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DEMENTIACENTRAL AMERICA HEALTH SCIENCE UNIVERSITY, BELIZE18TH NOV 2013INSTRUCTOR : DR. SURYA SUDARSHAN PRESENTER : MAHESH SUNDARAM : SYED ABDUL SAMIE : GIA K.SHARMA

WHAT IS IT :

Dementia Latin word De "without" + ment, means “mind”

Definition: It is a loss of brain function that effects memory, thinking, language, judgement, and behaviour. 

It is a degenerative (non-reversible) condition. This means that the damage done to the brain cannot be treated or stopped.

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GOALS IN DEMENTIA

Evaluation and Diagnosis

Current Therapy for Dementia

Complications

Resources for the Caregivers

Early Symptoms and Warning SignsAs we get older, many of us become more forgetful – for example we As we get older, many of us become more forgetful – for example we might misplace our keys occasionally or find it difficult to find the might misplace our keys occasionally or find it difficult to find the right word to describe something. This is normal and isn’t a cause right word to describe something. This is normal and isn’t a cause for concern.for concern.

It is important to be able to differentiate between these changes It is important to be able to differentiate between these changes and the early warning signs of a more serious condition. These early and the early warning signs of a more serious condition. These early signs can start to develop as much as twenty years before a signs can start to develop as much as twenty years before a diagnosis is made.diagnosis is made.

Research carried out at Stanford University in the USA suggests Research carried out at Stanford University in the USA suggests that a newly developed blood test can identify people most at risk that a newly developed blood test can identify people most at risk from developing DEMENTIA disease up to six years before the from developing DEMENTIA disease up to six years before the symptoms become apparent. symptoms become apparent.

The test measures the levels of a number of proteins in the blood The test measures the levels of a number of proteins in the blood associated with Alzheimer’s.associated with Alzheimer’s.

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Diagnosis Based on memory loss (both short and long-term),

plus one or more of the following: Aphasia – language problems Apraxia – organisational problems Agnosia – unable to recognise objects or tell their

purpose Disturbed executive function – personality and

inhibition

Is it JUST “Old Age?”Signs of Dementia Poor judgment and decision making Inability to manage a budget Losing track of the date or the

season Difficulty having a conversation Misplacing things and being unable

to retrace steps to find them

Typical Age Related Changes

Making a bad decision once in a while Missing a monthly payment Forgetting which day it is and

remembering later Sometimes forgetting which word to use Losing things from time to time.

Types of Dementia

Alzheimer’s – Most common , Memory, Language, Visuospatial, Indifferent to Loss

Lewy Body – second most common (vivid hallucinations), Visual hallucinations, delusions, flucutating mental status

Fronto-temporal – shrinking frontal and temporal lobes, Memory, Marked Personality changes, Preserved visuospatial

TYPES OF DEMENTIA cont… Vascular Dementia– aka multi-infarct dementia,15-

30% develop dementia Progressive Supranuclear Palsy The Rare Birds : Late onset Metabolic Disease Other causes: Alcoholism, AIDS, Pick’s disease, etc…

Disease

EVALUATION

HISTORY HPI, Medical, Medications, Psychiatric, Functional, Caregiver

EXAMPhysical, Neurologic, Psychiatric, Cognitive Testing

EVALUATION

LABORATORY Blood Work

CBC, TSH, Chem 7, Ca 2+, B12, Folate RPR

Imaging CT or MRI

Other Studies LP, neuropsychiatric testing, EEG, SPECT, PET

DIFFERENTIAL DIAGNOSIS

DEPRESSION Pseudodementia CNS: Neoplasm, NPH, stroke Vascular: subdural, vasculitis, Endocrine: Thyroid, Calcium, Nutritional: B12, Thiamine,ETOH Infections: HIV, Cryptococcus

CURRENT THERAPY

CHOLINESTERASE INHIBITORS For mild to moderate disease, slow progression,

stabilize ADL and MMSE 1st Generation

Tacrine hepatotoxic, last choice 2nd Generation

Donepezil 5-10 mg qd $113/mp Rivastigmine 3-6 mg bid $153/mo Galantamine 16-32 $298/mo

CURRENT THERAPY cont…

VITAMIN E Antioxident, inexpensive

GINKGO BILOBA Antioxident, anti-inflammatory

ESTROGENS neuroprotective?

