Dementia

Dementia

Dementia is our most-feared illness…Dr. David Perlmutter

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Definition:

Dementia is a common term used to describe a collection of symptoms, it is not a diagnosis.  The DSM, diagnostic and statistical manual for medical diagnosis uses the following definition.

Evidence from the history and clinical assessment that indicates significant cognitive impairment in at least one of the following cognitive domains:

  • Learning and memory
  • Language
  • Executive function
  • Complex attention
  • Perceptual-motor function
  • Social cognition

Furthermore, these conditions must be met:

  • The impairment must be acquired and represent a significant decline from a previous level of functioning
  • The cognitive deficits must interfere with independence in everyday activities
  • In the case of neurodegenerative dementias such as Alzheimer disease, the disturbances are of insidious onset and are progressive, based on evidence from the history or serial mental-status examinations
  • The disturbances are not occurring exclusively during the course of delirium (such as during an acute illness or intoxication)
  • The disturbances are not better accounted for by another mental disorder (eg, major depressive disorder, schizophrenia)

Manifesting as difficulty with one or more of the following:

  • Retaining new information (eg, trouble remembering events)
  • Handling complex tasks (eg, balancing a checkbook)
  • Reasoning (eg, unable to cope with unexpected events)
  • Spatial ability and orientation (eg, getting lost in familiar places)
  • Language (eg, word finding)
  • Behavior

Incidence/Prevalence/Costs:

  • 5.3 million Americans have dementia in 2015
    • Estimates for 2025 are 7.1 million
      • Nebraska has 33,000 cases
  • 5% of population in their 70’s have dementia
  • 25% of population in 80’s
  • 6th leading cause of death
  • 1 in 3 Americans have a demential condition at the time of their death
    • less than 1/2 of patients are aware they have a diagnosable dementia
  • most victims are over 65,
  • women have higher incidence at a ratio of 2:1.
  • higher incidence in hispanics and Black races.
  • Costs U.S. $226 billion in 2015.
  • Medicare costs are 300% higher for a senior with dementia than one without.

Types of Dementia:

Alzheimers Dementia, called AD

  • AD is responsible for 60-80% of dementia.

Vascular Dementia

  • Vascular disease is the second leading cause.

Dementia of Lewey Body, called DLB

  • manifests with hallucinations (visual and dramatic),
  • trouble walking,
  • tremor (like Parkinsonism)

Frontotemporal, FTD

  • manifest more as behavioral variant of dementia
    • change in personality,
    • lack of inhibition,
    • OCD behaviors,
    • apathy

Parkinson’s Disease with Dementia, PDD 

  • 30-40% of PD patients get dementia over course of their disease

 Cause:

 

Reversible: Minority of cases of dementia are from reversible causes (1%)

  • Thyroid disease
  • Vitamin Deficiencies
  • Hydrocephalus
  • CNS tumor
  • Depression
  • Alcohol or Drug abuse
  • Medications side effects:
    • pain pills,
    • sleeping pills,
    • sedatives,
    • anxiety meds,
    • depression meds,
    • anticholinergics (IBS, OAB meds),
    • antihistamines, benedryl, Tylenol PM
    • some Blood Pressure meds,
    • antipsychotics,
    • seizure meds.
    • Stress

Irreversible:

  • AD-protein tangles in the brain, Tau protein
  • LBD-amyloid proteins deposited in the brain, similar to AD
  • Creutzfeldt Jacob Disease, CJD
    • Prion infection in the brain, like Mad Cow Disease in cattle
  • Stroke, or combination of many mini-strokes over time
  • Parkinsons Disease, PD
  • Infections:
    • HIV,
    • Hepatitis
    • Meningitis/encephalitis(WNV, Syphilis)

Symptoms, differentiating dementia from forgetfulness or aging:

Dementia is characterized by:

  • Difficulty remembering recent events, familiar people.
  • Having to be told over and over.
  • Forgetting major events even happened, like a vacation.
  • Difficulty planning
  • Difficulty with following directions, like a recipe you’ve made several times.
  • Getting lost in familiar areas.
  • Difficulty balancing a check book.
  • The person doesn’t notice the issues, others do.
  • Become anxious, irritable with minor events or changes in routine.

Forgetfulness, or normal aging is more characterized by:

Diagnosis/Evaluation:

Your doctor can use several tools to determine if you have dementia.

