1. Dementia A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 Kendall L. Stewart, MD, MBA, DLFAPA May 17, 2013 1 My aim is to offer practical clinical insights that you can use right away in caring for patients. 2 Please let me know whether I have succeeded on your evaluation forms.

2. Why is this important? 1 Risk factors include being female, having a first-degree relative with the disorder and a history of head injury. 2 Alzheimer’s progresses gradually but steadily to death within 3 to 9 years of diagnosis. About 1.5-percent of people over age 65 have dementia.dementia And 16 to 25-percent of those over 85 do. About 50 to 60-percent of patients with dementia have Alzheimer’s disease. 1 Patients with Alzheimer’s disease occupy more than 50- percent (or 2 million) nursing home beds. Since our population is aging, the number of these cases will increase. The financial and emotional tolls extracted are enormous.financial After mastering the information in this presentation, you will be able to – Identify the other diagnoses in this category, – Identify the diagnostic criteria for dementia, – Specify three disorders that may produce dementia, – Describe the evaluation of the patient with dementia, – Discuss a differential diagnosis, – Write a typical treatment plan, and – Explain some of the typical treatment challenges.

3. What other disorders are included in this category? Delirium Dementia – Alzheimer’s Early Onset Alzheimer’s Early Onset – Alzheimer’s Late Onset – Vascular Dementia Vascular Dementia – Due to HIVHIV – Due to Head Trauma – Due to Parkinson’sParkinson’s – Due to Huntington’sHuntington’s – Due to Pick’sPick’s – Due to Creutzfeldt-Jakob DiseaseCreutzfeldt-Jakob Disease – Due to a General Medical Condition Substance-Induced, Persisting – Not Otherwise Specified (NOS) Amnestic Disorders Other Cognitive Disorders

4. How do these patients present? 1,2 1 Family members living with the patient usually provide the best histories. 2 View yourself as their consultant; they are the real experts. This is a 70 year-old retired barber. “I just can’t remember things like I used to.” “He’s not himself.” “He doesn’t pay attention to his appearance like he used to.” “He gets irritable and mad over nothing.” “He’s real suspicious of other people for no reason.” “He keeps asking me the same question over and over.” “He loses his keys and blames it on me.” “He misunderstand things and gets upset.” “He gets lost in the store.” “He gets more confused at night.” “He remembers things from years ago just fine, but he can’t remember something that happened this morning.” “Sometimes he doesn’t recognize his grandkids.” “He’s getting worse.”

5. What are the diagnostic criteria for Alzheimer’s dementia? 1 Good-natured confabulation is fairly common. 2 “What’s my name?” Multiple cognitive deficits manifested by both – Memory impairment 1,2 – One or more of Aphasia (language disturbance) Apraxia (impaired motor activity) Agnosia (failure to recognize objects) Disturbance in executive functioning (planning, organizing, sequencing, abstracting) Cognitive impairments reflect deterioration and cause impairment Course is characterized by gradual onset and continuing decline Cognitive deficits not due to – Other central nervous system conditions that cause dementia – Other systemic conditions that cause dementia – Substance-induced conditions Deficits do not occur exclusively during a delirium The disturbance is not better accounted for by another Mental Disorder (Schizophrenia, Major Depressive Disorder)

6. What are some of the many disorders that produce dementia? 1,2 Alzheimer’s disease Vascular dementia Drugs and toxins Intracranial masses Anoxia Trauma Normal-pressure hydrocephalus Neurodegenerative disorders – Parkinson’s disease – Huntington’s disease Infections – Creutzfeldt-Jakob – AIDS Nutritional disorders – Thiamine deficiency – Folate deficiency Metabolic disorders – Dialysis dementia – Hypothyroidism Chronic inflammatory disorders – Lupus – Multiple sclerosis 1 Every psychiatrist memorizes such a list for Board exams. 2 My hung-over examiner drilled me on these, then gave up and sent me out early.

