#82: The GeriSiders: Dementia Dos and Don’ts

February 12, 2018 | By Leah Witt

Challenge your beliefs on the efficacy of pervasive treatments used in dementia with expert Eric Widera, MD, Professor and clinician-educator in the Division of Geriatrics at the University of California-San Francisco. We explore the use of cholinesterase inhibitors, antipsychotics for behavior disturbances, feeding tubes, medications and supplements used for weight gain (inspired by Choosing Wisely and the American Geriatric Society’s “Ten Things Clinicians and Patients Should Question”). Plus, we introduce our new correspondent, Dr. Leah Witt, Geriatrics Fellow at UCSF.

Written and produced by: Jordana Kozupsky, NP, Nora Taranto, MS3, Leah Witt, MD; Edited by: Matthew Watto, MD

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Clinical Pearls:

1. Delivering a dementia diagnosis is a delivery of serious news. Use SPIKES for communication (Baile et al. The Oncologist. 2000): Setting (think about environment/participants/distractions, get chairs for all participants); Perception (“ask, tell, ask”– ask what patients know before you tell them); Invitation (obtain permission from patient/family about what they would like to know); Knowledge (share information with the family and patient) ; Emotions (address emotions with empathy); Summarize & strategize. Talk to patients/families about what to expect/disease progression.
2. Don’t fall for the red herring of only focusing on pharmacologic therapies (e.g. cholinesterase inhibitors) for dementia, because at best they are marginally effective, and have significant side effects (GI most common) (Birks. Cochrane Database Syst Rev. 2006).
3. Non-pharmacologic approaches are first-line to treat dementia-related behaviors. Try the DICE approach (Kales HC et al. J Am Geriatr Soc. 2014). Use pharmacologic means (e.g. antipsychotic agents) only if necessary, and for as short of a time as possible.
4. Prepare families and patients for the natural history of dementia progression, including progressive functional decline, anorexia, and aspiration (Mitchell et al. NEJM. 2009). Involve the multidisciplinary team.
5. Feeding tubes do not decrease risk of of aspiration or improve comfort. Avoid appetite stimulants (e.g. megestrol acetate). Thickened liquids do not improve patient-centered outcomes and comes at the risk of dehydration and UTIs (try it for yourself and take the #thickenedliquidchallenge).

Case from Kashlak Memorial:

Part I: Mrs. Sarah Quil is an 82 year old female with a history of hypertension, coronary artery disease,  TIAs, and newly diagnosed mild dementia, who presents to the Geriatrics clinic with her son, Mr. Hal Dolle. Mr. Dolle brought his mom in to discuss his concerns about her progressive memory loss. She was recently seen for a memory evaluation in the Neurology clinic, and she was diagnosed with likely Alzheimer’s disease and vascular dementia. Mrs. Quil lives alone, but her son checks on her every day and brings her food. Mrs. Quil was previously a gourmet chef, and has been burning food, leaving the stove on, and forgetting to take her medications. She is supposed to take atorvastatin, lisinopril, and clopidogrel. At the neurology visit three months ago, she was also started on donepezil 5mg daily.

Cholinesterase inhibitors:
AGS Choosing Wisely #6: “Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.”

The benefit of cholinesterase inhibitors in mild-moderate dementia is modest at best– an average of a 3 point improvement on the 70 point ADAS-Cog scale, though the clinical significance of this is questionable (Birks. Cochrane Database Syst Rev. 2006). Treatment with donepezil does not appear to reduce progression of disability or rates of nursing home residence over a 3 year course (Courtney et al. Lancet. 2004).

