Connie’s notes: I will be editing these notes soon.
Age is a risk factor in Dementia from 114 studies.
- African American pop literature on Dementia
- 65 and older, 6% non white , 22% in African America , Baltimore
- 18% before 65 yrs of age – 59% > over 65 in Manhattan study
- 8 out of 10 , 7 whites lower rate of dementia than African America
- Prevalence/incidence: latino sacramento study , 5% of 60 yrs and over , 30% 65 and older have dementia
- Veterans 16% have dementia ICD9 code
N Manhattan , carribean women , 8% – 74% under 65% age range , 24-63% over 85 age ; twice the range compared to Hispanics and African American
1950, Guam, late onset , nuero fibrlattory tangles no plaque , 9% guam dementia, 3% from other causes
- Japanese survivors , 1990 , 8% under 65 and 33% over 65 have dementia
- Seattle, 6% over 65 have dementia
Disaggregate data: Lowest and highest prevalence in Latino – Hispanic
- Life course mechanism in racial and social inequalities affecting Dementia
- Bay area: Reducing racial and ethnic disparity in Dementia
- Diagnostic criteria, geographic patterns
- How long people live after Dementia Dx?
Healthcare utilization, 1 visit per year
Starting age 65 yrs of age
- African American highest
- American Indian and Alaska natives
- Latinos , Mexican , Pacific Islanders
- Asian Americans: Chinese, Filipino, Japanese
What proportion shall develop Dementia, more than 1 in 4 at age 65 shall develop Dementia in their lifetime.
70% dementia higher in African American
Lifetime risk is higher in all race
Causes Dementia: Social and behavioral factors are primary factors
Years of formal education and vascular risk factors are factors contributing to Dementia.
20,000 LGBT seniors in SF , In 2013 LGBT access fewer than 10% services by admin of aging. 1. Ageism, homophobia, transphobia, heterosexism ; forces ; Health equity Issue: one third ; single, childless and living alone, did not have informal caregiving support ; 44% of transgender seniors fear accessing services, they experience distress,
Do not assume caregiving needs based on sexual status. Ask people how they identify themselves.
Dr Frank Longo , Stanford
- 2/3 causes of Dementia is AD. 1/3 vascular dementia, small blood vessels in brain is diseased, lewy body dementia – PD + AD
- Amyloid fragments are toxic to synapses, develops 20 yrs before Dementia starts. Synapses are connections , we lose them and then we lose our cognition.
- Cognitive impairment starts at age 30 plus, our memory function diminishes.MCI, mild cognitive impairment
- Day to day function is intact, MCI can be diagnosed.
- Genetics, exercise,western diet,medical condition,sleep apnea,chronic use of anti cholinergic meds (Benadryl,apaxil,bladder med) ,
- Let onset or sporadic, after age 65
- Lifetime risk: 15%
- With 1 copy of E4: 30%s
- With 1 parent with AD + E4: 45% risk: APOE
- Familial, < 2%, starts at 40s or 50s ; 50% risk, autosomal dominant ,
- Energy brain functions. Orange active memory function. AD = lost orange circuits imaging
- Prevention: sleep, diet, exercise, brain exercise
- Brain exercise: not supported, what is the evidence of transfer effect
- Midetereanian Diet: 20% risk reduction ; association research
We need randomized trial, prospective trial.
Pharmacologic intervensions: What about non-pharmacologic?
Be a champion for those with Alzheimer’s disease.
Creating a world without Alzheimer’s disease.
