Dementia in the Inpatient Rehabilitation Setting...attention, perceptual-motor, social cognition) – deficits must represent a decline from previous level of function and be severe

Dementia in the Inpatient Rehabilitation Setting

Ellen Chang, MDClinical Instructor

David Geffen School of Medicine at UCLADepartment of Neurology

A Sea of Innovation: 2019 Fall Educational Conference


Disclosures

• I have no relevant financial disclosures.


Outline

• Introduction

• Types of Dementia

• Patients with Dementia in Rehabilitation Setting

• Delirium and Dementia

• Goals of Inpatient Rehabilitation

• Interventions– Non-pharmacologic

– Pharmacologic

• Rehabilitation Outcomes in Patients with Dementia


Learning Objectives

• Introduction

• Types of Dementia

• Patients with Dementia in Rehabilitation Setting

• Delirium and Dementia

• Goals of Inpatient Rehabilitation

• Interventions– Non-pharmacologic

– Pharmacologic

• Rehabilitation Outcomes in Patients with Dementia


Introduction

• Dementia:– overall term for diseases and conditions characterized by a

decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, social cognition)

– deficits must represent a decline from previous level of function and be severe enough to interfere with daily function and independence

– not occurring in the context of delirium, and not attributable to other mental disorders (major depression, schizophrenia)

American Psychiatric Association. (2013). Diagnostic and statistical manual of

mental disorders (5th ed.). Arlington, VA


Introduction

• Diagnosis is based on a combination of the following:– Detailed history– Physical / Neurological / Neuropsychological Examination– Laboratory Tests– Imaging Findings

• The above will lead to “probable diagnosis” in most cases, with post-mortem autopsy identifying certain pathologic features required for “definite”


Introduction

Screenshot via Alz.org


Introduction

Screenshot via Alz.org

• Per RAND Corporation study 2013: “cost of dementia … more costly to the nation than either heart disease or cancer”

– NEJM April 2013: Greatest cost due to providing institutional and home-based long-term care


Introduction

• National Alzheimer’s Project Act (NAPA) signed into law by President Obama in 2011

– Aggressive coordinated national plan to accelerate research on AD & related dementia

– Provide better clinical care and services for people living with dementia and their families


Introduction

• Centers for Medicare & Medicaid Services (CMS) created National Partnership to Improve Dementia Care in Nursing Homes in 2012

– Partnering with federal & state agencies, nursing homes, other providers, advocacy groups, and caregivers to improve comprehensive dementia care

– Implement practices to enhance quality of life for people with dementia


Introduction

• Focused Dementia Care Survey– Started in 2014– Assess compliance with federal requirements related

to dementia care practices– Quality improvement for dementia care among

providers


Types of Dementia

Commonly seen in ARU:

• Alzheimer Disease

• Vascular Dementia

• Dementia with Lewy Bodies

• Parkinson Disease Dementia

– Parkinson Disease Psychosis

• Mixed

Cunningham EL, Mcguinness B, Herron B, Passmore AP. Dementia. Ulster

Med J. 2015;84(2):79-87.


Alzheimer Disease

• Most common: 50-75% of all dementias• Clinical Features:

– Age of Onset: Usually >60 years old• Doubles in prevalence every 5 years after 65 years old

– Diagnosis:• Cognitive impairment involving a minimum of 2:

– Memory, executive function, language, visuospatial, or changes in personality/behavior

– Most common symptoms:• Memory impairment (initially, primarily episodic memory)• Executive function and judgment/problem solving issues (poor

insight is common)• Behavioral and psychologic symptoms (later on)


Vascular Dementia

• Second most common: ~20%• Commonly Mixed dementia with Alzheimer Disease or

other dementias• Risk factors:

– Age, hypertension, hyperlipidemia, diabetes, smoking, prior strokes

• Diagnosis:– Temporal relationship between vascular events and

cognitive decline– “Step-wise” progression


Dementia with Lewy Bodies

• Prevalence ~4%• Diagnosis:

– Dementia (deficits usually in attention, executive function, visuospatial ability; memory impairment later on)

– Core features (2+ for “probable” diagnosis):• Fluctuating cognition with pronounced variations in attention and

alertness (~80%)• Recurrent visual hallucinations (>60%)• Rapid eye movement (REM) sleep behavior disorder (may precede other

symptoms) • Parkinsonism (bradykinesia, rest tremor, rigidity) (65-70%)

– Other supportive features:• Sensitivity to antipsychotic agents (>50%), repeated falls, autonomic

dysfunction, apathy/anxiety/depression


Parkinson Disease Dementia

• Prevalence 25-30% of patients with Parkinson Disease (PD)– At 15 years of duration, dementia (48%) or MCI (36%) – At 20 years, dementia prevalence is 83%

