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Dementia Carrie Plummer, PhD, ANP-BC Abby Parish, DNP, A/GNP-BC
Jennifer Kim, MSN, GNP-BC Vanderbilt School of Nursing Meharry-Vanderbilt GEC Qsource Webinar Series
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DEMENTIA FACTS
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Dementia - An Overview Definition Types of Dementia Risk Factors
Diagnosis Stages Treatment/Prevention Resources
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Statistics 7 million people suffer from Alzheimer’s disease (AD)
AD accounts for 50-70% of all dementias 8th leading cause of death in elderly AD lasts from 3-20 yrs (avg: 7 yrs) Cost in US: $100 billion/year Currently there is NO CURE
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Dementia More than just memory loss Mild Cognitive Impairment (MCI)
Deficits in SHORT TERM memory Deficits in attention, language and problem solving Interferes with social and occupational functioning Mild Cognitive Impairment (MCI) Memory deficits without functional impairment Can be difficult to distinguish from normal changes of aging Amnesia type - most studied, most likely to progress to AD donepezil (Aricept) may be protective for limited period (~1 year)
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Common Types of Dementia
Alzheimer’s Disease 50 – 70% Vascular Dementia 15 – 30% Dementia with Lewy Bodies (DLB) 10 – 25% Frontotemporal lobe Dementia rare Secondary dementias Normal Pressure Hydrocephalus (NPH) Parkinson’s dementia AIDS related dementia Alcohol related dementia
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Alzheimer’s Disease Alois Alzheimer- 1906 Histopathology:
“Unusual disease of the cerebral cortex” Histopathology: Neurofibillary plaques and tangles Parietal-temporal cortex, prefrontal cortex, hippocampus, amygdala Granulovacular bodies Large, double-membraned bodies
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Plaques & Tangles
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Results of cell death
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Alzheimer’s Disease Neurotransmitter Changes
Acetylcholine amount and activity decreased Needed for memory, language and thoughts. N-methyl-D-aspartate (NMDA) Somatostatin Serotonin
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Alzheimer’s Disease-Types
Sporadic No known cause No obvious inheritance patterns Familial Rare (<10%) Early onset ** Gene mutations on chromosomes 1,14 & 21 21 = abnormal amyloid precursor protein (APP) 14 = abnormal presenilin 1 1 = abnormal presenilin 2 Autosomal dominant pattern 1 copy of altered gene can cause AD
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Risk Factors of AD (Sporadic)
Exact cause of AD is unknown: Age 1 in 10 people over 65 30-50% of those 85+ High blood pressure High cholesterol Head injury Hormone replacement therapy
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Symptoms of AD Memory Loss Confusion/Disorientation Language problems
Slow progression Affects daily living Confusion/Disorientation Language problems Word finding Using words inappropriately or forgetting their meaning Judgment
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Symptoms of AD Difficulty with Changes Apathetic Handling money
Calculating numbers Keeping track of things Misplacing items Changes Personality Mood Apathetic
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Stages of AD Mild Moderate Primarily cognitive deficits
Mild personality/behavior changes Moderate More pervasive memory impairment Impairment of ADLs requiring supervision and minimal assistance Behavioral symptoms more pervasive
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Stages of AD Severe Profound memory impairment
Requires significant assistance with ADLs Vegetative symptoms more pervasive
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Stages of AD Mild (can last 2-4 years or longer) MMSE is ≥21
Appearance of health Symptoms may be mistaken for normal aging changes SYMPTOMS: easily loses way to familiar places, trouble with word finding, hoarding, taking longer time to finish familiar tasks, personality changes, anxiety, poor judgment.
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Stages of AD Moderate (can last 2-10 years) MMSE is 10-20
More damage to the brain, especially areas controlling language, reasoning, thought and processing of sensory information. Symptoms are more pronounced. SYMPTOMS: trouble recognizing familiar people & objects, behavior changes, more spontaneity, inappropriate comments, paranoia, problems with language (speech, reading, writing), loss of impulse control
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Stages of AD Severe (can last 1-3 years or longer) MMSE is ≤9
Damage to brain is widespread & full time care required. Difficult time for family & caregivers. SYMPTOMS: doesn’t recognize self or close family, loses control of bowel and bladder, weight loss, repetitive crying, complete loss of language, increased sleeping, difficulty swallowing.
