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Dementia

- Depression and insomnia - Depression - Selective serotonin reuptake inhibitors (SSRIs): Initiate low doses, citalopram (Celexa) 10 mg/day; escitalopram (Lexapro) 5 mg/day; sertraline (Zoloft) 25 mg/day. - Adverse events: nausea, vomiting, agitation, parkinsonian effects, sexual dysfunction, hyponatremia - Venlafaxine, mirtazapine, and bupropion are also useful.

para>Black box warning on antipsychotics due to increased mortality in elderly with dementia

  • Depression and insomniaDepressionSelective serotonin reuptake inhibitors (SSRIs): Initiate low doses, citalopram (Celexa) 10 mg/day; escitalopram (Lexapro) 5 mg/day; sertraline (Zoloft) 25 mg/day.Adverse events: nausea, vomiting, agitation, parkinsonian effects, sexual dysfunction, hyponatremiaVenlafaxine, mirtazapine, and bupropion are also useful.Sleep disturbancesLow-dose antidepressants (e.g., Remeron) have significant sedative properties at 7.5 or 15 mg.Trazodone 25 to 100 mg is frequently used because of better side effect profile.Psychosis and agitation/aggressive behaviorSome data for SSRIsBenzodiazepines if agitation with anxiety; in elderly, use PRN

Geriatric Considerations

Initiate pharmacotherapy at low doses and titrate slowly up if necessary.

  • Benzodiazepine are potentially inappropriate for older adults, yet their use persists

ALERT

Benzodiazepine use is associated with increased fall risk (5)[B].

  • Watch decreased renal function and hepatic metabolism.

ISSUES FOR REFERRAL

Neuropsychiatric evaluation particularly helpful in early stages or mild cognitive impairment

ADDITIONAL THERAPIES

Behavioral modification

  • Socialization, such as adult daycare, to prevent isolation and depression
  • Sleep hygiene program as alternative to pharmaceuticals for sleep disturbance
  • Scheduled toileting to prevent incontinence

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Vitamin E is no longer recommended due to lack of evidence
  • Ginkgo biloba is not recommended due to lack of evidence.
  • NSAIDs, selegiline, and estrogen lack efficacy and safety data.

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Worsening physical health issues
  • Psychiatry admission may be required because of safety concerns (self-harm/harm to others), self-neglect, aggressive behaviors, or other behavioral issues.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Progression of cognitive impairment by use of standardized tool (e.g., MMSE, ADAS-Cog)
  • Development of behavioral problems: sleep, depression, psychosis
  • Adverse events of pharmacotherapy
  • Nutritional status
  • Caregiver evaluation of stress
  • Evaluate issues that may affect quality of life.

PATIENT EDUCATION

  • Safety concerns
  • Long-term issues: management of finances, medical decision making, possible placement when appropriate; legal guardianship, if necessary, to avoid capacity and competency issues
  • Advance directives
  • National Institute on Aging. About Alzheimer's disease: other dementias. http://www.nia.nih.gov/alzheimers/topics/other-dementias

PROGNOSIS

  • AD: usually steady progression leading to profound cognitive impairmentAverage survival of AD is about 8 years.
  • VaD: incrementally worsening dementia, but cognitive improvement is unlikely
  • Secondary dementias: Treatment of the underlying condition may lead to improvement. Commonly seen with normal pressure hydrocephalus, hypothyroidism, and brain tumors.

COMPLICATIONS

  • Wandering
  • Delirium
  • Sundowner syndrome: It is frequently common in older people (who are sedated) and also in people who have dementia (adverse reaction to small dose of psychoactive substances).
  • Falls with injuryHip fractureHead trauma/hematomas
  • Neglect and abuse
  • Caregiver burnout

REFERENCES

11 McGuinness B, Craig D, Bullock R, et al. Statins for the prevention of dementia. Cochrane Database Syst Rev. 2009;(2):CD003160.22 Blass DM, Rabins PV. In the clinic. Dementia. Ann Intern Med. 2008;148(7):ITC4-1-ITC4-16.33 van Harten AC, Kester MI, Visser PJ, et al. Tau and p-tau as CSF biomarkers in dementia: a meta-analysis. Clin Chem Lab Med. 2011;49(3):353-366.44 Birks J. Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database Syst Rev. 2006;(1):CD005593.55 Softic A, Beganlic A, Pranjic N, et al. The influence of the use of benzodiazepines in the frequency falls in the elderly. Med Arch. 2013;67(4):256-259.

ADDITIONAL READING

  • Lyketsos CG, Colenda CC, Beck C. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry. 2006;14(7):561-572.
  • National Collaborating Centre for Mental Health. Dementia: The NICE-SCIE Guideline on Supporting People with Dementia and Their Carers in Health and Social Care. London, United Kingdom: British Psychological Society, Royal College of Psychiatrists; 2007. (National clinical practice guideline number 42). http://www.nice.org.uk/nicemedia/live/10998/30320/30320/pdf
  • Rabins PV, Blacker D, Rovner BW, et al; APA Work Group on Alzheimer's Disease and Other Dementias. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007;164(12)(Suppl):5-56.

SEE ALSO

Algorithm: Dementia

CODES

ICD10

  • F03 Unspecified dementia
  • G30.9 Alzheimer's disease, unspecified
  • F01.50 Vascular dementia without behavioral disturbance
  • G31.83 Dementia with Lewy bodies

ICD9

  • 331.0 Alzheimer's disease
  • 290.40 Vascular dementia, uncomplicated
  • 290.42 Vascular dementia, with delusions

SNOMED

  • 52448006 Dementia (disorder)
  • 429998004 Vascular dementia
  • 191464005 Arteriosclerotic dementia with delirium (disorder)
  • 191466007 arteriosclerotic dementia with depression (disorder)
  • 371024007 Senile dementia with delusion (disorder)
  • 191461002 Senile dementia with delirium
  • 15662003 Senile dementia (disorder)

CLINICAL PEARLS

  • Medications for AD show a small, statistically significant improvement in some cognitive measures, but it remains unclear if the improvement is clinically significant.
  • Do not forget the role of adult protective services in case of elderly abuse.
  • A particular concern in nursing homes relates to the use of physical restraints and antipsychotic medication, which are regulated in the United States by the Omnibus Reconciliation Act of 1987.