© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (2): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.

© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (2): ITC2-1.

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in the clinic

Dementia


What medical interventions or health behaviors can help patients prevent dementia or cognitive decline? Modify the following potential risk factors

Physical inactivity

Depression

Midlife hypertension

Midlife obesity

Cognitive inactivity or low educational attainment

Diabetes mellitus

Minimize the use of sedative-hypnotics in elderly

Minimize risk for head trauma

Use seat belts; wear helmet in contact sports, on motorcycle, bicycle


Sedative-hypnotics: minimize use

Benzodiazepines, anticholinergics, barbiturates

Can cause cognitive impairment

Estrogen: use in mid-life may reduce dementia risk

But in prospective prevention trials: estrogen + progestin was associated with increased dementia and other complications

Ginkgo biloba: lack of evidence for prevention

What medications can be used in patients presenting with signs of dementia?


Universal screening is not recommended

Consider screening adult patients with:

Memory difficulty interfering with daily function

Unexplained functional decline

Deterioration in hygiene

Questionable adherence to medication regimens

New-onset psychiatric symptoms

Should clinicians screen for dementia?


Obtain history from patient + knowledgeable informant

Use standardized screening instrument

MMSE: was widely used but now copyrighted

SLUMS: most similar to the MMSE

Mini-Cog: short

MoCA: best sensitivity but lower specificity

IQCODE questionnaire: filled out by family member or other informant

What methods should clinicians use when looking for dementia?


CLINICAL BOTTOM LINE: Prevention and Screening... Minimize sedative-hypnotics for the elderly

Benzodiazepines, anticholinergics, barbiturates

Screen selected elderly patients

Take brief history from patient and knowledgeable informant

Use standardized screening instrument


Check for cognitive deficits

Medical, neurologic, and psychiatric signs and symptoms

Identify their order of appearance, severity, and associated features

Collect collateral info from knowledgeable informant, because the patient may be unable to report accurately

What elements of the history are important in evaluating patients with suspected dementia?

Consider in the differential diagnosis

Delirium

Aging-related cognitive problems


Look for conditions that cause or worsen cognitive symptoms

Evaluate patient’s alertness, general appearance, cooperation

Evaluate speech for its content and form

Assess for depression, anxiety, mania, suicide risk

Examine for delusions or hallucinations and obsessions or compulsions

Test abstract reasoning, judgment, visual-spatial perception, praxis, and planning ability

Evaluate corticosensory deficits

Include a standard tool (SLUMS, MOCA) in cognitive exam

How should clinicians evaluate the physical, mental, and cognitive status of patients with suspected dementia?


Diagnostic Criteria for Alzheimer Disease Probable Alzheimer disease is defined by:

Dementia established by clinical examination and documented by instrument (MoCA, SLUMS, Mini- Mental)

Deficits ≥2 areas of cognition, one usually memory

Progressive, not abrupt, decline

No disturbance of consciousness

Onset between age 40–90 years

Absence of other disorders that could account for deficits

The diagnosis of probable AD is supported by the presence of:

Specific cognitive deficits (e.g., aphasia, agnosia, apraxia)

Impaired activities of daily living

Positive family history

Supportive lab tests

continued…


Diagnostic Criteria for Alzheimer Disease Diagnosis of Alzheimer disease is unlikely when:

The onset is acute and focal neurologic findings present

Seizure or gait disturbance present early in disease course

Possible Alzheimer disease is defined by:

Dementia established by clinical exam and documented by an instrument (Mini-Mental Status)

Absence of other conditions that cause dementia on exam

Variations in clinical course from typical course of AD

Another condition is present that could cause dementia but not felt to be primary cause

Single, severe, progressive cognitive deficit without identifiable cause

Definite Alzheimer disease is defined by:

Presence of clinical criteria for probable Alzheimer disease combined w/ biopsy- or autopsy-confirmed histopathology


Comprehensive metabolic profile

CBC, TSH, vitamin B12 level

What lab tests are helpful in the evaluation of any patient with cognitive dysfunction?

