Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Mental Competency
Mental Competency - Key Features
1. In a patient with subtle symptoms or signs of cognitive decline (e.g., family concerns, medication errors, repetitive questions, decline in personal hygiene),
a) Initiate assessment of mental competency, including use of a standardized tool,
b) Refer for further assessment when necessary.
2. In a patient with a diagnosis that may predict cognitive impairment, (e.g., dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability.
3. When a patient is making decisions (e.g., surgery/no surgery, resuscitation status) think about the need to assess their mental competency.
4. In a patient with cognitive impairment, identify intact decision- making abilities, as many may be retained.
Cognitive impairment should be suspected when there is a history that suggests a decline in occupational, social or day-to-day functional status. This might be directly observed or reported by the patient, concerned family members, friends and/or caregivers.
General population screening in asymptomatic individuals is not recommended
systemic diseases i.e vit B deficiency thyroid, Hypercalcemia
transient, usually reversible, cause of cerebral dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities. The clinical hallmarks are decreased attention span and a waxing and waning type of confusion.
I WATCH DEATH
•I nfections (Pneumonia, Urinary Tract Infections)
•W ithdrawal (Ethanol,opiate)
•A cute metabolic (acidosis, renal failure, imbalances, alkalosis)
•C NS pathology (epilepsy, cerebral haemorrhage)
•D eficiencies (vitamin B12, thiamine)
•E ndocrinopathies (thyroid, parathyroid, hypopituitarism, hyper/hypoglycemia, Cushing's)
•A cute vascular (Stroke, MI, PE, heart failure)
•T oxins or drugs (prescribed - Tramadol, recreational)
•H eavy metals
- 1) Alzheimer’s dementia
- Slow progressive onset
- Multiple cognitive deficits manifested by both:
- • Memory impairment
- • One or more additional cognitive deficits such as aphasia, apraxia, agnosia, disturbance in executive functioning
- Associated significant functional decline
- 2) Vascular Dementia
- abrupt onset, step-wise decline
- associated with cerebrovascular disease
- Clinical and neuroimaging evidence supports the diagnosis
- 3) Mixed Dementia:
- The degenerative changes of AD and the vascular changes of VaD commonly co-exist. Presentation more commonly of AD pattern with significant vascular risk factors +/- small vascular events
- 4) Dementia with Lewy body DLB
- Fluctuating cognition with pronounced variation in attention and alertness
- hallucinations, Dellusions, vivid dreams
- Parkinsonism (DLB should occur before or concurrently with onset of PD)
- Repeated falls/Syncope or transient loss of consciousness
- Hypersensitivity to antipsychotics (typical and atypical)
- reduced response to L-dopa compared to idiopathic PDD
- 5) Parkinson associated Dementia
- The cognitive features may appear similar to DLB Parkinsonian symptoms that typically are present many years before the onset of the dementia for PDD **
- 6) Fronto-temporal dementia:
- Insidious onset and gradual progression
- middle-aged patients
- Character & Behavioural changes
- Relatively preserved memory, perception, spatial skills and praxis
- Prominent language changes
- Normal Pressure Hydrocephlus NPH
- Urinary incontinence
Ask about onset, duration, Course (fluctuating? Progressive? Step-wise) alertness,memory loss( global? Recent? Emote?) perception (delusions, hallucinations) Sleep, Emotions, gait, features of systemic diseaseses i.e PD, Thyroid, Peripheral neuropathy
Chronic vascular disease i.e CVA, DM, CAD, HTN
Basic ADLs (DEATH )
- • Dressing
- • Eating
- • Ambolating
- • Toileting
- • hygiene
Instrumental ADLs (SHAFT)
- • Shopping
- • Housekeeping
- • Accounting
- • Food prepration
- • Transportation
- • Going out to symphony
Identify medical conditions contributing to cognitive decline, and Identify neurologic abnormalities including localizing signs, extrapyramidal signs, ataxia.
Mild Cognitive Impairment (MCI)
A diagnosis of MCI is made when other causes of impaired cognition (e.g., anxiety, depression, delirium or substance abuse) have been excluded and the patient does not meet the criteria for a diagnosis of dementia either because they lack a second sphere of cognitive impairment or because their deficits are not significantly affecting their daily living.
The following tests are recommended in the initial work up of suspected MCI or dementia:
- • CBC
- • Lytes also Serum calcium
- • Glucose
- • TSH
- • B12*
SHORT COGNITIVE ASSESSMENT
- • Say 3 words ask the repeat. Then recall items in 1 min
- • Clock drawing test (“Ten after eleven”)
- • If abnormal → do better test next time, send to OT
Better screening tests/ monitoring
- • MMSE – commonly used screening and monitoring (takes 5 min, Affected by age/educational level/language skills/hearing)
- >24 no dementia, ** needs to be taken in context with above
- • 3MS: Modified mini mental screening as well as monitoring has highly validity then SMMSE
- • MoCA: Montreal Cognitive Assessment: a 10-minute cognitive screening tool for detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia. In cases where there is a suspicion of cognitive impairment or concern about the patient’s cognitive status, and the SMMSE score is in normal range (24-30) MoCA is recommended
Competency of person
- o Must be able to understand and remember sufficiently to support decision making
- o Must be able to appreciate risks and benefits
- o Insight and judgement
A CDM approach establish a disease register and recall patients for review with a planned visits dedicated solely to the care of dementia
Involve family members in care
Involve allied health professionals( e.g. Home and Community Care case managers, mental health teams etc.
After early cognitive deficits are first diagnosed, consider entering into a discussion with the affected patient about eventual driving cessation.
Assist the affected driver to make the necessary lifestyle changes early and to cease driving by choice rather than by compulsion.
Encourage patient to register with HandyDart, HandyPASS and TaxiSavers
When doubt exists about a patient’s driving competence Re road test by Insurance Corporations i.e., ICBC
** Always document in the chart If pt unsafe to drive
If pt continues to drive physician is required to notify the Superintendent of Motor Vehicles
Self-Neglect, Neglect and Abuse
Refer to Home and Community Care or geriatric outreach teams
- • Do MMSE/cognitive assessment then...
- • Assets – property, vehicles, investments, banks
- • Debts
- • Income - where and how much?
- • Expenses
- • Power of attorney – only financial decisions
- o Trusted family member/friend
- o Can use joint bank accounts...
- o Careful of family disagreements/strangers, etc
- • Must know approx what pt owns
- • Must know who would be the beneficiary
- • Must be unbiased!!!
Drinking and Driving
- • Comprehensive Trail making test
- • Drive Able or Road test