SOS Dementia ProjectBuilding a Network for the Patient with

Cognitive Impairment Padova, 5 Ottobre 2012

What do (American) Families Need to Know?Richard W. Besdine, MD,FACP

Professor of Medicine and of Health Services Policy and PracticeGreer Professor of Geriatric Medicine

Director, Division of GeriatricsDirector, Center for Gerontology and Healthcare Research

A L P E R T

M E D I C A L

S C H O O L

Dementia Caregiver Interventions Alzheimer’s Association – a remarkable organization

providing education and support network FOR caregivers

Advance directives, LTC + financial planning Contact person identified, mobile phone # provided

for emergency situations Caregivers’ physical, mental health; consider primary

care visits coincident with those for AD patient Use of respite and adult day care Simplify and structure home environment Driving and home safety

Prevalence of Dementia by Age

0

5

10

15

20

25

30

35

40

45

60–64 65–69 70–74 75–79 80–84 85–89 > 90

All types of dementia

Alzheimer's disease

Vascular dementia

Age (years)

Pre

vale

nce

(%

)

Median survival of women in the longest-lived countries has increased 3 months/year since 1840

We And Many Of Our Patients Will Live Long Enough To Develop AD

Oeppen J et al. Science. 2002;296:1029-1031

Lif

e E

xpec

tan

cy i

n Y

ears

Year

What is Dementia?

An acquired disorder producing decline in memory and other cognitive functions sufficient to affect daily life in an alert patient

Progressive and disabling

NOT a part of pure aging

Very different from normal cognitive lapses

AD by far the most common cause

When to be Concerned Sometimes it is the psychomotor slowing of aging

+ Recall of words or names temporarily lost+ Misplacing the car keys+ Worrying about memory+ Why are you in front of the refrigerator?

Never retrieving names or words Losing the car, major financial mistakes Forgetting entire conversations or events Not recognizing that there is a memory problem Repetition not just for emphasis

Evaluation of Dementia1

Screening At annual physical >70 or earlier if red flags

Ask patient about any new problems with memory, mood, behavior and driving

Baseline MMSE and clock drawing or 3-word recall and clock (mini-cog)

Evaluation for positive screen Add reliable informant to interview Structured criteria – DSM or NINCDS-AD Search for causes Identify and manage co-morbidities Genetic testing not recommended in 2012

Chemistries (BUN, Cr, electrolytes, BS, calcium), CBC, Liver function tests

Thyroid, pituitary-adrenal axis Vitamin levels – B12, folic acid (?)

Serology for Lyme, HIV, Syphyllis Brain image (CT without contrast) IF <65,

symptoms recent (<2yrs), focal neurologic signs, suspicion of NPH, or recent trauma

Neuropsychological testing if diagnosis unclear

Evaluation of Dementia2

Small GW, et al. JAMA. 1997;278:1363-1371

Risk Factors for AD Definite Possible/Probable Age Head injury Family History Diabetes Atherosclerosis (stroke) History of depression Hypertension (stroke)HSV Apolipoprotein E4 Education (-) Down’s Syndrome Statins (-) Female Gender Exercise (-) Multiple mutations Intellectual work (-)

Physician Role in Care of Dementia Patients

Thorough evaluation to make the diagnosis Honest information - truth, but not bludgeon Continuing care - "patient" includes family unit, as well

as the victim with plaques and tangles Reality testing - timing and appropriateness of support

services and institutionalization Ethical and appropriate choices for EOL care - not at

first encounter, but not to wait for a crisis either+ Restricted Rx, advance directives beyond DNR+ Code status, tube feeding, hospitalization, Abx

Maximize General Medical Health

Decrease excess morbidity; i.e., evaluation and optimal care for co-morbidities - all worsen cognition Periodic examinations Routine lab screening, based on problem list Prevention interventions that make sense

+ Vaccines, mammograms, FOB/endoscopy, OP?+ Only if action consistent with advance directives

Comprehensive evaluation for sudden decline; delirium common, AD doesn’t worsen overnight

Non-pharmacologic Interventions Care management and psychosocial interventions Education of caregivers

+ Understanding of the disease+ Avoid antipsychotics

Performance and behavior+ Scheduled toileting, behavior modification+ Exercise+ Music, massage, pet therapy

Environmental modification+ Safe space to wander+ Remove toxins, weapons

Does AD Caregiver Support Effect Nursing Home Admission?