Additional tests may include:

Rapid plasma reagin

HIV test

Toxicology screen

Erythrocyte sedimentation rate

Heavy metal screen

Thiamine level

Paraneoplastic panel

Chest radiograph or CT of the chest

Urinalysis


Neuroimaging (CT or MRI) of the head

If cognitive difficulties <3 years in duration

When should clinicians order lab studies?

Glucose or amyloid PET scanning

Differentiate frontotemporal dementia from AD

Assess for early-onset dementia

Genetic studies

If there is a concern for Huntington disease

Autosomal dominant gene mutation testing if multiple family members affected, clinical picture + workup suggestive, and onset age <60y

Lumbar puncture

If <55y or if dementia is rapidly progressive, rapid plasma reagin is +, and CNS infection/cancer, paraneoplastic syndrome, or immunosuppression possible

EEG: If question of delirium, seizures, encephalitis, or CJD


What other disorders should clinicians consider in the assessment of cognitive dysfunction?

Medications

Depression

Mild cognitive impairment

Cognitive decline without impairment in function

Follow closely: 7% to 15% “convert” each year to dementia

After 5 years, nearly 50% meet dementia criteria


CLINICAL BOTTOM LINE: Diagnosis…

Evaluate patients who report cognitive and functional decline

Take history of medical, neurologic, and psychiatric symptoms from patient and knowledgeable informant

Perform thorough physical and mental status evaluation and cognitive exam

Obtain basic lab studies

Obtain additional studies based on clinical presentation


Patients may struggle to comprehend and organize care

Prepare care plan that compensates for these limitations

Patients may lose the ability to identify symptoms

Standard medical and preventive care are important

Good control of hypertension, diabetes, and cholesterol

Antiplatelet therapy when appropriate

Vaccinations

As dementia advances, nutrition, skin care, toileting schedules, and dental care become more important

What should clinicians advise patients and their caregivers about general health and hygiene?


Driving becomes impaired in early stages of dementia

Difficult to predict when patient should lose ability to drive

Encourage periodic driving evaluation

Update the history regularly to check for deterioration

What should clinicians advise about driving, cooking, and other activities that raise safety issues?

Assess other safety issues on an ongoing basis

Home therapists can perform home-safety assessments

Modifications often possible to allow ongoing participation

Patients eventually become unable to take medications; cook; or use power tools, lawnmowers, or firearms

Wandering away from home is a frequent problem


Try nonpharmacologic methods first unless symptoms cause immediate distress

Many emotional and behavioral disturbances can be “decoded”

Use 4-D or DICE approach

Patient may act agitated when hungry, tired, under pressure to perform, in pain, or lonely

Also when personal care is being provided, during shift changes, and in the presence of specific staff members

When patterns are recognized: develop, implement, and refine targeted interventions

What should clinicians advise about nonpharmacologic approaches to sleep problems, behavioral problems, and psychiatric manifestations of dementia?


Alzheimer Medications Only Slow Cognitive Decline

Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine)

In patients with mild, moderate, or advanced AD

Better tolerated if slowly titrated to target dose

Memantine

Approved for use in moderate-to-advanced AD

Can use with acetylcholinesterase inhibitors

When benefit is unclear, drug may be stopped; restart if acute cognitive deterioration occurs


Mild-to-moderate Parkinson disease: rivastigmine

Effective in improving cognitive performance in doses similar to those used in AD

Benefit may occur w/ other acetylcholinesterase inhibitors

Which other pharmacologic agents are helpful in treating specific types of dementia?