• Diagnosis:– Parkinson’s disease diagnosis preceding dementia– Cognitive impairment in at least 2 domains– At least 1 behavioral feature:

• Apathy• Depression/anxiety• Hallucinations (usually visual, well-formed) • Delusions (usually paranoid) • Excessive daytime sleepiness


Parkinson Disease Psychosis

• Associated with PD dementia, but can occur in patients with PD without meeting criteria for dementia

– Risk factor for developing PD dementia

• Common types of psychosis:– Hallucination

• Abnormal perception without physical stimulus• Any sensory modality: visual, auditory, tactile, olfactory, gustatory• May be simple or complex

– Sense of Presence• Experience that someone is present when no one is really there

– Sense of Passage• Fleeting, vague images in one’s peripheral vision

– Illusions– Delusions


• No studies specifically breaking down admission diagnoses in ARU for patients with dementia

• Dementia is not an IRF-compliant diagnosis for admission

Patients with Dementia in Rehabilitation Setting


Patients with Dementia in Rehabilitation Setting

Toot S, Devine M, Akporobaro A, Orrell M. Causes of hospital admission for

people with dementia: a systematic review and meta-analysis. J Am Med Dir

Assoc. 2013;14(7):463-70.


Delirium and Dementia

• Delirium– Disturbance in attention (reduced ability to focus, sustain,

or shift) and awareness– Develops over a short period of time (hours to days),

represents a change from baseline, and fluctuates during the course of the day

American Psychiatric Association. (2013). Diagnostic and statistical manual of

mental disorders (5th ed.). Arlington, VA


Predisposing/Precipitating Factors for Delirium

Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface

between delirium and dementia in elderly adults. Lancet Neurol.

2015;14(8):823-832.


Delirium and Dementia

Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The interface

between delirium and dementia in elderly adults. Lancet Neurol.

2015;14(8):823-832.


Goals of Inpatient Rehabilitation

• By the time patients with dementia reach ARU, there may have been a large shift from premorbid functioning

• Communicating clear expectations for patients and family members is key


Goals of Inpatient Rehabilitation

• Improve quality of life• Delay functional decline / maintain functional

independence• Identify other barriers that are impairing cognition

– Dementia is neurodegenerative, but other factors may be contributing to patient’s current debility:

• Deconditioning• Critical care myopathy• Stroke• Orthopedic procedures

• Focus on maintaining abilities rather than restoring disabilities

Cations M, Laver KE, Crotty M, Cameron ID. Rehabilitation in

dementia care. Age Ageing. 2018;47(2):171-174.


Interventions

• Care for a patient with dementia requires strong communication between all members of treatment team

– PT, OT, SLP, nursing, neuropsych, physicians may all have a different insights

– Maximizing rehabilitation potential takes patience and multidisciplinary coordination

• Structured program to:– Address specific symptoms– Identify goals meaningful to patients– Adapt as needs change

Cations M, Laver KE, Crotty M, Cameron ID. Rehabilitation in

dementia care. Age Ageing. 2018;47(2):171-174.


Interventions

• Cognitive Therapy:

– Restorative Strategy:• Aimed directly at improving, strengthening, or normalizing specific impaired

cognitive functions

– Compensatory Strategy:• Seek to provide alternative strategies for carrying out important activities

of daily living despite residual cognitive impairment

Cognitive, Rehabilitation Therapy for Traumatic Brain Injury Staff, et al.

Cognitive Rehabilitation Therapy for Traumatic Brain Injury : Evaluating the

Evidence, edited by Rebecca Koehler, National Academies Press, 2012.


Non-Pharmacologic Interventions

• Listen to the patient– Learn what the patient prefers to be called

– Understand the patient’s interests, passions

– Know the patient’s routine

• Integrate interests to engage patient in therapies

From CMS.gov



• Multisensory cues:– Nonverbal communication: gestures, reassuring touch

– Visual aids

– Approach patient from front

• Speak slowly and in simple phrases, positive commands

• Allow increased time for processing

• Minimize environmental distractions


• Avoid triggers for delirium:– Physical restraints

– Bladder catheter

– Manage sleep-wake cycle:• Lights on and blinds open during the day, reduce nighttime disruptions

– Sensory impairment• Visual/hearing aids when appropriate

• Reassurance and frequent reorientation

• De-escalate in moments of agitation

Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The

interface between delirium and dementia in elderly adults. Lancet Neurol.

2015;14(8):823-832.




From CMS.gov


Pharmacologic Interventions

• Treatment of causes of delirium:– Metabolic (uremia, hyponatremia, hypo/hyperglycemia,

metabolic acidosis)

– Infections

– Hypoxemia

– Dehydration

– Pain• Non-opioid medications preferred

Fong TG, Davis D, Growdon ME, Albuquerque A, Inouye SK. The

interface between delirium and dementia in elderly adults. Lancet Neurol.

