1. 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

2. DEMENTIA FACTS

3. Dementia - An Overview Definition Types of Dementia Risk Factors
Diagnosis
Stages
Treatment/Prevention
Resources

4. 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

5. 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)

6. 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

7. 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

8. Plaques & Tangles

9. Results of cell death

10. Alzheimer’s Disease Neurotransmitter Changes
Acetylcholine amount and activity decreased
Needed for memory, language and thoughts.
N-methyl-D-aspartate (NMDA)
Somatostatin
Serotonin

11. 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

12. 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

13. 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

14. Symptoms of AD Difficulty with Changes Apathetic Handling money
Calculating numbers
Keeping track of things
Misplacing items
Changes
Personality
Mood
Apathetic

15. 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

16. Stages of AD Severe Profound memory impairment
Requires significant assistance with ADLs
Vegetative symptoms more pervasive

17. 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.

18. 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

19. 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.

20. 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

21. 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!

22. 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

23. Frontotemporal lobe Dementia
Rare
Early onset (age 35-75)
Hyperorality
Impairment in executive functioning
Misdiagnosis common
TX: none approved

24. Parkinson’s Dementia 30-50% PD patients will develop dementia
TX: Exelon (mild to moderate)

25. Normal Pressure Hydrocephalus
Rare
Increase of CSF in ventricles
TBI
CVA
Unknown causes
Clinical triad
Altered gait
Urinary incontinence
Confusion
Treatment
Surgical shunt placement

26. MAKING THE DIAGNOSIS

27. 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.

28. It looks a lot like dementia…
Depression
Thyroid problems
Vitamin B12 deficiency
Alcoholism
Medications
Infections
Uncontrolled diabetes
Electrolyte imbalance
Tumors
Neurosyphyllis

29. 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)

30. Cognitive Testing for Dementia
MMSE
Not a diagnostic tool
Clock Drawing Test (CDT)
Mini Cog
Functional assessment

31. 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.

32. Dementia DSM-IV Criteria continued…
Significant impairment in social & occupational functioning
Decline from previous level of functioning

33. 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

34. Dementia in the Media

35. TREATMENT

36. 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

37. TREATMENT GOALS Maximize: Function Independence Quality of life
Individual with dementia
Caregivers
Time before institutionalization is needed

38. 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)

39. 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

40. 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

41. 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)

42. 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!

43. 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

44. 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. (

45. 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)

46. Non-pharmacological treatment of problem behaviors

47. 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

48. 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

49. 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!

50. 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)

51. Resources for Caregivers

52. 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.

53. 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

54. 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

55. 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

56. 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.

57. 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

58. Thank you for your time and attention.
Q & A Session