7. How should you evaluate the patient with dementia? A thorough history and physical 1 Vital signs Mental status examination Mini-Mental State Examination (MMSE) Consider using the faster mini-cog test.mini-cog test Review of medications and drug levels Blood and urine screens for alcohol, drugs and heavy metals Physiological workup Chest radiograph Electrocardiogram Neurological workup Neuropsychological testing if indicated 2 Neuropsychological testing 1 A careful evaluation is critical for ruling out treatable forms of dementia. 2 Very bright people are aware of cognitive challenge; a tenured professor was certain he had a learning disability! Slide 1 of 2

8. How should you evaluate the patient with dementia? 1,2 Physiological workup (if indicated) – Serum electrolytes/glucose/Ca 2+ /Mg – Liver, renal function tests – Serum chemistry profile – Urinalysis – Complete blood count with differential – Thyroid function tests including TSH – RPR (serum screen) – FTA-ABS (if CNS disease is suspected) – Serum B 12 – Folate levels Slide 2 of 2 – Urine corticosteroids – ESR – ANA, C 3 C 4, anti-DS, DNA – Arterial blood gases – HIV screen – Urine porphobilinogens Neurological workup (if indicated) – CT or MRI scan of the head – SPECT – Lumbar puncture – EEG 1 If you are a consultant, you will need to obtain copies of previous exams and studies. 2 This is a hassle, but do not take the patient’s word that appropriate studies were done; some repetition may be needed.

9. What are some of the psychiatric differential diagnoses? Delirium Amnestic Disorder Vascular Dementia Dementia due to General Medical Conditions Substance Intoxication Substance Withdrawal Substance-Induced Persisting Dementia Dementia NOS Mental Retardation Schizophrenia Major Depressive Disorder Malingering Factitious Disorder Normal aging

10. What is the treatment? Psychosocial Therapies 1 – Make sure the diagnosis is correct. – Consider behavioral treatment of problematic symptoms – Stimulation-oriented therapies have modest support from clinical trials and embody a common sense, humane approach. – Supportive counseling may help patients and their families deal with a sense of loss early in the illness. – Cognitive-orientated interventions are unlikely to be helpful; they are more likely to be annoying. Pharmacotherapy – Treat underlying conditions appropriately. – Taper and discontinue offending medications. – Use sedatives, antidepressants and antipsychotics sparingly since they can make matters much worse. – Consider cholinesterase inhibitors in patients with mild to moderate cognitive impairment Donepezil (Aricept) 5-10 mg/day – Vitamin E may slow the rate of progression – Selegiline may prevent further decline but Vitamin E is safer and just as effective. – Ergot mesylates cannot be recommended. – Benzodiazepines, atypical antipsychotics, mood stabilizers and antidepressants are somewhat helpful with agitation and combativeness. 1 While in widespread use, few of these interventions are truly evidence-based.

11. What are some of the typical treatment challenges? These diagnoses are hard to hear; always offer to arrange for another opinion at any world-class center of their choosing. 1 Patients and families need to confront the driving issue before they have to.driving issue It is much easier to obtain a power of attorney than to try for guardianship later.power of attorney guardianship Families typically put off nursing home placement too long. When patients are institutionalized, specialized Alzheimer’s units produce no better outcomes. Walking the razor’s edge between agitation and sedation is the preferred path; this walk is easier if the family understands the challenge. Nursing homes prefer sedation. Chemical and physical restraint should be minimized, but both— properly administered and supervised—still have their place. Preparing families for what is to come and how to cope with it is the physician’s greatest gift to loved ones. Preparing families Assisting daughters (particularly) with identifying and dealing with unreasonable guilt can be liberating. 2 1 A daughter insisted that the neurologist had told them that her mother “most certainly did not have dementia.” 2 In our culture, women tend to feel much more responsible—particularly when helpless—than men do.

12. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. Introduce yourself using AIDET 1.AIDET Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of my problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

13. How can you access the OU-HCOM psychiatry flash cards online? Go to Quizlet.Quizlet Create a free account. When you receive a confirmatory email, click on the link to activate your new account. With your activated account open in another browser window, click on this link to join the class.link You can download the free Quizlet app to your iPhone or import these learning sets to the more robust Flashcards Deluxe app. Enjoy. I hope you find these cards helpful. Please post your feedback or suggestions on the Quizlet site.

14. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 1Concise Textbook of Clinical Psychiatry, Third Edition Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007 2The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

15. Where can you find evidence-based information about mental disorders? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,” Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.here

16. Are there other questions?  Safety  Quality  Service  Relationships  Performance 