Diagnosing and Managing Dementia in Ambulatory Practice 35 th Annual Nurse Practitioners of Oregon Education Conference Elizabeth Eckstrom, MD, MPH Oregon Health & Science University Objectives Review the major types of dementia Enhance ability to diagnose dementia in the primary care setting Review treatment options for dementia Discuss other tasks related to care of patients with dementia Case discussion Prevalence of AD by age Evans, D. (1989). Prevalence of Alzheimer s disease in a community population of older persons. JAMA, 262;18, 2551-2556. 1
Why diagnose dementia early? Treat reversible causes of cognitive impairment Safety (driving, medication compliance, cooking, etc.) To anticipate post-operative delirium Family stress and misunderstanding (blame, denial, etc.) Early education of caregivers Advanced planning Patient and family right to know Warning signs of dementia Difficulties with finances (e.g., paying bills) Difficulties driving, getting lost, or using the telephone Poor historian; non-compliant with medications Poor hygiene / appearance of self-neglect Missed appointments Defers to a caregiver Unexplained weight loss or failure to thrive Person is more passive, unstable or suspicious than usual or experiences difficulty under stress Differential diagnosis of dementia Alzheimer s Disease (40%) Mixed AD & Vascular (15%) Mixed AD & Lewy body (16%) Lewy body dementias (10%) Vascular dementias (3%) Frontotemporal (5%) Others (11%) PSP, EtOH, infectious, TBI, NPH, CJD, etc. 2
Dementia Quick Screen- Give to everyone over 75 MINI-COG Scanlan et al, Int J Geriatr Pshcy 2001;16:216. 99% Sensitivity 3-Item recall ask the patient to remember the names of three objects (pencil, truck, book) the patient fails the screen if she is unable to remember at least 2 of 3 objects in one minute Clock Draw ask patient to draw a large circle, fill in the numbers on a clock face, and set the hands at 11:10 Abnormal Face Clock Draw- tests memory, visual-spacial, executive function, abstraction Abnormal Hands Abnormal Numbers Bottom Line- if not PERFECT, patient has some cognitive impairment Diagnostic Criteria for Dementia Hx & MSE show two areas of impairment (must include social and/or occupational functioning) impaired learning, impaired retention of newly acquired information (short term memory impairment) Impaired handling of complex tasks (executive function ie planning and organization) Impaired reasoning ability (abstract thinking) Impaired construction ability, apraxia and agnosia Impaired language Must be a decline from previous level of functioning Must rule out delirium and other medical and psychiatric diagnoses 3
Elements of dementia workup History/Family interview Administer: SLUMS Abstraction (similarities)/ Judgment ADL/IADL Scale for functional status Geriatric Depression Scale if suspect depression Targeted physical examination (sensory, neuro, gait) Lab studies if dementia suspected Head CT or MRI if dementia suspected History Short term memory loss Change in ADL s, IADL s cooking, hobbies, med management, finances Signifies a change in executive function Change in language Change in visual-spatial abilities, apraxia getting lost, trouble with ADL s (dressing) Ask about behavioral symptoms as they are often present even in early stages of dementia Symptom Mild (%) Mod (%) Severe (%) Total (%) Delusions 12 25 31 22 Hallucinations 12 15 8 10 Agitation 47 55 85 60 Dysphoria 12 45 62 38 Anxiety 24 65 54 48 Euphoria 18 0 8 8 Apathy 47 80 92 72 Disinhibition 35 40 31 36 Irritability 35 40 54 42 Restlessness 12 30 84 38 Lloyd et al. J. Geriatric Psychiatry Neuro 8:4:213-216, 1995 4
MMSE Tests orientation, memory, visual-spacial, verbal fluency Best to correct for age and educational level normal values- when you document the patient s score, also note the normal value for that patient. Be sure to ask the patient how far they progressed in school! The MMSE doesn t test all areas of cognitive function, so other cognitive testing must be done to determine what type of dementia a patient has SLUMS Validated for diagnosis of dementia AND for Mild Cognitive Impairment Does test all 5 brain areas Not validated for following over time 5
Physical Exam Neurologic Exam: Sensory- hearing, vision Reflexes, babinski (looking for signs of CVA) Weakness (looking for signs of CVA) Get up and Go: Ask to rise from chair without using arms, walk about 10 feet, turn (watch whether it is a smooth turn), return to chair, and sit back down without using arms (looking for signs of CVA or Parkinson features) Lab studies CBC TSH Complete metabolic Vitamin B12/Folate panel: Consider RPR electrolytes,calcium, Other lab studies if glucose, blood urea, indicated by history nitrogen/creatinine, or exam liver function Neuroimaging Non contrast CT scan or MRI Recommended for all patients undergoing workup* Especially for patients under 65 or patients over 65 with: Atypical presentation Unclear diagnosis Rapid unexplained deterioration Unexplained focal neurological symptoms History of head injury Urinary incontinence or gait ataxia early in illness Suspicion of undiagnosed CV disease * KnopmanDS, DeKoskyST, Cummings JL et al. Practice parameter: Diagnosis of dementia (an evidence-based review), Neurology 2001;56:1143-53. 6
