Dementia..
Content
Dementia
Medical Aspects of Disability October 17, 2006
DEMENTIA
• DEFINITION:
– Group of symptoms that can be caused by over 60-70 disorders. – Syndrome which refers to progressive decline in intellectual functioning severe enough to interfere with person‘s normal daily activities and social relationships. (National Institute on Aging1995 No. 95-3782)
Dementia
– Marked by progressive declines in • memory. • visual-spatial relationships • performance of routine tasks • language and communication skills • abstract thinking • ability to learn and carry out mathematical
calculations.
Dementia
• Two Types:
– Reversible – Irreversible
• Individuals must have intensive medical
physical to rule out reversible types of dementia.
Delirium vs. Dementia
• Delirium defined--- characterized by a disturbance
of consciousness and a change in cognition that develop over a short period of time • About 10-15% of surgical patients experience delirium, and 15-25% of medicine inpatients will experience delirium • 30% Surgical Intensive Care Unit patients develop delirium, and up to 30% of AIDS patients while inpatient, will develop delirium
Delirium vs. Dementia
• A major risk factor is advanced age
Other factors include very young people (children),
organic brain damage including stroke, MVA, etc, substance use, previous delirium, malnutrition, sensory deprivation (hearing or visual loss), diabetes, cancer
Having an episode of delirium is more than just
inconvenience
3 month mortality following an episode of delirium is
25-30%. 1 year mortality after an episode of delirium may be as high as 50%.
Delirium vs. Dementia
• Many causes of delirium:
Some examples… epilepsy, CNS trauma, CNS
infection, CNS neoplasm, endocrine dysfunction (pituitary, thyroid, adrenal, parathyroid, pancreas), liver failure, UTI, cardiac dysrhythmias, hypotension, vitamin deficiency, sepsis, electrolyte imbalance, iatrogenic- any medication, substance withdrawal
Delirium vs. Dementia
• Could be psychiatric disorder, i.e. major
depression or generalized anxiety disorder, in which case need to initiate treatment for this disorder, i.e. get a psych consult • Or is the cause a delirium from other meds or an infection, in which case should look at labs and med list. • Or is cause alcohol withdrawal, in which case need to treat w/d with benzodiazepines • If patient is having chronic trouble sleeping, a good choice to help them is Ambien/zolpidem or Sonata/zaleplon
Delirium vs. Dementia
• Watch for alcohol withdrawal as cause of
delirium. If elevated pulse and blood pressure, see elevated MCV, and patient begins to act bizarre, talk to family if at all possible, about substance use. If patient enters delirium tremens (DT‘s), untreated has a mortality rate of 20%.
Delirium vs. Dementia
• How is delirium treated?
First line treatment for delirium is to treat underlying cause. Often will need many labs- Complete Metabolic Panel, Complete Blood Count, TFT, EEG if indicated, CT/MRI of head, sometimes LP, etc. A psychiatric or psychological consult might be needed for agitation. Meds- Haldol 2.5-5 mg (less for geriatric) or now, Geodon 10-20 mg IM or Ativan IM
Delirium vs. Dementia
• A common problem in the US
– 5% of those over 65 have severe dementia, 15% have mild dementia – 20% those over 80 have severe dementia – One of first distinctions you must make is reversible from nonreversible. – Only about 10-15% are reversible
Delirium vs. Dementia
• Nonreversible does not mean non treatable! • Non reversible dementias– Alzheimer‘s is most common by far, accounting for about 70% of dementias. – See a tempero-parietal wasting at first, leading you to see the memory loss and speech problems first. The ―lost keys‖sign. – Then will progress to global atrophy of brain. – Genetics a risk factor (up to 35-40% patients have a family history of Alzheimer‘s
Dementia
• Reversible:
– D= – E= – – – – – – M= E= N= T= I= A= Drugs, Delirium Emotions (such as depression) and Endocrine Disorders Metabolic Disturbances Eye and Ear Impairments Nutritional Disorders Tumors, Toxicity, Trauma to Head Infectious Disorders Alcohol, Arteriosclerosis
Dementia
• Irreversible:
– – – – – – – Alzheimer‘s Lewy Body Dementia Pick‘s Disease (Frontotemperal Dementia) Parkinson‘s Heady Injury Huntington‘s Disease Jacob-Cruzefeldt Disease
Dementia
• Irreversible:
– – Alzheimer's most common type of irreversible dementia Multi-Infarct dementia second most common type of irreversible dementia • Death of cerebral cells • Blockages of larger cerebral vessels, arteries • More abrupt in onset • Associated with previous strokes, hypertension • Can be traced through diagnostic procedures
Dementia
– Lewy Body Dementia • Episodic confusion with intervals of lucidity with at least one of the following:
1. Visual or auditory hallucinations 2. Mild extrapyramidal symptoms (muscle rigidity, slow movements 3. Repeated unexplained falls
• Progresses to severe dementia—found at autopsy.
