Co-morbidity in the Co-morbidity in the Memory ClinicMemory Clinic

David Jolley May 2010David Jolley May 2010

Multiple pathology

Co-morbidities

• Dementia + physical (+ therapy)

• Dementia + mental (+ therapy)

• Dementia + physical + mental (+ therapy)

Influences

• Co-morbidities or their treatment may influence the development, course and/or outcome of dementia

• The presence and progress of dementia or its treatment may influence the development, course and/or outcome of other pathologies

Profile of pathologies and medication

• 69% 0f people 65 years + have 2 or more pathologies (Hoffman et al 1996)

• Prescriptions CVS 72%, CNS 37%, Musc/Sk 28%, Upper GI 24%, Resp 14%, Diabetes, Glaucoma, Thyroid 5-8% Naughton et al 2006)

• Dementia (known) Primary care average 2 – 3 other conditions, 5 medicines – half with anticholinergic activity (schubert et al 2006)

Some medication is unnecessary

• Review of medication can reduce prescriptions: Williams et al 2004 succeeded in reduces medication by 1-2 per individual. No change in function/symptoms. Cost savings $30.00 per month. Much resistance

• Barton et al 2008 Memory Clinic

Danger from medicines

• Weigh et al 2009 found that 20% of patients attending a German memory clinic took medicines which affected cognition adversely

• Barton et al 2008 found 22% of Memory Clinic patients were taking medication deemed inappropriate using Beers criteria (benzodiazepines, oxybutinin, amitriptyline, fluoxeteine, diphenhydramine

Grandma’s special

• Dergal et al2002 found that 33 of 195 Memory Clinic patients in Toronto were concurrent users of herbal and similar remedies. A further 19 had experimented with alternative therapies

• Gingko, garlic, glucosamine and echinacea were the most popular choices

Closer to home: what are we Closer to home: what are we like and what’s the outcomelike and what’s the outcome

Morbidity in Penn Memory Clinic 87 patients Morbidity in Penn Memory Clinic 87 patients with Alzheimer’s disease(Sarah Lyle MSc)with Alzheimer’s disease(Sarah Lyle MSc)

Recordings of cardiovascular disease, cerebro-Recordings of cardiovascular disease, cerebro-vascular disease, cancer, hypothyroidism and Vit vascular disease, cancer, hypothyroidism and Vit B12 statusB12 status

Half had no recorded illnessHalf had no recorded illness 31% Cardiovascular31% Cardiovascular 3% Cerebro-vascular3% Cerebro-vascular 3% cancer3% cancer 3% Hypothyroid3% Hypothyroid 31% had low B12 levels31% had low B12 levels

Marital statusMarital status MarriedMarriedWidowedWidowedSingleSingleOtherOther

52 (59)52 (59)33 (38)33 (38)2 (2)2 (2)1 (1)1 (1)

Home situation at referralHome situation at referral Home aloneHome aloneHome and spouseHome and spouseResidential homeResidential homeSheltered housingSheltered housing

31 (36)31 (36)48 (54)48 (54)5 (6)5 (6)2 (2)2 (2)

Physical illnessPhysical illness YesYesNoNo

43 (49)43 (49)44 (51)44 (51)

No. of years from onset of symptoms to No. of years from onset of symptoms to treatmenttreatment

MeanMeans.d.s.d.Min. & MaxMin. & Max

2.742.741.711.711-101-10

On psychotropic medication at baselineOn psychotropic medication at baseline YesYesNoNo

20 (23)20 (23)68 (77)68 (77)

Cognitive (MMSE) score at baselineCognitive (MMSE) score at baseline Mean Mean s.d.s.d.Min. & Max.Min. & Max.

18.7818.785.425.427 - 287 - 28

Mini-mouse at baselineMini-mouse at baseline Mean Mean s.d.s.d.Min. & Max.Min. & Max.

4.36 4.36 3.793.790 - 160 - 16

Carer GHQCarer GHQ Mean Mean s.d.s.d.Min. & Max.Min. & Max.

