Palliative care of advanced dementia

Palliative care of advanced dementia A patient centered approach
By:VJ Periyakoil, MD
Director, Palliative Care Fellowship Program
Stanford University General Internal Medicine &
VA Palo Alto Health Care System


Main Message
* Currently, patients with dementia do not get access to quality palliative care
* Access to quality palliative care can be facilitated only if we take an inter-disciplinary approach to care


Talk Agenda
* Current state of palliative care for dementia
* Key challenges in providing palliative care for dementia patients
+ Prognostication
+ Decision making
+ Advance care plan
+ Symptom management
+ Caregiver stress

Prognostication questions in dementia
* Patient’s question: “How long do I have before my mind is shot?”
* Health professional’s question: “ Is s/he eligible for palliative care?”
* Family’s question: “How long does s/he have to live ?”
* Caregiver’s question: “ I am exhausted. How much longer can I do this?”

Is dementia a terminal illness? If so, when do they start dying?

Dementia hospice eligibility
* Stage 7 or beyond according to the FAST scale
* Unable to ambulate without assistance
* Unable to dress without assistance
* Unable to bathe without assistance
* Urinary or fecal incontinence, intermittent or constant
* No meaningful verbal communication, stereotypical phrases only, or ability to speak limited to six or fewer intelligible words
* Plus one of the following within the past 12 months:
o Aspiration pneumonia
o Pyelonephritis or other upper UTI
o Septicemia
o Multiple stage 3 or 4 decubitus ulcers
o Fever that recurs after antibiotic therapy
o Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)

Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003;20:105-13.

Decision making in dementia
* Hierarchy of decision making
* Competence v. capacity
* Special circumstances

Special circumstances
Case 1: Incapacitated pt with no proxy and unknown preferences
Case 2: Chronically mentally ill pts with no capacity
Case 3: Chronically mentally ill pts with fluctuating capacity

Intact decision making prior to death in the elderly
Alzheimer’s Disease
Diseases other than Alzheimer’s
Lentzer HR et al “ The quality of life in the year before death”. Am J Public Health 82: 1093-1098, 1992
Interface between palliative care and dementia

* Clarity of decision making
o Soft balls ( relatively speaking):
o Hard balls

The decisions themselves are never easy.
Advance care planning
Shades of Gray
Possible levels of care:
Heroic life prolonging measures
* CPR
* “Whopper no veggie*”
* Artificial nutrition
* Artificial hydration
* Antibiotics

What are the goals of care?

Tube feed or not tube feed?
That’s the question
* The facts:
Palliative care symptoms and cognitive impairment
Symptoms
Presentation of these symptoms is skewed
What does dying look like?

* Decline in functional status
* Lack of desire to eat or drink
* Withdrawn
* Sleep- wake state
* Mottling of limbs
* Jaw movement
* Death rattle
* Co-morbid symptoms
* Unpaid
* Overworked
* On-call 24/7
* Sleep deprived
* No social life
* Poor support system

Palliative care of advanced dementia A patient centered approach.ppt

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Geropsychiatry: Delirium and Dementia

Geropsychiatry: Delirium and Dementia
By:Robert Averbuch, MD
Assistant Professor
Department of Psychiatry

Disorders of Cognition
* DSM-IV devotes an entire section to a subset of “organic” disorders that primarily affect cognition: “Delirium, Dementia, and Amnestic and other Cognitive Disorders”

What is “organic”?
* Previous differentiation between mental disorders with a clear “physical or biological” etiology (Organic) and those without (“Functional” or “Primary”)
* Falsely implied that Functional (or primary) disorders have no underlying pathophysiological basis
* Primary mental disorder- not due to a GMC or substance

Disorders of Cognition
* Delirium-disturbance in consciousness and cognition that develops rapidly
* Dementia- multiple cognitive deficits that include memory disturbance
* Amnestic Disorder- primarily memory impairment

Delirium
Delirium: defined
* Disturbance of consciousness (awareness of the environment) and attention,
* PLUS…
o Changes in cognition (ie, “thinking”-memory, orientation, language, etc) OR
o Perceptual disturbances

The Course of Delirium
* Evolves rapidly (hrs to days)
* Usually resolves rapidly as well:
o May be self-limited, persist for weeks, or progress to death
* Degree of impairment fluctuates

Delirium: Associated Features
* Disturbance in sleep-wake cycle
* Easily distracted by irrelevant stimuli
* Changes in activity level
o Restlessness, hyperactivity
o Picking at clothes, getting out of bed
o OR hypoactivity (lethargy)
* Emotional disturbances- mood lability, anger, irritability, euphoria, apathy

