OBJECTIVES DEMENTIA, DELIRIUM, DEPRESSION DEMENTIA

Transcription

1 OBJECTIVES DEMENTIA, DELIRIUM, DEPRESSION Carol Herzberg, R.N., BSN Health Care Consultant Differentiate between normal age related cognitive decline, mild cognitive impairment and dementia Differentiate between dementia, delirium and depression Review common causes and current treatment of dementia, delirium and depression I go somewhere to get something and then wonder what I m here after MILD COGNITIVE IMPAIRMENT MCI COGNITIVE IMPAIRMENT,NOT DEMENTED CIND Problems with memory, language or another mental function Severe enough to be noticeable Shows up on testing Does not interfere with daily life IS BRAIN DAMAGE IS PROGRESSIVE NEED TO PLAN DEMENTIA

2 DEMENTIA (DSM IV) DSM IV defines dementia as memory loss and at least one other area of cognitive impairment that interferes with social and occupational functioning, not due to delirium Other cognitive difficulties Speech problems Motor memory problems Sensory recognition problems Diminished executive functioning complex behavior sequencing problems WHY IS DEMENTIA IMPORTANT Disabling condition whose prevalence increases steadily with age Incidence: 1% at age 60 Doubles every 5 yr 85 yr olds chance of dementia = 32% Age wave is looming Cases are complex and costly FFS Medicare had dx of Alzheimer s Disease (AD) or other dementia had 2.6x higher total Medicare costs * *1999 Medicare claims for a 5% national random sample of Medicare beneficiaries GERIATRIC POPPULATION Number of adults 65 and older (US Census Bureau) 1 in every 8 people in the U.S =12.3% 37 million Number of adults 65 and older in in every 5 people (~20%) 71.5 million Fastest growing segment: 85 and older 2 million now 3 million million 2050 GERIATRICIANS Only about 7,000 MD s in the nation certified geriatricians By 2030 will need 36,000 geriatricians More elderly people will turn to the internist and family physician for care Older Adults and Chronic Disease 80% of older adults have at least one chronic disease 50% of older adults have at least two chronic diseases Most consistent risk of adverse drugs reactions = number of drugs taken DEMENTIA SCREENING What is best screening instruments for dementia in the primary care setting? Mini Co 3 word registration, clock drawing test, 3 word recall The Mini Cog can be done in the primary care setting in about 3 minutes False positive Depression Hypothyroidism Sleep deprevation

3 THE MONTREAL COGNITIVE ASSESSMENT (MoCA) MoCA 30 points 5 word recall Clock drawing Executive and visuospatial items May be more sensitive for MCI Available in all languages Google free MoCA DEMENTIA SCREENING History reliable family member or friend Medications Physical exam including mental testing Blood test including TSH, folate, B12, homocystine, syphilis screen, kidney function, liver function, CBC CT scan to rule out tumor/vascular lesions DEMENTIA Common signs and symptoms Memory loss Difficulty communicating Inability to learn or remember new information Difficulty with planning and organizing Difficulty with coordination and motor functions Personality changes Inability to reason Inappropriate behavior Paranoia Agitation Hallucinations TYPES OF DEMENTIA Cortical Alzheimer s Disease AD Frontotemporal Dementia FTD Pick s disease, semantic dementias Subcortical Vascular Dementia VaD Lewy Body Disease Other Wernicke Korsakoff

4 DISORDERS LINKED TO DEMENTIA Huntington s Disease Dementia pugilistic HIV associated dementia Creutzfeldt Jakob disease Parkinson s DRUGS FOR DEMENTIA Start low, go slow Improvement Plateau Slows cognitive & functional decline Cholinesterase inhibitors Aricept donepezil Exelon rivastigmine Razadyne galantamine hydrobromide Namenda memantine Psychotic symptoms Risperdol Seroquel Geodon Zyprexa Anxiety and agitation Xanax Ativan Serax OTHER DRUGS ALZHEIMER S DISEASE (AD) DSM IV Dementia with course is characterized by gradual onset and continuing cognitive decline Cognitive deficits not due to other CNS conditions (cerebrovascular, Parkinson s) or medical conditions (hypothyroidism, B12 deficiency) GENETIC ROLE OF ALZHEIMER S DISEASE Apolipoprotein E4 allele (APOE 4) is a marker for AD People of European descent 3x risk 70 s Homozygous have 15x risk earlier onset 60 s Cognitive decline with head injury Commercially available but test is still considered a research tool EPIDEMIOLOGY OF AD Mainly affects individuals > 65 years Affects ~ 10% > 65 years Affects ~ 50% of people >85 years Current trends continue cases could triple over the next 50 years 2050 = 13,200,000 cases

