DEMENTIA Ian Arnold MD CCFP - PowerPoint Presentation

Slide1

DEMENTIA

Ian Arnold MD CCFP

Civic Family Health Team

September 4, 2013

(based on a presentation developed by Dr. Michael Malek)

(with liberal quoting from UpToDate)

Slide2

Disclosures

I have no financial or other ties to the pharmaceutical industry

I have never taken any of the drugs mentioned in this presentation

I

do

drink coffee

I was in university in California in the '60s

(speaks for itself, as our Stephen H. would say)

No animals were harmed in the making of this presentation.

Slide3

Definition

Chronic acquired decline in memory

at least one other impairment in cognitive function (personality, language, executive, visual-spatial)

Sufficient to interfere with functioning (social, occupational) and ADL’s

> 6 months since onset

Slide4

Definition

DSM-IV Part 1

Evidence from the

history

and mental status examination that indicates major impairment in

learning and memory

as well as

at least one

of the following:

Impairment in handling

complex tasks

Impairment in

reasoning

ability

Impaired

spatial

ability and orientation

Impaired

language

Slide5

Definition

DSM-IV Part 2

The cognitive symptoms must

significantly

interfere with the individual's work performance, usual social activities, or relationships with other people

This must represent a

significant

decline

from a previous level of functioning

The disturbances are of

insidious

onset and are

progressive

, based on evidence from the history or serial mental-status examinations

The disturbances are

not

occurring exclusively during the course of

delirium

The disturbances are

not

better accounted for by a

major psychiatric diagnosis

The disturbances are

not

better accounted for by a

systemic disease

or

another brain disease

Slide6

Costs (2013)

Dementia the Most Expensive Health Condition in the U.S.

Dementia tops heart disease and cancer in terms of overall spending in the U.S.

will likely continue rising as the population ages, according to a study in the NEJM

Researchers calculated that dementia care (including out-of-pocket spending, nursing home costs, Medicare costs, and formal and informal home care) cost $41,000 to $56,000 annually per case in the U.S. In 2010.

Slide7

A Caregiver's Comment

(a woman responded on-line to the above article)

9 Apr 2013

My mother's around-the- clock home care for dementia came to $145,000 for 2012. Future costs are probably being underestimated. She has no real life.

I do not understand the endless push to keep people alive as long as possible.

I am doing everything I can to be heart unhealthy to avoid living to the age of dementia.

Slide8

Is the Prevalence of Dementia Changing?

In England, the prevalence fell from 8.3% to 6.5% during the past 20 years

This rigorous study is a persuasive piece of evidence that, at least in some settings, the prevalence of dementia in elders is declining and might be sensitive to societal efforts to improve education, primary prevention, and healthcare delivery.

Matthews FE et al. A two-decade comparison of prevalence of dementia in individuals aged 65 and older from three geographical areas of England: Results of the Cognitive Function and Ageing Study I and II. Lancet 2013 Jul 16

Slide9

Resources

Slide10

What is to be done?

V.I. Lenin 1902

'Primum non nocere'

c.1640

"given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good."

Benefits vs. Harms

Action vs. Inaction

“When in doubt, don't”

Benjamin Franklin and many others

Slide11

Two words to use correctly!

SCREENING

detect early disease or risk factors for disease in large numbers of

apparently healthy

individuals.

DIAGNOSTIC TESTING

establish the presence (or absence) of disease as a basis for treatment decisions in symptomatic or screen positive individuals

Slide12

What is to be done

? Part 1

V.I. Lenin 1902

Screening

2003

:The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults.

2013

:Population screening to detect Alzheimer's disease or other dementia can't currently be recommended because there isn't enough evidence to show it offers practical benefits, researchers reported here at the annual Alzheimer's Association International Conference.

“the bottom line here is that there are relatively few upsides to this general population screening and potentially there are some significant downsides."

Slide13

What is to be done

? Part 2

V.I. Lenin 1902

Prevention:

(from UpToDate Sept. 2013)

Most data on preventing dementia come from observational studies. Prospective studies and randomized controlled trials

have

not

shown an overall benefit

from

cholinesterase inhibitors, vitamin E, NSAIDS, or estrogen replacement

. Ongoing studies should help to clarify the role of statins.

Vitamin E supplementation

increases the risk for all-cause mortality

and there is no convincing evidence that it affects the risk of developing AD (see "Vitamin supplementation in disease prevention").

