geriatric population. the 3 d’s geriatric dementia, delirium & depression
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LET’S DISCUSS
Difference between geriatric dementia,
delirium and depression
Impact of dementia and the importance
of a quality diagnosis
Dementia assessment and treatment
comprehension
DEMENTIA
The term dementia describes a syndrome
Chronic and progressive brain disease
Affects higher cortical functions
memory
language
judgment
learning
capacity
thinkingorientation
calculation
Bereczki D, Szatmári S, 2009.
DELIRIUM
Cholinergic/dopaminergic excess
Cascade of events
Complicates hospitalizations
Is a medical emergency
Durso, S. C., et al. (2010).
Sometimes preventable by minimizing medication use and adequate hydration
Glutamate
Activation
GABA
Activation
Reduced
GABA
Activity
Cholinergic Inhibition
Dopamine
Activation
Cytokine Excess
Serotonin
Activation
Serotonin
Deficiency
Cortisol
ExcessHepatic
Failure
&
Alcohol
Withdrawal
Benzo’s
&
Hepatic
Failure
Benzo’s &
ETOH
Withdrawal
Medications
Surgical &
Medical Illness
Cholinergic Activation
Medications
Alcohol
Withdrawal
Medications
Substance
Withdrawal
Glucocorticoids
Stroke
Surgery
Surgical &
Medical Illness
Medications
Stroke
REVERSIBLE FACTORS
Drugs
Electrolyte imbalance
Lack of drugs
Infection
Reduced sensory input
Intracranial
Urinary retention/fecal impaction
Myocardial/Pulmonary
Feature Delirium Dementia Teaching
Onset Sudden Insidious Know Baseline
Attention Concentration
Disordered Normal Except in advanced dementia
Course Fluctuates Stable Need to know baseline and mental status
evaluation
Hallucinations Usually Visual Often Absent Requires attention to
mental status evaluation
Involuntary Movements
TremorPicking
Asterixis
Usually Absent Attentive observation
required
Dementia vs. Delirium
DEPRESSION
Two simple questions effectively
screen:
Over the past 2 weeks, have you felt
down, depressed or hopeless?
Have you experienced a loss of interest
or pleasure in most things?
https://www.youtube.com/watch?v=1XSPsWQAWGI
DEPRESSIONSupportive treatment
Counseling, relief of loneliness
Treat physical symptoms and pain
Address anxiety, financial, dependency
Consider stopping contributory drugs
Psychotherapy effective as antidepressants
Cognitive-behavioral therapy
IMPACT
35.6 million with dementia
Nearly doubles every 20 years
Alzheimer’s in the USA will
ALMOST TRIPLE BY 2050
World Alzheimer Report 2011.
28 million of the world’s 35.6 million people with
dementia have yet to receive a
diagnosis…
World Alzheimer Report 2011.
A Quality Dementia Diagnosis Changes
Everything …
Annual dementia
care costs
$32,865
per person
With a quality
dementia diagnosis
annual dementia cost
decreases to $5,000
per person
Improved health & quality of life
even more cost-effective
Impact of a Quality Dementia Diagnosis
World Alzheimer Report 2011.
Earlier diagnosis allows people with dementia to…
plan ahead while
they still have the
capacity, receive
timely practical
information, advice
and support
get access to available
drug and non-drug
therapies
participate in
research for the
benefit of future
generations
World Alzheimer Report 2011.
7.7 million new cases yearly.New case of dementia every?
A. 18 minutes
B. 23 hours
C. 4 seconds
D. 23 minutes
E. 30 seconds
C. NEW CASE OF DEMENTIA EVERY 4 seconds
WORLD’S 18TH LARGEST ECONOMY
D
E
M
E
N
T
I
A
de Vugt ME, Verhey F, 2013.
0 1 2 3 4 5 6
DEMENTIA
WAL-MART
EXXON MOBIL
100 BILLION US DOLLARS
Dementia Costs More Than 1% Gross Domestic Product
Borson, S. et al., 2013.
