FOCUS 2019: Caring for People with Chronic Mental Illness Who

Home , Vascular dementia

11/18/2019

Caring for people with chronic mental illness who develop dementia

Art Walaszek, M.D. Professor of Psychiatry November 21, 2019

Disclosures

Grant support National Institute on Aging U.S. Administration on Community Living UW Wisconsin Partnership Program

Honoraria Advocate Lutheran General Hospital United Way / Pharmacy Society of Wisconsin

Advance on American Psychiatric Association Publishing royalties Investigator (not Eisai Network Companies compensated)

Objectives

1. Appreciate about the increased risk of dementia with persons with chronic mental illness. 2. Recognize dementia in persons with chronic mental illness. 3. Develop a treatment plan for the care of a person with co- morbid chronic mental illness and dementia.

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Cognitive changes associated with aging

• slower information processing, and increased reaction time • decreased ability to store and recall memories • less cognitive flexibility • increased fund of knowledge • not associated with impairment in functioning

Definition of dementia • per DSM-5: major neurocognitive disorder

• syndrome of acquired, persistent decline in several realms of intellectual ability: • problems with memory • problems with language • visuospatial problems

• decreased problem-solving, abstraction and other executive functions • reduced attention • decreased ability to recognize faces, objects, etc. • decreased ability to perform complex tasks • plus functional impairment

Overview of dementia

Cognition IADLs* ADLs *

MILD PRECLINICAL COGNITIVE DEMENTIA IMPAIRMENT

time course

* change from baseline in instrumental activities of daily living (IADLs) or personal activities of daily living (ADLs) 6

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Causes of dementia in the U.S. vascular dementia Alzheimer’s disease 1.3% 14% 11% alcohol 62% 0.6% (AD alone) 1% 4% 0.4% 1.2% 5% other* frontotemporal dementia Lewy body disease

Goodman et al., Alzheimers Dement 2017;13:28-37. *Huntington’s disease, Creutzfeldt-Jakob disease, drug-induced dementia

Chronic mental illness & risk of dementia

• schizophrenia • bipolar disorder • major depressive disorder • alcohol • medications

Schizophrenia

• people with schizophrenia have roughly twice the risk of developing dementia as those without (RR*=2.29)1 • they may develop dementia earlier2: • by age 65: 1.8% had dementia (vs 0.6% for people w/o schizophrenia) • by age 80: 7.5% (vs 5.8%) • why? • tobacco -> vascular disease • other medical comorbidities (diabetes, heart disease) • alcohol & other substances • low physical activity • poor access to medical care (?) • lower cognitive reserve (?) • shared genetic risk (?)

1 2 Cai & Huang, Neuropsychiatr Dis Treat 2018; Ribe et al., JAMA Psychiatry 2015; * RR = relative risk 9

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Bipolar disorder

• people with bipolar disorder have roughly twice the risk of developing dementia as those without (OR*=2.36) • why? • tobacco, alcohol & other substances • medical comorbidities (obesity, diabetes, sleep apnea) • risky behaviors • diet & exercise • neuroinflammation & decreased neuroplasticity • unclear if number of episodes correlated with dementia

Dimiz et al., Am J Geriatr Psychiatry 2017; * OR = odds ratio 10

Veterans with schizophrenia or bipolar disorder

Bipolar disorder: IRR* = 2.57

Schizophrenia: IRR=3.27

Ahearn E, et al., presented at AAGP 2019; * IRR = incidence rate ratio 11

Major depressive disorder

• people with MDD have roughly twice the risk of developing dementia as those without (OR* either 1.90 or 2.03, depending on type of study) • risk of vascular dementia (2.52) slightly higher than risk of Alzheimer’s disease (1.65) • late-onset depression may represent prodrome of dementia • on the other hand, those with longer duration of depression have higher risk of dementia • why? • neuroinflammation • tobacco, alcohol • diet & exercise

Ownby et al., Arch Gen Psychiatry 2006; * OR = odds ratio 12

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Alcohol & risk of dementia

• in general, studies have shown that light alcohol use may reduce risk of dementia • high alcohol use increases risk of dementia and results in smaller hippocampi 10 units = five 12-oz beers

Sabia et al., BMJ 2018; Topiwala et al, BMJ 2017 13

Medications & risk of dementia

• lithium1: may be neuroprotective and reduce risk of dementia • valproic acid2: in people with dementia, may increase the rate of shrinkage of the brain • anticholinergic medications3: can cause reversible cognitive impairment in people with schizophrenia ≥ 50 years old • benzodiazepines4: conflicting evidence about risk of dementia; do cause reversible cognitive impairment • antipsychotics: ?

1 2 Diniz et al., Neuropsychiatr Dis Treat 2013; Tariot et al., Arch Gen Psychiatry 2011; 14 3Tsoutsoulas et al., J Clin Psychiatry 2017; 4Grossi et al., BMC Geriatr 2019

When to suspect dementia • difficulty remembering new information or recent events • repetitive conversation or word-finding problems • not recognizing familiar people • change from baseline cognition • change in personality or behavior • functional problems: • gets lost driving • difficulty with money management • less able to take care of self

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Alzheimer’s Disease International, www.alz.co.uk/info/early-symptoms 16

Screening for cognitive impairment

• MoCA – specifically studied in schizophrenia1, but soon to require certification • NTG-EDSD – for persons with intellectual/developmental disability2 • others (not specifically studied in severe mental illness): • Mini-Cog – three-object recall plus clock-drawing test • MMSE – proprietary • SLUMS

1Yang et al., Schizophr Res 2018; 2www.aadmd.org/ntg/screening 17

Diagnosing dementia

• assess cognition and functioning

• consider neuropsychological testing • identify and address potentially reversible etiologies:

• depression, anxiety, B12 deficiency, hypothyroidism, medications (anticholinergics, benzodiazepines, opioids), sleep apnea, alcohol, cannabis • determine cause of dementia:

• Alzheimer’s disease (AD)

• vascular dementia

• dementia with Lewy bodies (DLB)

• frontotemporal dementia (FTD)

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Behavioral & psychological symptoms of dementia (BPSD) Symptom Prevalence apathy 49% depression 42% aggression 40% sleep disorder 39% anxiety 39% irritability 36% appetite disorder 34% aberrant motor behavior 32% delusions 31% disinhibition 17% hallucinations 16%

Zhao et al., J Affect Disorder euphoria 7% 19 2016;190:264-271.