5 CLINICAL FEATURES OF AD: MILD STAGE Functional Impairment: Finances, Shopping, Cooking, Housekeeping, Reading, Writing Hobbies Behavior: Apathy, Withdrawal, Depression, Irritability CLINICAL FEATURES OF AD: MODERATE STAGE Functional Impairment: Loss of IADL s, Misplacing objects, Getting lost, Difficulty dressing (sequence and selection) Behavior: Delusions, Depression, Wandering, Insomnia, Agitation, Social skills unaffected TRAIL MAKING TEST To drive or not to drive CLINICAL FEATURES OF AD: SEVERE STAGE Functional Impairment in all basic ADL s Dressing, Grooming, Bathing, Eating, Continence, Walking, Motor Slowing Behavior: Agitation, Insomnia AGITATION BEHAVIORS Physical Inappropriate robing/disrobing Trying to get to a different place Restlessness Verbal Complaining Requests for attention Negativism Repeated questions/phrases Screaming VASCULAR DEMENTIA (VaD) DSM IV Dementia accompanied by evidence of cerebrovascular disease (focal neuro. Signs and symptoms and/or brain imaging) that is judged to be etiologically related to the dementia Onset is typically abrupt, followed by a stepwise and fluctuating course

6 RISK FACTORS FOR VaD Increasing age History of stroke Atherosclerosis High blood pressure Diabetes Smoking High cholesterol SYMPTOMS OF VaD Symptoms vary by affected part of brain Confusion and agitation Problems with memory Unsteady gait Difficulty planning ahead Decline in ability to organize thoughts MIXED DEMENTIA AD and VaD occur at the same time No current consensus on appropriate clinical or neuropathology criteria and terminology FRONTOTEMPORAL DEMENTIA FTD Both lobes shrink 3 rd common cause degenerative dementia More rapid onset than AD Deposits in brain called Picks bodies First symptoms change in personality, rude remarks to family, impaired executive function No FDA approved drug SUNDOWNING State of confusion at the end of the day and into the night Is not a disease Symptom in people with dementia Can be aggravated by Late day confusion Fatigue Low lighting Increased shadows PREVENT OR DELAY ONSET DEMENTIA Keep mind active Be physically and socially active Lower your homocysteine levels Lower your cholesterol levels Control your diabetes Lower your blood pressure Pursue education Lower stress Get a good nights sleep Maintain a healthy diet Get your vaccinations Don t smoke

7 BRAIN EXERCISE TO STAY FOCUSED STAY FOCUSED Look at the word Read out loud the color that each word is printed in Not the word itself COLOR WORD IS PRINTED IN BLACK BLUE GREEN RED YELLOW RED BLACK YELLOW STAY FOCUSED

8 COLOR WORD IS PRINTED IN YELLOW BLACK BLUE RED PINK GOLD ORANGE PURPLE DELIRIUM Delirium is an emergency that requires immediate intervention DELIRIUM Altered LOC Decreased attention span Disorganized thinking Develops over short period of time At least 2 of the following: Perceptual disturbances Disturbance in sleep/wake cycle Disorientation DELIRIUM 74% of ill cancer patients who recovered from delirium remember the episode Cancer, February 24, 2009 ETIOLOGY: DELIRIUM Dementia Electrolytes, EOTH withdrawal Lungs, liver, heart, kidney, brain Infection Rx (Drugs) withdrawal or new Injury, pain, stress, loss of sleep Unfamiliar environment: ICU, restraints, foley, noise Metabolic TYPES OF DELIRIUM Hyperactive not so frequent Aggressive Pulling out lines, etc May have visual hallucinations Hypoactive most common Wake up peacefully Smile, nod Yes to all questions Sign of inattention Decreased awareness of environment

