Associated Content

Transcript

 

Lee Tetreault:

Hello and welcome to frequently asked questions from the session, Managing Patients with Cognitive Decline. We are joined today by Dr. Stuti Dang, a professor of medicine in the Division of Geriatrics and Palliative Care at the University of Miami. Doctor, before we begin, can you provide a few key pointers for our audience from today's session? 

Stuti Dang: 

Absolutely. So as we think about managing patients with cognitive decline, some of the main things that we want to keep in mind are that cholinesterase inhibitors are the initial pharmacologic treatment of choice for all newly diagnosed patients with Alzheimer's dementia, and most patients who are newly diagnosed with vascular dementia, Parkinson's disease dementia, and dementia of Lewy body. Another thing to keep in mind is that the initial management of behavioral and psychological symptoms of dementia should always be non-pharmacologic. When feeding problems persist in this population despite conservative measures, we suggest continued oral feeding by hand rather than tube feeding for nutritional support. This is also one of the recommendations of the Choosing Wisely campaign. It's also important to assess and support the caregiver of the person with dementia. Caregivers are at high risk for physical and emotional strain. We can offer caregiving education and counseling, refer them to support groups and offer technology-based support, and also offer care planning and care coordination. These are really key.

Lee Tetreault:

Okay, so let's get into some of these frequently asked questions. First, how often do we routinely screen older adults for cognitive impairment? 

Stuti Dang: 

Asymptomatic older adults are not routinely screened for cognitive impairment. The United States Preventive Services Task Force and the American Academy of Neurology do not make recommendations for or against screening asymptomatic adults for impairment. However, if we see somebody that has any of the dementia warning signs or with concerns about memory from themselves or their family members, they definitely deserve a full workup.

Lee Tetreault:

What is the initial management of the behavioral and psychological symptoms of dementia? 

Stuti Dang: 

Non-pharmacologic interventions are always preferred and should be tried first. Research on the effectiveness of non-pharmacological interventions has increased over the last few years and has shown that there is positive impact on both the person living with dementia and on the family caregiver when non-pharmacologic interventions are used. For example, educating family caregivers has been shown to be as effective at reducing agitation as pharmacologic therapy. Music therapy, exercise, and other forms of activity and recreation have also been shown to help with behavioral and psychological symptoms of dementia.

Lee Tetreault:

So what are the latest recommendations on the pharmacological treatment of Alzheimer's dementia? 

Stuti Dang: 

So if we sorted by the stage of dementia, all newly diagnosed Alzheimer's dementia and most patients who are newly diagnosed with vascular dementia, Parkinson's disease, and dementia with Lewy bodies should be tried with cholinesterase inhibitors. For moderate Alzheimer's dementia, we should continue or start cholinesterase inhibitor as the case may be. We also recommend supplementing with vitamin E, unless the patient is on a combination with memantine with the cholinesterase inhibitor. For patients who have moderate to advanced Alzheimer's dementia, we recommend adding memantine to cholinesterase inhibitors. Use memantine alone in patients who do not tolerate or benefit from a cholinesterase inhibitor. Once prescribed, the cholinesterase inhibitors must be closely monitored for cognitive benefits and adverse GI effects at regular intervals.

Lee Tetreault:

Is hospitalization helpful for those with advanced dementia? 

Stuti Dang: 

Hospitalizations are absolutely not helpful. In fact, they're traumatic for patients with advanced dementia and are often unnecessary. Hospital transfer should be avoided unless clearly needed to achieve the desired goals of care for the patient.

Lee Tetreault:

What is the best way to maintain nutritional support in advanced dementia? 

Stuti Dang: 

It's important to remember that feeding problems are the most common clinical complication and source of treatment decisions in advanced dementia. Conservative measures that may be used to improve oral intake include altering the texture of food and offering finger foods, giving smaller portions at multiple times of the day, giving them the patient's favorite foods and nutritional supplements. When feeding problems persist despite conservative measures, we suggest continued oral feeding by hand rather than tube feeding for nutritional support. This is also one of the recommendations of the Choosing Wisely campaign. 

Lee Tetreault:

What should we include in comprehensive dementia care? 

Stuti Dang: 

In comprehensive dementia care, it's important to remember to do caregiver assessments, care coordination, education of the patient and the caregiver, community partnerships, and clinician training. Health systems and clinicians must train their workforce to systematically identify patients with dementia, and their caregivers, and to reorganize their workflows to include comprehensive caregiver assessment followed by matching services to the needs of the patients and the caregivers.

Lee Tetreault:

Can patients develop vascular dementia without clinical evidence of a stroke? 

Stuti Dang: 

Absolutely. Vascular dementia can manifest as a progressive or a stepwise cognitive decline without a concurrent history of symptomatic stroke, but with imaging evidence of clinically unrecognized cerebrovascular disease. Although frequently caused silent, this clinically unrecognized cerebrovascular disease is better termed covert because it is associated with lower cognitive performance and elevated risk for dementia. An MRI is more sensitive than the CAT scan for signs of cerebral small vessel disease, including microbleeds that can point to a diagnosis of cerebral amyloid angiopathy in this case.

Lee Tetreault:

What are the recommendations on treating agitation in dementia with antipsychotics? 

Stuti Dang: 

Atypical neuroleptics have been the agents of choice for treating psychotic symptoms and agitation in patients with dementia. Given the risk of increased mortality associated with the use of atypical neuroleptics in older adults with dementia, they're not approved by the FDA for this purpose. Their use is reserved for patients who have neuropsychiatric symptoms, particularly psychosis that are severe, debilitating, or posing a safety risk. Discontinuation of these atypical neuroleptics should be attempted at regular intervals, weighing the risk of relapse versus the risk of adverse effects from continued treatment. Patients with dementia of Lewy body are at especially high risk of severe side effects with neuroleptic medications.

Lee Tetreault:

And lastly doctor, what pharmacological treatment has the most benefit in dementia with Lewy bodies? 

Stuti Dang: 

According to research, donepezil and rivastigmine have shown improvements in cognition, hallucination, delusions, and ADLs without worsening motor symptoms of Parkinsonism in patients with dementia with Lewy bodies while galantamine has the potential for benefits for psychiatric symptoms and possibly for cognition. Memantine has not shown sufficient evidence of benefit and is not used in patients who have dementia with Lewy bodies.

Lee Tetreault:

This is great information, Doctor. Thank you so much for your time today.

Stuti Dang: 

Thank you.