Date post: | 26-Jun-2015 |
Category: |
Health & Medicine |
Upload: | decontee-dr-dee-jimmeh |
View: | 122 times |
Download: | 1 times |
DEMENTIA 101
Decontee “Dr. Dee”Jimmeh, MD
Norwood Clinic/ Brookwood Medical Center
September 30, 2014
OUTLINE Epidemiology Definition/Criteria Clinical Staging Evaluation Associated Symptoms Management
Forgetting has become part of who Daddy is, so I decide to try to honor his forgetfulness. I try to love it. It defines his being these days, and sometimes I feel that to see him I have to look through it, a shuttered window. Underneath the forgetting lie a few remembered things, shoelaces, the way to hold a razor to shave, song-lyrics he recalls, like cockles and mussels- but you have to catch them at the right moment of the day, when they shine through the slats. Daddy is Daddy now because he forgets.-ELIZABETH COHEN The House on Beartown Road: A Memoir of Learning and Forgetting London (p.196-7)
EPIDEMIOLOGY www.alz.org www.youtube.com/watch?v=waeuks1-3
Z4#action=share
DEMENTIA FACTS 6th leading cause of death in the US
More than 5,000,000 are currently living with the disease.
Every 67 seconds, someone develops dementia in the US.
Dementia costs in the US: $220 billion
DEFINITION Dementia: a progressive, NON-reversible
decline in cognitive function that significantly impacts daily activities and social interaction
DSM-IV & DSM-5 CRITERIA
DEMENTIA SIGNS Memory loss that interrupts daily life Challenges in problem-solving and planning Difficulty completing tasks Confusion with time or place Trouble understanding visual images and
spatial relationship New problems with words in speaking or
writing Misplacing things and inability to retrace steps Decreased or poor judgment Withdrawal from work or social activities Changes in mood and personality
STAGES OF DEMENTIA Stage 1 (No impairment)
Normal Stage 2 (Very mild)
Person notices memory lapsesNo symptoms noticed by family, friends or
doctor Stage 3 (Mild)
Family and friends start to observe problemMMSE picks up deficits
Stage 4 (Moderate)Difficulty with calculation, forgetting one’s
own personal history, social withdrawal begins
STAGES OF DEMENTIA Stage 5 (Moderate severe)
Begin needing help with day to day activities Remain independent with eating and toileting
Stage 6 (Severe) Lose awareness of surroundings and need
with most ADLs Major personality issues; Tend to wander and
get lost Stage 7 (Very Severe)
Little to no speech production, rigid muscles, impaired swallowing; Loss of interaction with the environment
TYPES OF DEMENTIA Alzheimer’s (AD)
Vascular dementia
Mixed dementia
Frontotemporal dementia
Dementia with Lewy bodies
Subcortical dementias
http://farmagain.com/braininjury.html
ALZHEIMER’S DEMENTIA Most common type
Onset age: >60 years of age
Accumulation of abnormal proteins (neurofibrillary tangles/ amyloid plaques)
Temporal and parietal lobes heavily affected
Early onset disease associated with chromosome 21
VASCULAR DEMENTIA Also known as multi-infarct dementia
“Step-wise” progression
Diverse clinical presentation
Risk factors: diabetes, hypertension, and high cholesterol
EVALUATION OF DEMENTIA History & Physical
Mini Mental Status Exam
Labs: B12, thyroid function, liver enzymes, ammonia, RPR, glucose
Neuropsychological testing
CT head or brain MRI
MINI MENTAL STATUS EXAM
EVALUATION OF DEMENTIA History & Physical
Mini Mental Status Exam
Labs: B12, thyroid function, liver enzymes, ammonia, RPR, glucose
Neuropsychological testing
CT head or brain MRI
ALZHEIMER’S DEMENTIA MRI
VASCULAR DEMENTIA MRI
TREATMENT There is NO cure for dementia.
Medication options seek to slow disease progressionCholinesterase inhibitors (Donezepil,
Galantamine, Rivastigmine)NMDA receptor antagonist (Memantine)
Other agentsE.g. Fish oil, ginkgo biloba, vitamin ENo definite improvement in clinical trials
NEUROPSYCHIATRIC SYMPTOMMANAGEMENT The mainstay of treatment is symptom
management Examples of symptoms:
DepressionSleep disorderAgitationSexually inappropriate behaviorWanderingFalls
DEPRESSION A dementia mimic Co-morbid illness SSRIs
Citalopram and Sertraline are good choicesParoxetine not ideal (most anticholinergic)Fluoxetine (long ½ life; drug-drug
interactionsStart low and titrate slowly
Atypicals may be of some utilityEffexor, Wellbutrin, Remeron
SLEEP DISORDER Multifactorial
Sleep-wake cycle alterations, decreased daytime physical activity, anxiety/depression, nocturia, and medication side effects
TreatmentAvoid daytime napsDaytime activity/exercise programLimiting evening liquid intakeGo to bed and wake at the same time dailyMedications: Melatonin, Trazadone,
Remeron
AGITATION Typically is a response or reactions to
misperceptions of the environment Precipitating factors:
Confusion because of cognitive, memory, language deficits
Frightening, paranoid delusions or hallucinations
Pain or discomfortDepressionSleep disorderOther medical illness (e.g. UTI, pneumonia)New medications
BEHAVIORAL MANAGEMENT:NON-PHARMACOLOGIC Keep a daily routine Avoid sudden changes in environment Frequent re-orientation Encourage good sleep hygiene Avoid physical restraints Redirection/distraction Use short, clear statements Use calm reassurance; Avoid
reprimanding Music therapy Aromatherapy
BEHAVIORAL MANAGEMENT:PHARMACOLOGIC Drugs to uses:
SSRIs (citalopram)Atypical antipsychotics (quetiapine,
olanzapine, risperidone)
Drugs to avoid:Anti-cholinergic medicationsAnti-histamine medicationsBenzodiazepines
Paradoxical effect
WANDERING All patients are at risk
Common in stage 4 and beyond
Alarms on doors; Noisy garments; proofing locks on cabinets with dangerous or flammable items
SAFE RETURN program www.alz.org/Services/SafeReturn.asp1.800.625.3780
FALLS Major safety issue in the elderly, especially
the demented
Visuo-spatial deficits, muscle stiffness, lossof postural reflexes, and impulsivity increases risk
Avoid clutter in walkways, use of handrails, nonslip mats and other assistive devices
Physical and Occupational Therapy
THE CAREGIVER’S PERSPECTIVE ABC News Report
www.youtube.com/watch?v=LL_Gq7Shc-Y Caregivers’ Support
Resource referralEnd of life planning (legal and financial)Personal respiteCounseling for grief and guilt
SUMMARY Dementia is a slowly progressive condition that affects
cognition and has NO cure.
Alzheimer’s and vascular dementia are the two most common types.
Patients present differently and progress through the various stages at various rates
Mainstay treatment includes non-pharmacologic therapies, along with medicines, that impede progression along with symptom management.
Caregiver support and patient empathy are essential to better outcomes.
THANKS TO SNF/ALF MEETING
??? QUESTIONS??? Follow Dr. Dee
Twitter: @drdeejimmeh Facebook: Decontee “Dr. Dee” Jimmeh, MD
Contact Dr. Dee Brookwood Medical Center, Professional Office
Building, Suite 301 Phone 205-250-6940 Fax 205-250-6942 www.norwoodclinic.com