5.15 5.15 6.016.010 - 280 - 28

Alive at 1/9/02 Alive at 1/9/02 YesYesNoNo

49 (56)49 (56)39 (44)39 (44)

Figure 2. A comparison of cognitive (MMSE) score over a period of 24 months between the survival group who completed 3-year treatment and the rest of the cohort

time scale in 3 months increment

191613107410

95

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mse

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20

10

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Patient Category

The rest

Survived

TABLE 1Variables selected by the logistic regression with an optimal predictive power (74.3%)

Variable Code

Variable Description S.E.Wald Score

SignificanceOf Log LR

SEXANYPHYSBANYPSYMDMMSEB

Gender of patientsAny physical illness at baseline?Any psychotropic medication at baseline?Score of Mini-Mental State Examination at baseline

0.667 0.638

0.719

0.059

2.8436.920

2.180

5.659

0.0920.009

0.140

0.017

TABLE 2Area under ROC curve given by different tests

Type of TestArea

Under ROC curve

Asymptotic 95% Confidence Interval

Lower Bound Upper Bound

Single Variable – SEXSingle Variable – ANYPHYSBSingle Variable – ANYPSYMDSingle Variable – MMSEBTwo Variables –(ANYPHYSB + MMSEB)All Four Variables

0.539

0.613

0.563

0.648

0.759

0.762

0.397

0.474

0.421

0.495

0.630

0.634

0.680

0.752

0.705

0.802

0.888

0.891

ROC Curve

Diagonal segments are produced by ties.

1 - Specificity

1.00.75.50.250.00

Se

nsi

tivity

1.00

.75

.50

.25

0.00

FIGURE 1FIGURE 1 ROC curve for the two most ROC curve for the two most significant variables; ANYPHYSB & MMSEB.significant variables; ANYPHYSB & MMSEB.

Med Care. 2008 Aug;46(8):839-46.Med Care. 2008 Aug;46(8):839-46.Implications of co-morbidity on costsImplications of co-morbidity on costs for patients with for patients with Alzheimer disease.Alzheimer disease.KuoKuo TC TC, , Zhao YZhao Y, , Weir SWeir S, , Kramer MSKramer MS, ,

Ash ASAsh AS..

From review of 600,00 on MedicareFrom review of 600,00 on Medicare AD pts 8.1 co-morbid conditions v 6.5 matched AD pts 8.1 co-morbid conditions v 6.5 matched

controlscontrols Excesses: Mental health, neurol, cerebro-Excesses: Mental health, neurol, cerebro-

vascular, diabetes, acute complics, injuryvascular, diabetes, acute complics, injury Costs + 34%Costs + 34%

BMC Health Serv Res. 2008 May 22;8:108.BMC Health Serv Res. 2008 May 22;8:108.Healthcare costs and utilization for Medicare beneficiaries with Healthcare costs and utilization for Medicare beneficiaries with

Alzheimer'sAlzheimer's..Zhao YZhao Y, , KuoKuo TC TC, , Weir SWeir S, , Kramer MSKramer MS, , Ash ASAsh AS..

Top 10 Reasons for Inpatient Admission by CohortOther and unspecified pneumonia

229 (1)

133 (2)

1.50‡

Femoral (hip) fracture209 (2)

88 (4) 2.32‡

Cystitis, other urinary tract infections161 (3)

42 (13) 3.46‡

Heart failure150 (4)

158 (1)

0.78‡

Disorders of fluid/electrolyte/acid-base balance, e.g., dehydration118 (6)

49 (11) 2.16‡

Septicemia (blood poisoning)/shock118 (7)

14 (39) 2.77‡

Syncope and collapse100 (8)

33 (30) 2.85‡

Aspiration pneumonia100 (9)

18 (16) 5.36‡

Pre-cerebral or cerebral arterial occlusion with infarction84

(10)48 (12) 1.74‡

Coronary atherosclerosis and other chronic ischemic heart disease (CAD)

70 (13)111 (3)

