Managing Dementia in Primary Managing Dementia in Primary Care: From Diagnosis to Driving Care: From Diagnosis to Driving

to Dangerous Medicationsto Dangerous Medications

Elizabeth Eckstrom, Elizabeth Eckstrom, MD, MPHMD, MPH

eckstrom@ohsu.edu

Providence Hood Providence Hood River Memorial River Memorial

HospitalHospital

November 5, 2013November 5, 2013

Goals for TodayGoals for Today

Confidently diagnose mild cognitive impairment Confidently diagnose mild cognitive impairment and dementia, and determine if your patient with and dementia, and determine if your patient with dementia has Alzheimer’s, Vascular, Lewy Body, dementia has Alzheimer’s, Vascular, Lewy Body, Frontotemporal, or MixedFrontotemporal, or Mixed

Gain some tools to assist in driving cessation Gain some tools to assist in driving cessation when older patients are no longer safe to drivewhen older patients are no longer safe to drive

Review medications that might be high risk for Review medications that might be high risk for people with cognitive impairmentpeople with cognitive impairment

Mrs. AtkinsonMrs. Atkinson

Mrs. A is a delightful 82 year old whose husband died 6 Mrs. A is a delightful 82 year old whose husband died 6 months ago.months ago.

Today, her daughter reports increasing “forgetfulness” in Today, her daughter reports increasing “forgetfulness” in the past 2-3 years which has gotten worse since her the past 2-3 years which has gotten worse since her father died. She notices that her mom quickly forgets father died. She notices that her mom quickly forgets conversations they had had and has had trouble paying conversations they had had and has had trouble paying the bills since the death of her husband.the bills since the death of her husband.

More recently she has also been neglecting her More recently she has also been neglecting her appearance and has been unable to keep up on the appearance and has been unable to keep up on the housework.housework.

She takes HCTZ, a baby aspirin, a daily multivitamin and She takes HCTZ, a baby aspirin, a daily multivitamin and occasional diphenhydramine for insomnia.occasional diphenhydramine for insomnia.

More on Mrs. AtkinsonMore on Mrs. Atkinson

-No trouble with ADLs other than occasional lack of -No trouble with ADLs other than occasional lack of grooming grooming

-No trouble with walking or mobility-No trouble with walking or mobility

-Initially very sad over the death of her husband, but now -Initially very sad over the death of her husband, but now has “come to terms” with her griefhas “come to terms” with her grief

-No wandering, or agitation-No wandering, or agitation

-No loss of appetite or weight loss-No loss of appetite or weight loss

-Never smoked, rarely drinks-Never smoked, rarely drinks

-Studied romance languages in college-Studied romance languages in college

-Still practices Italian once a week with a friend-Still practices Italian once a week with a friend

© 2013, KAISER PERMANENTE CENTER FOR HEALTH RESEARCH KPRA EPC

EPC Team: EPC Team: Jennifer S. Lin, MD, MCRJennifer S. Lin, MD, MCR

Elizabeth O’Connor, PhDElizabeth O’Connor, PhD

Rebecca C. Rossom, MD, MSCRRebecca C. Rossom, MD, MSCR

Leslie A. Perdue, MPHLeslie A. Perdue, MPH

Elizabeth Eckstrom, MD, MPHElizabeth Eckstrom, MD, MPH

Screening for Cognitive Impairment in Older Adults

Annals of Internal Medicine, Nov 5, 2013

Rationale for ScreeningRationale for Screening~29–76% of patients with dementia are not ~29–76% of patients with dementia are not diagnosed by PC cliniciansdiagnosed by PC clinicians

Early identification may have benefits even if Early identification may have benefits even if treatment cannot alter natural history of diseasetreatment cannot alter natural history of disease– Optimize clinical care (e.g., treatment of Optimize clinical care (e.g., treatment of

reversible causes, management of co-reversible causes, management of co-morbidities, patient safety)morbidities, patient safety)

– Facilitate decision-making (e.g., health care, Facilitate decision-making (e.g., health care, financial, legal)financial, legal)

