when it’s not dementia: other conditions that impair cognitive performance christine bradway, phd,...

When It’s Not Dementia: When It’s Not Dementia: Other Conditions That Impair Other Conditions That Impair

Cognitive PerformanceCognitive Performance

Christine Bradway, PhD, RN

Associate Professor of Nursing School of Nursing University of Pennsylvania

Joel E. Streim, MD Professor of Psychiatry Perelman School of Medicine University of Pennsylvania and Philadelphia VA Medical Center

PCA Regional Conference on AgingPCA Regional Conference on AgingOctober 2012October 2012

DisclosuresDisclosures

Dr. Streim receives salary support from grants funded by:

National Institute on Aging (NIA) VA Health Services Research & Development (VA HSR&D) Health Resources and Services Administration (HRSA) Donald W. Reynolds Foundation

Dr. Bradway receives salary support from Health Resources and Services Administration (HRSA)

Learning ObjectivesLearning Objectives

Identify cognitive domains that may become impaired in mental disorders of late-life

Describe syndromes of cognitive impairment commonly seen in older adults

Understand the importance of assessment for identifying potentially reversible or treatable causes of cognitive impairment; and for identifying the extent of cognitive disability and need for assistance

Recognize the ways that cognitive impairment can affect geriatric care, including behavioral health treatment and the role of caregivers

Identify at least 3 elements of cognitive capacity required for independent decision-making

Session OverviewSession Overview

1. Lecture on cognitive conditions, assessment, and management issues (Streim)

2. Interactive case presentations (Bradway)

3. Discussion of participant case experience (Bradway, Streim, audience)

PCA Regional Conference on AgingPCA Regional Conference on AgingOctober 2012October 2012

When It’s Not Dementia:

Other Conditions That Impair Cognitive Performance

Joel E. Streim, M.D.

Professor of Psychiatry

Perelman School of Medicine at the University of Pennsylvania

Geriatric Education Center

and

Philadelphia VA Medical Center

Mental Illness Research Education & Clinical Center

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What is “cognitive impairment” ??

Deficits in various cognitive domains:

—attention

—memory (amnesia)

—language (aphasia)

—recognition (agnosia)

—performing motor activities (apraxia)

—initiating/executing tasks (abulia)

—visual-spatial function

—insight

—judgment

Consequences of Cognitive ImpairmentConsequences of Cognitive Impairment

Cognitive impairment can interfere with Communication

— Comprehension

— Ability to report symptoms, express needs Social awareness, self-monitoring, behavior Ability to follow directions Self-care (basic ADLs) Household management (instrumental ADLs)

Impairment in Activities of Daily Living (ADLs)

Instrumental ADLs (Household Management)

— Shopping

— Cooking

— Cleaning

— Laundering

— Using Telephone

— Paying Bills

Basic ADLs (Personal Care)

— Bathing

— Hygiene

— Grooming

— Dressing

— Feeding

— Toileting

Other ConsequencesOther Consequences

Cognitive impairment can interfere with Personal safety

— Eating (e.g. risk of choking or aspiration)

— Walking (e.g. risk of getting lost, falling)

— Household tasks (e.g. risk of fires, accidents)

Receipt of medical, nursing, and personal care

— Patient participation

— Delivery of care by providers & caregivers

Syndromes of Cognitive ImpairmentSyndromes of Cognitive Impairment

Delirium = disturbance of

consciousness and attention

acute confusional state

Dementia = impairment of memory

chronic confusional state

(Dx requires interference (Dx requires interference with everyday functioning)with everyday functioning)

plus other cognitive domains

plus other cognitive domains

Delirium: clinical featuresDelirium: clinical features

Essential features:

— Disturbance of consciousness with impaired attention (inability to focus, fix, or shift attention)

— Change in cognition (impaired memory, disorientation, language disturbance), or

— Perceptual disturbance (hallucinations, illusions)

— Caused by a medical condition or medication effects

Associated features:

— Delusional thinking (psychosis)

