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Understanding Dementia and Cognitive Assessment
ANNA H. CHODOS, MD, MPH
DIVISION OF GERIATRICS
DIVISION OF GENERAL INTERNAL MEDICINE, ZSFG
CO-PI , OPTIMIZING AGING COLLABORATIVE
GERIATRICS WORKFORCE ENHANCEMENT PROGRAM
The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP28727.
DisclosuresI have nothing to disclose.
Outline
Dementia overview◦Definition◦Assessment
Behavioral issues in dementia
Dementia
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“A Senior Moment”Is there age‐related decline?
Appear to decline with age:◦ conceptual reasoning
◦memory
◦ processing speed
Gradual, not enough to impair function
Dementia• 1 in 9 adults age 65+, and ~1 in 3 age 85+ have dementia
Alzheimers Association Facts and Figures 2015; Yaffe K et al. BMJ 2013;347; Van Rensbergen G, Nawrot T. BMC Geriatrics 2010; Cordell Alz and Dementia 2013
Cognitive impairment unrecognized in ~50% of affected patients in primary care.
Dementia (Major Neurocognitive Disorder):
Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains:◦ Learning and memory◦ Language◦ Executive function◦ Complex attention◦ Perceptual‐motor◦ Social cognition = behavior
Part I
Dementia (Major Neurocognitive Disorder), cont’d:
The cognitive deficits interfere with independence in everyday activities.
The cognitive deficits do not occur exclusively in the context of a delirium.
The cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia)
Diagnosis of dementia= acquired cognitive impairment+ acquired functional impairment
DSM‐V (2013)
Part II
Part III
Part III
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A Case
88 yo man, here for follow‐up.
No complaints.
PMH: hypertension, glaucoma, depression
Meds: HCTZ, eye drops
Says he takes the medicines. “You have my list.”
Our CaseMr. H’s probability is high given his age.◦ Early warning signs present?
◦ Sparse details during conversation and no memory for current news events.
Red flags for DementiaRepetition (not normal in span of a clinic visit)
Losing track of conversation
Frequently deferring to caregiver/family
Unexplained medical decompensation
Unexplained weight loss
Missing appointments
Inattentive to appearance, behavioral changes
Falls or injury, hospitalizations
Paucity of content, detail
Dementia Assessment:Part I
Cognitive:◦History and trajectory of:
◦Memory
◦ Executive Function
◦ Visuospatial
◦ Language
◦Motor
◦ Psychiatric/Behavioral
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Dementia Assessment: Part INeurologic exam: MS, motor, balance
Cognitive Testing◦What tools are you familiar with?
◦What do you have time to do?
Screening Method: Mini‐Cog1‐2 min
3 item recall (3 points)
+ CLOCK DRAW (2 points)
Negative screen ≥3
Positive screen <3, consider DELIRIUM vs. DEMENTIA
http://www.alz.org/documents_custom/minicog.pdf
MOCA Test10‐20min
• Positives: Many languages, Many cognitive domains• Negatives: +1 education < HS, unclear if this is enough• USE THE INSTRUCTIONS the first few times you use it
www.mocatest.org (need to register)
GP‐COG5‐8 min
Part 1‐ Patient (memory)
Part 2‐ Informant (function)
Available in Spanish, Chinese, Korean.
http://gpcog.com.au/
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Our CaseNeurologic exam normal.
Mr H’s MOCA test: 14/30
What is his education?What is normal for 88yo?
Dementia Assessment: Part IIFunction:◦Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs)
How the person is doing is the most important part of this diagnosis.
Assessing FunctionADLs: Impacted late◦ Bathing
◦ Dressing
◦ Toileting, continence
◦ Transferring
◦ Feeding
IADLs: Impacted early◦ Driving/transportation
◦ Using phone
◦ Shopping for food
◦ Finances
◦ Cooking
◦ Housework
◦ Taking meds
Our CaseFunction: He reports no problems with ADLs or IADLs◦ In the clear?
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Dementia Assessment: Part IICollateral‐ family,
caregiver/sMemory
Executive fxn
Language
Visuospatial
Motor
Behavior
FUNCTION
Our Case
Collateral‐◦ His wife’s children ‐unaware anything serious was going on, says he drives daily.
◦Wife says he is more forgetful, forgets bills.
Dementia assessment: Part IIIR/o reversible causes
◦Delirium: acute, fluctuating, inattentive
◦Substance Use
◦Depression
◦Labs: TSH, B12, RPR and HIV
◦Medication review
Medications Causing Cognitive Symptoms
BenzodiazepinesAnti‐cholinergics: diphenhydramine, hydroxyzine, chlorpheniramine◦ Including OTC combination meds‐ tylenol PM
Sleep medications: Z‐drugsMuscle relaxants (cyclobenzaprine, carisoprodol) Antispasmotics: oxybutynin, tolterodineTCA anti‐depressantsAnti‐psychotics
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Dementia: Head imagingWhen should I order head imaging?