– Reduce patient and caregiver stress/burdenReduce patient and caregiver stress/burden

Treatment Evidence in DementiaTreatment Evidence in Dementia

AChEI and memantine can improve global cognitive AChEI and memantine can improve global cognitive function and global function in the short termfunction and global function in the short term

– Discontinuation of AChEI is common and serious Discontinuation of AChEI is common and serious harms of medications can include CNS, CV, and GI harms of medications can include CNS, CV, and GI symptomssymptoms

Complex interventions aimed at caregivers and patients Complex interventions aimed at caregivers and patients can improve caregiver burden and depressioncan improve caregiver burden and depression

Cognitive stimulation can improve global cognitive Cognitive stimulation can improve global cognitive functionfunction

77

Summary Task Force Summary Task Force RecommendationRecommendation

Still an “I” (insufficient evidence) for Still an “I” (insufficient evidence) for screeningscreening for cognitive impairment for cognitive impairment

Screening tools ARE good enoughScreening tools ARE good enough

Drugs, cognitive therapy, and caregiver Drugs, cognitive therapy, and caregiver interventions provide some benefit, but interventions provide some benefit, but clinical relevance uncertain clinical relevance uncertain

Not enough studies on how diagnosis of Not enough studies on how diagnosis of dementia affects decision making for overall dementia affects decision making for overall carecare

Summary Task Force Summary Task Force RecommendationRecommendation

“…“…while the overall evidence on routine while the overall evidence on routine screening is insufficient, clinicians should screening is insufficient, clinicians should remain alert to early signs or symptoms of remain alert to early signs or symptoms of cognitive impairment and evaluate as cognitive impairment and evaluate as appropriate”appropriate”

Recommendations are in draft form till Dec 2- Recommendations are in draft form till Dec 2- comments welcome at: comments welcome at: http://www.uspreventiveservicestaskforce.org/draftrec.htmhttp://www.uspreventiveservicestaskforce.org/draftrec.htm

New DSM-V Terminology: Major New DSM-V Terminology: Major Neurocognitive Disorder (MCD)Neurocognitive Disorder (MCD)

Patient/informant/clinician report of decline in abilities Patient/informant/clinician report of decline in abilities

Clear deficits in objective assessment of:Clear deficits in objective assessment of:– Complex attention Complex attention (sustained attention, divided attention, selective (sustained attention, divided attention, selective

attention, processing speed)attention, processing speed)– Executive ability Executive ability (planning, decision making, response to (planning, decision making, response to

feedback/error correction, mental flexibility)feedback/error correction, mental flexibility)– Learning and memory Learning and memory (immediate or recent)(immediate or recent)– LanguageLanguage (expressive and receptive) (expressive and receptive)– Visuoconstructionalperceptual ability Visuoconstructionalperceptual ability – Social cognition Social cognition (emotions, behavioral regulation)(emotions, behavioral regulation)

Deficits interfere with independence (IADLs)Deficits interfere with independence (IADLs)

Not delirium, psychotic disorder, etcNot delirium, psychotic disorder, etc

Minor Neurocognitive Disorder Minor Neurocognitive Disorder (Mild Cognitive Impairment)(Mild Cognitive Impairment)

Minor cognitive Minor cognitive decline from a previous decline from a previous level of performance in one or more of the level of performance in one or more of the domains domains

No interference with function but greater No interference with function but greater effort and compensatory strategies may be effort and compensatory strategies may be required to maintain independence.required to maintain independence.

Not delirium, depression, etcNot delirium, depression, etc

50% progress to dementia in 7.6 years50% progress to dementia in 7.6 years

A quick, accurate dementia A quick, accurate dementia screening testscreening test

MINI-COG MINI-COG Scanlan et al, Int J Geriatr Pshcy 2001;16:216.Scanlan et al, Int J Geriatr Pshcy 2001;16:216.

