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Dementia and Confusion in Older Women
OB GYN Grand Rounds 9/15/12
Teresa McCarthy MD,MS [email protected]
Dementia – umbrella diagnosis
Alzheimer’s Disease
Vascular Dementia
Lewy Body Dementia
FTD
Alzheimer’s disease: 60-80 % • Includes mixed AD + VD
Lewy Body Dementia: 10-25 %
– Parkinson spectrum
Vascular Dementia: 6-10 % – Stroke related
Frontotemporal Dementia: 2-5 %
– Personality or language disturbance
DSM – 5 Dementia = Neurocognitive disorders • Major Cognitive Impairment
– Substantial cognitive decline from previous level of performance based on history
– Formal testing (>2 SD from norm)
• Minor Cognitive Impairment – Modest decline from previous – Formal testing (1-2 SD from norm)
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Alzheimer’s Disease
• Chronic progressive decline in 2 or more areas of
cognition: – Memory* – Executive function – Ability to recognize objects - agnosia – Motor ability -apraxia – Language – aphasia
• Severe enough to interfere with occupational or social life
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Alzheimer’s disease
– Deficits are not due to DELRIUM – Deficits are not due to another mental
disorder
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Alzheimer’s: A Public Health Crisis
• Scope of the problem – 5.3M Americans with AD in 2015 – Growing epidemic expected to impact 13.8M Americans by
2050 and consume 1.1 trillion in healthcare spending – Almost 2/3 are women (longer life expectancy) – If disease could be detected earlier incidence would be
much higher • Pre-clinical stage 1-2 decades
• Some populations at higher risk – Older African Americans (2x as whites) – Older Hispanics (1.5x as whites)
6 Alzheimer’s Association Facts
and Figures 2015
Base Rates
• 1 in 9 people 65+ (11%) • 1 in 3 people 85+ (32%)
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Alzheimer’s Association Facts and Figures 2014
Challenges & Opportunities
• AD under-recognized by providers – Only 50% of patients receive formal diagnosis
• Millions unaware they have dementia
– Diagnosis often delayed on average by 6+ years after symptom onset
8 Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006
What is ACT on Alzheimer’s?
statewide
collaborative
volunteer driven
60+ O R G A N I Z A T I O N S
500+ I N D I V I D U A L S
I M P A C T S O F A L Z H E I M E R ’ S
BUDGETARY SOCIAL PERSONAL
Collaborative Goals/Common Agenda – www.actonalz.org
Five shared goals with a Health Equity perspective
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ACT Tool Kit
• Evidence and consensus-based, best practice standards for Alzheimer’s care
• Tools and resources for: – Primary care providers – Care coordinators – Community agencies – Patients and families
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Case Study: Colleen
• 66 y/o retired accountant for family business • Presents to primary care with memory complaints • Daughter agrees that short-term memory is poor • Began 2 years ago, seems to be worsening • Frequent medication changes, managing
independently • Lives with husband who is still running the family
business
Signs and Symptoms of AD – should prompt an evaluation/”screen”
• Memory loss • Confusion • Disorientation to time or place • Getting lost in familiar locations • Impairment in speech/language • Trouble with time/sequence relationships • Diminished insight
16 Alzheimer’s Association, 2009
Signs and Symptoms of AD – should prompt an evaluation/”screen
• Poor judgment/problem solving • Changes in sleep and appetite • Mood/personality/behavior changes • Wandering • Deterioration of self care, hygiene • Difficulty performing familiar tasks, functional
decline
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Practice Tips
• Clinical interview – Let patient answer questions without help – Remember: Social skills remain intact until
late stage dementia • Easy to be fooled by a sense of humor, reliance on old
memories, or quiet/affable demeanor
Practice Tips
• Red flags
– Repetition (not normal in 7-10 min conversation) – Tangential, circumstantial responses – Losing track of conversation – Frequently deferring answers to family member – Over reliance on old information/memories – Inattentive to appearance – Unexplained weight loss or “failure to thrive”
Practice Tips
• Family observations:
– ANY instances of getting lost while driving, trouble following a recipe, asking same questions repeatedly, mistakes paying bills
– Take these concerns seriously: by the time family report problems, symptoms have typically been present for quite a while and are getting worse
Screening Measures
• Wide range of options
– Mini-Cog™ (MC) – Mini-Mental State Exam© (MMSE) – St. Louis University Mental Status Exam™ (SLUMS) – Montreal Cognitive Assessment™ (MoCA)
• All but MMSE free, in public domain, and online
Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006
Mini-Cog™
Contents • Verbal Recall (3 points) • Clock Draw (2 points)
Advantages • Quick (2-3 min) • Easy • High yield (executive fx,
memory, visuospatial)
Subject asked to recall 3 words Leader, Season, Table
Subject asked to draw clock, set hands to 10 past 11
+3
+2
Borson et al., 2000
Mini-Cog Research
• Performance unaffected by education or language
• Borson Int J Geriatr Psychiatry 2000
• Sensitivity and specificity similar to MMSE (76% vs. 79%; 89% vs. 88%)
• Borson JAGS 2003
• Does not disrupt workflow & increases rate of diagnosis in primary care
• Borson JGIM 2007
• Failure associated with inability to fill pillbox • Anderson et al Am Soc Consult Pharmacists 2008
Mini-Cog: Colleen
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http://youtu.be/DeCFtuD41WY
Dementia Work-Up
• H&P • Diagnostics
– Labs – Imaging ?
