Dementia - Lecture notes 1 PDF

Preview

Summary

Dementia...

Description

Dementia

Overview of Dementia and Mild Cognitive Impairment Significance of Dementia • Prevalence • Worldwide 47 million people today131 million 2050 • 15% of people over age 70 in the US • 33% of older adults will die with dementia • Definition • Dementia is a general term; refers to decline in mental ability that becomes severe enough to affect a person’s daily functioning • cts the ABCs: ACTIVITIES, BEHAVIORS (& personality), and COGNITION • Activities = bill-paying; managing the checkbook; self-neglect; increased sleeping; • Behaviors/personality = loss of hobby interests/apathy; social withdrawal, hostility; disinhibition socially • Cognition = memory, disoriented to time; repetitive conversation, language decline (word finding, social skills), problem solving, judgment, spatial orientation, cannot do complex tasks. • Irreversible, progressive neurodegenerative disease: No cure • It is NOT a normal part of aging • Broad impact: physical, emotional, and financial impact on patients, families (caregivers), and society is huge (https://www.alz.org/) • $290 billion in 2019 all dementia types (US data); $1.1 trillion by 2050 • Caregiver impact: self-neglect, burnout, depression • Type of dementia impacts treatment choices

• Different Types of Dementia • Over 200 subtypes • Most common: • Alzheimer’s • Vascular • Lewy Body • Dementia with Lewy Bodies (DLB) • Parkinson Disease • Frontotemporal • 1 in 3 older adults dies with some type of dementia (alz.org) Risk Factors • Nonmodifiable – 65% • Age (>65 y.o.) • Genetics (ApoE4), family hx—Alzheimer’s Dementia • Race (African American, Hispanic) • Modifiable – 35% • Lower education • Hearing loss • HTN • Obesity • Smoking • Depression • Physical inactivity • Social isolation • Diabetes

Diagnostic Criteria – DSM-5 • “Major neurocognitive disorder” (aka, dementia) • Significant cognitive decline • Objective & subjective evidence • Interferes with instrumental activities of daily living (IADLs) • E.g., cooking, shopping, laundry, bill paying… • Cannot be due to delirium or other mental disorder • “Minor neurocognitive disorder” (aka, mild cognitive impairment) Diagnostic Criteria – NIA-AA • 2011 National Institute on Aging and Alzheimer’s Association (NIA-AA) – General dementia • 1. Cognitive or behavioral symptoms that: • 2. Interfere with ability to function • 3. Represent decline from previous ability • 4. Are not due to delirium or other mental disorder • 5. Detection based on subjective & objective assessment • At least 2 domains are affected: • Learning & memory (new information) • Handling of complex tasks • Visuospatial abilities (recognizing faces, finding objects, dressing) • Language • Personality or behavior Mild Cognitive Impairment (MCI) • DSM-5 diagnostic criteria: • “Minor neurocognitive disorder” • Modest cognitive decline, objective & subjective evidence • Does not interfere with IADLs, but they take more time & effort • Can present as • “amnestic” (i.e., memory) • “nonamnestic” (e.g., language) • POINTS to remember: • Distinct from dementia • Can remain stable, improve, or progress to dementia • Amnestic more likely to progress • No FDA approved drug therapy • Treatment: Manage risk factors for dementia Is it dementia or normal aging?