— Sleep-wake cycle disturbance

— Agitated behavior, or hypoactivity

Delirium: clinical course and etiologyDelirium: clinical course and etiology

Abrupt onset (hours to days) Fluctuating course Caused by various medical or neurological

conditions, drug effects (intoxication, withdrawal), or combination

Usually reversible if underlying condition is treated successfully

High mortality rates, especially if not recognized or treated

Delirium: common causesDelirium: common causes

Infection Dehydration, electrolyte disturbances Hypoglycemia Hypotension (low blood pressure) Hypoxemia (low blood oxygen levels) Cardiac events Respiratory illnesses Neurological events (stroke, brain injury) Medication effects

— Anticholinergics, antihistamines

— Narcotics

— Alcohol or drug intoxication OR withdrawal

NB: An acute episode of delirium can be superimposed on a chronic dementia

Recognition of Cognitive ImpairmentRecognition of Cognitive Impairment

Suspect delirium or dementia when patient has self-care deficits family has “taken over” responsibilities patient doesn’t participate well in medical,

nursing, rehabilitative, or personal care behaviors interfere with care delivery

Don’t blame “old age”

Symptom Overlap in Delirium and Dementia

Common features of acute and chronic confusion: Amnestic: forgetful, poor recall, misplacing things Disoriented: confused about time and place Aphasic: word-finding difficulty, impaired

comprehension Perseverative: repetition of words, thoughts Apraxic: difficulty dressing, grooming, hygiene Dependent: need help from caregivers Delusional: paranoid thoughts and fears Agitated: picking at clothes/hair/objects, motor

restlessness, verbal or physical aggression

Recognition of Cognitive Impairment:Recognition of Cognitive Impairment:Barriers and CluesBarriers and Clues

Patient’s may not be aware of changes

— lack insight into memory problems

— deny disability

Get history from family, friends, or caregivers

— onset may be abrupt (days, weeks) or gradual (over months, years)

— families may not notice gradual changes

— ask about change from baseline function, from “usual self”

Look for discrepancy between self-reported function and actual performance of ADLs

If patient has difficulty performing ADLs, ask for OT evaluation (clinic or in-home)

Cognitive Impairment: What are the obvious signs?

Forgetfulness

— Repetitious statements

— Misplacing things Disorientation

— Getting lost Speech deficits

— Word-finding difficulties

— Word substitutions Diminished judgment

Recognizing more subtle signs

Visual complaints; impaired recognition Trouble following directions Difficulty performing familiar tasks Family members take over usual roles Loss of initiative

— Disengagement from usual activities

— Self-neglect

— Weight loss Diminished social spontaneity

— Less conversation

Behavioral Disturbances Wandering Restlessness

— Fidgeting

— Pacing

Impulsivity Inappropriate handling of objects

— Rummaging / fiddling

— Hoarding

Verbal agitation

— Repetitious speech

— Verbal annoyance / aggression Physical combativeness

Not all cognitive impairment meets Not all cognitive impairment meets criteria for a diagnosis of dementiacriteria for a diagnosis of dementia When memory is not affected When function is not affected

— Performance of ADLs is preserved

Can be associated with various

— Neurological conditions

— Medical illnesses

— Psychiatric disorders

Other contributing factors

— Chronic pain

— Impaired vision and hearing

Neurological conditions associated Neurological conditions associated with cognitive impairmentwith cognitive impairment

Mild cognitive impairment

— No significant functional deficits

Neurological disorders

— Stroke

— Parkinson’s disease

Traumatic brain injury (TBI)

Medical causes of cognitive impairment

Metabolic

— Vitamin deficiencies

— Hypo- or hyperglycemia

— Electrolyte disturbances (low Na, high Ca) Hormonal

— Hypothyroidism Infectious

— AIDS

— Syphilis

— Pneumonia

— Urinary tract infection

Some of these are treatable and potentially reversible

Psychiatric conditions associated Psychiatric conditions associated with cognitive impairmentwith cognitive impairment

Poor cognitive performance may be partially or wholly explained by Anxiety

— impaired concentration, distractibility

— obsessional thinking, indecisiveness Depression

— lack of motivation, poor effort

— fatigue

— impaired concentration

— executive dysfunction

— indecisiveness

Cognitive performance may improve when anxiety or depression is treated.