Diagnostic Criteria Mild Cognitive Impairment New memory complaint, corroborated by an informant Objective evidence of short term memory loss Normal/unchanged cognitive ability No interference with activities of daily living Not demented Mild Cognitive Impairment 50% progress to dementia within 7.6 years Probably a pre-dementia state as almost all patients with MCI will develop dementia in 7-14 years Alzheimer s Dementia Impairment in learning and retaining new information plus at least one: impaired handling of complex tasks executive function abnormality impaired reasoning ability abstract thinking impaired spatial ability and spatial orientation agnosia, apraxia, impaired spatial abilities impaired language anomia, circumlocution, decreased verbal fluency 7
Vascular Dementia Remember: vascular insults are very common in Alzheimer s disease (20% of patients have both vascular and Alzheimer s pathology) DSM IV: dementia; focal neurological signs and symptoms or brain imaging evidence of cerebrovascular disease judged to be etiologically related to the dementia focal neurologic signs: hemiparesis, babinski, hemianopia, dysarthria, gait disturbance CVD evident on brain imaging: multiple large vessel infarcts, single strategic infarct, or multiple basal ganglia or extensive WMH relationship: a) dementia within 3 months of stroke or b) abrupt or fluctuating or stepwise deterioration Lewy Body Dementia Parkinsonian findings: shuffling gait, rigidity, trouble swallowing (tremor may not be prominent) Fluctuation in LOC and cognition Well formed visual hallucinations Attention, executive function and visual-spatial abnormalities may be more prominent than memory problems REM sleep disorders (ie frightening dreams) Lewy Body Dementia Very sensitive to the effects of neuroleptics- DON T use Haldol for visual hallucinations May markedly worsen with Parkinson s drugs and not recover after discontinuation of the medicine- DON T use Sinemet for rigidity Very responsive to Acetylcholine esterase inhibitors: best treatment for the hallucinations Can be very rapidly progressive 8
Frontotemporal Dementia Decline in personal or social interpersonal conduct loss of empathy, socially inappropriate behaviors (rude, irresponsible, sexually explicit), mental rigidity, inflexibility in relationships or severe apathy Impaired reasoning and difficulty with tasks out of proportion to impairments in memory, visualspatial skills May have marked language, gait abnormalities May have younger age of onset Features Atypical of Alzheimer s Disease Abrupt onset and stepwise deterioration (think of vascular dementia) Marked Behavior Change or apathy (think of frontotemporal dementia) Aphasia (VaD, Frontotemporal) Gait Disorder (VaD, Frontotemporal) Fluctuation LOC (Delirium, Lewy body) Parkinson s features, hallucinations (Lewy body) Treatment of Dementia Review medications: benzodiazepines: especially long acting centrally acting antihypertensives anticholinergics, H2-blockers, sedatives Safety and Living Arrangements driving, home safety, medications, financial Decision making capacity Advanced Directives Treat vascular risk factors 9
Treatment options for Dementia Acetylcholinesterase inhibitors Donepezil (Aricept)- start 5 mg, titrate to 10 mg after 4 wks Side effects: N/V, diarrhea, agitation, insomnia, dizziness N/V, dizziness, headache Galantamine (Razadyne)- start 4 mg BID, titrate to 8 mg BID then 12 mg BID q 4 wks Side effects: N/V, dizziness, headache Rivastigmine (Exelon)- start 1.5 BID, titrate q 2 wks to 6 BID Side effects: N/V, diarrhea, dizziness, anorexia Memantine (Namenda): start 5 mg daily, increase by 5 mg weekly to max 10 mg BID Acetylcholinesterase Inhibitors Modest improvement in memory mild to moderate dementia 24 weeks MMSE increased by 1-2 points Stabilization of memory, cognition, function NNT = 7 to stay unchanged at 1 year Delayed cognitive decline Function remains stable 72% longer with donepezil (6 months longer) Acetylcholinesterase Inhibitors Improved behavior Apathy Delusions Wandering Anxiety Reduced caregiver time and burnout Delayed nursing home placement (2 years) Improved cognition and function even in severe Alzheimer s (MMSE 1-12) (Neurology, 2007) Mild effect in vascular dementia as well (Neuro 2007) Not effective in MCI to prevent dementia 10
