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Geriatric Population. The 3 D’s Geriatric Dementia, Delirium & Depression

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Cognitive Disorders

Geriatric DementiaDeliriumDepression The 3 Ds

Michelle peck & CompanyMichelle Peck, MSN, MPH, ANP-BC, GNP-BC, CLNCNurse Practitioner | Nursing Faculty | Legal NurseWEB nursepeck.com

1Lets discussDifference between geriatric dementia, delirium and depression

Impact of dementia and the importance of a quality diagnosis

Dementia assessment and treatment

2comprehensionDEMENTIAThe term dementia describes a syndrome

Chronic and progressive brain disease

Affects higher cortical functions memorylanguagejudgment learning capacitythinkingorientationcalculationBereczki D, Szatmri S, 2009. 3

DELIRIUMCholinergic/dopaminergic excessCascade of eventsComplicates hospitalizations Is a medical emergency

Durso, S. C., et al. (2010).Sometimes preventable by minimizing medication use and adequate hydration

DELIRIUMGlutamateActivationGABA ActivationReduced GABA ActivityCholinergic InhibitionDopamine Activation Cytokine ExcessSerotonin ActivationSerotonin DeficiencyCortisol ExcessHepatic Failure &Alcohol WithdrawalBenzos & Hepatic Failure Benzos & ETOH WithdrawalMedicationsSurgical &Medical Illness Cholinergic Activation MedicationsAlcoholWithdrawalMedicationsSubstance WithdrawalGlucocorticoidsStrokeSurgery Surgical &Medical Illness Medications Stroke 5DELIRIUMManagement requires recognition of the deliriumhttp://www.gerisage.com/modules/delirium_module/index.htm

https://www.youtube.com/watch?v=zv38U8SNJFs

http://www.youtube.com/watch?v=jZ_-13ww9hM&feature=youtu.be

Reversible FactorsDrugsElectrolyte imbalance Lack of drugs InfectionReduced sensory inputIntracranial Urinary retention/fecal impactionMyocardial/PulmonaryFeatureDeliriumDementiaTeaching OnsetSuddenInsidiousKnow BaselineAttention ConcentrationDisorderedNormalExcept in advanced dementia

CourseFluctuatesStableNeed to know baseline and mental status evaluationHallucinationsUsually VisualOften AbsentRequires attention to mental status evaluation Involuntary MovementsTremorPickingAsterixisUsually AbsentAttentive observation requiredDementia vs. Delirium

DEPRESSIONTwo simple questions effectively screen:Over the past 2 weeks, have you felt down, depressed or hopeless?Have you experienced a loss of interest or pleasure in most things?

https://www.youtube.com/watch?v=1XSPsWQAWGI DepressionSupportive treatmentCounseling, relief of lonelinessTreat physical symptoms and painAddress anxiety, financial, dependencyConsider stopping contributory drugsPsychotherapy effective as antidepressants Cognitive-behavioral therapy

Public Health PriorityDEMENTIAWorld Health OrganizationIMPACT35.6 million with dementia

Nearly doubles every 20 years

Alzheimers in the USA will ALMOST TRIPLE BY 2050

World Alzheimer Report 2011. 1228 million of the worlds 35.6 million people with dementia have yet to receive a diagnosis

World Alzheimer Report 2011. 13A Quality Dementia Diagnosis Changes Everything

Annual dementia care costs $32,865 per person

With a quality dementia diagnosis annual dementia cost decreases to $5,000 per person

Improved health & quality of life even more cost-effectiveImpact of a Quality Dementia DiagnosisWorld Alzheimer Report 2011. 15

Earlier diagnosis allows people with dementia toplan ahead while they still have the capacity, receive timely practical information, advice and support

get access to available drug and non-drug therapies

participate in research for the benefit of future generations

World Alzheimer Report 2011. 167.7 million new cases yearly.New case of dementia every? A. 18 minutesB. 23 hoursC. 4 seconds D. 23 minutesE. 30 seconds

C. NEW CASE OF DEMENTIA EVERY 4 seconds 17

Worlds 18th largest economyDEMENTIA

de Vugt ME, Verhey F, 2013.If dementia care were a country, it would be the worlds 18th largest economy.18

Dementia Costs More Than 1% Gross Domestic Product Borson, S. et al., 2013.The worldwide costs of dementia exceeded 1% of global GDP in 2010, at US$604 billion. If dementia were a company, it would be the worlds largest by annual revenue exceeding Wal-Mart (US$414 billion) and Exxon Mobil (US$311 billion).19

