Dementia 101 by Decontee "Dr. Dee" Jimmeh, MD

DEMENTIA 101

Decontee “Dr. Dee”Jimmeh, MD

Norwood Clinic/ Brookwood Medical Center

September 30, 2014

OUTLINE Epidemiology Definition/Criteria Clinical Staging Evaluation Associated Symptoms Management

Forgetting has become part of who Daddy is, so I decide to try to honor his forgetfulness. I try to love it. It defines his being these days, and sometimes I feel that to see him I have to look through it, a shuttered window. Underneath the forgetting lie a few remembered things, shoelaces, the way to hold a razor to shave, song-lyrics he recalls, like cockles and mussels- but you have to catch them at the right moment of the day, when they shine through the slats. Daddy is Daddy now because he forgets.-ELIZABETH COHEN The House on Beartown Road: A Memoir of Learning and Forgetting London (p.196-7)

EPIDEMIOLOGY www.alz.org www.youtube.com/watch?v=waeuks1-3

Z4#action=share

DEMENTIA FACTS 6th leading cause of death in the US

More than 5,000,000 are currently living with the disease.

Every 67 seconds, someone develops dementia in the US.

Dementia costs in the US: $220 billion

DEFINITION Dementia: a progressive, NON-reversible

decline in cognitive function that significantly impacts daily activities and social interaction

DSM-IV & DSM-5 CRITERIA

DEMENTIA SIGNS Memory loss that interrupts daily life Challenges in problem-solving and planning Difficulty completing tasks Confusion with time or place Trouble understanding visual images and

spatial relationship New problems with words in speaking or

writing Misplacing things and inability to retrace steps Decreased or poor judgment Withdrawal from work or social activities Changes in mood and personality

STAGES OF DEMENTIA Stage 1 (No impairment)

Normal Stage 2 (Very mild)

Person notices memory lapsesNo symptoms noticed by family, friends or

doctor Stage 3 (Mild)

Family and friends start to observe problemMMSE picks up deficits

Stage 4 (Moderate)Difficulty with calculation, forgetting one’s

own personal history, social withdrawal begins

STAGES OF DEMENTIA Stage 5 (Moderate severe)

Begin needing help with day to day activities Remain independent with eating and toileting

Stage 6 (Severe) Lose awareness of surroundings and need

with most ADLs Major personality issues; Tend to wander and

get lost Stage 7 (Very Severe)

Little to no speech production, rigid muscles, impaired swallowing; Loss of interaction with the environment

TYPES OF DEMENTIA Alzheimer’s (AD)

Vascular dementia

Mixed dementia

Frontotemporal dementia

Dementia with Lewy bodies

Subcortical dementias

http://farmagain.com/braininjury.html

ALZHEIMER’S DEMENTIA Most common type

Onset age: >60 years of age

Accumulation of abnormal proteins (neurofibrillary tangles/ amyloid plaques)

Temporal and parietal lobes heavily affected

Early onset disease associated with chromosome 21

VASCULAR DEMENTIA Also known as multi-infarct dementia

“Step-wise” progression

Diverse clinical presentation

Risk factors: diabetes, hypertension, and high cholesterol

EVALUATION OF DEMENTIA History & Physical

Mini Mental Status Exam

Labs: B12, thyroid function, liver enzymes, ammonia, RPR, glucose

Neuropsychological testing

CT head or brain MRI

MINI MENTAL STATUS EXAM

EVALUATION OF DEMENTIA History & Physical

Mini Mental Status Exam

Labs: B12, thyroid function, liver enzymes, ammonia, RPR, glucose

Neuropsychological testing

CT head or brain MRI

ALZHEIMER’S DEMENTIA MRI

VASCULAR DEMENTIA MRI

TREATMENT There is NO cure for dementia.

Medication options seek to slow disease progressionCholinesterase inhibitors (Donezepil,

Galantamine, Rivastigmine)NMDA receptor antagonist (Memantine)

Other agentsE.g. Fish oil, ginkgo biloba, vitamin ENo definite improvement in clinical trials

NEUROPSYCHIATRIC SYMPTOMMANAGEMENT The mainstay of treatment is symptom

management Examples of symptoms:

DepressionSleep disorderAgitationSexually inappropriate behaviorWanderingFalls

DEPRESSION A dementia mimic Co-morbid illness SSRIs

Citalopram and Sertraline are good choicesParoxetine not ideal (most anticholinergic)Fluoxetine (long ½ life; drug-drug

interactionsStart low and titrate slowly

Atypicals may be of some utilityEffexor, Wellbutrin, Remeron

SLEEP DISORDER Multifactorial

Sleep-wake cycle alterations, decreased daytime physical activity, anxiety/depression, nocturia, and medication side effects

TreatmentAvoid daytime napsDaytime activity/exercise programLimiting evening liquid intakeGo to bed and wake at the same time dailyMedications: Melatonin, Trazadone,

Remeron

AGITATION Typically is a response or reactions to

misperceptions of the environment Precipitating factors:

Confusion because of cognitive, memory, language deficits

Frightening, paranoid delusions or hallucinations

Pain or discomfortDepressionSleep disorderOther medical illness (e.g. UTI, pneumonia)New medications

BEHAVIORAL MANAGEMENT:NON-PHARMACOLOGIC Keep a daily routine Avoid sudden changes in environment Frequent re-orientation Encourage good sleep hygiene Avoid physical restraints Redirection/distraction Use short, clear statements Use calm reassurance; Avoid

reprimanding Music therapy Aromatherapy

BEHAVIORAL MANAGEMENT:PHARMACOLOGIC Drugs to uses:

SSRIs (citalopram)Atypical antipsychotics (quetiapine,

olanzapine, risperidone)

Drugs to avoid:Anti-cholinergic medicationsAnti-histamine medicationsBenzodiazepines

Paradoxical effect

WANDERING All patients are at risk

Common in stage 4 and beyond

Alarms on doors; Noisy garments; proofing locks on cabinets with dangerous or flammable items

SAFE RETURN program www.alz.org/Services/SafeReturn.asp1.800.625.3780

FALLS Major safety issue in the elderly, especially

the demented

Visuo-spatial deficits, muscle stiffness, lossof postural reflexes, and impulsivity increases risk

Avoid clutter in walkways, use of handrails, nonslip mats and other assistive devices

Physical and Occupational Therapy

THE CAREGIVER’S PERSPECTIVE ABC News Report

www.youtube.com/watch?v=LL_Gq7Shc-Y Caregivers’ Support

Resource referralEnd of life planning (legal and financial)Personal respiteCounseling for grief and guilt

SUMMARY Dementia is a slowly progressive condition that affects

cognition and has NO cure.

Alzheimer’s and vascular dementia are the two most common types.

Patients present differently and progress through the various stages at various rates

Mainstay treatment includes non-pharmacologic therapies, along with medicines, that impede progression along with symptom management.

Caregiver support and patient empathy are essential to better outcomes.

THANKS TO SNF/ALF MEETING

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Twitter: @drdeejimmeh Facebook: Decontee “Dr. Dee” Jimmeh, MD

Contact Dr. Dee Brookwood Medical Center, Professional Office

Building, Suite 301 Phone 205-250-6940 Fax 205-250-6942 www.norwoodclinic.com