Feldman HH, et al. CMAJ. 2008 Mar 25;178(7):825‐36Cordel CB, et al. Alzheimers Dement. 2013 Mar;9(2):141‐50
• <65• Rapid onset• Other diagnoses: cancer, HIV
• Head injury• Focal neurologic findings• Meds: anti‐coagulants
Our caseLabs wnl
Diagnosed mild/moderate dementia–informed patient and CDPH (mandated reporter) ‐> they will inform DMV
Dementia: the take home
Suspect it– Recognize red flags and symptoms
Diagnosis it:◦ Part I Cognitive history
◦ Part II Functional history ◦ Get collateral
◦ Part III R/o reversible causes
Get specialist help when you are not sure
Types
• Alzheimer disease
• Vascular dementia
• Dementia with Lewy Bodies
• Parkinson’s disease with dementia
• Frontotemporal dementia
• Normal pressure hydrocephalus
• Alcohol-related dementia
• HIV-related dementia
• Syphilis-related dementia
• Progressive supranuclearpalsy
• Corticobasal degeneration
• Primary progressive aphasia
• Creutzfeldt-Jakob disease
• Huntington disease
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Types of Dementia
Type MCI Alzheimers Vascular Lewy Body FTD
Onset Gradual Gradual Sudden, or stepwise
Gradual Insidious, younger
Cognitive Features
Memory MemoryLanguage
Depends on injury
MemoryVisuaspatialHallucinationsFluctuating
ExecutiveDisinhibitionHyperorality<memory
Motor Features
Rare early Rare earlyApraxia-late
Depends on injury
Parkinsonian None
Other May progress to AD
Gradual Decline
Stepwise decline
Caution with antipsychotics-
Preserving cognition • Intellectually engaging activities
• Physical Activity
• Social Engagement
Harada, Clin Geriatr Med. 2013 Nov; 29(4): 737–752.
Behavioral symptoms of dementiaNeuropsychiatric symptoms of dementia
“Agitation” (nonspecific), aggression, arguing, irritability, delusions, hallucinations, wandering, depression, apathy, disinhibition, repetitive behaviors, sleep disturbances
Most patients have some NPS.◦ ~80% at some point, especially later in disease course
Panza F, et al. (2015) Expert Opinion on Pharmacotherapy 16:17, pages 2581‐2588. ; Lyketsos CG, et al. JAMA. 2002 Sep 25;288(12):1475‐83.
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NPS
Why are they important?◦Worse daily function◦Worse quality of life◦Burden on caregivers◦ Behavioral symptoms > physical needs
◦More institutionalizationAllegri RF, Neuropsychiatr Dis Treat. 2006;2:105–110.; Lyketsos CG, et al. Alzheimers Dement. 2011 Sep; 7(5): 532–539.Torti FM, Alzheimer Disease & Associated Disorders 200418(2), pp 99‐109
A Case: Neuropsychiatric Symptoms in Dementia
Ms. L who lives in a board and care, spends many afternoons banging on the chairs causing a lot of noise.
Her daughter is asking if there is “anything we can give her to calm her down” so the staff will stop calling her?
Example: www.teepasnow.com‐‐“About Videos”: Challenging Behaviors
What can we do? An Approach to NPS
Identify and describe the behavior
Identify triggers
Identify if it’s a problem and if it is leading to potential harm
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Identify the behaviorMs. L– Behavior‐‐ repetitive behavior, argumentative
Examples:
Yelling, vocalizing
Repetitive behaviors‐ cleaning, reorganizing
Hitting
Identify triggers
Needs: thirst/hunger, pain, toileting, boredom, tired, comfort
Environment: Attendant gender, bathing, undressing
Over or understimulated◦ Isolation and loneliness
◦ Unwanted interaction, fear
Depression, anxiety
Our Case: NPS in dementiaMs. L was a housekeeper prior to retirement.
In reviewing her needs, staff noticed she was not taken to the toilet enough during the afternoon because she was resistant.
Identify if it’s a problemWhat is the consequence of this behavior?◦Caregiver stress
◦Harm to others/self
What has been tried?
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Identify the behavior to identify solutions
Common NPS Interpretations/solutions
Toileting issues Timed voiding
Agitated, upset, restless
Overstimulation, unrealistic expectations, delirium? Provide structure, calm, pets, music
Repetitive behavior Give outlet for activity, safe environment, substitutions
Argumentativeness Agree, avoid debates, calm environment
Adapted from Kathryn Eubank, MD
Educate caregivers
Alzheimers Association
Family Caregiver Alliance
Companies/programs, e.g. teepasnow.com
UCSF Memory and Aging Center videos (Alz Dis)
Choosing Wisely Campaign Geriatrics Rec #2 (2013)
Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia
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Treatment with antipsychoticsAre modestly effective.◦ Agitation, aggression, psychosis
1 in 3 nursing home residents and 1 in 7 community‐dwelling adults with dementia◦ Use goes up with age
GAO Antipsychotic Drugs and Older Adults 2012 Olfson M., et al. J Clin Psychiatry. 2015 Oct;76(10):1346‐53
CATIE‐AD RCT421 outpatients
Risp (1mg) > olanz (5mg) > quet (50mg)
Affected: Paranoia, hostility, aggression, mistrust, psychosis
No change in function, care needs, QOL
Withdrawal from treatment high
Olanz: worsening ADL function
Sultzer DL et al. Am J Psych 2008 Jul;165(7):844‐54. Schneider L, N Engl J Med 2006;355:1525‐38.
