your role in dementia detection and treatment

Your Role in

Dementia Detection and Treatment: An Interdisciplinary Approach

MaineHealth Concepts in Common: Communication Strategies to Improve Care For Hospitalized

Elders

Objectives

• Define and understand dementia and its significance in patient

care

• Learn how to administer and interpret the Mini-Cog

• Define your role on an interdisciplinary team in caring for

patients with dementia

• Learn how to communicate effectively about dementia using

SBAR

2015, 2011 Sarah Hallen, MD and contributors

What Is Dementia?

Dementia is “an acquired

syndrome of decline in at least

two cognitive domains, sufficient

to affect daily life in an alert

patient”

William Utermohlen

Threlfall AW. Barton C. Yaffee K. Dementia. Geriatrics Review Syllabus. 8th ed. Durso SC and Sullivan GM eds. New York, NY: American Geriatrics

Society; 2013.


Dementia is a…

• Geriatric syndrome

• General name for a group of diseases that share similar signs and

symptoms

- Patients can act differently depending on the type of dementia

» Behavior or language may be worse than memory


Dementia is a…

• Degeneration of the brain cells

- Slow and steady decline over months to years

- Gradual or step-wise changes common

• Terminal illness


Dementia diagnosis

• Clinical diagnosis

- Patient history

- Cognitive testing

- Physical exam & diagnostic tests

» Evaluates for things other than dementia that cause cognitive problems

▪ Stroke

▪ Vitamin deficiencies

▪ Infectious diseases


Risk Factors for Dementia

• Age

• Family history

• Genetics

• Low education level

• Cardiovascular disease

• Head trauma and traumatic

brain injury (TBI)

• History of delirium

• Mild cognitive impairment


Mild Cognitive Impairment (MCI)

• Impairment in cognition without impairment of function

• 10-15% of MCI patients may convert to dementia each year

• Monitor over time

Dementia. Geriatrics Review Syllabus. 7th ed. Pacala JT and Sullivan GM eds. New York, NY: American Geriatrics Society; 2010.


Dementia is NOT Delirium

• Delirium is a sudden change in cognition with

- Fluctuation

- Inattention

- Disorganized thinking and/or

- Changes in level of activity

• Dementia is a slow progressive change


Dementia is NOT Delirium

• Dementia and delirium are related

- Patients with delirium are at increased risk of dementia

- Patients with dementia are at increased risk of delirium

• Relationship more complex than one causing the other…

- May share a common etiology (e.g. hypotension; acute

illness)


Dementia is NOT Depression

• Depression can affect mood and cognition like dementia

• Cognitive changes due to depression may improve with

treatment

• Can be hard to distinguish between dementia and

depression - especially if apathy is present

- Symptom onset and functional history can help


Dementia is NOT Normal Aging

• As people age, it is common to have:

- Increased difficulty with multi-tasking

- Occasional forgetfulness

• Normal aging does not affect daily function


Alzheimer’s Disease (AD)

• The most common type of

dementia

- >50% of people with dementia have AD

- 6th leading cause of death in the United

States

» 5th for those > 65 years of age

Auguste D.

Thies W, Bleiler L. Alzheimers Dement. 2011;7:208-244.


Plaques: Extracellular

accumulation of insoluble

fragments of beta-amyloid

(A)

Tangles: Intracellular

accumulation of

hyperphosphorylated

tau strands

Amyloid plaques and neurofibrillary tangles

(NFTs) found in the

cerebral cortex

Image courtesy of the National Institute on Aging/National Institutes of Health 2015, 2011 Sarah Hallen, MD and contributors

Changes in the brain

Cortex shrivels, especially near

hippocampus

ventricles enlarge

Images courtesy of the National Institute on Aging/National Institutes of Health


Alzheimer’s Disease

• Clinical Manifestations

- Short term memory loss

- Spatial & temporal disorientation

- Aphasia

- Apraxia

A. Alzheimer


Other common types of dementia

• Vascular dementia

- Atherosclerosis

- Slowed processing

- “Cue-able” memory loss

- Tremor & gait abnormalities

• Mixed

- Alzheimer’s + Vascular dementia

• Lewy Body dementia

- Parkinsonism/Falls

- Hallucinations

- “Spells”

