MANAGEMENT OF DEMENTIA

Jonathan T. Stewart, MDProfessor in Psychiatry

University of South Florida College of Medicine

Chief, Geropsychiatry Section

Bay Pines VA Medical Center

DEMENTIA

Affects 10% of Americans over 65 Fourth most common cause of death Only 10% of cases are reversible or

arrestable

DEMENTIA: BEHAVIORAL PROBLEMS

Present in 80% of cases Major source of caregiver stress,

institutionalization Common at all stages of the disease Much more treatable than the

underlying dementia Poorly described in the literature

THE DEMENTIA WORKUP

Thorough history Physical examination Mental status examination Blood work Neuroimaging study

70% degenerative dementia 20% vascular dementia 10% other

POSTROLANDIC Memory deficits Aphasia Apraxia Agnosia Personality

preserved MMSE valid

FRONTAL/SUBCORTICAL Memory deficits Loss of goal-oriented behavior,

behavioral plasticity Personality changes

– Disinhibition– Abulia

Incontinence MMSE useless

TWO TYPES OF DEMENTIA

FRONTAL/SUBCORTICAL CIRCUITS

Frontal cortex

Striatum

Pallidum

Thalamus

Subcortical white matter

THREE SYNDROMES

Loss of goal-oriented behavior (dorsolateral prefrontal circuit)

Abulia (anterior cingulate circuit) Disinhibition (orbitofrontal circuit)

Don’t miss this one:

DIFFUSE LEWY BODY DISEASE

Postrolandic dementia– More rapidly progressive than AD– Fluctuation, episodes of “pseudodelirium” common

Mild parkinsonism– Tremor often absent– Poor response to antiparkinsonian meds– Shy-Drager sx’s common

Prominent psychotic sx’s, esp visual hallucinations

SEVERE NEUROLEPTIC INTOLERANCE

NEUROLEPTICS AND DLBD Most patients have severe reactions to

neuroleptics, including severe akinesia, dystonias and NMS-like syndromes

Increases LOS in 81%; reduces lifespan in 50% (McKeith et al, 1992)

Doubles rate of cognitive decline (McShane et al, 1997)

A severe, unexpected reaction to low-dose neuroleptics is highly suggestive of DLBD

MEDICATIONS FOR ALZHEIMER’S DISEASE

Donepezil Rivastigmine Galantamine

Memantine

A TYPICAL STUDY

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MANAGEMENT

WOOF.

MEDS OTHER

THE BEST NUMBER OF MEDICATIONS TO USE IS

ZERO (or sometimes one)

WHEN IN DOUBT, GET RID OF MEDICATIONS!

THREE BASIC PRINCIPLES

STRUCTURE LIMITED GOALS THE “NO-FAIL” ENVIRONMENT

“THE CUSTOMER IS ALWAYS

RIGHT!”

SOME “NO-FAIL” TECHNIQUES

Remove challenges from the environment Don’t correct unless absolutely necessary Distract, change the subject Always help the patient save face The “universal mistake” technique Validation therapy

DEPRESSION

15-30% incidence in Alzheimer’s disease Often early in the course of the illness Sometimes previous personal or family

history of depression Most important treatable cause of excess

disability Responds very well to treatment

TYPICAL SYMPTOMS OF DEPRESSION

Mood symptoms “Cognitive” symptoms Vegetative symptoms

OTHER POSSIBLE SYMPTOMS OF DEPRESSION Anxiety Fearfulness Somatization Excessive complaining, requests for

help (Kunik et al, 1999)

“Personality change” Screaming (Greenwald et al, 1986; Cohen-

Mansfield et al, 1990)

DEPRESSION: TREATMENT

Selective serotonin reuptake inhibitors Tricyclics Other agents ECT

AGITATION

Present in 40-80% of patients Up to 34% of patients are combative Few predictors It is unusual for medications to be

dramatically effective

ACUTE BEHAVIOR CHANGE I atrogenic

I nfection

I llness

I njury

I mpaction

I nconsistency

I s the patient depressed?

“SUNDOWNING”

4 PM 2 AM

MANAGING SLEEP DISTURBANCE

Increase time cues (“Zeitgebers”) Aerobic exercise Restrict caffeine and alcohol Restrict naps Manage incontinence, pain Keep the room cool and quiet Don’t forget the night-light Hypnotics (NOT ANTIHISTAMINES!)

CATASTROPHIC REACTIONS

“A substantive emotional reaction precipitated by task failure.” (Goldstein, 1952)

Responds well to a “no-fail” environment, but not really to meds

RESISTIVENESS

Common in patients with severe dementia or frontal/subcortical disease

LIMIT GOALS Slow, gentle approach “As soon as we do this, I’ll leave you

alone.” Premedication with lorazepam may help

PSYCHOTIC SYMPTOMS IN DEMENTIA

50% incidence, esp. in moderate dementia

Includes:– Delusions (usu. theft, jealousy or “living in

the past”)– Hallucinations (usu. “phantom boarder”)– Reduplicative paramnesia– Misidentification of mirror, TV, etc.

MEDS ARE OFTEN NOT NEEDED

MANAGING PSYCHOSIS Rule out acute decompensation Is it really a psychosis? Is treatment really necessary? Try non-pharmacologic techniques first Try to stick to low-dose atypicals (mainly for

delusions); don’t use anticholinergics Goals of therapy are quite modest Try to dechallenge neuroleptics every three

months

COMMON SIDE-EFFECTS OF TYPICAL NEUROLEPTICS

Parkinsonian symptoms Akathisia Neuroleptic malignant syndrome Tardive dyskinesia Functional decline Cognitive decline

ATYPICAL NEUROLEPTICS

Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole

DISINHIBITION

Mostly in frontal/subcortical disease Use antecedent control and

environmental manipulation, not operant conditioning

Can use anticonvulsants, propranolol, other agents for aggression

Can use SSRI’s or antiandrogenics for sexual disinhibition

SCREAMING

Seen in severely demented patients Multifactorial:

– RESTRAINT– Pain, discomfort– Sensory deprivation– Depression (?)

EMPIRICALLY EFFECTIVE MEDS FOR AGITATION

Anticonvulsants Atypical neuroleptics (best when

agitation is clearly related to psychosis) Trazodone Buspirone Lorazepam, oxazepam

MORE HEROIC OPTIONS

Lithium Beta-blockers Narcotics Estrogens Typical neuroleptics ECT

THE BEST NUMBER OF MEDICATIONS TO USE IS

ZERO (or sometimes one)

WHEN IN DOUBT, GET RID OF MEDICATIONS!

WANDERING

Up to 2/3 of patients Can lead to serious injury or death Four types:

– Exit seekers– Self stimulators– Akathisiacs– Modelers

(Hussian, 1987)

WANDERING: MANAGEMENT

Manage sleep disturbance aggressively Discontinue neuroleptics if possible Exercise, stimulation, outdoor time Alarms Visual barriers Locks (consider fire hazard, though) Medicalert bracelet, police registry, etc.

DON’T FORGET SAFETY ISSUES!

DrivingDrivingFirearmsFirearmsPower toolsPower toolsSmoking in bedSmoking in bedPoisons, medicationsPoisons, medicationsFall riskFall risk

WOOF!

MEDS OTHER

GOOD LUCK!