RISKAgeFamily history and geneticsPsychiatric disordersCardiovascular disease related factorsHead traumaAlcohol, drugs & toxinsVasculitis, Endocrine & Infectious disorders Neoplastic & Respiratory disordersBrain lesions, normal pressure hydrocephalusFillit HM, et al., 2010. & Patterson C, et al., 2007. Age is the most potent risk factor. AD 40 years to 90 years for diagnosis. In familial AD onset is in the 30s is not unheard of. FTD typically with onset younger than 65.Family history and genetics young onset more often associated with strong family history with autosomal dominance. FTP are more likely to have family history. In AD mutations of the presenilin-1 gene predominate in patients who are less than 60. Occasionally families with late onset dementia occur.Gender men more likely to have vascular, dementia with Lewy bodies and women more likely to have AD. Gender influences behavior and hormonal levels which could influence dementia risk. Psychiatric disorders - In several studies depression precedes dementia. Psychosis visual hallucinations part of core criteria for lewy bodies and common in PD can precede dementia. Delusions notably paranoia common in AD. Impaired insight and judgment spectrum of symptoms in FTD and vascular. CV HTN, DM, smoking, hyperlipidemia increase risk of late life dementia.Educational attainment and physical activity level have been associated with dementia risk.Head trauma factor for late life dementia.Direct effects of alcohol on CNS can produce syndromes such as Wernicke encephalopathy (nystagmus, restricted EOM, ataxia) and Korsakoff syndrome (persistent executive and memory dysfunction). Medications have been associated with chronic cognitive impairment (corticosteroids, anticholinergic medications, benzodiazepines, psychiatric medications, antiepileptic's, etc.)Toxins like aluminum, mercury, bismuth, lead, pesticides, copper, and zinc. Vasculitis can cause dementia through ischemic damage.Thyroid, parathyroid, adrenal disorders are associated with chronic cognitive impairment. Diabetes may lead to cognitive dysfunction with or without CV events. 20Mild Cognitive ImpairmentNOT the result of normal agingForgetfulness is hallmark symptomSometimes called a transitional phase Conversion rate 2 - 15% per yearUp to 80% conversion at 6 years

Fillit HM, et al., 2010. 21MAJOR DEMENTIA TYPESAD Alzheimers disease VaD Vascular dementia FTD Frontotemporal dementia PDD Parkinsons disease dementia DLB Dementia with Lewy bodies

Others: SD Semantic dementia, Progressive nonfluent aphasia, etc.22Neuropsychological Domains Premorbid ability: review of educational, occupation

Verbal memory: verbal and memory learning tests

Visual memory: visual reproduction, figure drawing

Simple attention: digit span

Language: animal naming, oral word association test

Executive function: card sort test, similarities

Visuospatial: digit symbol test, clock drawing

Motor: finger tapping

Cognitive screening: MMSE, SLUMS, MoCA, etc.

Fillit, H. M., et al. (2010). 23Other DomainsFunctionKatz Index of Activities of Daily Living ADL Lawton Instrumental Activities of Daily Living Scale IADLGet-up and go

Caregiver Input

Depression Hamilton Depression Rating Scale HDRSGeriatric Depression Scale GDS

Fillit HM, et al., 2010.24DIAGNOSTICLaboratoryCBC, CMP, Thyroid, B12, Folate, CRP, RPR, Lipids, HIV, SED rate, etc.May need to rule out delirium urine sample, blood cultures, chest x-ray, CSF

NeuroimagingMRI or CT - Choice depends on availability, cost, patient acceptability, contraindicationMRI is preferred. SPECT & PET scanning, Pittsburgh Compound-B ligand for PET

Fillit HM, et al., 2010.Imaging rules out subdural hematoma, NPHRules in cortical and subcortical infarcts and white matter changes, localized atrophyExample: atrophy of the hippocampus and medical temporal lobe is an early and sensitive marker for AD; atrophy of the frontal and anterior temporal lobe may be seen in FTD25Reports of progressive change in cognition or ADLClinical assessmentIs cognitive impairment confirmed on formal testing?Is ADL impairedIs onset relatively sudden with disturbed attention? Investigations, including neuroimagingIs a non-vascular etiology for dementia identified?Is a vascular etiology for dementia identified?Is parkinsonism, visual hallucinations or fluctuating cognition present?Is presentation with isolated language and/or executive deficits?Is episodic memory deficit prominent? Consider depression, anxiety, normal agingNONOMild Cognitive ImpairmentYESDeliriumIs cognitive impairment persistent despite appropriate treatment YESYESToxic, NPH, tumor, Huntington, head injury, MS, HIV, Neurosyphilis, CJD, metabolic thyroid, B12 deficiencyYESVascular dementia, SDH, vasculitisYESDementia with Lewy bodies, Parkinsons disease dementiaYESFrontotemporal dementiaYESAlzheimers diseaseDiagnostic Process Fillit HM, et al., 2010.26Alzheimers DiseaseMost prevalent 60%-80% of US dementias

Mayo Clinic: There are five stages associated with Alzheimer's disease: preclinical Alzheimer's disease, mild cognitive impairment, mild dementia due to Alzheimer's, moderate dementia due to Alzheimer's and severe dementia due to Alzheimer's. Dementia describes a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning.