– 99% Sensitivity99% Sensitivity

3-Item recall3-Item recall– ask the patient to remember the names of three ask the patient to remember the names of three

objects (pencil, truck, book)objects (pencil, truck, book)– the patient fails the screen if she is unable to the patient fails the screen if she is unable to

remember at least 2 of 3 objects in one minuteremember at least 2 of 3 objects in one minute

Clock DrawClock Draw– ask patient to draw a large circle, fill in the numbers ask patient to draw a large circle, fill in the numbers

on a clock face, and set the hands at 11:10on a clock face, and set the hands at 11:10

Abnormal Face

Abnormal Numbers

Abnormal Hands

Bottom Line- if not PERFECT, patient has some cognitive impairment

Clock Draw- tests memory, visual-spacial, executive function, abstraction

SLUMSSLUMS

Validated for MCI and dementia, Free and fairlyquick to perform

MoCAMoCA

Good test for vascular Dementia, Parkinson’s patients, and if you are concerned about driving

MMSE- use for following dementiaMMSE- use for following dementia

– Tests orientation, memory, visual-spacial, verbal Tests orientation, memory, visual-spacial, verbal fluencyfluency

– Correct for age and educational level- when you Correct for age and educational level- when you document the patient’s score, also note the normal document the patient’s score, also note the normal value for that patient. Be sure to ask the patient value for that patient. Be sure to ask the patient how far they progressed in school!how far they progressed in school!

– The MMSE doesn’t test all areas of cognitive The MMSE doesn’t test all areas of cognitive function, so other cognitive testing must be done function, so other cognitive testing must be done to determine what type of dementia a patient hasto determine what type of dementia a patient has

– ONLY TEST VALIDATED FOR FOLLOWING ONLY TEST VALIDATED FOR FOLLOWING ALZHEIMER DISEASE OVER TIMEALZHEIMER DISEASE OVER TIME

Alzheimer’s DementiaAlzheimer’s Dementia

Impairment in learning and retaining new Impairment in learning and retaining new information plus at least one:information plus at least one:– Complex attention Complex attention (sustained attention, divided (sustained attention, divided

attention, selective attention, processing speed)attention, selective attention, processing speed)– Executive ability Executive ability (planning, decision making, response (planning, decision making, response

to feedback/error correction, mental flexibility)to feedback/error correction, mental flexibility)– LanguageLanguage (expressive and receptive) (expressive and receptive)– Visuoconstructionalperceptual ability Visuoconstructionalperceptual ability

– Social cognition Social cognition (emotions, behavioral regulation) (emotions, behavioral regulation)

Vascular DementiaVascular Dementia

Remember: vascular insults are very common in Alzheimer’s disease Remember: vascular insults are very common in Alzheimer’s disease (20% of patients have both vascular and Alzheimer’s pathology)(20% of patients have both vascular and Alzheimer’s pathology)

DSM IV: dementia; focal neurological signs and symptoms DSM IV: dementia; focal neurological signs and symptoms or brain imaging evidence of cerebrovascular disease or brain imaging evidence of cerebrovascular disease judged to be etiologically related to the dementiajudged to be etiologically related to the dementia– focal neurologic signs: hemiparesis, babinski, hemianopia, focal neurologic signs: hemiparesis, babinski, hemianopia,

dysarthria, gait disturbancedysarthria, gait disturbance– CVD evident on brain imaging: multiple large vessel infarcts, CVD evident on brain imaging: multiple large vessel infarcts,

single strategic infarct, or multiple basal ganglia or extensive single strategic infarct, or multiple basal ganglia or extensive WMHWMH

– relationship: a) dementia within 3 months of stroke or b) abrupt relationship: a) dementia within 3 months of stroke or b) abrupt or fluctuating or stepwise deterioration or fluctuating or stepwise deterioration

Lewy Body DementiaLewy Body Dementia

Parkinsonian findings: shuffling gait, rigidity, Parkinsonian findings: shuffling gait, rigidity, trouble swallowing (tremor may not be trouble swallowing (tremor may not be prominent)prominent)

