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Pamela Pride MD December 3, 2009.  Differentiate dementia from delirium and depression  Recall the testing characteristics of screening instruments.

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Presentation on theme: "Pamela Pride MD December 3, 2009.  Differentiate dementia from delirium and depression  Recall the testing characteristics of screening instruments."— Presentation transcript:

1 Pamela Pride MD December 3, 2009

2  Differentiate dementia from delirium and depression  Recall the testing characteristics of screening instruments  Differentiate different types of dementia  Recognize and manage caregiver stress  Demonstrate appropriately 3 screening instruments to differentiate dementia, delirium, and depression

3  Evidence from the history and mental status examination that indicates major impairment in learning and memory as well as at least one of the following:  - Impairment in handling complex tasks - Impairment in reasoning ability - Impaired spatial ability and orientation - Impaired language  It is progressive, usually incurable and terminal

4  There are approximately 5.1 million Americans 65 years and older with dementia.  1 in 8 persons 65 and over  Nearly 50% of all persons over the age of 85 have some type of dementia.  It is the sixth leading cause of death in the US  It is the third most expensive disease after cardiovascular disease and cancer. Alzheimer’s Association 2009 Facts and Figures

5 Projected numbers of demented patients

6 Signs of Dementia  Poor judgment and decision making  Inability to manage a budget  Losing track of the date or the season  Difficulty having a conversation  Misplacing things and being unable to retrace steps to find them Typical Age- Related Changes  Making a bad decision once in a while  Missing a monthly payment  Forgetting which day it is and remembering later  Sometimes forgetting which word to use  Losing things from time to time. Alzheimer’s Association

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8 Major Depression  Acute, nonprogressive  Depression  Affective before cognitive  Attention impaired  Orientation intact  Vocal memory complaint  Gives up on testing  Language intact  Patient complains  Better at night  Criticizes self  Self-referred Dementia  Insidious & progressive  Depression mild if present  Cognitive before affective  Recent memory impaired  Orientation impaired  Minimizes memory problem  Patient makes effort  Possibly aphasic  Family complains  Sundowning  Criticizes others  Referred by others

9 A ntiparkinson drugs C orticosteroids U I drugs T heophylline E mptying drugs (motility drugs) C ardiovascular Drugs H 2 blockers A ntimicrobials N SAIDs G eropsychiatric drugs E NT drugs I nsomnia drugs N arcotics M uscle relaxants S eizures Drugs Look to these medications if there is an ACUTE CHANGE IN MS Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1):

10 Antidepressants Amitriptyline (Elavil ® ) Clomipramine (Anafranil ® ) Desipramine (Norpramin ® ) Doxepine (Sinequan ® ) Imipramine (Tofranil ® ) Nortriptyline (Pamelor ® ) Trazodone (Desyrel ® ) Antidiarrheals Diphenoxylate/Atropine (Lomotil ® ) Antiemitics/Antivertigo Dimenhydrinate (Dramamine ® ) Meclizine (Antivert ® ) Prochlorpromazine (Compazine ® ) Promethazine (Phenergan ® ) Scopolomine (Transerm-Scop ® ) Antihistamines Chlorpheniramine (Chlor-Trimeton ® ) Cyproheptadine (Periactin ® ) Diphenhydramine (Benadryl ® ) Hydroxyzine (Vistaril/Atarax ® ) Antiparkinsonian Agents Benzotropine (Cogentin ® ) Trihexyphenidyl (Artane ® ) Antipsychotics Chlorpromazine (Thorazine ® ) Clozapine (Clozaril ® ) Fluphenazine (Prolixin ® ) Thioridazine (Mellaril ® ) Triflupromazine (Stelazine ® ) Gastrointestinal/Urinary Agents Belladona alkaloids (Donnatol ® ) Dicyclomine (Bentyl ® ) Hyoscamine (Levsin ® ) Oxybutinin (Ditropan ® ) Muscle Relaxants Carisoprodol (Soma ® ) Cylobenzaprine (Flexeril ® ) Orphenadrin (Norflex ® ) Opiates

11  30 point maximum  <24 c/w impairment  Influenced by education  Does not distinguish dementia from delirium

12 Borson, S., et al (2000). Int J Geriatr Psych 15 (11):

13 Sunderland T et al. (1989), J Am Geriatr Soc 37(8): ; Borson S et al. (1999), J Gerontol A Biol Sci Med Sci 54(11):M534-M540 Quick office-based assessment tool Quick office-based assessment tool Brief (1-5 minutes) Brief (1-5 minutes) Minimal language requirement Minimal language requirement Does not require specialized testing materials Does not require specialized testing materials Easily adapted for non- English-speaking elderly Easily adapted for non- English-speaking elderly Clock Drawing Test

14  Tests functional limitations/changes rather than cognitive  Sensitivity and specificity comparable to the MMSE  Rating functional abilities over past 4 weeks  Not applicable  Normal  Some difficulty but does by self  Needs assistance  Dependent Pfeffer RI, et al. J Gerontol 37: :1982

15  Writing checks, paying bills, balancing checkbooks  Assembling tax records, business affairs, or papers  Shopping alone for clothes, household necessities, or groceries  Playing a game of skill, working on a hobby  Heating water, making a cup of coffee, turning off stove  Preparing a balanced meal  Keeping track of current events  Paying attention to, understanding, discussing a TV show, book, magazine  Remembering appointments, family occasions, holidays, medications  Traveling out of neighborhood, driving, arranging to take buses Source: Pfeffer RI et al. J Gerontol. 1982;15:

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17  Alzheimer’s Disease  Vascular Dementia (MID)  Lewy Body Dementia  Frontotemporal Dementia  PD  CJD  Secondary Causes  NHP  Syphilis  Thyroid dz  B12 deficiency