2015;14(8):823-832.


Pharmacologic Interventions

• Examine medication list closely and avoid:– Benzodiazepines– Opioids– Drugs with anticholinergic propreties

• Antihistamines (Benadryl, Tylenol PM)• Drugs for overactive bladder (Oxybutynin)• Tricyclic antidepressants (Amitriptyilne)• Muscle relaxants (Cyclobenzaprine)

– For DLB:• Antipsychotics (hypersensitivity reactions: sudden deterioration,

mental status changes, severe parkinsonism)• PD drugs: anticholinergics (trihexyphenidyl, benztropine), dopamine

agonists, amantadine (worsened behavior, psychosis)

Armstrong MJ. Lewy Body Dementias. Continuum (Minneap Minn).

2019;25(1):128-146.


Managing Behavioral and Psychological Symptoms in Dementia (BPSD)• Includes: psychosis, agitation, depression, anxiety,

apathy, altered circadian rhythms

• Antidepressants:– Sertraline (may help with agitation)

– Citalopram (may help with psychosis, agitation)

– Trazodone (may help with agitation, helps with sleep)

– Mixed results with paroxetine, failed trials with fluoxetine

Madhusoodanan S, Ting MB. Pharmacological management of

behavioral symptoms associated with dementia. World J Psychiatry.

2014;4(4):72-9.


Managing Behavioral and Psychological Symptoms in Dementia (BPSD)• Antipsychotics:

– Black Box Warning: Increased risk of death due to cardiovascular events / infection

• Prescribe at lowest possible dose for shortest possible duration

– Olanzapine (helps with aggression)

– Risperidone (helps with psychosis, less with agitation)

– For dementia with Lewy Body: Quetiapine / Clozapine preferred – less parkinsonism, sedation, orthostatic hypotension

– For Parkinson disease psychosis: Pimavanserin (Nuplazid, FDA approved 2016)



2014;4(4):72-9.


Managing Behavioral and Psychological Symptoms in Dementia (BPSD)

• Resultant ~9% decrease in the prevalence of antipsychotic use for nursing home residents

From CMS.gov


Managing Behavioral and Psychological Symptoms in Dementia (BPSD)• Alzheimer Disease Medications

– Worth trialing early on, may delay/reduce symptoms of BPSD

– Cholinesterase inhibitors:• Donepezil, Galantamine, Rivastigmine (chronic, mild-mod BPSD)

– May be helpful for both AD and DLB• Memantine (improvement in Neuropsychiatric Inventory

Questionnaire)

• Sleep aids:– Melatonin (may also help with REM sleep behavior

disorder)



2014;4(4):72-9.


Managing Behavioral and Psychological Symptoms in Dementia (BPSD)


Rehabilitation Outcomes in Patients with Dementia

• Delirium superimposed on dementia is a strong predictor of functional dependence, institutionalization, and mortality in elderly admitted to ARU (Morandi et al, 2013)

– Importance of avoiding delirium

• Elderly patients with mild-mod dementia and hip fracture had comparable benefits in physical gains as cognitively intact patients (McFarlane, Isbel, & Jamieson, 2017)

– Benefit from early mobilization, delirium and pain management

• Pre-fracture functional impairment contributes more to poor outcomes than cognitive impairment (McGilton et al, 2016)

– Patients with cognitive impairment may regain mobility

Mcfarlane RA, Isbel ST, Jamieson MI. Factors determining eligibility and access to subacute rehabilitation for elderly

people with dementia and hip fracture. Dementia (London). 2017;16(4):413-423.

Mcgilton KS, Chu CH, Naglie G, Van wyk PM, Stewart S, Davis AM. Factors Influencing Outcomes of Older Adults

After Undergoing Rehabilitation for Hip Fracture. J Am Geriatr Soc. 2016;64(8):1601-9.

Morandi A, Davis D, Fick DM, et al. Delirium superimposed on dementia strongly predicts worse outcomes in older

rehabilitation inpatients. J Am Med Dir Assoc. 2014;15(5):349-54.


Questions?

Common Movement Disorders

Michael Su, MDAssistant Clinical Professor

David Geffen School of Medicine at UCLA

Department of Neurology



Disclosures

• I have no relevant financial disclosures.


