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Dementia Diagnosis and Prognosis EMILY MORGAN, MD 2020 OHSU INTERNAL MEDICINE and GERIATRICS Objectives

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Dementia Diagnosis and Prognosis EMILY MORGAN, MD 2020 OHSU INTERNAL MEDICINE and GERIATRICS Objectives Dementia Diagnosis and Prognosis EMILY MORGAN, MD 2020 OHSU INTERNAL MEDICINE AND GERIATRICS Objectives Define dementia and mild cognitive impairment Identify and differentiate the 5 most common types of dementia Explore key elements of treatment and prognosis in dementia BILL Creator:Raul Rodriguez Copyright:© Fotoluminate LLC Bill 82 year old man, recently moved to assisted living after his wife died 12 months ago. His daughter has noticed increasing “forgetfulness” in the past 2-3 years. Bill has good days and bad days, but his family notices he has been neglecting his appearance recently. No agitation or delusions, but occasional visual hallucinations. No loss of appetite or weight loss. He has had 2 falls in the last 3 months. Never smoked, rarely drinks. Meds: HCTZ, baby aspirin, multivitamin and occasional diphenhydramine for insomnia. Dementia defined by DSM-V: Major Neurocognitive Disorder Deficit in at least one objective assessment of: ◦ Complex attention ◦ Executive ability ◦ Learning and memory ◦ Language ◦ Visuo-constructional-perceptual ability ◦ Social cognition Deficits must interfere with independence (ADLs/IADLs) Mild cognitive impairment defined: Minor Neurocognitive Disorder Minor cognitive decline from a previous level of performance in one or more of the stated domains No interference with function but greater effort and compensatory strategies may be required to maintain independence Why is MCI important? 50% progress to dementia within 7 years There are interventions that can potential prevent or slow the rate of conversion to dementia ◦ Controlling vascular risk factors (OSA) ◦ Exercise (Tai chi) ◦ Diet (Mediterranean) ◦ Socialization (avoiding isolation) Must rule out depression and delirium when assessing for dementia! 6 types of dementia Alzheimer’s Vascular Lewy Body Frontotemporal Alcohol related HIV Associated Dementia 5% 15% 45% 20% 15% Alzheimers Vascular Mixed LBD FTD Alzheimer’s Dementia Impairment in learning and memory plus one: ◦ Complex attention ◦ Executive function ◦ Language ◦ Visuo-constructional-perceptual ability ◦ Social cognition Vascular Dementia New cognitive deficit + Focal neurological signs and symptoms +/- Brain imaging evidence of cerebrovascular disease Judged to be temporally related to the dementia MIXED vascular-Alzheimer’s dementia Vascular insults are very common in Alzheimer’s disease 20% of patients have evidence of both vascular and Alzheimer’s pathology Lewy Body Dementia New cognitive deficits + 2/3 symptoms: Parkinsonian findings: shuffling gait, rigidity, dysphagia >>>tremor Fluctuation in LOC and cognition Well formed visual hallucinations LBD – suggestive findings REM sleep disorders Severe antipsychotic sensitivity: Exaggerated extrapyramidal symptoms Increased rigidity and bradykinesia Frontotemporal Dementia A TALE OF 2 DEMENTIAS Frontotemporal Dementia: Behavioral variant Decline in personal or social interpersonal conduct Impaired reasoning and difficulty with tasks out of proportion to impairments in memory Frontotemporal Dementia: progressive aphasia variant Deficits in language out of proportion to memory impairment ◦ Motor speech ◦ Word comprehension or object recognition ◦ Word retrieval or speech errors (substitution) Alcohol related dementia Deficiency in thiamine (Vitamin B1) The toxic effects of alcohol on brain cells The biological stress of repeated intoxication and withdrawal Alcohol-related cerebrovascular disease Head injuries from falls sustained when inebriated Alcohol related dementia Learning and memory most effected Confabulation - making up information not remembered People with alcohol related dementia many benefit from extended treatment with oral thiamine and magnesium With treatment: ¼ will completely recover ½ will improve without complete recovery ¼ will remain unchanged HIV Associated Dementia Late stage disease: CD4<200 and high viral loads Characterized by symptoms of cognitive, motor, and behavioral disturbances Behavioral changes including apathy and social withdrawal Motor changes include gait impairment, falls, impaired fine motor skills No quick screening test validated – MoCA likely the best, also Modified HIV Dementia Scale https://aidsetc.org/guide/hiv-associated-neurocognitive-disorders Quick memory Screen The Mini Cog ◦ 3 item recall ◦ Clock draw Validated for diagnosis of dementia AND for MCI Tests 5 brain domains Tests 6 brain domains Helps to assess driving ability MoCA < 18 Abnormal trails B Abnormal clock MMSE (proprietary- $1.68/use) Tests 4 brain domains: ◦ orientation, memory, visual-spatial, verbal