Dementia
Diagnosis of Frontemporal Dementia (Pick‘s
Disease)
Pick‘s bodies in cells. Personality changes Behavioral dis-inhibition. Loss of social or personal awareness. Disengagement with apathy Maintain ability to draw and calculate well into later stages
Alzheimer's Disease
• Estimated that 4,000,000 people in U.S.
have Alzheimer's disease. • Estimated that 25-35% of people over age 85 have some time of dementia. • After age 65 the percentage of affected people, doubles with every decade of life. • Caring for patient with Alzheimer's disease can cost $47,000 per year (NIH).
Changes Caused by Alzheimer's
• • • •
Diminished blood flow Neurofibrillary Tangles Neuritic Plaques Degeneration of hippocampus, cerebral cortex, hypothalamus, and brain stem
Atrophic hippocampus in AD
Compare central sulcus of Alzheimer‘s patient with normal 81 year old woman
From Whole Brain Atlas at http://www.med.harvard.edu/AANLIB/home.html
74 year old AD patient: reduced blood flow on SPECT in temporal areas
Normal vs AD Brain
Normal brain
Alzheimer‘s brain
AD Prognosis
• Alzheimer‘s has a slowly progressive
decline. These meds can slow the progression, NOT halt it.
Function
Time
Pick‘s disease
• • • •
25 times rarer than Alzheimer‘s dementia Frontal lobe clinical features Assymetrical frontal or temporal atrophy Has been connected with semantic dementia, but evidence is not conclusive yet
Case history: Pick's Disease This 59 year old woman had a three year history of a progressive alteration in social behavior which included apathy and occasional disinhibition. Images reveal severe focal shrinkage of temporal and frontal lobes bilaterally.
Degeneration of the basal ganglia
• Huntington‘s disease
– Rare: 5 in 100,000 – abnormal ‗exaggerated movements
• Parkinson's disease
– Common: 1 in 100 over age 65 – General slowing of voluntary movements
• Both diseases involve the basal ganglia, but
in large opposite ways
Basal ganglia
• • • • •
Caudate Striatum Putamen Globus pallidus Subthalamic nuclei Substantia nigra
Multi-infarct dementia (MID)
• Many small strokes • Often mixed with Alzheimer‘s dementia
Viral dementia: HIV
• 20-60% of HIV patients suffers from
dementia • Cerebral atrophy may be caused by microglial nodules
Vocational Rehabilitation and Dementia
• Can dementia occur while an individual is
•
•
•
•
employed? Is dementia covered under the American‘s with Disabilities Act? Can jobs and tasks be modified to assist individuals with mild forms of dementia? Can job discrimination occur for these individuals? What types of job modifications and/or assistive technology can you think of for an individual with dementia?
