Скачать презентацию Dementia in Clinical Practice Mary Ann Forciea Скачать презентацию Dementia in Clinical Practice Mary Ann Forciea

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Dementia in Clinical Practice • Mary Ann Forciea MD • Clinical Prof of Medicine Dementia in Clinical Practice • Mary Ann Forciea MD • Clinical Prof of Medicine • Division of Geriatric Medicine • UPHS • Photo: Nat Geographic

Who has dementia? • 78 yr old retired librarian • Lives alone, children visit Who has dementia? • 78 yr old retired librarian • Lives alone, children visit on holidays • Family concerned about ‘clutter’ in house, hygiene, unpaid bills • 68 yr old child care worker • Lives with her husband, drives, in charge of ‘house money’ • “Forgot” a child in classroom at end of day

Who has dementia (2) ? • 84 yr old urology inpatient • 70 yr Who has dementia (2) ? • 84 yr old urology inpatient • 70 yr old homebound patient – Post op day 1: hostile – Bedbound, mute – Family caregivers – Oral intake decreasing • Attempts to strike nurse with cane • Refusing blood draw • Pulled out catheter

Terms • Dementia – Chronic, progressive – Impairment in >1 “domain of cognition” • Terms • Dementia – Chronic, progressive – Impairment in >1 “domain of cognition” • Memory, language use, executive function(judgment), attention, coordination • Mild cognitive impairment – Impairment in 1 “domain of cognition” – ? “pre-dementia” • Delirium – Short term

How do we know about Brain Function? • Cell structure – Microscope (biopsy, cell How do we know about Brain Function? • Cell structure – Microscope (biopsy, cell culture) – CT, MRI, PET scans • Brain regions – imaging • “Domains” of cognition – Imaging – Psychological testing

Cell structure: Neurons • Networks • Grey matter/white matter Cell structure: Neurons • Networks • Grey matter/white matter

Brain regions • Regions have different activities Brain regions • Regions have different activities

Domains of cognition • • • Memory Calculation Language Orientation Spatial construction Executive function Domains of cognition • • • Memory Calculation Language Orientation Spatial construction Executive function (judgment)

Mapping Memories Natl Geographic Mapping Memories Natl Geographic

What is wrong in dementia? Theories Neurons: waste products, shape of cells, signaling, genetic What is wrong in dementia? Theories Neurons: waste products, shape of cells, signaling, genetic flaws Regions: biochemistry, structure Domains: communication We don’t yet know.

Clinical observations • All patients with dementias are not alike. – Age of onset Clinical observations • All patients with dementias are not alike. – Age of onset – Family history – Initial symptom – Most troublesome symptom – Rate of progression – Response to treatment • Is dementia a symptom, not a disease?

Dementia Subtypes • Alzheimer’s Disease • Fronto-temporal dementia (formerly Pick’s Disease) – 15% • Dementia Subtypes • Alzheimer’s Disease • Fronto-temporal dementia (formerly Pick’s Disease) – 15% • Corticobasilar dementias • Dementia with Lewy Bodies – 20% – Distinguished from Parkinson’s Disease with dementia • Vascular disease

Alzheimer’s type dementia • Gradual onset • Global impairment in cognition – Usually memory Alzheimer’s type dementia • Gradual onset • Global impairment in cognition – Usually memory impairment predominant • Increased risk in siblings – Apo e allele risk • Slow progression (5 -7 years) – Predictable course (global deterioration scores)

AD - pathology • Imaging • Neuropathology – quantity and location – Senile plaques AD - pathology • Imaging • Neuropathology – quantity and location – Senile plaques • White matter • Amyloid core – Neurofibrillary tangles • Tau protein abnormalities – Initial concentrations highest in hippocampus and temporal lobes

Plaques Plaques

Tangle Tangle

What clinical problems do patients with Alzheimer’s Dementia Encounter? • Diagnosis • Symptom Management What clinical problems do patients with Alzheimer’s Dementia Encounter? • Diagnosis • Symptom Management • End of life care

Case 1 NC • 64 yr old retired OR nurse • Referred for evaluation Case 1 NC • 64 yr old retired OR nurse • Referred for evaluation of impaired memory – Birthdates, telephone numbers – Impaired job performance for 1 -2 yrs prior – Inability to ‘balance checkbook’ • Gradual decline over 5 years • Died of pneumonia

Diagnosis • • Largely on history Exclude other conditions Role for biomarkers in near Diagnosis • • Largely on history Exclude other conditions Role for biomarkers in near future Staging – Mental status testing (MMSE, MOCA, Mini. Cog) – Functional status staging (FAST, GDR)

Biomarkers for Alzheimer’s Dementia • Apo lipo protein E subtypes – Apo E-2, E-3, Biomarkers for Alzheimer’s Dementia • Apo lipo protein E subtypes – Apo E-2, E-3, E-4 • 2 copies of E 4 increases risk in some populations • Spinal fluid ‘tau’ protein levels • PET scans for amyloid – People with unexplained MCI – Patients with an unusual course – Early onset dementia

Concerns about PET scans • How specific is an abnormal test? • May not Concerns about PET scans • How specific is an abnormal test? • May not be useful for staging – (how advanced is the disease) • Will abnormal scans result in ‘overdiagnosis’ employment or insurance implications?

FAST • • The FAST scale has seven stages: 1 which is normal adult FAST • • The FAST scale has seven stages: 1 which is normal adult 2 which is normal older adult 3 which is early dementia 4 which is mild dementia 5 which is moderate dementia 6 which is moderately severe dementia 7 which is severe dementia

7 a. speaking limited to 6 words or fewer in an average day b. 7 a. speaking limited to 6 words or fewer in an average day b. Speech ability limited to the use of a single intelligible word in an average day c. Ambulatory ability lost (cannot walk without personal assistance). d. Ability to sit up without assistance lost (e. g. , the individual will fall over if there are no lateral rests [arms] on the chair). e. Loss of the ability to smile.

AD - treatment • Improve all co-existing conditions! • Specific treatments – Cholinesterase inhibitors AD - treatment • Improve all co-existing conditions! • Specific treatments – Cholinesterase inhibitors • Donepazil, rivastigmine – Adrenergic stimulants • Memantine • Treatment of associated symptoms – Agitated behaviors • Non pharmacologic, environmental • drugs

End of life issues • Should be anticipated – Advance Directives, conversations with proxies End of life issues • Should be anticipated – Advance Directives, conversations with proxies • Goals of care – Nutrition – Hospitalization – Caregiver burdens – Hospice involvement

Summary • “Dementia” is a symptom complex • We are in the early stages Summary • “Dementia” is a symptom complex • We are in the early stages of understanding the pathology, and discovering effective treatment • Optimal care requires advance planning, caregiver involvement, and a team of professionals