fluency USE ONLY FOR FOLLOWING DEMENTIA OVER TIME Physical Exam Neurologic Exam: ◦ Sensory, Reflexes, Strength, Motor Coordination ◦ E/o Parkinsonism? ◦ Gait assessment: Timed Get up and Go (TUG) Lab studies TSH Vitamin B12 (MMA) Consider HIV and RPR If none recently: CBC and metabolic panel Neuroimaging Non contrast CT scan or MRI For any patients under age 65 Or patients over age 65 with: ◦ Atypical presentation ◦ Unclear diagnosis ◦ Rapid unexplained deterioration ◦ Unexplained focal neurological symptoms ◦ History of head injury ◦ Urinary incontinence or gait ataxia early in illness ◦ Suspicion of undiagnosed CV disease BILL Creator:Raul Rodriguez Copyright:© Fotoluminate LLC Bill SLUMS Orientation 3/3 Calculation 1/3 Naming 2/3 Object Recall 3/5 Attention 1/2 Clock 0/4 Shapes 2/2 Story Recall 4/8 Total 16/30 Bill Gait – wide based, mild shuffling, TUG>15 sec Tone – mild cog wheeling on L side No tremor, normal facial movements On further questioning, Bill has a long hx of “insomnia” caused by restless sleep. He has vivid dreams, often acting them out in his sleep. Lewy Body Dementia Now that my patient has a diagnosis, what next? ◦ Staging Dementia for treatment ◦ Behavioral symptoms assessment ◦ Driving assessment ◦ Home safety evaluation ◦ Caregiver burden ◦ Goals of care planning Staging dementia Mild Moderate MoCA 20-16 Advanced Decline in MoCA 15-10 End stage IADLs, mild Decline in behavioral ADLs, MoCA <10 symptoms Increasing FAST staging behavioral Needing 24 for hospice symptoms hour care care A review of Reviews – what works? Exercise Patient+Caregiver QOL interventions AChE-I Memantine Laver K, Dyer S, Whitehead C, Clemson L, Crotty M. Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews. BMJ Open. 2016;6(4):e010767. Published 2016 Apr 27. doi:10.1136/bmjopen-2015-010767 Cholinesterase Inhibitors Most studies with statistically significant difference favoring cholinesterase inhibitors –Delay in progression of up to 7 months in mild dementia –Delay of 2-5 months in moderate dementia –Statistically significant improvement in behavioral symptoms in mild and moderate dementia –Effective for all dementia types except FTD Raina 2008, Rodda 2009 When to stop? A Systematic Review of Practice Guidelines and Recommendations for Discontinuation of Cholinesterase Inhibitors in Dementia. Renn BN, Asghar-Ali AA, Thielke S, et al. Am J Geriatr Psychiatry. 2017;26(2):134-147. Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents With Severe Dementia Journal of the American Geriatrics Society, First published: 26 November 2019, DOI: (10.1111/jgs.16241) Memantine Memantine for Alzheimer's Disease: An Updated Systematic Review and Meta-analysis. Kishi et al. J Alz Disease, 2017. Memantine showed a significant improvement Cognitive 95% CI (-0.34, -0.15) p < 0.00001 Behavioral 95% CI (-0.34, -0.07) p = 0.003 Memantine Studies in vascular, LBD, and FTD trend toward benefit Dual therapy with AChE-I or monotherapy Dose: 5mg daily -10 mg bid eGFR of 30-60, max dose is 10 mg daily Stop if eGFR below 30 Mild Dementia Alzheimer’s Vascular Lewy Body FTD mixed Trial AChE-I Control vascular risk Trial AChE-I (NO AChE-I) factors PT/OT Trial memantine Trial AChE-I Driving and safety Driving and assessment Safety assessment Exercise (Tai chi) Mediterranean diet Socialization Mild Dementia Conversations with patient and family: What are your wishes? What’s it going to look like? Assisted living options Advance Directive Plan to stop driving Moderate Dementia AlzheimerSs Vascular mixed Lewy Body FTD Trial AChE-I Control vascular Trial AChE-I Trial memantine risk factors Trial memantine Trial memantine Trial AChE-I Trial memantine Moderate Dementia Conversations with patient and family: What is our safety plan? Neuropsychiatric symptoms Yes and… approach to communication Memory care options POLST Advanced Dementia Alzheimer’s Vascular Lewy Body FTD mixed Consider Consider Consider Trial memantine stopping AChE-I stopping AChE-I stopping AChE-I Trial memantine Trial memantine Trial memantine Advanced Dementia Conversations with caregiver: 24 hour caregiving Planning for end stages ◦ Loss of mobility ◦ Loss of verbal interaction ◦ Complete Incontinence ◦ Dysphagia ◦ Weight loss References Laver K, Dyer S, Whitehead C, Clemson L, Crotty M. Interventions to delay functional decline in people with dementia: a systematic review of systematic reviews. BMJ Open. 2016;6(4):e010767. Published 2016 Apr 27. doi:10.1136/bmjopen-2015-010767 Lockhart IA, Orme ME, Mitchell SA. The efficacy of licensed-indication use of donepezil and memantine monotherapies for treating behavioural and psychological symptoms of dementia in patients with Alzheimer’s disease: systematic review and meta-analysis. Dement Geriatr Cogn Dis Extra. 2011;1(1):212–27. McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev. 2006;2:CD003154.
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