1. Mental Health and Older Adults in Primary Care Setting Part I – Normal Changes vs Neurocognitive Disorders Presented by: Ruth Tadesse, MS, RN Date: 04/09/15

2. Disclosures and Learning Objectives Learning Objectives: Recognize at least 4 important normal changes in healthy aging brain. Identify 3 main early symptoms of Neuropsychiatric cognitive Disorders. Know screening tools used in early stages of dementia. Identify DSM 5 criteria used to diagnose Minor and Major Neurocognitive Disorders Disclosures: Ruth Tadesse has nothing to disclose.

3. Normal Changes in the Healthy Aging Brain -Prefrontal cortex and the hippocampus will start shrinking. -Communication between neurons and neurotransmitters will be reduced. -Blood flow can be reduced because arteries will start to narrow. http://www.nia.nih.gov/alzheimers/publication/par t-1-basics-healthy-brain/changing-brain- healthy-aging

4. Normal Changes in the Healthy Aging Brain Plaques and tangles can develop outside of and inside neurons in much smaller amounts. Free radicals increases. Inflammation increases. http://www.nia.nih.gov/alzheimers/publication/part- 1-basics-healthy-brain/changing-brain- healthy-aging http://www.nia.nih.gov/alzheimers/alzheimers- disease-video

5. Normal Changes in Aging and Mental Function in Healthy Older Adults Modest decline in the ability to learn new things and retrieve information, such as remembering names may be common. Difficulty in performing complex tasks on attention, learning, and memory than a young person is not uncommon. *It is important to note, given enough time to perform the task, the scores of healthy people in their 70s and 80s are often similar to those of young adults. http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy- brain/changing-brain-healthy-aging

6. Changes in brain caused by Alzheimer's Disease (AD) Amyloid plaques are found in the brain in large numbers in the spaces between the nerve cells. Neurofibrillary tangles increase and collapses neuron’s internal transport network. This collapse damages the ability of neurons to communicate with each other. Gradual loss of connections between neurons leads to significant brain atrophy. The destruction and death of nerve cells causes the memory failure, personality changes, problems in carrying out daily activities, and other features of the disease. http://www.nia.nih.gov/alzheimers/publication/part-2-what-happens-brain-ad/hallmarks-ad

7. Brain Atrophy: What is normal? http://coloradodementia.org/ http://coloradodementia.org/

8. Neuropsychiatric Symptoms (NPS) seen in Patients with Neurocognitive Disorders (ND) NPS of dementia include psychosis, depressed or labile mood, anxiety, irritability, apathy, euphoria, disinhibition, aggression, sleep disturbance and disordered eating. Virtually all patients with the diagnosis of ND exhibit some NPS during the first 6 years of their illness. Agitation is the most prevalent symptom (with rates up to 80%) in community dwelling patients. Borsje, P., et al. (2015). The course of neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review. International Psychogeriatrics / IPA, 27(3), 385-405.

9. Question about The Haves and the Have Nots Why do some people remain cognitively healthy as they get older while others develop Neurocognitive Disorders or Dementia? ‘Cognitive Reserve’ may provide some insights. Cognitive reserve refers to the brain’s ability to operate effectively even when some function is disrupted. It also refers to the amount of damage that the brain can sustain before changes in cognition are evident. People vary in the cognitive reserve they have. http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy-brain/changing-brain-healthy-aging

10. Normal Aging vs Neurocognitive Disorders Depending on a person’s cognitive reserve and unique mix of genetics, environment, and life experiences, the balance may tip in favor of a disease process that will ultimately lead to neurocognitive disorders or dementia. For another person, with a different reserve and a different mix of genetics, environment, and life experiences, the balance may result in no apparent decline in cognitive function with age. http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy-brain/changing-brain-healthy-aging

11. Factors that could explain differences in Cognitive Reserve Variability in cognitive reserve depends on factors such as differences in genetics, education, occupation, lifestyle, leisure activities, or other life experiences. These factors could provide a certain amount of tolerance and ability to adapt to change and damage that occurs during aging. http://www.nia.nih.gov/alzheimers/publication/part-1-basics-healthy-brain/changing-brain-healthy- aging

12. Making the diagnosis of Neurocognitive Disorders or Dementia: Changes from DSM IV DSM 5 Dementia on DSM IV was recognized under Delirium, Dementia, Amnestic, and Other Cognitive Disorders. Dementia has been eliminated and have been replaced as Major or Minor Neurocognitive Disorders on DSM 5. http://www.todaysgeriatricmedicine.com/archive/110612p12.shtml

13. Neurocognitive Disorder (aka Dementia) Alzheimer’s Disease Vascular Parkinson’s Lewy Body Disease Fronto-temporal HIV Huntington’s Prion Disease Traumatic Brain Substance-Induced (Alcohol)

14. Subtypes of Dementia (Brunnstroom, H., et al, 2009) Brunnström, H., Gustafson, L., Passant, U., & Englund, E. (2009). Prevalence of dementia subtypes: a 30-year retrospective survey of neuropathological reports. Archives Of Gerontology And Geriatrics, 49(1), 146-149.