Delirium: Associated Features
* Speech or language disturbances
* Perceptual abnormalities- common:
o Illusions, hallucinations, delusions
* Neurological deficits/dysfunction

What Are the Causes?
* DIRECT: Brain pathology: head injury, seizures (during and after), strokes, infections
* INDIRECT: Systemic Illness: electrolyte abnormalities, dehydration, uremia, hepatic encephalopathy, cardiovascular compromise

More Causes of Delirium
* Sensory deprivation
* After surgery (post-operative state)- ie. “ICU Psychosis”
* Side effects of medications or toxins or with abused recreational drugs:
“Substance-Induced Delirium”
o Ex. NMS (Neuroleptic Malignant Syndrome)
o Ex. Serotonin Syndrome

Treating Delirium
* Considered a Medical Emergency
* Supportive care in an ICU setting
* Safety- close monitoring
* Remove offending agent, treat underlying cause

Dementia
Hallmark is Memory Impairment
* Memory problems usually evident early
* Memory impairment alone is not enough to make the diagnosis…

Dementia- defined
* Memory problems AND at least one additional cognitive deficit:
o Aphasia
o Apraxia
o Agnosia
o Problems with “executive functioning”

Details, Details: Aphasia
* Aphasia is a drop off in language function that shows up in a variety of ways

Apraxia
* “impaired ability to pantomime the use of known objects or to execute known motor acts”

Agnosia
* Trouble recognizing or identifying things despite intact sensations (ex. You can see fine, but you can’t recognize a stop sign)
* May include difficulty recognizing family members or even themselves in the mirror

Disturbances in Executive Functioning
* Abstract thinking
* Planning, initiating, sequencing, and stopping behaviors
* May manifest as trouble with novel tasks or new situations

Associated Features
* Spatial disorientation
* Poor insight and judgment means…they get themselves in trouble by overestimating their abilities and underestimating risks
* Perceptual Abnormalities:
o Delusions- especially persecution
o Hallucinations- especially visual

More associated features
* Personality Changes:
o Disinhibition
o Neglect of personal hygiene
o Apathy and withdrawal

Course of Dementia
* Course may be progressive, static, or remitting
* Small percentage of cases are reversible

What causes Dementia?
* Alzheimer’s is by far the most common type
* Cerebrovascular Disease
* Degenerative Diseases: Parkinson’s, Huntington’s, CJD (Mad Cow Disease)

More causes:
* Autoimmune Illness
o Lupus
o Multiple Sclerosis
* B12, Folate Deficiencies
* Head Trauma, Brain Tumors
* Infections- like HIV and Syphilis

Alzheimer’s
Dementia of the Alzheimer’s Type (DAT)
* Diagnosis of exclusion
* Hallmark: gradual onset of recent memory problems
* Onset may be early (65 y/o or younger) or Late (over 65)

DAT
* Slowly progressive (8-10 years from diagnosis to death)
* Many show personality changes
* Often with associated behavioral disturbances (wandering, agitation, etc.)

Vascular Dementia
Aka Multi-Infarct Dementia
Vascular Dementia
* Evidence of cerebrovascular disease on physical exam and head scans
* Usually caused by several strokes over time
* Onset abrupt, followed by stepwise, fluctuating course with “patchy” deficits

Treatment of Dementia
* Search for a reversible cause and treat (ex. B12 deficiency, Normal Pressure Hydrocephalus, Syphilis, etc)
* Rule out Pseudodementia (change in cognition associated with depression)
* Environmental/behavioral interventions- ex. no fail environment
* Medications

Medications
* Cholinesterase Inhibitors:
o Aricept (donepezil)
o Reminyl (galantamine)
o Exelon (rivastigmine)

Medications
* NMDA-receptor antagonists
o Namenda (memantine)
o Neuroprotective by blocking excessive glutamate stimulation of the NMDA (N-methyl-D-aspartate) receptor

Geropsychiatry: Delirium and Dementia.ppt

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Warts Diagnosis and Treatment

Warts Diagnosis and Treatment
By:Rick Lin, DO MPH
Texas Division of KCOM Dermatology Residency Program

Background Information
* Warts are small harmless lesions of the skin
* caused by a virus: the human papilloma virus.
* The appearance of warts can differ based on the type of wart and where it is located on the body.
* Warts are common in children. Most cases occur between ages 12-16 years.
* Up to 30% of warts disappear by themselves within 6 months. Most will disappear without any treatment within 3 years.
* Warts are caused by the DNA-containing human papillomavirus (HPV). There are at least 63 genetically different types of HPVs.
* The virus enters the skin after direct contact with recently shed viruses kept alive in warm, moist environments such as a locker room, or by direct contact with an infected person.
* The entry site is often an area of recent injury. The incubation time—from when the virus is contracted until a wart appears—can be 1-8 months.
* Contrary to popular mythology, touching a frog will not give you warts.

