medical aspects of disability october 17, 2006

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Dementia

Medical Aspects of Disability

October 17, 2006



DEMENTIA

• DEFINITION:

– Group of symptoms that can be caused by over

60-70 disorders.

– Syndrome which refers to progressive decline

in intellectual functioning severe enough to

interfere with person’s normal daily activities

and social relationships. ( National Institute on Aging-1995 No. 95-3782)



Dementia – Marked by progressive declines in

• memory.

• visual-spatial relationships

• performance of routine tasks• language and communication skills

• abstract thinking

• ability to learn and carry out mathematical

calculations.



Dementia• Two Types:

– Reversible

– Irreversible

• Individuals must have intensive medical

physical to rule out reversible types of

dementia.



Delirium vs. Dementia

• Delirium defined--- characterized by a disturbance

of consciousness and a change in cognition that

develop over a short period of time

• About 10-15% of surgical patients experiencedelirium, and 15-25% of medicine inpatients will

experience delirium

• 30% Surgical Intensive Care Unit patients developdelirium, and up to 30% of AIDS patients while

inpatient, will develop delirium




• A major risk factor is advanced age

Other factors include very young people (children),organic brain damage including stroke, MVA, etc,substance use, previous delirium, malnutrition, sensorydeprivation (hearing or visual loss), diabetes, cancer

Having an episode of delirium is more than justinconvenience

3 month mortality following an episode of delirium is25-30%. 1 year mortality after an episode of deliriummay be as high as 50%.




• Many causes of delirium:

Some examples… epilepsy, CNS trauma, CNS

infection, CNS neoplasm, endocrine

dysfunction (pituitary, thyroid, adrenal,

parathyroid, pancreas), liver failure, UTI,

cardiac dysrhythmias, hypotension, vitamin

deficiency, sepsis, electrolyte imbalance,iatrogenic- any medication, substance

withdrawal




• Could be psychiatric disorder, i.e. major depression or generalized anxiety disorder, in which case need to initiatetreatment for this disorder, i.e. get a psych consult

• Or is the cause a delirium from other meds or an infection, in

which case should look at labs and med list.• Or is cause alcohol withdrawal, in which case need to treat

w/d with benzodiazepines

• If patient is having chronic trouble sleeping, a good choice tohelp them is Ambien/zolpidem or Sonata/zaleplon




• Watch for alcohol withdrawal as cause of

delirium. If elevated pulse and blood

pressure, see elevated MCV, and patient

begins to act bizarre, talk to family if at all

possible, about substance use. If patient

enters delirium tremens (DT’s), untreated

has a mortality rate of 20%.




• How is delirium treated?

First line treatment for delirium is to treat underlying

cause. Often will need many labs- Complete Metabolic

Panel, Complete Blood Count, TFT, EEG if indicated,CT/MRI of head, sometimes LP, etc.

A psychiatric or psychological consult might be needed

for agitation.

Meds- Haldol 2.5-5 mg (less for geriatric) or now,Geodon 10-20 mg IM or Ativan IM




• A common problem in the US

– 5% of those over 65 have severe dementia, 15%

have mild dementia

– 20% those over 80 have severe dementia

– One of first distinctions you must make is

reversible from nonreversible.

– Only about 10-15% are reversible




• Nonreversible does not mean non treatable!

• Non reversible dementias- – Alzheimer’s is most common by far, accounting for

about 70% of dementias. – See a tempero-parietal wasting at first, leading you to

see the memory loss and speech problems first. The“lost keys”sign.

– Then will progress to global atrophy of brain.