• Frontotemporal dementia

» Younger onset (40-60)

» Behavior change/disinhibition

» Language difficulties

» Poor judgment and planning


Benefits of Detection

• Potential discovery of reversible causes of cognitive

impairment:

• Anoxia

• Uremia

• Hepatic

Encephalopathy

• Vitamin B1/B12

deficiency

• Hydrocephalus

• Thyroid disease

• Adrenal disease

• Infection

• Inflammatory disorders

• Malignancy



• Symptom modifying medications

- Acetylcholinesterase inhibitors

- NMDA-receptor antagonists



• Enrollment in clinical trials for experimental therapies

• Avoidance of certain medical regimens that may worsen

cognition

- Anticholinergics

- Benzodiazepines



• Development of a treatment plan:

- Education and discussion about expected prognosis

- Resources regarding anticipatory planning about future care

needs

- Personal/public safety

- Caregiver education


Dementia: Unrecognized & Untreated

• > 50% of people with dementia have not been diagnosed1-3

- Typical AD patient has symptoms for 2–6 years prior to diagnosis

- Most patients diagnosed at the moderate stage of illness2

• Only 35% of people with AD have received treatment4

1Callahan et al. Ann. Intern. Med.1995;122:422-429. 2Valcour et al. Arch Intern Med.2000;160:2964-2968.

3Borson et al. Int J Geriatr Psychiatry. 2006;21(4):349-355. 4Sano et al. Alzheimers Dement. 2005;1(2):136-144.


ANYONE Can Suspect Dementia

• ASK YOURSELF:

- Are the changes observed new?

- How long have they had the symptoms?

- Could they normally manage their household and self-care at baseline?

- Are they missing appointments? Medications?

- Do they seem confused when they call the office?

- Have you noticed differences in dress or behavior?


ANYONE Can Suspect Dementia • Delirium: changes are new (hours to days)

- Perform the Confusion Assessment Method (CAM) questions

- Notify a provider

- Delirium can indicate a medical emergency

• Dementia: changes are not new (months to years)

• Dementia can be difficult to diagnose in the hospital

setting


Mini-Cog

• Dementia screening test

• Administered in 3 minutes

• No special equipment required

• Sensitive (76-99%) and specific (89-93%)

• Effective for diverse socioeconomic status and education

level

Borson S. et al. Int J of Geriatr Psychiat 2000; 15:1021-1027.

Borson S et al. J Am Geriatr Soc 2003; 51:1451-1454. Borson S et al.

J Am Geriatr Soc. 2005; 53:871-4. Scanlan JM, Borson S. Int J of Geriatr Psychiat. 2001; 16:216-222.

©2015, 2011 Sarah Hallen, MD and contributors

Mini-Cog

1) Registration

2) Clock draw test

3) Three word recall


Registration

• Ask the patient to remember 3 words:

APPLE, TABLE, PENNY

• If they can’t repeat all 3 – say them all again

• Ask patient to: remember the three words and say you will

ask for the three words later


Clock Draw (CDT)

• Give the patient a pre-drawn

circle

• Ask them to place the numbers

so they “look like the face of a

clock”

• Ask them to “draw the hands of

the clock so it reads ten past

eleven”


Scoring the Mini-Cog

Clock

• Numbers present and in the right sequence

• Hands joining in the center of the clock

• Short hand pointing to the 11

• Long hand pointing to the 2

Recall

• Must remember all 3 words

http://www.theagepage.co.uk/.a/6a00d83443d1b053ef0176166513f2970c-pi


Scoring

Borson et al. Int J. Geriatr Psychiatry 2000


If the Mini-Cog is Positive,

You need to ACT

• A positive screen does NOT mean the patient has dementia –

only that further evaluation is necessary

• Communicate concerns to other team members

• Consider any safety concerns that you may be able to address


Who Makes Up The Team?