We

do not recommend NSAID use

even in patients at high risk for AD (i.e, those with very strong family histories) because of the possible increased risk of cardiovascular events associated with NSAIDs and COX-2 inhibitors.

We encourage all patients, especially those with early dementia or at higher risk for dementia, to maintain or increase

physical activity and exercise

as long as there are no contraindications. Similarly, we encourage

cognitive leisure activities and social interaction

for as long as these are feasible. However, we recognize that these lifestyle factors remain

unproven

as a means of preventing dementia.

Slide14

What is to be done

? Part

3

V.I. Lenin 1902

Awareness, Diagnosis and Management:

Know what might be dementia and how to investigate

Know what treatments might be useful and when and how to prescribe

Know what resources are available to support and protect

the patient

the caregivers

the community

Slide15

Risk factors: unpreventable

Age

Family history (risk doubles for each 1

st

degree relative)

Low education

Previous CVA, MI

Slide16

Risk factors: preventable?

Vascular risk factors:

risk

doubles

for every vascular risk factor

Atrial fibrillation

Diabetes

Hypertension

CAD

Hyperlipidemia

Smoking

Past CVA/TIA

Slide17

e.g. Diabetes

The Lancet Diabetes & Endocrinology, Early Online Publication, 20 August 2013

Risk score for prediction of 10 year dementia risk in individuals with type 2 diabetes: a cohort study

Although patients with type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult.

We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10 year dementia risk for individuals with type 2 diabetes

.

Slide18

Using the Dementia Risk Calculator

Risk

doubles

for every 5 years of age

AGE:

<65

-1% ,

65

-2% ,

70

-4%,

75

-8%,

80

-16%,

85

-32%

Each additional vascular risk factor approximately

doubles

the risk

(One risk factor: risk multiplier is 2; 2 or more risk factors: risk multiplier is 4)

Positive family history

doubles

the risk.

(One family member: risk multiplier is 2; 2 or more family members: risk multiplier is 4)

Overall risk

= age risk _____% x family history

risk multiplier

___x vascular

risk multiplier

___=

___%

But why do the math? Does it help the patient?

Slide19

What does the patient notice?

Often,

NOTHING

And is brought to the office by the spouse, relatives or friends who have concerns

Slide20

What do caregivers notice?

from the Alzheimer Society of Canada

Memory loss that affects day-to-day function

It's normal to occasionally forget appointments, colleagues' names or a friend's phone number and remember them later.

A person with Alzheimer's disease may forget things more often and not remember them later, especially things that have happened more recently.

Difficulty performing familiar tasks

Busy people can be so distracted from time to time that they may leave the carrots on the stove and only remember to serve them at the end of a meal. A

person with Alzheimer's disease may have trouble with tasks that have been familiar to them all their lives, such as preparing a meal.

Problems with language

Everyone has trouble finding the right word sometimes, but

a person with Alzheimer's disease may forget simple words or substitute words, making her sentences difficult to understand.

Slide21

What do caregivers notice? (2)

Disorientation of time and place

It's normal to forget the day of the week or your destination -- for a moment. But

a person with Alzheimer's disease can become lost on their own street, not knowing how they got there or how to get home.

Poor or decreased judgment

People may sometimes put off going to a doctor if they have an infection, but eventually seek medical attention.

A person with Alzheimer's disease may have decreased judgment, for example not recognizing a medical problem that needs attention or wearing heavy clothing on a hot day.

Problems with abstract thinking

From time to time, people may have difficulty with tasks that require abstract thinking, such as balancing a cheque book.

Someone with Alzheimer's disease may have significant difficulties with such tasks, for example not recognizing what the numbers in the cheque book mean.

Slide22

What do caregivers notice? (3)

Misplacing things

Anyone can temporarily misplace a wallet or keys.

A person with Alzheimer's disease may put things in inappropriate places: an iron in the freezer or a wristwatch in the sugar bowl.

Changes in mood and behaviour

Everyone becomes sad or moody from time to time.

Someone with Alzheimer's disease can exhibit varied mood swings -- from calm to tears to anger -- for no apparent reason.

Slide23

What do caregivers notice? (4)

Changes in personality

People's personalities can change somewhat with age. But

a person with Alzheimer's disease can become confused, suspicious or withdrawn

. Changes may also include apathy, fearfulness or acting out of character.

Loss of initiative

It's normal to tire of housework, business activities or social obligations, but most people regain their initiative.

A person with Alzheimer's disease may become very passive, and require cues and prompting to become involved.