  • MiniCog testing, can be given at home by family member or caregiver:
    • recall 3 familiar objects after 1 minute of time.
    • Draw a clock face with numbers and hands to display the correct time.
    • If fail MiniCog, further testing is needed.
  • MME: 30 point exam done at doctor’s office

Treatment:

There are treatments available for dementia.  First and foremost is to determine if there is a reversible cause.  Several non-medical strategies can be helpful for dementia.  Modification of vascular risk factors has a favorable outcome in slowing the progression of dementia.

  • Diet,
    • Heart healthy, Mediterranean diet
  • Exercise
  • Social engagement.
    • socializing with friends and relatives
    • games
    • reading
    • learning new skills
    • formal education
    • active hobbies
    • volunteerism

There are medical therapies available to help with dementia.

Medications:

1. Acetylcholinesterase inhibitors (Exelon, Aricept)

  • Can be used in all causes of dementia, score of 26 or less in MMSE.
  • First line treatment in early dementia.

2. Memantine (Namenda)

  • NMDA receptor antagonist, may be protective of neurons.  May have modest benefit in moderate to severe dementia.
  • Used in combination with AcetylCoA inhibitors for moderate to severe dementia.

 3. Vitamin E, 2000 U per day

  • May have some benefit in Dementia,
  • should not be used in combination with Memantine.

Prevention:

Several strategies have been found to delay the onset or slow the progression of dementia.

  • At the Alzheimer’s Association International Conference® 2014, a two-year clinical trial of older adults at risk for cognitive impairment showed that a combination of physical activity, nutritional guidance, cognitive training, social activities and management of heart health risk factors slowed cognitive decline.-1
  • Onion Model of cognitive decline:
    • Aging affects the brain like pealing the layers of an onion.
    • The more layers we build up over our lifetime the longer it takes to peal.
    • The core of the onion is equated to our ability to live independently with quality of life.
  • Learn a new skill (bilingualism delays the onset of dementia by 4 years), engage in formal education.  Stay socially engaged, volunteerism.  Active hobbies that require planning, thinking.
  • Practice Vascular health:
    • Good diet
      • Mediterranean diet:
        • fish, nuts, whole grains, fruits and veggies, olive oil, low in saturated fats (red meat, butter, cheese, sour cream, processed foods),
    • control weight, 
    • exercise, 
    • treat high blood pressure, 
    • control your cholesterol through diet, exercise and medications if necesary, 
    • aspirin may be appropriate 
      • (age > 65 with other vascular risk factors)
    • Don’t smoke,
    • get enough sleep,
    • manage stress (circle of influence vs circle of concern).
  • Avoid excess alcohol, 
  • evaluate and treat depression.

Research:

  • NIH spends $6B on cancer research,
  • $4B on heart disease research,
  • $3B on HIV,
  • but only $480M on AD.
  • Future research is focusing on the protein tangles in the brain and inflammation.
    • Immunizations
    • Antibodies against the proteins
    • Anti-Inflammatories

Conclusion/Call to Action:

Dementia is unfortunately very common.  As we live longer we will have increased incidences of health conditions related to aging.  Our actions, or lack thereof, when we are younger can influence the development and severity of dementia.  Be proactive about your health through preventive and protective habits.   Take action when you are healthy to diminish the impact of conditions associated with aging such as dementia, heart disease and cancer.

Resources:

An Unintended Journey, A Caregivers Guide to Dementia

Bible Verses-Alzheimer’s/Dementia/Memory Loss Activity Book for Patients and Caregivers

Shadowbox Press activity books for Dementia patients

http://www.alz.org

References:

1. Alzheimer’s Association,

2. Web MD

3.Up To Date

4.American Academy of Family Physicians

Telehealth: Access to Healthcare Using New Technology

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The advent of technologies for face to face video conferencing have led to exciting new possibilities to revolutionize medical care.  With apparent shortages of physicians predicted in the future, our patients need another method of obtaining necessary healthcare.  The trend to high deductible, high copay insurance plans have left many patients reluctant to seek care in expensive traditional settings like ER’s, Urgent Cares, and doctors offices.  Now, for $40-$50, patients can see their doctor for minor medical conditions, or chronic medical disease management through telehealth.  Convenient, cost effective medical care delivered to their own homes or offices without traveling or waiting in a office, ER or UC.  Many companies and the health care industry in general are adapting and reacting to this new technology.  Many insurance plans now cover telehealth visits for nominal $10-$15 copays, saving patients hundreds of dollars.  Employers appreciate the cost savings to their insurance plans and patients appreciate the low cost, and convenience of telehealth.

