The3Ds(Demen+a,DeliriumandDepression):ImpactonRehabilita0onforOlderAdults

David Conn - Baycrest & U. of Toronto!

GTARehabNetwork'sBestPrac5cesDay2019

Faculty/PresenterDisclosure

•  Faculty:DavidConn•  Rela+onshipswithcommercialinterests:

–  Grants/ResearchSupport:None–  SpeakersBureau/Honoraria:None–  Consul5ngFees:None

Attheendofthesessionpar/cipantswillbeableto:•  Describediagnos5ccriteriaforeachofthe3Ds.•  Outlinehowtoassessandmanagethesedisorders.•  Discusstheimplica5onsforprac5ceinrehabilita5onseNngs.

4

TheNewNarra+ve

Highandstablecapacity

Decliningcapacity

Significantlossofcapacity

Functionalability

Intrinsiccapacity

Supportcapacity-enhancingbehaviours Ensurea

dignifiedlatelife

Promotecapacity-enhancingbehaviours

Removebarrierstopar5cipa5on,compensateforlossofcapacity

Preventchroniccondi5onsorensureearlydetec5on

andcontrol Reverseorslow

declinesincapacity Manage

advancedchroniccondi5ons

WHO. World Report on Ageing and Health. Available at: http://www.who.int/ageing/events/world-report-2015-launch/en/, pp33

Medicine2016

12

A.  AdisturbanceinaWen5onandawareness(reducedorienta5on)B.  Developsoverashortperiod,representsachangefrombaselineand

tendstofluctuateinseverityduringthecourseofadayC.  Anaddi5onaldisturbanceincogni5on(e.g.memory,disorienta5on,

language,visuospa5alabilityorpercep5on)D.  AandCarenotbeWerexplainedbyanotherpre-exis5ng,established,or

evolvingneurocogni5vedisorderanddonotoccurinthecontextofaseverelyreducedlevelofarousal(e.g.coma)

E.  Thereisevidencefromthehistory,physicalexamina5on,orlaboratoryfindingsthatthedisturbanceisadirectphysiologicalconsequenceofanothermedicalcondi5on,substanceintoxica5onorwithdrawal,orexposuretoatoxin,orisduetomul5plee5ologies.

DSM-5CriteriaforDelirium

•  HYPOACTIVEdelirium(lethargic,somnolent,sluggish)-moreoaennotrecognizedastheydon’tcausea“disturbance”;maybeseenasdepressed;19-71%

•  HYPERACTIVEdelirium(agitated,hallucina5ng,inappropriateness);15-47%

•  MIXED-combina5onofboth

Categories

Index episode of delirium

Prior delirium

Prior cognitive impairment Medical

comorbidity

Increased length of stay

Increased mortality rate

Increased institutionalization

Persistent cognitive impairment

Possible Delirium Outcomes And Key Related Factors (Adapted from Trzepacz et al, 2002)

51people>65withnodiagnosisofdemen5aadmiWedviaEmergencyDept.withacutedelirium.27%receiveddiagnosis

ofdemen5aduringadmissionandanother28%receiveddiagnosisofdemen5aoverthenext2years.

17

SHORT REPORT

Delirium episode as a sign of undetected dementiaamong community dwelling elderly subjects:a 2 year follow up study

Terhi Rahkonen, Riitta Luukkainen-Markkula, Satu Paanila, Juhani Sivenius,Raimo Sulkava

AbstractCognitive decline is commonly stated asone of the main risk factors for delirium.The aim was to assess the importance of adelirium episode as a symptom of anunderlying dementia among communitydwelling healthy elderly people in a pro-spective 2 year follow up study. The studypatients consisted of 51 people living athome and older than 65 years of age, with-out severe underlying disorders includingdiagnosed dementia, admitted consecu-tively as emergency cases to hospitalbecause of an acute delirious state andfollowed up for 2 years. The diagnosis ofdelirium and dementia were based on theDSM-III-R criteria. The communitydwelling patients were evaluated andtested annually by a clinical investigator, ageriatric study nurse, and a neuropsy-chologist. The medical records of theinstitutionalised patients were also evalu-ated. Dementia was diagnosed immedi-ately after the assurance that deliriumsymptoms had subsided in 14 out of 51subjects (27%) and the additional 14subjects were diagnosed as beingdemented during the 2 year follow up,28 out of 51 patients (55%) altogether.Alzheimer’s disease or mixed dementiawas diagnosed in 14 out of 51 patients(27%), vascular dementia in 10 (20%), anddementia with Lewy bodies in two (4%).One case of alcoholic dementia and onecase of a non-alcoholic hepatic encepha-lopathia were also found. A deliriumepisode is often the first sign of dementiarequiring attention from medical andsocial professionals.(J Neurol Neurosurg Psychiatry 2000;69:519–521)

Keywords: delirium; dementia; elderly

Cognitive decline or dementia is commonlystated as one of the main risk factors fordelirium.1 The importance of a deliriumepisode as the sign of dementia is not known.The aim of this study was to assess theimportance of a delirium episode as a symptom

of an underlying dementia among communitydwelling elderly people.