End-stage Dementia
Prognosis < 6 mos: • Severe dementia with need for total assistance in ADLs (dressing, bathing, continence), unable to walk, only able to speak a few words • Comorbid conditions – aspiration pneumonia, urosepsis, decubiti, sepsis • *Unable to maintain caloric intake with weight loss of 10% or more in 6 months (and no feeding tubes)
Complications from dementia
• • • •
Delusions in up to 50%, most with paranoia Hallucinations in up to 25% Depression, social isolation may also occur Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness
Treatment of complications
• Hallucinations, delusions, agitation, sun-downing may be
• • • • •
•
improved with anti-psychotics like haloperidol, risperdal, mellaril… If any signs of depression, may be beneficial to treat Anxiety may respond to benzodiazepines Behavioral mod – reinforce good behavior, DON‘T fight aggressive behavior Familiarity (change in environments make things worse) Safety – key locks, knobs off stoves, take away car keys/cigarettes/firearms…, lights, watch stairs Avoid restraints, use human contact/music/pets/ distraction
Artificial Nutrition in Dementia
• Many excellent reviews demonstrate no •
improvement in quality of life and quantity of life with G-tubes. 5% morbidity and mortality with the procedure itself No decrease in aspiration with them Risk of infection Can keep patient comfortable without it
• • •
Complications from dementia
• • • •
Delusions in up to 50%, most with paranoia Hallucinations in up to 25% Depression, social isolation may also occur Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness
Drug treatment in Alzheimer‘s disease
• Many drugs aim to stimulate the cholinergic
system • These drugs have limited positive effects and do not reverse the causes of AD
Dementia patients are very sensitive to additional disabilities
• • • • •
Illness Pain Medications Poor hearing Poor vision
Management of depression at end of life
• Psychotherapy – behavioral, cognitive, and other
supportive approaches by psychologists, licensed social workers, chaplains, even bereavement counselors may help • New coping strategies like meditation, relaxation, guided imagery, hypnosis may help • Medications
Suicide
• Women attempt it twice as much, but men are 4x more
likely to succeed • White men over 85 are at highest risk to do it • All patients with depressive symptoms should be assessed for it • Talking about it can decrease risks • High risk of attempt if thoughts are recurring or if have thought out the plan ONE OTHER POTENTIAL EMERGENCY: • If risk high – DON‘T leave client alone, immediately consult a psychiatrist – may need in-patient care or involvement of authorities
Anxiety
• May be a normal response to the situation – fears,
uncertainty, reaction to physical condition, social or spiritual needs • Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension • Look for signs of depression, delirium, alcohol/drug abuse, caffeine abuse • About 5% are affected by agoraphobia
Related anxiety conditions
• Panic attacks – acute onset of palpitations,
sweating, hot, shaking, chest pain, nausea, dizzy, derealization, fear, numbness; usually short lived • Phobias – fears with avoidance, feelings of being trapped, exposed • Post-traumatic Stress Syndrome – in response to severe trauma, get more intense fear, terror, dreams, feelings of helplessness, detachment that can occur later on
Other EOL care needs for dementia
• In bedbound, watch out for and prevent decubiti • Feeding instructions to prevent aspiration – head
up, chin tucked, thick consistency foods like pudding/jello/ice cream… • Caregiver stress – difficult care, poor sleep, education to prevent aggressive behavior, early bereavement losing loved one before they are gone, need for support/respite
Summary
• A change in mental or emotional status of the
patient is not uncommon with a life-threatening illness • Need to be aware of conditions that may be normal reactions or have causes that are potentially reversible, but at the end of life, may need to focus on acute management of these conditions • Need compassionate, supportive care for patient and caregiver, always addressing safety
Links
• Alzheimer‘s Association: http://www.alz.org/ • National Institute of Neurological Disorders
and Stroke‘s page on dementia:
http://www.ninds.nih.gov/disorders/dementias/de mentia.htm
• How to manage difficult behaviors from the
Association for Frontotemporal Disorders:
http://www.ftd-picks.org/?p=caregiver.managing
Medical Aspects of Disability October 17, 2006
DEMENTIA
• DEFINITION:
– Group of symptoms that can be caused by over 60-70 disorders. – Syndrome which refers to progressive decline in intellectual functioning severe enough to interfere with person‘s normal daily activities and social relationships. (National Institute on Aging1995 No. 95-3782)
Dementia
– Marked by progressive declines in • memory. • visual-spatial relationships • performance of routine tasks • language and communication skills • abstract thinking • ability to learn and carry out mathematical
calculations.