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Vascular Dementia 5% of all dementias; 22% mixed with AD
Stepwise progression PMH: CVA, MI, DM, HTN, PVD, HLD Memory impairment less severe than AD TX: No current FDA-approved medications donepezil (Aricept) shown to be effective in mild-mod VD
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Dementia with Lewy Bodies (DLB)
Characterized by loss of dopamine and acetylcholine: Common presenting symptoms: Visual hallucinations Parkinsonian symptoms Cognitive fluctuations Other symptoms: Repeated falls REM sleep behavior disorder Depression/apathy TX: No approved medications, but cholinesterase inhibitors have been found to be helpful. Paradoxical response to antipsychotics!
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Distinguishing DLB from AD
Presenting deficits Executive function Visuospatial function Memory (particularly short term) Early MMSE deficits Overlapping pentagons, clock drawing, serial sevens (or WORLD backwards) Orientation, 3 item recall
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Frontotemporal lobe Dementia
Rare Early onset (age 35-75) Hyperorality Impairment in executive functioning Misdiagnosis common TX: none approved
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Parkinson’s Dementia 30-50% PD patients will develop dementia
TX: Exelon (mild to moderate)
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Normal Pressure Hydrocephalus
Rare Increase of CSF in ventricles TBI CVA Unknown causes Clinical triad Altered gait Urinary incontinence Confusion Treatment Surgical shunt placement
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MAKING THE DIAGNOSIS
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Diagnosing Dementia History Neuroimaging? Medical and blood tests
Physical exam Cognitive tests ability to count, language & problem-solving Autopsy Early diagnosis is beneficial to allow for early pharmacological and non-pharmacological treatment.
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It looks a lot like dementia…
Depression Thyroid problems Vitamin B12 deficiency Alcoholism Medications Infections Uncontrolled diabetes Electrolyte imbalance Tumors Neurosyphyllis
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Dementia vs. Depression
Confabulation 50% will show some degree of depressive symptoms Depression “pseudodementia” “I don’t know” Trial of an antidepressant may assist to distinguish (Dharmarajan & Norman)
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Cognitive Testing for Dementia
MMSE Not a diagnostic tool Clock Drawing Test (CDT) Mini Cog Functional assessment
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Dementia DSM-IV Criteria
Development of multiple cognitive deficits manifested by both: Memory impairment One or more of the following cognitive disturbances: Apraxia (inability to execute learned purposeful movements) Aphasia (disturbance of comprehension and formulation of language), Agnosia (loss of ability to recognize objects, persons, sounds, shapes or smells), Disturbances in executive functioning.
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Dementia DSM-IV Criteria continued…
Significant impairment in social & occupational functioning Decline from previous level of functioning
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Advanced Directives A Special Note
Discuss early to allow patient opportunity to participate in decision making Resuscitation/Intubation Feeding tube Long term fluids Antibiotics DPOA for Healthcare
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Dementia in the Media
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TREATMENT
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Protective Factors High education Leisure activities
Aerobic & strength training Cholesterol-lowering strategies Good control of HTN, DM & hyperlipidemia Cognitive Stimulation Therapy: Cochrane Review Not efficacious
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TREATMENT GOALS Maximize: Function Independence Quality of life
Individual with dementia Caregivers Time before institutionalization is needed
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Treatment for Dementia
No known cure Cholinesterase inhibitors stabilize behaviors: Indicated for mild-moderate AD Inhibits acetylcholinesterase thereby reducing amount of acetycholine breakdown in brain Aricept (donepezil) Exelon (rivastigmine) Razadyne (galantamine)
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Cholinesterase Inhibitors
Treatment goals: Low rate of short term improvement Moderate rate of stabilization Primary goal is of less than expected decline Benefits: Don’t give families false hope Decision to discontinue: Cost Uncertain/diminished benefit? Side effects If discontinuation is appropriate, use slow taper Some patients continue on CI’s indefinitely
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Namenda N-methyl-D-asparate (NMDA) antagonist
blocks action of the chemical glutamate Use cautiously with amantidine or dextromethorphan Monitor closely with coadministration of HCTZ, triamterene, metformin, cimetidine, ranitidine, quinidine & nicotine Use the same renal system & can result in elevated plasma levels of medications. Common SE: constipation, headache, dizziness, pain
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Treatment of Associated Symptoms and/or Diseases
Depression Common co-morbidity Symptoms often overlap which complicates diagnosis SSRIs (avoid Prozac can increase agitation and sleep disturbances)
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Treatment of Associated Symptoms and/or Diseases
Sundowning Trazodone Medications for agitation- no FDA approved meds Mood stabilizer? Atypical antipsychotics? Behavioral problems: Assessment of “other” causes and initiate non-pharmacological interventions before medications!