Fluctuation in LOC and cognitionFluctuation in LOC and cognition

Well formed visual hallucinationsWell formed visual hallucinations

Attention, executive function and visual-spatial Attention, executive function and visual-spatial abnormalities may be more prominent than abnormalities may be more prominent than memory problemsmemory problems

REM sleep disorders (ie frightening dreams)REM sleep disorders (ie frightening dreams)

Lewy Body DementiaLewy Body Dementia

Very sensitive to the effects of neuroleptics- Very sensitive to the effects of neuroleptics- DON’T use Haldol for visual hallucinationsDON’T use Haldol for visual hallucinations

May markedly worsen with Parkinson’s drugs May markedly worsen with Parkinson’s drugs and not recover after discontinuation of the and not recover after discontinuation of the medicine- DON’T use Sinemet for rigiditymedicine- DON’T use Sinemet for rigidity

Very responsive to Acetylcholine esterase Very responsive to Acetylcholine esterase inhibitors: best treatment for the hallucinationsinhibitors: best treatment for the hallucinations

Can be very rapidly progressiveCan be very rapidly progressive

Frontotemporal DementiaFrontotemporal DementiaDecline in personal or social interpersonal Decline in personal or social interpersonal conduct conduct – loss of empathy, socially inappropriate behaviors loss of empathy, socially inappropriate behaviors

(rude, irresponsible, sexually explicit), mental rigidity, (rude, irresponsible, sexually explicit), mental rigidity, inflexibility in relationships or severe apathyinflexibility in relationships or severe apathy

Impaired reasoning and difficulty with tasks out Impaired reasoning and difficulty with tasks out of proportion to impairments in memory, visual-of proportion to impairments in memory, visual-spatial skillsspatial skills

May have marked language, gait abnormalitiesMay have marked language, gait abnormalities

May have younger age of onsetMay have younger age of onset

Differential diagnosis of Differential diagnosis of dementiadementia

Alzheimer’s Disease (40%)Alzheimer’s Disease (40%)

Mixed AD & Vascular (15%)Mixed AD & Vascular (15%)

Mixed AD & Lewy body Mixed AD & Lewy body (16%)(16%)

Lewy body dementias Lewy body dementias (10%)(10%)

Vascular dementias (3%)Vascular dementias (3%)

Frontotemporal (5%)Frontotemporal (5%)

Others (11%)Others (11%)– PSP, EtOH, infectious, TBI, PSP, EtOH, infectious, TBI,

NPH, CJD, etc.NPH, CJD, etc.

AD w/ VaDADLewyAD w/ LewyVaDOthersFrontotemporal

Mrs. AtkinsonMrs. Atkinson

Disheveled, hard of hearingDisheveled, hard of hearing

Non-focal neuro exam, gait okNon-focal neuro exam, gait ok

SLUMS- fully oriented, registers 5 items, but SLUMS- fully oriented, registers 5 items, but able to recall only 3 of 5, Able to name 12 able to recall only 3 of 5, Able to name 12 animals in one minute, clock poor, misses animals in one minute, clock poor, misses items on storyitems on story

In total she scored 18/30In total she scored 18/30

What is her diagnosis?What is her diagnosis?

Cholinesterase Inhibitors and DementiaCholinesterase Inhibitors and Dementia• Studies done in patients with mild to Studies done in patients with mild to

moderate Alzheimer's disease moderate Alzheimer's disease • Most studies found a statistically significant Most studies found a statistically significant

difference favoring cholinesterase inhibitorsdifference favoring cholinesterase inhibitors– Slowing of decline approximately equivalent to a Slowing of decline approximately equivalent to a

delay in disease progression of up to 7 months in delay in disease progression of up to 7 months in a person with mild dementia, or a delay of 2 to 5 a person with mild dementia, or a delay of 2 to 5 months in a person with moderate dementiamonths in a person with moderate dementia

• In general, little or no effect on functional In general, little or no effect on functional decline after 6 months of treatment, and decline after 6 months of treatment, and small difference from placebo after 12 monthsmall difference from placebo after 12 month

Raina, P, et al. Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review for a Clinical Practice Guideline. Ann intern Med. 2008;148: 379-397.

