3D s. Delerium Dementia Depression

Transcription

1 3D s Delerium Dementia Depression Greg Thomson M.D. Family Physician Medical Program Lead Rehabilitation and Geriatrics Halton Healthcare August 2017 Collaboration with Dr. T. Bibic

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Faculty/Presenter Disclosure Faculty: Dr. Greg Thomson Relationships with commercial interests: Moderator /Honoraria: - Janssen Canada - Astella Pharma - Amgen Canada

4 Disclosure of Commercial Support This program has not received financial support in the form of an educational grant Speaker will receive an honoraria from Sea Courses for these talks

5 Mitigating Potential Bias Dr. Greg Thomson This talk will review multiple geriatric and family medicine conditions and and will not focus on treatments beyond class effects. Information/recommendations in the program are evidence- and/or guidelines-based; opinions of the presenter will be identified as such. The Speaker completed the CPFC Mainpro+ Declaration of Conflict of Interest form evidencing compliance with Mainpro+ requirements

6 objectives Review Delirium Review Dementia Review Depression Distinguish between 3D s Inter-relationship amongst them

7 depression delirium dementia

8 DELIRIUM

9 Setting Incidence of Delirium Emergency Department 33% General Medicine Service 11-42% Admission to ICU 72% After cardiac surgery or stroke 25% Discharged to Community 1-2% Discharged to Skilled Nursing Facility 16% End-of-life Delirium 85%

10 Forms of Delirium Hyperactive only 25% of cases Hypoactive apathy, slowness of movement, staring, decreased alertness quiet delirium is most common, often confused with adjustment/depressive symptoms, associated with poorer prognosis. Delirium with mixed features

11 Baseline or Predisposing Factors Advanced Age 1/3 of over 70y.o. Cognitive impairment Visual impairment Impairment in ADLs High medical comorbidity burden Also: male, hearing loss, depression, alcohol abuse Acute or Precipitating Factors Drugs Electrolyte disturbances Lack of drugs Infection Reduced sensory Intracranial Urinary/fecal Myocardial/pulmonary JGIM 1998 March; 13: 204