Types of warts
* Common warts (verrucae vulgaris): These common warts typically develop on the hand, especially around the nail. They are gray to flesh colored, raised from the skin surface, and covered with rough, hornlike projections.
* Plantar warts (verrucae plantaris): Plantar warts, by definition, occur on the plantar surface, or bottom, of the foot.
* They usually occur in high pressure areas such as the heel and the metatarsal heads (just behind the toes).
* They usually grow into the skin, not outward like common warts.
* This growing into the skin makes them more difficult to treat.
* Flat warts (verrucae plana): Flat warts are most commonly seen on the face, the back of the hands, and lower legs.
* They usually appear as small individual bumps about 1/4 inch across.
* Flat warts may spread rapidly on the face and lower legs from the activities involved in shaving.

Histopathology
* Verruca vulgaris (common wart) is caused by varous strains of human papilloma virus (HPV 1, 2, 4, 7, 26-29).
* Macroscopically verruca vulgaris may present as hard, rough surfaced papule
2 – 20 mm (solitary or multiple).
* Microscopically, this is an exophytic, symmetric, papillomatous lesion with large keratohyaline granules and characteristic inturning of the rete ridges.

Histopathology
* Parakeratotic columnar tiers of stratum corneum overlie the papillomatous surface.
* Small amounts of hemorrhage may be present within the columns of parakeratosis.
* Other characteristic features include koilocytosis, hypergranulosis and presence of multinucleated cells.

Treatment
* Home care is effective in making the wart or warts go away. No matter what technique you use, warts will disappear 60-70% of the time.
* Techniques may be done with and without medication.
* The ultimate goal of the medical therapies (not the surgical treatments) is to get your body to recognize the wart as something foreign and to destroy it, much like the body destroys a cold virus.

Adhesive tape therapy
* Place several layers of waterproof adhesive tape over the wart region (even duct tape).
* Do not remove the tape for 6-1/2 days. Then take off the tape and open the area to the air for 12 hours.
* Reapply tape for another 6-1/2 days.
* The tape works best in the region around the fingernail.
* Tape works because the air-tight, moist environment under the tape does not allow the virus to grow and reproduce

Salicylic acid therapy
* Salicylic acid is available by many different trade names at the drug store.
o Dual Film
o Wart-Off
o Dr. Scholl’s Wart Medication
o Medi-Plast
* It comes either as a liquid to paint on the wart or as a plaster to be cut out and placed on the wart tissue.
* The area with the wart should be soaked in warm water for 5-10 minutes.
* The wart should then be pared down with a razor. A simple razor works fine for this, then throw it away.
* Do not shave far enough to make the wart bleed.
* Apply the salicylic acid preparation to the wart tissue.
* Do not apply it to other skin because of salicylic acid's potential to injure normal tissue.
* Follow directions on the package for how long to apply the acid.

Cryosurgery
* Liquid nitrogen or cryotherapy is used to deep freeze the wart tissue.
* With liquid nitrogen applied to the wart, the water in the cells expands, thus exploding the infected tissue.
* The exploded cells can no longer hide the human papillomavirus from the body's immune system.
* The immune system then works to destroy the virus particles.
* Periungual area may scar if cryotherapy with liquid nitrogen is used improperly.
* Scarring could lead to permanent nail disfiguration.

Laser Therapy
* Laser therapy: Lasers are simply very intense light sources.
* This light has an enormous amount of energy that heats the tissue enough that it vaporizes.

Shave Removal
* Shave removal and electrodessication of the base may be necessary when other treatment methods fail.
* This would involve numbing the region around the wart and shaving the wart flat with the surface and light electrodessication of the base.

Prognosis:
* Most warts will disappear without treatment anywhere from 6 months to 3 years.
* Warts may recur after treatment and require additional treatments.
Prevention:
* Avoid touching warts on others or touching them on yourself (refrain from rubbing a warty finger across your face).
* Children needs to avoid biting or chewing warts.
* Wear shower shoes in the gym locker room to lower your risk of picking up the virus that causes plantar warts from the moist environment.

When to Refer
* If you feel uncomfortable treating warts.
* Warts that are resistant to your treatment
* Unsure of diagnosis

Warts Diagnosis and Treatment.ppt

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