dementiatalk mbwc nw geri (002).pptx - read-only · 2019-03-28 · patients and families can be a...

ByAngela HansonMemory BrainWellness Center, HMCLast updated: 02/05/2019

Alz.orglbda.orgAftd.orgMemory BrainWellness Center website:http://depts.washington.edu/mbwc/

HRSA dementia curriculum:https://bhw.hrsa.gov/grants/geriatrics/alzheimerscurriculum

Area agency on aging in your county

Early Dx of Dementia (Hanson), NW GWEC Winter 2019 1

Part 1: Discuss the importance of diagnosingand documenting cognitive impairmentPart 2: Become familiar with the workup for apatient with cognitive impairmentPart 3: Know the criteria for themostcommon forms of dementiaPart 4: Brief overview of medications for AD

Part 1: Discuss the importance ofdiagnosing and documenting cognitiveimpairmentPart 2: Become familiar with the workup for apatient with cognitive impairmentPart 3: Know the criteria for themostcommon forms of dementiaPart 4: Brief overview of medications for AD


75 year old man with HTN,GERD new to clinicHe wants to discuss his medications, seasonalallergies, and heartburn symptomsTriage vitals: BP 160/90Near end of visit, as you are prescribing anadditional BP agent, his daughter says, “I’mworried about my dad’s memory, he might notbe taking his medications properly. Do you thinkhe has dementia?”What do you do?

Physicians vary in ability to diagnose anddocument symptomatic dementia (up to 75%missed in some studies)Lack of knowledge/lack of protocols/lack of timeOpinion that specialists should do thisScreening for asympt disease vs active case finding

Concerned about negative impact of diagnosisMay doubt usefulness of early diagnosis/limitedtreatment optionsDifficulty relaying the diagnosis

Bradford et al, 2009


Missed opportunity to identify contributing factorsand potential beneficial treatmentsUninformed hospital/consult care providers

One study: 42% of acute medical admissions > age 70 haddementia, but only half were diagnosed at the time

Changes the care planLess able to trust medical history takingNeed simpler med regimen, written instructionsOverall goals of care may change

Missed opportunity for advanced care planningPatients with mild AD can still participate in discussions

Test Items Time Sen/Spec Notes

Mini Cog 2 (6 points) 3 min 76/89 Clock + recall

AD8 8 items 3 5 min 74 84/8086

Caregiver assessmentonly

GPCOG 6 items 5 6min 85/86 Cog test + caregiverassessment

There are lots of other tests...these are some recommended onesHanson’s pearl: Mini Cog orGPCOG preferred as they test >1 domain andthe clock draw is very visual for families (if abnormal)These can all be administered by non physician staff (LPNs, MA, etc)

Int JGeriatr Psychiatry. 2010Feb;25(2):111 20

Alzheimers Dement. 2013Mar;9(2):151 9


Test Items Time Sen/spec Notes

MMSE 10 (30points)

10 min 79/88 Less sensitive in educatedpop, other forms ofdementia

MoCA 12 (30points)

10 15min 90%MCI, 100%AD (spec=9094)

Can detect MCI, less biasedfor cultural, education level

ShortBlessed

6 (12points)

6 8min 82/88 Visually impairedValidated in ER

RUDAS 6 (30points)

10 15min 89/98 Less affected by edu,language. Tests praxis

SLUMS 30points

10 12min ?? [Improvedover MMSE]

Validated inVA population

Int JGeriatr Psychiatry. 2010Feb;25(2):111 20

Alzheimers Dement. 2013Mar;9(2):151 9

Visual impairmentMoCA without the vision questions: 63% sens for MCI, 94% sensfor AD, 98% specAD (Short Blessed test, AD8 alternatives

Hearing impairmentEnsure hearing aids in, pocket talkerAD8: caregiver. Some tests have a written version (RUDAS)

Non English speaking patientsmocatest.org : translated in 37 different languagesRUDAS also available: newer, not as well studiedCaveat: different words in English score differently, so interprettest scores with caution

