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FPA panel, audience discuss diagnoses, treatment and resources

March 2018

“Dementia is tragic, and it’s costly,” says Kevin Nelson, MD, Fairview Physician Associates (FPA) Network president, as he welcomed attendees of the Feb. 28 FPA Network Institute on Dementia. The meeting was fourth in a series of panel discussions designed to surface resources and barriers that impact our success in coming together as a network around significant patient care issues.

More than five million Americans--92,000 in Minnesota--live with dementia, according to the Centers for Disease Control and Prevention. In Minnesota, 4,500 of these patients reside in a hospice, costing Medicaid $781 million a year.

FPA_ElderlyWoman_stockThe Dementia institute addressed:

• The four most common subtypes of dementia
• The role of caregivers
• The importance of advance care planning
• Knowledge of occupational therapy as a bridge to dementia care specialists

Four health care professionals discussed three hypothetical dementia case vignettes. Panelists included Emily Olson, DO, internist and geriatrician, Fairview clinics; Alvin Holm, MD, founder and medical director, Cognitive and Behavioral Disorders Program, Bethesda Hospital; Kenneth Kephart, MD, Fairview Partners & Geriatric Services, and medical director, Fairview Senior Services; and Patty Carlson, MPH, CPPM, co-lead, Minnesota Brain Aging Research Collaborative.

Case Study #1:
Pamela Pinguis, 70, lives at home with her husband. Two children died young of an undetermined cause associated with some type of “liver failure.” Pamela has become withdrawn, confused and clumsy. Her history includes moderate alcohol use and no medications other than an OTC laxative and low dose of Effexor for “her nerves.” Physical exam reveals a slightly disheveled appearance, varicose veins, somewhat thinning hair, dry skin and a slightly palpable liver. She fails her Mini-Cog and has a SLUMS score of 23, Mild Neurocognitive Disorder. Her husband complains that she “sits around the house all day.” The couple report frequent disagreements.

Olson: The family history of liver disease and alcohol use could be related. Her history of anxiety could be a contributing factor, and sitting around the house all day can cause someone to be depressed. She may have the start of dementia and simply not know what to do next.

Holm: When a case is this complicated it can be helpful to attempt to attempt to simplify the process of evaluation. We don’t know when the symptoms started and what they were, what “clumsy” means and how her children died. While the process of evaluation can take some time, many forms of treatment can be started right away. I’d first deal with the alcohol use disorder.

Kephart: Simple blood work can rule out some things. I’d screen for early depression and look for ways to provide support to the husband.

Carlson: The husband needs support, information and reassurance We have resources in the community, such as the Alzheimer’s Association and Senior Linkage Line.

Audience question: Does the patient need an MRI of the brain?

Kephart: The younger the patient, the more likely he or she is to get an MRI.

Holm: All authoritative bodies now feel that at least one imaging study of the brain is required in the process of evaluation. While MRI with selected weightings is most recommended, certain circumstances allow for CT of the brain to be considered adequate.
 
Four Most Common Subtypes of Dementia

Holm
: As many as 100 illnesses fall under the category of dementia, but more than 90 percent will be one of these:

1. Alzheimer’s disease represents 60 to 70 percent of all dementia. It usually presents with forgetfulness and the inability to learn new information. Uncommon presentations include disturbances in behavior, language, vision and spatial orientation.

2. Dementia with Lewy bodies commonly involves visual hallucinations, confusion, inattention and/or signs of Parkinsonism.

3. Frontotemporal dementia most commonly begins with changes in language function, personal conduct or interpersonal behavior.

4. Dementia due to vascular disease can result in a variety of cognitive or behavioral changes, depending on the location and extent of the vascular damage.
 
Holm: The clinical presentation of dementia can reflect the presence of more than one dementing disorder. Medical comorbidities also can influence the presentation of cognitive impairment. Two most important questions when obtaining a history are: What were the first signs of the illness, and was the onset acute, subacute or chronic?