Slide24

What do they mean?

Apraxia

loss of the ability to execute or carry out learned purposeful movements, despite having the

desire

and the

physical ability

to perform the movements. It is a disorder of

motor planning

, but is not caused by incoordination, sensory loss, or failure to comprehend simple commands

Agnosia

loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is

not defective

nor is there any significant memory loss

Slide25

What do they mean

? Part 2

Aphasia

a disturbance of the comprehension and formulation of language

Impaired executive function

an umbrella term for cognitive processes that regulate, control, and manage other cognitive processes, such as planning, working memory, attention, problem solving, verbal reasoning, inhibition, mental flexibility, task switching, and initiation and monitoring of actions.

Slide26

How would you test?

Apraxia

imitate use of common objects, such as toothbrush, hammer

Agnosia

have patient close eyes, and ask to identify a common object placed in hand

Aphasia

name body parts or objects in room

Impaired executive function

perform series of simple tasks

3 item instruction (in MMSE)

Serial 7’s or “WORLD” backwards

Verbal word lists

Slide27

Take a history!

Level of education of patient

Onset: abrupt vs gradual

Progression: steady vs step-wise

Has there been an effect on functional activities?

ADL’s

Instrumental ADL’s

Having an 'informant' is essential as the patient may not be aware of deficits

Slide28

What are the other two 'D's?

Delerium

Acute onset

Fluctuating cognition; clouding of sensorium

Depression

More likely to

self-report

memory loss

'slowing' and poor effort on testing

Dementia patients try hard but get it wrong

Slide29

ADLs

and IADLs

Bathing and showering (washing the body)

Bowel and bladder management (recognizing the need to relieve oneself)

Dressing

Eating (including chewing and swallowing)

Feeding (setting up food and bringing it to the mouth)

Functional mobility (moving from one place to another while performing activities)

Personal device care

Personal hygiene and grooming (including washing hair)

Toilet hygiene (completing the act of relieving oneself)

DEATH

: dressing/bathing, eating, ambulating (walking), toileting, hygiene.

Slide30

ADLs and

IADLs

Part 2

Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community:

Housework

Taking medications as prescribed

Managing money

Shopping for groceries or clothing

Use of telephone or other form of communication

Using technology (as applicable)

Transportation within the community

A useful mnemonic is

SHAFT

: shopping, housekeeping, accounting, food preparation/meds, telephone/transportation.

Slide31

ADLs and

IADLs Part 3

Here are samples of some commonly used assessment tools:

Katz for ADLs and

Lawton for IADLs

Slide32

Do some tests!

Physical exam

MMSE

MOCA

Trails A and B

What to do if the patient doesn't speak English?

Or doesn't read English?

Slide33

Order some tests

The AAN recommends screening for

B12 deficiency

and

hypothyroidism

in patients with dementia.

There are no clear data to support or refute ordering "routine" laboratory studies such as a complete blood count, electrolytes, glucose, and renal and liver function tests.

Screening for neurosyphilis is

not recommended

unless there is a high clinical suspicion.

Tailor tests to patients with a compatible history (e.g. RBC folate in a patient with ethanol dependence, or ionized serum calcium in a patient with multiple myeloma, prostate cancer, or breast cancer).

Slide34

Neuroimaging

Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4) Dec. 2012

The issue of whether all patients with dementia should have structural imaging is debated at every CCCDTD conference, with the opinion that it is not required in all patients, but rather for those who have special clinical features.

The practical message is that structural imaging is not required in all (although will be indicated in most) persons with cognitive impairment. Although more costly and less available, MRI is preferable to CT.

Slide35

Dementia, in all it's glory

MCI

AD

FTD

DLB

VaD

NPH

Etc.

Slide36

Mild Cognitive Impairment (MCI)

(Amnestic and Non-amnestic)

Amnestic MCI (aMCI)

refers to those individuals with significantly impaired memory who do not meet criteria for dementia

(classic MCI).

Memory complaint, preferably corroborated by an informant

Objective memory impairment

(for age and education)

Preserved general cognitive function

Intact activities of daily living

Not demented

Progression to Dementia: 10%/year

(about 3x the average rate)

But 11-40% of patients with MCI

improve

, even to normal, over a one to three-year follow-up

Slide37

Mild Cognitive Impairment (MCI

) -2

(Amnestic and Non-amnestic)

Single domain non-amnestic MCI (naMCI)

is similar aMCI, except that this form of MCI is characterized by a relatively isolated impairment in a single non-memory domain, such as

executive functioning,

language, or

visual spatial skills.

may progress to other syndromes, such as frontotemporal dementia (FTD), primary progressive aphasia, dementia with Lewy bodies, progressive supra-nuclear palsy, or corticobasal degeneration.

