GERIATRICS

Dementia

August 9, 2023 / No Comments

Common types

  • 40% Alzheimer’s disease (NB – can get mixed Alzheimer’s and vascular disease)
  • 20% vascular dementia
  • 20% Lewy body
    • progressive cognitive decline
    • fluctuating cognition
    • visual/auditory hallucinations
    • Parkinsonism, sensitivity to neuroleptic
    • repeated unexplained falls
    • transient loss of consciousness
  • 20% other:
    • frontal lobe dementia – disordered executive function + behaviour 
    • subcortical dementia (e.g. Parkinson’s, Huntington’s)
    • Vascular
    • alcohol and toxins (e.g. heavy metals)
    • normal pressure hydrocephalus
    • infection (e.g. HIV, syphilis)
    • prion disease . metabolic (calcium), endocrine (thyroid), deficiencies (B12/folate/thiamine)
    • space-occupying lesion (tumour, subdural haematoma)
    • Creuzfelt Jakob

Differentials of dementia

  • Primary neurodegenerative disease
    • Alzheimer’s disease
    • Cortical Lewy body disease
    • Pick’s disease
    • Huntington’s disease
  • Metabolic disorders
    • Hypothyroidism
    • Hypocalcaemia 
    • Mitochondrial cytopathies
    • Wilson’s disease
    • Leucodystrophy
  • Infections
    • HIV
    • Prion disease
    • Syphilis
  • Normal pressure hydrocephalus
  • Psychiatric
    • Pseudodementia – pts who are severely depressed may appear demented
    • Depression
  • Vascular
  • Toxic
    • Alcohol
    • Occupational exposures
    • Lead, mercury poisoning
  • Deficiency
    • Thiamin 
    • Vit B12
    • folate
  • Traumatic
    • Punch-drunk syndrome (boxers)
  • Intracranial lesions
    • Subdural haematomas
    • Tumour
Modifiable protective and risk factors for dementia
Protective factors for dementia: Strengthening, building cognitive reserve
Early life
– Healthy pregnancy
– Secure home environment
– Good diet
– Good hearing and language acquisition
– Strong development and engagement in education and learning
Middle and later life Social and cultural connection
– Healthy lifestyle
– Good diet and healthy weight
– Smoking cessation
– Regular physical activity
– Safe alcohol consumption
– Education and employment
– Cognitive stimulation
Risk factors for dementia: Damaging, reducing or limiting cognitive reserve
Childhood and adolescence Childhood trauma and early life adversityA
– Middle ear disease and hearing impairment
– Low level of education
– Smoking
Middle life Hearing impairment A
– Hypertension A
– Other cardiovascular risk factors including atrial fibrillation, dyslipidaemia
– Smoking
– Diabetes
– Obesity
– Psychosocial stressors
– Excessive alcohol intake
– Traumatic brain injury
– Air pollution
– Low physical activityA
– Chronic kidney diseaseA
Later life StrokeA
– History of head traumaA
– Epilepsy
– Delirium
– History of depression/chronic grief
– Social isolation/loneliness
– Physical inactivity
– Anticholinergic medicationsA
– PolypharmacyA
– Vision problemsA
AThese factors have been derived from cohort studies in the Kimberley, Far North Queensland and urban and regional New South Wales.3–5
other:
Apo E4 Allele: Confers 8% risk if two Alleles

Assessments to be made in dementia(carer/family input preferable)