• Objective cognitive measurement – More specific testing (e.g., neuropsychometric)
SLUMS
High School Diploma Less than 12 yrs education
Pass > 27 > 25
Fail 26 or less 24 or less
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Tariq SH, Tumosa N, Chibnall et al. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006 Nov;14(11):900-10.
Tool Selection Montreal Cognitive Assessment (MoCA) • Sensitivity: 98% for dementia • Specificity: 87% St. Louis University Mental Status (SLUMS) • Sensitivity: 98% for dementia • Specificity: 81% Mini-Mental Status Exam (MMSE) • Sensitivity: 78% for dementia • Specificity: 88%
Larner 2012; Nasreddine et all, 2005; Tariq et al., 2006; Ismail et al., 2010
CPT- Cognitive performance test
• Fairview Occupational Therapist – Identify level of functional impairment associated
with cognitive deficit
• Formal neuropsychiatric testing
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Delivering the Diagnosis
• GIVE the diagnosis • Connect patient/family to community
resources – Examples: Senior linkage line, Alzheimer’s
Association
• Discuss follow-up – regular intervals (e.g., q 6 months) for proactive
care
• Provide written summary of visit 40
Delivering the Diagnosis
• Address immediate problems: – Management of medications, finances, meals – Home safety – Caregiver burnout – Need care supporter to track and come to
appointments
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Delivering the Diagnosis: Sam
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https://www.youtube.com/watch?v=vy2ZC5ZSZL8
Treatment: Medications
• Cholinesterase inhibitors
– Donepezil, Rivastigmine, Galantamine, Cognex – Possible side effects: nausea, vomiting, syncope,
dizziness, anorexia
• NMDA receptor antagonist – Memantine – Possible side effects: tiredness, body aches,
dizziness, constipation, headache 46
Care and Treatment
• The care for patients with Alzheimer’s has very little to do with pharmacology and more to do with psychosocial interventions
• Connect patient and family to experts in the community – Alzheimer’s Association, care coordinator – Stress this is part of their treatment plan and you
expect to hear about their progress at next visit
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Confusion in older adults - beyond dementia Dementia • Chronic, progressive
decline in cognitive function
Delirium • Acute onset of
confusion with lack of attention
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What is delirium? DSM 5
• Impaired attention • Acute disturbance of consciousness • Fluctuating course
• Disorganized thinking • Perceptual disturbances • Psychomotor changes • Sleep disturbance • Evidence that there is an underlying physiologic or
medical condition causing the disorder
• Anyone with underlying physiologic or medical instability
= Those stressed and with limited reserve* *This is the frail geriatric population
Who is at risk for delirium?
• “Anything” that can acutely disrupt normal brain function – Medications – Brain trauma – Blood chemistry abnormalities – Infection – Pain – Myocardial ischemia
Causes of Delirium usually multiple causes!