Individuals within this group appear to be

at less of a risk of conversion to dementia

, although supporting evidence is limited.

Slide38

Mild Cognitive Impairment (MCI

) -3

(Amnestic and Non-amnestic)

Epidemiology

:

Findings from epidemiological studies vary significantly, partially due to the differing diagnostic criteria, measuring instruments, definitions, and use of population verses clinic-based samples.

prevalence among older adults (>70 years) to be between 14 and 18 percent

In contrast to the

impaired awareness

of deficits commonly present in patients with AD, patients with MCI are often

particularly troubled

by their symptoms.

However, over time, patients with MCI who convert to AD shift to a relatively greater preponderance of informant-reported symptoms over self-reported symptoms.

Slide39

Evaluation

Mild Cognitive Impairment (MCI)

Detailed history

(from patient and family/friends)

MMSE

&/or

Montreal Cognitive Assessment (MoCA)

Physical examination

(e.g. neuro exam for possible vascular etiology)

In one community-based study

depression and other psychiatric disease (10.2 percent),

alcohol and drug related causes (6.9 percent), and delirium (1 percent).

neurologic disease: brain

tumor

, Parkinson disease, multiple sclerosis, cerebrovascular disease, and epilepsy) (25%)

Among the remaining 57.5 percent, most (31.7 percent) had circumscribed memory impairment.

Slide40

Differential diagnosis of memory loss

Slide41

Alzheimer's Disease (AD)

Usually presents with concerns about memory

Or memory problems can elicited at presentation.

Slide42

Dementia with Lewy bodies (DLB)

Visual hallucinations (detailed, recurrent)

Pronounced fluctuation in cognition over hours/days

Parkinsonism (esp. rigidity, bradykinesia)

Executive function worse than memory

Neuroleptic sensitivity

Unexplained falls/LOC

Slide43

Clinical and radiologic features of

dementia with

Lewy

bodies

Slide44

Fronto-temporal Dementia (FTD)

FTD typically presents as

either

a progressive change in

personality and social behaviou

r or as a progressive form of

aphasia

; in both cases continuing ultimately to a global dementia.

The behavioural variant is more common.

Slide45

Fronto

-temporal Dementia (FTD

) -2

Behavioural changes (disinhibition, apathy)

Impulsivity, poor judgement

Self-neglect

Socially inappropriate

Executive function worse than memory

Language problems

Abnormal gait

Slide46

Fronto

-temporal Dementia (FTD

) -3

Personality change

This can manifest as apathy with social withdrawal, loss of spontaneity, and abulia that can be mistaken for depression. Some patients alternate between passive behaviour and disinhibited outbursts.

Lack of insight

Most patients seem unaware or incompletely aware of their deficits at presentation, and virtually all exhibit impaired insight within two years of symptom onset. On probing, this is often a

lack of concern

rather than a lack of knowledge of their impairments.

Loss of social awareness

Individuals may infringe upon social norms in a manner that is incongruent with their premorbid behaviour. Their sense of decorum appears altered; they may make offensive remarks and behave inappropriately. Personal hygiene may be affected. Patients may be incontinent — voiding urine or feces in inappropriate places without apparent concern. They may commit antisocial, even criminal acts. While inappropriate sexual comments are somewhat common in patients with FTD, hyper-sexual behaviour is not; most patients with FTD have diminished libido.

Slide47

Fronto

-temporal Dementia (FTD

) -4

Stereotyped or ritual behaviours

These can include insisting on the same foods or employing a repetitive "catch-phrase." Hoarding, counting, and pacing are among the described behaviours

Change in eating patterns.

Patients with FTD frequently overeat and may binge or develop food fads. Alcohol consumption may be excessive. As the disease

progresses, there may be oral exploration of nonfood objects.

Emotional blunting and loss of empathy

.

Patients may be described as more self-centred, unconcerned about family and friends, and "cold." They may have difficulty recognizing emotional expression in others.

Mental rigidity.

Patients with FTD often appear inflexible in their adherence to routines, as well as unable to adapt to new situations and see another's point of view.

Slide48

Fronto

-temporal Dementia (FTD

)-5

Deficits in modulating attention

.

