Mini-CHAMPMini-CHAMP

Dementia in the Hospitalized Older AdultDementia in the Hospitalized Older Adult

Deon Cox Hayley, DODeon Cox Hayley, DOUniversity of ChicagoUniversity of Chicago

OutlineOutline

• Dementia 101Dementia 101• 2 topics you can teach:2 topics you can teach:

– Pain assessment and Pain assessment and management management

– Tube feeding Tube feeding

ObjectivesObjectives

Learners will:Learners will:• Appreciate that dementia is a common but Appreciate that dementia is a common but

generally overlooked condition in generally overlooked condition in hospitalized elderly hospitalized elderly

• Understand how pain might present Understand how pain might present differently in the patient with dementiadifferently in the patient with dementia

• Assess and treat patients with dementia Assess and treat patients with dementia who have painwho have pain

• Understand the arguments against the use Understand the arguments against the use of tube feeding in end stage dementiaof tube feeding in end stage dementia

Dementia 101: Facts you can use Dementia 101: Facts you can use on the wardson the wards

Dementia is commonDementia is common

• Prevalence in general populationPrevalence in general population– 4 million currently; 14-16 million by 4 million currently; 14-16 million by

20502050– Affects 5-10% of people over 65Affects 5-10% of people over 65– May affect up to 50% of people over age May affect up to 50% of people over age

8585

Kennedy, GJ. Dementia in Geriatric Medicine, an Evidence Based Approach, 4th Ed. Cassel et al, Eds. 2003. p.1079

Dementia is commonly Dementia is commonly overlookedoverlooked

• Dementia is often not mentioned in Dementia is often not mentioned in the medical record of patients with the medical record of patients with dementiadementia– 64% overlooked in Canadian Study of 64% overlooked in Canadian Study of

Health and AgingHealth and Aging– 79% overlooked in Indiana study79% overlooked in Indiana study

Sternberg SA et al. JAGS, 2000

Boustani M. et al. JGIM, 2005

Dementia is progressive and Dementia is progressive and incurableincurable

• TerminalTerminal

PrognosisPrognosis

Average life expectancy Average life expectancy

from time of diagnosis:from time of diagnosis:

6 years6 years

PrognosisPrognosis

Comparison of Life Expectancy by Quartiles (Men age 70)

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Larson, E.B. et al, Ann Intern Med, 2004

Comparison of Life Expectancy by Quartiles (Women age 70)

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When to suspect dementia? When to suspect dementia?

ScreeningScreening• MMSEMMSE• MiniCogMiniCog

DiagnosisDiagnosis• Diagnostic criteriaDiagnostic criteria• Can’t make the Can’t make the

diagnosis if diagnosis if deliriousdelirious

If you suspect dementia…If you suspect dementia…

Diagnostic Criteria

A. Development of multiple cognitive deficits:1. Memory impairment

2. One or more of the following:(a) aphasia (b) apraxia (c) agnosia

(d) disturbance in executive functioning B. Leading to-- impairment in functioning.

C. Gradual onset and progressive decline

Why does dementia matter in Why does dementia matter in an inpatient hospitalization?an inpatient hospitalization?

• Affects other diseasesAffects other diseases• Bounce backs (d/c planning)Bounce backs (d/c planning)• Capacity for decision makingCapacity for decision making• DeliriumDelirium• End of life issuesEnd of life issues

A B C D E

Pain in patients with Pain in patients with dementiadementia

Impaired Impaired communication communication

• Number of pain Number of pain complaints decreases complaints decreases as cognitive as cognitive impairment increasesimpairment increases

• Pain discounted Pain discounted because of because of inconsistent reports inconsistent reports

LaChapelle, Hadjistavropoulos, & Craig, 1999; Parmelee, Katz, & Lawton, 1993Weiner et al., 1999a

Symptoms in end stage Symptoms in end stage dementia dementia

Symptoms reported last year of life Symptoms reported last year of life persons who died with dementiapersons who died with dementia

PainPain 64%64%AgitationAgitation 87%87%ConfusionConfusion 83%83%ConstipationConstipation 59%59%IncontinenceIncontinence 72%72%Poor appetitePoor appetite 57%57%DepressionDepression 64%64%

McCarthy M, Addington-Hall J, Altman D. Int J Geriatr Psychiatry 1997.