Avoid MMSE as screening: better alternatives


Identify patients with cognitive impairmentActive case finding/screening high risk popIf a patient/caregiver concerned: they haveeffectively ‘screened in’Pick one two tests which are appropriate to yourspecific population, and know themwellAvoid MMSE as a screening tool

Document cognitive impairment in the chartSet aside a visit to address cog impairment

Part 1: Discuss the importance of diagnosingand documenting cognitive impairmentPart 2: Become familiar with the workup fora patient with cognitive impairmentPrt 3: Know the criteria for the most commonforms of dementiaPart 4: Brief overview of medications for AD


Mr. Jones struggles with the clock draw portion, anddraws a clock similar to the middle one below:He recalls only 1 of 3 words


Medical disease:Diabetes, glu,Na, thyroid, OSA

Medications:anti

cholinergics,sedatives,EtOH, MJ

Psychiatric:Depression,anxiety, poor

sleep

Psychosocial:Caregiver andsocial supports(or lack of)

Neurologicdisease:AD,TBI, LBD,stroke

Look for reversible causesRare but important workup: B12,TSH, (RPR, HIV)Drugs/EtOH/MedicationsUrgent imaging or deliriumworkup needed?

Look for contributing factors (LIKELY)Mood disorders, medical disorders, medications

Ultimately the question is...does this patienthave a neurodementing illness?No one test rules dementia in or outIt’s ok to diagnose over time


o Wide variability in this!o A general slowing of cognitive performanceo A decrease in mental flexibilityo Some difficulties finding the right wordo Amild decrease in short term (working) memoryo Intact memory for current eventso Independence inADL and IADLo Retention of verbal abilities and vocabulary

o Changes in perceptual systems or speed of processingassociated with normal aging can influence cognitiveprocesses such as attention andmemory

Dumas, 2015; EmoryAlzheimer’s Disease ResearchCenter, 2017; UCSFMemory andAgingCenter, 2018d

Blazer DG,Yaffe K, Liverman, CTIOMCognitiveAging 2015


NormalAging:Making a bad decisiononce in a whileMissing amonthlypaymentForgetting which day it is,and remembering laterSometimes forgettingwhich word to useLosing things from time totimeSometimes needing helpusing electronic devicesMore time/energy neededto encode new information

Dementia:Poor judgment anddecision makingCan no longer manage abudgetLosing track of the seasonor yearDifficulty having aconversationMisplacing things andunable to retrace stepsDifficulty with familiartasksVery difficult to encodenew information

Alzheimer’sAssociation (alz.org)

o MCI: problems with memory, language, judgment, andthinking—problems greater than expected for the age of theperson, but less than is required for dementia diagnosis

o “Can still carry out everyday activities”o Not all MCI progresses to dementia

o About 10–20% a year will progresso Treatable predictors (or risk or prognostic factors) associated

with MCI include diabetes, prediabetes, metabolicsyndrome, hypertension, hyperlipidemia, low dietary folate,chronic alcohol abuse, renal failure, depression

Source: HRSAmodules on MCI, (Etgen et al., 2011; Langa & Levine, 2014)


Presence of cognitive impairment detectedvia history taking and cognitive assessmentDecline from previous level of functionInterference with the ability to function atwork or usual activitiesExclusion of delirium or major psych disorderDistinguish from normal aging

Alzheimer’s & Dementia 7 (2011) 263–269

Attention:Sustained and divided attention, processing speed

Learning and memory:Amnestic: difficultly remembering new infoRepeat questions, misplace things, forget appts

Executive function:Inability to manage finances, plan complex activities,poor judgment

Language:Word finding trouble, speech and spelling errors

Alzheimer’s & Dementia 7 (2011) 263–269, CMECourse 2016


Visuospatial:Difficulty recognize faces, objects in direct view,orienting clothes to body

Personality and behavior:Apathy, social withdrawal, socially unacceptablebehaviors