Patients and methodsThe study was carried out in the Harjula CityHospital and in the Brain Research and Reha-bilitation Center Neuron, Kuopio, Finland.The Harjula Hospital, which has 124 acutebeds, services Kuopio, a city with a populationof about 85 000. Neuron is a private hospitalwith 50 beds for rehabilitation.

The study patients were senior citizens, olderthan 65 living at home in Kuopio. They wereconsecutive admissions to Harjula Hospitalbetween 1 May 1994 and 31 October 1996with an acute delirious state as one of thesymptoms leading to admission, or theirdelirium was seen immediately after admission.

The clinical investigator (TR or SP) visitedall of the relevant wards twice a week. If adelirium was suspected between these visits thestudy group was also consulted. In addition,before the start of the study the ward personnelhad received special training to be able todetect and identify the symptoms of delirium.The clinical investigator contacted and exam-ined the patients and reviewed their medicalrecords.

The study patients were restricted to healthyelderly people living at home and without anyserious underlying disorders predisposing todelirium. Subjects with diagnosed dementia orsymptoms of moderate or severe dementiadetermined by information from medicalrecords, from relatives, or from care givers wereexcluded. However, it was decided to includethose with mild cognitive impairment becauseof the diYculties in diVerentiating deliriumand the early stages of dementia in a shortperiod. Patients were also excluded if they hadsevere communication disorder (n=2). Patientswith severe stroke or an illness requiring treat-ment in the intensive care ward or cardiac unitand all surgical patients going on to UniversityHospital of Kuopio were excluded, as werepatients with alcoholism, major psychiatric dis-orders, or those with malignant disorder andpatients who were discharged within 24 hoursof admission.

J Neurol Neurosurg Psychiatry 2000;69:519–521 519

Brain Research andRehabilitation CenterNeuron, Kuopio,FinlandT RahkonenR Luukkainen-MarkkulaS PaanilaJ Sivenius

Division of Geriatrics,Department of PublicHealth and GeneralPractice, University ofKuopio, PO Box 1627,70211 Kuopio, FinlandT RahkonenS PaanilaR Sulkava

Department ofNeurology andNeuroscienceJ Sivenius

Kuopio UniversityHospital, FinlandR Sulkava

Correspondence to:Dr Terhi RahkonenTerhi.Rahkonen@uku.fi

Received 7 February 2000and in revised form18 May 2000Accepted 19 June 2000

www.jnnp.com

group.bmj.com on September 23, 2014 - Published by jnnp.bmj.comDownloaded from

RiskFactorsForDelirium:Predisposing•  Demen5a•  Psychiatricdisorder•  Abnormalsodiumlevel•  Sensoryimpairment•  Impairedphysicalfunc5oning•  Malegender•  Medicalillness•  Polypharmacy(especiallyan5cholinergics)

Cole MG. Delirium in elderly patients. Am J Geriatr Psychiatry. 2004 Jan-Feb;12(1):7-21. Tune LE. Serum anticholinergic activity levels and delirium in the elderly. Seminars in Clinical Neuropsychiatry 2000; 5(2):149-53.

CommonCausesofDelirium

•  Infec5ons•  Drugsordrugwithdrawal•  Metabolicdisturbance•  Cardio-respiratory,anemia,shock•  Endocrine•  Neurological/trauma

DrugsAssociatedWithDelirium

• Seda5ve/hypno5cs• Narco+cs• An+cholinergicdrugs• Cardiacmedica5ons• H2blockers(Cime5dine,rani5dine,famo5dine,niza5dine),metoclopramide

• Miscellaneous(an5convulsants,steroids,levodopa,lithium)

• Nonprescrip5ondrugs(coldprepara5ons,sleepwakeprepara5ons)

PrevalenceofDelirium

Population Prevalence Adults >18 0.4% Adults >55 1.1% Hospitalized elderly 10-40% Nursing home residents > 75 ??