RISKAge
Family history and genetics
Psychiatric disorders
Cardiovascular disease – related factors
Head trauma
Alcohol, drugs & toxins
Vasculitis, Endocrine & Infectious disorders
Neoplastic & Respiratory disorders
Brain lesions, normal pressure hydrocephalus
Fillit HM, et al., 2010. & Patterson C, et al., 2007.
MILD COGNITIVE IMPAIRMENT
NOT the result of normal aging
Forgetfulness is hallmark symptom
Sometimes called a transitional phase
Conversion rate 2 - 15% per year
Up to 80% conversion at 6 years
Fillit HM, et al., 2010.
MAJOR DEMENTIA TYPES
AD Alzheimer’s disease
VaD Vascular dementia
FTD Frontotemporal dementia
PDD Parkinson’s disease dementia
DLB Dementia with Lewy bodies
Others: SD Semantic dementia, Progressive
nonfluent aphasia, etc.
NEUROPSYCHOLOGICAL DOMAINS
Premorbid ability: review of
educational, occupation
Verbal memory: verbal and
memory learning tests
Visual memory: visual
reproduction, figure drawing
Simple attention: digit span
Language: animal naming, oral
word association test
Executive function: card
sort test, similarities
Visuospatial: digit symbol
test, clock drawing
Motor: finger tapping
Cognitive screening:
MMSE, SLUMS, MoCA, etc.
Fillit, H. M., et al. (2010).
OTHER DOMAINS
FunctionKatz Index of Activities of Daily Living ADL
Lawton Instrumental Activities of Daily Living Scale IADL
Get-up and go
Caregiver Input
DepressionHamilton Depression Rating Scale HDRS
Geriatric Depression Scale GDS
Fillit HM, et al., 2010.
DIAGNOSTIC
LABORATORYCBC, CMP, Thyroid, B12, Folate, CRP, RPR, Lipids, HIV, SED rate, etc.
May need to rule out delirium urine sample, blood cultures, chest x-ray, CSF
NeuroimagingMRI or CT - Choice depends on availability, cost, patient acceptability, contraindicationMRI is preferred. SPECT & PET scanning, Pittsburgh Compound-B ligand for PET
Fillit HM, et al., 2010.
Reports of progressive
change in cognition or ADL
Clinical assessment
Is cognitive impairment
confirmed on formal testing?
Is ADL impaired
Is onset relatively sudden
with disturbed attention?
Investigations, including
neuroimaging
Is a non-vascular etiology for
dementia identified?
Is a vascular etiology for
dementia identified?
Is parkinsonism, visual hallucinations
or fluctuating cognition present?
Is presentation with isolated
language and/or executive deficits?
Is episodic memory deficit prominent?
Consider depression,
anxiety, normal agingNO
NOMild Cognitive
Impairment
YES Delirium
Is cognitive impairment
persistent despite
appropriate treatment YES
YESToxic, NPH, tumor, Huntington, head
injury, MS, HIV, Neurosyphilis, CJD,
metabolic – thyroid, B12 deficiency
YESVascular dementia,
SDH, vasculitis
YESDementia with Lewy bodies,
Parkinson’s disease dementia
YES Frontotemporal dementia
YES Alzheimer’s disease
DIAGNOSTIC PROCESS F
illi
t H
M,
et
al.
, 2
010
.
ALZHEIMER’S DISEASEImpairment in memory
Functional impairment social
or vocational
And impairment in one other
cognitive areaAgnosia - impaired ability recognize objects
Aphasia - language disturbances in expressing,
understanding
Apraxia - inability to carry out motor activities
Attention
Executive function
Visuospatial ability
Other criteria:
Progression is
insidious and
other diseases that
could cause
cognitive decline
have been ruled
out, diagnosis is
primarily based on
clinical judgment.
