July 30, 2021
PAs Kathy Kemle and Freddi Segal-Gidan Host Huddle Ask Me Session on Alzheimer’s
June 30, 2021
This Alzheimer’s and Brain Awareness Month, AAPA invited Kathy Kemle, MS, PA-C, DFAAPA, and Freddi Segal-Gidan, PA, PhD, to host the latest Huddle Ask Me session on Alzheimer’s. Both PAs are passionate about the care of older adults who have been underrepresented in medical studies and remain subject to many of the iatrogenic ills that well-intentioned healthcare providers cause or worsen. Older adults are the most heterogenous group in the country. They often have multiple co-morbidities that make care more challenging, and they must be treated as individuals in order to live to their full potential.
Here are some of the insights Kemle and Segal-Gidan shared during their Ask Me session. AAPA members can head to Huddle to read the full session.
Q: Not all dementia is Alzheimer’s. Is there a “quick” (or any) way to determine which dementia is which at a bird’s-eye level? Are there any pathognomonic behaviors, etc. that would help providers understand or recognize the differences?
A – Kemle: You ask a very interesting question which unfortunately does not have a simple answer. Dementing illnesses are a spectrum, and people often have more than one type. To make the diagnosis, you must have evidence of decline in two areas of cognition, such as memory and judgement. Less than that or with no change in daily life is considered mild cognitive impairment. Alzheimer’s (AD) is the most common type, so persons often receive it as their first diagnosis; however, autopsy studies have shown that many of those said to have AD actually have a mixed type, with vascular dementia being the most common co-dementing illness. Sadly, multiple forms of dementia result in a more rapid decline.
Vascular dementia is probably more common where there is a higher prevalence of hypertension (HTN) and has a slow stepwise deterioration. You should suspect it when you see someone with history of stroke, HTN, and a stop-start-stop pattern of decline. In the past it had the worst prognosis but now that we can better control atherosclerotic cardiovascular disease (ASCVD); it can be less rapidly debilitating than Alzheimer’s. Often you will see other signs of neurological dysfunction as well.
Early Alzheimer’s is missed by family and healthcare providers, especially now that we are in the COVID pandemic and many of our older adults have been isolated by the need to remain apart. The more isolated the patient, the greater the risk of rapid decline or the family may not have noticed until they return to check on their loved one. This may cause the patient to develop an accompanying depression, which can make the dementia look worse as well. Usually there will be a decline in recent memory while older memories remain preserved.
Persons with Parkinson’s disease (PD) display their own brand of dementia. It shares features with Lewy body disease (LBD), which is characterized by early emotional lability, movement disorder, and psychosis. This may result in providers prescribing an antipsychotic which is exactly the wrong thing to do. LBD patients develop extreme stiffness with antipsychotics, considered a hallmark of this disease. If the dementia occurs early in the disease, consider LBD. If it is late, it is most likely the dementia of PD.
The other types are less common than those three. If you are in doubt, refer the patient to a memory disorders clinic. They have the personnel and tools to make a more definitive diagnosis.
Q: Can you provide an update on any Alzheimer’s disease therapies currently in the pipeline, and do any seem promising for slowing disease progression? Any new research into preventative practices or therapies?
A – Segal-Gidan: A major focus of treatments currently under development are disease modifying agents, largely small molecules, monoclonal antibodies, and other biological therapies. These target the abnormal proteins that comprise the underlying pathologies of Alzheimer’s disease, amyloid beta (or a-beta) which comprise the plaques that disrupt synaptic connections between neurons and phospho-tau (tau) which causes the intracellular tangles. Agents currently in clinical trials are either anti-amyloid, targeted at disrupting plaque formation or increasing plaque clearance, or directed at interfering with the development of tau. We know that amyloid beta begins to slowly build up in the brain in specific regions a decade or more before clinical symptoms. The tau deposition begins later, around the time of first clinical symptoms, and deficits are closely associated with where tau accumulates. This understanding has occurred over the past decade and may explain why many agents studied in the past were not successful, as they were given too late in the course of the disease. For a treatment to be successful, we now understand it will need to be used early in the course of the disease and most likely will require a combination of two or more therapeutic agents (an Alzheimer’s or dementia “cocktail”).
I believe we are getting closer to a therapeutic agent or agents that will actually work and be able to arrest the underlying disease.
Q: I do part-time call for skilled nursing facilities and I get a lot of calls on behavior problems with dementia patients. How do you address this when redirection doesn’t work? Behaviors such as aggression towards staff and others, sexually inappropriate behaviors, not sleeping. I’m so glad we have gotten away from the antipsychotics, but I’m often asked to prescribe benzodiazepines.
A – Segal-Gidan: Alzheimer’s disease includes not just memory loss and cognitive decline, but also functional and behavioral changes. Behavioral changes are also common in other dementias, such as Lewy body dementia (LBD) and frontotemporal dementia (FTD). Thus, behavior changes should be considered among the expected symptoms during the course of Alzheimer’s disease and in many neurodegenerative dementias.
Staff training is essential for residents of long-term care facilities and family/caregiver training for those living at home. Redirection, as you point out, is one technique. Identification of triggers should always be considered – does the behavior occur at certain times of the day, associated with a specific activity (bathing or toileting can often produce resistance that can escalate to agitation), or with a certain aide and not others? Has there been a recent change in medication or schedule that the person could be responding to emotionally and with behavior change? An exam to ascertain that there is no underlying infection (UTI, foot ulcer, tooth abscess, etc.) or other treatable medical problem (e.g., constipation, bowel impaction) should not be overlooked.
Use of medications to manage behavior is a last resort – when nothing else works – and should be initiated with a clear plan of what is the behavior one is targeting and what the goal of treatment is (for example, 50% reduction in episodes of X, increased cooperation with Y,) over what period of time, and monitoring. Antipsychotics are to be avoided, as are benzodiazepines in persons with dementia as they lead to increased confusion and falls. We often use antidepressants, escitalopram when there is anxiety, trazodone for its sedating effects when there is agitation. Another class of drugs that can be considered are anticonvulsants. The choice of drug is often dictated by the patient’s other co-morbidities, chronic medications, and the drug side effects. Consultation with a geriatric psychiatrist or pharmacist is sometimes required. Good communication with staff, regular training, and the recognition that each patient is unique is also important. What worked for Mrs. A may not work for Mr. P.
Access the full Q and A here.