•

Differentiating 5 Major Dementia Types Vascular Dementia • Definition/pathophysiology: New onset dementia following stroke ( 1 of the key features of Parkinson Disease -- bradykinesia, tremor, rigidity • 4. REM sleep behavior disorder (RBD) • Supportive features • Severe sensitivity to antipsychotic agents; postural instability; hypersomnia; hyposmia; constipation, orthostatic hypotension; apathy, anxiety, and depression. • Additional diagnostic support: Reduced dopamine transporter uptake on PET scan; sleep studies confirm RBD Parkinson Disease Dementia (PDD) • The other of the 2 “Lewy Body” dementias • Definition: PD diagnosis + cognitive decline (onset >1 y later) • Pathophysiology similar to DLB: Lewy Bodies + Alzheimer’s pathology • Clinical Presentation (in contrast to DLB) • Faster decline of motor symptoms • Better response to levodopa • No fluctuations in cognitive function • Diagnosis • Onset in late stages of Parkinson Disease; 70% prevalence at 10 yrs. • Cognitive decline occurs >1 year after onset of motor symptoms (vs. w/DLB, onset cognitive & motor symptoms close together) • Associated symptoms: delusions, hallucinations, daytime sleepiness, apathy Frontotemporal Dementia • Definition/pathophysiology: nerve cell death in frontal & temporal lobes affecting behavior & personality • Clinical presentation: • Earlier onset (32% at age 85 • 6th leading cause of death in US • Caregiver burden: 16 million unpaid (informal) caregivers in the US Pathophysiology • 1. Extracellular plaques that contain protein amyloid-β-protein (Aβ or amyloid) • Aβ plaques accumulate  neurodegeneration • 2. Neurofibrillary tangles that contain protein tau (sticky) •

• •

Genetic mutations favor production of longer Aβ proteins (Aβ42) • Early onset AD: presenilin mutations • Older onset: apolipoprotein E4 (ApoE4) isoform Pathology is present before clinical symptoms become apparent Role of brain glucose metabolism (type 3 diabetes) • People with insulin resistance (T2DM) have ~2-fold risk of developing Alzheimer’s disease • Brains of people with Alzheimer’s disease show insulin deficiency and insulin resistance • Impairments in cerebral glucose utilization  cognitive impairment • Glucose hypometabolism seen on brain scans • Research area for future drug therapy

Diagnostic criteria of Alzheimer’s disease • Meets criteria for general dementia PLUS… • Core criteria for Alzheimer’s dementia: • 1. Insidious onset of months to years • 2. Clear history of progression of cognitive decline – objectively confirmed by neuropsychological testing • 3. Cognitive deficits are evident as: • Amnestic—memory impairment—e.g., ability to learn & retain new information • Nonamnestic—impairment of executive function (language, reasoning, planning, problem solving) • 4. Patient unlikely to have another type of dementia Stages of Alzheimer’s per NIA-AA

•

Diagnosis of AD • Evolving from a clinical diagnosis to one that incorporates biomarkers • No longer a diagnosis only on autopsy • Specialized & expensive techniques; not used routinely • Use of Imaging & CSF Biomarkers in diagnosis • PET scans to detect Aβ (amyloid) deposits, tau • May 2020, FDA approved radioactive agent (Tauvid®) to estimate density & distribution of tau in brain • CSF samples to measure amyloid (Aβ42), tau • Physical & financial burden • MRI can detect neurodegeneration (functional abnormalities) in brain & atrophy patterns – distinguish b/t dementia subtypes NIA-AA Proposed Biomarker Profiles to define/diagnose AD • Definition (specific for AD): • A= amyloid (Aβ); specific for Alzheimer’s continuum • T= tau (pathologic); specific for Alzheimer’s disease • Staging severity (nonspecific for AD): • (N): neurodegenerative (neuro-injury) biomarkers • (C): cognitive symptoms

Clinical Presentation of AD • Marked by cognitive impairment & memory loss • Early stage: short-term memory issues • Forgetting where things were placed, recent conversations – multiple times per day • Gradually: impaired concentration, confusion, decline in ability to manage day-to-day functioning (skills for living); difficulty with directions, gets lost • Behavioral changes: social withdrawal, anxiety/depression • Late stage: challenging behaviors can emerge

Progression of Alzheimer’s dementia • It’s a continuum, rather than distinct phases/stages • Duration of each stage is unpredictable

•

Medication-Induced Cognitive Impairment Reversible Causes of Cognitive Impairment • Medications • Alcohol use • Vitamin B12 deficiency • Metabolic abnormality • Thyroid • Hyponatremia • Medical condition • Brain tumor • Hydrocephalus • Severe depression • Infection Delirium • Distinct from dementia • Acute onset change in cognition, decreased ability to focus • Cognitive changes fluctuate during the course of the day. • Occurs due to an “event” – medications, hospitalization, anesthesia, e.g. • Delirium episodes increase risk of dementia Medication-induced Cognitive Impairment • •