Cancer patients 25-40 % Terminal illness Up to 80%

Fann JR. The epidemiology of delirium: a review of studies and methodological issues. Seminars in Clinical Neuropsychiatry. 2000;5(2):64-74

ClinicalCourseofDelirium• Thedura5onofsymptomsofdeliriumhasbeenreportedtorangefromlessthan1weektomorethan2months

• Typicallythesymptomsofdeliriumresolvewithin10-12days;however,upto15%ofpa5entswithdeliriumhavesymptomsthatpersistforupto30daysandbeyond

• Elderlypa5entswithdeliriummaybemorelikelytohaveaprolongedcourse,withsymptomdura5onsfrequentlyexceeding1month

APA. Practice guidelines for the treatment of patients with delirium. APA, 1999.

Management-Non-pharmacological

•  Treatmentofallpoten5allycorrectable,contribu5ngcauses

shouldbedoneina5mely,effec5vemanner[D]–  Maintaincardiovascularstability–  Temperaturecontrol–  Adequateoxygena5on–  Fluidandelectrolytebalance–  Controlglucoselevels,–  Maintainnormalelimina5onpaWern(avoidingcon5nuous

catheteriza5on)–  Correctmicronutrientdeficiencies

Management-Non-pharmacological

•  Preventolderpersonsfromharmingthemselvesorothers

usingtheleastrestric5vemeasures[D]•  Suggestedenvironmentalstrategiesinclude:

–  Avoidsensorydepriva5onoroverload[C]–  Adequateligh5nginroom[C]–  Useofclocks,calendar,chartofday’sschedule[C]–  Avoidroomchanges[C]–  Useoffamiliarobjects[D]–  AvoidpuNngdeliriouspa5entsinthesameroomtogether[D]

PharmacologicManagement•  Psychotropicmedica5onsshouldbereservedthosein

significantdistressduetoagita5onorpsycho5csymptoms,inordertocarryoutessen5alinves5ga5onsortreatment,and/ortopreventolderdeliriouspersonsfromendangeringthemselvesorothers.[D]

•  Intheabsenceofpsycho5csymptomscausingdistressto

thepa5ent,treatmentofhypoac5vedeliriumwithpsychotropicmedica5onsisnotrecommended[D]

•  Demen5a

– anacquiredsyndromeconsis5ngofadeclineinmemoryandothercogni5vefunc5ons

DSM-5Diagnosis:MajorNeurocogni5veDisorder

•  Significantcogni5vedeclineinoneormoredomain

•  Deficitssufficienttointerferewithindependence

•  NotdeliriumoraWributabletoanothermentaldisorder

•  NOTE:MCIistermedMildNeurocogni5veDisorderinDSM-5

The7A’sofDemen5a

Summary of the evidence on modifiable risk factors for cognitivedecline and dementia: A population-based perspective

Matthew Baumgarta, Heather M. Snyderb,*, Maria C. Carrillob, Sam Fazioc,Hye Kima, Harry Johnsd

aDivision of Public Policy, Alzheimer’s Association, Washington, DC, USAbDivision of Medical & Scientific Relations, Alzheimer’s Association, Chicago, IL, USA

cDivision of Constituent Relations, Alzheimer’s Association, Chicago, IL, USAdPresident & CEO, Alzheimer’s Association, Chicago, IL, USA

Abstract An estimated 47 million people worldwide are living with dementia in 2015, and this number isprojected to triple by 2050. In the absence of a disease-modifying treatment or cure, reducing the riskof developing dementia takes on added importance. In 2014, the World Dementia Council (WDC)requested the Alzheimer’s Association evaluate and report on the state of the evidence on modifiablerisk factors for cognitive decline and dementia. This report is a summary of the Association’s eval-uation, which was presented at the October 2014 WDC meeting. The Association believes there issufficient evidence to support the link between several modifiable risk factors and a reduced riskfor cognitive decline, and sufficient evidence to suggest that some modifiable risk factors may beassociated with reduced risk of dementia. Specifically, the Association believes there is sufficientlystrong evidence, from a population-based perspective, to conclude that regular physical activity andmanagement of cardiovascular risk factors (diabetes, obesity, smoking, and hypertension) reduce therisk of cognitive decline and may reduce the risk of dementia. The Association also believes there issufficiently strong evidence to conclude that a healthy diet and lifelong learning/cognitive trainingmay also reduce the risk of cognitive decline.! 2015 The Authors. Published by Elsevier Inc. on behalf of the Alzheimer’s Association. This is anopen access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: World Dementia Council; Alzheimer’s Association; Alzheimer’s disease; Cognitive decline; Dementia; Risk fac-tors; Modifiable risk factors; Cardiovascular disease risk factors; Lifestyle risk factors; Physical activity; Diabetes;Obesity; Smoking; Hypertension; Diet; Lifelong learning; Cognitive training