Dementia
• Two Types:
– Reversible – Irreversible
• Individuals must have intensive medical
physical to rule out reversible types of dementia.
Delirium vs. Dementia
• Delirium defined--- characterized by a disturbance
of consciousness and a change in cognition that develop over a short period of time • About 10-15% of surgical patients experience delirium, and 15-25% of medicine inpatients will experience delirium • 30% Surgical Intensive Care Unit patients develop delirium, and up to 30% of AIDS patients while inpatient, will develop delirium
Delirium vs. Dementia
• A major risk factor is advanced age
Other factors include very young people (children),
organic brain damage including stroke, MVA, etc, substance use, previous delirium, malnutrition, sensory deprivation (hearing or visual loss), diabetes, cancer
Having an episode of delirium is more than just
inconvenience
3 month mortality following an episode of delirium is
25-30%. 1 year mortality after an episode of delirium may be as high as 50%.
Delirium vs. Dementia
• Many causes of delirium:
Some examples… epilepsy, CNS trauma, CNS
infection, CNS neoplasm, endocrine dysfunction (pituitary, thyroid, adrenal, parathyroid, pancreas), liver failure, UTI, cardiac dysrhythmias, hypotension, vitamin deficiency, sepsis, electrolyte imbalance, iatrogenic- any medication, substance withdrawal
Delirium vs. Dementia
• Could be psychiatric disorder, i.e. major
depression or generalized anxiety disorder, in which case need to initiate treatment for this disorder, i.e. get a psych consult • Or is the cause a delirium from other meds or an infection, in which case should look at labs and med list. • Or is cause alcohol withdrawal, in which case need to treat w/d with benzodiazepines • If patient is having chronic trouble sleeping, a good choice to help them is Ambien/zolpidem or Sonata/zaleplon
Delirium vs. Dementia
• Watch for alcohol withdrawal as cause of
delirium. If elevated pulse and blood pressure, see elevated MCV, and patient begins to act bizarre, talk to family if at all possible, about substance use. If patient enters delirium tremens (DT‘s), untreated has a mortality rate of 20%.
Delirium vs. Dementia
• How is delirium treated?
First line treatment for delirium is to treat underlying cause. Often will need many labs- Complete Metabolic Panel, Complete Blood Count, TFT, EEG if indicated, CT/MRI of head, sometimes LP, etc. A psychiatric or psychological consult might be needed for agitation. Meds- Haldol 2.5-5 mg (less for geriatric) or now, Geodon 10-20 mg IM or Ativan IM
Delirium vs. Dementia
• A common problem in the US
– 5% of those over 65 have severe dementia, 15% have mild dementia – 20% those over 80 have severe dementia – One of first distinctions you must make is reversible from nonreversible. – Only about 10-15% are reversible
Delirium vs. Dementia
• Nonreversible does not mean non treatable! • Non reversible dementias– Alzheimer‘s is most common by far, accounting for about 70% of dementias. – See a tempero-parietal wasting at first, leading you to see the memory loss and speech problems first. The ―lost keys‖sign. – Then will progress to global atrophy of brain. – Genetics a risk factor (up to 35-40% patients have a family history of Alzheimer‘s
Dementia
• Reversible:
– D= – E= – – – – – – M= E= N= T= I= A= Drugs, Delirium Emotions (such as depression) and Endocrine Disorders Metabolic Disturbances Eye and Ear Impairments Nutritional Disorders Tumors, Toxicity, Trauma to Head Infectious Disorders Alcohol, Arteriosclerosis
Dementia
• Irreversible:
– – – – – – – Alzheimer‘s Lewy Body Dementia Pick‘s Disease (Frontotemperal Dementia) Parkinson‘s Heady Injury Huntington‘s Disease Jacob-Cruzefeldt Disease
Dementia
• Irreversible:
– – Alzheimer's most common type of irreversible dementia Multi-Infarct dementia second most common type of irreversible dementia • Death of cerebral cells • Blockages of larger cerebral vessels, arteries • More abrupt in onset • Associated with previous strokes, hypertension • Can be traced through diagnostic procedures
Dementia
– Lewy Body Dementia • Episodic confusion with intervals of lucidity with at least one of the following:
1. Visual or auditory hallucinations 2. Mild extrapyramidal symptoms (muscle rigidity, slow movements 3. Repeated unexplained falls
• Progresses to severe dementia—found at autopsy.