Pain in patients with Pain in patients with dementiadementia

• CommonCommon– Outpatient- 30-50%Outpatient- 30-50%– Nursing home- 60-80%Nursing home- 60-80%

• Other medical conditions Other medical conditions – Osteoarthritis, other arthritides, Osteoarthritis, other arthritides,

osteoporosis with vertebral compression osteoporosis with vertebral compression fractures, PMRfractures, PMR

– Peripheral or post-herpetic neuropathy, Peripheral or post-herpetic neuropathy, pressure sores, dental, constipation, pressure sores, dental, constipation, GERD, hunger GERD, hunger

Pain is under treated in Pain is under treated in persons with dementiapersons with dementia

• 41% in pain at first assessment were 41% in pain at first assessment were still in pain months laterstill in pain months later

• Dementia patients Dementia patients – Hip surgeryHip surgery1/3 opioid compared to 1/3 opioid compared to

cognitively intact patients. cognitively intact patients. – 1.5 times less likely to receive 1.5 times less likely to receive

analgesicsanalgesics

Teno J et al. JAMA 2001Teno J et al. JAMA 2001

Assessment of pain in Assessment of pain in patients with dementiapatients with dementia

• Experience of pain persists, Experience of pain persists, communication gradually lost communication gradually lost

• Patient reportPatient report• Caregiver reportCaregiver report• Observation Observation

– ScalesScales

Assessing pain: Mild to Assessing pain: Mild to moderate cognitive moderate cognitive impairmentimpairment

• Patient report --ASK Patient report --ASK – Moderately impaired pts can reliably report painModerately impaired pts can reliably report pain

– Severe cognitive impairment, 30% can complete at Severe cognitive impairment, 30% can complete at least one pain scaleleast one pain scale

– Ask about Ask about presentpresent pain pain

– Determine the patient’s preferred pain terminology Determine the patient’s preferred pain terminology (e.g. discomfort, hurting, soreness)(e.g. discomfort, hurting, soreness)

Parmalee Pain Management 1996. Herr and Garand Pain Management in the Elderly 2001. Sengstaken and King JAGS 1993. Feldt et al. JAGS 1998.

Assessing pain: Mild to Assessing pain: Mild to moderate cognitive moderate cognitive impairmentimpairment

• Find a pain scale that works for the Find a pain scale that works for the individualindividual

• Insure understanding of tool useInsure understanding of tool use

-simplest, clear explanation, give examples-simplest, clear explanation, give examples

-give time to grasp task and respond-give time to grasp task and respond

-repeat, repeat, repeat-repeat, repeat, repeat

• Modify sensory deficitsModify sensory deficitsFerrell et al. J Pain Symptom Manage 1995. Chinball and Tait Pain 2001.Herr and Garand. Pain Management in the Elderly 2001

Caregiver report of patient Caregiver report of patient painpain

• Patients may have experienced pain Patients may have experienced pain but can’t rememberbut can’t remember

• Caregiver source of informationCaregiver source of information– In cancer literature caregivers over In cancer literature caregivers over

report painreport pain– Our research suggest dementia Our research suggest dementia

caregivers also over report paincaregivers also over report pain

Assessing pain: Nonverbal, Assessing pain: Nonverbal, moderate to severe impairment moderate to severe impairment (AGS Panel 2002)(AGS Panel 2002)

1)1) Presence of non-verbal pain behaviors?Presence of non-verbal pain behaviors?-assess at rest and with movement-assess at rest and with movement

2)2) Timely, thorough physical examTimely, thorough physical exam3)3) Insure basic comfort needs are being metInsure basic comfort needs are being met

(e.g. hunger, toileting, loneliness, fear)(e.g. hunger, toileting, loneliness, fear)4)4) Rule out other causative pathologiesRule out other causative pathologies

(e.g. urinary retention, constipation, (e.g. urinary retention, constipation, infection)infection)

5)5) Consider empiric treatmentConsider empiric treatment

Unique Pain SignatureUnique Pain Signature

• How does the patient usually act?How does the patient usually act?

