DEMENTIAS

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DEMENTIAS

• Pat Borman, MD
• Director Advanced Training in Geriatrics

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GOALS IN DEMENTIA

• Evaluation and Diagnosis
• Current Therapy for Dementia
• Complications
• Resources for the Caregivers

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DEFINITION OF DEMENTIA

• MEMORY IMPAIRMENT
• AND One or more
• APHASIA APRAXIA
• AGNOSIA VISUOSPATIAL
• LOSS OF EXECUTIVE FUNCTION
• Gradual, Progressive, Impairs function social,
  job, family, no other explainations

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TYPES OF DEMENTIA

• Alzheimers
• Memory, Language, Visuospatial, Indifferent to
  Loss
• Frontotemporal (Picks)
• Memory, Marked Personality changes, Preserved
  visuospatial
• Lewey Body
• Visual hallucinations, delusions, flucutating
  mental status

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TYPES OF DEMENTIA

• Parkinsons Disease
• 15-30 develop dementia
• Vascular Dementia
• Progressive Supranuclear Palsy
• The Rare Birds
• Late onset Metobolic Disease
• Creutzfeld-Jacob

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EVALUATION

• HISTORY
• HPI, Medical, Medications, Psychiatric,
  Functional, Caregiver
• EXAM
• Physical, Neurologic, Psychiatric, Cognitive
  Testing

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EVALUATION

• LABORATORY
• Blood Work
• CBC, TSH, Chem 7, Ca 2, B12, Folate
• RPR
• Imaging
• CT or MRI
• Other Studies
• LP, neuropsychiatric testing, EEG,
• SPECT, PET

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DIFFERENTIAL DIAGNOSIS

• DEPRESSION Pseudodementia
• CNS Neoplasm, NPH, stroke
• Vascular subdural, vasculitis,
• Endocrine Thyroid, Calcium,
• Nutritional B12, Thiamine,ETOH
• Infections HIV, Cryptococcus

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CURRENT THERAPY

• CHOLINESTERASE INHIBITORS
• For mild to moderate disease, slow progression,
  stabilize ADL and MMSE
• 1st Generation
• Tacrine hepatotoxic, last choice
• 2nd Generation
• Donepezil 5-10 mg qd 113/mp
• Rivastigmine 3-6 mg bid 153/mo
• Galantamine 16-32 298/mo

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CURRENT THERAPY

• VITAMIN E
• Antioxident, inexpensive
• GINKGO BILOBA
• Antioxident, anti-inflammatory
• ESTROGENS
• neuroprotective?
• NSAIDS
• Epidemiologic suggestions

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COMPLICATIONS

• Depression 40
• Suspicion 30
• Disinhibition 50
• Agitation 50
• Verbal, Vocal,
• Motor
• Psychosis
• Hallucinations15
• Delusions 30

• Anxiety 40
• Aggression 30
• Withdrawal 40
• Vegetative
• sleep 90
• appetite 30
• Wandering 60
• Apathy 60

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APPROACHES TO BEHAVIOR PROBLEMS

• 1. Define target symptoms
• 2. Revisit medical diagnoses
• 3. Establish neuropsychiatric diagnoses
• 4. Assess and remove provoking factors
• environmental, psychosocial, other
• 5. Adapt environment and treatments to specific
• cognitive deficits
• 6. Educate caregivers
• 7. Employ behavior management principles
• 8. Treat specific psychiatric disease
  specifically
• 9. For remaining behavior problems consider
• symptomatic pharmacotherapy

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PHARMACOTHERAPY

• DEPRESSION
• SSRIS Paroxetine, Sertraline, Others
• TCADS Nortriptyline
• ECT if life threatening
• ANXIETY
• Buspirone,Lorazepam, Propanolol
• PSYCHOSIS
• Rispiridone, Olanzepine, Haloperidol

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PHARMACOTHERAPY

• Aggression
• Trazedone, Buspirone, Olanzepine, Others
• Agitation
• Haloperidol, Lorazepam, Trazedone, Carbamazepine
• Insomnia
• Melatonin, Benzodiazepines, Trazedone
• Sundowning
• Trazedone, Haloperidol, Risperidone, Olanzepine

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PROGRESSION

• Forgetfulness
• complains of memory deficits, misplace objects,
  trouble word finding, functional
• Confusional
• getting lost, job trouble, language problems,
  lost objects, denial, anxiety, lost current
  events, cant handle finances other executive
  functions, withdrawal
• Early Dementia
• Need assistance, cant use phone reliably,
  disorentation to time, place, know family, can
  feed and toilet with reminders

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PROGRESSION

• Middle Dementia
• Unaware of surroundings, forget spouses name,
  loss of recent events of life, personality and
  behavior changes, needs help with most ADL
• Late Dementia
• Loss of all verbal abilities, complete
  incontinence, no thirst or hunger responses
• TIME COURSE

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DAY TO DAY CARE

• Be Firm, Dont Rush or Argue
• Now it time to.., dont rush or argue
• Minimize Distractions
• Decrease noise, remove visual clutter
• Keep It Simple, Keep It Safe
• Cannot follow multi-step commands
• Lower Your Standards
• Expect less from the patient
• Establish Routines
• Reassuring, reduce agitation

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Day to Day Care

• Alzheimers Association
• 1-800-848-9707 www.alza.org
• Washington Adult Day Care Assoc
• 206-461-3899 www.adultday.org
• Senior Information and Assistance
• 206-448-3110 www.seniorservice.org

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CARE FOR CAREGIVERS

• Information about progression
• Facilitate Day-to-Day Care
• Stress Reduction Skills
• Support
• Risk for depression, illness, fatigue, elder
  abuse
• How to know when you can no longer provide care
  at home

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CARE GIVER SUPPORT

• Alzheimers and Related Disorders Association
• 1-800-272-3900
• Alzheimers Disease Education and Referral Center
• 1-800-438-4380
• www.alzheimers.org/adear
• Family Caregiver Alliance
• 1-800-445-8160
• www.caregiver.org

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Economics of Dementia

• 2-5 million affected
• With current demographics 10 million by 2030
• Expenses TOTAL 100 Billion
• Ranks third (Heart disease and Cancer)
• Per Capita
• Direct 10-25K home, 40-50k NH
• Indirect 60k
• Unpaid Care 10-50k
• Paid Out of Pocket 65

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REFERENCES

• Small, GW et.al. Diagnosis and Treatment of
  Alzheimer Disease and Related Disorders, JAMA
  Oct 1997.
• Raskind MA, Peskind ER. Alzheimers Disease and
  Related Disorders, Medical Clinics of NA May
  2001.
• Alzheimers Disease The Reality and the Promise,
  Patient Care Nov 1996. (Entire issue devoted to
  this topic.)
• Fillit H, Cummings J. Practice Guidelines for the
  Diagnosis and Treatmentof Alzheimers Disease in a
  Managed Care Setting Part I and II, Managed Care
  Interface Dec 1999.
• Tariot PN et. al. Treating Aggression in Patients
  witrh Dementia, Medical Education Collaborative
  and ABComm May 2000.
• Practical Alheimers Disease Management A
  ComparativeReview of New Compounds, Diasnosis,
  Treatment and Outcomes Assessment, Post Graduate
  Medicine May 1999.