Fillit HM, et al., 2010.
AD - Damage to plaque and neurofibrillary tangles, synapse
loss, atrophy starts medial temporal lobe
SIGNS AND SYMPTOMSUnderstanding Language
Processing Auditory Information
Organizing InformationMemory Learning
JILL, 86 YO CAUCASIAN FEMALE, COMPLETED SOME COLLEGE
ADLs: Independent in eating & transfer
IADLs: Dependent in ALL
GDS: 4/15, negative
Labs: not remarkable
Brain Imaging: Diffuse atrophy
PMH: HTN, DM II, CAD
Physical Exam: Confabulates
Increasingly more forgetful for the past 6 months…
On Autopsy the average Alzheimer’s brain weighs about
___the weight of the normal brain?
A. Two thirds
B. One fifth
C. Three times
D. The same
E. One sixth
A. Two thirds
VASCULAR DEMENTIASecond most prevalent dementia 1/3
Also know as multi-infarct dementia
The brain has multiple vascular lesions in the cortex and subcortical areas, sometimes called “small strokes”
Memory loss most common complaint
The cognitive changes that occur are directly related to the location of the lesions
Working memory more likely to be impaired more than delayed recall
Fillit HM, et al., 2010.
VASCULAR DEMENTIA
Cued recall
recognition
previously
learned
material
generally
intact
Executive
dysfunction
more
commonly
reported than
in AD
Depression
common
Fillit HM, et al., 2010.
JOHN, 66 YO CAUCASIAN MALE, RETIRED ENGINEER
ADLs: Independent in ALL
IADLs: Dependent in ALL
GDS: 3/15, negative
Labs: ESRD
PMH: Insulin dependent since childhood
Physical Exam: gait imbalance, due
worsening vision/peripheral neuropathy
Reports he trusts his wife to make all his decisions as he no longer can, “I do whatever
she wants…”
JOHN’S MRI
MRI Brain:
Small punctate acute ischemic lesion
in the right hippocampus, diffuse
extensive chronic white matter
microvascular ischemic changes and
volume loss advanced for age.
FRONTOTEMPORALDEMENTIA
SIGNS & SYMPTOMS
Planning/ReasoningProblem Solving
RecognizingRegulating Emotion
Social Skills
PARKINSON’S DEMENTIA
Parkinson’s affects the
extrapyramidal system
Usually diagnosed 50-60’s
Substantia nigra
approximately 50%
reduction neurons
May develop in 20-40%
Parkinson’s patients
Motor symptoms precede dementia by
at least 1 year
Depression occurs up to 50% of PD
Fillit HM, et al., 2010.
PARKINSON’S DEMENTIA
IMPAIRMENTS:
Attention
Executive function
Visuospatial function
Insidious onset,
variable rates of
progression
Episodic memory
deficits milder
than in PD
Problems more
retrieval than
encoding/storage
Fillit HM, et al., 2010.
DEMENTIA WITH LEWY BODIES
The form of dementia that has
both cognitive impairment
with extrapyramidal signs
DLB – dangerous sensitivity to
neuroleptic medications
Decreased dopamine transporter
binding
Motor symptoms occur no more
than a year before then onset of
dementia and frequently after the
dementia
DLB Symptoms:
fluctuating
cognition,
Parkinson-like
symptoms and visual
hallucinations, other
symptoms may
include REM sleep
disorders, and
frequent falls.
Fillit HM, et al., 2010.
Functional Assessment Staging (FAST)
Stage 1 Normal adult.
No functional decline.
Stage 2 Normal older adult.
Personal awareness of some functional
decline.
Stage 3 Early AD. Noticeable deficits
in demanding job situations.
Stage 4 Mild AD. Requires assistance
in complicated tasks such as handling
finances, planning parties, etc.
Stage 5 Moderate AD.
Requires assistance in choosing proper attire.
Stage 6 Moderately Severe AD.
Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.