1. Introduction

An estimated 47million peopleworldwide are living withdementia in 2015 [1], and this number is projected to tripleby 2050 [2]. In the absence of a disease-modifying treatmentor cure, reducing the risk of developing dementia takes onadded importance. Even when effective treatments becomeavailable, risk reduction will likely remain a fundamentalstrategy in reducing the number of individuals affected; formany non-communicable diseases with available treatments

(such as diabetes, cancer, and heart disease), risk reductionefforts remain a major component of the campaigns againstthese diseases.

As a science-based advocacy organization, theAlzheimer’s Association—the largest voluntary healthorganization dedicated to Alzheimer’s disease and otherdementias—is the global nonprofit leader in Alzheimer’sdisease research and the leading resource for more than5 million individuals living with the disease in the UnitedStates and their caregivers. In this role, we are often askedfor both expertise and guidance related to risk reductionfor Alzheimer’s disease. The Association monitors thescience and develops its positions accordingly.

*Corresponding author. Tel.: 312-335-5184; Fax: 866-875-2553.E-mail address: hsnyder@alz.org

http://dx.doi.org/10.1016/j.jalz.2015.05.0161552-5260/! 2015 The Authors. Published by Elsevier Inc. on behalf of the Alzheimer’s Association. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Alzheimer’s & Dementia 11 (2015) 718-726

Using the Dementia Risk Calculator

The Dementia Risk Calculator Doubling Rule (de la Torre, 2004, Gauthier et al.,1997 and Siu, 1991)

Risk doubles for every 5 years of age

<65 years 1% 65 years 2% 70 years 4% 75 years 8% 80 years 16% 85 years 32%

Each additional vascular risk factor approximately doubles the risk (One risk factor: risk multiplier is 2; 2 or more risk factors: risk multiplier is 4)

Positive family history doubles the risk. (One family member: risk multiplier is 2; 2 or more family members: risk multiplier is 4)

Overall risk = age risk _____% x family hx risk multiplier___x vascular risk multiplier ___= ___%

4

Norma5veDataonMMSE

Age (years)

Education 18-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

>84

4th Grade 22 25 25 23 23 23 23 22 23 22 22 21 20 19

8th Grade 27 27 26 26 27 26 27 26 26 26 25 25 25 23

High School 29 29 29 28 28 28 28 28 28 28 27 27 25 26

College 29 29 29 29 29 29 29 29 29 29 28 28 27 27

Norma5vescoresvarywithageandeduca5onlevel!

MMSEProsandCons

•  Pros– Widelyusedandthereforecantrackcogni5onover5meandbetweenclinicians

– 5-10minutes.

•  Cons– Falseposi5ves:thosewithliWleeduca5on.– Falsenega5ves:thosewithhighpremorbidintellectualfunc5oning.

MOCAisbeWerforMildCogni5veImpairment(MCI)

Screening

VeryBriefScreening

•  Mini-Cog(Borsonetal,2006)-3itemrecall-clocktest

•  Demen5aQuickScreen-Sameasaboveplus:

AnimalNameGenera5on

Assessment•  Takingthepa5ent’shistory•  Interviewingcaregiver/family-ADLs,Behaviour,Cogni5on

•  Cogni5vetests•  Basiclabtests•  Physicalexamina5on•  Structuralimaging–ifcertaincriteriaaremet ref:CCCDTD-3

Has There Been An Effect On Functional Activities?

Instrumental Activities of Daily Living Independent Can do

with difficulty

Needs some help

Dependent on others

1. Pay bills/manage finances (forgets to pay bills, pays bills twice)

0 1 2 3

2. Plan meals and organize shopping (food spoiled)

0 1 2 3

3. Food preparation/Cooking 0 1 2 3 (oven or stove left on, food has “funny”

taste, not properly cooked)

4. Ability to deal with emergencies 0 1 2 3 (fire, fall, medical emergency, lock

outside, power outages)

5. Manage medication 0 1 2 3 (misses doses, takes too many) 6. Transportation 0 1 2 3 (driving issues, gets lost, wandering) 7. Plan trip and outings 0 1 2 3 8. Home maintenance 0 1 2 3 9. Housekeeping/laundry 0 1 2 3 (difficulty using appliances) 10. Ability to carry out hobbies 0 1 2 3 11. Telephone use 0 1 2 3

