OHSU Presentation Template - White

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Mental Health and Older Adults in Primary Care
Setting Part I Normal Changes vs
Neurocognitive Disorders
Presented by Ruth Tadesse, MS, RN
Date 04/09/15
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Disclosures and Learning Objectives

• Learning Objectives
• Recognize at least 4 important normal changes in
  healthy aging brain.
• Identify 3 main early symptoms of
  Neuropsychiatric cognitive Disorders.
• Know screening tools used in early stages of
  dementia.
• Identify DSM 5 criteria used to diagnose Minor
  and Major Neurocognitive Disorders
• Disclosures Ruth Tadesse has nothing to
  disclose.

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Normal Changes in the Healthy Aging Brain

• Prefrontal cortex and the hippocampus will start
  shrinking.
• Communication between neurons and
  neurotransmitters will be reduced.
• Blood flow can be reduced because arteries will
  start to narrow.
• http//www.nia.nih.gov/alzheimers/publication/part
  -1-basics-healthy-brain/changing-brain-healthy-agi
  ng

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Normal Changes in the Healthy Aging Brain

• Plaques and tangles can develop outside of and
  inside neurons in much smaller amounts.
• Free radicals increases.
• Inflammation increases.
• http//www.nia.nih.gov/alzheimers/publication/part
  -1-basics-healthy-brain/changing-brain-healthy-agi
  ng
• http//www.nia.nih.gov/alzheimers/alzheimers-disea
  se-video

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Normal Changes in Aging andMental Function in
Healthy Older Adults

• Modest decline in the ability to learn new things
  and retrieve information, such as remembering
  names may be common.
• Difficulty in performing complex tasks on
  attention, learning, and memory than a young
  person is not uncommon.
• It is important to note, given enough time to
  perform the task, the scores of healthy people in
  their 70s and 80s are often similar to those of
  young adults.
• http//www.nia.nih.gov/alzheimers/publication/part
  -1-basics-healthy-brain/changing-brain-healthy-agi
  ng

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Changes in brain caused by Alzheimer's Disease
(AD)

• Amyloid plaques are found in the brain in large
  numbers in the spaces between the nerve cells.
• Neurofibrillary tangles increase and collapses
  neurons internal transport network. This
  collapse damages the ability of neurons to
  communicate with each other.
• Gradual loss of connections between neurons leads
  to significant brain atrophy.
• The destruction and death of nerve cells
  causes the memory failure, personality changes,
  problems in carrying out daily activities, and
  other features of the disease.
• http//www.nia.nih.gov/alzheimers/publication/part
  -2-what-happens-brain-ad/hallmarks-ad

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Brain Atrophy What is normal?http/
/coloradodementia.org/
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Neuropsychiatric Symptoms (NPS) seen in Patients
with Neurocognitive Disorders (ND)

• NPS of dementia include psychosis, depressed or
  labile mood, anxiety, irritability, apathy,
  euphoria, disinhibition, aggression, sleep
  disturbance and disordered eating.
• Virtually all patients with the diagnosis of ND
  exhibit some NPS during the first 6 years of
  their illness.
• Agitation is the most prevalent symptom (with
  rates up to 80) in community dwelling patients.
• Borsje, P., et al. (2015). The course of
  neuropsychiatric symptoms in community-dwelling
• patients with dementia a systematic review.
  International Psychogeriatrics / IPA,
• 27(3), 385-405.

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Question about The Haves and the Have Nots

• Why do some people remain cognitively healthy
  as they get older while others develop
  Neurocognitive Disorders or Dementia?
• Cognitive Reserve may provide some
  insights.
• Cognitive reserve refers to the brains ability
  to operate effectively even when some function is
  disrupted. It also refers to the amount of damage
  that the brain can sustain before changes in
  cognition are evident.
• People vary in the cognitive reserve they have.
• http//www.nia.nih.gov/alzheimers/publication/part
  -1-basics-healthy-brain/changing-brain-healthy-agi
  ng

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Normal Aging vs Neurocognitive Disorders

