1. Dementia and Other Cognitive Disorders in Older Adults Funded by Master’s Advanced Curriculum Project University of Texas at Arlington The development of this learning module was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center’s Master’s Advanced Curriculum (MAC) Project and the John A. Hartford Foundation.

2. Selective Glossary/Abbreviations  Etiology - Causes of a condition  Symptoms - Characteristics of a condition  Prognosis - Expected outcome of a condition  Soft signs - Observable indicators of neurological deficits  R/O - Abbreviation for “rule out”  NOS - Abbreviation for “not otherwise specified”  ADL - Abbreviation for “activities of daily living”  DSM-IV – Diagnostic and Statistical Manual - 4 th Edition 2

3. Shared Features of the Cognitive Disorders DSM Class  These disorders constitute a “clinically significant deficit in cognition [that is] a significant change from a previous level of functioning” (DSM-IV-TR, p.135).  Etiology is either a general medical condition (GMC), a substance, or combination. 3

4. Disorder Characteristics  Delirium - A disturbance of consciousness and change in cognition over a short period of time.  Dementia - Multiple cognitive deficits including memory impairment.  Amnestic disorder - Memory impairment in the absence or other significant accompanying cognitive impairments. 4

5. Cognitive Disorders  Delirium due to a GMC 293.0  Delirium NOS 780.09  Dementia - Alzheimer’s Type or due to GMC 294.1x  Vascular Dementia 290.4x  Dementia NOS 294.8  Amnestic Disorder due to a GMC 301.13  Amnestic Disorder NOS 294.8  Cognitive Disorder NOS 294.9  Substance-induced Delirium Subs use code  Substance-induced Persisting Dementia Subs use code  Substance-induced Persisting Amnestic Disorder Subs use code 5

6. Prevalence and Incidence of Dementia  DSM-IV-TR (2000, p. 156) reports increasing prevalence with increasing age, with a lifetime prevalence of 16-25% for adults >85 years (11% males; 14% females); 40-60% of prevalence rates are moderate-severe.  Clinical Evidence/BMJ (2004) reports lifetime prevalence of some form of dementia at 30% for those who reach age 90, with vascular and Alzheimer’s (AD) each accounting for 35- 50% of all dementia cases.  According to the Alzheimer's Association the number for AD: 26.6 million in 2006; may quadruple by 2050. They estimate the incidence to double every 5.5 years; incidence of 835 out of 3838 pop. Sample  Estimated lifetime cost of care for a person with AD = $174,000 Retrieved from the Alzheimer’s Association website: http://www,alz.org/AboutAD/Statistics.asp http://www,alz.org/AboutAD/Statistics.asp Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health (11), 74-101. 6

7. Dementia Subtypes  Classification by Age of Onset  with Early Onset (≤65 years old)  with Late Onset (>65 years old)  Classification by  without Behavioral Disturbance 294.10 (cognitive impairment only)  with Behavioral Disturbance 294.11 (wandering, agitation, foul language, aggression, disrobing/exposure, sexual acting out)  Other prominent features may be coded on Axis I, such as Personality Change due to Alzheimer’s Disease, Aggressive Type 310.1 DSM-IV-TR, p.155 7

8. Dementia of the Alzheimer’s Type  Few RCTs and meta-analyses are conducted for people with types of dementia other than Alzheimer’s disease.  Symptoms include progressive memory impairment, aphasia (language deterioration), apraxia (motor impairment despite intact motor abilities), agnosia (failure to recognize objects), and executive function deficits. 8

9. Slowly Progressive Stages of Dementia of the Alzheimer’s Type 1. No observable impairment, but loss of 3-4 points per year on standardized instrument such as the Mini-Mental State Exam (MMSE). 2. Very mild decline, with early deficits in recent memory; if bilingual, may gradually revert to language of origin. 3. Mild decline, with increased irritability/personality change beginning and partial aphasia, apraxia, agnosia after several years, with progression. 4. Moderate decline (early stage identifiable AD) 5. Moderately severe decline (mid-stage AD), with more pronounced behavioral/personality changes; may be postponed (average of 7 yrs.) if responsive to medication. 6. Severe decline (still considered mid-stage) 7. Very severe decline (late stage AD), with pronounced gait/motor disturbance (risk of falls), eventually mute and bedridden. Retrieved from Alzheimer’s Association website: http.//www.alz.org/AD/Stages.asp http.//www.alz.org/AD/Stages.asp 9

10. Differential Diagnosis  In specifying the clinical condition, first consider and rule out conditions in other categories, such as the psychoses and organic brain syndromes.  Then screen for and distinguish this person’s symptoms from those for other disorders in the same Cognitive Disorder class. 10