Activities of Daily Living

1. Feeding 0 1 2 3 2. Bathing 0 1 2 3 3. Grooming (hair, shaving, nails, makeup) 0 1 2 3 4. Dressing 0 1 2 3 5. Toileting 0 1 2 3 6. Transfers 0 1 2 3 7. Ambulation 0 1 2 3 8. Climbing stairs 0 1 2 3

(Adapted from the Dementia Tool Box, 2006)

Other resources: (see appendix) The Modified Physician Self-Maintenance Scale /Instrumental Activities of Daily Living Scale Lawton-Brody Functional Assessment Questionnaire (FAQ) SMAF and e-SMAF – e-mail to get French and English copies and information: iugs@ssss.gouv.qc.ca

8

AssessmentofFunc5onismoreimportantthananycogni5vetest:manytoolsavailable

Dementia

900 American Family Physician www.aafp.org/afp Volume 84, Number 8 ◆ October 15, 2011

checking folate levels (Table 327,28).27 If the patient has a history of risk factors for sexu-ally transmitted infections, testing for syph-ilis and human immunodeficiency virus (HIV) infection should be added.27 Other testing such as urinalysis, urine culture, and heavy metal screening should be performed when clinical suspicion is high. Lumbar puncture with cerebrospinal fluid analy-sis may be indicated if there is suspicion of neurosyphilis, HIV infection, cerebral Lyme disease, or vasculitis.27

The yield for neuroimaging is low (approx-imately 5 percent); however, it may be useful in some symptomatic patients.28 Neuroim-aging via computed tomography or magnetic resonance imaging of the brain may detect clinically significant structural lesions that would otherwise be missed. The AGS recom-mends neuroimaging in patients with any of the following: onset of symptoms before 60 years of age; abrupt onset or rapid cogni-tive decline (weeks to months); focal neuro-logic symptoms; or predisposing conditions such as malignancy, HIV disease, or con-current anticoagulation.27 Neuroimaging should also be considered if vascular dis-ease, normal pressure hydrocephalus, infec-tion, or subdural hematoma is suspected. If imaging studies are indicated, magnetic

resonance imaging without contrast media is the preferred study.34

Newer diagnostic methods, such as posi-tron emission tomography (PET) and evalu-ation of cerebrospinal fluid biomarkers, have been shown to have good diagnostic sensitiv-ity.35,36 One study has shown a significant rela-tionship between levels of cerebrospinal fluid biomarkers, such as beta amyloid and tau protein, and the development of Alzheimer disease and mild cognitive impairment.35 PET can help differentiate among types of demen-tia, including frontotemporal dementia.37 Another study showed PET with Pittsburgh Compound B protocol to accurately measure the amount of amyloid in the brain and pre-dict Alzheimer disease.36 The implications and benefits of these novel approaches in research settings are straightforward, although their role in clinical medicine is unclear because of issues such as availability, cost, and lack of effective treatment. PET can be considered if differentiation among dementia types would affect management.

Data Sources: A search was completed in Medline via Ovid, the National Guidelines Clearinghouse, the Institute for Clinical Systems Improvement, and the Cochrane Data-base of Systematic Reviews using the following keywords: dementia, Alzheimer’s, verbal fluency, Mini-Cog, clock draw test, Mini-Mental State Exam, cognitive assessment, and geriatric depression scale.

Table 3. Studies Recommended by the American Geriatrics Society for Patients with Suspected Dementia

Laboratory tests Imaging testsTests to consider in patients with specific risk factors

Calcium level

Complete blood count

Complete metabolic panel

Folate level

Thyroid-stimulating hormone level*

Vitamin B12 level*

Computed tomography or magnetic resonance imaging of the brain if any of the following are present:

• Abrupt or rapid decline

• Age younger than 60 years

• Focal deficits

• Predisposing conditions

Consider positron emission tomography if definitive diagnosis will change management decisions

Cerebrospinal fluid analysis

Human immunodeficiency virus test

Lyme titer

Rapid plasma reagin test

*—The only tests routinely recommended by the American Academy of Neurology for all patients with suspected dementia are thyroid-stimulating hormone and vitamin B12 levels.28

Information from references 27 and 28.

October 15, 2011 ◆ Volume 84, Number 8 www.aafp.org/afp American Family Physician 897

assessed, because these can influence scores on several cognitive tests.

Although the physical examination is not usually affected in patients with Alzheimer disease, abnormalities can give clues about less common types of dementia. Focal defi-cits from a previous stroke are common in patients with vascular dementia. Parkinson-ism is seen in patients during the later stages of dementia with Lewy bodies. Table 1 lists key findings from the patient history and physical examination that may accompany cognitive dysfunction, and the suggested diagnoses.