Social cognition:Difficulty regulating emotion and behavior

Different dementias show different patterns

Alzheimer’s & Dementia 7 (2011) 263–269, CMECourse 2016

History: symptoms, timing, collateral infoAs with most dx, most important piece is the history

Physical exam:GEN/CV/Resp:Weight loss, signs of systemic illness?Neurologic: Narrow down your DDx (see following slide)Psychiatric: appearance, affect, speech, thought, cog

Formal test of cognition: MoCA like test vsneuropsych testingLabs: CBC, CMP, B12,TSH (folate, RPR, HIV)Imaging: See future slidesConsider referral if atypical, rapid onset, if LP/EEGneeded, etc

Modified fromAmericanAcademy of Neurology (AAN)andAlzheimer’s Association


Always start with the patient: have them sitnext to you, with caregivers to the sideEven when talking to caregivers, bring thepatient back into the conversationShow that it’s ok to talk about ‘memory loss’in front of the patient: modeling that helpspatients and families

Can be a tough exam in dementia patientsDo exam same way every time, mimic tests

Goal for exam: focus on DDxFocal weakness (face esp): CVA/vascular diseaseEyemovements: Prog supranuclear palsyTone: Lewy body, Parkinsons DementiaGait: signs of parkinsonism or frontal gait (NPH)Praxis: difficulty mimicking movementsReflexes: Looking for asymmetry


“You are always examining this!”Appearance: well dressed or disheveled?Mood: “how are you feeling today”Affect: level and rangeLanguage: word finding, hypophonia,dysarthriaThought content: what are they focused on?Thought process (Hallucinations/delusions,linear, jumping topics)Judgment/insight

Lancet Neurol 2010 Jan;9(1):119 28


Most guidelines recommend imaging for anew diagnosis of dementiaCTmay be adequate if classic AD: rule out‘surprises’MRI far superior at smaller strokes, looking forNPH, tumors, cerebellar/posterior disease,hippocampal volumes

MRI andCTmay be normal in early stagesPET: patterns of glucose hypometabolismSPECT: patterns of decreased blood flow

Common brain MRI findings:“Non specific mild to moderate atrophy, appropriatefor age”“Evidence of cerebral white matter hyperintensities”

Be aware: report might say “appropriate for age”for a wide range of atrophy and age, notstandardizedWe are looking for localized atrophy, whitematter change, microhemorrhagesBe aware that an MRI in early stage dementiamight appear ‘normal’ because atrophy hasn’thappened yet (PET scan more sensitive)


3 4 hours of history and cognitive testingMuchmore information about the specificdomains affectedCan compare scores to age and educationadjusted normsIdentify strengths and weaknesses forpatients

If patient has cognitive impairment:Rule out reversible causes, contributing factorsMedication list, good review of systems, reviewstatus of medical and psychiatric illnesses

Once these are ruled out: Consider dementiaDo they meet criteria for dementia:Will needcollateral info, and info on timing of symptomsDo they need further testing: imaging, NP testingDo they need to see a specialist?


Part 1: Discuss the importance of diagnosingand documenting cognitive impairmentPart 2: Become familiar with the workup for apatient with cognitive impairmentPart 3: Know the criteria for the mostcommon forms of dementiaPart 4: Brief overview of medications for AD

#1:Alzheimer’s disease: 60 70%

#2 & 3:Lewy Body Dementia/Parkinson Disease Dementia andVascular Dementia, in some order (depending on study)

Frontotemporal dementiaTBIEtoH related dementiaNormal Pressure HydrocephalusRare cases of rapidly progressive (see next slides)Mixed etiologies common (esp in older adults)Diagnosis will change management/prognosis


Clinical diagnosis• What domains are affected?• What are the symptoms ?• Age and rapidity of onset?