– Genetics a risk factor (up to 35-40% patients have afamily history of Alzheimer’s



Dementia

• Reversible: – D= Drugs, Delirium

– E= Emotions (such as depression) and

Endocrine Disorders – M= Metabolic Disturbances

– E= Eye and Ear Impairments

– N= Nutritional Disorders

– T= Tumors, Toxicity, Trauma to Head

– I= Infectious Disorders

– A= Alcohol, Arteriosclerosis



Dementia

• Irreversible: – Alzheimer’s

– Lewy Body Dementia

– Pick’s Disease (Frontotemperal Dementia) – Parkinson’s

– Heady Injury

– Huntington’s Disease

– Jacob-Cruzefeldt Disease



Dementia

• Irreversible:

– Alzheimer's most common type of irreversible

dementia

– Multi-Infarct dementia second most common type of irreversible dementia

• Death of cerebral cells

• Blockages of larger cerebral vessels, arteries

• More abrupt in onset• Associated with previous strokes, hypertension

• Can be traced through diagnostic procedures



Dementia

– Lewy Body Dementia

• Episodic confusion with intervals of lucidity with at

least one of the following:

1. Visual or auditory hallucinations2. Mild extrapyramidal symptoms

(muscle rigidity, slow movements

3. Repeated unexplained falls• Progresses to severe dementia—found at autopsy.



Dementia

Diagnosis of Frontemporal Dementia (Pick’s Disease)

Pick’s bodies in cells.

Personality changes

Behavioral dis-inhibition. Loss of social or personal awareness.

Disengagement with apathy

Maintain ability to draw and calculate well into later stages



Alzheimer's Disease

• Estimated that 4,000,000 people in U.S.have Alzheimer's disease.

• Estimated that 25-35% of people over age

85 have some time of dementia.

• After age 65 the percentage of affected people, doubles with every decade of life.

• Caring for patient with Alzheimer's diseasecan cost $47,000 per year (NIH).



Changes Caused by Alzheimer's

• Diminished blood flow

• Neurofibrillary Tangles

• Neuritic Plaques• Degeneration of hippocampus, cerebral

cortex, hypothalamus, and brain stem



Atrophic hippocampus in AD



Compare central sulcus of

Alzheimer’s patient with normal81 year old woman

From Whole Brain Atlas at http://www.med.harvard.edu/AANLIB/home.html



74 year old AD patient: reduced blood

flow on SPECT in temporal areas



Normal vs AD Brain

Normal brain Alzheimer’s brain



AD Prognosis

• Alzheimer’s has a slowly progressive

decline. These meds can slow the

progression, NOT halt it.

Time

F u

n c t

i o

n



Pick’s disease

• 25 times rarer than Alzheimer’s dementia

• Frontal lobe clinical features

• Assymetrical frontal or temporal atrophy• Has been connected with semantic

dementia, but evidence is not conclusive yet



Case history: Pick's Disease

This 59 year old woman had a three year history of a

progressive alteration in social behavior which included

apathy and occasional disinhibition. Images reveal severe

focal shrinkage of temporal and frontal lobes bilaterally.



Degeneration of the basal ganglia

• Huntington’s disease

– Rare: 5 in 100,000

– abnormal ‘exaggerated movements

• Parkinson's disease – Common: 1 in 100 over age 65

– General slowing of voluntary movements

•Both diseases involve the basal ganglia, but inlarge opposite ways



Basal ganglia

• Caudate

• Putamen

• Globus pallidus• Subthalamic nuclei

• Substantia nigra

Striatum



Multi-infarct dementia (MID)

• Many small strokes

• Often mixed with Alzheimer’s dementia



Viral dementia: HIV

• 20-60% of HIV patients suffers from

dementia

• Cerebral atrophy may be caused bymicroglial nodules



Vocational Rehabilitation and

Dementia• Can dementia occur while an individual is

employed?

• Is dementia covered under the American’s with

Disabilities Act?• Can jobs and tasks be modified to assist

individuals with mild forms of dementia?

• Can job discrimination occur for these

individuals?• What types of job modifications and/or assistive

technology can you think of for an individual withdementia?



