Diagnosis and Management of Dementia

1
Diagnosis and Management of Dementia

• Michael Mistric, PhD, RN, FNP, BC
• Nurse Practitioner
• Michael E. DeBakey VA Medical Center

2
Objectives

• Describe the demographics associated with
  Alzheimers dementia
• Describe the clinical features of Alzheimers
  dementia
• Describe the medical management of Alzheimers
  dementia
• Describe caregiver support services for
  individuals with Alzheimers dementia
• Describe caregivers basic social process of
  formulating expectations of dementia care

3
Dementia What it is

• A syndrome that has multiple reversible and
  irreversible causes and requires systematic
  evaluation of the patient presenting with a
  cognitive complaint
•    An acquired, persistent decline (not secondary
  to delirium) involving at least three of the
  following five domains language, memory,
  visiospatial skills, executive function, and
  personality and mood

4
Why Use Alzheimers Disease (AD) as the Exemplar?

• Approximately 5 million Americans have
  Alzheimers disease (AD).  Unless a cure or
  prevention is found, that number will increase to
  14 million by 2050.
• An estimated 280,000 Texas have Alzheimers
  disease.
• One in eight persons over 65 and nearly half of
  those over 85 have AD.  A small percentage of
  people as young as their 30s and 40s get the
  disease.
• AD is degenerative disease of the brain from
  which there is no recovery.
• AD is now the seventh leading cause of death in
  adults.

5
Why Use Alzheimers Disease (AD) as the Exemplar?

• Direct and indirect costs of AD and other
  dementias amount to more than 148 billion
  annually.
• Almost 10 million Americans are caring for a
  person with AD or another dementia approximately
  one out of three of these caregivers is 60 years
  or older.
• In 2005, it was estimated that unpaid caregivers
  of people with AD and other dementias provided
  8.5 billion hours of care valued at almost 83
  billion dollars.  
• More than half the states in the United States
  provide more than a billion dollars in unpaid
  care each year Texas 5.8 billion.

6
Quick Patho Overview

• The primary pathologic features of AD are
  amyloid deposition, neurofibrillary tangle
  formation, and neuronal loss

7
AD and the Brain
Plaques and Tangles The Hallmarks of AD The
brains of people with AD have an abundance of two
abnormal structures

• beta-amyloid plaques, which are dense deposits of
  protein and cellular material that accumulate
  outside and around nerve cells
• neurofibrillary tangles, which are twisted fibers
  that build up inside the nerve cell

An actual AD plaque
An actual AD tangle
8
AD and the Brain
Beta-amyloid Plaques Amyloid precursor protein
(APP) is the precursor to amyloid plaque. 1.
APP sticks through the neuron membrane. 2.
Enzymes cut the APP into fragments of protein,
including beta-amyloid. 3. Beta-amyloid
fragments come together in clumps to form
plaques.
1.
2.
In AD, many of these clumps form, disrupting the
work of neurons. This affects the hippocampus and
other areas of the cerebral cortex.
3.
9
AD and the Brain
Neurofibrillary Tangles
Neurons have an internal support structure partly
made up of microtubules. A protein called tau
helps stabilize microtubules. In AD, tau changes,
causing microtubules to collapse, and tau
proteins clump together to form neurofibrillary
tangles.
10
The 10 Warning Signs

• Memory loss
• Difficulty with familiar tasks
• Problems with language
• Disorientation to time and place
• Poor or decreased judgment

• Trouble with abstract thinking
• Misplacing things
• Changes in mood or behavior
• Changes in personality
• Loss of initiative

11
DSM-IV Criteria for Dementia

• Memory impairment and 1 or more
• Aphasia (language disturbance)
• Apraxia (inability to carry out motor activities
• Agnosia (failure to recognize objects)
• Disturbed executive function (planning,
  organizing)
• Cognitive deficits
• Gradual onset, continued decline
• Deficits not due to another condition
• Deficits not exclusive to delirium

12
AD and the Brain
The Changing Brain in Alzheimers Disease
No one knows what causes AD to begin, but we do
know a lot about what happens in the brain once
AD takes hold.
Pet Scan of Normal Brain
Pet Scan of Alzheimers Disease Brain
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Importance Significance of Diagnostic Work-Up

• Treat a reversible condition
• Treat co-morbid conditions
• Avoid exacerbation
• Limit complications
• Relieve symptoms

• AD no longer a diagnosis of exclusion
• Drugs programming depend on staging
• Caregivers can be secondary victims provide for
  them as well