Dementia with Lewy bodies: acetylcholinesterase inhibitor

Use for cognition

Not recommended for patients with vascular dementia

Dementia: vitamin E

May benefit function but not cognition


Ginkgo biloba

Herbal supplement does not slow progression of dementia

Coconut oil and Axona

Inadequate data on these food supplements to recommend

Nonsteroidal anti-inflammatory drugs

Estrogen

Ergoid mesylates

Which pharmacologic agents are ineffective in treating specific types of dementia and should be avoided?


Evidence is mixed for efficacy

Nearly 1/3 patients with dementia develop episode of major depression after the onset of dementia

Clinicians need high index of suspicion for major depression

Symptoms of major depression may be produced by dementia alone and complicate diagnosis

When should clinicians prescribe antidepressants in patients with dementia?


When should clinicians prescribe antipsychotic agents to treat behavioral disturbances or psychotic symptoms?

When symptoms cause significant distress for patient or create a dangerous situation

2nd-generation antipsychotics: lower tardive dyskinesia risk

Efficacy of these agents is modest overall

Prescribe lowest possible dose for shortest possible time

Try to decrease dose and then discontinue within 3 months

Drug use increases death rates and cerebrovascular events

Associated with metabolic syndrome, weight gain, hyperlipidemia, and diabetes mellitus


Which drugs should clinicians use to treat sleep problems in patients with dementia?

Try nonpharmacologic methods first

Pay attention to factors that can affect sleep

Sleep environment

Caffeine consumption

Daytime sleeping

Afternoon and evening medications

Other elements of basic sleep hygiene

Beware risks associated with sedative-hypnotics

If necessary: 25–50mg trazodone with cautious monitoring


What other steps should clinicians take to maximize the quality of life of patients with dementia? Address issues that have potential to affect QOL

Sensory aids (glasses, hearing aids)

Dental care

Noise, lighting, and temperature

Social and cognitive stimuli

Cleanliness

Pain

Constipation

Encourage patient to complete early advance directive


When should clinicians consult a neurologist, psychiatrist, or another professional for patients with dementia?

When features are atypical

When it’s unclear if dementia is present

When in-depth documentation of impaired and preserved capacities would benefit the patient

When neuropsychiatric symptoms are difficult to treat

When physical restraints are required


When should clinicians recommend hospitalization for patients with dementia?

When patient can’t be evaluated as an outpatient due to

Dangerous behavior or lack of cooperation

Unsafe living conditions

Compromised nutrition or neglected medical conditions

Severe psychiatric symptoms (psychiatric hospitalization may be required)

Hospitalization facilitates history-taking, evaluation, and future care planning


How can clinicians help families decide to move a patient with dementia into a long-term care facility?

Encourage families to investigate facilities before placement decisions are needed, because patients may suddenly develop limitations that can’t be managed at home

Families need support and guidance

Possible to provide many services at home if families have ample financial resources

Periods of respite care may help families delay placement


What caregiver needs should be addressed by the clinician?

Common caregiver symptoms

Guilt, anger, grief,

Fatigue, loneliness, demoralization, depression

Assess caregiver’s well-being at every visit

Demands on caregiver can change over time

Offer education about dementia, skills training, and caregiver well-being

Direct to pamphlets, books, and educational web sites

Inform about psychoeducational and other support groups


What are the options for end-of-life care?

Therapy for pain

Calling out, grimacing when touched, crying may be indicators of pain

Therapy for neuropsychiatric symptoms

Supportive medical care

Treatment for symptoms that occur in late stages

Skin breakdown

Impaired swallowing

Aspiration pneumonia

Marked weight loss


CLINICAL BOTTOM LINE: Treatment…

Adopt a broad approach that pays attention to

Comfort and quality of life

Cognitive enhancement

Stabilization of psychiatric symptoms

Safety issues

Caregiver well-being

Treat AD with acetylcholinesterase inhibitors

Add memantine for moderate-to-severe AD

Identify and treat psychiatric symptoms

Depression, psychosis, anxiety, behavioral disturbances

Use both behavioral and pharmacologic treatment

© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (2): ITC2-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.

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