Rate of progression through Alzheimer's stagesThe rate of progression for Alzheimer's disease varies widely. On average, people with Alzheimer's disease live eight to 10 years after diagnosis, but some survive as long as 25 years. Pneumonia is a common cause of death because impaired swallowing allows food or beverages to enter the lungs, where an infection can begin. Other common causes of death include complications from urinary tract infections and falls.

27Alzheimers DiseaseImpairment in memoryFunctional impairment social or vocationalAnd impairment in one other cognitive areaAgnosia - impaired ability recognize objects Aphasia - language disturbances in expressing, understanding Apraxia - inability to carry out motor activitiesAttentionExecutive functionVisuospatial ability

Other criteria: Progression is insidious and other diseases that could cause cognitive decline have been ruled out, diagnosis is primarily based on clinical judgment. Fillit HM, et al., 2010.28AD - Damage to plaque and neurofibrillary tangles, synapse loss, atrophy starts medial temporal lobe

temporal lobe SIGNS AND SYMPTOMSUnderstanding LanguageProcessing Auditory InformationOrganizing InformationMemory Learning29Jill, 86 yo Caucasian female, completed some collegeADLs: Independent in eating & transferIADLs: Dependent in ALLGDS: 4/15, negativeLabs: not remarkableBrain Imaging: Diffuse atrophyPMH: HTN, DM II, CADPhysical Exam: Confabulates

Increasingly more forgetful for the past 6 months30

31On Autopsy the average Alzheimers brain weighs about ___the weight of the normal brain?Two thirds One fifthThree timesThe sameOne sixth

A. Two thirds

32Vascular DementiaSecond most prevalent dementia 1/3

Also know as multi-infarct dementia

The brain has multiple vascular lesions in the cortex and subcortical areas, sometimes called small strokesMemory loss most common complaint

The cognitive changes that occur are directly related to the location of the lesions

Working memory more likely to be impaired more than delayed recall

Fillit HM, et al., 2010.33

Vascular DementiaCued recall recognition previously learned material generally intactExecutive dysfunction more commonly reported than in AD

Depression common

Fillit HM, et al., 2010.34John, 66 yo Caucasian male, RETIRED engineerADLs: Independent in ALLIADLs: Dependent in ALLGDS: 3/15, negativeLabs: ESRDPMH: Insulin dependent since childhoodPhysical Exam: gait imbalance, due worsening vision/peripheral neuropathy

Reports he trusts his wife to make all his decisions as he no longer can, I do whatever she wants35Johns MRIMRI Brain:Small punctate acute ischemic lesion in the right hippocampus, diffuse extensive chronic white matter microvascular ischemic changes and volume loss advanced for age.

Over the years, three main ideas of hippocampal function have dominated the literature: inhibition, memory, and space.

36

37Frontotemporal Dementia

frontal lobe SIGNS & SYMPTOMSPlanning/ReasoningProblem SolvingRecognizingRegulating EmotionSocial Skills38

Parkinsons DementiaParkinsons affects the extrapyramidal systemUsually diagnosed 50-60sSubstantia nigra approximately 50% reduction neuronsMay develop in 20-40% Parkinsons patientsMotor symptoms precede dementia by at least 1 year

Depression occurs up to 50% of PDFillit HM, et al., 2010.39

Parkinsons DementiaIMPAIRMENTS: AttentionExecutive function Visuospatial functionInsidious onset, variable rates of progressionEpisodic memory deficits milder than in PDProblems more retrieval than encoding/storage

Fillit HM, et al., 2010.40Dementia with Lewy BodiesThe form of dementia that has both cognitive impairment with extrapyramidal signsDLB dangerous sensitivity to neuroleptic medicationsDecreased dopamine transporter binding Motor symptoms occur no more than a year before then onset of dementia and frequently after the dementia DLB Symptoms:fluctuating cognition, Parkinson-like symptoms and visual hallucinations, other symptoms may include REM sleep disorders, and frequent falls.Fillit HM, et al., 2010.Extrapyramidal syndrome (EPS) is due to the blockade of dopamine receptors in the basal ganglia, leading to Parkinson-like symptoms such as slow movement (bradykinesia), stiffness, and tremor.41Functional Assessment Staging (FAST)Stage 1 Normal adult. No functional decline. Stage 2 Normal older adult. Personal awareness of some functional decline. Stage 3 Early AD. Noticeable deficits in demanding job situations. Stage 4 Mild AD. Requires assistance in complicated tasks such as handling finances, planning parties, etc.