15. Subtypes of Dementia (Keefover, R.W., 2013) Dementia Examined.docx Dementia Examined.docx

16. Age Is a Strong Factor! Prevalence of Dementia 4.97 % Among 71-79 yrs. old 24.19 % Among 80-89 yrs. old 37.36% Among 90 yrs. old & older

17. Prevalence of Dementia in other Countries

18. Dementia Progression http://www.nia.nih.gov/alzheimers/publication/part-2-what-happens-brain-ad/changing-brain-ad

19. Common Screening Tools in Primary Care related to assessment of NC Disorders Standard history and physical exam Functional Status (FAQ) Mental State Examination (MOCA, MMSE, GDS) Labs (CBC, Electrolytes, Kidney Function, Glucose, TSH, Vit. D, Vit. B12, and Drug Levels) Family/Caregiver interview to rule out personal strain, and assess patient behavior changes Refer to neurologist if suspected Mild or Major Neurocognitive Disorders Dementia Examined.docx

20. Flowchart for Early Identification of Dementia ( National Alzheimer's Organization, 2003) Interview family or caregivers Evaluate signs/symptoms for possible dementia using “Ten Warning Signs” Initial Dementia Assessment Treat & Reassess Care management & family support Assess & reassess s/sxs using MMSE every 6 months Delirium or depression Negative workup Uncertain results https://www.alz.org/national/documents/brochure_toolsforidassesst reat.pdf

21. DSM 5 Criteria: Minor Neurocognitive Disorder -Modest cognitive decline from a previous level of performance -The cognitive deficits do not occur exclusively in the context of a delirium -The cognitive deficits are not primarily attributable to another mental disorder (eg, major depressive disorder, schizophrenia). Note that in diagnosing a minor neurocognitive disorder, one and two standard deviations below appropriate norms is required. American Psychiatric Association ((APA) (2013). Diagnostic and Statistical Manual of Mental Disorders. (5 th ed.) Washington, DC: American Psychiatric Association Press

22. DSM 5 Criteria: Major Neurocognitive Disorder Evidence of substantial cognitive decline from a previous level of performance. The cognitive deficits are sufficient to interfere with independence. The cognitive deficits are not primarily attributable to another mental disorder (e.g, major depressive disorder, schizophrenia). * In diagnosing a major neurocognitive disorder, two or more standard deviations below appropriate norms are required. American Psychiatric Association ((APA) (2013). Diagnostic and Statistical Manual of Mental Disorders. (5 th ed.) Washington, DC: American Psychiatric Association Press.

23. What is the best way to manage symptoms of neurocognitive disorders? All atypical antipsychotic medications include a Black Box warning regarding the increased risk of mortality in elderly people with dementia-related psychosis (FDA, 2005) and they have required a similar warning for conventional antipsychotics since 2008 ( FDA, 2008 ). Current guidelines (AMDA, 2012; Herrmann, Lanctôt, & Hogan, 2014; NICE & SCIE, 2006) suggest that people with dementia should be prescribed antipsychotics only in cases in which they are severely distressed (severe agitation, aggression and psychosis) and/or there is immediate risk of harm. In addition, most guidelines also recommend that antipsychotic medications be used in a time-limited fashion. Dementia medications such as Namenda are underutilized and should be considered for both Mild and Major ND.

24. Preventing Memory Loss w/ Current Evidence http://tucson.com/news/science/ua-researcher-barnes-provides-insights-into-aging- memory/article_9319afe0-b21d-59dc-af76-a5a00f87a27a.html

25. References American Medical Directors Association (AMDA). (2012). Dementia in the long term care setting. Columbia (MD): American Medical Directors Association (AMDA). Borsje, P., Wetzels, R. B., Lucassen, P. L., Pot, A. M., & Koopmans, R. T. (2015). The course of neuropsychiatric symptoms in community-dwelling patients with dementia: a systematic review. International Psychogeriatrics / IPA, 27(3), 385-405. Brunnström, H., Gustafson, L., Passant, U., & Englund, E. (2009). Prevalence of dementia subtypes: a 30-year retrospective survey of neuropathological reports. Archives Of Gerontology And Geriatrics, 49(1), 146-149. Hebert, L. E., Weuve, J., Scherr, P. A., & Evans, D. A. (2013). Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. Neurology, 80(19), 1778-1783. Herrmann, N., Lanctôt, K. L., & Hogan, D. B. (2013). Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012. Alzheimer's Research & Therapy, 5(Suppl 1), S5. Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2014). Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. Journal Of The American Geriatrics Society, 62(4), 762-769.

26. References Ma, H., Huang, Y., Cong, Z., Wang, Y., Jiang, W., Gao, S., & Zhu, G. (2014). The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo- controlled trials. Journal Of Alzheimer's Disease: JAD, 42(3), 915-937. NICE and SCIE (2006) Dementia: Supporting People with Dementia and their Carers in Health and Social Care. NICE clinical guideline 42. Available at www.nice.org.uk/CG42www.nice.org.uk/CG42 Plassman, B.L., Langa, K.M., Fisher, G.G., Heeringa, S.G., Weir, D.R., Ofstedal, M.B., Burke, J.R., Hurd, M.D., Potter, G.G., Rodgers, W.L., Steffens, D.C., Willis, R.J., Wallace, R.B. (2007). Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study. Neuroepidemiology. 29:125-132. U.S. Food and Drug Administration (FDA). (2005). Public Health Advisory: Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances. Available at http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/u cm053171.htm http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/u cm053171.htm U.S. Food and Drug Administration (FDA). (2008). FDA Requests Boxed Warnings on Older Class of Antipsychotic Drugs. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm116912.htm http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm116912.htm

27. End of Gero. Series Part I Next Week Medications & Older Adults By Dr. Ann Hamer 04/16/15