14
AD Research Diagnosing AD
Providers today use a number of tools to diagnose
AD

• a detailed patient history
• information from family
• and friends
• physical and neurological exams and lab tests
• neuropsychological tests (MMSE, GDS, Global
  Deterioration Scale, Affect Balance, BEHAVE-D
• imaging tools such as CT scan, or magnetic
  resonance imaging (MRI), PET scans

15
Assessment Protocols

• Complete PE History
• Mini-Mental State Exam (MMSE) or Physical
  Self-Maintenance Scale (PSMS) to establish
  baseline cognition and functional ability
• Global Deterioration Scale useful for staging
• Affect Balance or Geriatric Depression Scale
• Katz ADLs IADLs
• BEHAVE-AD

16
Cultural Considerations

• Members of various ethnic groups, cultures, and
  races manifest and cope differently with the
  disease, care-giving, and related stresses
• Some Asian/Pacific Islanders view AD as a normal
  part of aging
• Some Hispanics view AD as a spiritual test or
  punishment for a past deed.
• Some African Americans rely on their spiritual
  faith to deal with the illness and care-giving.

17
Research Findings African Americans

• 1st degree African American relatives have higher
  risk than Caucasians.
• African Americans are 4 times more likely to
  develop AD by age 90
• African Americans and Hispanics may be at higher
  genetic risk based on APOE-4 allele aberration
• Hypertension and hypercholesterolemia each place
  African American at a 4 times risk for AD

18
Socio-Cultural-Behavioral African Americans

• African American family members caregivers may
  not consider dementia an illness, but rather an
  expected consequence of aging
• Some believe it is a form of mental illness
• May be believed to be the result of worriation
  and behaviors may be interpreted as spells
• First cue may be in the failure to carry out role
  and social functions (later than desired
  recognition per professional assessment)

19
Research Findings Hispanics

• Hispanics may be 2 times more likely than
  Caucasians to develop AD by age 90
• Vascular dementia has higher prevalence than AD

20
Socio-Cultural-Behavioral Hispanics

• Female family members are the designated
  caregivers
• Dementia may be viewed as some form of mental
  illness
• Dementia is a source of shame, embarrassment,
  stigma and, therefore may be a barrier to
  getting help
• Problem not typically shared in the cultural
  network

21
Socio-Cultural-Behavioral Asians/Pacific
Islanders

• Dementia is a form of normal aging
• Dementia is a form of mental illness
• Dementia is a source of shame
• Dementia is a family secret that should not be
  shared
• Dementia is a result of fate

22
Stages of Dementia

• Early Dementia
• All dressed up and no where to go
• Middle Dementia
• I want to go with you
• Late Dementia
• In his own little world

23
CharacteristicsEarly Stage Dementia

• Physical Appearance
• May still dress self appropriately
• Awareness
• Lost in Time
• Behaviors
• Wandering
• Anxious
• Resistance to ADLs
• Sleep disturbance

24
AD and the Brain
Preclinical AD

• Signs of AD are first noticed in the entorhinal
  cortex, then proceed to the hippocampus.
• Affected regions begin to shrink as nerve cells
  die.
• Changes can begin 10-20 years before symptoms
  appear.
• Memory loss is the first sign of AD.

Slide 20
25
Caregiving ChallengesEarly Stage Dementia

• Eating
• Eats independently
• May need cueing
• Remove stimulants from diet
• Toileting
• Needs supervision locating bathroom and reminders
  to go
• Usually continent
• Hydration
• Needs supervision
• Provide favorite beverages frequently

26
Caregiving ChallengesEarly Stage Dementia

• Dressing
• Needs help locating and choosing clothing
• Coaxing--resistance
• Personal Hygiene
• Needs supervision-is relatively independent
• Bathing
• Needs supervision
• Awareness of need to bathe is variable

27
CharacteristicsMiddle Stage Dementia

• Physical Appearance
• Looks unfinished does not want to change clothes
• Change in posture
• Awareness
• May be awareness of past versus present
• Unable to think in the abstract
• Behaviors
• Wanders, is suspicious, resistant to caregivers,
  social butterfly

28
AD and the Brain

• AD spreads through the brain. The cerebral cortex
  begins to shrink as more and more neurons stop
  working and die.
• Mild AD signs can include memory loss, confusion,
  trouble handling money, poor judgment, mood
  changes, and increased anxiety.
• Moderate AD signs can include increased memory
  loss and confusion, problems recognizing people,
  difficulty with language and thoughts,
  restlessness, agitation, wandering, and
  repetitive statements.