12 Beers List AGS 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

13 ACB Scale Anticholinergic Cognitive Burden Drugs with ACB Score of 1 Generic Name Brand Name Alimemazine Theralen Alverine Spasmonal Alprazolam Xanax Aripiprazole Abilify Asenapine Saphris Atenolol Tenormin Bupropion Wellbutrin, Zyban Captopril Capoten Cetirizine Zyrtec Chlorthalidone Diuril, Hygroton Cimetidine Tagamet Clidinium Librax Clorazepate Tranxene Codeine Contin Colchicine Colcrys Desloratadine Clarinex Diazepam Valium Digoxin Lanoxin Dipyridamole Persantine Disopyramide Norpace Fentanyl Duragesic, Actiq Furosemide Lasix Fluvoxamine Luvox Haloperidol Haldol Hydralazine Apresoline Hydrocortisone Cortef, Cortaid Iloperidone Fanapt Isosorbide Isordil, Ismo Levocetirizine Xyzal Loperamide Immodium, others Loratadine Claritin Metoprolol Lopressor, Toprol Morphine MS Contin, Avinza Nifedipine Procardia, Adalat Paliperidone Invega Prednisone Deltasone, Sterapred Quinidine Quinaglute Ranitidine Zantac Risperidone Risperdal Theophylline Theodur, Uniphyl Trazodone Desyrel Triamterene Dyrenium Venlafaxine Effexor Warfarin Coumadin Generic Name Amantadine Belladonna Carbamazepine Cyclobenzaprine Cyproheptadine Loxapine Meperidine Methotrimeprazine Molindone Nefopam Oxcarbazepine Pimozide Drugs with ACB Score of 2 Brand Name Symmetrel Multiple Tegretol Flexeril Periactin Loxitane Demerol Levoprome Moban Nefogesic Trileptal Orap Categorical Scoring: Possible anticholinergics include those listed with a score of 1; Definite anticholinergics include those listed with a score of 2 or 3 Numerical Scoring: Add the score contributed to each selected medication in each scoring category Add the number of possible or definite Anticholinergic medications Notes: Each definite anticholinergic may increase the risk of cognitive impairment by 46% over 6 years. 3 For each on point increase in the ACB total score, a decline in MMSE score of 0.33 points over 2 years has been suggested. 4 Additionally, each one point increase in the ACB total score has been correlated with a 26% increase in the risk of death. 4 Aging Brain Care Drugs with ACB Score of 3 Generic Name Brand Name Amitriptyline Elavil Amoxapine Asendin Atropine Sal-Tropine Benztropine Cogentin Brompheniramine Dimetapp Carbinoxamine Histex, Carbihist Chlorpheniramine Chlor-Trimeton Chlorpromazine Thorazine Clemastine Tavist Clomipramine Anafranil Clozapine Clozaril Darifenacin Enablex Desipramine Norpramin Dicyclomine Bentyl Dimenhydrinate Dramamine, others Diphenhydramine Benadryl, others Doxepin Sinequan Doxylamine Unisom, others Fesoterodine Toviaz Flavoxate Urispas Hydroxyzine Atarax, Vistaril Hyoscyamine Anaspaz, Levsin Imipramine Tofranil Meclizine Antivert Methocarbamol Robaxin Nortriptyline Pamelor Olanzapine Zyprexa Orphenadrine Norflex Oxybutynin Ditropan Paroxetine Paxil Perphenazine Trilafon Promethazine Phenergan Propantheline Pro-Banthine Propiverine Detrunorm Quetiapine Seroquel Scopolamine Transderm Scop Solifenacin Vesicare Thioridazine Mellaril Tolterodine Detrol Trifluoperazine Stelazine Trihexyphenidyl Artane Trimipramine Surmontil Trospium Sanctura Drugs with ACB Score of 1 Generic Name Brand Name Alimemazine Theralen Alverine Spasmonal Alprazolam Xanax Aripiprazole Abilify Asenapine Saphris Atenolol Tenormin Bupropion Wellbutrin, Zyban Captopril Capoten Cetirizine Zyrtec Chlorthalidone Diuril, Hygroton Cimetidine Tagamet Clidinium Librax Clorazepate Tranxene Codeine Contin Colchicine Colcrys Desloratadine Clarinex Diazepam Valium Digoxin Lanoxin Dipyridamole Persantine Disopyramide Norpace Fentanyl Duragesic, Actiq Furosemide Lasix Fluvoxamine Luvox Haloperidol Haldol Hydralazine Apresoline Hydrocortisone Cortef, Cortaid Iloperidone Fanapt Isosorbide Isordil, Ismo Levocetirizine Xyzal Loperamide Immodium, others Loratadine Claritin Metoprolol Lopressor, Toprol Morphine MS Contin, Avinza Nifedipine Procardia, Adalat Paliperidone Invega Prednisone Deltasone, Sterapred Quinidine Quinaglute Ranitidine Zantac Risperidone Risperdal Theophylline Theodur, Uniphyl Trazodone Desyrel Triamterene Dyrenium Venlafaxine Effexor Warfarin Coumadin Generic Name Amantadine Belladonna Carbamazepine Cyclobenzaprine Cyproheptadine Loxapine Meperidine Methotrimeprazine Molindone Nefopam Oxcarbazepine Pimozide Drugs with ACB Score of 2 Brand Name Symmetrel Multiple Tegretol Flexeril Periactin Loxitane Demerol Levoprome Moban Nefogesic Trileptal Orap Categorical Scoring: Possible anticholinergics include those listed with a score of 1; Definite anticholinergics include those listed with a score of 2 or 3 Numerical Scoring: Add the score contributed to each selected medication in each scoring category Add the number of possible or definite Anticholinergic medications Notes: Each definite anticholinergic may increase the risk of cognitive impairment by 46% over 6 years. 3 For each on point increase in the ACB total score, a decline in MMSE score of 0.33 points over 2 years has been suggested. 4 Additionally, each one point increase in the ACB total score has been correlated with a 26% increase in the risk of death. 4 Aging Brain Care Drugs with ACB Score of 3 Generic Name Brand Name Amitriptyline Elavil Amoxapine Asendin Atropine Sal-Tropine Benztropine Cogentin Brompheniramine Dimetapp Carbinoxamine Histex, Carbihist Chlorpheniramine Chlor-Trimeton Chlorpromazine Thorazine Clemastine Tavist Clomipramine Anafranil Clozapine Clozaril Darifenacin Enablex Desipramine Norpramin Dicyclomine Bentyl Dimenhydrinate Dramamine, others Diphenhydramine Benadryl, others Doxepin Sinequan Doxylamine Unisom, others Fesoterodine Toviaz Flavoxate Urispas Hydroxyzine Atarax, Vistaril Hyoscyamine Anaspaz, Levsin Imipramine Tofranil Meclizine Antivert Methocarbamol Robaxin Nortriptyline Pamelor Olanzapine Zyprexa Orphenadrine Norflex Oxybutynin Ditropan Paroxetine Paxil Perphenazine Trilafon Promethazine Phenergan Propantheline Pro-Banthine Propiverine Detrunorm Quetiapine Seroquel Scopolamine Transderm Scop Solifenacin Vesicare Thioridazine Mellaril Tolterodine Detrol Trifluoperazine Stelazine Trihexyphenidyl Artane Trimipramine Surmontil Trospium Sanctura

