From MCI to Dementia DR YU- MIN LIN GERIATRICIAN AUG 2018

Transcription

1 From MCI to Dementia DR YU- MIN LIN GERIATRICIAN AUG 2018

2 Overview What is dementia? Common causes Normal cognitive decline Abnormal decline and mild cognitive impairment How do we manage dementia Can we prevent dementia

3 Dementia - Major Neurocognitive Disorder 1. substantial cognitive decline from a previous level of performance in brain function complex attention, learning and memory, executive ability, language, visuoconstructional- perceptual ability, and social cognition 2. The cognitive deficits are sufficient to interfere with functional and instrumental independence. 3. The cognitive deficits is not delirium or a mental health illness.

4 Dementia: Main Causes Other Causes Alcohol Trauma Anoxia Huntington s Disease Prion Diseases Mitochondrial Disorders Progressive Supranuclear Palsy NPH AIDS / Syphilis Wilson s Disease Depression Delirium Psychosis

5

6 Normal Cognition Cognition Functional threshold Time (Years)

7 Mild cognitive impairment (AD/mixed)?Intervention Cognition Functional threshold Time (Years)

8

9 Mild cognitive impairment (Vascular/medical) Cognition Functional threshold Time (Years)

10 Functional impairment Remember recent events (news) Recalling conversation few days later Losing/misplacing items Able to use electronics Learn new things Handle money/pay bills Personal Hygiene Prepare meals Unexplained weight loss Driving Accidents/family concerns Manage medication Dispensing records Sudden poorly controlled diabetes and blood pressure

11 Reversible causes Physical and clinical assessment Blood tests Depression/anxiety CT/MRI scan Medication review

12 Medication review New medications Time correlation Drug withdrawal Deprescribe unnecessary medications Anticholinergic Withdraw benzodiazepine (slowly) Opiates/high dose neuropathic agents/seizure medications Antidepressant? Omeprazole? Statins Are they truly taking it?

13 Management Legal EPOA, Wills (if appropriate depending on stage at diagnosis) Driving Medication if appropriate. Compliance. Review dispensing record. Deprescribing. Blister pack. Simplify regime. Vascular risk caution with aggressive blood pressure and diabetes management Lifestyle regular exercise, routines, cognitive stimulation Local dementia society for carer support, programs Needs assessment ensure family/carer is present for assessment Advanced care planning if appropriate

14 Medication for dementia Cholinesterase Inhibitors Donepezil ** Rivastigmine patch **** (Galantamine) NMDA inhibitor (Memantine) Alzheimer s, Lewy Body Dementia, Parkinson s dementia Vascular Dementia FTD

15

16

17 Can we prevent dementia 35% is potentially preventable or modifiable Key is to start early as the condition is lifelong and slow process

18

19 Preventative factors Early education or life long education, bilingual Obesity - midlife Hypertension - midlife Smoking Excessive alcohol Diabetes avoidance of low sugars (hypo) Diet Physical inactivity Depression Yoga, Taichi, mindfulness Social isolation

20 When to think about risks - Basic annual check (at all age group) blood pressure, vascular risk factors especially if there is a family history health check (risk factors) health check routinely ask about cognitive difficulties Driver licence renewal - Those with chronic disease - patient and family raising concerns

21 News > Neurology Dementia Incidence on the Decline Pauline Anderson September 11, 2017

22 Polypharmacy - Appropriate prescribing - Deprescribing DR YU- MIN LIN GERIATRICIAN AUG 2018

23 Polypharmacy - multiple concurrent medications - usually >5 medications

24 Why is it a problem? Reduced adherence and compliance Significant cost to health services Higher risk of adverse side effects - 13% with 2 medication - 58% with 5 medication - 82% with 7 or more - Dose also becomes critical in more elderly and frail patients

25

26

27 Age (%) Dispensed 5 or more long- term medicines 5 7 long- term medicines long- term medicines or more long- term medicines Dispensed 11 or more long- term medicines: Health quality and safety commission NZ

28

29 Appropriate prescribing/medication review What condition is this medication for? How certain are we about the diagnosis? Is it for prevention or is it for a symptom? Did the medication help? Is there a symptom that can be explained by a medication? Should the medication be long term or short term? What stage is the patient at in his illness?

30 Deprescribing (PPI) Proton pump inhibitors ie omeprazole/pantoprazole - heartburn, gastritis, gastric ulcers Only few specific indication for long term use Requires slow wean and education frequent rebound symptoms on withdrawal Linked with osteoporosis/fractures, bowel infections, pneumonia, Vit B12 deficiency, low magnesium. Possible link with increased risk of dementia

31 Deprescribing (BP medications) Postural hypotension common in elderly Falls and dizziness May need dose adjustment depending on medical state/stability and increasing fraility Frequent hypotension (low blood pressure) linked with increased risk of dementia

32 Deprescribing (diabetic medications) Metformin chronic diarrhoea Avoid aggressive management in very frail patients, poor appetite Key is to avoid hypoglycaemia (sugars <4). More aggressive control for younger age group who are physically robust Frequent hypoglycaemia linked to increased risk of dementia

33 Anticholinergic medications Amitriptyline, nortriptyline, oxybutynin,? Tramadol Frequently causes constipation, dry mouth, dry mucosa, delirium/confusion, postural hypotension, falls, urinary retention Long term use linked with increased risk of dementia

34 Benzodiazapine Lorazapam, clonazepam, triazolam, temazepam, diazepam?zopiclone Sedation, falls, addiction, cognitive impairment, physical dependence Very careful with weaning (weeks - months). Usually very slow and complete cessation difficult especially history of very long term use. Aim for as low as possible and tolerable. Abrupt or rapid withdrawal is potentially very harmful

35 Antipsychotic Haloperidol, risperidone, quetiapine, olanzapine Acute delirium short course and should not be used long term Mental health disorders usually long term, requires psychiatrist oversight Dementia related behavioural and psychological symptoms could consider if no significant behaviour and on treatment for >3 months. Slow wean over weeks with monitoring of symptoms. Engagement with family about return of symptoms.

36 Osteoporosis treatment Alendronate (Fosamax) - 5 year treatment - need review to consider drug holiday or reduced frequently Teriparatide - only approved for 18 month treatment course

37

38