You can schedule a Telehealth appointment with me if you are in Nebraska, where I am licensed.  I am usually only available on the site by appointment so you must call my office number, or email my office to schedule the visit so I can be logged in and waiting to see you.  You must select me from the available physicians after you have logged in and registered.  You must download the App from your App store or register on line at Amwell.com to use your desktop or laptop computer.

Steps:

  1. Be located in Nebraska, where I am licensed.
  2. Install the Amwell App on your phone or iPad through your App store.
  3. Input you medical, insurance, and demographic information on their secure site.
  4. or Register for Amwell on their website, Amwell site
  5. Notify my scheduler that you would like a Telehealth visit, call (308)534-8383 or email us at statesfamilypractice@yahoo.com
  6. Log in to the Amwell site or App at the scheduled time and select me as your provider.

History of Telehealth:

Q: How long has this type of service been available and who’s using it?

  • Rural community hospitals and mental health facilities have been using telehealth for years to expand access to specialists and psychiatrists in underserved areas.  Care had to be received at a medical office though.
  • The government’s VA system has been using telehealth to care for veterans, again they must be at a facility.
    • Recently they have introduced in home services.
    • Called Banner iCare, must have at least 5 chronic conditions.
    • They have shown 45% reduction in hospitalizations, 32% reduction in care costs.
  • In Alaska it was estimated that telehealth saved the state $8.5 M in one year in Medicaid related travel expenses.

Q: What type of care can be obtained?

  • Primary care mostly but consultation with specialists are becoming available.
  • Psychological services like counseling
  • Dietary and Nutritional services with a dietician
  • Health coaching is available as well.

Current State of Telehealth:

Q: How does it work?  How does a patient seek medical care using telehealth?

  • The newest innovations are called mhealth, for mobile health.
    • These products utilize smartphones and tablets, as well as desktop and laptop comuters.
    • Patients download an  App, then register and log on.
      • Input their health history: medical conditions, medications, allergies, pharmacy and current symptoms.
      • They can input their vital signs.
      • Then they activate a visit and the doctor is usually available in in 1-2 minutes unless with another patient.

Q: How does it work from the doctors side of the visit?

Doctors are credentialed with the various products and trained to use them.  If a doctor makes himself available to see telehealth patients he is notified when a patient requests a visit.  The doctor then utilizes the physician App and initiates a visit with patient after reviewing the health information input by the patient.  The doctor can see and talk to the patient and then come to a diagnosis and treatment plan.  The App then can be used to send in a prescription and document and bill the visit.  Patient follow up can be accomplished through the App for quality control.

Q: What kind of gadgets are required?

  • Really not much, commonly available devices.
    • Computer, iPad, smartphones
  • Kiosks are available in malls and pharmacies, like a phone booth
    • High Def video, BP cuffs, thermometers, ear scopes, heart monitors, glucometers.
  • Devices are being developed to measure patient data and transmit it to the provider.
    • even EKG’s at home and wearables (smart watches)

Q: Which insurance companies in NE cover telehealth?

  • I found that BCBS of NE covers telehealth.
    • using Amwell product
  • Aetna/Coventry did not.
  • My daughter’s company in Lincoln is now offering telehealth services, Cigna?
    • through MD Live.
  • Medicare and Medicaid still have some restrictions but these are rapidly changing.
  • CMS just released, last week, a statement of “Next Generation ACO model” which will reportedly cover telehealth services to medicare and medicaid patients.
    • ACO product, like SERPA ACO here in Nebraska.

Q: What type of visits are possible in telehealth?

  • Respiratory infections
  • Injuries
  • rashes
  • fevers
  • chronic medical condition management
    • Diabetes
    • Hypertension
    • Obesity
  • NOT: pain pills, or chest pain in older adults, emergencies.

Q: Who are the big players in developing the technologies?

  • American Well, Amwell https://amwell.com
    • this is the product I use.
    • many brand names of products offered under various titles through insurance companies and major employers.
  • Dr On Demand www.doctorondemand.com
  • MD Live https://www.mdlive.com
  • SnapMD
    • lets a provider or network set up their own branded product, can interface with existing EHR
  • John Sculley, former CEO of Apple is involved in the industry as a capital venturist.