14 For prevention of delirium: only non-pharmacologic interventions HELP program Evidence shows no significant difference in prophylaxis with pharmaceutical agents.

15 PREVENTABLE IN 30% OF CASES Cognitive Stimulation Sleep hygiene* Mobilize Address visual and hearing impediments Volume repletion NEJM 1999 March; 340(9): 669

16 Treatment with Antipsychotics may be warranted for severe agitation endangering patient safety for psychotic symptoms, such as hallucinations or delusions, causing severe distress. prescribed in the lowest effective dose for the shortest possible duration, generally less than 1-2 days. should always be revaluated regularly, especially with transition of care.

17 Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta- Analysis Conclusion: Current evidence does not support the use of antipsychotics for prevention or treatment of delirium. Additional methodologically rigorous studies using standardized outcome measures are needed JAGS 64: , 2016

18 Adverse Outcome after Hospitalization and Delirium in person with AD There is increased risk of: death cognitive decline institutionalization AIM 2012

19 Witlox, J. (2012). Delirium in the elderly: biomarkers and outcomes

20 DEMENTIA

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22 As of 2016 there were an estimated 564,000 Canadians living with dementia 25,000 new cases expected each year By 2031 expect 937,000 Canadians will have dementia From Alzheimer s Society Canada February 2017

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24 neurocognitive disorder Dementia has been renamed by DMS-V: 'major neurocognitive disorder' 'mild neurocognitive disorder'.

25 Diagnostic criteria for Mild Neurocognitive disorder = MCI Evidence of modest cognitive decline from a previous level of performance based on the cognitive deficits that do not interfere with capacity for independence in everyday activities but greater effort, compensatory strategies, or accommodation may be required DSM 5, 2013

26 Dementia = Major Neurocognitive Disorder Criteria A. 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 * Evidence of decline is based on: Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits interfere with independence in everyday activities. At a minimum, assistance should be required with complex instrumental activities of daily living, such as paying bills or managing medications C. The cognitive deficits do not occur exclusively in the context of a delirium D. The cognitive deficits are not better explained by another mental disorder (eg, major depressive disorder, schizophrenia) DSM 5, 2013