18  Disease of old age, slight female predominance  Insidious and progressive memory impairment  Characteristic pattern of memory loss  Episodic→semantic→immediate recall→motor  Verbal, visual-spatial and subtle executive function problems can be early signs  Apraxia, neuropsych sx and profound exec function problems occur late in disease  Pts have poor insight  Neurologic exam normal early on

19  Various atypical forms exist  Posterior cortical atrophy  Primary progressive aphasia  Biparietal syndrome  Common to have AD and other dementia  Progressive, incurable and ultimately terminal  Mean survival 3-8 years  Death results from loss of motor memory

20  Cognitive dysfunction related to brain ischemia  Abrupt onset of symptoms followed by stepwise deterioration  Executive func impairment early, memory later  Neuro exam and imaging c/w previous stroke  Risk factor modification and antiplatelet rx recommended

21  Progressive cognitive decline  Usually executive func impaired prior to memory  Fluctuating cognition  Visual hallucinations  Spontaneous features of parkinsonism  Severe autonomic dysfunction  Neuroleptic sensitivity  Can mimic delirium

22  Earlier onset, more rapidly progressive  3 clinical variants  Behavioral variant  Semantic dementia  Progressive nonfluent aphasia

23  Parkinson’s related  CJD  Huntington’s disease  TBI

24  10-20% of pts labeled with dementia have reversible causes  Of “true” dementias 5% are potentially reversible  NPH most common  Hypothyroidism  B12 deficiency  Syphilis  SDH, cns neoplasms

25 Memory Concern Affecting Daily Life (Positive Screen) Mini-Cog and Clock Drawing Screen Unclear or No Obvious DeficitsCognitive Deficit Present Consider Neuropsychological Testing Assess for Potentially Reversible Causes: H & P Laboratory Testing Medication Review Potentially Reversible Condition Present (including Depression & Delirium) No Potentially Reversible Condition Present No or Partial Improvement Treat and Reassess DEMENTIA Memory Concern Affecting Daily Life (Positive Screen) Mini-Cog and Clock Drawing Screen Unclear or No Obvious DeficitsCognitive Deficit Present Consider Neuropsychological Testing Assess for Potentially Reversible Causes: History and Neuro Exam Laboratory Testing Medication Review Potentially Reversible Condition Present (including Depression & Delirium) No Potentially Reversible Condition Present Treat and Reassess DEMENTIA

26  Cholinesterase inhibitors  Offer modest improvement in surrogate end points for mild-mod disease  Questionable cost benefit ratio  Expected ADRs  Memantine  shows improvement in surrogate end points for mod-severe disease  Appears safe, well tolerated

27  Managing behavioral sx  Aggression  Wandering  Physical and chemical restraints  Co-morbid depression  Is it ok to use neuroleptics?  Treating the family  Recognizing and managing caregiver stress

28 With any behavioral change it is important to evaluate for underlying delirium and depression  Wandering  Maintain and active daytime schedule  Re-orient frequently  Use alarm systems to keep pt safe  Aggression  Medically evaluate pt for delirium, pain, anxiety etc  Calming environment strategies  Carefully weigh risk:benefit with neuroleptics and discuss with caregivers

29  Educate caregiver re: course of disease  Encourage HCPOA early and end of life preferences  Encourage Caregivers to find PCP’s and have routine MD visits for themselves  Mobilize resources and make caregivers aware of respite and day care services  Encourage caregivers to become familiar with NH’s  Encourage caregivers to stay with demented pt in event of hospitalization

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31  Evaluation & Diagnosis  Prognosis  Association Behavioral Symptoms  Safety Issues  Caregiver Stress  Community Resources

32 Over the past two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day Feeling down, depressed, or hopeless. 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day PHQ-2 ScoreProbability of major depressive disorder (%) Probability of any depressive disorder (%) T hibault, JM, Prasaad Steiner, RW. (2004) “Efficient Identification of Adults with Depression and Dementia.” American Family Physician (70):6.

33 1 = Acute Onset & Fluctuating Course PLUS 2 = Inattention AND EITHER 3 = Disorganized Thinking OR 4 = Altered LOC (Most Common = Hypoactive) Inouye et al. Ann Intern Med 1990

34 Falls Strangulation Loss of Muscle Tone Pressure Sores Decreased Mobility Agitation Reduced Bone Mass Stiffness Frustration Loss of Dignity Incontinence Constipation

35 PLST/Environment Progressively Lower Stress Threshold Solutions Avoid placing patient in a room with high noise and traffic Avoid room changes Subdue physical environment Be sensitive to amount of light Remove threatening artwork Use pictures and large words

36 Pt Admitted with Known or Suspected Dementia CAM Identify Underlying Cause of Delirium and Treat No Delirium PHQ2 (If Possible ) Mini-Cog IF AT ANY TIME PATIENT REQUIRES PHYSICAL RESTRAINTS, DOCUMENT IN CHART REASON WHY AND NOTIFY FAMILY Discuss Dementia with Family Evaluation & Diagnosis Prognosis Associated Behavioral Symptoms Safety Issues Caregiver Stress Community Resources No Action Equivocal or Inconsistent with Depression Consistent with Depression Treat Depression or Discuss Options Not Impaired Impaired Schedule Family Meeting Normal Abnormal Re-Evaluate After Treatment

37  Alzheimer’s Association St. Louis Chapter and  Washington University Alzheimer’s Disease Research Center  Dementia-Friendly Hospitals: Care Not Crisis: “Medical Overview: Recognition and Management of Hospitalized Patients with Cognitive Impairment.”  National Alzheimer’s Association “2009 Facts and Figures”


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