest No longer desire to do things Can exist by itself or be a part of dementia or depression Usually bothers family more than individual

44 Onset Delirium Dementia Depression Hours-days (usually can say day when behavior started to change) Months-years (realize looking back that started having memory problems) Weeks Course Fluctuates throughout day Slowly progressive Stable, perhaps some worsening Thinking Fluctuations in alertness and memory Gradual onset of problems with memory Decreased concentration, memory, thinking Psychosis Misperceptions or hallucinations, sometimes paranoia Delusions of theft/persecution, possible hallucinations Delusions of poverty, guilt, somatic symptoms Sleep Disturbed but no set pattern May be disturbed but usually with a pattern Early morning awakening or excessive sleep Mood Often with fluctuations in emotions Depressed or apathetic Depressed or irritable Activity May be restless or withdrawn May be restless or withdrawn May be restless or withdrawn

45 Additional Resources Alzheimer s Association: Consultgerirn.org for the Try This Series: Best Practices in Nursing Care to Older Adults Geriatric Mental Health Foundation: National Institute on Aging: