Mar 15

Dementia Treatment Guide

By Dr. Micaela Wexler

One size does not fit all!WexlerPsychiatryDementia1

The treatment of dementia is a skill that is becoming more urgent for the primary care physician. While it is essential to treat dementia early, it is equally important to remember that one size does not fit all. For example, Aricept, a medication ideal for Alzheimer’s Disease (AD) may be detrimental for Frontotemporal Lobar Dementia (FTLD).

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What follows is a Dementia Treatment Guide, a short description of the most common forms of dementia, and their treatments. This is meant to be a quick guide, not all-encompassing. Please read disclaimer before using this guide.

Alzheimer’s Disease (AD) – most common form of dementia, begins with memory loss followed by language difficulties. As AD progresses from mild to moderate, people lose executive function. Severe AD is characterized by imbalance, decreased movement and complete lack of communication.

AD Treatment:

Mild to moderate AD – acetylcholinesterase inhibitors (Aricept, Exelon, Razadyne)

Moderate to severe AD – NamendaWexlerPsychiatryDementia3

Research shows that targeted lifestyle choices can decrease cognitive decline associated with AD: elimination of simple carbohydrates and gluten, increased consumption of fruits and vegetables, fasting for 12 hours between dinner and breakfast, 7-8 hours of sleep each night, exercising 30 minutes a day 6 days a week, yoga, mediation and stress reduction.

Vascular Dementia (VD) – the second most common type of dementia characterized by a step-wise decline in memory and cognitive functioning caused by decreased blood flow to the brain due to strokes.

VD Treatment: stroke prevention to stop progression; lifestyle modifications to target heart disease, hypertension and diabetes; Namenda is both neuroprotective and improves cognition, preferred over Aricept.

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Dementia with Lewy Bodies (DLB) – movement problems EARLY, memory problems LATER (opposite of AD); rapid progression; visual hallucinations; REM sleep disorder; 3-minute test to screen for LBDWexlerPsychiatryDementia6

DLB Tx: very responsive to Aricept and Exelon, for both memory and behavior; Klonopin for REM sleep disorder; extreme caution using anti-psychotics

Frontotemporal Lobar Dementia (FTLD) – strikes YOUNG people; memory normal in early stages, behavior and mood problems prominent, loss of impulse control; misdiagnosed as Bipolar Disorder; rapidly progressiveWexlerPsychiatryDementia7

FTLD Tx: behavior problems – use Depakote, Tegretol; memory – use Namenda, AVOID Aricept and Exelon; speech therapy preserves function, avoid benzodiazepines

Parkinson’s Disease Dementia a (PPD) – 1 of 5 patients with Parkinson’s Disease gets PPD, 4 of 10 patients with PD get AD.

PPD Tx: Namenda or Aricept for memory, Aricept does not affect movement; extreme caution using anti-psychotics; use Seroquel if needed

Wernicke-Korsakoff Dementia - confabulation, often preceded by Wernicke’s encephalopathy which is characterized by confusion, ataxia and nystagmus. Caused by thiamine deficiency, which can result from alcohol dependence, eating disorders, AIDS, malnutrition.

WKD Tx: thiamine, Namenda, Aricept, Exelon. Namenda neuroprotective. Anti-psychotics do NOT decrease confabulation.

This Dementia Treatment Guide was originally created as a supplement for a CME course given at the Missouri Association of Osteopathic Physicians and Surgeons Annual Convention in Branson, Missouri on May 1, 2015.

Note: photos do not represent people with dementia; they are photos of actors and models, go to 123rf.com for information on releases and credits.
References:
10 Warning Signs of Alzheimer’s

Vascular Dementia: Signs, Symptoms and Treatment

Frontotemporal Lobar Dementia

Lewy Body Dementia Association

The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score

Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey

Poor Dental Health May Lead to Alzheimer’s Disease

Treatment of Frontotemporal Dementia

Clock-drawing: is it the ideal cognitive screening test?

Treatment of behavioral and psychological symptoms of AD with Yokukansan

Aricept beneficial in mod-severe AD and comparable to Namenda in mod-severe AD. No improvement in combining both for Mod-severe AD.

Long term use of donepezil in DLB 108 patients enrolled in 52 week study – improvement in cognitive function, reduced caregiver burden lasted 52 weeks with few adverse events

Risperidone Versus Yokukansan in the Treatment of Severe Alzheimer’s Disease

Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review

ACETYLCHOLINESTERASE INHIBITORS FOR THE TREATMENT OF WERNICKE–KORSAKOFF SYNDROME−THREE FURTHER CASES SHOW RESPONSE TO DONEPEZIL

Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop

Reversal of cognitive decline – a novel therapeutic program

Results of a large, federally funded trial showed that 10 milligrams of donepezil (Aricept) daily reduced the risk of progressing from amnestic MCI to Alzheimer’s disease for about a year, but the benefit disappeared within three years.

Early diagnosis beneficial in AD
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Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Jun 28

Rural Psychiatry

By Dr. Micaela Wexler
I am a  psychiatrist working in a rural setting in Missouri. I provide both inpatient and outpatient care, as well as consultations on the medical unit, and emergency psychiatry. I treat children, adolescents, adults and geriatric patients. My specialty is treating family psychiatry.
I received my medical degree from Western University in Pomona, CA, and completed my residency in psychiatry at Kansas University Medical Center.
When I accepted this job right after residency, I had several fantasies about what I would experience.  I thought it was going to be an easy way to pay off my student loans and  I felt guilty signing the contract.   I thought I would have enough leisure time to learn how to play golf, remodel a Victorian house, and  make a quilt. I was worried that I would be bored at work and lose all the skills I had learned in residency. On the other hand, I was very scared about the statistics involving substance abuse and suicide for rural physicians, especially psychiatrists.
Three years into my job, none of these fears, or fantasies, have come true. I decided to preserve rather than remodel my Victorian house. I still haven’t made a quilt.  But, no, this job is not boring, and I won’t lose my skills. Rural psychiatry is hard work, but it is very rewarding. Every single day I see a new, challenging case. I see between 20 to 30 patients a day.  And, I have been forced to learn new skills: autism assessment, family therapy, marriage therapy.
My patients have complex situations; the suicide rate is much higher than in the urban setting; the unemployment rate is difficult to confront; and, the substance abuse problem can be mind numbingly overwhelming.
My biggest challenge is confronting the severe shortage of mental health services day after day. And, while I do feel overwhelmed at times, I also have had many days when I see the hopefulness that comes from helping people through desperate situations.
And, there have been some wonderful surprises for me. My neighbors are phenomonemal, making sure I am safe and well cared for. The employees also take care of me. Something I did not expect at all from a small town is the openness neighbors and hospital employees have shown about my “alternative lifestyle.” To them, I am not part of a “lesbian” couple; I am simply part of a couple. Everyone has been so welcoming to my partner, me and our daughter. People here have their priorities straight: they LOVE children, and it doesn’t matter to them how those children got here.