Most of these are treatable

Other contributing factorsOther contributing factors

Chronic pain

— Osteoarthritis

— Peripheral neuropathy

Hearing impairment Low vision

— Age-related macular degeneration

— Diabetic retinopathy

— Cataracts

Careful Evaluation is EssentialCareful Evaluation is Essential

Up to 90% of individuals with acute and 20% with chronic cognitive impairment may have a reversible component

Need to identify treatable impairments. However, most with dementia will have persistent deficits

Relationship of Depression and Cognitive Relationship of Depression and Cognitive Impairment in Old Age: What’s New?Impairment in Old Age: What’s New?

1/3 to 1/2 of patients with late-life depression have at least mild cognitive impairment (MCI).1

Depression with onset in late-life is often associated with vascular risk factors and executive dysfunction.2

This has been called vascular depression, and is distinct from pseudodementia, as cognition does not improve with antidepressant treatment.2

Geriatric patients with depression have a higher incidence of progression to MCI and dementia.1,3

1 Panza F et al. Am J Geriatr Psychiatry 2010; 18:98-116; 2 Alexopoulos GS et al. Am Psychiatry 1997; 154:562-565; 3 Steffans DC et al. Arch Gen Psychiatry 2006; 63:130-138

Recognition of executive dysfunction Recognition of executive dysfunction in clinical practicein clinical practice History of observable functional and behavioral signs1

— Difficulty with initiation— Inability to perform sequential tasks— Poor task completion— Disengagement from activities— Task avoidance (BADL, IADL)

Referral for evaluation of functional status by occupational therapist2

Consider referral for selective neurocognitive testing

1 Alexopoulos. J Clin Psychiatry. 2003;64(suppl 14):18-23. 2 Erez et al. Am J Occup Ther. 2009;63(5):634-640.

Executive function is crucial for both Executive function is crucial for both tasktask performanceperformance and and decision-makingdecision-making

Encompasses:

Awareness of one’s situation (presence of unmet needs, medical problems, disability, danger) and what needs to be done

Planning solutions and actions

Initiation of tasks

Sequencing and performance of tasks

Individuals with executive dysfunction may be able to describe how a task can be accomplished, but unable to perform the task.

Therefore, a medical or psychiatric interview may need to be complemented by observations of actual task performance

Observations may be made during examination by a psychiatrist, cognitive or neuropsychologist, or occupational therapist

Self-reported abilities vs. demonstrated performance

Individuals with executive dysfunction or deficits in other cognitive domains

• may or may not meet criteria for dementia or delirium

• may or may not have impaired decision-making capacity

How do clinicians translate examination findings into a clinical assessment of

decision-making capacity?

Evaluation of Decision-making Evaluation of Decision-making Capacity from a Capacity from a ClinicalClinical Perspective Perspective

Key elements of capacity

Awareness of the situation or need (healthcare, financial, living arrangements)

Understanding of the treatment options / available solutions

Appreciation of risks and benefits, or consequences of a choice (ability to reason and deliberate)

Ability to communicate the choice

Cognitive Impairment and Decision-making Cognitive Impairment and Decision-making Capacity: seeing clinical “shades of grey”Capacity: seeing clinical “shades of grey”

Pattern and severity of cognitive deficits usually includes areas of spared cognitive function and impaired cognitive function.

Individual may have retained the capacity to

— Recognize a basic need for help

— Express wishes or preferences

which form the basis for participation in decision-making

…But same individual may have lost the capacity to

— Appreciate the extent of disability

— Recognize the type or magnitude of the assistance needed

— Deliberate about risks, benefits

— Appreciate potential consequences of a decision

which creates a need for assistance in decision-making

Basis for Assisted Decision-MakingBasis for Assisted Decision-Making

Concept of substituted judgment Effort to determine what the person wants or would

have wanted for him or herself

Duty to represent person’s advance directives, if available

Need to educate and support caregivers and surrogates to use

Substituted judgment in decision-making

Assisted decision-making, when possible

Training of Caregivers to Function as Training of Caregivers to Function as Surrogate Decision-MakersSurrogate Decision-Makers

Concept of assisted decision-making: Preservation of autonomy to the extent possible

— Identify areas of spared cognitive function and encourage their continued use

— Help individual compensate for areas of impaired cognition

Take current wishes and preferences into account, when consistent with realistic options

Risk tolerance may reflect the persons life-long values

Responsibility for the final decision rests with the surrogate

Assisted Decision-Making:Assisted Decision-Making:Practical Approaches to CommunicationPractical Approaches to Communication

Caregivers and surrogate decision-makers should be encouraged to:— Use simple language to explain situation, options, etc.