Clinical history: Cognitive symptoms Behavioural symptoms psychological symptoms

  • decline in memory
    • Forgetfulness 🡪 S-T memory problems 🡪 then long term memory loss
  • decline in thinking/planning/organising (executive function)
    • initially Impairment of learning & retention
    • ability to perform complex tasks
    • Difficulty thinking, understanding and concentrating
    • lack on insight
    • poor judgement
    • Impairment of perception
  • difficulty with communication (aphasia)
    • repeating
    • asking same questions
    • not finishing sentences
    • difficulty finding the right word
  • difficulty with complex tasks (apraxia)
    • operating computer
    • driving car
  • difficulty recognising familiar people or places (agnosia) 
  • behavioural changes
    • Personality changes
    • Impulsive behaviour
    • Agitation/ shouting/ pacing
    • Aggression 
    • Resistance to care interventions
  • Reduced ability to perform activities of daily living Activities of daily living 
  • safety issues
    • falls risk
    • accident risk (e.g. stove, appliances, fires)
    • driving risk
    • self-neglect (e.g. poor self-care, malnutrition, hygiene)
  • Psychiatric symptoms
    • depression (e.g. mood, anhedonia, sleep, appetite, weight)
    • delirium (e.g. impaired consciousness/orientation/attention, sleep-wake cycle, sun-downing, visual hallucinations, behaviour, affect)
  • Medical –
    • psychiatric, neurological, cardiovascular risk factors (vascular dementia), hearing, vision, falls, pain, incontinence, infections, recent surgery
  • Medications (especially recent changes)
  • Alcohol intake
  • Family history
  • Risk factors
    • psychiatric
    • neurological
    • cardiovascular risk factors (vascular dementia)
    • hearing
    • vision
    • falls
    • pain
    • incontinence
    • infections
    • recent surgery
  • Functional Assessment
    • Does she need help? Who helps at the moment? Any aids?
      • ADL – bathing, dressing, toilet, transfer, continence, feeding
      • IADL – telephone, transport, shopping, preparing meals, housework, taking medicine, managing money 
    • Barthel’s scale
  • social context – 
    • other family members and friends
    • home assessment – type, accessibility, cleanliness, proximity to transport/shops
    • major life events and stressors (depression triggers?), financial situation,  legal situation
  • Physical examination:
    • causes of cognitive impairment (eg. urinary tract infection, cardiac failure, visual or hearing impairment)
  • Depression = Geriatric Depression Scale
  • Medication review

Cognitive screening test 

  • GPCOG
    • sensitivity of 85% specificity of 86%
    • 2 parts
    • Patient interview – 9 questions
      • Score 9/9  = cognitively intact, no further tests, re-testing in 12months 
      • Score of 5 – 8 = some impairment, need informant 
      • Score  4 or less = cognitive impairment. no need for informant interview
    • Informant interview – 6 questions
      • Score  4 – 6  = cognitively intact for the time being. Re-testing in 12 months 
      • Score 0 – 3 = cognitive impairment
  • MMSE
    • 24/30 raise concerns about possible dementia.
    • 19 – 24     : Mild dementia
    • 10 – 18     : Moderate dementia
    • 9 and lower : Severe dementia
    • Performance affected by age and education
    • Test items that are most sensitive to detection:
      • orientation to date (especially year)
      • delayed word recall and intersecting pentagons
    • Pros:
      • familiar and takes a relatively short time to administer
    • Cons:
      • takes longer than other similar tests
      • tests a limited number of cognitive domains (relatively less emphasis on memory and executive functioning)
      • often not sensitive to early cognitive change
      • An educated person with dementia, might be able to score above 24.
  • Clock Drawing Test 
    • This test involves asking patients to draw a clock on a blank piece of paper 
    • can be scored as either normal (correctly drawn) or abnormal (any other result).
    • It evaluates organisation and planning. 
    • It is a useful screen for frontal functions of planning and conceptualisation.
    • Pros:   not influenced by age or education; easy, very quick and acceptable to most patients; some measure of visuospatial and executive function
    • Cons: does not test memory or language abilities
  • The Rowland Universal Dementia Assessment Scale (RUDAS) 
    • recommended for use with those from culturally and linguistically diverse backgrounds.
  • Kimberly Indigenous Cognitive Assessment (KICA)
    • validated dementia assessment tool for older indigenous Australians
  • U.K. Biobank Dementia Risk Score [UKBDRS]
    • calculator
    • take account of age, education, parental history of dementia, material deprivation, a history of diabetes, stroke, depression, hypertension, high cholesterol, household occupancy, and sex
  • If cognitive impairment diagnosed: need to rule out reversible causes of cognitive impairment

