Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Dementia

Dementia - Key Features

1. In patients with early, non-specific signs of cognitive impairment:
a) Suspect dementia as a diagnosis.
b) Use the Mini-Mental State Examination and other measures of impaired cognitive function, as well as a careful history and physical examination, to make an early positive diagnosis.

2. In patients with obvious cognitive impairment, select proper laboratory investigations and neuroimaging techniques to complement the history and physical findings and to distinguish between dementia, delirium, and depression.

3. In patients with dementia, distinguish Alzheimer’s disease from other dementias, as treatment and prognosis differ.

4. In patients with dementia who exhibit worsening function, look for other diagnoses (i.e., don’t assume the dementia is worsening). These diagnoses may include depression or infection.

5. Disclose the diagnosis of dementia compassionately, and respect the patient’s right to autonomy, confidentiality, and safety.

6. In patients with dementia, assess competency. (Do not judge clearly competent patients as incompetent and vice versa.)

7. In following patients diagnosed with dementia:
a) Assess function and cognitive impairment on an ongoing basis.
b) Assist with and plan for appropriate interventions (e.g., deal with medication issues, behavioural disturbance management, safety issues, caregiver issues, comprehensive care plans, driving safety, and placement).

8. Assess the needs of and supports for caregivers of patients with dementia.

9. Report to the appropriate authorities patients with dementia who you suspect should not be driving.

10. In patients with dementia, look for possible genetic factors to provide preventive opportunities to other family members, and to aid in appropriate decision-making (e.g., family planning).

Note: Specific cognition-enhancing pharmacotherapy (initiation/discontinuation) may be assessed later, as controversy on indications diminishes.

Recognition: no general population screening, cognitive impairment suspected with a Hx of decline in occupational, social or daily functional status, may be reported by pt, family member, friend and/or caregiver.

History
Complete Hx: (important to get collateral Hx) • Review medications, OTC • Alcohol dependence, drug Hx • Symptoms: • Onset gradual, abrupt, stepwise? Dramatic fluctuations in cognition? • Needs new information repeated or asks same question repeatedly? • Disorientation to time of day or place, ex. Gets lost when away from home? • Difficulty with problem solving, sequencing, multi-tasking, mental flexibility? (Executive Function) • Aphasia: Difficulty understanding or finding words and expressing oneself? • Apraxia: Difficulty with complex learned motor behaviors, ex: tying shoes, dressing, playing instrument, knitting • Agnosia: Difficulty recognizing faces or recognizing objects and knowing what they are used for? • Behavioral and psychological symptoms of dementia, ex: agitation, delusions, hallucinations, apathy, depression, social withdrawal, unaccustomed anger or irritability? • Other: hx of falls, poor balance, urinary incontinence?
Physical Exam	Diagnostic Tests
• General physical exam • Gait and balance • Parkinsonian features • AbN neurological signs, esp. lateralizing or localizing signs • Carotid bruits, vasculature	• CBC • Lytes/Ca/glucose • TSH • Serum B12 • Other tests based on clinical suspicion: HIV, RPR, renal/liver function	• Neuroimaging not routinely indicated • CT/MRI of brain may be useful, ex: age <60, abrupt or rapid progression, atypical or Dx uncertain, Hx of CA, recent head injury, CNS signs, Vasc dementia suspected, pt on anticoagulants, new deterioration in gait, onset incontinence
Functional Status		Objective Tests of Cognition
IADLs • Meal prep/housework • Managing finances/meds • Shopping • Driving, access to transportation • Telephone	ADLs • Bathing/personal hygiene/toileting • Dressing • Walking	• Standardized Mini Mental State Exam (SMMSE) • Clock drawing test • Montreal Cognitive Assessment (MoCA) for suspected Mild Cognitive Impairment (MCI) • Record for baseline and F/U

A new presentation of cognitive decline or confusion, rule out acute or treatable causes, distinguish between dementia, delirium and depression

Feature	DEMENTIA	DELIRIUM	DEPRESSION
Onset	Insidious	Acute	Gradual; may coincide with life changes
Duration	Months to years	Hours to < one month, seldom longer	At least 2 weeks, but can be several months to years
Course	Stable and Progressive Vasc Dementia: Usually stepwise	Fluctuates: worse at night Lucid periods	Diurnal: usually worse in am, improves as day goes on
Alertness	Generally N	Fluctuates lethargic or hyper-vigilant	N
Orientation	May be N but often impaired for time/later in the dz, place	Always impaired: time/place/person	Usually N
Memory	Impaired recent and sometimes remote memory	Global memory failure	Recent memory may be impaired, long term memory intact
Thoughts	Slowed; reduced interests Makes poor judgments Words difficult to find Perseverates	Disorganized, distorted, fragmented Bizarre ideas and topics such as paranoid grandiose	Usually slowed, preoccupied by sad and hopeless thoughts; somatic preoccupation Mood congruent delusions
Perception	N Hallucinations (often visual)	Distorted (visual and auditory) Hallucinations common	Intact Hallucinations absent except in psychotic depression
Emotions	Shallow, apathetic, labile Irritable	Irritable, aggressive, fearful	Flat, unresponsive or sad and fearful May be irritable
Sleep	Often disturbed, nocturnal wandering common Nocturnal confusion	Nocturnal confusion	Early morning awakening
Other features	Poor insight into deficits Careless	Other physical dz may not be obvious Inattentive	Past Hx of mood d/o Poor effort on cognitive testing; gives up easily
Standard Tests	Comprehensive assessment (hx, Cpx, lab, SMMSE)	Confusion Assessment Method (CAM)	Geriatric Depression Scale (GDS)

Diagnosis:
Multiple cognitive deficits manifested by both:

Memory impairment and ≥ 1cognitive deficits:

• Aphasia (language disturbance)

• Apraxia (impaired ability to carry out purposeful movement)

• Agnosia (failure to recognize objects),

• Disturbance in executive functioning (planning, organizing, abstract thinking).

