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CLARIFYING  DEMENTIA  DISORIENTATION G. Blair Sarbacker, Pharm.D. Assistant Professor of Pharmacy Practice University of the Incarnate Word Feik School of Pharmacy

Disclosures Clarifying Dementia Disorientation is accredited by ACPE for pharmacists, ACPE 0154­0000­15­045­L01­P, and technicians, ACPE 0154­0000­15­045­L01­T, for 1 contact hour. Blair Sarbacker has not disclosed any financial or conflicts of interest in relation to this program.

What is Dementia?  An acquired syndrome of decline in memory and at least 1 other cognitive function sufficient to affect daily life in an alert patient  Language, executive, etc

 Progressive & disabling  Not a normal aspect of aging

AGS. A Guide to Dementia Diagnosis and Treatment

Learning Objectives At the end of this program, pharmacists and technicians should be able to:  Differentiate between the most common types of dementia  In a case scenario, recommend the appropriate medications for dementia, based on the type and stage of dementia  When reviewing a medication list, identify drugs that can potentiate dementia or induce delirium in patients with dementia

Alzheimer’s Association. Alzheimer’s Facts & Figures.

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Normal Aging

Frequencies of Dementia Causes

 Some decline in processing and recall of new information

Frequency

 Slower, harder

 Reminders work

Alzheimer's

5%

 Visual tips, notes

35%

 Word finding difficulty

60%

 Difficulty with divided attention  No consistent, progressive deviations on testing of memory

Completely Reversible Causes**

 Absence of significant effects on ADLs or IADLs due to cognition AGS. Dementia. Geriatrics Evaluation & Management Tools.

Other Progressive Disorders*

AGS. A Guide to Dementia Diagnosis and Treatment

Activities of Daily Living (ADLs)

Mild Cognitive Impairment

 D ressing

 Memory problem without deficits in other domains

 E ating

 Objective impairment with validated memory screening tools

 A mbulating  T oileting  H ygiene – bathing

 No functional impairment  Absence of delirium  12% per year progress to Alzheimer’s disease  SLUMS 21­26 (w/ high school education)  MMSE 26­30  FAST 3

Katz Index of Independence in Activities of Daily Living (ADL). Ann Longterm Care. 2006;14(11).

AGS. Dementia. Geriatrics Evaluation & Management Tools. AGS. A Guide to Dementia Diagnosis and Treatment.

Instrumental Activities of Daily Living (IADLs)

Delirium vs. Dementia

 S hopping

Delirium and dementia can occur together. The distinguishing signs of delirium are:

 H ousework – cleaning, laundry  A ccounting



 F ood Preparation  T ransportation  M edication management

The Lawton Instrumental Activities of Daily Living (IADL) Scale. Ann Longterm Care. 2007; 15(7).

 

Disturbance in attention and awareness  Acute onset (hours to days)  Fluctuates in severity Additional disturbance in cognition Has an attributable cause

APA: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

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Types of Dementia

Progression of Dementia Mild

 Vascular Dementia

MMSE 21­25 SLUMS 1­20 (HS) FAST 4

• • • •

Disoriented to date Naming difficulties Mild difficulty copying figures Problems managing finances

•Recent recall problems • Decreased insight • Irritability, mood change • Social withdrawal

 Lewy Body Dementia

Moderate

• • • •

Disordered to date, place Comprehension difficulties Impaired calculating skills Impaired new learning

• Getting lost in familiar places • Problems with dressing, grooming • Not cooking, shopping, banking • Restless, anxious, depressed • Delusions, agitation, aggression

Severe

• Remote memory gone • Nearly unintelligible verbal output • Unable to copy or write

• No longer grooming or dressing • Incontinent • Motor or verbal agitation

 Alzheimer Disease

 Frontotemporal Dementia  Normal Pressure Hydrocephalus

MMSE 11­20 SLUMS 1­20 (HS) FAST 5­6

MMSE 0­10 SLUMS 1­20 (HS) FAST 7

AGS. A Guide to Dementia Diagnosis and Treatment.

Patient Case Scenario LP is a 67 year old female who presents with increased confusion. She was recently discharged from the hospital after having a stroke. Her SLUMS shows dementia.

Alzheimer Disease (AD) Onset

Gradual

Cognitive Symptoms

Primarily memory with difficulty learning new information

Motor Symptoms

Rare early, apraxia later

Progression

Gradual, over 8–10 yr on average

Imaging

Possible global atrophy, small hippocampal volumes

AGS. Dementia. Geriatrics Evaluation & Management Tools.

Alzheimer Disease – DSM-5 All three of the following are present:

1. Clear evidence of decline in memory and learning and at least one other cognitive domain  Complex attention, executive function, perceptual­motor, social cognition

2. Steadily progressive, gradual decline in cognition, without extended plateaus 3. No evidence of mixed etiology APA: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

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Alzheimer’s Disease

Frontotemporal Dementia

 Early onset: 40 – 64  Late onset: 65 and older

Alzheimer’s Association. What is Alzheimer’s.

Vascular Dementia

Onset

Gradual, usually age 3 days, reinitiate with lowest daily dose and titrate  Max dose 13.3 mg/24 hour – higher doses confer no additional benefit Exelon [package insert]. Novartis, East Hanover, NJ; Oct. 2013. Micromedex® Healthcare Series [Internet database].

 Mild to moderate Alzheimer’s dementia

 Evidence

 Numerous large, prospective, randomized, double­blind, placebo­controlled studies  3 – 6 months duration  Mild to moderate Alzheimer disease  Efficacy when dosed at 24 mg/day  Mean improvement of 3 to 4 point ADAS­cog

Galantamine [package insert]. Apotex Corp. Weston, FL; Sept. 2013. Micromedex® Healthcare Series [Internet database].

Rivastigmine (Exelon®)

Galantamine (Razadyne®, Razadyne ER®)

 Converting from oral to transdermal  Apply first patch on day following last oral dose  Can increase after 4 weeks

 Renal, hepatic – 4.6 mg/24 h max dose  Body weight