MemantineMemantineIndicated for moderate to severe Indicated for moderate to severe dementia. Patient should be able to dementia. Patient should be able to perform at least one ADL with minor perform at least one ADL with minor assistanceassistance

Monotherapy Monotherapy or or in addition to a in addition to a cholinesterase inhibitorcholinesterase inhibitor

Dose: Dose: 5mg -10 mg bid5mg -10 mg bidFor creatinine clearance of 40-60, max dose is For creatinine clearance of 40-60, max dose is 10 mg. Not to be used for patients requiring 10 mg. Not to be used for patients requiring dialysis.dialysis.

SupplementsSupplements

Vitamin EVitamin E

Vitamin BVitamin B

GingkoGingko

NSAIDSNSAIDS

None have shown any slowing of None have shown any slowing of progression to Alzheimer's, but…progression to Alzheimer's, but…

Exercise and dietExercise and diet

Several prospective cohort studies have Several prospective cohort studies have shown that adherence to a Mediterranean shown that adherence to a Mediterranean diet and physical activity were associated diet and physical activity were associated with a reduced risk for Alzheimer’s with a reduced risk for Alzheimer’s Disease.Disease.

Scarmeas et.al. “Physical activity, diet and risk of Alzheimer disease”. JAMA. Aug 12; 302 (6) 627-37. 2009Feart et.al. “Adherence to a Mediterranean diet, cognitive decline and risk of dementia”. JAMA. Aug 12; 302(6) 638-48Sofi et. Al. “Physical activity and risk of cognitive decline: a meta-analysis of prospective studies”. J Intern Med. Jan; 269 (1) 107-17; 2011

Tools for CaregiversTools for Caregivers

Give all patients and family members the Give all patients and family members the phone number to the Alzheimer's phone number to the Alzheimer's Association 24 hour help line:  Association 24 hour help line: 

1-800-272-39001-800-272-3900

Alz.orgAlz.org

Also consider referral for a research study: Also consider referral for a research study:

Alz.org/trialmatchAlz.org/trialmatch

Dementia Advance PlanningDementia Advance Planning

Allow natural death if patient has dementiaAllow natural death if patient has dementia

Eventually patients with dementia cannot eat or Eventually patients with dementia cannot eat or swallow on their own; feeding tubes do not prolong swallow on their own; feeding tubes do not prolong life or improve quality of lifelife or improve quality of life

Hospice eligibility in dementia: Patient can no longer Hospice eligibility in dementia: Patient can no longer perform own ADLs, plus can speak no more than 6 perform own ADLs, plus can speak no more than 6 words at a time, plus have another dementia related words at a time, plus have another dementia related comorbidity (aspiration pneumonia, weight loss comorbidity (aspiration pneumonia, weight loss >10% body weight, etc).>10% body weight, etc).

Consider memory units, home caregiving, other Consider memory units, home caregiving, other optionsoptions

Strategies for Specific Types of Strategies for Specific Types of DementiaDementia

People with Alzheimer’s disease and vascular People with Alzheimer’s disease and vascular dementia maintain social graces until late; family dementia maintain social graces until late; family underestimate & need to know what the person’s underestimate & need to know what the person’s deficits are. deficits are.

LBD course may progress from “normal” to very LBD course may progress from “normal” to very impaired over a few years; family need to impaired over a few years; family need to understand delusions, waxing and waning, and understand delusions, waxing and waning, and affective Sx.affective Sx.