Future of Telehealth:

Q: What are the projections for growth in the industry?

  • In 2013 there were 250,000 patient visits.
  • By 2018 it is projected to be 3.2 million.
  • Amwell’s study:
    • 64% of Americans are willing to use video conferencing for health care.
      • Average wait time nationally to see doctor, 18.5 days.  Telehealth < 3 minutes
    • 57% of doctors are willing to use telehealth to care of patients.

Q: What web sites or Apps are available today to allow people to utilize telehealth?

  • Amwell, this is the site I utilize.

  • MD Live
  • Dr On Demand
  • May be coming to your doctor’s office in the future through a self branded product.

Conclusion:

We are seeing a paradigm shift in health care delivery.  Keep an open mind about changes in medical care.  Ask your doctor’s office if they are planning to implement telehealth services.   Check with your insurer or employer to see if telehealth is a covered benefit or plans to become one.  Download an App and become familiar with it.  Then, if the need arises for convenient, cost effective access to medical care you may just find yourself using this new technology.

Skin Cancer

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Introduction:

Skin cancer is the most common type of cancer in the U.S.  3 million cases of skin cancer are diagnosed annually in the U.S.  1 in 5 Americans will be diagnosed with skin cancer over there lifetime.  Melanoma is the fastest growing preventable cancer in the U.S.

Types of Skin Cancer:

1. non-Melanoma, of which there are 2 kinds

  • Basal Cell Cancer (BCC ) and Squamous Cell Cancer (SCC)
  • BCC
    • 3 kinds: superfical, nodular, morpheaform
      • most common type of skin cancer
      • 1 in 3 in life
      • assoc. with sunlight or tanning or radiation exposure
      • 250,000 cases in U.S. per year
  • SCC
    • 2nd most common
    •  older individuals.
    • 2.1% mortality
    • treatment is shave, excise or desiccate

2. Melanoma, of which there are 5 kinds

  • superficial, nodular, lentigo, acral-lentiginous and amelanotic
  • Differential, or things that look like melanoma
    • Atypical nevi
    • seborrheic keratosis
    • AK, actinic keratosis
    • keratoacanthomas
    • Lentigo
    • dermantofibromas
    • sebaceous hyperasia
    • blue nevi
    • venous lakes800,000 individuals in U.S. have a history of melanoma.
  • fasting growing preventable cancer in U.S.
  • 9700 cases of Melanoma are related to tanning beds.
  • 8500 mortalities annually
  • related to sun, genetics, multiple nevi and atypical nevi individuals.
  • UVB is most potent ultraviolet light
  • 75% of adolescents, 33% of adults report at least one burn per year
  • UVA is also dangerous (tanning beds) and associated with photo aging, and cancer

Causes of skin cancer:

Tanning

  • 20% increased risk of melanoma if ever used a tanning device
    • Double the risk if age 35 or younger
  • 1:6 h.s. kids admit to tanning bed use.
    • risk is cumulative,
    • Group 1 Carcinogen to humans (definite link)

 

Prevention of skin cancer:

Screening for skin cancer:

  • USPSTF, the U.S. preventive services task force
    • No recommendation for doctors to screen everyone
    • if you are high risk, tell your doctor.
      • examine thyself, and family
  • ABCDE’s of melanoma
    • Asymmetry
      • right side different from left
    • Border
      • irregular
    • Color
      • change
      • irregular
    • Diameter
      • >6 mm
    • Evolution
      • changing, looks different than all others

Special Cases:

  • Large congenital nevi have 5 % lifetime risk of M.
    • >20 cm

 

References:
Dr. Rick Kellerman, Clinical Update
FP Essentials, Skin Cancer 10/2012
skincancer.org

Sleep

Newborn baby and puppy

two Sleeping newborn babies with a dachshund puppy.

Definitions, Sleep Physiology, Sleep Disorders, Insomnia, Sleep Hygiene, Sleep Testing, Therapies for Insomnia

Introduction

Definition of sleep:
Sleep is an immediately reversible unconsciousness. Sleeping individuals can respond to exogenous (burglar alarm) and endogenous stimuli (you can scratch an itch without waking).
in contrast to a coma or anesthesia, or hybernation

Physiology of sleep:
The brain doesn’t rest. It’s engaged in 2 distinct stages of sleep. REM and non-REM. Deep sleep occurs in non-REM. Deep sleep has 4 stages. REM is when dreaming occurs, about 20-25% of night. REM and non-REM alternate through the night, in cycles of 60-90 minutes.