NSAIDS Epidemiologic suggestions

COMPLICATIONS

Depression Suspicion Disinhibition Agitation

Verbal, Vocal, Motor

PsychosisHallucinationsDelusions

Anxiety Aggression Withdrawal Vegetative

sleep appetite

Wandering Apathy

APPROACHES TO BEHAVIOUR PROBLEMS

1. Define target symptoms 2. Revisit medical diagnoses 3. Establish neuropsychiatric diagnoses 4. Assess and remove provoking factors: environmental, psychosocial, other 5. Adapt environment and treatments to specific cognitive deficits 6. Educate caregivers 7. Employ behavior management principles 8. Treat specific psychiatric disease specifically 9. For remaining behavior problems consider

symptomatic pharmacotherapy

PHARMACOTHERAPY

DEPRESSION SSRI’S Paroxetine, Sertraline, Others TCADS Nortriptyline ECT if life threatening

ANXIETY Buspirone,Lorazepam, Propanolol

PSYCHOSIS Rispiridone, Olanzepine, Haloperidol

PHARMACOTHERAPY

Aggression Trazedone, Buspirone, Olanzepine, Others

Agitation Haloperidol, Lorazepam, Trazedone, Carbamazepine

Insomnia Melatonin, Benzodiazepines, Trazedone

Sundowning Trazedone, Haloperidol, Risperidone, Olanzepine

PROGRESSION Forgetfulness

complains of memory deficits, misplace objects, trouble word finding, functional

Confusional getting lost, job trouble, language problems, lost objects,

denial, anxiety, lost current events, can’t handle finances other executive functions, withdrawal

Early Dementia Need assistance, can’t use phone reliably, disorientation

to time, place, know family, can feed and toilet with reminders

PROGRESSION

Middle Dementia Unaware of surroundings, forget spouse’s name,

loss of recent events of life, personality and behavior changes, needs help with most ADL

Late Dementia Loss of all verbal abilities, complete incontinence,

no thirst or hunger responses TIME COURSE

DAY TO DAY CARE

Be Firm, Don’t Rush or Argue Now it time to….., don’t rush or argue

Minimize DistractionsDecrease noise, remove visual clutter

Keep It Simple, Keep It SafeCannot follow multi-step commands

Lower Your StandardsExpect less from the patient

Establish Routines Reassuring, reduce agitation

CARE FOR CAREGIVERS

Information about progression Facilitate Day-to-Day Care Stress Reduction Skills

Support Risk for depression, illness, fatigue, elder abuse

How to know when you can no longer provide care at home

Economics of Dementia

2-5 million affectedWith current demographics 10 million by 2030

Expenses TOTAL $100 BillionRanks third (Heart disease and Cancer)

Per CapitaDirect $10-25K home, $40-50k NHIndirect $60kUnpaid Care $10-50kPaid Out of Pocket 65%

Consider Hospice/Palliative Care

Dementia is a terminal disease. Consider palliative care referrals and/or referrals to support agencies early on.

Once patient has progressed and is in the late stages of the disease, consider a hospice referral to help keep the patient comfortable and provide ongoing support for the family.

ResearchIn 2013, multiple AD biomarkers are receiving research attention,

including structural and metabolic brain alterations as well as amyloid and tau protein levels in both the brain and cerebrospinal fluid (CSF). Lilly’s experimental Alzheimer’s drug (Solanezumab):

Created to attach to protein fragments in the brain before those fragments clump together to become plaques.

DIAN studies – Alzheimer’s Association has funded 4.2 million for this study. DIAN is a network of investigators recruiting families with dominantly inherited AD. These families have rare, inherited gene mutations that cause young onset, familiar AD.

Thank you