Vanderbilt & atom Alliance Webinar Series Vanderbilt University - PowerPoint PPT Presentation

Vanderbilt & atom Alliance Webinar Series

 Vanderbilt University Medical Center  Vanderbilt University Center for Quality Aging  atom Alliance

 Session #2: Dementia & Behavioral Disturbances  Session #3: Psychopharmacology in the Nursing Home  Session #4: Principles of Non-pharmacologic Management & the Formulation of Behavioral Care Plans  Session #5: The Implementation of Behavioral Strategies & the Management of Pharmacologic Interventions  Session #6: Addressing Barriers to Change: the Perspective of Psychiatry, Nursing, and Medical Directors

 Chat Monitor: Britt Kuertz, RDN Brittany.t.kuertz@vanderbilt.edu 615-936-1499  Moderator: Emily Hollingsworth, MSW Emily.k.hollingsworth@vanderbilt.edu 615-936-2718

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Paul Newhouse, MD

 Paul Newhouse, MD Director, Vanderbilt Center for Cognitive Medicine, Jim Turner Chair in Cognitive Disorders Department of Psychiatry, Vanderbilt University

 Become familiar with common dementing disorders and their clinical symptoms.  Describe common behavioral problems in dementia  Understand the context in which behavioral disturbances occur in dementia patients

Clinical Picture of Behavioral Problems in Dementia Auguste Deter November, A 51 year old , A.D. is admitted to the long- 1902 term care facility for being unmanageable at home..  Her condition steadily deteriorates  Her husband reports that she has loss of despite treatment with memory loss, memory, delusions, and temporary speech difficulty, confusion, suspicion, vegetative states. She will drag sheets agitation, wandering and screaming to across the house, and scream for hours becoming bedridden, incontinent, and in the middle of the night. unaware of her surroundings.  On examination, she has a cluster of  She dies and her brain is sent for symptoms that include reduced autopsy by… comprehension and memory, as well as  Dr Alois Alzheimer language disturbance, disorientation,  Recently, her tissue was reexamined unpredictable behavior, paranoia, and found to show a rare familial auditory hallucinations, and severe Alzheimer’s Disease gene mutation social impairment. ( PS1 ).

Dr Alois Alzheimer Alzheimer’ s disease (AD)  refers to the neurodegenerative brain disorder regardless of clinical More Recent Cases of Alzheimer ’ s Disease status AD can be conceptualized as  having two major stages  Preclinical (presymptomatic)  Symptomatic  Prodromal (MCI)  Dementia of the 16� Alzheimer type Thursday, March 19, 15�

A global impairment of higher cortical functions including memory, capacity to solve problems of daily living, performance of learned perceptuomotor skills, correct use of social skills and control of emotional reactions.  Multiple Cognitive Deficits:  Memory dysfunction: especially new learning, a prominent early symptom  At least one additional cognitive deficit  aphasia, apraxia, agnosia, or executive dysfunction  Cognitive Disturbances must be sufficiently severe to cause impairment of occupational or social functioning  Must represent a decline from a previous level of functioning

Symptom Trouble remembering new information 46% Difficulty with complicated tasks 27% Trouble responding to problems 14% Frequently getting lost or trouble staying oriented 18% Trouble expressing thoughts, ideas, or following 21% conversations Change in personality or behavior 25% CHS Alzheimer ’ s Disease Caregiver Project: Wave 6, 2000

Time (y) 0 y 10 y Time? MCI MMSE 24 – 30 Mild AD MMSE 20 – 23 • Mild subjective/ • Forgetfulness objective Moderate memory Cognitive function • Repetitive AD loss questions MMSE 10 – 19 • Normal • Daily function function impaired • Progression of cognitive deficits Severe AD • Short-term memory loss MMSE 0 – 9 • Word-finding • Agitation difficulties • Altered sleep patterns • Total dependence: dressing, feeding, bathing

MILD STAGE  Forgetfulness, difficulty learning new information  Difficulty planning meals, managing finances, taking medications on schedule Symptoms sometimes mistaken  for depression Ability to perform activities of daily  living (ADL) usually maintained Sources: Galasko D. Eur J Neurol . 1998;5(suppl 4):S9-S17. Cefalu C, Grossberg GT. Diagnosis and Management of Dementia . Leawood, Kan: American Academy of Family Physicians; 2001.