• • • • •

Anticholinergics Antipsychotics Benzodiazepines Non-BZD hypnotics • Eszopiclone, zaleplon, zolpidem Antidepressants:

• • • •

• Tricyclics (TCAs) & paroxetine Opioid analgesics • Notably meperidine Muscle relaxants Corticosteroids H2-receptor antagonists • Dose adjust for renal impairment needed! NSAIDs—rarely, but ’d risk elderly • Especially indomethacin • Psychosis, confusion

Anticholinergic (Ach) drug exposure and risk of dementia

• Anticholinergic Burden • Anticholinergic scales have been developed to quantify anticholinergic burden • No standardized list exists • Different scales include different drugs, have different interpretations • Importance of identifying anticholinergic drug use as a reversible cause of cognitive impairment

Management, Prevention, Treatment Cognitive Screening for Dementia • •

•

Universal screening not recommended • per USPSTF; insufficient evidence Screening is appropriate when patient or informant (caregiver/partner, e.g.) expresses concern • Several validated tools to choose from • Can be used for initial screen and some can be used to track progression Option for self-administration at home: SAGE • Self-Administered Gerocognitive Exam • Administer at home; take to physician to interpret

Cognitive Screening and Assessment Tools

• •

See slide 44 for full dementia screening interview

Manage Risk Factors for AD/Dementia/MCI – for prevention AND for treatment • Address/manage cardiovascular risk factors • HTN, T2DM, HLD, smoking, obesity • Healthy diet • Mediterranean, DASH diet are being studied • Omega-3 fatty acids, antioxidants • Physical activity/exercise • Limit alcohol consumption • Sufficient sleep • Social engagement & brain games Drug Therapy for Treating Dementia

• Drug Therapy: “Cognitive Enhancers” – ChEIs & memantine Cholinesterase Inhibitors (ChEIs) • Cholinergic theory: decreased acetylcholine production and number of cholinergic receptors in the brain • Cholinergic transmission affects cognition, memory • Approved to treat mild through severe stages of Alzheimer’s • *Rivastigmine approved treat PDD Donepezil – clinical pearls • 1 dose per day; no dose titration needed • 5 mg is therapeutic dose, but can increase to 10 mg per day for greater effect • 23 mg dosage form • film-coated, extended release; do not crush or chew • Minimal clinical benefit (vs. 10 mg), but with significant ↑ GI ADRs. • Off-label: • vascular dementia, PDD, DLB Rivastigmine – clinical pearls • Titration needed to get to therapeutic dose • Take with food • Reduces GI ADEs • Increases extent of absorption (but slows it down) • Side effects can be significant: nausea, vomiting • Start at low doses and increase slowly • Monitor decreased appetite; n,v,d • Patch formulation better tolerated (ADEs) • Off-label = vascular dementia, DLB • (remember, it’s approved for PDD) Galantamine – clinical pearls • Titration needed to get to therapeutic dose • GI side effects can be problematic. • If therapy is interrupted for >2 days, need to restart titration. ChEIs – Person Centered Care • Benefits

•

• • Risks • • •

Clinical value controversial; minimal benefit for many patients Statistical vs. clinical significance Cost $40-$140/mo Added pill burden, adherence issues ADRs, e.g., • GI  appetite, weight loss; • Syncope (r/t bradycardia) • Urinary incontinence

NMDA Receptor Antagonist (memantine) • Glutamatergic theory: too much activity at the “NMDA” (N-methyl-D-aspartate) receptors in the brain • Glutamate = excitatory transmitter • Approved to treat moderate to severe Alzheimer’s disease