ANY change in drug therapy
– New – Discontinued – Dose change – Time change
Medications – common contributor to delirium
• Most common offenders:
ANTICHOLINERGIC medications
Benadryl Urinary incontinence drugs Antidepressants Antipsychotics
Medications
• 1. Acute onset and fluctuating course • 2. Inattention
• 3. Disorganized thinking • 4. Altered level of consciousness
• Probable delirium requires (1 and 2) + (3 or 4)
Identifying delirium tool
CAM – Confusion Assessment Method
Delirium
• Evidence that there is an underlying physiologic or medical condition causing the disorder
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Causes of Delirium
• Mnemonic Drugs Electrolyte disturbances Lack of drugs Infection Reduced sensory input Intracranial Urinary, fecal Myocardial, pulmonary
Summary
• Confusion in older women can be confusing
– Dementia is a chronic progressive decline in
cognitive function
– Delirium is an acute decline in cognition with lack of attention and should be reversible
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Objectives
1. Be aware of the updated DSM5 criteria for “dementia” 2. Identify indications for "screening" for dementia in older women 3. Know the components of a diagnostic evaluation – www.actonalz.org 4. Recognize delirium in older women
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#3 Caregiver Support
Alzheimer’s Association
800.272.3900 | www.alz.org/mnnd
One stop shop for: – Care Consultation – Support Groups (Memory Club) – 24/7 Helpline
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References & Resources • Alzheimer’s Association (2014). Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, Volume 10, Issue 2. • Anderson K, Jue S & Madaras-Kelly K 2008. Identifying Patients at Risk for Medication Mismanagement: Using Cognitive
Screens to Predict a Patient's Accuracy in Filling a Pillbox. The Consultant Pharmacist, 6(14), 459-72. • Barry PJ, Gallagher P, Ryan C, & O‘mahony D. (2007). START (screening tool to alert doctors to the right treatment)--an
evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing, 36(6): 632-8. • Blendon RJ, Benson JM, Wikler, EM, Weldon, KJ, Georges, J, Baumgart, M, Kallmyer B. (2012). The impact of experience
with a family member with Alzheimer’s disease on views about the disease across five countries. International Journal of Alzheimer’s Disease, 1-9.
• Boise L, Neal MB, & Kaye J (2004). Dementia assessment in primary care: Results from a study in three managed care systems. Journals of Gerontology: Series A; Vol 59(6), M621-26.
• Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. (2000). The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15(11):1021-1027.
• Borson S, Scanlan JM, Chen P, Ganguli M. (2003). The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc;51(10):1451-1454.
• Borson S, Scanlan J, Hummel J, Gibbs K, Lessig M, & Zuhr E (2007). Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior. J Gen Intern Med; 22(6): 811–817.
• Boustani M, Peterson B, Hanson L, et al. (2003). Systematic evidence review. Agency for Healthcare Research and Quality; Rockville, MD: Screening for dementia.
• Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Hui SL, Hendrie HC (2005). Implementing a screening and diagnosis program for dementia in primary care. J Gen Intern Med. Jul; 20(7):572-7.
• Ferri CP, Prince M, Brayne C, et al. (2005). Alzheimer’s Disease International Global prevalence of dementia: A Delphi consensus study. Lancet, 366: 2112–2117.
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References & Resources • Finkel, SI (Ed.) (1996). Behavioral and Psychological Signs of Dementia: Implications for Research and Treatment.
International Psychogeriatrics, 8(3). • Folstein MF, Folstein SE, & McHugh PR (1975). "Mini-mental state". A practical method for grading the cognitive state of
patients for the clinician. J Psychiatr Res, Nov 12(3):189-98. • Gallagher P & O’Mahony D (2008). STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions):
Application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing, 37(6): 673-9. • Gitlin LN, Kales HC, Lyketsos CG, & Plank Althouse E (2012). Managing Behavioral Symptoms in Dementia Using
Nonpharmacologic Approaches: An Overview. JAMA, 308(19): 2020-29. • Holroyd S, Turnbull Q, & Wolf AM (2002). What are patients and their families told about the diagnosis of dementia?
Results of a family survey. Int J Geriatr Psychiatry, Mar;17(3):218-21. • Ismail Z, Rajji TK, & Shulman KI (2010). Brief cognitive screening instruments: An update. Int J Geriatr Psychiatry, 25:111–20. • Jeste DV, Blazer D, Casey D et al. (2008). ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with
Dementia. Neuropsychopharmacology, 33(5): 957-70. • Larner AJ (2012). Screening utility of the Montreal Cognitive Assessment (MoCA): In place of – or as well as – the MMSE?
Intern Psychogeriatrics, 24, 391–396. • Lin JS, O’Connor E, Rossom RC, Perdue LA, Burda BU, Thompson M, & Eckstrom E (2014). Screening for Cognitive
Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Evidence Syntheses, 107.