27 Risk factors Age Family History and Genetics Severe or repeated head injury Vascular Disease Certain Brain infections Smoking Hypertension Poor diet (lack of Vit D) Lack of physical activity COMMON SIGNS Frequent forgetfulness, especially of recent events Difficulty with common tasks Forgetting common words Becoming lost in familiar areas Poor judgement Changes in mood, behaviour or personality Lack of interest or involvement in life activities

28 Treatment modalities Pharmacological: Acetylcholinesterase Enzyme Inhibitors NMDA Receptor Inhibitor CVD/Risk Factors Medication optimization Non-Pharmacological: Ensure Supports Increased brain stimulatory activity Exercise and good nutrition Monitor for Caregiver Burnout

29 Depression

30 Depression in older adults A significant public health problem for older adults Under-recognized Undertreated May not meet strict diagnostic criteria Symptoms overlap with those of dementia Treatable If missed potentially life threatening

31 SIGECAPS A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure: Sleep disorder (increase or decrease) Interest deficit (anhedonia) Guilt (worthless, hopeless, regret) Energy deficit (fatigue) Concentration deficit Appetite disorder (decrease or increase) Psychomotor retardation or agitation Suicidal ideation B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. DSM 5, 2013

32 RISK FACTORS A prior episode of major depression Severe psychosocial events (stressors), such as death of a loved one, marital separation, divorce Chronic general medical conditions Substance dependence issues A family history of depressive disorders Being female Loss of independent functioning Acutely disabling conditions (e.g., stroke, MI) Physical disability

33 There is reciprocal interaction between depression and frailty in older adults. Specifically, each condition is associated with an increased prevalence and incidence of the other, and may be a risk factor for the development of the other. P. Soysal et al., Ageing Research Reviews 36 (2017) 78 Low HDL cholesterol and high triglyceride levels are associated with lower likelihood of long-term symptom resolution in depression. Virtanen, M., et. Al. J Clin Psychiatry, 78 (1) e1 Insomnia leads to more severe depression, as well as associated poor verbal fluency and poor memory. Virtanen, M. et. Al. J Clin Psychiatry, 78 (1) e1january 2017

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35 SCREENING TOOLS Requires administration of Mini-Mental State Examination, and Geriatric Depression Scale Short Form or Cornell Scale for Depression in Dementia, depending on level of cognitive functioning. Journal of Gerontological Nursing 2015: 41(11), 15.

36 Geriatric Depression Scale (Short Form) Patient s Name: Date: Instructions: Choose the best answer for how you felt over the past week. No. Question Answer Score 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO TOTAL Scoring: Assign one point for each of these answers: 1. NO 4. YES 7. NO 10. YES 13. NO 2. YES 5. NO 8. YES 11. NO 14. YES 3. YES 6. YES 9. YES 12. YES 15. YES A score of 0 to 5 is normal. A score above 5 suggests depression. Source: Yesavage J.A., Brink T.L., Rose T.L. et al. Development and validation of a geriatric depression screening scale: a preliminary report. J. Psychiatr. Res. 1983; 17:37-49.

37 SCREENING The AGS recommends depression screening two to four weeks after admission to a nursing home and then repeated screening at least every six months after admission. GDS score 5 may indicate possible depressive episode CSDD score 11 may indicate possible depressive episode

38 Apart from pharmacotherapy

39 Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial Collaborative care was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of 6 weekly sessions. Among older adults with subthreshold depression, collaborative care compared with usual care resulted in a statistically significant difference in depressive symptoms at 4-month follow-up, of uncertain clinical importance. JAMA. 2017;317(7 ):728

40 Am J of Geri Psych 2016 Jan;24(1):11 Problem-Solving Therapy Reduces Suicidal Ideation In Depressed Older Adults with Executive Dysfunction. PST is a promising intervention for older adults who are at risk for suicide.

41 Mirza SS, et. Al. Lancet Psychiatry 2016 Benefits of early treatment Early onset of treatment of depression has effect on future cognitive decline. Depression increases risk of dementia.

42 QUESTIONS?