Cliff Singer, MDChief, Geriatric Mental Health and Neuropsychiatry

Acadia Hospital and Eastern Maine Medical Center

Bangor, Maine

Once Dementia is Diagnosed……

Know What You’re Treating:

Primary Dementia: gradual, progressive Alzheimer’s disease Multi-infarct vascular dementia Dementia with Lewy Bodies Parkinson’s Disease Dementia Frontotemporal Dementia

Secondary dementia: acute or subacute: Traumatic Brain Injury CNS Infections Alcohol-related (Korsakoff’s)

“Reversible” Causes Medical and psychiatric causes

Rule Out Depression and Delirium*

Memory

Mood

Motor

AttentionDepression

Dementia

Delirium

Executive

*Fact is, this may not be so easy; they often co-exist.

Clinical Features At DiagnosisAD VaD DLB FTD NPH MDD Delirium

age older older older younger older older older

memory poor recent recall

slow retrieval

slow retrieval

variable slow retrieval

slow retrieval

poor recent recall

executive less severe

more severe

more severe

concrete, dysfluent speech

more severe

more severe

very severe

attention problems

normal to mild

variable waxing/waning

ADD variable variable waxing/waning

motor findings

slowing focal and EPS

EPS normal to mild

gait dyspraxia

slowing ataxia

psychiatric apathy,

anxiety

apathy,

anxiety

apathy,

VH

apathy,

disinhibit, delusions

apathy anxious, sad, irritable

VH, delusion

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Tasks in Early Dementia

Clarify diagnosis Discuss prognosis Discuss safety issues Encourage quality of life activities Basic geriatric care to minimize incontinence,

maximize mobility and stability, address hearing and vision impairments

Planning for smooth transitions of care

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More Tasks in Early Dementia

Caregiver wellbeing addressed Consider cognitive enhancing meds Adapt daily activities to changing abilities Address pain to enhance comfort and

mobility Minimize iatrogenic problems Advanced directives established

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The Edinburgh PrinciplesWilkinson H, Janicki M et al. J Intell Disabil Res 2002; 46:3:279-84

1. Focus on QOL as that person would define it 2. Focus on a person’s capabilities 3. Involve the family 4. Ensure good diagnostic assessment and

treatment 5. Work to keep people with ID and dementia in their

chosen home 6. Ensure people with ID and dementia have access

to the broad range of dementia care in general community

7. Advocate for research and public policy to meet current and future needs

Goals in Severe Dementia

Maintain function and maximize comfort Explore options for change of residence

based on caregiver capabilities and needs Consider small details that may enhance

quality of life Minimize transitions between home and

ED and hospital

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Tasks for Severe Dementia Assess cognition, behavior, function,

nutrition/hydration, pain/discomfort, caregiver wellbeing at frequent intervals

Make adjustments for decline in mobility Make adjustments for change in diet and

feeding strategies Review advanced directives Discuss transition to palliative care or

hospice

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Cognitive enhancing medicatinos: Cholinesterase Inhibitors Many neurodegenerative diseases

associated with reduced cholinergic function (↓Ach)

Inhibit acetylcholinesterase and ↑ Ach Acetylcholine: promotes alertness,

concentration, memory, visual perception

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Cholinesterase Inhibitors 2

Donepezil (Aricept: AD, Mild-Mod-Sev AD) 5 mg daily for one month, then 10 mg daily.

May go to 23 mg daily. Galantamine (Razadyne ER: Mild-Mod AD)

8 mg daily for one month, then 16 mg. May go to 24 mg daily.

Rivastigmine (Exelon Patch: Mild-Mod AD, PDD)4.6 mg/24 hrs. daily for one month, then 9.5

mg/24 hrs. May go to 13.3 mg/24 hrs.

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Cholinesterase Inhibitors 3 Alzheimer’s Disease

Start and maintain for at least 1 yr.Expect improvement in some, slowed decline in

most, mild psychotropic effectMultiple small trials in DS w AD: generally positive

results but evidence of efficacy not yet convincing (methodology?)

PDD/LBD Expect better response and moderate

psychotropic effect (VH, delusions)No controlled data in DS or ID

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Other Clinical Issues

When to stop? Are they worth the money? Relative contraindications: PUD,

bradycardia, syncope, weight loss Off label

Vascular dementia: possible benefit?FTD, EtOH, TBI: No benefitNo controlled data in ID

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Memantine (Namenda)

Effective in monotherapy but better as adjunctive therapy with ChEI

Improves neuronal function Well tolerated Approved for moderate to severe AD Started at 5 mg daily, with weekly

increases of 5 mg a day to 10 mg BID Not proven to be effective in DS w AD

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Case Example 1 Psychiatric consult requested for 62

year old man with Down’s Syndrome Admitted to med-surg unit Yelling for 6 weeks. Consult request: “Help with yelling.

Dementia getting worse.” Patient kept in room down hallway with

two doors to reduce disruptions from loud patients.