— Present information slowly

— Repeat information, check for comprehension

— Point out consequences

— Ask about wishes and preferences

— Ask about priorities (values)

e.g., “What’s most important to you?”

Essentials of Family-Caregiver EducationEssentials of Family-Caregiver Education

Explain functional limitations due to confusion Set expectations for

— Recovery from delirium; risk of recurrence

— Progression of dementia

Clarify care needs

— Provide a safe environment

— Communication strategies (optimize vision & hearing)

— Supervision / assistance with ADLs

Encourage medical follow-up

— Optimize treatment of other conditions

— Reduce and manage co-morbidity

Questions ???Questions ???

DiscussionDiscussion

Standardized cognitive screening Standardized cognitive screening instruments: Short and Shortestinstruments: Short and Shortest

Mini Cog

— 3 recall items

— Clock drawing

3 minutes to administer

Scoring quick, simple

Less affected by education, ethnicity, language than other, longer tools

Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11):1021

Mini-Cog Scoring Algorithm

http://geriatrics.uthscsa.edu/tools/MINICog.pdf

Montreal Cognitive Assessment Montreal Cognitive Assessment (MoCA)(MoCA) Tests multiple cognitive domains

— Attention

— Memory

— Language

— Visuospatial

— Executive function

— Abstract thinking

10 minutes to administer

Score range 0-30

<26 is abnormal

Nasreddine ZS, et al. The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For Mild Cognitive Impairment. J American Geriatr Soc 53:695-699, 2005.

Montreal Cognitive Assessment Montreal Cognitive Assessment (MoCA)(MoCA)

http://www.mocatest.org/

Case #1 Case #1

Mrs. T. is 90 and has just been discharged to home after a 5 day hospital stay

Came to the hospital with “confusion” at home

—Did not recognize daughter

—Not eating

—Fearful of burglars in house

Case #1: Continued Case #1: Continued

Hospital diagnoses/problems included:

— Urinary tract infection

• Dehydration

— Delirium

— Deconditioning

— She is ordered home physical/occupational therapy to determine her ability to continue to live at home


1. What pre-hospital information is important to know about Ms. T?

2. What assessments are essential when she returns home from the hospital?

3. What factors need to be considered when making Ms. T.’s plan of care?

4. What caregiver information/support should be initiated?

Case #2 Case #2

Mr. R is an 81 year-old widower now at home after a 3-day hospitalization for acute pneumonia. He has underlying mild COPD.

Mr. R worked as a mechanic and retired at age 62. His wife died 3 years ago and he sold his home and now lives with his daughter.

Mr. R.’s daughter has noticed he is less physically active and seems to interact less and less with family and friends for the past 6 months.


At home you note that Mr. R:

Requires oral antibiotics for 5 more days to complete pneumonia treatment

Has lost 10lbs. within last month

Had unreported diarrhea during hospitalization

Began a medication, Amitriptyline, for depression

—Was given a sleep medication, Ambien, while hospitalized and to take at home


On interview, Mr. R is a little lethargic and has slowed speech. He is also unsteady and nearly falling with walking. He has increased confusion at night; he had some mild memory loss before being hospitalized. He has had diarrhea since coming

home and his appetite is poor.


What else would you like to know about Mr. R’s memory and cognition?


Mr. R’s daughter’s main concern is her father’s changed behavior. Prior to hospitalization Mr. R was functioning with minimal assistance at home, was forgetful, but mostly independent. Mr. R’s hearing aid was lost during hospitalization and so, until his daughter can secure another, Mr. R’s hearing is quite impaired. The Mini-Mental State Examination pre-hospitalization is unavailable. Mr. R’s current MMSE is 21 (normal 24-30). Since discharge he has been quite dependent, more short of breath than normal, and is often “not making sense”.