• Family and visitors

• CNAs

• Social Workers

• Pharmacists

• Care Coordinators

• Transport

• Sitters

• Chaplain

• Rehabilitation Services

• Dieticians

• Nurses

• Prescribers

• Anyone who interacts with the

patient


Role of the Nurse

• Observe for any changes in:

- Cognition

- Behavior

- Function

• Assess:

- Vital signs

- Weight loss

- Evidence of poor self-care

- Falls & other injuries

- Medication compliance

• Perform:

- CAM (if hours to days)

- MINI-COG (if weeks to months)


SBAR

• Situation

• Background

• Assessment

• Request


SBAR – Nurse

S: Situation • Report clinical changes observed

B: Background • Background and baseline functioning

• Events that may be associated with change (new medications, procedures, etc.)

• Vital signs and clinical assessment

• Results of Mini-Cog and/or CAM (Confusion Assessment Method)


SBAR – Nurse

A: Assessment • Report that you believe the patient may have dementia

R: Request • Report any safety issues you have been able to identify and modify

• Ask for the provider’s assessment

• Communicate plan to other care providers, patient and family


If Mini-Cog suggests Dementia…

• It is NOT a diagnosis – evaluation by provider required

• Don’t wait for diagnosis to screen for common safety

issues: - medication adherence

- risk of financial exploitation

- home safety hazards

- driving


If Mini-Cog suggests Dementia…

• Refer to local and national agencies for education and

patient/caregiver support

- Alzheimer’s Association

• Utilize delirium prevention while hospitalized - Frequent ambulation

- Encourage fluids

- Limit tethers and encourage mobility

- Hearing aids and glasses available

- Non-pharmacologic sleep enhancement


Role of Other Clinical Providers

• Report concerns of behavior change or functional decline

observed or reported by family

• Note vital signs; look for weight loss and evidence of poor

self-care

• Think about delirium (CAM questions)


SBAR – Other Providers



• Onset of symptoms

• Vital signs and weight

• Safety concerns


SBAR – Other Providers

A: Assessment • Report that you believe the patient has changes in behavior or cognition

concerning for dementia

R: Request • Report any safety issues you have been able to identify and modify

• Ask for nurse or provider assessment


Role of the Provider


Role of the Provider

• If dementia is suspected

- Perform the CAM, Mini-Cog and/or additional cognitive tests

- Perform medication review

- Assess for reversible causes of memory loss: CMP, CBC, thyroid function tests,

vitamin B12, folate

- Depending on risk factors, a RPR, HIV and other testing, such as Lyme titer,

etc. may be appropriate

- Consider brain imaging

- Consider neurology referral or referral for neuropsychological testing or geriatric

assessment


Role of Provider • In the hospital, new dementia = tentative diagnosis

• Consider trial of anti-dementia medications

- May wish to defer until outpatient when at medical/cognitive baseline

- Discuss and anticipate common safety issues with patient/caregiver, including

medication adherence, risk of financial exploitation, home safety hazards,

driving, etc.

- Refer to local and national agencies for education and patient/caregiver support

• Communicate plan to team


SBAR – Provider



• Events that may be associated with change (new medications, procedures, etc.)

• Vital signs and physical exam findings

• Results of Mini-Cog and/or CAM (Confusion Assessment Method)


SBAR – Provider

A: Assessment • Report that you believe the patient has dementia and/or delirium to care

providers, patient and family as appropriate

R: Request • After examining patient, reviewing data, social situation and safety issues

modify treatment plan accordingly

• Consider additional testing

• Consider anti-dementia medications

• Communicate plan to other care providers, patient and family as appropriate


Role of Family & Friends

• Friends and family should be vigilant for changes

• Any change in behavior or thinking should be reported

immediately


Resources

• Alzheimer’s Association

- National Hotline: 1.800.272.3900

- www.alz.org


http://www.alz.org/

Final Take Home Points

• Dementia is common and often missed

• Dementia can present differently depending on the underlying

disease

• Screening is important

• Think team work & communication (SBAR)!

• Think Mini-Cog!


Contributors

• Maine Medical Center Geriatric Assessment Center

- Laurel Coleman, MD

- Heidi Wierman, MD

• MaineHealth: Concepts in Common

- Sharon Foerster, LCSW

- Sarah Hallen, MD

• Maine Medical Center

- Rhonda Babine, MS, ACNS-BC

• HRSA Geriatric Academic Career Award Grant #K01HP20461


your role in dementia detection and treatment

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