Mild to Moderate AD
Slide 21
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Caregiving ChallengesMiddle Stage Dementia

• Eating
• Trouble using utensils, positioning, and
  swallowing--precut food, use prompting/cueing
• Toileting
• Needs assistance with mechanics--wiping,
  flushing, pulling down underwear, reminders
• Hydration
• Hydration is dependent on caregiver attention

30
Caregiving ChallengesMiddle Stage Dementia

• Dressing
• Assistance in dressing due to agnosia, apraxia
• Personal Hygiene
• Assistance due to agnosia, apraxia, Parkinsonian
  symptoms
• Needs tasks broken down
• Bathing
• Needs supervision
• Awareness of need to bathe is dependent on
  caregiver

31
CharacteristicsLate Stage Dementia

• Physical Appearance
• Looks abnormal, undresses, looks lost,
  posture/balance deficits, loses weight, loss of
  3D vision
• Awareness
• Limited to field of vision, seeks sensory
  stimulation
• Behaviors
• Hyper/hypo activity, cannot communicate needs,
  does not recognize self or loved ones

32
AD and the Brain
Severe AD

• In severe AD, extreme shrinkage occurs in the
  brain. Patients are completely dependent on
  others for care.
• Symptoms can include weight loss, seizures, skin
  infections, groaning, moaning, or grunting,
  increased sleeping, loss of bladder and bowel
  control.
• Death usually occurs from aspiration pneumonia or
  other infections. Caregivers can turn to a
  hospice for help and palliative care.

Slide 22
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Caregiving ChallengesLate Stage Dementia

• Eating
• Total loss in eating skills using utensils,
  position, swallowing difficulty
• Toileting
• Total Care
• May resist
• Hydration
• Unable to pour water or understand need or
  mechanics of drinking water

34
Caregiving ChallengesLate Stage Dementia

• Dressing
• Needs total assistance
• May disrobe or fiddle with clothes
• Personal Hygiene
• Needs total assistance.
• Able to do one step tasks e.g. washing face
• Bathing
• Unable to comprehend bathing
• May resist sponge or bed bath

35
Treatment Goals

• All are focused on maximizing the potential of
  the patient and managing symptoms
• Support cognitive functioning
• Reduce and prevent functional disabilities
• Ameliorate and mediate behavioral disturbances

36
AD Research Managing Symptoms
Between 70 to 90 of people with AD eventually
develop behavioral symptoms, including
sleeplessness, wandering and pacing, aggression,
agitation, anger, depression, and hallucinations
and delusions. Experts suggest these general
coping strategies for managing difficult
behaviors

• Stay calm and be understanding.
• Be patient and flexible. Dont argue or try to
  convince.
• Acknowledge requests and respond to them.
• Try not to take behaviors personally. Remember
  its the disease talking, not your loved one.

Experts encourage caregivers to try non-medical
coping strategies first. However, medical
treatment is often available if the behavior has
become too difficult to handle. Researchers
continue to look at both non-medical and medical
ways to help caregivers.
37
Barriers to Overcome

• Still are people that accept memory loss
  confusion as a natural part of aging
• Cognitive impairments of any kind are not easy to
  admit, recognize, or discuss
• Patients hide or compensate for early signs
• Families deny what is being seen

38
Diagnosis and Evaluation

• Requires comparison of cognitive and physical
  functioning relative to a previous level of
  performance
• Eliminate or reverse any other (vascular,
  metabolic, etc.) causes
• Proceed by clinical criteria and protocols for
  radiologic laboratory studies
• Refer to neurologist and Alzheimers Disease
  Research Center

39
Interview and Care for the Caregiver

• What Alzheimer symptoms are most prevalent?
• What significant changes have you noticed?
• Memory
• Behavior
• Personality
• Skills
• Other
• How have you successfully accommodated for these
  changes?
• What caregiving challenges are you facing?
• What activities does your loved one still enjoy?
• Describe a special moment you shared with your
  loved one recently.

40
Treatment Realities

• Current treatments for Alzheimers are not
  designed to reverse the disease process totally,
  yet they can produce some improvements in
  cognition.
• Existing medications can be effective in slowing
  the progression of the disease and helping
  patients remain independent for longer periods of
  time.
• Treating symptoms effectively is valuable not
  only to patients but also to their caregivers and
  families.

