The Gray Plague: Effective Management Strategies for Dementia in Primary Care

Dementia is an epidemic, particularly among the oldest old, but physicians can do much more for patients now than a decade ago, said geriatrician David Reuben, MD, FACP, a professor at the David Geffen School of Medicine at the University of California, Los Angeles, during a presentation at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL.

“We call dementia the gray plague,” Reuben said. “This is a devastating disorder.”

Dementia is an acquired decline in memory and at least on other cognitive function, such as aphasia, apraxia, agnosia or executive function, as well as having a significant effect on daily life. Consequences include falls, swallowing disorders, aspiration pneumonia, urinary and fecal incontinence, and behavioral disturbances. It is the 6th leading cause of death in the United States, costing per patient up to $56,290 in direct costs annually. It costs the health care system $130 billion annually. Alzheimer’s disease is the most common cause of dementia and has three stages: mild, moderate, and severe.

“Our job is to detect, treat, and provide support,” Reuben told the internists in the audience.

The US Preventive Services Task Force does not recommend routine screening. Patients present with memory impairment and may have problems with language or visual-spatial or executive functioning. They may appear apathetic.

When indicated, screening can be done with one of several tools, such as the Mini-Cog, a three-item recall plus a clock drawing, and the mini mental state exam. All of the tools are quite effective.

“But, all they do is tell you something is wrong, not what’s wrong, but it’s a good start,” Reuben said.

Reuben said he follows up with a clinical exam and interview. While able to determine the patient has dementia 90 percent of the time, he does not tell the news on the first visit. “It’s a bitter pill to swallow,” Reuben said. “I tell them there’s a need for additional testing.”

Reuben will send them for neuropsychological testing, lab tests to exclude medical conditions that may be contributing, and a CT-scan or magnetic resonance imaging to rule out a tumor, subdural hematoma, or something else unexpected. A PET scan can be valuable but is only approved for differentiating Alzheimer’s disease from frontotemporal dementia.

With Alzheimer’s, physicians must manage the disease and the patient. Reuben recommends advance planning early in the disease course, while the patient can still express his or her wishes and select a surrogate decision maker.

Cholinesterase inhibitors or memantine may slow progression of the disease. “These are not home run drugs,” Reuben said. “They are not going to fix the problem.”

Between 10 percent and 25 percent of patients may get a boost from taking one of the three approved cholinesterase inhibitors. Whether they affect behavioral symptoms is controversial, and some patients decline rapidly when the drug is discontinued, such as when admitted to the hospital. The chief benefit of memantine, he said, is that it may improve behavioral symptoms, enabling the patient to stay at home longer. It is indicated for moderate to severe Alzheimer’s.

A recent study found Vitamin E, at 2000 IU, slowed the rate of decline. But 42 percent of participants did not complete the study. “I’m not using it as a first-line drug,” Reuben said. “You have to watch for bleeding at those doses.”

No other medications or supplements have proven beneficial in this patient population.

Managing the patient requires aiming for the highest level of independence that works for everyone—the patient and caregivers. “The caregiver is the most important resource the patient has,” Reuben said. “The more knowledgeable and more empowered the caregiver is, the better care the patient will receive.”

Reuben suggested referrals to the Alzheimer’s Association and other community resources. Meanwhile, the physician must manage hot-button issues, such as driving and behavioral complications. He recommended trying to interrupt problematic behaviors and training caregivers how to redirect the patient.

The antidepressant citalopram may reduce agitation but may worsen mini mental state scores and increase the QT interval. Antipsychotics are no better than placebo, Reuben said, and all have potential side effects. Mood stabilizing medications, such as valproate, may be tried but has potentially confounding sedating effects.

A systems approach to disease management has been shown to be effective in some cases. In one study, a social worker provided case management, which led to better quality of care and better health related quality of care scores. Another study at Indiana University and UCLA, which used nurse practitioners, reduced behavioral symptoms, caregiver stress, emergency department visits, hospitalizations and 30-day readmission rates.

Reuben concluded by saying there is hope on the horizon, with various prevention strategies and new treatments in the pipeline, but they are a long way off. In the meantime, he advised, “take advantage of what is available.”