Investigation Rationale and comments

FBC
X
Exclude anaemia and infection
ESR or CRPXExclude inflammation, auto-immune disease, infection
Electrolytes
X		Exclude reversible metabolic causes of dementia: Delirium
CalciumXHyperparathyroidism, other causes of hypercalcaemia
GlucoseXHypoglycaemia, hyperglycaemia
  urea and creatinineXKidney failure
LFTXHepatic disease
Thyroid functionXExclude hypothyroidism or thyrotoxicosis
B12 & folate levelsXExclude vitamin and folate deficiency
CT scan of brain without contrast
X		Indications  – age at dementia onset < 60- focal neurological signs- rapid progression of dementia- recent head trauma- use of anticoagulants- unusual symptoms or gait disturbance.Minimum neuroimaging to exclude presence of a tumour, intracranial space occupying lesion or haematoma. Structural imaging may not be needed in those presenting with moderate-to-severe dementia, if the diagnosis is already clear and other reversible causes have been excluded.
Fasting lipid studyXXRisk factor for cerebrovascular disease
Fasting homocysteine (HCy) levelsXHigh levels are linked to heart disease, stroke and Alzheimer’s disease. HCy levels can be reduced by taking 1 mg of folic acid daily with additional oral vitamin B6 and B12.
Chest X-Ray (CXR)XXClinical presentation should determine whether CXR is needed to exclude lung disease or an occult tumour
ECG/EKGXXAn ECG should be considered if intending to prescribe acetylcholinesterase inhibitors
Mid-stream specimen of urine (MSU)XXExclude bacterial infection, a common comorbidity in older people
Serology for syphilis and HIVXOnly in those with histories suggesting they are at risk
EEGEEG should not be used as a routine investigation in people with dementia, but should be considered if a diagnosis of delirium or Creutzfeldt–Jakob disease is suspected, or in the assessment of associated seizure disorder in those with dementia.
MRI Scan*

X		Structural imaging or MRI can be used to exclude other cerebral pathologies and to help establish the dementia subtype diagnosis, unless clinical judgement indicates this is inappropriate or if it is contra-indicated (e.g. metal in body, claustrophobia). Structural imaging may not always be needed in those presenting with moderate-to-severe dementia if the diagnosis is already clear. HMPAO SPECT should not be used in people with mild cognitive impairment (MCI) either for the differen- tiation of dementia from MCI or for the differentiation of progressive from non-progressive MCI.
Cerebrospinal fluid (CSF) examination*

X		Specialist referral is required for CSF examination. It may be indicated if Creutzfeldt-Jakob disease is suspected or in rapidly progressive dementia. CSF testing may also be indicated for infectious causes (e.g. neurosyphilis), for confirmation of Alzheimer’s disease (increased levels of tau and phospho-tau and decreased levels of Aβ) or as part of a procedure to detect normal pressure hydrocephalus.
Positron emission tomography (PET)*
X		PET-FDG, i.e. routine glucose PET, or PET for amyloid or tau imaging can be performed upon specialist referral to diagnose neuronal injury or for difficult to diagnose cases. Note that amyloid and tau imaging are not readily available.2
Genetic testing*Familial dementiaApolipoprotein E genotyping
X
Genetic testing for familial dementia (e.g. autosomal dominant Alzheimer’s disease) can be performed upon specialist referral for early onset cases with very strong family histories.
Neuropsychological assessment*
X		Neuropsychological assessment extends beyond clinical cognitive testing1 and requires specialist referral. Assessment is comprehensive, demanding and rigorous, usually requiring approx. 3 hours. It can be useful to diagnose the cause of dementia, especially to differentiate it from psychiatric conditions, to monitor progress and for medico-legal reasons.