41
Primary Treatment

• Cholinesterase inhibitors
• Receptor agonists
• Estrogen
• Anti-inflammatory drugs
• Antioxidants
• Various experimental agents
• Behavioral controls

42
Medications used to treat Dementia

• Cholinesterase Inhibitors
• Donepezil (Aricept) Mild/Moderate Dementia
• Start with 5 mg/day increase to 10 mg/day in 4
  weeks
• Nausea Diarrhea Poor Appetite
• Rivastigmine (Exelon) Mild/Moderate Dementia
• Start with 4.6 mg/24 hour patch daily increase
  to 9.5 mg/24 hour patch daily in 4 weeks
• Nausea Diarrhea Poor Appetite
• Galantamine (Reminyl) Mild/Moderate Dementia
• Start with 8 mg a day increase by 8 mg every
  four weeks up to 24 mg a day
• Nausea Diarrhea Poor Appetite

43
Medications used to treat Dementia

• N-methyl-D-aspartate (NMDA)
• Memantine (Namenda) Moderate/Severe Dementia
• Start with 5 mg a day increase by 5 mg a week up
  to 10 mg twice a day
• Headache Dizziness Confusion
• Tacrine (Cognex)
• Not used anymore
• Prototypical cholinesterase inhibitor for the
  treatment of Alzheimer's disease

44
Cholinergic Receptor Agonists

• Muscarinic receptor agonists
• M1-type muscarinic acetylcholine receptors play a
  role in cognitive processing.
• In Alzheimer disease (AD) amyloid formation may
  decrease the ability of these receptors to
  transmit their signals leading to decrease
  cholinergic activity.
• A number of muscarinic agonists have been
  developed and are under investigation to treat
  AD.
• These agents show promise as they are
  neurotrophic, decrease amyloid depositions, and
  improve damage due to oxidative stress.

45
Cholinergic Receptor Agonists

• Nicotinic receptor agonists
• Nicotine has long been known to improve cognitive
  function, but its adverse effects make it
  problematic as a treatment for diseases of
  cognitive dysfunction
• Recent research has revealed that certain
  subtypes of nicotinic acetylcholinesterase
  receptors (nAChRs) in the brain are involved in
  cognitive function
• Agents that target these nAChRs have shown
  promise in Alzheimers disease
• Research also suggests that these agents may not
  only improve cognition but also be
  neuroprotective

46
Estrogen

• Early studies of estrogen suggested that it might
  help prevent AD in older women.
• However, a clinical study of several thousand
  postmenopausal women aged 65 or older found that
  combination therapy with estrogen and progestin
  substantially increased the risk of AD.
• Estrogen alone also appeared to slightly
  increase the risk of dementia in this study.
• Therefore, based on epidemiological
  correlations, the use of estrogen to prevent or
  treat dementia has not been supported by
  follow-up studies and is not recommended.

47
Anti-inflammatory Agents

• Several studies have found evidence of brain
  inflammation in AD and researchers have proposed
  that drugs that control inflammation, such as
  NSAIDs, might prevent the disease or slow its
  progression and early studies of these drugs in
  humans have shown promising results.
• However, a large NIH-funded clinical trial of
  two NSAIDS (naproxen and celecoxib) to prevent AD
  was stopped in late 2004 because of an increase
  in stroke and heart attack in people taking
  naproxen, and an unrelated study that linked
  celecoxib to an increased risk of heart attack.
• Therefore, based on epidemiological
  correlations, the use of NSAIDs to prevent or
  treat dementia has not been supported by
  follow-up studies and is not recommended.

48
Antioxidants Vitamin E

• A recent double-blind, placebo-controlled study
  of Vitamin E and donepezil for the treatment of
  mild cognitive impairment was unable to
  demonstrate benefit form Vitamin E and showed
  only modest and short-term benefit from
  donepezil.
• This result suggested there was no role for the
  use of Vitamin E in the prevention or early
  treatment of Alzheimers Dementia.

49
Investigative Vaccines

• Many researchers believe a vaccine that reduces
  the number of amyloid plaques in the brain might
  ultimately prove to be the most effective
  treatment for AD.
• In 2001, researchers began one clinical trial of
  a vaccine called AN-1792.
• The study was halted after a number of people
  developed inflammation of the brain and spinal
  cord.
• Despite these problems, one patient appeared to
  have reduced numbers of amyloid plaques in the
  brain.
• Other patients showed little or no cognitive
  decline during the course of the study,
  suggesting that the vaccine may slow or halt the
  disease.
• Researchers are now trying to find safer and more
  effective vaccines for AD.