Side effects of cholinesterase inhibitors include GI symptoms like nausea and diarrhea (most common), weight loss, and bradycardia. In an observational study of adverse events in patients taking donepezil, galantamine and rivastigmine, 81.2% reported adverse events (Campbell et al. JAGS. 2017

Don’t let the discussion about pharmacologic therapies become the focus– it is most important to discuss the natural history of dementia with patients and families and to plan for the future. In a study of the course of advanced dementia, 54.8% patients died over 18 months, 41.1% had pneumonia and 85.8% had an eating problem (Mitchell et al. NEJM. 2009)

Case (Part II): A year later, Mr. Dolle is back with Mrs. Quil. She is now living in a Memory Care residential care facility. She has been having frequent falls, difficulties bathing and dressing herself, and frequent verbal and physical outbursts when she is frustrated or scared. The nursing assistants have been asking if her doctor can prescribe something to help calm her down. The behaviors tend to happen more at night. He asks about Tylenol PM and clonazepam, which he has taken before for anxiety.

Treating Dementia-Related Behaviors
AGS Choosing Wisely #2: “Don’t use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.”

First line treatment for dementia-related behaviors (e.g. agitation) is non-pharmacologic treatment, e.g. via the DICE approach (Kales HC et al. JAGS. 2014).

Describe: Caregivers describe the distressing behaviors (e.g. environment, patient-centered issues, context)

Investigate: Team-members look into possible causes of the behavior (e.g. pain, medications, sleep, sensory impairment, psychiatric issues)

Create: The multi-disciplinary team and patient/family collaborates to create a plan (e.g. treating pain, changing the environment, or improving communication/provide reassurance)

Evaluate: The team evaluates iteratively if the plan has been effective.

Patients with Alzheimer’s Disease, prescribed antipsychotics, have a long-term increased risk of mortality (DART-AD trial, Ballard et al. Lancet Neurol. 2009). The number needed to harm with antipsychotics in patients with dementia is 26 for haloperidol, 27 for risperidone, 40 for olanzapine and 50 for quetiapine (Maust et al. JAMA psychiatry. 2015).

Citalopram may have a role in reducing the dementia-related behavior of agitation along with caregiver distress, but its cognitive and QTc prolonging effects may limit its use (Porsteinsson et al. JAMA. 2014). Max dose is citalopram 20 mg daily in the elderly.

Dextromethorphan-quinidine (“tussin and tonic”, TM Eric Widera) is gaining wider use, based on a 2015 study showing improvement in agitation in patients with dementia (Cummings et al. JAMA. 2015), however the risk of adverse events is significantly increased compared to placebo (falls, diarrhea, and UTIs)

AGS Choosing Wisely #4: “Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.”

Benzodiazepines/sedative-hypnotics should not be used for insomnia/agitation. While they may make the night easier, the next day will be much worse, as they increase the risk of delirium. These medications do have a role in symptom-management at the end of life.

AGS Choosing Wisely #10: “Don’t use physical restraints to manage behavioral symptoms of hospitalized older adults with delirium”.

Part III: Three more years pass and Mrs. Quill now had bladder/bowel incontinence, is dependent with all activities of daily living, and appears to have trouble speaking. She has moved to a long-term nursing home. However, Mr. Dolle is most worried about her appetite– a nursing assistant hand feeds her over an hour, but she barely eats anything. On top of that, she coughs frequently after eating and was hospitalized twice in the past year for pneumonia. Her son asks for more information regarding a feeding tube.

Food
AGS Choosing Wisely #1: “Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.”

Talk to families early on about the progression of dementia and the high prevalence of eating problems with advanced dementia. Read this JAMA case discussion of a 93 y/o man with advanced dementia and eating problems, and consider patient, family and provider perspectives as you plan your communication strategy around this issue (Mitchell. JAMA. 2007). Among family members who had relatives with dementia in whom a feeding tube was placed, almost 60% had not had a discussion about feeding tube placement, and their relatives were less likely to report excellent care at the end of life (Teno et al. JAGS. 2011). Feeding tubes often bother patients, leading to restraints (pharmacologic or physical), increased time in bed, and pressure ulcers.

There is wide variability in feeding tube placement rates by nursing facilities, states/regions, and demographics. Increased feeding tube placement has been noted in facilities housing non-white patients, for-profit status facilities, and high Medicaid populations (Lopez et al. Arch Intern Med. 2010).

AGS Choosing Wisely #8: “Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations.”