11. Differential Diagnosis for AD  Rule Out (R/O) Mental Retardation  R/O normal Age-Related Cognitive Decline  R/O Factitious Disorder/Malingering  R/O Schizophrenia  R/O Major Depressive Disorder  R/O Other Cognitive Disorders  R/O Substance-Induced Acute or Persistent Dementia  R/O Systemic Conditions Known to Cause Dementia: B12/folic acid/niacin deficiency, hypothyroidism, hypercalcemia, HIV, neurosyphilis. 11

12. Differential Diagnosis for AD, cont.  No one diagnostic test currently available until autopsy.  CT and FMRI scans show larger cerebral ventricles and wider cortical sulci than in normal aging.  Genetic correlates  MMSE will show 3-4 point decline annually (score > 24 points is “normal”). 12

13. Differential Diagnosis for Vascular Dementia  Etiology: Multiple strokes at different times, pre-existing vascular disease/hypertension (coded on Axis III).  Onset usually abrupt with fluctuating course of rapid changes in functioning.  Variable pattern of cognitive deficits. 13

14. Subtypes of Vascular Dementia  With Delirium  With Delusions  With Depressed Mood  Uncomplicated 14

15. Specifier of Vascular Dementia  Uncoded: With Behavioral Disturbance (wandering, etc., as in AD) 15

16. Differential Diagnosis for Dementias due to General Medical Condition (GMC)  Establish presence of a GMC by history, physical exam, lab results.  Assess for delirium (MMSE useful) to verify that deficits do not occur exclusively during the course of a delirium.  Common GMCs re: HIV, head trauma, Parkinson’s (Lewy body dementia), Huntington’s/Pick’s (frontotemporal dementia), Creutzfeldt-Jakob Disease  Can occur in children with these GMCs, presenting as significant delay or deviation in development; decreased school performance may be an early sign. 16

17. Subtypes for Dementia due to GMC  Without Behavioral Disturbance 294.10  With Behavioral Disturbance 294.11 (as in AD) 17

18. What Does It Look Like?  Challenges of daily living: Safety, memory enhancement, support for activities of daily living (ADL - hygiene, diet, etc.).  Common issues for caregivers: 1. As with other chronic mental disorders, caregiving for persons with dementia contributes to psychiatric/physical illness and increased mortality risk. 2. Higher levels of behavioral disturbance may pose safety risks for caregivers/other family members. 3. Spouse caregivers are aging as person with dementia’s health status is deteriorating.  Policy applications: Increased need for long-term care insurance, benefits or programs to cover personal care aides in earlier stages of the condition, multi-level housing. Schulz, R. & Beach, S.R. (1999). Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. Journal of the American Medical Association, 282, 2215-2219. 18

19. Evidence-Based Treatments  Beneficial for cognitive symptoms in adults: 1. Memory medications: a.Donepezil and b.Galantamine Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health, (11), 74-101. 19

20. Evidence-Based Treatments  Likely to be beneficial for cognitive symptoms: 1. Ginkgo biloba 2. Memantine 3. Reality orientation  Likely to be beneficial for behavioral symptoms. management and health status: 1. Disease management training and intensive case management for caregivers documented by one Randomized Control Trial (RCT) Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health (11), 74-101. Vickrey, B., et al. (2006). The effect of a disease management program on quality and outcomes of dementia care: A randomized controlled trial. Annals of Internal Medicine, 145, 713-726. 20

21. Evidence-Based Treatments  Likely to be beneficial for behavioral and psychological symptoms: 1. Carbamazepine 2. Reality orientation  Trade off between benefits and harm for behavioral and psychological symptoms: 1. Haloperidol 2. Olanzapine 3. Risperidone Warner, J., Butler, R., & Arya, P. (2004). Dementia. Clinical Evidence Mental Health, 11, 74-101.. 21

22. Evidence-Based Treatments  For caregivers, likely to be beneficial for quality of life: 1. REACH* II multi-faceted community- based intervention, including enhanced communication technology (1 RCT) *REACH = Resources for Enhancing Alzheimer’s Caregiver Health Belle, S. et al. (2006). Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: A randomized controlled trial. Annals of Internal Medicine, 145, 727-738. 22

23. Evidence-Based Treatments  For caregivers, unknown effectiveness: 1. Caregiver support group 2. Educational interventions (how to prevent falls; how to provide safe, supportive environment; how to provide appropriate activities and routine; how to locate peer groups for support and recreation for person with dementia and caregiver) 3. Respite care (adult day care, home health aide, family care/domiciliary care home, temporary stay in assisted living facility) 4. Individual and family counseling 23