50
General Management Guidelines

• Look for concurrent illness/problems
• Look at medications
• Try non-pharmocologic alternatives
• Target the dominant symptom
• Start drugs low and go slow
• Look at drug with best side effect profile
• Review compliance
• Simplify
• Give clear and written instructions

51
Medications Antipsychotics

• Respiridone (Resperdal)
• 0.5 - 2 mg/day in two divided doses
• Sedation Parkinson's Disease symptoms
• Haloperidol (Haldol)
• 0.25 - 2 mg/day. Gradually increase this
  dose. Use sparingly only for severe agitation
• Parkinson's Disease symptoms Sedation Falling
  Abnormal Movements
• Quetiapine (Seroquel)
• 12.5 - 200 mg/day in two divided doses
• Sedation Light headedness
• Olanzapine (Zyprexia)
• 2.5 - 10 mg/day
• Sedation Light headedness Confusion Dry Mouth
  Constipation

52
Medications Antidepressants

• Citalopram (Celexa)
• 10 - 60 mg/day
• Nausea Dry Mouth Sedation
• Mirtazepine (Remeron)
• 15 - 30 mg at night
• Sedation Weight Gain Dry Mouth
• Sertraline (Zoloft)
• 50 - 200 mg/day
• Insomnia Diarrhea Tremor

53
End of Life Care

• People with AD usually die from complications
• Without an advance directive executed while the
  individual was competent, a substitute decision
  maker makes difficult life and death decisions
• End-of-life choices may include the use,
  limitation, withdrawal or refusal of
• procedures, treatments or technology such as tube
  feeding
• mechanical respirators or ventilators
• cardiopulmonary resuscitation (CPR)
• surgery
• the use of antibiotics
• A hospice program offers a more humane and
  compassionate option than the nursing home or
  hospital during the final months

54
Take Home Points to Remember

• Simplify - Simplify - Simplify
• Medications Start Slow
• Look for concurrent illness/problems
• Remember your goal
• To improve quality of life
• Do no harm!
• Consider the caregiver and family

55
Dementia Caregivers Journeys and Expectations of
Care

• The specific aims were to
• Elicit subjective perspectives of family members
  about what constitutes quality LTC for loved-ones
  with dementia, and
• Develop a grounded theory of shared meanings
  about quality dementia care that reflects the
  expectations of family members in various stages
  of giving care and relinquishing care for a
  loved-one with dementia
• Research Question
• How do family members describe their expectations
  of dementia care in the LTC setting?

56
Five transition stages in the lives of dementia
caregivers

• Stage 1 Transitions to caregiver role
• Sees losses
• Stage 2 Takes on caregiver role
• Fills gaps
• Stage 3 Relinquishes caregiver role
• Recognizes limits
• Acknowledges need for LTC placement
• Responds to relinquishment of care
• Stage 4 Selects and evaluates LTC facility
• Makes selection
• Evaluates care
• Stage 5 Accepts LTC resident status
• Accepts LTC status
• Justifies LTC placement

57
Six Categories of Dementia Care Expectations

• Patient Care
• Nutrition, hygiene, toileting, medications, and
  activities
• Pleasant Surroundings
• Residents room and facility common areas
• Competent Staff
• Ability to provide dementia care and care of
  individuals in LTC

• Caring Staff
• Treat with dignity and respect free from neglect
  and abuse
• Communication
• What is communicated when communication should
  occur
• Institutional Responsiveness
• Staff response to questions and concerns

58
Internet ExplorationTheres a Ton Out There!

• The Alzheimers Association
• http//www.alz.org
• Family Caregiver Alliance
• http//www.caregiver.org
• AgeNet follow the "Geriatric Health" link
• http//www.agenet.com/early_alz_guide.html
• Mayo Clinic Health Oasis
• http//www.mayohealth.org/

59
Internet ExplorationTheres a Ton Out There!

• Alzheimer's Disease Education and Referral Center
  (ADEAR Center)
• http//www.alzheimers.org
• Alzheimer's Research Forum
• http//www.alzforum.org
• American Academy of Neurology
• http//www.aan.com
• National Institute of Neurological Disorders and
  Stroke
• http//www.ninds.nih.gov

60
Internet ExplorationTheres a Ton Out There!

• Medic Alert
• http//www.medicalert.org
• National Institute on Aging and Eldercare Locator
• http//www.eldercare.gov
• American Health Assistance Foundation (AHAF)
• http//www.ahaf.org
• Ethnicity and Dementia
• http//www.ethnicelderscare.net

61
Prevalence Rises exponentially with age to
nearly 50 by age 85Diagnosis Early diagnosis
now done clinically with 85-95
accuracyPrognosis Progressive decline lasting
up to 20 years before deathGoalRelieve symptoms
complications and improve quality of life
through early diagnosis and prompt treatmentAs
of yet, there is no prevention or cure!
Summary