Definition of Sleep Disorder or insomnia:
Difficulty falling asleep, staying asleep or getting back to sleep resulting in impairment such as fatigue occurring at least 3 days per week.

Prevalence of sleep disorders:
Insomnia affects up to 30%-50% of adults.

What factors affect our sleep?

Sleep hygiene

  • environment, schedule, TV in bedroom, computers in evening
  • emotions
    • drama and stress in evening
    • bereavement
    • disorganization (mind racing due to subconscious mind)
      • use a calendar
      • make to-do lists and project lists
  • diet
    • eating within 2-3 hours of bedtime
  • obesity
    • causes OSA, sleep apnea
  • meds and drugs
    • cold medicine, stimulants, steroids, antidepressants, diuretics
    • substance withdrawal
    • sleeping pills, sedatives, alcohol, pain meds
    • caffeinealcohol
      • within 4 hours of bedtime
      • within 4-6 hours of bedtime
    • Alcohol worsens sleep.
      • Distorts the REM, non-REM cycle,
      • worsens snoring and apnea and increases early morning awakenings.
    • smoking and chewing tobacco
  • exercise
    • too close to bedtime
  • naps
    • long naps in closer to bedtime
  • environment,
  • schedules.
    • swing shifts
    • travel/ jet lag
  • Medical conditions
    • Overactive Bladder Syndrome
    • IBD, Inflammatory Bowel Disease (Colitis, Crohn’s)
    • prostate disease (BPH, enlargement)
    • cancer
  • psychiatric conditions
  • pain

What testing is available to measure sleep physiology?

Polysomnography-a sleep lab study

  • Study brain waves, eye movement, oxygen, limb movements, chest movements, snoring, and body position
  • cost about $2,000

Home Testing:

  • Nocturnal oximeters
  • Home Sleep Studies
  • Wearables:
    • Apple watches
      • smart watches
    • brain wave monitors
      • sync to smart phone and record stages of sleep and wakefulness
      • provide tips and tricks and hygiene advice.
      • ZEO brand home sleep system is what I have.

What are some of the consequences of sleep disorders?

  • Strokes
  • Heart disease
  • Hypertension
  • Mood disorders
    • behavioral disorders
    • Depression
    • Anxiety
  • Motor Vehicle Accidents-more car accidents are associated with sleep disorders than alcohol.
  • Obesity
    • sleep deprivation causes stress hormones which stimulate appetite.
  • Fatigue and malaise

What can be done for people with sleep disorders?

Multifaceted approach:

  • Gather information
    • Keep a sleep diary,
  • Rule out OSA, RLS (Restless Limb Syndrome) with sleep study or oximeter
  • CPAP, APAP and biPAP devices
    • Positive Airway Pressure devices (ventilator type devices)
      with or without oxygen added
    • Dental devices
    • oxygen
  • See your doctor for medical evaluation
    • rule out depression
    • thyroid disease
    • diabetes
    • medication side effects.
  • Assess environment and lifestyle
    • sleep environment,
    • schedule,
    • stress,
    • habits (alcohol, smoking,exercise)
      • evening habits
        • relaxing bedtime routine
        • no late, prolonged napping
          • short afternoon naps are good for your
          • avoid evening naps longer than 30 minutes
        • avoid alcohol,
        • quit smoking and chewing tobacco,
        • computers and TV
          • “blue light” distorts your Circadian Rhythm
        • get a routine
    • Work on sleep hygiene
      • bedtime
        • same each night
      • environment
        • cool, dark, quiet
      • get out of bed if not asleep in 15 minutes
        • pursue a quiet activity until sleepy
    • Cognitive behavioral therapy with relaxation training.
    • Lastly consider medications
      • Sleeping medications can be addictive,
      • tolerance can develop,
      • side effects are common and can be serious.
      • not recommended for more than few weeks
      • OK for travel, “stress”, or bereavement

 

Conclusion:

Sleep disorders are very common. Prioritize your sleep, it is vital to being healthy and feeling your best. Shoot for 7 hours of good sleep. Schedule and plan your sleep time. Don’t be afraid to take a short nap, 20-30 minutes during the day to catch up on your sleep. Work on your sleep hygiene, and see your doctor if you think you have a sleep disorder.

References:

  • AAFP Home Study
  • American Family Physician journal