Dementia
Diagnosis of Frontemporal Dementia (Pick‘s
Disease)
Pick‘s bodies in cells. Personality changes Behavioral dis-inhibition. Loss of social or personal awareness. Disengagement with apathy Maintain ability to draw and calculate well into later stages
Alzheimer's Disease
• Estimated that 4,000,000 people in U.S.
have Alzheimer's disease. • Estimated that 25-35% of people over age 85 have some time of dementia. • After age 65 the percentage of affected people, doubles with every decade of life. • Caring for patient with Alzheimer's disease can cost $47,000 per year (NIH).
Changes Caused by Alzheimer's
• • • •
Diminished blood flow Neurofibrillary Tangles Neuritic Plaques Degeneration of hippocampus, cerebral cortex, hypothalamus, and brain stem
Atrophic hippocampus in AD
Compare central sulcus of Alzheimer‘s patient with normal 81 year old woman
From Whole Brain Atlas at http://www.med.harvard.edu/AANLIB/home.html
74 year old AD patient: reduced blood flow on SPECT in temporal areas
Normal vs AD Brain
Normal brain
Alzheimer‘s brain
AD Prognosis
• Alzheimer‘s has a slowly progressive
decline. These meds can slow the progression, NOT halt it.
Function
Time
Pick‘s disease
• • • •
25 times rarer than Alzheimer‘s dementia Frontal lobe clinical features Assymetrical frontal or temporal atrophy Has been connected with semantic dementia, but evidence is not conclusive yet
Case history: Pick's Disease This 59 year old woman had a three year history of a progressive alteration in social behavior which included apathy and occasional disinhibition. Images reveal severe focal shrinkage of temporal and frontal lobes bilaterally.
Degeneration of the basal ganglia
• Huntington‘s disease
– Rare: 5 in 100,000 – abnormal ‗exaggerated movements
• Parkinson's disease
– Common: 1 in 100 over age 65 – General slowing of voluntary movements
• Both diseases involve the basal ganglia, but
in large opposite ways
Basal ganglia
• • • • •
Caudate Striatum Putamen Globus pallidus Subthalamic nuclei Substantia nigra
Multi-infarct dementia (MID)
• Many small strokes • Often mixed with Alzheimer‘s dementia
Viral dementia: HIV
• 20-60% of HIV patients suffers from
dementia • Cerebral atrophy may be caused by microglial nodules
Vocational Rehabilitation and Dementia
• Can dementia occur while an individual is
•
•
•
•
employed? Is dementia covered under the American‘s with Disabilities Act? Can jobs and tasks be modified to assist individuals with mild forms of dementia? Can job discrimination occur for these individuals? What types of job modifications and/or assistive technology can you think of for an individual with dementia?