MODERATE STAGE  Short- and Long- term memory impairment  Difficulty performing tasks (e.g., following written notes, using the shower or toilet)  Agitation, behavioral symptoms appear (e.g., restlessness, wandering, delusions, hallucinations)  Deficits in intellect and reasoning (e.g., Sources: Galasko D. Eur J Neurol . 1998;5(suppl 4):S9-S17. National Institute on Aging Alzheimer ’ s Disease poor judgment, forgets manners) Education and Referral Center. Available at: http://www.alzheimers.org/unraveling/unraveling.pdf. Accessed April 6, 2005.

SEVERE STAGE  May lose language function and mumble or speech may be unintelligible  Behavioral symptoms common (e.g., refuses to eat, cries out inappropriately)  Failure to recognize family or faces  Difficulty with all essential ADL (e.g., eating, toileting, walking) Source: Gwyther LP. Caring for People With Alzheimer ’ s Disease: A Manual for Facility Staff . 2nd ed. Washington, DC and Chicago, Ill: American Health Care Association and the Alzheimer ’ s Association; 2001.

Mild Moderate Severe Years 0 2 4 6 8 10 Keep Appointments Use the Telephone Obtain Meal/Snack Activities of Daily Living Travel Alone Use Home Appliances Find Belongings Select Clothes Dress Groom Maintain Hobby Dispose of Litter Clear Table Walk Eat 25 20 15 10 5 0 MMSE Score Progressive Loss of Function Adapted from Galasko D, et al. Eur J Neurol . 1998;5(suppl 4):S9-S17.

 Safety (driving, compliance, cooking, etc.)  Family stress and misunderstanding (blame, denial)  Early education of caregivers of how to handle patient (choices, getting started)  Advance planning while patient is competent (will, proxy, power of attorney, advance directives)  Specific treatments:  May slow underlying disease process, (disease-modifying treatments now under study)  Standard treatment may delay nursing home placement longer if started earlier  May slow conversion from Mild Cognitive Impairment to AD

Patient initially diagnosed Patient’s first diagnosis other than AD with AD 35% 14% No 72% 14% 9% Yes 28% 7% 21% Dementia (not AD) Stroke Depression No diagnosis Source: Consumer Health Sciences, Normal aging Other LLC. Alzheimer ’ s Caregiver Project. 1999.

 Clinical features of FTD include  decline in personal hygiene and grooming,  mental rigidity and inflexibility, distractibility and impersistence,  hyperorality and dietary changes,  Common cause of early onset dementia  perseverative and stereotyped  1:1 with AD 45-64 years  More common than AD below behavior, and utilization behavior 60 years

 Lack of concern for loved one’s illness  Cruelty to children, animals, elderly  Lack of concern when others are sad  Rude comments to others  Lose respect for intrapersonal space  “Disgusting” behaviors  Diminished response to pain

 Presence of dementia, gait/balance disorder, prominent hallucinations and delusions, sensitivity to traditional antipsychotics, and fluctuations in alertness  Neuropsychological tests do not reliably differentiate DLB from AD  Brain shows cortical Lewy bodies (alpha synuclein)

 Fluctuating cognition with pronounced variations in attention and alertness Occurs in 80-90% of DLB, only 20% of AD  Recurrent visual hallucinations that are typically well formed and detailed ▪ can involve scenes and bizarre situations ▪ can start with misinterpretations and are usually short ▪ often occur at night  Spontaneous motor features of parkinsonism: slow gait, increased muscle tone, tremor

Management Goals Preserve cognition and reduce decline 1. Maintain quality of life 2. Maximize function and maintain dignity 3. Treat mood and behavior problems 4. Refer, educate, and counsel 5. Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia . Leawood, Kan: American Academy of Family Physicians; 2001.

(Secondary Prevention)  Cholinesterase inhibitors are the mainstay of therapy  3 oral drugs currently on the market  Though some patients experience immediate improvement, most prominent effect is cognitive stabilization  Functional improvement may follow cognitive enhancement or stabilization  Positive effects of these agents appear to be sustained but fade over long periods

Feldman et al. Poster presented at the 8 th International Montreal/Springfield Symposium on Advances in Alzheimer Therapy, 2004

. Randomization to donepezil continuation or placebo . Neuropsychiatric Inventory total score (NPI) (n ~ 96) Holmes et al, 2004