• What changes are seen when they are in pain?What changes are seen when they are in pain?– Family membersFamily members– Other caregiversOther caregivers

• Communication is key!Communication is key!

Kovach et al. J Pain Symptom Manage 1999. Kovach et al. J Pain Symptom Manage 1999. Feldt et al. JAGS 1998. Feldt et al. JAGS 1998. Weiner et al. Aging 1998.Weiner et al. Aging 1998.

Nonverbal Pain IndicatorsNonverbal Pain Indicators

• Facial expressionsFacial expressions (grimacing) (grimacing)-Less obvious: slight frown, rapid blinking, -Less obvious: slight frown, rapid blinking, sad/frightened, any distortionsad/frightened, any distortion

• VocalizationsVocalizations (crying, moaning, groaning) (crying, moaning, groaning) -Less obvious: grunting, chanting, calling out, noisy -Less obvious: grunting, chanting, calling out, noisy breathing, asking for helpbreathing, asking for help

• Body movementsBody movements (guarding) (guarding) -Less obvious: rigid, tense posture, fidgeting, pacing, -Less obvious: rigid, tense posture, fidgeting, pacing,

rocking, limping, resistance to movingrocking, limping, resistance to moving

Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Medicine 2000Kaasalainen et al Perspectives 1998. Herr and Garand Clinics in Geriatric Medicine 2000

Nonverbal Pain IndicatorsNonverbal Pain Indicators

• Changes in interpersonal interactionsChanges in interpersonal interactions -combative, disruptive, resisting care, -combative, disruptive, resisting care, decreased social interactions, withdrawndecreased social interactions, withdrawn

• Changes in mental statusChanges in mental status -confusion, irritability, agitation, crying-confusion, irritability, agitation, crying

• Changes in usual activityChanges in usual activity -refusing food/appetite change, increased -refusing food/appetite change, increased wandering, change in sleep habitswandering, change in sleep habits

Treatment of painTreatment of pain

• With careWith care• Start low, go slowStart low, go slow• Non-pharmacologic optionsNon-pharmacologic options• Frequent assessment, Frequent assessment,

reassessment reassessment • Attention to detailsAttention to details

Summary: Symptom Summary: Symptom ManagementManagement

• Patients with dementia still can Patients with dementia still can experience discomfort and painexperience discomfort and pain

• Symptoms may manifest Symptoms may manifest differently differently

• Look for pain and discomfort in Look for pain and discomfort in behavioral changesbehavioral changes

• TreatTreat

Tube Feeding in End-stage Tube Feeding in End-stage DementiaDementia

Not eating? Not eating?

• Anorexia vs Anorexia vs

dysphagia vs dysphagia vs

agnosia/apraxia vsagnosia/apraxia vs

agitationagitation

• Acute vs ChronicAcute vs Chronic– acute (then can treat underlying cause)acute (then can treat underlying cause)– chronic (due to dementia itself?)chronic (due to dementia itself?)

FAST stagesFAST stages

©1984 by Barry Reisberg, M.D. All rights reserved.₁Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653-659.                     

1. No difficulties2. Subjective complaints 3. Decreased job functioning 4. Needs assistance with IADLs 5. Requires assistance in choosing

proper clothing to wear for the day6. Needs assistance with ADLs7. Stops talking, walking, sitting,

smiling

Why put in a tube? Why put in a tube?

Prevent aspiration? Prevent aspiration?