Pathologic diagnosis• Plaques and tangles (AD)• Tau only (FTD/TBI)• Lewy Bodies• Vascular strokes/damage

Three stages ofAD:Pre clinical (research definition)Mild Cognitive Impairment (mild neurocognitivedisorder, DSM V)Alzheimer’s Dementia (major neurocognitivedisorder, DSM V)ProbablePossible

Rare < age 60 (unless familial)

NIA/AA DiagnosticGuidelines for Alzheimer’s Disease


Interference with work, usual activitiesDecline from previous level of functionSx not better explained by delirium, stroke, etcInsidious onset and progressive courseObjective cognitive impairment, at least 2 domains:

Impaired ability to acquire and remember new information(most common first symptom: “amnestic” presentation)Impaired visuospatial abilities (predominant in PCA variant)Impaired language functions (predominant in logopenic variant)Impaired reasoning/handing of complex tasks, poor judgmentChanges in personality, behavior, or comportment

NIA/AA DiagnosticGuidelines for Alzheimer’s Disease

Generaldementia


http://radiopaedia.org/cases/

Large vessel stroke ORSmall vessel strokesBilateral thalamic lesionsORMultiple basal ganglia, thalamic and frontalWMlacunar stroke: need at least 2 in the BG area andat least 2 in the frontal white matterOR“Extensive” periventricularWM lesions

These patients may look more likeAD interms of progression (gradual rather thanstepwise)

NINDS AIREN criteria


An 82 yo man with slowly progressive memory impairment

Mental and Behavioural Disorders and Diseases of the Nervous System, 2013

Consensus criteria for DLB 2017: Core featuresFluctuating cognition with variation in attention/alertness: 60 80%Recurrent well formed visual hallucinations: 50 75%REM sleep behavior disorderParkinsonism features (onset within 1 year of dementia, otherwise it’sPDD): 80 90%

Suggestive features: neuroleptic sensitivity, low dopamine uptakeon SPECT/PET, fallsMay respond better toAcetylcholinesterase InhibitorsAge of onset: range 50 85, Survival < AD, median<5yPathology: Lewy body inclusionsCog testing: more impaired on attention, exec fxn, visuospacial

McKeith IG et al, Neurology 2005; 65:1863, updated 2017


More sparing of thetemporal structures, atrophy of the putamen.

Ferman et al, 2004

As common asAD in younger patientsMean age of onset: 58 (reports age 20 80)

Up to 30% of cases are familial/geneticTau,TDP 43, FUS, othersSome overlap withALS in families (TDP 43)Pathology: tau/tdp43 tangles only

Twomain variants:Behavioral: Often mistaken for mental illnessLanguage: can be subtle early on in the illness

Brain 2011: 134,2456 2477


FTD

BehavioralVariant

bvFTD

Other tau

opathies: PSP, CBD

PrimaryProgressive

Aphasia (PPA)

Semantic variant

Non fluent variant

Logopenic variant*

* Pathologically this is a form of AD (plaques and tangles)

Early behavioral disinhibition: sociallyinappropriate behavior, loss of decorum,impulsivityEarly apathy or inertiaLoss of empathy:Early perseverative, stereotyped, compulsivebehavior or speechHyperorality, diet change: binge eating, picaNeuropsych profile: executive function deficitswith relative sparing of episodic and visuospatialmemory

Brain 2011: 134,2456 2477


Note thejagged edges,and theasymmetry

Relativesparing ofhippocampus

http://radiopaedia.org/cases/


Repeated head injuries: boxing, football, combatblast injuries. AKA “Dementia Pugilistica”Pathology: progressive tauopathy in frontal,temporal cortex (distinct pattern fromAD)Clinical features: Increased anger, irritability,apathy. Cog: poor episodic memory, executivefxn. Late stage: movement and speech probsTBI is also a risk factor for AD and probably otherneurodegenerative diseases

Front Aging Neurosci. 2013 Jul 9;5:29


Heterogeneous syndrome: confounding head trauma, psych dx78% of patients with alcoholism have some pathology