Screening Tests for Cognitive ImpairmentDuring the initial visit, quick assessment tools can be used as a screening test to help decide whether further evaluation is warranted (Table 2).13-15 One of the following tests should be performed during the initial visit, with further evaluation if the result is abnormal.

VERBAL FLUENCY TEST

Of the two types of verbal fluency tests, cat-egory (or semantic) fluency has superior sen-sitivity and specificity compared with letter

Table 2. Summary of Screening Tests for Cognitive Impairment

TestTime required How to administer How to interpret

Sensitivity (%)

Specificity (%)

Verbal fluency test

One minute Ask patient to name as many animals as possible in 60 seconds

Patient receives one point for each unique animal named

Score < 15 = suggestive of dementia

Consider lowering cutoff score to 12 for persons with one to seven years of education

Consider lowering cutoff score to 9 for persons with no education

88 96

Mini-Cognitive Assessment Instrument

Two to four minutes

Three-item recall combined with clock drawing test

Patient receives one point for each correctly recalled word and two points for normal clock drawing test

Score of 0 to 2 = high likelihood of dementia

Score of 3 to 5 = low likelihood of dementia

76 89

Sweet 16 Two to three minutes

Three-item recall, eight-item orientation, and backward digit span

Patient receives one point for each correct item, for a maximal score of 16

Score < 14 = suggestive of dementia

80 70

Information from references 13 through 15.

Table 1. Key Findings and Suggested Diagnoses in Patients with Cognitive Dysfunction

Key findings on history and physical examination Suggested diagnosis

Ascending paresthesias, tongue soreness, limb weakness, weight loss

Vitamin B12 deficiency

Broad-based shuffling gait, urinary incontinence Normal pressure hydrocephalus

Current use of psychoactive drugs, such as benzodiazepines or anticholinergics

Adverse effects from medication

Depressed mood, anhedonia, feelings of worthlessness, flat affect, slowed speech

Depression

Fatigue, cold intolerance, constipation, weight gain, reduced body hair

Hypothyroidism

Head trauma within the previous three months, headache, seizures, hemiparesis, papilledema

Subdural hematoma

History of alcoholism, nystagmus or extraocular muscle weakness, broad-based gait and stance

Wernicke-Korsakoff syndrome

History of high-risk sexual behavior or drug use, hyperreflexia, incoordination, peripheral neuropathy

Human immunodeficiency virus–associated dementia

History of high-risk sexual behavior or drug use, hyporeflexia, papillary abnormalities, decreased proprioception

Neurosyphilis

Recent hospitalization or acute illness, inattention, fluctuating behavioral changes, altered level of consciousness

Delirium Simmonsetal,2011

Types of Dementia (mixed not included)

Vasculardemen5as–mul5-infarctdemen5a–Binswanger’sdisease

DLBD–Parkinson’sdisease–diffuseDLB–LewybodyvariantofAD

Otherdemen5as–frontallobedemen5a–Creutzfeldt-Jakobdisease–cor5cobasaldegenera5on–progressivesupranuclearpalsy–poten5allyreversibledemen5as

AD

Gersingetal.,1998;Cras,1998

17.5%

7.5%

55% 20%

S.Landau,UCB

46

AD Progression

FDG PET

Function (ADL)

Cognitive performance

MRI hippocampal volume CSF Tau Amyloid imaging

CSF abeta42

Abnormal

Normal Time Pre-symptomatic eMCI LMCI Dementia

CourseoftheDisease

Adapted from Feldman H, et al. Can J Neurol Sci 2001; 28 (Suppl 1):S17-S27.

Years

0 2 6 7 8 4 3 5 1 9 0

15

25

20

10

5

30

MM

SE S

core

Loss of functional independence

Nursing home placement

Death

Mild Mild-Moderate Disease

Severe Disease

Memory loss

Diagnosis Mood & Behavioural problems

MMSE = Mini Mental State Examination

Vascular Dementia – classic features

•  Abrupt onset •  Stepwise progression •  Memory problems (not predominant) •  Impaired executive function •  Emotional lability •  History of cerebrovascular risk factors •  Focal neurological signs and symptoms

or neuroimaging evidence

Scheltens,2001.