Consider

  1. EPOA
  2. Advanced care plan
  3. Rationalizing medications, webster packs
  4. Dementia service to confirm diagnosis
  5. Consider driving
  6. Social care services
  7. Support services
  8. Safety at home- ?adjust environment
  9. Educate – dementia Australia
  10. Positive effects social connection, cognitive training

Non-pharmacological treatments

  • Symptoms of cognitive impairment and BPSD may be treated with a variety of non-pharmacological interventions that span psychological, behavioural and environmental domains.  
  • Cognitive Behavioural Therapy
    • may be useful to assist with adjustment to the initial diagnosis, forward planning and in treating depression in early stage dementia.
    • These interventions may be particularly useful at the time of initial diagnosis
  • Reminiscence Therapy:
    • Encouraging individuals to talk about past experiences and memories can enhance cognitive function and emotional well-being.
    • Reminiscence therapy can involve using photographs, music, or other stimuli from the individual’s past.
  • Behavioural Management Therapy
    • may be useful in targeting challenging (difficult to manage) behavioural patterns in persons with dementia
    • Such behaviours may include wandering, agitation and repetitive questioning.
  • Structured Routine and Activities:
    • Establishing a consistent and structured daily routine can help individuals with dementia feel more secure. Engaging in activities that match their interests and abilities can also contribute to a sense of purpose.
  • Frequent orientation reinforcement
    • Orientation to time with large clocks, large calendars and routinizing daily activities
    • orientation to person by medical staff wearing large nametags
    • repeated introducing themselves.
  • Environmental approaches/modification
    • non-stressful, constant and familiar
    • Frequent orientation reinforcement
    • Clear Signage:
      • Use clear and easily understandable signage to help individuals navigate through the environment. This includes labeling rooms, restrooms, and common areas with large, simple signs and pictures.
    • Color Contrasts:
      • Use color contrasts to highlight important features or elements in the environment. For example, contrasting colors between walls and doors can make it easier for individuals to distinguish different areas.
    • Good Lighting:
      • Ensure that spaces are well-lit to reduce shadows and create a safer environment.
      • Use natural light whenever possible, and avoid harsh or flickering lights that may cause discomfort.
    • Uncluttered Spaces:
      • Minimize clutter and unnecessary decorations in living spaces to reduce visual and cognitive overload. Simplify the environment by keeping only essential items.
    • Familiar Objects:
      • Incorporate familiar and meaningful objects in the environment, such as family photos, personal belongings, and items with sentimental value. These can provide a sense of comfort and familiarity.
    • Adaptive Furniture:
      • Choose furniture that is easy to navigate and comfortable. Avoid furniture with sharp edges, and ensure that chairs are at an appropriate height for ease of sitting and standing.
    • Safety Measures:
      • Install handrails in hallways and grab bars in bathrooms to support individuals with mobility challenges.
      • Remove or secure tripping hazards, such as loose rugs or electrical cords.
    • Quiet Spaces:
      • Designate quiet and calm areas where individuals can retreat if they feel overwhelmed or agitated. Provide comfortable seating and soothing colors in these spaces.
    • Memory Aids:
      • Use memory aids such as visual cues or labels on drawers and cabinets to assist individuals in locating items. This can enhance independence in daily activities.
    • Clocks and Calendars:
      • Place large, easy-to-read clocks and calendars in visible locations to help individuals maintain a sense of time and reduce disorientation.
    • Adaptable Spaces:
      • Design spaces that can be easily adapted to accommodate changing needs. For example, create flexible dining areas that can be adjusted based on the preferences and abilities of individuals.
    • Technology Integration:
      • Integrate technology, such as GPS tracking devices or smart home systems, to enhance safety and monitor the well-being of individuals, especially those prone to wandering.
  • Montessori activities – focuses on supporting the independence of people with memory loss through  meaningful activities, roles and environmental cueing.
    • Sorting and Matching:
      • Provide a variety of objects or pictures and encourage individuals to sort them based on a specific criterion (color, shape, size).
      • Match objects with corresponding pictures or words.
    • Simple Puzzles:
      • Offer puzzles with large, easy-to-handle pieces that match familiar images or scenes.
      • Gradually increase the complexity of puzzles based on the individual’s abilities.
    • Sensory Bins:
      • Create bins with various textured materials (sand, rice, fabric scraps) and hide small objects for individuals to find by touch.
      • Include scented items for olfactory stimulation.
    • Art and Craft Activities:
      • Provide materials for simple arts and crafts, such as drawing, painting, or crafting with clay.
      • Focus on process rather than the final product.
    • Memory Games:
      • Use memory cards with matching pairs of images or words.
      • Start with a small number of cards and increase the difficulty as the individual progresses.
  • Alternative therapies
    • light massage and aromatherapy
    • music and dance therapy
    • animal assisted therapy
    • multi-sensory therapy
  • Dementia support groups