Prominent white matter loss in prefrontal cortex, corpus callosum,cerebellumAtrophy/neuronal loss in frontal lobes, hypothalamus, cerebellum

Debate if alcohol the primary toxin vs thiamine deficiency vs bothCog: somewhat preserved semantic (naming, category fluency)and verbal memory, whereas impaired in visuospacial, workingmemory, motor speed, exec fxn, antegrade amnesia and impairedrecallMay be reversible in early stagesLikely co occurs withAD, vascular (not well studied)Tx: Abstinence is the key, thiamine and B12 supplementation

Ridley NJ,Alzheimers Res &Therapy 2013, 5:3SachdevaA et al, Int J High Risk BehavAddict 2016

Gait difficulty: Frontal ataxia. “Magnetic gait”– feet appear stuck to the floorCognition: psychomotor slowing, decreasedattention & conc, executive function, apathyUrinary urgency/incontinenceMay have hyperreflexia/spasticityMRI: ventriculomegaly without sulcalenlargement, loss of signal in Sylvianaqueduct

Up to Date


Note enlarged subarachnoid spaces (arrow) proportionate to ventriculomegaly indicatingbrain atrophy (A), and the open high convexity and medial subarachnoid spaces (arrow)despite enlarged ventricles (*) suggesting chronic occlusive hydrocephalus (B).

Hashimoto M, Cerebrospinal Fluid Res 2010

Due to brainatrophy

Due to obstruct.hydrocephalus

Definition: normal dementia in 2 yrsOften associated with neurologic symptomsThorough neuro exam and med history requiredCJD, paraneoplastic, thyroid antibodies

Imaging: brain MRI +/ MRA (or CT A if MRIcontraindicated)DDx: See next slide...Referral to neurologist/specialist isrecommended: spinal tap, EEG, etc

Neurologist. 2011 Mar;17(2):67 74


To formally diagnose dementia:Work up in a standardized way: Labs, exam,imaging, when to referKnow the criteria for the most common forms ofdementiasWatch for rapidly progressive dementiasMany patients will havemixed dementia

Ok to diagnose over timeHistory often themost important piece


Part 1: Discuss the importance of diagnosingand documenting cognitive impairmentPart 2: Become familiar with the workup for apatient with cognitive impairmentPart 3: know the criteria for the mostcommon forms of dementiaPart 4: Brief overview of medications forAD


PROCHOLINE:Acetylcholinesterase inhibitor e.g. donepezil for AD:Inhibits breakdown of acetylcholine, improvingneurotransmission

Anticholinergic: i.e. benadryl, Detrol,amitryptyline: competitive inhibitor ofacetylcholine, blocking neurotransmission


Multiple studies now show a fairly strongpositive association with these drugs and thefollowing:Development of cognitive impairment/MCIRisk factor for actually developing dementia

Recommendations:Reduce or stop as many definite anticholinergicsas you canRemember that new drugs won’t be on these lists

Ancelin ML. BMJ 2006; 25:455

Acetylcholinesterase inhibitorsDonepezil (Aricept)Galantamine (Razadyne)Rivastigmine (Exelon) comes in a patch form

Side effectsNausea, diarrhea, vivid dreams. May stop if unexplained weightlossBradycardia, syncope, falls (HR 1.5 1.7): If unexplained syncope,consider stopping

Memantine (Namenda): NMDA receptor antagonistCommon: N/V, diarrhea, dizziness, Hypo or Hypertension

Probably ok to continue in hospital??Minimal drug:drug interactions, but…Little to no data on how to stop these meds

Gill SS et al. Arch InternMed. 2009;169:867


Alz.orglbda.orgAftd.orgMemory BrainWellness Center website:http://depts.washington.edu/mbwc/

HRSA dementia curriculum:https://bhw.hrsa.gov/grants/geriatrics/alzheimerscurriculum

Area agency on aging in your county


dementiatalk mbwc nw geri (002).pptx - read-only · 2019-03-28 · patients and families can be a...

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