0.53‡

Acute myocardial infarction, initial episode of care 83 (11) 81 (5) 0.92

Atrial arrhythmia 56 (16) 62 (6) 0.83

Osteoarthritis of lower leg (knee) 27 (29) 62 (7) 0.39‡

Gastrointestinal hemorrhage, except peptic ulcer and anal/rectal 78 (12) 55 (9) 1.22‡

Any inpatient admission 3,796 2,4081.55

‡

J Am Geriatr Soc. 1998 Apr;46(4):444-52.J Am Geriatr Soc. 1998 Apr;46(4):444-52.Prognostic factors in very old demented adults: a seven-year follow-up Prognostic factors in very old demented adults: a seven-year follow-up

from a population-based survey in Stockholm.from a population-based survey in Stockholm.Agüero-Torres H, Fratiglioni L, Guo Z, Viitanen M, Winblad B.Agüero-Torres H, Fratiglioni L, Guo Z, Viitanen M, Winblad B.

Follow-up clinical examinations of dementia patients from a Follow-up clinical examinations of dementia patients from a population-based study after 3- and 7-year intervals. SETTING AND population-based study after 3- and 7-year intervals. SETTING AND PARTICIPANTS: In an established population aged 75 years and PARTICIPANTS: In an established population aged 75 years and older in Stockholm, Sweden, there were 133 cases of AD, 52 of older in Stockholm, Sweden, there were 133 cases of AD, 52 of VaD, and 38 of OD. VaD, and 38 of OD.

Older age, male gender, low education, comorbidity, and Older age, male gender, low education, comorbidity, and functional disability predicted shorter 7-year survival in functional disability predicted shorter 7-year survival in the 223 prevalent dementia cases. Other factors, the 223 prevalent dementia cases. Other factors, including type of dementia, dementia severity, and including type of dementia, dementia severity, and duration of the disease were not significant. duration of the disease were not significant.

Am J Geriatr Psychiatry. 2005 Sep;13(9):781-6.Am J Geriatr Psychiatry. 2005 Sep;13(9):781-6.Sensory impairment and cognitive functioning in oldest-old subjects: Sensory impairment and cognitive functioning in oldest-old subjects:

the Leiden 85+ Study.the Leiden 85+ Study.GusseklooGussekloo J J, , de de CraenCraen AJ AJ, , OduberOduber C C, , van van BoxtelBoxtel MP MP, Westendorp RG., Westendorp RG.

Within the Leiden 85+ Study. METHODS: Within this Within the Leiden 85+ Study. METHODS: Within this population-based study of 459 participants aged 85+ population-based study of 459 participants aged 85+ years, hearing impairment was measured by audiometry years, hearing impairment was measured by audiometry and visual impairment by a visual acuity chart, both and visual impairment by a visual acuity chart, both under standardized conditionsunder standardized conditions

Both hearing impairment (prevalence: 85%) and visual Both hearing impairment (prevalence: 85%) and visual impairment (prevalence: 59%) were associated with impairment (prevalence: 59%) were associated with lower scores on the MMSE. Increasing visual impairment lower scores on the MMSE. Increasing visual impairment was associated with poorer scores on memory and was associated with poorer scores on memory and cognitive speed, as measured with visually presented cognitive speed, as measured with visually presented cognitive tests. In contrast, there was no association cognitive tests. In contrast, there was no association between hearing impairment and memory and cognitive between hearing impairment and memory and cognitive speed speed

J Neurol. 2010 Feb;257(2):238-46. Epub 2009 Sep 1.J Neurol. 2010 Feb;257(2):238-46. Epub 2009 Sep 1.Taste in mild cognitive impairment and Alzheimer's disease.Taste in mild cognitive impairment and Alzheimer's disease.

Steinbach S, Hundt W, Vaitl A, Heinrich P, Förster S, Bürger K, Zahnert Steinbach S, Hundt W, Vaitl A, Heinrich P, Förster S, Bürger K, Zahnert T.T.