BPSD: overlap with pre‐existing psychiatric symptoms (1) • hallucinations: • in dementia, visual more common than auditory • in Lewy body disease, visual hallucinations can be very detailed • delusions: • in dementia, most common are delusions of theft, home is not one’s own, and infidelity • usually not as complex and well-formed as in schizophrenia

BPSD: overlap with pre‐existing psychiatric symptoms (2) • depression: • similar presentation as in people without dementia, except that irritability may be more prominent • anxiety: • in dementia, may include repetitive statements/questions, following caregivers around the house, being apprehensive about caregivers leaving • euphoria/mania: • rare in dementia • apathy or aggression/impulsivity: • consider frontotemporal dementia

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Suicide across the life span 60 Rate of suicide by age in 2017 (per 100,000 per year)

0 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Male Female

CDC WISQARS accessed November 2019

Suicide and dementia

• risk of suicide does not appear to be higher in patients with dementia compared to age-matched general population • but history of inpatient psychiatric hospitalization, substance abuse, bipolar disorder & depression do increase risk of suicide • the time immediately after diagnosis of dementia may be a period of higher risk • firearms most common method (73%) • pathological studies of suicides with dementia reveal low rate of AD pathology

Seyfried et al., Alzheimers Dement 2011;7:567-573. 23

Managing dementia in persons with pre‐ existing mental illness • support ADLs and help maintain independence • address behavioral & psychological symptoms of dementia • address pain • identify and address safety concerns • address caregiver burden • screen for elder abuse • minimize use of psychotropic medications • ethical issues: decisional capacity • legal issues: power of attorney, advanced directives, estate planning

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Addressing BPSD

• treat underlying medical causes • discontinue offending medications & substances • support & educate caregivers & other family members • develop a psychological, behavioral & environmental management plan, e.g., using DICE • avoid adding new medications, unless there is risk of harm to patient or others • if a medication is added, regularly monitor outcomes & attempt discontinuation (start low, go slow) • ensure that patients & caregivers are in a safe environment

Walaszek Behavioral & Psychological Symptoms of Dementia 2019. 25

Practical tips

• increase activity levels, tapping into preserved capabilities and previous interests • educate and support caregivers • improve communication, e.g., • use a calm, reassuring voice • provide 1- to 2-step simple verbal commands • allow sufficient time to respond • reduce clutter, noise & distractions in the environment (or, if it’s too bland, enhance it) • simplify tasks and provide structured daily routines

Kales et al, JAGS 2014: 62(4):762-9. 26

Pain in persons with dementia • epidemiology: • 64% of community-dwelling elders with dementia report pain that is bothersome • 43% report pain that limits their activities • screening: • mild to moderate dementia: Iowa Pain Thermometer • severe dementia: Pain Assessment in Advanced Dementia (PAINAD) Iowa Pain • treatment: Thermometer • scheduled acetaminophen 1000 mg bid or tid

Hunt et al., 2015; Ware et al., 2015; Warden et al., 2003; AGS 2009 27

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Addressing safety concerns

 falls  CDC Older Adult Fall Prevention  fires  cooking safety, tobacco cessation  other threats in the home  guns*, chemicals, power tools  lack of adherence to  pill boxes, blister packs, automated medications dispensers  driving  encourage to stop driving  wandering  door locks/alarms, wearable GPS  hoarding  address comorbidities, “dig out”  elder abuse  maintain high index of suspicion

Walaszek Behavioral & Psychological Symptoms of Dementia 2019; * 91% of elder suicides are by gun 28

Caregivers of people with dementia

• screen for caregiver depression (PHQ-2) • 32% of dementia caregivers have depressive symptoms • burden affects caregiver’s reporting of patient’s symptoms • education • Mace & Rabins’ 36 Hour Day • ADRCs and Dementia Care Specialists • caregiver support groups • treatment of patients improves caregiver symptoms

Sink, et al., JAGS 2006;54:796-803. 29

What to do about psychotropic medications

• consider dose reduction or discontinuation of medications for pre-existing mental illness, especially valproate, benzodiazepines, anticholinergics, antipsychotics • consider cognitive enhancer to delay progression of dementia • use medications for BPSD only if imminent dangerousness or severe distress (start low, go slow)

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Conclusions

• People with pre-existing severe mental illness (SMI) are at increased risk of developing dementia. Alcohol use and other substances may further increase risk. • We need to watch carefully for dementia as people with SMI age, perhaps with regular screening. • Behavioral and psychological symptoms of dementia (BPSD) may mimic psychiatric symptoms of pre-existing mental illness. • Managing dementia includes supporting ADLs, addressing pain, reassessing risks/benefits of all psychotropic medications, supporting caregivers, and addressing safety concerns (including suicide).

Thank you

Feel free to contact me with questions: [email protected] @artwalaszek