Case Example 2 82 year old woman in SNF with large right

frontal CVA three years ago Consult requested because of months of

intense crying episodes unresponsive to multiple trials of antidepressants

Cried with ADL care but also loud sobs and long periods of wakefulness at night

Exam: L hemiparesis w/contractures, marked abulia and apathy, but could make eye contact and show gentle smile

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Behavioral Symptoms ADLloyd et al. J. Geriatric Psychiatry Neuro 8:4:213-216, 1995

Symptom Mild (%) Mod (%) Severe (%) Total (%)

Delusions 12 25 31 22

Hallucinations 12 15 8 10

Agitation 47 55 85 60

Dysphoria 12 45 62 38

Anxiety 24 65 54 48

Euphoria 18 0 8 8

Apathy 47 80 92 72

Disinhibition 35 40 31 36

Irritability 35 40 54 42

Restlessness 12 30 84 38

Agitation

Can be due to anything causing distress R/O urinary retention, impaction, pain Consider the environment/interpesonal May be due to primary or secondary

psychiatric disorders But, dysphoric irritability is also a

primary symptom of neurodegeneration

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Other Sources of Agitation

Environmental Interpersonal Neurological Psychological

Chaotic Can’t hear Overreact Dysphoric

Complex Can’t understand

Underreact Anxious

Noisy Can’t see Forget Bored

Glare Disrespected Slow processing Feel useless & out of place

Cold/hot Rushed Dyspraxia Has agenda

Symptom Review

• MOMS– mobility, output, memory, senses

• AND– aches, neuro, delirium/delusions

• DADS– depression, appetite, dermis, sleep

Analegesics:Percentage of NH Residents With Dementia Receiving Analgesics

None Mild Moderate Severe

Non-opioid prescribed

68.2 75.0 35.5 28.6

Non-opioid administered

54.3 50.0 22.6 11.6

Opioid prescribed

40.9 4.2 6.5 7.1

Opioid administered

36.4 4.2 3.2 7.1

Sources of Pain

Obvious: arthritis, spondylosis, GERD, known injury or infection, headache, neuropathy, pressure ulcers, skin tears, joint deformities, compression fractures, shingles, fibromyalgia

Subtle: contractures, pressure points, immobility, dental and periodontal, constipation, urinary retention, unknown injury, tight clothes, ear infection

AGS Guidelines in Mild Dementia Generally able to reliably report pain but

less reliable in people with low IQ Pose questions in present tense Use various terms for pain, discomfort,

hurt, uncomfortable, etc. Use frequent direct questioning Multidimensional pain instrument may

be helpful but not necessary

APS and AGS in Severe Dementia Recommend using a validated pain scales for

cognitive impaired or nonverbal patientsScales are based on observation of behavior and

expressionScales have limitations (false + and -)Verbal scales may be best in this group6

In DS w AD: Note recent changes in vocalizations, facial expression, body posture and movement patterns, agitation with ADL care

Physiologic clues of distress may be only clue: increased breathing or heart rate, increased BP

Behavioral Clues

Facial expressions and affect Verbalizations/vocalizations Irritability and agitation Postural guarding Restlessness Withdrawn Anorexic Insomnia

Suggested Scalescontent validity

construct validity

reliability Practi-cality

Global score

PACSLAC

100 67 92 90 87

Abbey Scale

81 61 56 93 73

DOLO-PLUS

78 53 56 73 65

PADE 56 67 82 53 64

PAINAD 78 50 49 77 63

Numbers are percentages.

Discriminant validityZwakhalen, S., Hamers, J. & Berger, M. (2007). Journal of Advanced Nursing, 58(5), 493-502.

PADEVillanueva M et al. JAMDA 2003; 4:1:9-15

24 items Facial expression ADLs Caregiver’s judgment of pain Good reliability and validity 5-10 minutes to administer

Agitated Behavior and PainHusebo BS et al. Am J Ger Psych 2013; in Press

Controlled trial of pain intervention 352 patients in Norwegian NHs Dementia and moderate to severe pain All patients in intervention group

received scheduled analgesics in stepwise approach

CMAI factor analysis:Verbal agitation showed greatest reductionAggressive behaviors declined

CMAI Scores: Cohen-Mansfield Agitation Scale scores for verbal agitation

Most Common Behaviors in Cohen-Mansfield Study:

General restlessness Constant requests for attention Pacing Complaining Repetitiveness Cursing Oppositional behavior

Scheduled Analgesic Trial for Agitation Topical agents, lidocaine skin patch Avoid NSAIDs, muscle relaxants Acetaminophen 325-1000 mg TID or QID

(max. 3000 mg/day) Gabapentin 100-800 mg BID or TID Tramadol 25-50 mg BID or TID Opioid analgesics

Hydrocodone 2.5-5 mg Q4-6 hrs.Oxycodone 2.5-5 mg Q 6 hrs.Hydromorphone 1-2 mg Q 4-6 hrs.Methadone 2.5 mg Q 8-12 hrs.