Associated with a decline in social/occupational functioning
Not explained by other neurological, medical or Psychiatric disorders

IF not all criteria met consider Mild Cognitive impairment: subjective memory impairment and objective impairment with other cognitive abilities preserved, with no medical, neurological or psychiatric d/o.
• May progress to dementia, F/U q6mos and counsel prn

Distinguish Alzheimer’s dz from other Dementia’s (often Mixed Dementia: Alzheimer and Vascular Dementia):

Probable AD	Vascular Dementia	Dementia with Lewy Bodies	Fronto-temporal Dementia	Other examples:
• Gradual progression • Negative CNS exam • No early gait involvement Prognosis:	• Abrupt onset and stepwise decline • Temporal connection b/w dementia and CVD • CVD by focal signs and imaging	• Dementia present • At least 2 of marked fluctuation in cognition, visual hallucinations, Parkinsonism	• Insidious onset and gradual progression • Early impairment in control of personal, social and interpersonal conduct • Emotional blunting, loss of insight • Language deficits	• Normal pressure Hydrocephalus • Dementia of late stage Parkinson’s Dz or HIV • Dementia associated with alcohol dependence

In patients with dementia who exhibit worsening function, look for other Dx, don’t assume the dementia is worsening. These dx’s may include depression or infection.

Disclose the diagnosis compassionately and respect the patient’s right to autonomy, confidentiality and safety.
• At disclosure visit, Ask if the caregiver/family member can be in attendance (yes in most situations)
• Consider timing/extent of info and pt/caregiver readiness for coping with the diagnosis
• Use open-ended Q’s ex: What do you think is causing the change in your memory and thinking?
• Establish a relationship – pt/caregiver input is valued and integral to goal setting and care planning
• Discuss anticipated prognosis in a sensitive manner and indicate commitment to F/U care
• Provide written info about dementia care and around support and resources as appropriate

In patients with dementia, assess competency. (Do not judge clearly competent pt’s as incompetent and vice versa)

Develop an on-going care plan/clinical action plan:
• Identify and modify potential safety issues with pt and caregiver ex: driving, nutrition, med mgmt., kitchen safety, hygiene and wandering
• Support pt functioning and decision making to maximize independence ex: socialization, financial and legal planning, neglect and abuse, end of life care
• Treat co-morbid conditions ex: HTN, depression, delirium, DM
• Refer pt and caregiver to Home and community care for adult day care, home care, respite care, assisted living, long term care services as appropriate
• Refer pt and caregiver to the Alzheimer society
• F/U at least every 6 months

Assess the needs of and supports for caregivers of pt’s with dementia.

Report to the appropriate authorities patients with dementia who you suspect should not be driving.
• Enter into discussion with the patient early about eventual driving cessation
• Get collateral hx of driving habits from observers
• On cognitive testing, visuospatial abilities and judgment may be predictors of driving risk
• In doubt recommend a performance based eval, ex: road test by ICBC, DriveAble or a driver fitness review through the office of the superintendent of motor vehicles

In pt’s with dementia, look for possible genetic factors to provide preventative opportunities to other family members and to aid in appropriate decision-making (ex: Family planning).
• Minority of AD cases are familial, autosomal dominant (5-10%), there are four genes that affect disease development
• With ≥2 Family members with early onset Dementia <60, referral for genetic counseling and testing offered
• If gene identified: referral for 1st degree relatives offered

Quick note on Pharmacotherapy (note: not a key feature):
AChEI’s are approved for symptomatic Rx of mild to moderate Alzheimer’s type dementia

o VaD or mixed dementia: Treat vascular risk factors. Possible role (AChEIs)

o Mixed dementias: Treat both pathologies

o DLB: Many patients respond to AChEIs

• Starting dose/usual effective max dose

o Donepezil (Aricept) 5mg daily/10mg daily

o Rivastigamine (Exelon) 1.5mg BID/3-6mg BID

o Galantamine (Reminyl) 8mg ER daily/16mg-24mg ER daily

• AChEI Relative CI’s: PUD, hepatic or renal dz, significant bradycardia or AV block, significant bronchospastic dz, obstructive urinary dz, epilepsy or hx of seizure

Behavioral and psychological symptoms of Dementia (BPSD):

• 1st line: Environmental and behavioral modifications

• Pharmacological interventions (1st line: atypical antipsychotic agents, cautions around increased risk of CV events, stroke, and mortality) for BPSD are only recommended when:

o Alternate therapies are inadequate on their own

o There is an identifiable risk of harm to the patient and others

o Symptoms are severe enough to cause suffering and distress

• Use of antipsychotics in patients with DLB is associated with an increased risk of extrapyramidal side effects and should be used with extreme caution

Study Guide

Dementia

Resources

BC Clinical Practice Guidelines: Cognitive Impairment in the Elderly – Recognition, Diagnosis and Management
Third Canadian Consensus Conference on Diagnosis and Treatment of Dementia
Alzheimer’s Society of Canada: Genetic testing