What are the risk factors Mr. R has for the development of delirium?

What are the risk factors Mr. R has for depression?

What concerns do you have for Mr. R. now that he is at home?


What further information might be helpful in terms of Mr. R.’s nutritional and fluid intake?

How might this affect Mr. R.’s cognitive abilities?


What interventions would you suggest implementing for Mr. R’s plan of care?

How should Mr. R’s depression be addressed?

Are there interventions that could have been implemented in the hospital to prevent/minimize the delirium?


What other strategies might be helpful to support Mr. R’s daughter?

Case #3: Ms. W* Case #3: Ms. W*

75 y.o.

In good health; lives alone in the community

No history of dementia or psychiatric illness

Comes to office with left face/eye pain

Diagnosed with temporal arteritis and started on oral steroids

Long term steroid treatment is appropriate for temporal arteritis

* Cipriani, et al (July 2012). Reversible dementia from corticosteroid therapy. Clinical Geriatrics, pp 38-41.

Case #3: Clinical CourseCase #3: Clinical Course

After 7 months of steroid treatment Ms. W:

— Became forgetful

— Developed insomnia and impaired memory

— Family noted anxiety, labile mood

— Decreased motivation to perform IADLs/ADLs

• Bathing

• Driving

One month later she was unable to care for herself

Case #3: Additional Data at 7 MonthsCase #3: Additional Data at 7 Months

MMSE 22/30

EEG and labs normal

Why is dementia probably not what is happening to her now?

Case #3: Follow-Up Case #3: Follow-Up

Ms. W was diagnosed with steroid-induced delirium

Steroids were tapered and then discontinued over a 20-day period

15 days after the steroids were stopped, memory and cognitive deficits improved

Two months after stopping the steroids her MMSE was 28/30 and ADL/IADL function much improved

Case #4: Mr. H.G.Case #4: Mr. H.G.

Patient is an 89 year old male

Is the caregiver for his wife, who has dementia and low vision.

Mr. H.G. was ambulatory, driving, shopping for groceries, cooking, doing light housekeeping, and paying the bills until the last couple of months.

His daughter brings him to see his primary care provider after her mother complains that she’s tired of eating microwaved hotdogs every night. Daughter also notices spoiled food in the refrigerator.

Case #4: ContinuedCase #4: Continued

Patient complains of pain in his back, shoulders and knees that prevents him from standing in the kitchen and preparing meals. He says he doesn’t need any help with shopping or other household tasks, except maybe with meal preparation.


What else do you want to know about Mr. H.G.’s health and function?


Physical exam:

— Weight is down 23# since his doctor’s visit 3 months ago.

— He has arthritic changes in both hands and knees, with muscle wasting in arms and legs.

— His hearing aids are not working, even with new batteries

Cognitive exam:

— He can recite all the names and doses of his wife’s medications

— MMSE=19/30 (below 24 is abnormal)

Laboratory and x-ray findings:

— Anemia

— Spinal stenosis

— Severe degenerative changes in both knees R>L


What else do you want to know?

What factors might be causing or contributing to Mr. H.G.’s decline in functioning?

Case #4:Case #4:

What might you learn from doing a home visit at this point?

— What would you look for?

— What else would you ask about?

What might you recommend?

Case #4: Follow-upCase #4: Follow-up

Management included:

— Discontinuation of NSAIDs that were thought to be causing gastritis and GI blood loss

— A regular pain medication regimen

— Physical therapy

— Replacement of hearing aids

— Nutritional supplements

He gained 6#, anemia resolved, strength and ambulation improved, with increased ability to stand in the kitchen…

Case #4: Follow-upCase #4: Follow-up

…But executive dysfunction persisted and the couple needed a home health aid to help with grocery shopping and meal preparation

Over the next 12 months, his short-term memory became worse, and he could no longer supervise his wife’s medications

when it’s not dementia: other conditions that impair cognitive performance christine bradway, phd,...

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