FTD behavior and disinhibition predominate early FTD behavior and disinhibition predominate early (for most other dementia these are late)(for most other dementia these are late)

SummarySummary

If you suspect cognitive impairment, use the If you suspect cognitive impairment, use the history and physical to determine type of history and physical to determine type of cognitive disorder as this will guide your carecognitive disorder as this will guide your care

Offer medications with patient and family Offer medications with patient and family goals of care in mind; often value is marginalgoals of care in mind; often value is marginal

Support the patient and the familySupport the patient and the family

ALZ.ORGALZ.ORG

Mr. HartMr. HartMr. Hart is 86 and a healthy, Mr. Hart is 86 and a healthy,

retired university professor retired university professor who just moved to Portland who just moved to Portland from Boston. He is rather from Boston. He is rather proud that he has already proud that he has already learned to drive to my office at learned to drive to my office at OHSU. His SLUMS score is OHSU. His SLUMS score is 22. He states he will “never 22. He states he will “never give up driving.” His wife is a give up driving.” His wife is a little worried by several “near little worried by several “near misses.”misses.”

What would you do?What would you do?

The Importance of DrivingThe Importance of Driving to Older Adults to Older Adults

Driving defines independence and Driving defines independence and provides a sense of self-esteem.provides a sense of self-esteem.

Over 88% of older Americans rely on a Over 88% of older Americans rely on a private automobile for their transportation private automobile for their transportation needs.needs.

Driving cessation often leads to decreased Driving cessation often leads to decreased ability to freely participate in social ability to freely participate in social opportunities or engage in IADLs.opportunities or engage in IADLs.

Conditions Example

Polypharmacy Anticholinergics, some antidepressants, anti-convulsants, sedatives-narcotics

Cardiovascular disease Unstable angina, heart failure

Neurological disease Parkinsons, dementia, seizures, vertigo

Psychiatric disease Depression, substance abuse

Metabolic disorders DM with hypoglycemia

Visual disease Cataracts, macular degeneration

Respiratory disease COPD, sleep apnea

Musculoskeletal disease Arthritis

Conditions Associated withConditions Associated withDriving RiskDriving Risk

Our EPIC dotphraseOur EPIC dotphraseDriving EvaluationDriving EvaluationHPI: HPI: Do you ever feel confused/disoriented while driving?: ***Do you ever feel confused/disoriented while driving?: ***Are you a daily or near-daily driver?: ***Are you a daily or near-daily driver?: ***Do you avoid driving alone?: ***Do you avoid driving alone?: ***Do you have difficulty seeing the license plate of the car stopped ahead of you?: ***Do you have difficulty seeing the license plate of the car stopped ahead of you?: ***Crashes/citations in last 12 months: Crashes/citations in last 12 months: ******Family Concerns: ***Family Concerns: ***  Exam:Exam:Visual AcuityVisual Acuity: 20/ OD, 20/ OS, 20/ OU {w-w/o:5700} corrective lenses (<20/70 passes): 20/ OD, 20/ OS, 20/ OU {w-w/o:5700} corrective lenses (<20/70 passes)Visual FieldVisual Field: grossly {INTACT/LIMITED:325059} on confrontation, (at 3 feet) {FIELD : grossly {INTACT/LIMITED:325059} on confrontation, (at 3 feet) {FIELD CUT:325091} field cutCUT:325091} field cutMSKMSK: {FULL/LIMITED:325060} active ROM in neck, {FULL/LIMITED:325060} ROM in finger : {FULL/LIMITED:325060} active ROM in neck, {FULL/LIMITED:325060} ROM in finger curl, shoulder/elbow flexion, ankle dorsiflexion, and plantar flexion. Extremity strength ***/5 curl, shoulder/elbow flexion, ankle dorsiflexion, and plantar flexion. Extremity strength ***/5 (score of 4/5 or higher passes). {ABLE/UNABLE:325092} to perform (score of 4/5 or higher passes). {ABLE/UNABLE:325092} to perform get-up-an-go get-up-an-go (20 feet in (20 feet in 15 seconds), {ABLE:900340} to rise {w-w/o:5700} use of arms.15 seconds), {ABLE:900340} to rise {w-w/o:5700} use of arms.Neuro:Neuro: Alert and oriented. Gait and speech normal. DTR ***, sensation Alert and oriented. Gait and speech normal. DTR ***, sensation {INTACT/IMPAIRED:325061}.{INTACT/IMPAIRED:325061}.Cognition: Cognition: SLUMS score in last 6 months {SLUMS SCORE/NOT DONE:325062}; Clock SLUMS score in last 6 months {SLUMS SCORE/NOT DONE:325062}; Clock drawing test shows {NO DEFICITS/DEFICITS:325063}. Trail-Making Test B completed in *** drawing test shows {NO DEFICITS/DEFICITS:325063}. Trail-Making Test B completed in *** seconds (less than 180 seconds passes).seconds (less than 180 seconds passes).