• No study has shown decrease in risk of No study has shown decrease in risk of aspiration pneumonia from PEG placementaspiration pneumonia from PEG placement

• Doesn’t prevent aspiration of oral Doesn’t prevent aspiration of oral secretionssecretions

• Refluxed gastric contents can still be Refluxed gastric contents can still be aspiratedaspirated– Enteral feeding may increase risk of aspiration Enteral feeding may increase risk of aspiration

(data mixed)(data mixed)– LES pressure is decreased in tube fed patientsLES pressure is decreased in tube fed patients– J tubes may not be better than G tubesJ tubes may not be better than G tubes

Finucane, JAMA, 1999; Dharmarajan TS, Am J Gastroenterology, 2001

Improved Survival?Improved Survival?

• Observational studies:Observational studies:– NH patients show no survival advantage with NH patients show no survival advantage with

tube feedingtube feeding– 1 retrospective review of 41 consults for PEG 1 retrospective review of 41 consults for PEG

• survival without PEG 60 days, with PEG 59 dayssurvival without PEG 60 days, with PEG 59 days

• Mortality is high after G-tube placementMortality is high after G-tube placement– 6-28% in first 30 days6-28% in first 30 days– 50% in first year50% in first year

Murphy LM. Arch Int Med, 2003; Dharmarajan TS, Am J Gastroenterology, 2001; Mitchell SL, Arch Int Med, 1997

Survival after PEG placementSurvival after PEG placement

Dharmarajan TS, Am J Gastroenterology, 2001

• For those who don’t die after PEG For those who don’t die after PEG placement, artificial nutrition and placement, artificial nutrition and hydration may be prolonging the hydration may be prolonging the dying processdying process

Patient Comfort?Patient Comfort?

• Studies of dying cancer, ALS patients Studies of dying cancer, ALS patients with anorexia:with anorexia:– Little hunger or thirstLittle hunger or thirst

• Any thirst can be treated with mouth swabs Any thirst can be treated with mouth swabs and ice chipsand ice chips

– Sense of euphoria (endorphins)Sense of euphoria (endorphins)• Goes away if fedGoes away if fed

– Patients were left alone morePatients were left alone more

Gillick MR. NEJM, 2000

McCann RM, JAMA, 1994

Comfort?Comfort?

• Eating is pleasant!Eating is pleasant!– depriving a person (who wants to depriving a person (who wants to

eat) of the pleasure of eating eat) of the pleasure of eating does not increase comfortdoes not increase comfort

• Restraints are not Restraints are not

comfortablecomfortable

Help wound healing/prevent Help wound healing/prevent pressure ulcers? pressure ulcers?

• Very little dataVery little data• One observational study failed to One observational study failed to

show an associationshow an association• Common sense:Common sense:

– More likely to be immobileMore likely to be immobile– More likely to be restrainedMore likely to be restrained– More often wet skin (sweat, stool, urine)More often wet skin (sweat, stool, urine)

Finucane, JAMA, 1999; Dharmarajan TS, Am J Gastroenterology, 2001

Other benefits of tube Other benefits of tube feeding?feeding?

• Observational studies show:Observational studies show:– No recovery of functionNo recovery of function– No decrease in risk of infectionNo decrease in risk of infection

Finucane, JAMA, 1999

Other considerationsOther considerations

• Pulling out the tubePulling out the tube– Return trips to GI or IRReturn trips to GI or IR– RestraintsRestraints

• Incontinence (stool and Incontinence (stool and urine)urine)– Caregiver burdens highCaregiver burdens high

Slow hand feedingSlow hand feeding

• Survival can be substantial despite Survival can be substantial despite emaciation and poor po intakeemaciation and poor po intake

• Human, nurturing, time for closeness Human, nurturing, time for closeness with loved oneswith loved ones

Feeding tipsFeeding tips

• Sit upSit up• Decrease distractionsDecrease distractions• Feed finger foods, thick liquids (gravy, Feed finger foods, thick liquids (gravy,

ice cream, add cream and butter), ice cream, add cream and butter), strong flavors, favorite foods, good strong flavors, favorite foods, good temp.temp.