High calorie supplements do increase weight, but they don’t improve patient-centered outcomes such as quality of life, function or survival (Hanson et al. JAGS. 2011). All appetite stimulant medications are off-label. Megestrol acetate should be avoided– 1 in 12 patients given this medication will gain weight but 1 in 23 will have an adverse event leading to death (Campanelli. JAGS. 2012).

Thickened liquids are one of the most common food-related interventions that we inflict on patients with dementia, due to concerns about aspiration. Thickened liquids may decrease aspiration on videofluoroscopy, but they do not change the rates of aspiration pneumonia (Wang and Charlton. JAMA. 2016). AND thickened liquids increase dehydration, fever and UTI, as compared to the chin-tuck posture (Robbins et al. Annals of Internal Medicine. 2008). Try it yourself and take the #thickenedliquidchallenge. Change your practice!

Goal: Listeners will reflect on pervasive medical treatments used for patients with dementia, that have little efficacy and notable harms.

Learning objectives:
After listening to this episode listeners will…

1. Decide how and when to re-evaluate cognition during use of a cholinesterase inhibitor for dementia.
2. Utilize nonpharmacologic therapies for behavior disturbances in dementia.
3. Recall the risk of using off-label pharmacologic therapy for behavior disturbances in dementia.
4. Counsel caregivers on benefits, risks, and limitations of pharmacologic therapy for patients with dementia.
5. Know why percutaneous feeding tubes are not recommended in patients with advanced dementia.
6. Counsel patients and families about the use of high calorie supplements and/or appetite stimulants like megestrol

Disclosures: Dr Widera and The Curbsiders report no relevant financial disclosures.

Time Stamps
00:00 Disclaimer
00:37 Guys set up the show
02:00 Dr Widera’s bio
03:15 Getting to know our guests
13:10 Picks of the week
16:40 Clinical case: new diagnosis of dementia
17:40 Discussing dementia with patients and caregivers
23:42 Cholinesterase inhibitors
27:35 Stopping cholinesterase inhibitors
33:35 Follow up to therapy
36:05 Dealing with behavior disturbances
39:15 DICE approach
44:17 Risks of antipsychotic medications
48:00 Use of benzos or sedative hypnotics
49:45 Melatonin for delirium or sleep
52:00 Mirtazapine
53:54 Clinical case: patient with dementia not eating
54:40 Feeding tubes
59:40 Dysphagia and NPO orders
62:04 Misinformation on malnutrition and girth creep
65:10 Thickened liquid challenge
70:25 Appetite stimulants
72:38 Megestrol
73:54 Take home points from Dr Widera
79:17 Outro

Links from the show:

1. Top 10 Reasons Eric Widera is the Best Fellowship Director Ever
2. Body Pump: An international sensation, originating in New Zealand, which builds muscle (and physician wellness) via choreographed weight lifting set to music. Run, don’t walk, to your nearest class.
3. Dr. Widera’s book pick: Drive, The Surprising Truth About What Motivates Us
4. Dr. Witt’s book pick: Extreme Measures: Finding a Better Path to the End of Life
5. Extraordinary Measures (with Harrison Ford)
6. Extremis, Dr. Zitter’s documentary on Netflix
7. Dr. Widera’s favorite medical app: Twitter. Tweet about Hospice-Palliative Medicine using #hpm or Geriatrics using #geriatrics
8. Dr. Witt’s pick of the week: iTonya
9. Dr. Widera pick of the week: Dark (series) on Netflix, especially if you’re a Donnie Darko fan
10. Dr. Williams’s pick of the week: Wormwood (documentary) on Netflix
11. Thomas Finucane (Audio Digest) Misinformation on Malnutrition
12. Dr. Widera’s GeriPal Blog & Podcast, co-hosted by Dr. Alex Smith.
13. American Geriatrics Society Choosing Wisely: Ten Things Clinicians and Patients Should Question
14. Take the Thickened Liquid Challenge (and tweet the video with #thickenedliquidchallenge)