pass the casc - mild cognitive impairment - tutorial for mrcpsych casc exam

Mild Cognitive Impairment

Structure: Cognitive examination

• Halo-Intro-Set the scene

• MMSE

• Digit span• Long-term memory

Frontal Lobe tests:• Cognitive Estimates/Lexical Fluency/Proverbs• Executive functioning

Fronto-Parietal Lobe tests• Clock face

Clock drawing

• Perseveration: >2 hands, beyond 12, same numbers (AD / frontal)

• Agraphia: too large (AD) / too small (HD) • Spatial/Planning: hemi-space neglect of 1-side,

numbers outside, anti-clockwise > anosagnosia • Conceptual deficits: not a clock, incorrect time,

(sensitive to early onset conditions)

Script (A): Mild Cognitive Impairment

• “Hello, my name is Mrs.Page my name is Dr.X and I have come to see you today to test your memory”

• “Would it be okay if I asked you a few questions and also do some memory tests to see how you are at the moment?”

• “A lot of these questions and tests are going to seem a little strange but they are just all part of a standard assessment I need to carry out”


Orientation:

• “Okay, (NAME) could you tell me what day it is today?”

• “How about the date?”

• “Do you know what month we are in? / season & year it is?”

• “Do you know what country we are in? county / town / hospital / floor?”


Short-term memory

• “Okay – I’d now like to test your memory a little more…”

• “Could you remember the following words for me word apple, table and penny”

• “Can you repeat those back to me?”

• “Okay, try and remember those words as I’ll ask you to repeat them to me again in a few minutes”


Attention and Concentration

• “Next, I’d like to see how well you can concentrate..”

• “Do you think you could spell the word WORLD for me” / “the world in which we live?”

• “Okay and could you now spell it backward for me?”


Recall• “Could you remember those three words I asked you again?”

Language• Can you tell me what this is? (pencil) / and this? (watch)

Speech• “I’d like you to say the following phrase after me - no ifs ands or buts”

• Could you do the following for me? (CLOSE YOUR EYES)• 3-stage command – piece of paper.• Write a sentence of your choosing• Can you copy this design?


• Digit span (working memory)

• “I’m going to give you a series of numbers and ask you to repeat these back to me in the order that I read them out…”

• “3,9,2 – could you repeat those back to me?”

• “4,7,3,1 – could you repeat those back to me?”

• “9,4,3,2,6 – could you repeat those back to me?”


• Lexical Fluency“Alright, this is a different type of question – over the next minute could you name as many words (as long as they are not people’s names or places) as you can beginning with the letter A?”

• Long-term memory“Could you tell me who the current president of the US is?” (semantic)

• “Could you tell me who the current prime minister?” > “Could you tell me when WWII ended?”


FRONTAL:

• Cognitive Estimates/Proverbs

“How many camels do you think there are in Holland?”

“Could you tell me what ‘a stitch in time saves nine’ means?” / “If I asked you what ‘too many cooks spoil the broth’ mean?

“Okay (NAME), In what way are a banana and an apple alike?” / “In what way are a child and a dwarf different?”


Executive function• “I’d like you to imagine you lost a key in this

field – could you show me with this pen how you would find it?”

Clock-face• “Could you draw the face of a clock and put

the time ten minutes to two?”

Structure (B): Mild Cognitive Impairment

• Halo-Intro-Set the scene• HPC - O,D,P,I memory problems:

Previous level of functioningPMP > personality/behavioural/social risksADLs Co-morbidity – depression inc. risk

• Past Psych / Medical / Drug / Family History• Drugs / Alcohol

• Carer stress

• Explanation of MCI

• Address concerns

Script (B) : Mild Cognitive Impairment

• “Hello Mr.Page my name is Dr.X, and I have just assessed your mother. I understand you have both been worried about her memory”

• “I’d like to ask you some questions about her first if I may and am then happy to answer any questions you may have about her”


• “What have been your main concerns about her memory at the moment?”

• “Prior to you noticing these difficulties, how would you have described her?” > what sorts of things did she like to do?” > “What sorts of things does she do now?”

• “What kinds of things does she forget?” >“Could you give me an example?”

• “When did you first notice these problems yourself?” > “Did they gradually come on?”


• “Has she had to learn anything new recently?” > “How has she

coped with it?” >“How does she deal with new problems that come her way?”

• “From what you’ve told me, it appears as though her short term memory has worsened but long term it hasn’t changed – would you say that is accurate?”

• “Has she been able to recognise her own change in behaviour?”


• “Does she ever make decisions without thinking about them?”

• “How would you describe her temper?”> “Has she ever verbally threatened anyone?” > “How about physically?”