Pharmacological treatments

  • Eliminate or restrict drugs with CNS activity
  • Antidepressants can temporarily improve function in patients who develop clinical depression – use nonanticholinergic antidepressants
  • Treat anxiety and sleep disorders with short or medium acting benzodiazepines

  • Cholinesterase inhibitors
    • Cholinisterase Inhibitors are the most commonly prescribed medications for dementia.
    • it stops or inhibit enzymes from breaking down acetylcholine when it travels from one cell to another. This means that the acetylcholine, which is in short supply in people with Alzheimer’s disease, is not destroyed so quickly and there is more chance of it being passed on to the next nerve cell. Cholinesterase inhibitors result in higher concentrations of acetylcholine, leading to increased communication between nerve cells, which in turn, may temporarily improve or stabilise the symptoms of dementia.
    • Effect of these drugs varies for different people:
      • Some will not notice any effect
      • Some may find that their symptoms improve slightly.
      • Some may stay the same when they would have expected their symptoms to become gradually worse.
      • There is no way to predict how an individual will respond.
      • Some people with dementia report immediate benefits and some report benefits for longer periods.
      • Some research has shown benefits can be sustained for up to five years, though it depends on the individual response
    • The areas in which some people with Alzheimer’s disease may find improvement are:
      • ability to think clearly
      • memory
      • function in daily activities
      • behavioural and psychological symptoms
    • There are 3 cholinisterase inhibitors: 
      • Donepezil (Aricept) – tablets 5mg & 10mg
      • Galantamine (Galantyl) – prolonged capsules 8mg, 16mg, 24mg
      • Rivastigmine (Exelon, Exelon Patch) – transdermal patches 4.6mg/24 hours and 9.6mg /24 hours
    • Side Effects
      • diarrhoea, nausea, vomiting, muscle cramps, lowered blood pressure, insomnia, fatigue, loss of appetite, falls and dizziness
    • Important to note:
      • There are no significant differences in effectiveness between the three drugs. 
      • Choice depends on availability, cost and side-effects.
      • Adverse effects may be minimised by increasing the dose gradually and ensuring the patients take their medication with a meal.
      • Side effects usually resolve over time or, if necessary, with dose reduction.
      • Patients who do not respond to one acetylcolinersterase inhibitor may respond to another.
      • Monitor patients who have a history of peptic ulcer or who are taking NSAIDS.
      • Monitor patients for bradycardia who are taking B-blockers or other rate slowing medications.
    • PBS-indications:
      • Cholinisterase Inhibitors are PBS-listed for patients with mild-to-moderate Alzheimer’s Disease.
      • It should be noted that, in Australia, a specialist medical practitioner (neurologist, psycho-geriatrician, geriatrician or psychiatrist) must confirm the diagnosis of Alzheimer’s disease in order for a patient to be eligible for subsidised Alzheimer’s disease medications.
      • Cholinisterase Inhibitors are notlisted on the PBS when used in later stages of AD or other types of dementia (e.g. Lewy body disease, vascular dementia).
        • However, there are clinical trials that suggest the drug’s effectiveness on this cohort.
  • Memantine (Ebixa, APO-Memantine, Memanxa)
    • Memantine is usually well-tolerated, although the dose may need to be reduced in patients with renal impairment
    • Can improve cognition and function
    • Consider as alternative to Cholinesterase Inhibitor if side effects limit use
    • Memantine may be better tolerated than Cholinesterase Inhibitors
    • adverse effects: GI, Bradycardia, Syncope
    • PBS-indications are:
      • Memantine is listed for patients with moderately severe Alzheimer’s Disease.
      • It should be noted that, in Australia, a specialist medical practitioner (neurologist, psycho-geriatrician, geriatrician or psychiatrist) must confirm the diagnosis of Alzheimer’s disease for a patient to be eligible for subsidised Alzheimer’s disease medications.
      • There is some evidence the drug may be effective for people with mild to moderate Alzheimer’s disease and for people with vascular dementia.
      • However, in Australia it is not yet PBS-approved for these conditions.
  • Risperidone
    • The only drug listed by the PBS for treating Behavioural and Psychological Symptoms of Dementia (BPSD)
    • Depending on state laws, psychotropic interventions may require informed consent or proxy consent, verbally or in writing
    • This medication has the strongest evidence for its effectiveness for the treatment of aggression and psychosis.
    • Like all other agents used to treat BPSD, it may not be effective, or may cause significant side effects
    • Start with a dose of 0.25 mg twice daily.
      • If necessary, adjust gradually, by increments of 0.25 mg twice daily, but not more frequently than every other day.
      • For most patients, the optimum dose is 0.5 mg two times per day.
      • Some patients, however, may benefit from doses up to 1 mg twice daily
    • Adverse Effects
      • Sedation or Somnolence
      • Insomnia
      • Hypotension
      • Weight gain
      • Constipation
      • Sialorrhea
      • Dizziness
      • Serum Prolactin increased
      • Extrapyramidal Side Effects
        1. Low risk when daily dose under 10 mg
        2. Hyperkinesis
        3. Exacerbates Parkinson’s Disease movement, Fall Risk (and increased risk of Neuroleptic Malignant Syndrome)
        4. Akathisia
        5. Dystonia
      • Peristent Tardive Dyskinesia
    • PBS-indications:
      • The updated indications for risperidone include treatment (up to 12 weeks) of psychotic symptoms, or persistent agitation or aggression unresponsive to non-pharmacological approaches in patients with moderate to severe dementia of the Alzheimer type.