Prospective study which investigated the quantitative Prospective study which investigated the quantitative and qualitative taste function of patients with mild and qualitative taste function of patients with mild cognitive impairment (MCI) and Alzheimer's disease cognitive impairment (MCI) and Alzheimer's disease (AD). 29 healthy, elderly subjects, 29 MCI and 30 AD (AD). 29 healthy, elderly subjects, 29 MCI and 30 AD patients were tested using a validated taste test, the patients were tested using a validated taste test, the

"taste strips"."taste strips". there was a significant reduction of total taste scores and there was a significant reduction of total taste scores and

also the score for individual tastes on either side of the also the score for individual tastes on either side of the tongue between controls and MCI/AD patients. tongue between controls and MCI/AD patients.

Int Psychogeriatr. 2010 May;22(3):417-25. Dental health of community-Int Psychogeriatr. 2010 May;22(3):417-25. Dental health of community-living older people attending secondary healthcare: a cross-sectional living older people attending secondary healthcare: a cross-sectional comparison between those with and without diagnosed mental illness.comparison between those with and without diagnosed mental illness.

PurandarePurandare N N, , Woods EWoods E, , Butler SButler S, , Morris JMorris J, , Vernon MVernon M, , McCord JFMcCord JF, , Burns ABurns A..

The need for dental treatment was significantly higher The need for dental treatment was significantly higher among the psychiatry group compared to the medical among the psychiatry group compared to the medical group (85% vs 52%; p<0.001); even after taking account group (85% vs 52%; p<0.001); even after taking account of the effect of age, gender, teeth status, physical co-of the effect of age, gender, teeth status, physical co-morbidity, cognition, depressive symptoms, and overall morbidity, cognition, depressive symptoms, and overall mental and social health [adjusted odds ratio, OR (95% mental and social health [adjusted odds ratio, OR (95% confidence interval): 4.32 (2.09, 8.91)]. confidence interval): 4.32 (2.09, 8.91)].

The presence of any natural remaining teeth [OR: 4.44 The presence of any natural remaining teeth [OR: 4.44 (2.10, 9.42)] and Barthel Index [OR: 0.96 (0.93, 0.99)] (2.10, 9.42)] and Barthel Index [OR: 0.96 (0.93, 0.99)] were the two other independent predictors of the need were the two other independent predictors of the need for treatment. for treatment.

Holmes C et al (2009) Systemic Holmes C et al (2009) Systemic inflammation and disease progression in inflammation and disease progression in Alzheimer’s disease. Neurology 73; 768-Alzheimer’s disease. Neurology 73; 768-774774

275 subjects with probable or possible Alz275 subjects with probable or possible Alz Baseline ADAS-COG mean 29.6 (SD 13.0)Baseline ADAS-COG mean 29.6 (SD 13.0) f/u at 2, 4 and 6 monthsf/u at 2, 4 and 6 months Those with episodes of acute inflammation Those with episodes of acute inflammation

(rise in TNF-alpha) rate of cognitive decline x 2(rise in TNF-alpha) rate of cognitive decline x 2 Those with high baseline of TNF-alpha Those with high baseline of TNF-alpha

sustained throughout: rate of decline X4sustained throughout: rate of decline X4 Those with low TNF-alpha throughout no Those with low TNF-alpha throughout no

declinedecline

SummarySummary Multiple pathology is common in older Multiple pathology is common in older

peoplepeople Co-morbidity is at least as common Co-morbidity is at least as common

amongst people with dementia as those amongst people with dementia as those without dementiawithout dementia

The presence of co-morbidity in dementia The presence of co-morbidity in dementia produces difficulties, reduces the likelihood produces difficulties, reduces the likelihood of remaining in therapy, impacts on the of remaining in therapy, impacts on the quality of life, increases use of hospitals quality of life, increases use of hospitals and costs and hastens deathand costs and hastens death

Evidence of inflammatory processes is Evidence of inflammatory processes is associated with more rapid cognitive associated with more rapid cognitive declinedecline

Sensory impairments are associated with Sensory impairments are associated with cognitive declinecognitive decline

Attention to other pathologies and Attention to other pathologies and medication regimes may have multiple medication regimes may have multiple benefits for patients, families and servicesbenefits for patients, families and services