• Multiple swallows after each bolusMultiple swallows after each bolus• Gentle coughs after each swallowGentle coughs after each swallow• Small bolus (less than teaspoon)Small bolus (less than teaspoon)• Liquid supplementsLiquid supplementsFinucane TE, JAMA. 1999 Oct 13;282(14):1365-70.

SummarySummary-tube feeding for the -tube feeding for the patient with end stage dementiapatient with end stage dementia

• No evidence that tube feeding:No evidence that tube feeding:– Decreases risk of aspirationDecreases risk of aspiration– Prolongs survival (60% mortality at 6 Prolongs survival (60% mortality at 6

months, perhaps 90% at one year)months, perhaps 90% at one year)– Improves comfortImproves comfort– Decreases pressure sore riskDecreases pressure sore risk

• Recommend slow hand feedingRecommend slow hand feeding

Finucane TE, JAMA. 1999 Oct 13;282(14):1365-70.Gillick MR. N Engl J Med. 2000 Jan 20;342(3):206-10.

ReferencesReferences

1.1. Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Hui SL, Hendrie HC. Implementing Perkins AJ, Fultz BA, Hui SL, Hendrie HC. Implementing a screening and diagnosis program for dementia in a screening and diagnosis program for dementia in primary care. J Gen Intern Med. 2005 Jul;20(7):572-7. primary care. J Gen Intern Med. 2005 Jul;20(7):572-7.

2.2. Sternberg SA, Wolfson C, Baumgarten M. Undetected Sternberg SA, Wolfson C, Baumgarten M. Undetected dementia in community-dwelling older people: the dementia in community-dwelling older people: the Canadian Study of Health and Aging. J Am Geriatr Soc. Canadian Study of Health and Aging. J Am Geriatr Soc. 2000 Nov;48(11):1430-4. 2000 Nov;48(11):1430-4.

3.3. Callahan CM, Hendrie HC, Tierney WMCallahan CM, Hendrie HC, Tierney WM.. Documentation Documentation and evaluation of cognitive impairment in elderly and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med. 1995 Mar primary care patients. Ann Intern Med. 1995 Mar 15;122(6):422-9.15;122(6):422-9.

4.4. Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen JD, Teri L, Kukull WA. Survival after initial diagnosis of JD, Teri L, Kukull WA. Survival after initial diagnosis of Alzheimer disease.Alzheimer disease.Ann Intern Med. 2004 Apr 6;140(7):501-9. Ann Intern Med. 2004 Apr 6;140(7):501-9.

5. Appelbaum PS, Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med 1988, 319(25), 1635-1638.

References, cont.References, cont.

6. Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998, New York: Oxford University Press. 31-60, 77-126.

7.7. Finucane TE, Christmas C, Travis K. Tube feeding in Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the patients with advanced dementia: a review of the evidence. JAMA. 1999 Oct 13;282(14):1365-70.evidence. JAMA. 1999 Oct 13;282(14):1365-70.

8.8. Gillick MR. Rethinking the role of tube feeding in patients Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000 Jan with advanced dementia. N Engl J Med. 2000 Jan 20;342(3):206-10.20;342(3):206-10.

9.9. Dharmarajan TS., et al. Percutaneous endoscopic Dharmarajan TS., et al. Percutaneous endoscopic gastrostomy and outcome in dementia. Amer J gastrostomy and outcome in dementia. Amer J Gastroenterology. 2001; 96:2556-2563.Gastroenterology. 2001; 96:2556-2563.

10.10. Murphy LM, Lipman TO. Percutaneous endoscopic Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with gastrostomy does not prolong survival in patients with dementia. Arch Int Med. 2003; 163:1351-1353. dementia. Arch Int Med. 2003; 163:1351-1353.