OHSU DIFFERENTIATING DEMENTIA · 2019. 3. 14. · BILL 82 year old man that has recently moved to...

DIFFERENTIATING DEMENTIADEMENTIA FOR PRIMARY CARE

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OBJECTIVES

Define dementia and mild cognitive impairment

Identify and differentiate the 5 most common types of dementia

Explore key elements to diagnosis and treatment of dementia

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BILL82 year old man that has recently moved to assisted living since his wife died

3 months ago.

His daughter has noticed increasing“forgetfulness” in the past 2-3 years, which has gotten worse since his wife died. Bill has good days and bad days, but his family notices he has been neglecting his appearance recently.

He is still very sad about the loss of his wife and perseverates on the loss. No agitation, 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.

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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)

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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

Rule out delirium, depression, etc

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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)

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6 TYPES OF DEMENTIA

Alzheimer’s

Vascular

Lewy Body

Frontotemporal

Alcohol related

HIV Associated

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DEMENTIA

45%

15%

20%

15%5%

Alzheimers Vascular Mixed LBD FTD

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DEFINING THE DEMENTIASOHSU

ALZHEIMER’S DEMENTIA

Impairment in learning and memory plus one:

Complex attention

Executive function

Language

Visuo-constructional-perceptual ability

Social cognition

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VASCULAR DEMENTIA

New cognitive deficit +

Focal neurological signs and symptoms +/-Brain imaging evidence of cerebrovascular

disease

Judged to be temporally related to the dementia

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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

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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

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LBD – SUGGESTIVE FINDINGS

REM sleep disorders

Severe antipsychotic sensitivity:Exaggerated extrapyramidal symptoms

Increased rigidity and bradykinesia

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FRONTOTEMPORAL DEMENTIA

A TALE OF 2 DEMENTIASOHSU


Behavioral variant

Decline in personal or social interpersonal conduct

Impaired reasoning and difficulty with tasks out of proportion to impairments in memory

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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)

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ALCOHOL RELATED DEMENTIA

Alcohol misuse may lead to brain damage through:

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

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ALCOHOL RELATED DEMENTIALearning 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

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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

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CLINICAL CLUES HOW TO DIFFERENTIATE DEMENTIASOHSU

HISTORY/ONSET

Alzheimer’s Vascularmixed

Lewy Body FTD

Gradually progressive over years

Stepwise decline +/-progressive decline between steps

Delirium-likefluctuations in cognition

Early visual hallucinations

Insidious personality, behavioral, or language changes

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MEMORY


Lewy Body FTD

Short term memory loss early

Difficulty learning and retaining new information

Short term memory lossearly

More difficulty with retrieval of memories than storage

Short term memory may not be impacted until later in disease course

Short term memory not impacted until very late in disease course

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VISUOSPATIAL


Lewy Body FTD

Gradualprogressive decline

Depends on location of lesion

Prominent early impairment

Minimalimpairment OHSU

EXECUTIVE FUNCTION


Lewy Body FTD



Prominent early impairment

Depends on FTD sub-type

Behavioral subtype is very impaired early on

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LANGUAGE


Lewy Body FTD

Decreased verbal fluency due to word finding difficulties early on

Depends on location of lesion

Noted slowing– decrease in verbal speed


Aphasic subtype is very impaired early on

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MOTOR FUNCTION


Lewy Body FTD

Parkinsonism very late in course

Depends on location of lesion – may have vascular parkinsonism early on

Early parkinsonism -RigidityBradykinesiaGait issuesHypophonia


Behavioral subtype is very impaired early on

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3 months ago.

His daughter has noticed increasing “forgetfulness” in the past 2-3 years, which has gotten worse since his wife died. Bill has good days and bad days, but his family notices he has been neglecting his appearance recently.



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QUICK MEMORY SCREEN

Mini Cog

3 item recal

Clock draw

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Validated for diagnosis of dementia AND MCI

Tests 5 brain domainsOHSU

Validated for diagnosis of dementia AND MCI

Tests 6 brain domains

Helps assess driving ability

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MMSE(PROPRIETARY- $1.68/USE)

Tests 4 brain domains:

Orientation

Memory

Visual-spatial

Verbal fluency

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PHYSICAL EXAM

Neurologic Exam:

Sensory, Reflexes, Strength, Motor Coordination

E/o Parkinsonism?

Gait assessment: Timed Get up and Go

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LAB STUDIES

TSH

Vitamin B12 (MMA) Consider HIV and RPR

If none recently: CBC and metabolic panel

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NEUROIMAGING

Non contrast CT scan or MRIFor 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

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3 months ago.

His daughter has noticed increasing “forgetfulness” in the past 2-3 years, which has gotten worse since his wife died. Bill has good days and bad days, but his family notices he has been neglecting his appearance recently.



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BILLSLUMS Orientation 3/3Calculation 1/3Naming 2/3Object Recall 3/5Attention 1/2Clock 0/4Shapes 2/2Story Recall 4/8Total 16/30

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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

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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

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STAGING DEMENTIA

Mild

MoCA 20-16Starting to see behavioral symptoms

Moderate

MoCA 15-10 Increasing behavioral symptoms

Advanced

MoCA <10Needing 24 hour care

End stage

FAST staging for hospice care

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A REVIEW OF REVIEWS – WHAT WORKS?

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

ExercisePatient+Caregiver QOL interventionsAChE-IMemantineOHSU

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

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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. OHSU

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

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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

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MILD DEMENTIA


Lewy Body FTD

Trial AChE-I Controlvascular risk factors

Trial AChE-I

Trial AChE-I

PT/OT

Driving and safetyassessment

(NO AChE-I)

Trialmemantine

Driving andSafetyassessmentExercise

Tai chi Mediterranean dietSocialization

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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

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MODERATE DEMENTIA

AlzheimerSs Vascularmixed

Lewy Body FTD

Trial AChE-ITrial memantine

Controlvascular risk factors

Trial AChE-ITrial memantine

Trial AChE-ITrialmemantine

TrialmemantineOHSU

MODERATE DEMENTIA

Conversations with patient and family:

What is our safety plan?

Neuropsychiatric symptoms

Yes and… approach to communication

Memory care options

POLST

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ADVANCED DEMENTIA


Lewy Body FTD

Considerstopping AChE-I

Trial memantine

Controlvascular risk factors

Consider stopping AChE-I

Trial memantine

Considerstopping AChE-I

Trialmemantine

TrialmemantineOHSU

ADVANCED DEMENTIA

Conversations with caregiver: 24 hour caregiving Planning for end stages

Loss of verbal interactionLoss of mobilityIncontinenceDysphagiaWeight loss

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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 memantinemonotherapies 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.

Raina, P, et al. Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review for a Clinical Practice Guideline. Ann intern Med. 2008;148: 379-397.

Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr. 2009;21(5):813–24.

Stinton, et al. Pharmacological Management of Lewy Body Dementia: A Systematic Review and Meta-Analysis. Am J Psychiatry. 2015 Aug 1; 172(8): 731–742. Published online 2015 Jun 18. doi: 10.1176/appi.ajp.2015.14121582.

Wang H, Yu J, Tang S, et al. Efficacy and safety of cholinesterase inhibitors and memantine in cognitive impairment in Parkinson's disease, Parkinson's disease dementia, and dementia with Lewy bodies: systematic review with meta-analysis and trial sequential analysis. J Neurol Neurosurg Psychiatry 2015;86:135-143.

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QUESTIONS???

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OHSU DIFFERENTIATING DEMENTIA · 2019. 3. 14. · BILL 82 year old man that has recently moved to...

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