Randomized trial of >200 AD spouses or caregivers, follow up 3.5 yrs

6 sessions of individual, family counseling within 4 months of enrollment and join support group

What happened to the Alzheimer patients after their caregivers attended the 6 sessions?

What about nursing home admission?

Mittelman MS et al. JAMA. 1996;276:1725-1731

Mittelman MS et al. JAMA. 1996;276:1725-1731

Probability of NH Admission After Caregiver Intervention

Pro

po

rtio

n o

f A

D P

atie

nts

Rem

ain

ing

at

Ho

me

Time in Years

2/3 RR,329 days more at

home

Caregivers in intervention 1/3 less likely to place spouses in NH; greatest benefit if mild or moderate dementia

Treatment of AD Symptoms

Consider possibility of excess disability

Depression - >50% during disease course

Agitation, aggression, delusions

Wandering – behavioral, caregiver interventions

Incontinence – evaluate, treat

Malnutrition – treat, but weight loss common

Altered sleep – behavioral, modern hypnotics

Treatment of AD Pathology Proven effective therapies+ Reduce stroke risk+ Cholinesterase inhibitors (“minimally effective”)+ Memantine (not much better)+ Proven ineffective therapies+ Antioxidants+ Estrogen+ Anti-inflammatory drugs (NSAIDs)+ Drugs to improve cerebral blood flow

Statins? Probably not

Cholinesterase Inhibitor Side Effects

Common, sometimes transient, but may be long-lasting and disabling - dose-related; titrate slowly, take with food+GI – NVD, anorexia, weight loss+Vivid dreams/nightmares

Less common

+Agitation

+Hypotension

Delay in NH Placement with Donepezil

0.4

0.6

0.8

1

0 100 200 300 400 500 600 700 800

Days

Pro

bab

ilit

y o

f R

emai

nin

g a

t H

om

e Placebo

High Dose

Higher Dose

Drugs for Dementia Behavior Disorders

Antipsychotics have demonstrated superior results in most randomized trials, but off label use

Be sure symptoms justify these dangerous drugs: agitation, aggression or delusions that disrupt care and impair life quality for caregiver and patient

Data conflicting whether atypical agents are better, but easier to use – fewer daily side effects of sedation or movement disorders, but FDA black box for all antipsychotic agents (stroke, CV death)

Use should be short-term, low dose

Resources for Managing Dementia

Attorney for will, conservatorship, estate planning; can be helpful with advance directives

Community: neighbors & friends, aging & mental health networks, adult day care, respite care, home-health agency

Organizations: Alzheimer’s Association (caregiver support groups), Area Agencies on Aging, Councils on Aging

Services: Meals-on-Wheels, senior citizen centers

Principles of Dementia Care

Complicating diseases often missed Hospitals are dangerous - avoid if at all possible

Dementia brain exquisitely sensitive to drugs - avoid

Useful Rx should not be withheld for age or dementia

Painful Rx should be very carefully considered

Symptomatic Rx without evaluation is dangerous

Stop Rx whose side effects are worse than symptoms

Assess response to Rx often and stop ineffective Rx

Summary

Dementia is common, but never normal aging

AD is most common, followed by vascular dementia and dementia with Lewy bodies

Thorough evaluation is mandatory, both for diagnosis and identification of co-morbidities

Treatment directed at function and quality of life, using drugs and behavioral interventions

Social and instrumental resources supplement care for patient, caregivers and family members