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Antipsychotic Use in AD
Short term improvement in aggression and psychosis (6-12 weeks) Increased risk of mortality in long term use Other unwanted side effects: Orthostasis Anticholinergic effects Increased fall risk Dementia Antipsychotic Withdrawal Trial (DART-AD) Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study: Modest benefits do not justify adverse events
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Elderly patients with dementia-related psychosis treated with atypical
WARNING: Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at increased risk of death compared to placebo. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients. Over the course of the typical 10-week controlled trial, the rate of death in the drug treated group was about 4.5%, compared to a rate of death of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Abilify (aripiprazole)/Geodon (zipraxidone)/Risperdal (risperidone)/ Symbyax (olanzapine and fluoxetine)/Zyprexa (olanzapine) are not approved for the treatment of patients with dementia-related psychosis. (
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Drugs which have NOT shown a therapeutic benefit for dementia
For cognitive symptoms: Vitamin E NSAIDS Estrogen For behavioral symptoms: Bezodiazepines (typically) Lithium Beta-blockers (APA)
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Non-pharmacological treatment of problem behaviors
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Behavioral symptoms of dementia
Behavioral symptoms have been reported to affect as many as 90% of dementia patients Most common in moderate to severe stages Symptoms include: Irritability Medication/care refusal Eloping Agitation Combative behavior Non-pharmacological interventions are first line for these symptoms
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Causes of Behavior Changes
Physical discomfort caused by an illness or medications Overstimulation from loud noises or a busy environment Unfamiliar surroundings such as new places or inability to recognize home Complicated tasks Frustrating interactions due to the inability to communicate effectively Taken from
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Approach to problem behaviors
Explore possible causes Medication review, pain Calm demeanor Be sympathetic Minimize distractions & stimulation Relaxation Maintain a routine Redirection and reorientation Simple, one-step commands Remove physical restraints!
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Interventions for agitated patients
Therapeutic options with poor evidence base, but being studied: Music therapy Documentary “Alive Inside” Touch therapy (e.g., massage) Pet therapy Simulated presence therapy (audio or video of family or other) Reminiscence therapy (Beier)
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Resources for Caregivers
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Caregiver Burden: Emotional
Characteristics of the disease change, and caregivers must constantly develop new coping mechanisms. “Constant vigilance” “Loss of personhood” The point at which the patient no longer consistently recognizes the caregiver can be particularly emotional.
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Caregiver Advice (Ham & Sloane, 2009)
Be realistic Recognize a need for assistance Seek a support group Communicate with family to share burden Ensure optimal health Anticipate problems & plan strategies Plan legal & financial aspects early
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Resources Alzheimer’s Association Council on Aging
Directory of Services for Seniors (new edition 1/09) Caregiver Resource Guide ($10) Aging & Caring: Things Families Need to Know Area Agency on Aging Financial and legal planning- do it EARLY Certified elder law attorney Medicaid managed care Qualifications vary from state to state
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Resources Reading Materials
Rabins, Peter & Mace, Nancy (2006). 4th edition. The 36-Hour Day Dunn,Hank (2001). Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care and the Patient with a Life-Threatening Illness Broyle, Frank (2006). Coach Broyles’ Playbook for Alzheimer’s Caregivers
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Resources Children’s Books
Fox, Mem (1985). Wilfrid Gordon McDonald Partridge. Altman, Linda Jacobs & Johnson, Larry (2002). Singing with Momma Lou Ballman, Swanee (2001). The stranger I call Grandma: a story about Alzheimer’s disease.
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More Helpful websites Alzheimer’s Association
Alzheimer’s Disease Education & Referral Center (ADEAR). U.S. NIA Clinical Trials Information Alzheimer’s Association website Home>Alzheimer’s Disease > Clinical Studies Timothy Takacs Elderlaw Practice Free referral service for elder care options
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Thank you for your time and attention.
Q & A Session
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