Driving with dementia

  • Unfortunately, as there is neither a test nor a historical feature that accurately quantifies driving risk, clinicians can only make ‘qualitative estimates of driving risk’
  • Iverson et al26 concluded that patients with mild dementia are at a substantially higher risk for unsafe driving and thus should strongly consider discontinuing driving
  • Dementia may affect driving ability in several ways including:
    • errors with navigation, including forgetting routes and getting lost in familiar surroundings
    • limited concentration or ‘gaps’ in attention, such as failing to see or respond to ‘stop’ signs
    • errors in judgement, including misjudging the distance between cars and misjudging the speed of other cars
    • confusion when making choices – for example, difficulty choosing between the accelerator or brake pedals in stressful situations
    • poor decision making or problem solving, including failure to give way appropriately at intersections and inappropriate stopping in traffic
    • poor insight and denial of deficits
    • *slowed reaction time, including failure to respond in a timely fashion to instructions from passengers
    • *poor hand–eye coordination
  • Raise the issue of driving with all patients with cognitive impairment
  • Assessment: The following points may assist in assessing a person:
    • Driving history. Have they been involved in any driving incidents? Have they been referred for assessment by the police or a driver licensing authority?
    • Vision. Can they see things coming straight at them or from the sides?
    • Hearing. Can they hear the sound of approaching cars, car horns and sirens?
    • Reaction time. Can they turn, stop or speed up their car quickly?
    • Problem solving. Do they become upset and confused when more than one thing happens at the same time?
    • Coordination. Have they become clumsy and started to walk differently because their coordination is affected?
    • Praxis. Do they have difficulty using their hands and feet when asked to follow motor instructions?
    • Alertness and perception. Are they aware and understand what is happening around them? Do they experience hallucinations or delusions?
    • Insight. Are they aware of the effects of their dementia? Is there denial?
    • Other aspects of driving performance.
      • Can they tell the difference between left and right?
      • Do they become anxious or confused on familiar routes?
      • Can they comprehend road signs?
      • Can they respond to verbal instructions?
      • Do they understand the difference between ‘stop’ and ‘go’ lights?
      • Are they able to stay in the correct lane?
      • Can they read a road map and follow detour routes?
      • Has their mood changed when driving? (Some previously calm drivers may become anxious, panicked, angry or aggressive.)
      • Are they confident when driving?
  • Avoid an over reliance on MMSE scores
  • Some people with mild dementia may drive safely
  • It is not reasonable to suspend a patient’s license based solely on a diagnosis of mild dementia
  • A driving co-pilot is not a recognised safe practice for reducing safety risk in dementia
  • An occupational therapy on-road driving test is accepted as a ‘gold standard’ assessment
  • Neuropsychological results generally do not sufficiently or consistently correlate with on-road driving performance
  • Regular review (at least 6 monthly) of safe driving capacity is required in patients who retain a driving licence in early dementia
  • Process of retirement from driving may be voluntary or involuntary.
    • autonomy for the elderly is an extremely important goal both socially and economically
    • the transition to nondriving has been linked to increased rates of depression and placement in residential care
    • Discuss
      • alternative forms of transport (eg. public transport, family members)
      • potential impact an accident would have on others
      • Inform patients that should an accident occur they may face civil or criminal prosecution
      • Explain that car or life insurance policies may be void if driving when deemed medically unfit to do so
    • Re-assess dementia severity and fitness to drive every 6 months for those patients with mild dementia who are deemed safe to continue driving
    • Consider an occupational therapist driver assessment referral (limited by availability and cost) which can be repeated
    • If unsure as to how to proceed, then refer the patient to a geriatrician or neurologist