Overview

• Parkinson’s Disease (PD)– Cardinal Features– Management

• Parkinson Plus Syndromes

• Essential Tremor


Learning Objectives

• Recognize the key features of PD (motor and non motor)

• Understand how to treat the most common symptoms of PD

• Distinguish PD from other movement disorders


HistoryFirst clear description recorded by James Parkinson in 1817:

Renamed Parkinson’s Disease in by William Gowers in 1888


Parkinson’s Disease

• 2nd most common neurodegenerative disease• Estimated 1-2 million people in the US have PD• Age is greatest risk factor, men > women

• Loss of dopaminergic cells in the substantia nigra


Classic Symptoms

Motor Non Motor

Resting Tremor REM Sleep Behavioral Disturbances

Rigidity Anosmia

Bradykinesia Cognitive Decline / Dementia

Postural instability Autonomic Dysfunction

Shuffling gait

-festination, freezing

-constipation, orthostatic hypotension,

sexual dysfunction

Depression / Anxiety

Pain

Visual Hallucinations

Asymmetric


Motor Symptoms


Motor Symptoms

Rest Tremor: first symptom in 50-70% of patients, usually suppressed by action but as disease progresses, will be seen with action, worse with stress. Very bothersome

Bradykinesia: leads of loss of fine motor coordination impaired ADL performance

Rigidity: may cause cramping, pain

Postural Instability / Impaired Gait: seen later in course, may see festination, freezing, retropulsion fall risk


Non Motor Symptoms

Often seen prior to onset of motor symptoms, sometimes up to a decade prior

Hyposmia / Anosmia

REM Sleep Behavior Disorders (RBD): acting out dreams, talking

Autonomic Symptoms: Constipation. Later: orthostasis, urinary urgency / incontinence

Cognitive: early: subtle cognitive deficits, later: dementia, psychosis, visual hallucinations

Psychiatric: depression and anxiety are common early


Natural History

-Progressive motor and non motor symptoms

-Younger patients tend to have slower rate of progression, more tremor, more dyskinesia, less dementia

-Older patients have faster rate of progression, more postural instability, gait disturbances, more non motor symptoms and more dementia

-As disease progresses, patients will experience “wearing off” phenomenon

-Timing of PD meds is essential


Dyskinesias


Management – circa 1892

Goetz, Cold Spring Harb Perspect Med 2011


Motor symptoms Management - MedsNO CURE. Only symptomatic management.

-Dopamine replacement: levodopa – carbidopa, various formulations

-COMT inhibitor: entacapone, tolcapone

-Dopamine agonist: pramipexole, ropinirole, rotigotine, bromocriptine

-Monoamine oxidase inhibitor: rasagiline, selegiline

-Anticholinergic: trihexyphenidyl, benztropine

-NMDA antagonist: amantadine


Non Motor symptoms Management - Meds-Constipation: polyethylene glycol, dietary changes, fiber, suppositories

-Orthostasis: midodrine, fludrocortisone, droxidopa

-Psychiatric symptoms: SSRIs

-Dementia: rivastigmine

-Psychosis: quetiapine, clozapine, pimavanserin

-RBD: melatonin, benzodiazepines


Management - Surgical


Management - Exercise

Physical exercises may improve gait and balance-unclear how it effects the brain, affects neuroplasticity of

dopaminergic signaling?, may increase synaptic strength and modulate circuitry?

-reduces oxidative stress

Traditional: treadmill training, balance therapy

Non traditional: Virtual Reality, robotics, Tai Chi, dance


Management - Rehabilitation






Parkinson’s Plus Syndromes

- Multiple Systems Atrophy

- Progressive Supranuclear Palsy

- Corticobasilar Degeneration

- Dementia with Lewy Bodies


Essential Tremor

- Most common movement disorder- Postural and action tremor, faster than in PD, affecting

UEs- May also develop a vocal tremor, head tremor (yes/ yes

or no/no), or chin tremor- Often responds to alcohol- Often positive family history- Slowly progressive


Essential Tremor Treatment

- Medical:- 1st line: propranolol, primidone- 2nd line: gabapentin, benzos- 3rd line: botulinum toxin

- Surgical:- DBS- Thalamotomy

- Focused ultrasound


References

Abbruzzese, G et al. Rehabilitation for Parkinson’s disease: current outlook and

future challenges. Parkinsonism and Related Disorders. 2016: S60- S64.

Goetz, CG. The history of Parkinson’s disease: early clinical descriptions and

neurological therapies. Cold Spring Harbor Perspect Med. 2011: 1:a008862.

Haliday, G and Murphy K. Pathology of Parkinson’s disease. Blue Books of

Neurology. 2010: 132-154.

Kalia, LV and Lang, AE. Parkinson’s disease. Lancet. 2015: 896-912.

Ostrem, JL and Galifianakis, NB. Overiew of common movement disorders. Cont

Neurol. 2010: 13-48.

Documents

Dementia in the Inpatient Rehabilitation Setting...attention, perceptual-motor, social cognition) – deficits must represent a decline from previous level of function and be severe