• Depending on a persons cognitive reserve and
  unique mix of genetics, environment, and life
  experiences, the balance may tip in favor of a
  disease process that will ultimately lead to
  neurocognitive disorders or dementia.
• For another person, with a different reserve and
  a different mix of genetics, environment, and
  life experiences, the balance may result in no
  apparent decline in cognitive function with age.
• http//www.nia.nih.gov/alzheimers/publication/part
  -1-basics-healthy-brain/changing-brain-healthy-agi
  ng

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Factors that could explain differences in
Cognitive Reserve

• Variability in cognitive reserve depends on
  factors such as differences in genetics,
  education, occupation, lifestyle, leisure
  activities, or other life experiences.
• These factors could provide a certain amount of
  tolerance and ability to adapt to change and
  damage that occurs during aging.
• http//www.nia.nih.gov/alzheimers/publication/part
  -1-basics-healthy-brain/changing-brain-healthy-agi
  ng

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Making the diagnosis of Neurocognitive Disorders
or Dementia Changes from DSM IV DSM
5

• Dementia on DSM IV was recognized
• under Delirium, Dementia, Amnestic, and Other
  Cognitive Disorders.
• Dementia has been eliminated and have been
  replaced as Major or Minor Neurocognitive
  Disorders on DSM 5.
• http//www.todaysgeriatricmedicine.com/archive/110
  612p12.shtml

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Subtypes of Dementia (Brunnstroom, H., et al,
2009)
Brunnström, H., Gustafson, L., Passant, U.,
Englund, E. (2009). Prevalence of
dementia subtypes a 30-year retrospective
survey of neuropathological reports. Archives
Of Gerontology And Geriatrics, 49(1), 146-149.
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Subtypes of Dementia (Keefover, R.W.,
2013)Dementia
Examined.docx
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Age Is a Strong Factor!
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Prevalence of Dementia in other Countries
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Dementia Progression

• http//www.nia.nih.gov/alzheimers/publication/part
  -2-what-happens-brain-ad/changing-brain-ad

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Common Screening Tools in Primary Care related to
assessment of NC Disorders

• Standard history and physical exam
• Functional Status (FAQ)
• Mental State Examination (MOCA, MMSE, GDS)
• Labs (CBC, Electrolytes, Kidney Function,
  Glucose, TSH, Vit. D, Vit. B12, and Drug Levels)
• Family/Caregiver interview to rule out personal
  strain, and assess patient behavior changes
• Refer to neurologist if suspected Mild or Major
  Neurocognitive Disorders
• Dementia Examined.docx

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Flowchart for Early Identification of Dementia
(National Alzheimer's Organization, 2003)
Interview family or caregivers
Evaluate signs/symptoms for possible dementia
using Ten Warning Signs
Assess reassess s/sxs using MMSE every 6 months
Negative workup
Initial Dementia Assessment
Uncertain results
Delirium or depression
Treat Reassess
Care management family support
https//www.alz.org/national/documents/brochure_to
olsforidassesstreat.pdf
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DSM 5 Criteria Minor Neurocognitive Disorder

• Modest cognitive decline from a previous level of
  performance
• The cognitive deficits do not occur exclusively
  in the context of a delirium
• The cognitive deficits are not primarily
  attributable to another mental disorder (eg,
  major depressive disorder, schizophrenia).
• Note that in diagnosing a minor neurocognitive
  disorder, one and two standard deviations below
  appropriate norms is required.
• American Psychiatric Association ((APA) (2013).
  Diagnostic and Statistical Manual of Mental
  Disorders. (5th ed.) Washington, DC American
  Psychiatric Association Press

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DSM 5 Criteria Major Neurocognitive Disorder

• Evidence of substantial cognitive decline from a
  previous level of performance.
• The cognitive deficits are sufficient to
  interfere with independence.
• The cognitive deficits are not primarily
  attributable to another mental disorder (e.g,
  major depressive disorder, schizophrenia).
• In diagnosing a major neurocognitive disorder,
  two or more standard deviations below appropriate
  norms are required.
• American Psychiatric Association ((APA) (2013).
  Diagnostic and Statistical Manual of Mental
  Disorders. (5th ed.) Washington, DC American
  Psychiatric Association Press.

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What is the best way to manage symptoms of
neurocognitive disorders?