ALZHEIMERS

  • Most common form dementia
  • Insidious onset – memory impairment – eventually dysphasia, dysprazia and personality change
  • Accumulation beta amyloid peptide and intracellular tau protein
  • Causes destruction of neurons, including cholinergic neurons – fall in acetylcholine concentration
  • No medication to prevent or modify pathology
  • Treatment
    • Two classes of medications – acetylcholinesterase inhibitors (AChEIs) and memantine (NMDA antagonist)
    • AChEIs
      • Decrease breakdown Ach – reduce apparent deficiency
      • Diagnosis must be confirmed by medical specialist
      • MMSE > 10
        • Donepezil 5mg
        • galantamine 8mg
        • rivastigmine 1.5mg BD
      • similar efficacy and safety – sometimes switching is beneficial
      • Contraindications – GI or ureteric obstruction, active peptic ulcer
      • Cautions – history peptic ulcer, seizures, heart block, bradyarrythmias, asthma, COPD
      • Avoid concurrent use of meds with anti-cholinergic properties and be cautious if meds can cause bradycarida, hypotension, syncope
      • Adverse effects – GI related, dizziness, drowsiness, bradycardia, syncope
    • Memantine 5mg
      • NMDA receptor antagonist
      • Reduced glutamate induced neuronal degradation
      • Moderate- to – severe alzheimers or who are intolerance/contraindicated AChEi
      • Can be used in combination AChEi
      • Stand-alone therapy if MMSE 10-14
      • Contraindicated – seizures
  • Before starting
    • ECG, weight, falls risk assessment
    • Review other medications that may worsen cognition – anticholinergics, antipsychotics, antidepressants, urinary incontinence, antihistamines
    • Consider Webster packs, administration aids, minimise generic substitutions
  • Monitoring efficacy medication
    • Modest efficacy in improving cognition/reducing rate of cognitive decline
    • 30-50% no benefit, small proprotion large beenfit
    • Don’t need to monitor bloods
    • Ongoing PBS – clinically meaningful response from quality of life, cognition or behavioural symptoms
    • If on AChEi/memantine for > 12 months consider trial discontinuing if –
      • Function/cognition deteriorated
      • No benefit observed
      • Severe/advanced
    • Slow taper down

NONEPHARM Management

  • Education/ explanation- pt/ family/ caregivers
    • Dementia process
    • Cognitive & behavioural problems
  • Social support
    • counselling and education
    • refer to Alzheimer’s Australia
    • carer training programs
    • housing (most patients prefer staying at home vs. institutionalisation)
    • legal matters: will, enduring power of attorney for financial affairs, enduring guardianship for decisions about healthcare, advance directives
    • financial matters: Carer’s pension
    • driving
  • Health Promotion:
    • diet
    • exercise
    • medications (Webster Pack
  • Allied health
    • ACAT 
    • Social worker
    • OT
    • Alzheimer’s Australia
      • Information
      • Care advice
      • Support groups
      • Counselling
  • Provide a safe, calm environment
    • Appropriate stimulation
    • Orienting cues
    • Glasses
    • Hearing aids
  • Legal considerations– while still capable
    • Enduring power of attorney
    • Will & testament
    • Advanced care directives
  • regular checking of carer’s health
  • Co-morbidities: regular review to ensure optimal control
  • medication and compliance review
  • detect physical illness
  • detect depression and anxiety