• “How is she in social situations eg. with friends?” > “Has she ever been inappropriate with other people?”

• “Have her current memory problems ever got her into trouble?” > “Have

they ever put her in danger?” > “Has she ever got lost?” > “Has she ever left the gas on at home?”

• “Has she lent other people money?”


• “When she was last well, how was she with usual day to day chores?” > “For example her own personal hygiene? > “How about now?”

• “Does she work?” > “What kind of work does

she do?” > “Any problems?”

• “Does she drive?” > “Have there been any problems with this at all?”


• “How has she been coping at the moment?”

• “How would you describe her mood in general?” > “Has she ever become tearful?” > “Has she ever expressed any thoughts to not want to carry on?”

• “How was she on holiday?” > “Enjoy it?” > “Did she get tired easily?”

• “Just to summarise what you’ve told me so far…”


• “Has she ever seen a psychiatrist before?”

• “Any history in the family of problems like these?”

• “Does she have any other medical problems that you are aware of?” > “What medications is she on?” > “Have you noticed any new physical problems with her?” > “Is able to walk normally?” > “Has she had any falls recently?” > “Does she appear weaker in anyway?”

• “From what you have told me (NAME) has become more direct in the way she talks to people, have you noticed anything else with the way she communicates with you now?” >”Have you noticed any problems with her speech?”


• “Does she drink alcohol?” > “Does he take any other illicit drugs at the moment?”

• “Who lives with her at the moment?”

• “How are you coping?” > “Do you think you need any assistance in helping look after her?”


• ”Overall when I examined your mother, I could only find some minor changes in her short-term memory and in her ability to plan”

• “Based on this as well as from speaking to you, she has a condition called Mild Cognitive Impairment, have you ever heard of that condition before?”

• “This is a condition where we it is possible to detect subtle changes in memory however these changes are not severe enough to effect her overall ability to live normally (e.g. effect personal hygiene / work) and are not enough to warrant a diagnosis of dementia – does that make sense?”


Is it just aging?

• “Well, whenever we are asked to assess memory we have to decide whether their difficulties are purely to do natural aging, MCI or dementia”

• “In some cases it is obvious if there are serious problems however at other times these changes are more subtle and we have to use our clinical judgement”

• “In your mother’s case although she has minor problems with her memory these have been out of character for her current level of functioning hence us thinking that this is MCI.”


• “MCI can be an early warning sign for dementia however I must emphasise that it is NOT a definitive diagnosis. In fact a proportion cases of MCI revert back to normal memory”

• “Out of 100 people with MCI, about 4 people will develop dementia in any one year. We can't yet identify those people who will go on to develop dementia”

• “At the moment it is extremely early to predict whether your mother will develop dementia”


• “Our role would be to monitor her in our memory clinic on a regular basis e.g 6 months to test her memory – if there are concerns her memory has worsened significantly we may also consider starting anti-dementia treatment”

• “Also like to do more comprehensive memory tests longer more sensitive to detecting memory changes”


• “At the present time we would strongly recommend she continue keeping both mentally and physically active with the lifestyle she has, diet, exercise, working etc.”

• “Fine to drive at the moment, however if there have been any driving lapses or getting lost in familiar areas then contact me immediately.”


• “It is a tricky one to answer as depression and memory

problems can occur together and are more common after the age of 70.”

• “Brain changes in Alzheimer’s disease can occur long before people develop memory problems and people with depressive symptoms by themselves can also have memory problems – so the direction of what causes what is unclear”

• “Our main aim is to treat any depressive symptoms if they occur.”


• “We also understand that one of the common fears is the worry your mother may have about the future and what preparations need to be made”

• “However, I must emphasise again that a diagnosis of MCI is only that of an increased risk of dementia rather than a definitive diagnosis which I hope can help alleviate any anxiety and fear she may have at the moment.”

• “Here are some leaflets about MCI”

Classification

• No ICD-10 criterion yet

• MCI:• -Amnesic• -Non-amnesic

• Single or multiple domain

Epidemiology

• Conversion rate is 4 in 100 cases per year

Investigations

• Full physical exam• Dementia screen

• ?CSF• ?MRI

Management

• AChEIs no benefit• SSRIs if depressive symptoms

• Formulation of optimal package of care

Management

• Optimise healthy lifestyle• Memory training

• Follow up in memory clinic 6/12

Alternate Scenario

• Consultant presentation

pass the casc - mild cognitive impairment - tutorial for mrcpsych casc exam

Education

cognitive estimatesproverbshow

script b

memory id

memory tests

memory im

shortterm memory

current memory problems

structure b