9 DELIRIUM DRUG MANAGEMENT Haldol mg every 4 hours as needed PROPHYLACTIC LOW DOSE HALOPERIDOL 430 hip surgery patient Haldoperidol 0.5 mg TID Reduction in severity and duration of delirium episode Reduce LOS Kalisavaart et al JAGS 2005; 53: 1658 DELIRIUM MANAGEMENT Adequate lighting and familiar objects including clocks and calendars Promote physical comfort, pain assessment Access to all normal sensory input, glasses, dentures, hearing aids Frequent re orientation presence of family or friends Adequate nutrition, hydration, oxygenation and sleep Try to avoid restraints increase agitation TWO MOST EFFECTIVE INTERVENTIONS Hospitalization precipitates delirium, and worsens it, therefore: 1.Discharge 2.Bring home to the patient, i.e. have family stay, bring in familiar objects, etc DELIRIUM VS. DEMENTIA DELIRIUM DEMENTIA Onset Abrupt Insidious Attention Impaired Normal, unless very severe Consciousness Fluctuating, reduced Clear Speech Incoherent, disorganized Ordered DEPRESSION S&S Change in activity level, appetite, weight Change in cognitive abilities Fatigue Abnormal thoughts about death, suicide Change in sleep pattern Impaired functioning Withdrawal or isolation Irritability or anger

10 CAUSES OF DEPRESSION IN ELDERLY Changes within the family Chronic pain and illness Difficulty getting around Frustration with memory loss Financial problems Loss of a spouse or close friend Trouble adapting to a life change home to retirement facility DEPRESSION Difficult to assess in patients with dementia Depression is not normal part of aging Apathy is seen in both dementia and depression Depression and dementia may coexist leading to greater disability and faster cognitive decline Suicide is seen frequently in the elderly. Those at higher risk are white males older than 80 DEPRESSION TREATMENT SSRI are the preferred agents but may have significant side effects Prozac (fluoxetine) Paxil (paroxetine) Zoloft (sertraline) Celexa (citalopram) SSRI ISSUES Falls and urinary incontinence May decrease appetite during the initial tx Anti cholinergic properties may lead to delirium, constipation, dry mouth Tremors can be seen with all SSRIs Hyponatremia, bruising and increased bleeding time DEPRESSION TREATMENT Effexor (venlafaxine) and Cymbalta (duloxetine) may help in pain syndromes, can cause anorexia and elevated BP at higher doses. Effexor can be associated with insomnia Wellbutrin (bupropion) risk of seizures is seen at higher levels. High incidence of weight loss. Remeron (mirtazapine) improves sleep and appetite: but may not be the best option for those with diabetes, hyperlipidemia or obesity DEPRESSION TREATMENT Trazodone at low doses may help with sleep but at antidepressant does may cause orthostatic side effects

11 GOOD DRUG WEB SITE Institute for Safe Medication Practices Do Not Crush List Black Box Warnings Error Prone Abbreviations FDA Safety Alerts IOM Report on Medication Errors Confusing Drug Name List Throw Away Your Old Medicine Safely If I d know how old I was going to be, I d have taken better care of myself.» Adolph Zukor BIBLIOGRAPHY Inouye, S.K. (2006) Delirium in older persons. New England Journal of Medicine. 354 (11), Larson EB, et al.(2004) Survival after initial diagnosis of Alzheimer s disease. Annals of Internal Medicine, Apr 6;140 (7): Mace, Nancy, M.A., Robins, Peter V. MD The 36 Hour Day, The Johns Hopkins University Press, BIBLIOGRAPHY Shankle, William Rodman MD, Amen, Daniel G. MD, Preventing Alzheimer s, Penguin Group, New Your, Small, Gary MD, The Memory Bible, An innovative Strategy for Keeping your Brain Young, Hyperion, New York, Unutzer, J. (2007). Clinical practice. Late life depression. New England Journal of Medicine, 357: