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Neurocognitive Disorders Florida Conference on Aging August 25, 2020

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Neurocognitive Disorders Florida Conference on Aging August 25, 2020 Neurocognitive Disorders Florida Conference on Aging August 25, 2020 Heather Cappello MD CMD Medical Director and Clinton Jules MD HUMANA CONFIDENTIAL – INTERNAL USE ONLY Learning Objectives: • Explain the differences between the most commonly encountered Neurocognitive Disorders. • Describe Delirium and other Neurocognitive Disorders in their forms and manifestations. • List the assessment and diagnostic measures to identify the correct Neurocognitive Disorder. • Explain treatment measures that are most effective for the various Neurocognitive Disorders • Apply the principles discussed to clinical examples of members with Neurocognitive Disorders 2 HUMANA CONFIDENTIAL – INTERNAL USE ONLY DSM V Neurocognitive Disorders • Neurocognitive disorder replaces the term “dementia”: • Dementia arose from the Latin for “mad” or “insane” • Experts felt that the name change would reduce the stigma associated with dementia 3 HUMANA CONFIDENTIAL – INTERNAL USE ONLY DSM V© Criteria for Neurocognitive Disorders 1) Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains: Learning and memory, language, executive function, complex attention, perceptual-motor and social cognition 2) The cognitive deficits interfere with independence in everyday activities. At a minimum, assistance should be required with complex instrumental activities of daily living, such as paying bills or managing medications. 3) The cognitive deficits do not occur exclusively in the context of a delirium 4) The cognitive deficits are not better explained by another mental disorder ( major depressive disorder, schizophrenia) 4 HUMANA CONFIDENTIAL – INTERNAL USE ONLY DSM V© Neurocognitive Disorders In DSM V © “Neurocognitive Disorder” replaces the term “Dementia” Clinicians still use the term “dementia,” and the DSM‐ 5 © work group considered dementia to be useful in settings where medical personnel are familiar with the term. Neurocognitive disorders can be classified as Delirium, and Major or Mild Neurocognitive disorders with or without behavioral disturbances. 5 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Delirium 1590s; from Latin delirium "madness“, from deliriare "be crazy, rave," literally "go off the furrow," a plowing metaphor, from phrase de lire, from de "off, away" (see de‐) + lira "furrow, earth thrown up between two furrows," from PIE *leis‐ (1) "track, furrow. 6 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Delirium: A Medical Emergency • Delirium is an acute, fluctuating syndrome of altered attention, awareness, and cognition • In practice and in the literature, it has commonly been referred to by other names: • Altered Mental Status • Acute Confusional State • Sundowning • Encephalopathy • Acute Organic Brain Syndrome 7 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Incidence And Prevalence Of Delirium Incidence during hospital admission : • After hip fracture 28 to 61% • After surgery 15 to 53% • During hospitalization (medical inpatients) 3 to 29% Prevalence: • Intensive care unit with mechanical 8 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Excerpt from DSM V 9 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Delirium Causes ‐ 1 of 2 Drugs: anticholinergics, sedatives, hypnotics, benzodiazepines, barbiturates, opioids and polypharmacy Electrolyte imbalance: Dehydration, Sodium or Potassium Imbalance Lack of Drugs: Stopping certain medicines such as Benzodiazepines, Opioids or ETOH abruptly Infection: Urinary, Respiratory, Wounds and Sepsis t 10 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Delirium Causes ‐ 1 of 2 Reduced Sensory Input: Poor or uncorrected vision or hearing Intracranial: Stroke, Head Trauma, ICH or SDH Urinary or Fecal Problems: Fecal impaction or urinary retention Myocardial: Heart attack, cardiovascular condition causing lack of oxygen 11 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Hyperactive Delirium Characterized by: Agitation restlessness pulling at catheters or intravenous tubing hitting, biting emotional lability Treatment: Low dose Haloperidol ( 0.5 to 1.0 mg) remains standard of therapy for severe agitation Shortens duration and decreases severity 12 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Hypoactive Delirium Characterized by: Withdrawal, flat affect, apathy, This can go unrecognized often as can be confused with depression or dementia lethargy perhaps unresponsiveness More common than hyperactive but less recognized delirium Outcome is worse than hyperactive delirium 13 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Hypoactive Delirium Treatment: Treat correctable cause: Limited role for Haloperidol and some evidence supports use of methylphenidate (Methylphenidate hydrochloride improves cognitive function in patients with advanced cancer and hypoactive delirium: a prospective clinical study. Gagnon B, Low G, Schreier G , J Psychiatry Neurosci. 2005 Mar;30(2):100‐7. ) 14 HUMANA CONFIDENTIAL – INTERNAL USE ONLY 15 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Risk Factors for Delirium Alcoholism Dementia Chronic Pain Depression History of lung, liver, kidney, heart or brain disease Falls Terminal illness History of Delirium Age older than 65 Polypharmacy Male Sex Sensory impairment 16 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Prevention of Delirium Assess those at risk within 24 hours of Mobilize after surgery hospital admission Assess for pain Address cognition Nutritional support Provide appropriate lighting, calendar, 24 hour clock that is visible Dentures if needed Regular visits from friends and family Glasses in place and hearing aids Keep patient hydrated and bowels moving Encourage calm sleep environment 17 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Major and Mild Neurocognitive Disorders The severity of the cognitive decline is the distinguishing factor between major and minor neurocognitive disorders The decline in function and ones ability to carry out activities of daily living are affected in both major and minor, most noted in major (Activities of Daily Living): Bathing/Grooming Dressing/Undressing Meal prep/Feeding Functional Transfers Safe restroom use and continence Ambulation and Memory care 18 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Major and Mild Neurocognitive Disorders There will be a decline in one or more domains in both major and mild including: complex attention executive function learning and memory Language social cognition 19 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Major and Mild Neurocognitive Disorders Should not occur in the context of delirium Should not occur in the context of another mental disorder/psychosis Frequently observed: mood disturbances agitation apathy Other behavioral symptoms 20 HUMANA CONFIDENTIAL – INTERNAL USE ONLY 21 HUMANA CONFIDENTIAL – INTERNAL USE ONLY World wide Demographics 22 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Alzheimer’s Disease Irreversible and progressive brain disorder that destroys memory and thinking skills Symptoms typically first appear in the mid 60s Sixth leading cause of death in the United States with an estimated 5 million Americans affected Most common cause of Dementia amongst older adults 1906 Dr. Alois Alzheimer examined the brain tissue of a woman with unexplained mental illness highlighted by memory loss, language problems and unpredictable behavior 23 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Progression of the brain with Alzheimer’s 24 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Diagnosis of Alzheimer’s Disease Definitive diagnosis is histopathologic examination Should be suspected in any older adult with subtle gradual onset , progressive memory decline and a cognitive domain that leads to impaired function Detailed Neurological and Physical Exam Montreal Cognitive Assessment preferred brief tool due to higher sensitivity (the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%) 25 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Montreal Cognitive Assessment 26 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Routine evaluation of Dementia CBC, Vitamin B12, TSH, Electrolyte panel, glucose Syphilis screening only if high suspicion Non contrast head CT or MRI is routine Brain biopsy has limited role in diagnosis of dementia PET scan has more of a use for Frontotemporal dementia 27 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Neuroimaging for Dementia Evaluation 28 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Treatment for Alzheimer's Dementia 29 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Alzheimer's Disease Treatment There is no cure Pharmacologic therapy with Donepezil (Aricept), Rivastigmine (Exelon) and Galantamine (Razadyne) These drugs have shown modest beneficial impact on neuropsychiatric and functional outcomes for patients with Alzheimer's Dementia (Efficacy of cholinesterase inhibitors in the treatment of neuropsychiatric symptoms and functional impairment in Alzheimer disease: a meta‐analysis, Trinh NH, Hoblyn J, Mohanty S, Yaffe K JAMA. 2003;289(2):210. ) 30 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Vascular Dementia This is the second most common form of dementia after Alzheimer’s Caused by problems in the supply of blood due to damage to the vascular system Damage typically caused by strokes, hypertension, hyperlipidemia and diabetes Symptoms often present as confusion, agitation, memory loss, decrease ability to organize and poor attention and concentration 31 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Progression of Vascular Dementia 32 HUMANA CONFIDENTIAL – INTERNAL USE ONLY Treatment of Vascular Dementia Acetylcholinesterase inhibitors have been studied and approved for use in Vascular dementia (Donepezil, Galantamine and Rivastigimine). Improved cognition
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