• All atypical antipsychotic medications include a
  Black Box warning regarding the increased risk of
  mortality in elderly people with dementia-related
  psychosis (FDA, 2005) and they have required a
  similar warning for conventional antipsychotics
  since 2008 (FDA, 2008).
• Current guidelines (AMDA, 2012 Herrmann,
  Lanctôt, Hogan, 2014 NICE SCIE, 2006)
  suggest that people with dementia should be
  prescribed antipsychotics only in cases in which
  they are severely distressed (severe agitation,
  aggression and psychosis) and/or there is
  immediate risk of harm.
• In addition, most guidelines also recommend that
  antipsychotic medications be used in a
  time-limited fashion. Dementia medications such
  as Namenda are underutilized and should be
  considered for both Mild and Major ND.

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Preventing Memory Loss w/ Current Evidence
http//tucson.com/news/science/ua-researcher-barne
s-provides-insights-into-aging-memory/article_9319
afe0-b21d-59dc-af76-a5a00f87a27a.html
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References

• American Medical Directors Association (AMDA).
  (2012). Dementia in the long term care setting.
  Columbia (MD) American Medical Directors
  Association (AMDA).
• Borsje, P., Wetzels, R. B., Lucassen, P. L., Pot,
  A. M., Koopmans, R. T. (2015). The course of
  neuropsychiatric symptoms in community-dwelling
  patients with dementia a systematic review.
  International Psychogeriatrics / IPA, 27(3),
  385-405.
• Brunnström, H., Gustafson, L., Passant, U.,
  Englund, E. (2009). Prevalence of dementia
  subtypes a 30-year retrospective survey of
  neuropathological reports. Archives Of
  Gerontology And Geriatrics, 49(1), 146-149.
• Hebert, L. E., Weuve, J., Scherr, P. A., Evans,
  D. A. (2013). Alzheimer disease in the United
  States (2010-2050) estimated using the 2010
  census. Neurology, 80(19), 1778-1783.
• Herrmann, N., Lanctôt, K. L., Hogan, D. B.
  (2013). Pharmacological recommendations for the
  symptomatic treatment of dementia the Canadian
  Consensus Conference on the Diagnosis and
  Treatment of Dementia 2012. Alzheimer's Research
  Therapy, 5(Suppl 1), S5.
• Kales, H. C., Gitlin, L. N., Lyketsos, C. G.
  (2014). Management of neuropsychiatric symptoms
  of dementia in clinical settings recommendations
  from a multidisciplinary expert panel. Journal Of
  The American Geriatrics Society, 62(4), 762-769.

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References

• Ma, H., Huang, Y., Cong, Z., Wang, Y., Jiang, W.,
  Gao, S., Zhu, G. (2014). The efficacy and
  safety of atypical antipsychotics for the
  treatment of dementia a meta-analysis of
  randomized placebo-controlled trials. Journal Of
  Alzheimer's Disease JAD, 42(3), 915-937.
• NICE and SCIE (2006) Dementia Supporting People
  with Dementia and their Carers in Health and
  Social Care. NICE clinical guideline 42.
  Available at www.nice.org.uk/CG42
• Plassman, B.L., Langa, K.M., Fisher, G.G.,
  Heeringa, S.G., Weir, D.R., Ofstedal, M.B.,
  Burke, J.R., Hurd, M.D., Potter, G.G., Rodgers,
  W.L., Steffens, D.C., Willis, R.J., Wallace, R.B.
  (2007). Prevalence of Dementia in the United
  States The Aging, Demographics, and Memory
  Study. Neuroepidemiology. 29125-132.
• U.S. Food and Drug Administration (FDA). (2005).
  Public Health Advisory Deaths with
  Antipsychotics in Elderly Patients with
  Behavioral Disturbances. Available at
  http//www.fda.gov/Drugs/DrugSafety/PostmarketDrug
  SafetyInformationforPatientsandProviders/ucm053171
  .htm
• U.S. Food and Drug Administration (FDA). (2008).
  FDA Requests Boxed Warnings on Older Class of
  Antipsychotic Drugs. Available at
  http//www.fda.gov/NewsEvents/Newsroom/PressAnnoun
  cements/2008/ucm116912.htm
•  

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End of Gero. Series Part I

• Next Week
• Medications
• Older Adults
• By Dr. Ann Hamer
• 04/16/15