• Long KH, Moriarty JP, Mittelman MS, & Foldes SS (2014). Estimating The Potential Cost Savings From The New York University Caregiver Intervention In Minnesota. Health Affairs, 33(4), 596-604.
• McCarten JR, Anderson P Kuskowski MA et al. (2012). Finding dementia in primary care: The results of a clinical demonstration project. J Am Geritr Soc;60(2):210-217.
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• Mittelman MS, Haley WE, Clay OJ, & Roth DL (2006). Improving caregiver well-being delays nursing home placement of
patients with Alzheimer disease. Neurology, November 14(67 no. 9), 1592-1599. • Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, & Chertkow H. (2005). The
Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment. J Amer Ger Soc, 53(4), 695-99.
• National Chronic Care Consortium and the Alzheimer’s Association. 1998. Family Questionnaire. Revised 2003. • Silverstein NM & Maslow K (Eds.) (2006). Improving Hospital Care for Persons with Dementia. New York: Springer Publishing
CO. • Tariq SH, Tumosa N, Chibnall JT, Perry MH, & Morley E. (2006). Comparison of the Saint Louis University mental status
examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder: A pilot study. Am J Geriatr Psychiatry, Nov;14(11):900-10.
• Turnbull Q, Wolf AM, & Holroyd S (2003). Attitudes of elderly subjects toward “truth telling” for the diagnosis of Alzheimer’s disease. J Geriatr Psychiatry Neurol, Jun;16(2):90-3.
• Zaleta AK & Carpenter BD (2010). Patient-Centered Communication During the Disclosure of a Dementia Diagnosis. Am J Alzheimers Dis Other Demen, 25, 513.
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References & Resources
References & Resources
• 2012 Updated AGS Beers Criteria: http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
• After a Diagnosis (ACT): http://www.actonalz.org/sites/default/files/documents/ACT-AfterDiagnosis.pdf Alzheimer’s Association • Basics of Alzheimer’s Disease: https://www.alz.org/national/documents/brochure_basicsofalz_low.pdf • Caregiver Notebook - http://www.alz.org/care/alzheimers-dementia-caregiver-notebook.asp • Driving Center: www.alz.org/care/alzheimers-dementia-and-driving.asp • Facts & Figures video: http://youtu.be/waeuks1-3Z4 • Facts & Figures Report: https://www.alz.org/facts/downloads/facts_figures_2015.pdf • Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf • Know the 10 Signs. http://www.alz.org/national/documents/checklist_10signs.pdf • Living with Alzheimer’s – Mid Stage: https://www.alz.org/documents_custom/middle-stage-caregiver-tips.pdf • Living with Alzheimer’s – Late Stage: https://www.alz.org/documents_custom/late-stage-caregiver-tips.pdf • Living Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf • Taking Action Workbook: http://www.alz.org/mnnd/documents/2010_taking_action_e-book(1).pdf • Trial Match: http://www.alz.org/research/clinical_trials/find_clinical_trials_trialmatch.asp
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References & Resources
• AD8 Dementia Screening Interview: http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf • At the Crossroads: http://www.thehartford.com/sites/thehartford/files/at-the-crossroads-2012.pdf • Caring for a Person with Alzheimer’s Disease:
http://www.nia.nih.gov/sites/default/files/caring_for_a_person_with_alzheimers_disease_0.pdf • Coach Broyles Playbook on Alzheimer’s: http://www.caregiversunited.com • Honoring Choices Minnesota:http://www.honoringchoices.org • Hospitalization Happens: http://www.nia.nih.gov/sites/default/files/hospitalization_happens_0.pdf • Medicare Annual Wellness Visit: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/downloads/MM7079.pdf • MiniCog™ http://www.alz.org/documents_custom/minicog.pdf • MN Health Care Home Care Coordination Tool Kit:
http://www.health.state.mn.us/healthreform/homes/collaborative/lcdocs/cliniccarecoordtoolkit.pdf • Montreal Cognitive Assessment (MoCA)http://www.mocatest.org • National Alzheimer’s Project Act: http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf • Next Step in Care: http://www.nextstepincare.org • Physician Orders for Life Sustaining Treatment (POLST): http://www.polst.org • St. Louis University Mental Status (SLUMS) examination
http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
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