Patient InstructionsPatient Instructions

OR DMV link for patients/families: OR DMV link for patients/families: http://cms.oregon.gov/ODOT/DMV/50plus/Pages/index.aspxhttp://cms.oregon.gov/ODOT/DMV/50plus/Pages/index.aspxImpact of aging on drivingImpact of aging on drivingWhen to stop drivingWhen to stop drivingHow to talk about driving concernsHow to talk about driving concernsReporting an unsafe driverReporting an unsafe driverAlternative transportation optionsAlternative transportation optionsFamily and community resourcesFamily and community resources

WA DOT Resources for Senior Drivers: WA DOT Resources for Senior Drivers: http://www.dol.wa.gov/driverslicense/seniors.htmlhttp://www.dol.wa.gov/driverslicense/seniors.htmlCollision prevention coursesCollision prevention courses

AARP Driving Resources:AARP Driving Resources:http://www.aarp.org/home-garden/transportation/driver_safety/http://www.aarp.org/home-garden/transportation/driver_safety/

Family Conversations about Alzheimer’s Disease, Dementia, and Driving: Family Conversations about Alzheimer’s Disease, Dementia, and Driving: http://hartfordauto.thehartford.com/UI/Downloads/Crossroads.pdfhttp://hartfordauto.thehartford.com/UI/Downloads/Crossroads.pdf

Mr. Hart, continuedMr. Hart, continued

Mr. Hart is not unsafe to drive yet, but he may be in Mr. Hart is not unsafe to drive yet, but he may be in the next couple years. the next couple years.

You suggest he start thinking about alternatives to You suggest he start thinking about alternatives to driving. He and his wife moved to an area of driving. He and his wife moved to an area of Portland that has good public transportation (we are Portland that has good public transportation (we are not often so lucky!) so you suggest he start taking not often so lucky!) so you suggest he start taking the bus.the bus.

After about 18 months of care and discussion, Mr. After about 18 months of care and discussion, Mr. Hart is still driving safely, but has learned the bus Hart is still driving safely, but has learned the bus system- and uses it at during high traffic timessystem- and uses it at during high traffic times

Dr. M (Retired Medical School Dean)Dr. M (Retired Medical School Dean)

92 year old admitted to your assisted living 92 year old admitted to your assisted living with his wifewith his wife– Mild memory decline- SLUMS 17/30Mild memory decline- SLUMS 17/30– BPH and nocturia 6-7 times per night; usually BPH and nocturia 6-7 times per night; usually

has at least one incontinent episode per nighthas at least one incontinent episode per night– Losing weight, not interested in exerciseLosing weight, not interested in exercise– Falls at least twice per weekFalls at least twice per week

– Would you start medications for cognition Would you start medications for cognition and/or bladder symptoms?and/or bladder symptoms?

What is known about dementia drugs and What is known about dementia drugs and incontinence?incontinence?

Patients who are started on an Patients who are started on an acetylcholinesterase inhibitor had a 49% acetylcholinesterase inhibitor had a 49% increased risk of having a bladder agent increased risk of having a bladder agent added within 6 monthsadded within 6 months

NO good data on exact risk of UI with NO good data on exact risk of UI with ACEIs but if your patient already has UI, ACEIs but if your patient already has UI, consider using memantine first if you are consider using memantine first if you are going to try a dementia medicationgoing to try a dementia medication

Concomitant use of ACHIs and Concomitant use of ACHIs and AnticholinergicsAnticholinergics

Retrospective cohort study of 5625 patients age Retrospective cohort study of 5625 patients age 50 and older who began an ACHI50 and older who began an ACHI

37% of people who got started on an ACHI were 37% of people who got started on an ACHI were also on an anticholinergic, and 25% of them had also on an anticholinergic, and 25% of them had both drugs continued for at least 12 monthsboth drugs continued for at least 12 months

STOP the anticholinergic before considering an STOP the anticholinergic before considering an acetylcholinesterase inhibitor!acetylcholinesterase inhibitor!