Stage 7 Severe AD.
Speech ability declines to about a half-dozen intelligible words. Progressive loss of the ability to walk, sit-up, smile, and hold head up.
WHAT IS JILL’S FAST STAGE?
ADLs: Independent in eating & transfer
IADLs: Dependent in ALL
GDS: 4/15, negative
Labs: not remarkable
Brain Imaging: Diffuse atrophy
PMH: HTN, DM II, CAD
Physical Exam: Confabulates
SLUMS 3/30
WHAT IS JILL’SFAST STAGE?
A. STAGE 1
B. STAGE 2
C. STAGE 3
D. STAGE 4
E. STAGE 5
F. STAGE 6
G. STAGE 7
F. Stage 6
maintaining reestablishing independence
Improving andstabilizing cognitive
ability and mood
TREATMENT GOALS
effective future planning
symptom management
orientating redirecting
pharmacologic therapies
daily caresafety as needed
Fillit HM, et al., 2010 & Bereczki D, Szatmári S, 2009.
caregiver interventions
nonpharmacologic
promoting autonomy
TREATMENT
Considerable
variation in clinical
practice regarding
pharmacological
treatment of
dementias
Bereczki D, Szatmári S, 2009.
DEMENTIA KEY FINDINGS
Most people with early stage dementia wish to be told of their diagnosis
Improving the likelihood of earlier diagnosis:
medical practice-based educational programs, introduction of accessible dementia care services, promoting effective interaction in the health system
Early therapeutic interventions:
improving cognitive function, treating depression, improving caregiver mood, delaying institutionalization
World Alzheimer Report 2011
TIPS COGNITIVELY IMPAIRED
Reduce environmental distractions
Approach from the front, make eye contact, address
person by name, speak in calm voice
To reduce sense of threat, talk first, then touch
Avoid verbal testing or questioning beyond the
person’s ability
Do not argue or insist they accept your reality
REFERENCESBereczki D, Szatmári S. Treatment of dementia and cognitive impairment: What can
we learn from the Cochrane library. J Neurol Sci [Internet]. 2009 8/15;283(1–2):207-
10.
Borson S, Frank L, Bayley PJ, Boustani M, Dean M, Lin P, McCarten JR, Morris JC,
Salmon DP, Schmitt FA, Stefanacci RG, Mendiondo MS, Peschin S, Hall EJ, Fillit H,
Ashford JW. Improving dementia care: The role of screening and detection of
cognitive impairment. Alzheimer's & Dementia [Internet]. 2013 3;9(2):151-9.
de Vugt ME, Verhey FRJ. The impact of early dementia diagnosis and intervention on
informal caregivers. Prog Neurobiol [Internet]. 2013 In Press.
Durso, S. C., Bowker, L. K., Price, J. D., & Smith, S. C. (Eds.). (2010). Oxford
American handbook of geriatric medicine (First ed.). New York, New York: Oxford
University Press Inc.
REFERENCESFillit HM, Rockwood K, Woodhouse K. The nervous system In: Brocklehurst's
textbook of geriatric medicine and gerontology. 7th ed. Philadelphia: Elsevier;
2010; p. 385-432.
Patterson C, Feightner J, Garcia A, MacKnight C. General risk factors for
dementia: A systematic evidence review. Alzheimer's & Dementia [Internet].
2007 10;3(4):341-7.
Rozzini, R., & Trabucchi, M. (2012). Depressive symptoms, their management,
and mortality in elderly people. Journal of the American Geriatrics Society,
60(5), 989-990. Retrieved from SCOPUS database.
Wimo A, Jönsson L, Bond J, Prince M, Winblad B. The worldwide economic
impact of dementia 2010. Alzheimer's & Dementia [Internet]. 2013 1;9(1):1,11.e3
Special Thank You: Department of Veterans Affairs, Saint Louis University, SLUMS Examination. World Alzheimer Report 2009 & 2011.
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