End-stage Dementia
Prognosis < 6 mos: • Severe dementia with need for total assistance in ADLs (dressing, bathing, continence), unable to walk, only able to speak a few words • Comorbid conditions – aspiration pneumonia, urosepsis, decubiti, sepsis • *Unable to maintain caloric intake with weight loss of 10% or more in 6 months (and no feeding tubes)
Complications from dementia
• • • •
Delusions in up to 50%, most with paranoia Hallucinations in up to 25% Depression, social isolation may also occur Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness
Treatment of complications
• Hallucinations, delusions, agitation, sun-downing may be
• • • • •
•
improved with anti-psychotics like haloperidol, risperdal, mellaril… If any signs of depression, may be beneficial to treat Anxiety may respond to benzodiazepines Behavioral mod – reinforce good behavior, DON‘T fight aggressive behavior Familiarity (change in environments make things worse) Safety – key locks, knobs off stoves, take away car keys/cigarettes/firearms…, lights, watch stairs Avoid restraints, use human contact/music/pets/ distraction
Artificial Nutrition in Dementia
• Many excellent reviews demonstrate no •
improvement in quality of life and quantity of life with G-tubes. 5% morbidity and mortality with the procedure itself No decrease in aspiration with them Risk of infection Can keep patient comfortable without it
• • •
Complications from dementia
• • • •
Delusions in up to 50%, most with paranoia Hallucinations in up to 25% Depression, social isolation may also occur Aggressive behavior in 20-40% (may be related to above problems, misinterpretation) • Dangerous behavior – driving, creating fires, getting lost, unsafe use of firearms, neglect • Sundowning – nocturnal episodes of confusion with agitation, restlessness
Drug treatment in Alzheimer‘s disease
• Many drugs aim to stimulate the cholinergic
system • These drugs have limited positive effects and do not reverse the causes of AD
Dementia patients are very sensitive to additional disabilities
• • • • •
Illness Pain Medications Poor hearing Poor vision
Management of depression at end of life
• Psychotherapy – behavioral, cognitive, and other
supportive approaches by psychologists, licensed social workers, chaplains, even bereavement counselors may help • New coping strategies like meditation, relaxation, guided imagery, hypnosis may help • Medications
Suicide
• Women attempt it twice as much, but men are 4x more
likely to succeed • White men over 85 are at highest risk to do it • All patients with depressive symptoms should be assessed for it • Talking about it can decrease risks • High risk of attempt if thoughts are recurring or if have thought out the plan ONE OTHER POTENTIAL EMERGENCY: • If risk high – DON‘T leave client alone, immediately consult a psychiatrist – may need in-patient care or involvement of authorities
Anxiety
• May be a normal response to the situation – fears,
uncertainty, reaction to physical condition, social or spiritual needs • Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension • Look for signs of depression, delirium, alcohol/drug abuse, caffeine abuse • About 5% are affected by agoraphobia
Related anxiety conditions
• Panic attacks – acute onset of palpitations,
sweating, hot, shaking, chest pain, nausea, dizzy, derealization, fear, numbness; usually short lived • Phobias – fears with avoidance, feelings of being trapped, exposed • Post-traumatic Stress Syndrome – in response to severe trauma, get more intense fear, terror, dreams, feelings of helplessness, detachment that can occur later on
Other EOL care needs for dementia
• In bedbound, watch out for and prevent decubiti • Feeding instructions to prevent aspiration – head
up, chin tucked, thick consistency foods like pudding/jello/ice cream… • Caregiver stress – difficult care, poor sleep, education to prevent aggressive behavior, early bereavement losing loved one before they are gone, need for support/respite
Summary
• A change in mental or emotional status of the
patient is not uncommon with a life-threatening illness • Need to be aware of conditions that may be normal reactions or have causes that are potentially reversible, but at the end of life, may need to focus on acute management of these conditions • Need compassionate, supportive care for patient and caregiver, always addressing safety
Links
• Alzheimer‘s Association: http://www.alz.org/ • National Institute of Neurological Disorders
and Stroke‘s page on dementia:
http://www.ninds.nih.gov/disorders/dementias/de mentia.htm
• How to manage difficult behaviors from the
Association for Frontotemporal Disorders:
http://www.ftd-picks.org/?p=caregiver.managing