Carlson: If patients are screened routinely, they are less stigmatized by a diagnosis.

Holm: Studies show the most important aspect of successful treatment is the caregiver, because if the caregiver fails, the patient is going to fail. Forty percent of caregivers suffer from depression.

Audience question: How reliable are SLUMS and other screening tools?

Kephart: Both are 80 to 90 percent effective.

Holm: Remember, a more sensitive screen can be an informed caregiver.

Olson: The MiniCog®, administered in a wellness visit, gives quite a bit of information in a short amount of time and leads to next steps such as the SLUMS exam or the Montreal Cognitive Assessment

Carlson: Not all patients are able to take screens. Some might be illiterate, traumatized or non-English speaking. Having an informant is helpful.
 
Case study #1 follow-up:
Six months later, Pamela has progressed to multiple repetitions of the same question. Her appearance is disheveled, and her husband looks tired. He reports that she left the iron on, and they almost had a fire.

Olson: Occupational therapists are trained in cognitive performance testing and look at functionality regarding daily activities.

Audience question: Is use of Aricept an opportunity or is it overrated?

Holm: Aricept will often not substantively improve memory, but it works well with behavioral problems, like delirium or agitation. Think of cholinesterase inhibitors as neuropsychiatric medications that can improve such things as one’s sleep-wake cycle, motivation, attention and reduce rates of psychiatric illness and subsequent hospitalization.
 
Audience question: When do you recommend a neuropsychiatric evaluation?

Olson: It is best to order one when you are just starting to see mild changes.

Holm: Neuropsychiatric testing has great utility in the early clinical stages of dementia. It also can provide the ability to characterize the pattern of impairment so as to answer important questions regarding functional ability/disability and capacity.
 
Audience question: How would treatment differ among the four different types of dementia?
 
Kephart: Prepare the family for symptoms such as hallucinations with Lewy bodies or the rapid progression of behavioral changes. There also are differences in management of medications.

Holm: Remember that, even for common dementing illnesses, treatment programs need to be individualized and focused not only on treatments specific to the dementing illness itself but also on aspects specific to wellness and environmental support.

Carlson: It can take a long time to get a diagnosis. It is important to have a discussion about cognitive impairment in general.
 
Case Study #2:
Isaac Immemor, 79, is a retired chemist living at Good Shepherd nursing home due to mobility issues. His short-term memory and ability to communicate have declined, according to his son. Isaac repeats himself frequently. His mood can change for no apparent reason, and he has become increasingly disruptive. Isaac takes a low maintenance dose of Risperdal and medication for angina. He takes Ditropan to stop occasional “leaking.” Isaac receives virtually no visits from family or friends.

Olson: He seems to have some underlying depression. Ditropan can cause confusion and so it should be considered to discontinue this medication if possible.

Kephart: I would remove the Ditropan, as long as he can still empty his bladder. I’d also discontinue Risperdal and screen him for depression.

Case Study #2 Follow-Up:
One night, Isaac is found holding his chest and is sent to the ER. After an evaluation, Isaac receives two stents after suffering a small MI with a resultant ejection fraction of 45 percent. The hospital team recommends new medications, cardiac rehab, dietary changes and treatment for his confusion.

Kephart: Cognitive impairment reduces the threshold for delirium, so Isaac should receive a cognitive screening, and review of his medications. Depression is a comorbidity with MI. I recommend an advance care plan early to address issues such as feeding tubes, which haven’t been shown to be effective in people with progressive dementia.

Audience question: What are the chances that some other vascular disease is affecting his brain? Would this show up on an MRI?

Holm: Ditropan is a potent anticholinergic. I’d withdraw it and then evaluate the patient’s cognitive condition. I’d conduct a metabolic screen and an imaging study of the brain. It may be that he was cognitively normal for his age but just got on a medication that caused confusion. More likely he has susceptibility for adverse effects from such a medication such as a sub-clinical neurodegenerative illness. The neuropathogenic effects of Alzheimer’s exist 15 to 20 years before we see anything clinically. Prior to symptoms manifesting in such patients, if given medications like Ditropan, they often become confused.