Side effects of anti‐psychotics for NPS
1.5‐1.7x increased risk of mortality◦risk of death occurs as early as <6mo
2‐3x increased stroke risk◦CV and metabolic effects (obesity, glucose)
Extrapyramidal symptoms
Worsening cognition and falls
HospitalizationsTampi RR, et al. Ther Adv Chronic Dis 2016, Vol. 7(5) 229–245 ; Maust et al. JAMA Psychiatry 2015; GAO Antipsychotic Drug Use, Jan 2015; Jeste DV J Comp EffRes. 2013 Jul; 2(4): 355–358.
Approach for NPS: Medication
Try dementia medications and antidepressants first.
Consider an antipsychotic if it’s a severe problem:◦ Quetiapine > risperidone > olanzapine
◦ Record target symptom
◦ Schedule it, lowest dose possible
◦ Record response, trial off after 3‐6 months
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Our CaseFor Ms. L, staff put cleaning cloths in easy reach and would clean next to her. This would get her to use cloths to clean the chairs instead of hitting them and so no one would have to try to get her to stop.
Staff started to regularly offer her bathroom trips. She seemed more comfortable afterward and would spend less time cleaning the chairs and “annoying” the staff.
NPS: the take home
Identify the behavior, triggers, if it’s a problem.
NONPHARMACOLOGIC approaches first
Educate caregivers
If decided, plan a medication trial carefully.
https://www.healthcare.uiowa.edu/igec/iaadapt/
Thank youHelen Kao, MD
Kathryn Eubank, MD
Stephanie Rogers, MD
Stefanie Bonigut, LCSW, Alz Association
Kirby Lee, PharmD
Kate Radcliffe
For more information contact: [email protected]
THE OPTIMIZING AGING COLLABORATIVE AT UCSF IS SUPPORTED BY THE UCSF GERIATRICS WORKFORCE ENHANCEMENT PROGRAM: HEALTH RESOURCES AND SERVICES ADMINISTRATION
(HRSA) GRANT NUMBER U1QHP28727.
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EXTRA SLIDESQuestions you can ask to elicit history about cognitive impairment in the various cognitive domains
Cognitive Symptoms: MemoryProblems with recent events – Trouble remembering conversations, repeating things
Remote events (generally remain intact until later in disease)
Misplacing objects
Repetitive Questions
Missing appointments
Objective findings: Repeats complaint stated earlier in visit, unable to do short‐term recall exercise
Cognitive Symptoms: Executive FunctionDifficulty with planning or organization
Multi‐tasking
Concentration/attention span
Problem Solving
Impulsivity (acting without thinking)
Mental rigidity/inflexibility
Objective findings: Difficulty following complex instructions, difficulty with clock draw or trails
Cognitive Symptoms: LanguageWord finding trouble
Poor articulation
Impaired comprehension
Impoverished speech (e.g. “thingie” instead of specific word)
Impaired reading/writing/spelling
Mutism/ Decreased speech output
Objective findings: Can name <11 words in 1 minute, poor score on Boston Naming Test (doesn’t know names of high frequency words)
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Cognitive Symptoms: VisuospatialLost in familiar environments
Difficulty recognizing faces
Difficulty driving
Difficulty parking
Objective finding: Trouble drawing a cube
Cognitive Symptoms: BehavioralChanges in emotional expression (blunting/labile)
Changes in personality/behavior
Apathy/decreased motivation
Obsessive/compulsive behaviors
Agitation/aggression
Depression
Delusions/Hallucinations
Impaired Hygiene/eating
Changes in sleep
Cognitive Symptoms: MotorDifficulty with walking or balance
Trouble using utensils (apraxia)
Change in handwriting
Tremor
Weakness
Involuntary movements
Trouble Swallowing
Objective findings: Falls, cannot demonstrate how to brush teeth or hair (apraxia)
EXTRA SLIDESManagement of Dementia
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Pharmacological ManagementDepends on the type of dementia
Treatment of risk factors for stroke and cardiovascular disease
Tailor to patient’s goals of care
Setting realistic expectations◦ Most treatments don’t have a big effect on cognition or function
Pharmacological ManagementCHOLINESTERASE INHIBITORS
MILD/MODERATE DEMENTIA
Donepezil
Rivastigmine
Galantamine
General side effects: nausea, diarrhea, anorexia, insomnia
NMDA RECEPTOR ANTAGONIST
MODERATE/SEVERE DEMENTIA
Memantine
Minimal impact on function and quality of life.Do not really change the disease course.
What works?
Effect sizes are: small = 0.2; moderate= 0.5; large= 0.8
Address the environmental, social factors and engage caregivers
Future Drug TherapiesAnti-beta amyloid◦ Solanezumab & bapineuzumab- no improvement in
cognition or function in Phase 3 study
Many other still in early phase studies◦ Beta-secretase (BACE) inhibitors- prevents
formation of beta-amyloid◦ Preservation of tau protein- maintain neuronal
structures◦ Anti-inflammatory medication