Stage 5 Moderate AD. Requires assistance in choosing proper attire. Stage 6 Moderately Severe AD. Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence. Stage 7 Severe AD. Speech ability declines to about a half-dozen intelligible words. Progressive loss of the ability to walk, sit-up, smile, and hold head up.42What is Jills FAST STAGE?ADLs: Independent in eating & transferIADLs: Dependent in ALLGDS: 4/15, negativeLabs: not remarkableBrain Imaging: Diffuse atrophyPMH: HTN, DM II, CADPhysical Exam: ConfabulatesSLUMS 3/30

43

WHAT IS JILLS FAST STAGE?Stage 1Stage 2Stage 3Stage 4Stage 5Stage 6Stage 7

F. Stage 6

44maintaining reestablishing independenceImproving andstabilizing cognitive ability and moodTREATMENT GOALS effective future planning symptom managementorientating redirectingpharmacologic therapiesdaily caresafety as neededFillit HM, et al., 2010 & Bereczki D, Szatmri S, 2009. caregiver interventions nonpharmacologic promoting autonomy45

TREATMENTConsiderable variation in clinical practice regarding pharmacological treatment of dementiasBereczki D, Szatmri S, 2009. 46Dementia Key FindingsMost people with early stage dementia wish to be told of their diagnosis

Improving the likelihood of earlier diagnosis:medical practice-based educational programs, introduction of accessible dementia care services, promoting effective interaction in the health system

Early therapeutic interventions:improving cognitive function, treating depression, improving caregiver mood, delaying institutionalizationWorld Alzheimer Report 2011 47Tips cognitively impairedReduce environmental distractionsApproach from the front, make eye contact, address person by name, speak in calm voiceTo reduce sense of threat, talk first, then touchAvoid verbal testing or questioning beyond the persons abilityDo not argue or insist they accept your reality

ReferencesBereczki D, Szatmri S. Treatment of dementia and cognitive impairment: What can we learn from the Cochrane library. J Neurol Sci [Internet]. 2009 8/15;283(12):207-10.

Borson S, Frank L, Bayley PJ, Boustani M, Dean M, Lin P, McCarten JR, Morris JC, Salmon DP, Schmitt FA, Stefanacci RG, Mendiondo MS, Peschin S, Hall EJ, Fillit H, Ashford JW. Improving dementia care: The role of screening and detection of cognitive impairment. Alzheimer's & Dementia [Internet]. 2013 3;9(2):151-9.

de Vugt ME, Verhey FRJ. The impact of early dementia diagnosis and intervention on informal caregivers. Prog Neurobiol [Internet]. 2013 In Press.

Durso, S. C., Bowker, L. K., Price, J. D., & Smith, S. C. (Eds.). (2010). Oxford American handbook of geriatric medicine (First ed.). New York, New York: Oxford University Press Inc.

49ReferencesFillit HM, Rockwood K, Woodhouse K. The nervous system In: Brocklehurst's textbook of geriatric medicine and gerontology. 7th ed. Philadelphia: Elsevier; 2010; p. 385-432.

Patterson C, Feightner J, Garcia A, MacKnight C. General risk factors for dementia: A systematic evidence review. Alzheimer's & Dementia [Internet]. 2007 10;3(4):341-7.

Rozzini, R., & Trabucchi, M. (2012). Depressive symptoms, their management, and mortality in elderly people. Journal of the American Geriatrics Society, 60(5), 989-990. Retrieved from SCOPUS database.

Wimo A, Jnsson L, Bond J, Prince M, Winblad B. The worldwide economic impact of dementia 2010. Alzheimer's & Dementia [Internet]. 2013 1;9(1):1,11.e3

Special Thank You: Department of Veterans Affairs, Saint Louis University, SLUMS Examination. World Alzheimer Report 2009 & 2011. Thank You Learn it - Live it - Love it Your path for a more informed Life!Nursepeck.com

Chart1600410310

US$ BILLIONS100 BILLION US DOLLARS

Sheet1US$ BILLIONSDEMENTIA600WAL-MART410EXXON MOBIL310To resize chart data range, drag lower right corner of range.

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