This can manifest as distractibility and impersistence, or as perseverative behaviour In addition, some patients demonstrate utilization behaviours. These are stimulus-bound actions in which the individual repeatedly uses and reuses objects within their sight, despite irrelevance to situation (e.g., they might repeatedly pick up a comb in front of them and use it while participating in a conversation).

Slide49

Vascular Dementia (VaD)

At present, the entity of VaD is best understood as a

heterogeneous syndrome

rather than a distinct disorder, in which the underlying cause is cerebrovascular disease in some form and its ultimate manifestation is dementia.

In patients with cognitive deficits ultimately attributable to VaD,

memory impairment appears somewhat later

, and these patients may have

significant cognitive disability

long before they meet criteria for dementia.

Slide50

Vascular Dementia (

VaD

) -2

Cortical:

multiple small infarcts that are not recognized as strokes

Can appear

fluctuating or step-wise

, as some patients improve after the event

Subcortical:

both lacunar infarctions and chronic ischemia affect the deep cerebral nuclei and white matter pathways.

may be

gradual

or

stepwise

and either

slow

or

fast

in decline.

Slide51

Normal Pressure Hydrocephalus (NPH)

Urinary incontinence (early in course of dementia)

Rapidly progressive dementia

Abnormal gait

Slide52

Comparison

AD:

short term memory, word finding, and way finding.

VaD:

acute vascular history, focal findings, positive imaging

Mixed AD/VaD:

mixed clinical picture or positive imaging

DLB:

fluctuations in cognition, hallucinations, Parkinsonism.

FTD:

under 70, behavioural issues, social tactlessness.

NPH:

early gait apraxia, incontinence, rapid progression of dementia

Slide53

You have a diagnosis. Now what?

Address vascular risk factors

Assess safety (e.g home, driving)

Assess involvement of caregivers/family

Screening for caregiver burnout

Linking with Alzheimer’s society, CCAC, Champlain LHIN or other community resources

Slide54

Driving safety: quick checklist

Family expresses concerns

Severity worse than MILD

FTD or Lewy Body dementia

Visuospatial problems (e.g. clock drawing test; intersecting polygons)

Fails Trails A and/or Trails B

Poor judgement/insight

Other important medical/physical problems; poor reaction time (e.g. “drop ruler” test)

Slide55

Drugs

Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4) Dec. 2012

The practical messages are that:

concurrent causes of dementia have to be managed;

CIs are recommended for AD in mild to severe stages of dementia, AD with a cerebrovascular component, Parkinson Disease dementia, but

not

for probable vascular dementia;

the combination of CIs and memantine is logical, but an additive benefit has not been conclusively demonstrated

Slide56

Cholinesterase Inhibitors

Indications

Efficacy of the 3

similar

for

mild-moderate dementia

(MMSE 10-26)

Approx. 1 year’s delay in progression of Alzheimer’s

Symptomatic drugs

May help apathy, hallucinations & delusions

Slide57

Cholinesterase Inhibitors

Names and dosage forms

Aricept (donezepil): 5 and 10 mg tabs

Reminyl (galantamine): 8,16,24 mg extended release caps

Exelon (rivastigmine): 1.5, 3, 4.5, 6 mg given BID; also in patch form and oral solution

Slide58

Cholinesterase Inhibitors

Dosing

Titrate dose every 4 weeks to maximum dose, if tolerated

Max doses:

Aricept 10 mg qAM

Reminyl ER 24 mg q AM

Exelon 6 mg BID

Slide59

Cholinesterase Inhibitors

Contraindications

Cardiac: bradycardia, SSS, heart block

Active PUD

Severe asthma or COPD

Possible interaction with other anticholinergic meds

Slide60

Cholinesterase Inhibitors

Common Side Effects

GI (>10%): nausea, vomiting, diarrhea, bloating, anorexia

Muscle cramps

Sleep disturbance (insomnia, nightmares)

Fatigue

Side effects can be self-limited

Slide61

Cholinesterase Inhibitors

Effective?

20%

are

“super-responders”

seen within 6 weeks

30-50 % non-responders

with continued deterioration at the previous rate of decline

The rest are

mild responders

Must individualize based on response

Caveat:

The AD2000 study, the only

non-pharmaceutical industry

sponsored trial of cholinesterase inhibitors, found

no significant benefit of donepezil compared with placebo

for the two primary endpoints: entry to institutional care and progression of disability