Management Behavioral and psychological symptoms of dementia (BPSD)

  • PHARM management
  • SSRIs best evidence for agitation – citalopram
  • Avoid antidepressants with anticholinergic properties e.g. TCAs
  • Uncertainty about anti-depressants for depression in Alzheimer’s
  • Avoid antipsychotics – risk stroke, death, worsening cognition
    • Can trial if severe BPSD – Review every 4-12 weeks
  1. Psychosis
    1. Atypical anti-psychotics
      1. Risperidone 0.5-2.0mg PO daily
      2. Olanzapine 2.5-10mg PO daily
      3. Quetiapine
    2. Avoid typical anti-psychotics
  2. Severe anxiety/ agitation
    1. Oxazepam 15 mg PO 1-4 x daily
    2. Avoid use for > 2 wks
    3. SEs
      1. Sedation
      2. Respiratory depression
      3. Dependence
      4. Exacerbate cognitive impairment
      5. FALLS
      6. DELIRIUM
  • Reassure and reduce triggers
    • Actively listen to, respond and reassure the patient.
    • Avoid surrounding the patient with too many staff at one time
    •  Provide activities to reduce agitation 
    • quiet areas – avoid the over stimulating environment
  • Wandering
    • keep objects that might encourage wandering out of sight (for example a coat or handbag)
    • make sure the patient’s room is convenient for observation, is away from stairs or elevators, and is located so the patient has to pass the nursing station to reach an exit
    • provide appropriate opportunities for exercise and activity.
    • designate a safe place for the patient to mobilse
  • Sundowning
    • use early evening routines that are familiar for the patient; ask their family or carer
    • find out what activities or strategies calm the patient (for example, warm milk, back rubs, calming music). 
    • encourage an afternoon rest, if fatigue is making sundowning worse
    • consider environmental factors, such as lighting and noise
  • Anxiety or agitation
    • talk about the anxiety-producing thoughts
    • reassure the patient,identify and relieve the cause of the anxiety. 
  • Aggression
    • triggered by issues such as fatigue, an over-stimulating environment, asking the patient too many questions at one time, asking the patient to perform tasks beyond their abilities, too many strangers in a noisy, crowded atmosphere, failure at simple tasks
    • remain calm and use a low tone of voice
    • state things in positive terms – constantly saying ‘no’; or using commands increases resistance
    • don’t force or restrain the patient. 
  • Disinhibited behaviour
    • respond with patience and in a gentle, matter-of-act manner
    • don’t over-react; remember it is part of the condition
    • reassure and comfort the person who may be anxious
    • gently remind the patient that the behaviour may be inappropriate
    • lead them gently to a private place

Frontal dementia

  • Younger onset 45-65 yrs
  • Focal atrophy of frontal & temporal lobes in absence of Alzheimer’s pathology
  • Familial clustering- 20-40%
  • Picks disease is a variant
  • Initialy
    • Personality changes
    • Language changes
    • Behavioural changes
      • Inappropriate personal & social conduct
      • Social disinhibition, Loss of insight
  • Progression
    • Apathy, Withdrawal, Memory impairment- late

Lewy body dementia

  • Dementia PLUS 2 of – visual hallucinations, parkinsonism, fluctuating mental state
    • (not caused by delirium)

Vascular dementia

  • Dementia caused by Cerebrovascular disease or impaired blood flow
    • Hypoperfusion, embolism
  • Often stepwise following stroke, accompanied by focal neurological signs
  • Evidence of atherosclerotic disease elsewehere
  • Can be multi-infarct of strategic infarct in a key area
  • If definite history of stroke/TIA – antiplatelet
  • ACHEis for treatment of progressive cognitive decline

Alcoholic dementia

Cognitive deficits:  New learning, Frontal lobe function

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