Vascular Dementia

Alzheimer’s disease and vascular dementia share common risk factors

•  hypertension •  generalized

atherosclerosis •  coronary heart

disease •  atrial fibrillation •  diabetes mellitus

•  hyperlipidemia•  elevatedplasmahomocysteine

• whitemaWerlesions•  historyofstroke

Skoog I. Neuroepidemiology 1998;17:2-9. MacPherson KM, et al. Perspectives in Cardiology 2001;June/July:19-26.

Seshadri S, et al. N Engl J Med;346:476-483.

Campbell, Stephens, Ballard, 2001.

Dementia With Lewy Bodies

•  Characterized by 3 core symptoms: – Fluctuating cognitive impairment (~80%) – Persistent visual hallucinations (>60%) – Parkinsonism (65%–70%)

Also:

– Systematized delusions (~70%) – Depression (38%) – Neuroleptic sensitivity (>50%) – REM Sleep Disorder

Dementia: Care & Management

•  Optimal Environment •  Person-Centred Care •  Caregiver education & support / respite •  Psychosocial interventions •  Optimal healthcare •  Pharmacological treatment

Cholinergic Treatment of AD and related dementias

•  Aricept® (donepezil hydrochloride) – approved 1997

•  Exelon® (rivastigmine) – approved 2000

•  Reminyl® (galantamine) – approved 2001

•  Note: Memantine (Ebixa) works on Glutamate receptors (blocks NMDA).

BEHAVIOURALPROBLEMS(Responsivebehaviours)

• Beginwithenvironmentalmodifica5onandnon-pharmacologicalapproaches

• Monitorandwithdrawmedica5onsifpossible

ResponsiveBehaviours:Medica5ons

•  An5depressants(trazodone,SSRIse.g.sertraline)•  An5psycho5cs-Atypical(risperidone,que5apine)

Lessoaen:•  Benzodiazepines(lorazepam,clonazepam)•  An5convulsants(carbamazapine)

•  Evidencethatfollowingahipfracture,pa5entswithmildtomoderatedemen5awhoreceivedrehabilita5onshowsimilarrela5vegainsinfunc5ontopa5entswithoutdemen5a.

•  Moreresearchisneededtodeterminetheeffectofrehabilita5onfollowinghipfractureinpa5entswhoresideincon5nuingcareseNngsandthosewithseveredemen5a.

•  Includedfivetrialswithatotalof316par5cipants.Fourtrialsevaluatedmodelsofenhancedinterdisciplinaryrehabilita5onandcare,twooftheseforinpa5entsonlyandtwoforinpa5entsandathomeaaerdischarge.Allwerecomparedwithusualrehabilita5onandcareinthetrialseNngs.Thefiahtrialcomparedoutcomesofgeriatrician-ledcareinhospitaltoconven5onalcareledbytheorthopaedicteam.

•  Allpapersanalysedsubgroupsofpeoplewithdemen5a/cogni5veimpairmentfromlargerRCTsofolderpeoplefollowinghipfracture.

•  Thereiscurrentlyinsufficientevidencetodrawconclusionsabouthoweffec5vethemodelsofenhancedrehabilita5onandcareaaerhipfractureusedinthesetrialsareforpeoplewithdemen5aaboveac5veusualcare.

•  Thecurrentevidencebasederivesfromasmallnumberofstudieswithqualitylimita5ons.Thisshouldbeaddressedasaresearchprioritytodeterminetheop5malstrategiestoimproveoutcomesforthisgrowingpopula5onofpa5ents.

CochraneDatabaseSystRev.2015Jun15;(6):CD010569.

Enhancedrehabilita+onandcaremodelsforadultswithdemen+afollowinghipfracturesurgery.

SmithTO1,HameedYA,CrossJL,HendersonC,SahotaO,FoxC.

Canweprevent/delayDemen5a?

FinnishGeriatricInterven5onStudytoPreventCogni5veImpairmentandDisability(FINGER)

studyAproof-of-conceptrandomisedcontrolledtrialassessesamul+domainapproachtopreventcogni+vedeclineinat-riskelderlypeoplefromthegeneralpopula5on.Double-blindrandomisedcontrolledtrial;aged60–77years2yearmul5domaininterven5on(diet,exercise,cogni5vetraining,vascularriskmonitoring),oracontrolgroup(generalhealthadvice).Primaryoutcome:changeincogni5on-comprehensiveneuropsychologicaltestbaWery(NTB)Zscore.Screened2654individualsandrandomlyassigned1260totheinterven5ongroup(n=631)orcontrolgroup(n=629).