Memantine – clinical pearls • Moderate to severe AD – can be used as monotherapy or added to ChEI therapy • Mild AD – not approved; off-label use not recommended • no better than placebo • Off-label for vascular dementia • Possible small benefit in thinking, behavior, mood (moderate to low quality evidence) Drugs in Pipeline • Aducanumab (Biogen Inc.) • Monoclonal antibody targets Aβ-plaques, early dementia • FDA Advisory panel recommended against approval on 11/6/20 • FDA will make final determination by 3/21/21 • Donanemab (Lilly)—targets amyloid beta • Phase 2 study (1/21)—slowed cognitive decline by 32% • AMX0035 (Amylyx Pharmaceuticals) – targets endoplasmic reticulum & mitochondrial dysfunction • Phase 2 studies for ALS and AD • Drug is combo of sodium phenylbutyrate (Rx) and tauroursodeoxycholic acid (supplement) Additional treatment considerations, non-AD dementias • Vascular – think CVD, PAD, stroke management/prevention • DLB – Avoid antipsychotics due to extreme sensitivity to ADRs • Antipsychotic sensitivity: heavy sedation, irreversible parkinsonism; confusion;  mortality • Extrapolate from PD psychosis management with caution (clozapine, quetiapine); pimavanserin not yet studied • PDD – prefer carbidopa/levo over dopamine agonists for motor symptoms

•

• [WHY? (HINT: think of ADEs of from PD lecture)] • Pimavanserin FDA approved to treat PD psychosis Frontotemporal • Health maintenance, Safety – personal & environmental, Speech therapy • SSRIs for behavioral symptoms; antipsychotic agents for agitation

Optimize Drug Therapy for Dementia (Alzheimer’s disease) Goals of Drug Therapy • Not a panacea; ~3 month trial to assess impact • Can improve quality of life • Extend patient independence -- able to maintain daily functioning (bathing, dressing, feeding) • Reduce troublesome behaviors • Decrease demands on caregiver’s time • Stabilize cognitive function (slow progression of the disease) • Early treatment can delay nursing home placement 6-12 mos. • Improvement seen in ADLs, behavior, cognitive fxn Family/Caregiver Support • Community resources: https://www.communityresourcefinder.org/ • Alzheimer’s Association: https://www.alz.org/help-support/resources • Adult day care: patient receives daytime group care; caregiver gets respite • In-home assistance: home care agencies, private duty chore workers, etc. • Housing options: memory care facility Monitor & Adjust Drug Therapy • Monitor effectiveness • Ensure therapeutic dose • Review regimen to identify medications that affect cognitive function • Monitor cognitive function over time (stabilization of vs. worsening) • Use standardized tools at start of therapy, repeat every 3-6 months • Goal = no change in cognitive function or minimal decline (MMSE benefits in older adults • considered “potentially inappropriate medications”

Use of antipsychotics for treating BPSD • Start with low doses & titrate slowly • Monitor for side effects – sometimes subtle changes • Sedation is NOT the goal! • “PRN” use is NOT appropriate • Once stable, evaluate @ 3-4 month intervals and consider TAPER and discontinuation Antipsychotics • Drug selection depends on dementia subtype: • AD: risperidone, olanzapine, quetiapine, aripiprazole • DLB: clozapine, quetiapine; extreme sensitivity to antipsychotic ADEs (D2 antagonism) • Side effects (dose related) • drowsiness, dizziness, weight gain, increased blood glucose, fall risk • BBW--stroke & death

Antidepressants (for BPSD treatment) • Treatment of depression, too • SSRIs • Citalopram > benefits; should be avoided in older adults. No safe duration or dose. Risks: paradoxical excitation; fall risk, tolerance, dependence, delirium, cognitive decline Short-acting: alprazolam, lorazepam

Summary: Dementia • Understand the disease (MCI, dementia) • Address risk factors & prevention • MEDICATION STEWARDSHIP: • Medication review for drugs that can impact cognitive function, memory, confusion, etc. • Guide appropriate use of dementia medications • Adherence • Management of BPSD -- Support family, caregivers, health care providers as disease & symptoms progress in appropriate use of non-drug & drug therapies...