Boudreau, JAGS 59: 2069-2076, 2011Boudreau, JAGS 59: 2069-2076, 2011

So what is the bottom line? So what is the bottom line?

Improve environmental factors for both Improve environmental factors for both dementia and incontinencedementia and incontinence– Scheduled toiletingScheduled toileting– No fluids after 6 pm, leg elevation before bedNo fluids after 6 pm, leg elevation before bed– Regular daily activity to reduce edema and Regular daily activity to reduce edema and

improve sleepimprove sleep– Lighted path to the bathroom at nightLighted path to the bathroom at night

So what is the bottom line? So what is the bottom line?

Focus on Quality of LifeFocus on Quality of Life– If memory most frustrating for resident, try a If memory most frustrating for resident, try a

medication; do repeat SLUMS/MMSE to medication; do repeat SLUMS/MMSE to determine effectivenessdetermine effectiveness

– Consider memantine instead of Consider memantine instead of acetylcholinesterase inhibitor if incontinence acetylcholinesterase inhibitor if incontinence is an issueis an issue

– If incontinence most frustrating, do a good If incontinence most frustrating, do a good family PARQ and consider trospiumfamily PARQ and consider trospium

So what is the bottom line? So what is the bottom line?

Do your best NOT to treat a medication Do your best NOT to treat a medication side effect with another medication- if the side effect with another medication- if the side effect lowers quality of life, side effect lowers quality of life, discontinue the original medication discontinue the original medication (remember, none of these drugs are (remember, none of these drugs are miracle cures!)miracle cures!)

Fred, age 87, is admitted forFred, age 87, is admitted forGI illness and dehydrationGI illness and dehydration

Fred’s issues Fred’s Meds

Probable Alzheimer’s Donepezil

CHF/CAD Furosemide, metoprolol, lisinopril, ASA, simvastatin

Osteoarthritis Acetaminophen, tramadol

Osteoporosis Calcium, D, alendronate

Insomnia Zolpidem

Type 2 Diabetes Metformin, glyburide

BPH Tamsulosin

CRF- eGFR 28

Fred’s MedsFred’s MedsCondition Medical Treatment

Probable Alzheimer’s Donepezil

CHF/CAD Furosemide, metoprolol, lisinopril, ASA, simvastatin

Osteoarthritis Acetaminophen, tramadol

Osteoporosis Calcium, D, alendronate

Insomnia Zolpidem

Type 2 Diabetes Metformin, glyburide, finger sticks

BPH Tamsulosin

FREE Beers Criteria AppsFREE Beers Criteria Apps

““Choosing Wisely” for Patients with Choosing Wisely” for Patients with DementiaDementia

DON’T recommend feeding tubes in patients with DON’T recommend feeding tubes in patients with advanced dementia; instead offer oral assisted advanced dementia; instead offer oral assisted feedingfeeding

DON’T use antipsychotics as first choice to treat DON’T use antipsychotics as first choice to treat behavioral and psychological symptoms of dementiabehavioral and psychological symptoms of dementia

AVOID using medications to achieve HbA1C<7.5AVOID using medications to achieve HbA1C<7.5

DON’T use benzodiazepines or other sedative DON’T use benzodiazepines or other sedative hypnotics as first choice for insomnia, agitation or hypnotics as first choice for insomnia, agitation or deliriumdelirium

DON’T use antimicrobials to treat bactiuria unless DON’T use antimicrobials to treat bactiuria unless specific urinary tract symptoms are presentspecific urinary tract symptoms are present

Questions?Questions?

eckstrom@ohsu.edueckstrom@ohsu.edu