Cholinesterase Inhibitors Titrate dose over 1-2mos Start therapy when dementia is diagnosed, or patient is distressed by cognitive symptoms Determine if responder mild improvement over 3-6mos stabilization over 6-12 months Patient s rate of decline is reduced Continue therapy for responders Cholinesterase Inhibitors Discontinuing medication when to discontinue is problematic can cause abrupt decline, consider the timing carefully restarting medication will not regain losses for responders, continue at least through the moderate stage and perhaps until later in the disease process if patient has meaningful interactions Watch for decline including attention, interaction with family, behavioral issues, function May need to restart Memantine Most studied for moderate to severe AD (MMSE 7-9) Significantly slows decline in memory, ADL loss (Alz D and Assoc DO, 2006) Behavior improved with donepezil Also effective (improved language and memory) in mild-moderate AD (MMSE 10-22) with or without ACEIs (J Alz Dz, 2007, Alz Dz and Assoc DO, 2007) Not effective in MCI (Intl J Geri Psych, 2007) 11
Clinician Tasks in Caring for Patients with Dementia Treat cognitive impairment Prevent Progression Treat Co-morbidities Caregiver care Address behavioral symptoms Quality of life issues: e.g., driving, decisionmaking capacity, advanced directives End of Life Care Strategies for safer driving In early stages, encourage: Daytime driving only Non-rush hour driving Using secondary roads Avoiding distractions (radio, cell phone, etc) Driving with a competent, supervising passenger Interventions for unsafe drivers Encourage voluntary surrender of license Write a prescription for driving cessation Remove keys Remove/disable car Notify DMV that patient is unsafe Case 1 An 87-year old woman comes to the office because of short-term memory loss persisting for several months, which is getting worse according to her husband. She has some college education. She has a history of hypertension, which is well controlled with HCTZ, 12.5 mg daily. She is otherwise in good health. She sleeps and eats normally and has no day-to-day problems except for occasional difficulty locating her car in the parking lot. Physical and neurologic examination reveal nothing remarkable. There is no evidence of sadness or anhedonia. She scores 25 of 30 points on the mini-mental state examination, losing 3 points on recall and 2 on orientation. What further workup would you like to do? What is her diagnosis? How would you like to treat her? 12
Case 2 An 80-year old woman comes to your office accompanied by her daughter, who is concerned about the patient s memory. During the past year she has been repeating questions and having problems getting her words out. Symptoms probably have worsened. She is sometimes sad when talking about deceased relatives. The patient lives alone and does most of her own household chores, but the daughter reports finding several overdue bills recently, and a messy garden for the first time. The patient completed the tenth grade. Her MMSE score is 23/30, with three errors ( near-misses ) in orientation, two in short-term recall, and WORLD backwards spelled DLORW. Physical examination shows decreased arm swing on the right. Blood pressure is 180/92. Laboratory studies show cholesterol 245, LDL 135, others NL. What is her diagnosis? How would you like to treat her? Case 3 An 85-year old man is brought to the office by his family because he sees hallucinations of children and small animals when he is alone in a room. At times he has been disturbed and agitated by these hallucinations. His family also notes that he is having more difficulty walking and at times has hand tremors when he sits quietly. He has a 1-year history of short-term memory loss and word-finding difficulties. Examination is unremarkable except for cogwheel rigidity and resting tremors. MMSE is 20/30. What is the most likely diagnosis? How would you like to treat him? If you need to add a medication for the hallucinations, what would you choose? Case 4 An 82-year old man who lives in a nursing home has gradual onset of socially inappropriate actions characterized by loud, intrusive, and exhibitionistic behavior. He has no history of psychiatric illness or substance use. His family says he had always been introverted and considerate. The nursing staff has become angry with him because his behavior and his lack of concern for their requests. On examination, he is alert, has clear speech, and has a steady gait. MMSE is 25/30, and labs are normal. What is the most likely diagnosis? How might you treat him? 13
Case 5 A 68-year-old man has a 2-year history of progressive impairment of gait, posture, and balance. He walks with small, shuffling steps and has fallen repeatedly. Cognitive dysfunction developed in the past 6 months, although mentation sometimes is normal. The patient s wife described episodes in which the patient seems to go blank. Levodopa therapy was discontinued because of florid visual hallucinations. MMSE today is 23/30. What is the most likely diagnosis? How would you treat this patient? Summary If you suspect cognitive impairment, use the history and physical to determine type of dementia as this will guide your care Offer medications with patient and family goals of care in mind; often value is marginal Support the patient and the family ALZ.ORG 14