End-stage Dementia

Prognosis < 6 mos:

• Severe dementia with need for total assistance inADLs (dressing, bathing, continence), unable to walk,only able to speak a few words

• Comorbid conditions – aspiration pneumonia,urosepsis, decubiti, sepsis

• *Unable to maintain caloric intake with weight loss of 10% or more in 6 months (and no feeding tubes)



Complications from dementia

• Delusions in up to 50%, most with paranoia

• Hallucinations in up to 25%

• Depression, social isolation may also occur

• Aggressive behavior in 20-40% (may be related toabove problems, misinterpretation)

• Dangerous behavior – driving, creating fires, gettinglost, unsafe use of firearms, neglect

• Sundowning – nocturnal episodes of confusion withagitation, restlessness



Treatment of complications

• Hallucinations, delusions, agitation, sun-downing may be improvedwith anti-psychotics like haloperidol, risperdal, mellaril…

• If any signs of depression, may be beneficial to treat

• Anxiety may respond to benzodiazepines

• Behavioral mod – reinforce good behavior, DON’T fight

aggressive behavior • Familiarity (change in environments make things worse)

• Safety – key locks, knobs off stoves, take away car keys/cigarettes/firearms…, lights, watch stairs

• Avoid restraints, use human contact/music/pets/

distraction



Artificial Nutrition in Dementia

• Many excellent reviews demonstrate noimprovement in quality of life and quantityof life with G-tubes.

• 5% morbidity and mortality with the procedure itself

• No decrease in aspiration with them

• Risk of infection• Can keep patient comfortable without it



Complications from dementia

• Delusions in up to 50%, most with paranoia

• Hallucinations in up to 25%

• Depression, social isolation may also occur

• Aggressive behavior in 20-40% (may be related toabove problems, misinterpretation)

• Dangerous behavior – driving, creating fires, gettinglost, unsafe use of firearms, neglect

• Sundowning – nocturnal episodes of confusion withagitation, restlessness



Drug treatment in Alzheimer’s

disease• Many drugs aim to stimulate the cholinergic

system

• These drugs have limited positive effectsand do not reverse the causes of AD



Dementia patients are very

sensitive to additional disabilities• Illness

• Pain

• Medications• Poor hearing

• Poor vision



Management of depression at end

of life• Psychotherapy – behavioral, cognitive, and other

supportive approaches by psychologists, licensed

social workers, chaplains, even bereavement

counselors may help• New coping strategies like meditation, relaxation,

guided imagery, hypnosis may help

• Medications



Anxiety

• May be a normal response to the situation – fears,uncertainty, reaction to physical condition, socialor spiritual needs

• Usually with 1 or more of the following signs – agitation, restless, sweating, tachycardia,hyperventilation, insomnia, excessive worry,tension

• Look for signs of depression, delirium,alcohol/drug abuse, caffeine abuse

• About 5% are affected by agoraphobia



Related anxiety conditions

• Panic attacks – acute onset of palpitations,

sweating, hot, shaking, chest pain, nausea, dizzy,

derealization, fear, numbness; usually short lived

• Phobias – fears with avoidance, feelings of beingtrapped, exposed

• Post-traumatic Stress Syndrome – in response to

severe trauma, get more intense fear, terror,

dreams, feelings of helplessness, detachment that

can occur later on



Other EOL care needs for dementia

• In bedbound, watch out for and prevent decubiti

• Feeding instructions to prevent aspiration – head

up, chin tucked, thick consistency foods like

pudding/jello/ice cream…• Caregiver stress – difficult care, poor sleep,

education to prevent aggressive behavior, early

bereavement losing loved one before they are

gone, need for support/respite



Summary

• A change in mental or emotional status of the patient is not uncommon with a life-threateningillness

• Need to be aware of conditions that may benormal reactions or have causes that are potentially reversible, but at the end of life, mayneed to focus on acute management of theseconditions

• Need compassionate, supportive care for patientand caregiver, always addressing safety



Links

• Alzheimer’s Association: http://www.alz.org/

• National Institute of Neurological Disorders and

Stroke’s page on dementia:

http://www.ninds.nih.gov/disorders/dementias/dementia.htm

• How to manage difficult behaviors from the

Association for Frontotemporal Disorders: http://www.ftd-picks.org/?p=caregiver.managing

http://www.alz.org/


http://www.ftd-picks.org/?p=caregiver.managing

http://www.ftd-picks.org/?p=caregiver.managing


http://www.alz.org/

medical aspects of disability october 17, 2006

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