Opioid Concerns Real

Opioid naïve patients may have strong reactions: over-sedation or delirium

ConstipationToleranceDiversion

MythologicalAddictionDementia: Opioids may increase confusion

initially, but cognitive tolerance develops quickly and correlates with sedation

Case Example 1

Quick exam revealed tender, distended abdomen

Abdominal X-ray confirmed obstipation A wonderful nurse volunteered, did the

work and the yelling stopped

Case Example 2

Crying not due to depression but stroke-related affect dysregulation

But crying likely due to distress:Pain from contractures and immobilityAnxiety during the night

Interventions:Scheduled analgesiaNighttime medication for anxiety and sleepEnvironmental and comfort measures

Aggression

If due to agitation or delusions, treat with appropriate medications

If episodic, requires root cause analysis to identify triggers

Stimulus and response need to be modified

Medications do not work well for episodic aggression

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Pacing and Wandering

Consider trials of meds for anxiety, akathisia, pain, RLS

May be “agenda-driven”, such as looking for something

May be frontal hyperactivity (ADHD) May be tardive akathisia Need exercise and safe and secure

surroundings May be a terminal sign

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Sexual Disinhibition

Consider mania (especially in women) Consider legitimate need for intimacy If stimulus bound (eg breast grabbing),

isolate from stimulus If driven by libido, medroxyprgesterone

can be tried (case reports and small case series)

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Apathy

Majority of patients with dementia Not depression Impoverished thinking Patients are quiet, placid, withdrawn No initiative, reluctant to shower “Ghosts”….spouses feel lonely Occasionally responds to stimulants, ChEI

and memantine

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Hallucinations

Visual: optimize vision, keep nightlights on, cholinesterase inhibitors and low dose quetiapine if Lewy Body or PDD

Auditory: optimize hearing, mask with “white noise”

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Sundowning

Circadian delirium with no effective treatment

Suggestions:Midday nap?Music?Structured activities?Enhance exposure to bright light in AM?Cholinesterase inhibitor?Decrease stimulation?Trials of low dose antipsychotic midday?

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Sleep Disorders

Nighttime insomnia: Modest effect: daytime activity, enhanced light

exposure, melatonin augmentationMore effective: trazodone, quetiapine, analgesia

Daytime sleepiness: R/O obstructive apnea, reduce sedating meds, increase daytime activity

REM Behavior Disorder: clonazepam, melatonin, cholinesterase inhibitor

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Psychotropics for Agitation Antipsychotics

Use when delusions presentMost evidence for efficacy in general dementia

populationNo data in ID dementia (fair quality data in

younger ID people with aggressive behaviors) Antidepressants (esp. SSRIs)

Use for irritability, anxiety, dysphoria Antiepileptics (caution) Benzodiazepines (caution)

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All psychotropics nearly double mortality risk. Sedation and lethargy = falls, aspiration and death

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Targeting Psychotropics

Mood Stabilizer Antidepressant

Antipsychotic

delusionshallucinations

impulsivityhyperactivity

physical aggression

agitation

anxietydysphoria

Analgesic:restlesscalling outgrimacingcombative

ChI:apathyhallucinationsmisperceptionsconfusioninattention

Trazodone,Sed/Hyp:insomniairritability

Clonazepam:REM sleep behavior

Stimulants:apathysleepiness

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Comfort Measures Music Snacks and drinks Scheduled toileting Low stimulation 1:1 activities: reading, singing, hand

massage, games, etc.

Resources

National Task Group on Intellectual Disabilities and Dementia Practices www.aadmd.org/ntg

Alzheimer’s Disease Education and Referral Center www.nia.nih.gov/Alzheimer’s

Family Caregiver Alliance www.caregiver.org

Alzheimer’s Foundation of America http://www.alzfdn.org

Nameste End of Life Dementia Care http://namastecare.com

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References

Herrman N and Gauthier S. Diagnosis and Management of Dementia: Management of Severe Dementia. CMAJ 2008; 179:2:1279-87

Hogan DB et al. Diagnosis and Management of Dementia: Nonpharmacologic and pharmacologic therapy for mild to moderate dementia. CMAJ 2008; 179:10:1019-26

Hogan DB et al. Diagnosis and treatment of dementia: Approach to management of mild to moderate dementia. CMAJ 2008; 179:8: 787-93

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References Sadowsky CH and Galvin JE. Guidelines for the

management of cognitive and behavioral problems in Dementia. JABFM 2012; 25:3:350-366

Stanton LR and Coetzee RH. Down’s Syndrome and Dementia. Adv Psychiatric Treatment 2004; 10:50-8

Steinberg M and Lyketsos. Atypical antipsychotic use in patients with dementia: Managing safety concerns. Am J Psychiatry 2012; 169:9:900-906

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