MiiaKivipeltoetal.Lancet;Volume385,No.9984,p2255–2263,6June2015

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Alzheimer's & Dementia: The Journal of the Alzheimer's Association 2013 9, 657-665DOI: (10.1016/j.jalz.2012.09.012) 65

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TheFountainofHealthIni5a5vewww.fountaino{ealth.ca

BringingSeniors’MentalHealthPromo+onintoClinicalPrac+ce

FoH5KeyMessages

Averageage76.6,MMSE18.8Excellenttreatmentadherence.Highlevelsofacceptabilityandfeasibility.

22RCTsincludedEvidenceofsomecogni5veimprovementinMCI

(execu5vefn,aWen5onanddelayedrecall)Noevidenceinstudiesofpeoplewithdemen5a.

Depression:Stressorsaffec5ngElderly

•  PhysicalIllness •  Sensorydepriva5on•  Re5rement•  Povertyandpoorlivingcondi5ons•  Bereavement•  Socialisola5on•  Lossofroles/status

SpectrumofDepressiveDisorders•  Majordepressiveepisode(singleorrecurrent)•  PersistentDepressiveDisorder=Dysthymia•  Mixedanxiety/depressivedisorder•  Bereavement•  Adjustmentdisorder•  Subthresholddepressivedisorder•  Bipolardisorder•  Demen5awithdepression•  Depressionassociatedwithanotherpsychiatricor

substanceusedisorder

MajorDepressioncriteriaSIG:eCAPS

•  S-Sleep•  I-Interest•  G-Guilt•  E-Energy•  C-Concentra5on•  A-Appe5te•  P-Psychomotor•  S-Suicide

DiagnosisofDepressionintheElderly:KeyMessages

•  Bevigilent•  Alwaysaskaboutsuicidalfeelings•  Beawareofdiagnos5ccriteria•  Rememberunusualpresenta5ons•  Considerthedifferen5aldiagnosis(medicalandpsychiatric)

•  Considerbiological,psychologicalandsocialfactors

•  Makeadiagnosis(DSM-5)

SuicideRiskFactors(1)

•  Malegender•  Livingalone•  Inadequatesocialsupport•  Recentsignificantloss•  chronicmedicalillness(esp.pain)•  alcoholabuse•  Culturalacceptability

SuicideRiskFactors(2)

•  PastaWempt•  Agita5on•  Guilt•  Hopelessness•  Lowself-esteem•  Hypochondriacalpreoccupa5on

Overallobjec5vesofTreatment

•  Resolu5onofdepression•  Reintegra5onintofamilyandsocialenvironment

•  Restora5onoffunc5oningandsocialroles•  Preven5onofrelapseandrecurrence

TreatmentOp5ons:An5depressants

•  SSRIs(sertraline,citalopram,escitalopram)•  SNRI(venlafaxine,duloxe5ne)•  5-HT2receptorblockers(trazodone)•  NASSA(mirtazapine)•  Bupropion•  Tricyclics(nortriptyline,desipramine)

ChoosinganAn5depressant

•  TolerabilityandSafety•  Poten5alfordrug-druginterac5ons•  Pharmakokine5cs•  Pa5ent’sPreviousResponse•  FamilyHistory•  RiskofSuicide•  Cost

Insomnia Anxiety Nervousness Increased Sweating Seizures EPS Somnolence Asthenia GI Nausea Constipation Diarrhea Dyspepsia Weight Change Dry mouth

Sexual Function Decreased libido Impotence Ejaculation disorder Anorgasmia

Cardiovascular Hypertension Orthostatic hypotension Arrhythmias

Potential Antidepressant side effects

CNS

PsychologicalTherapies

•  Suppor5ve•  Family•  CBT•  Dynamic•  Self-helpprograms

•  Groupvs.Individual

Goldappleetal.ArchGenPsychiatry,Volume61(1).January2004.34–41

OtherTreatments

•  ElectroconvulsiveTherapy(ECT)•  TranscranialMagne5cS5mula5on(TMS)•  Phototherapy•  Herbal(St.John’sWort)

3themes:ChallengesNeedto“thinkoutsidethebox”Posi5veexperiences

Challenges

Thinkingoutsidethebox

•  Comprehensivegeriatricapproachisessen5al.•  Mustgetclearpictureofpre-morbidleveloffunc5oning.•  Importanttoruleoutco-exis5ngdeliriumordepressionandif

presentac5velyassessand/ortreat.•  Outcomesforpeoplewithmildtomoderatedemen5aand#

hiparegenerallyposi5ve.•  Importanttounderstandcogni5vestrengthsandweaknesses–

e.g.the7A’s•  Mul5pletreatmentop5onsfordepressiondependingonthe

type•  Needformoreresearch!

FinalThoughts