- San Mateo Measure A Funds
- Ombudsman Services
- Dignity Health Care/Sutter
- Home Care Assistance
- Care Indeed
DR Anna Chodos , geriatrician. UCSF
- Guideline : 1page why? Focused on health care providers
- Since 2008: AD is the most predominant Dementia. African American and Hispanics have higher prevalence. Medicare reimbursement = compassion allowance benefit, healthy brain initiative CDC
- CMS policy: annual visit, new billing mechanism for care planning, cognitive assessment
- SS compassion allowance
- Healthy brain initiative
- Practice trends: earlier detection, gaps and doc issue,
- Anti-psychotic med danger
- Lifestyle mod supports healthy brain
CVD risk modification
- Weight mgt, reg exercise and diet
- Clinical care guideline: 1 assessment, care plan, education and support and important considerations
- 1 Understand the patient: confirm and disclose diagnosis , emphasize culture, values and language preferences, caregiver assessment
AD cognitive toolkit
Annual functional and cognitive monitoring and reassessing at regular intervals. Upon sudden
1 MOCA and 2 ADA
Know your patient: beneficial interaction with impact, disease mgt – progression and stages , managing the comorbidity , consider using appropriate meds,
First line of Tx: behavior meds, simplifying tasks, involving mental health pros, de-emphasize meds.
- Education support: engaging with the community, involving patient in care planning, tx decisions and care referrals, linking caregivers to community organization
- Time sensitive issues: safety, adequate care planning ,advance care planning,
- Capacity eval, elder abuse,
- Aware of the benefits
- 211.org financial resources canhr.org legal assistance for the elderly in SF
- 6m to 1 yr for dementia Dx
Thyroid med, not taken Delirium
Dr Maldonado, psychosomatic med at Stanford, adult psychiatry, addiction med, forensic med
- American delirium society
- Senile but not demented
- Delirium (1. Global disturbance in cognition, changes in consciousness, agitated delirium – low prevalence, circadian rhythm – obliterated, 5 factors ) vs Dementia
- N acute brain failure: mental changes ,
- 1.hypo active 2. Hyper active 3. Mixed type delirium
- Catatonic type and excited type
- 26 / 47 in ICU w delirium
Common Dx 1. 6 leading causes of preventable disease
Change protocol to sedate heart surgery patients reduces incidence of Delirium. Help reduces 40% delirium
- W delirium higher morbidity , causing more disability
- 1% increase per yr after 65 , Dementia
- 2% increase per yr after 65, delirium , esp with multiple medical condition, seeing a doctor, getting med
- If you have no dementia, 30% chance of developing delirium , 100% if you have dementia to develop into delirium
- 4-5 fold increase when no alteration in lifestyle, diet, exercise
- ICU experience, 63% developing delirium
- Long term prospective data , 20k patients, well defined association in development of delirium and dementia. Get delirium, 40% chance of never going back to baseline cognitive function.
- Longer duration of delirium, worse the cognitive outcome
- 10 weeks to recover from delirium , correct neuro transmitter imbalance…10days if____
If you have any cognitive impairment, developing delirium will dramatically accelerate progression of disease
- Relationship bet development of delirium and dementia
- Delirium: when the patient develop delirum, it spreads in all cognitive impairment areas
- Continuity of brain bundles: brain atrophy -> cognitive impairment
- Sub-syndrome of delirium. All of current Dx tools ; 2 to 4 criteria in DSM V
- Those who survive, develop significant sequele = PTSD , anxiety : 1. Factor is use of Benzo -> PTSD
- Sig increase in mortality: 49% hospital patients who are delirious
Death rate 1 to 8%
Survival rate, no delirium, delirium for 1 d .
$164B delirium costs per year
Dx delirium more effectively:
- Hyper active delirium
- Hypo = common ; 60% ; most people cannot recognize it ; depressed or delightful
- Mixed = not real
If med service call psy to assess: 50-50 depression or delirium , 46% depressed has hypo active delirium , greater incidence of persistence delirium, lowest amount of acetycholine in their brain.
The most abundant dietary sources of choline—a precursor to acetylcholine—are animal fats such as egg yolks, cream, fatty cheeses, fatty fish, fatty meats, and liver. Non-animal sources include avocadoes and almonds.
Physical therapist can diagnose delirium better.
- SPTD has sensitivity of 70% , specificity of 90% ; score intensive ; graduation measure
- CAM, 5x longer to do, cannot score ; binary measure
- Minimize incidence of Delirium
- Stop Delirium as early
- System failure: neuro pathy miscommunication
- Risk factor: 1. Getting a hip , 40% 2. Longest duration of delirum, 3. Mod impairment
- Discontinuity on white matter
- Based on Surgical studies because of the insult….all studies for Delirium and mental…