Kephart: An MRI is appropriate. He could have cognitive impairment or mixed dementia with small strokes. 
 
Audience question: What do you advise about the use of general anesthesia in patients with dementia?
 
Holm: It can be dangerous. Post-operative delirium is related to more than just anesthesia. We talk about medical tune-ups before surgery. We should talk about cognitive tune-ups. A patient with mild cognitive impairment on certain medications may need to have these medications held. During surgery we can monitor EEG waveforms to show anesthesia depth. We also can measure O2 saturation in the prefrontal cortex in an attempt to mitigate against postoperative delirium.

Audience question: What is your advice for families dealing with behavioral issues in the home?

Carlson: The Alzheimer’s Association has a 24/7 help line. Senior Linkage Line can also help.

Kephart: It is tempting to prescribe an antipsychotic to help the patient sleep, and occasionally this is necessary for safety; but, it should be used only short term. Behaviors can erupt during pain or a change in caregiver.

Olson: Understand that caregivers are stressed, too. Sometimes just the tone of their voice can be picked up by a patient.

Holm: Studies show social cognitive capabilities are well preserved in patients with Alzheimer’s disease. They may not understand what you are saying, but they certainly understand how you are saying it. Caregivers need to learn to control vocal inflection, affect and posture to communicate effectively to their loved-one with Alzheimer’s so as to reduce conflict and subsequent behavioral disturbances.
 
Case Study #3:
Francine Furoris, 81, lives alone. Her husband has died and her nearest child lives 90 miles away. Francine’s mother died with Alzheimer’s after a series of small strokes at age 77. She now struggles with conversations, cares little about her surroundings and loses her temper frequently. Francine smokes five to six cigarettes daily. Her house has become increasingly messy, and her meal preparation consists mostly of canned foods and frozen entrees. Her BMI measures 22. The rest of her physical exam is appropriate for her age. She sees only occasional visitors, and no longer drives. You diagnose early-stage Alzheimer’s disease. She returns for follow up in three months. Her BMI is now 24. She is now on two medicines for her dementia, but is complaining of nausea so skips her pills often.
 
Olson: This is a great time to bring in care coordinators, occupational therapists and the Alzheimer’s Association. Look for immediate safety issues.

Kephart: I’d rule out lung cancer or vascular dementia with her history of stroke. An MRI is as sensitive as you can get for vascular dementia.

Holm: Vascular dementia is mostly a clinico-radiologic diagnosis, but psychometric testing can give good clues to its presence. The prognosis depends on what form of vascular disease we’re talking about and where in the brain it manifests itself.

Audience question: What is the prognosis for vascular dementia?

Holm: Again it depends on what form of vascular disease is involved and where in the brain the disease is manifesting. Small strokes can be devastating in the wrong area, such as the angular gyrus, basal forebrain or the brain stem. There can be bleeding strokes from hypertension. It’s difficult to know if this causes cognitive impairment. Increasingly we’re dealing with a multifactorial process. It’s about identifying and treating emerging problems, depression, diet, physical activities and environmental support. Wellness and environmental support are critical.

Audience feedback, dementia resources and toolkit
Feedback from attendees of the FPA Dementia Institute showed that 97.9 percent of those responding (48) said the quality of faculty was excellent or very good. Of those responding, 79.6 percent said they anticipate making changes to their practice based on the program.

Faculty members offered the following resources:

Dementia Toolkit

- Symptoms of Dementia: Differential Diagnosis

- Dementia Clinical Pearls

- Dementia Toolkit

- Choosing Wisely: Ten Things Clinicians and Patients Should Question

- Choosing Wisely: Feeding Tubes for People with Alzheimer's Disease

- Choosing Wisely: Treating Disruptive Behavior in People with Dementia

- Minneapolis Clinic of Neurology: Occupational Therapy and Dementia Care

- Caregiver Assurance Fact Sheet

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