Download Dementia Screening

Dementia Screening
Elena Loomis, MSN, APRN, A-GNP-C, CDP, CCRN
Objectives
Dementia Definition
Dementia is a disorder that is
characterized by a decline in cognition
involving one or more cognitive
domains:
Learning and memory
Language
Executive function
Complex attention
Perceptual-motor
Social cognition
The deficits must represent a decline
from previous level of function and be
severe enough to interfere with daily
function and independence
DSM-V updated manual
replaces the term “dementia” with major
neurocognitive disorder and mild
neurocognitive disorder
Most Common Types of Dementia
AD
Vascular Dementia
Dementia with Lewy
Bodies
Parkinson’s Disease
Frontotemporal Dementia
Mixed Dementia
Disease Process with
Symptoms Like Dementia
Delirium
Creutzfeldt-Jakob Disease
Wernicke-Korsakoff Syndrome
Normal Pressure Hydrocephalus
(NPH)
Facts
There are various types of dementia
Alzheimer’s Disease is most common making
up 60-80% of all dementias
Alzheimer’s is the 6th leading cause of death
Change in biomarkers occur 25 years before
symptoms
25 years Aβ42 begins to decline
15 years tau begin to rise
10 years brain shrinkage and atrophy is evident
the brain’s consumption of the sugar glucose is
discernibly lower and some memory impairment can be
measured.
Pathophysiology
Senile Plaque
Neurofibrillary Tangle
Pathway of Lesions
Start Cerebral Cortex
Hippocampus
Whole brain
Start in Hippocampus
Memory & Learning
Centrofugal movement
Causing Atrophy
Global dysfunction
Corresponds with Symptoms:
Memory Problems
Language
Recognition
Incapacity to perform
gestures
Centripetal movement
Movement throughout
brain does NOT
correspond with symptoms
Neuronal Death
3 Phases of Dementia
Amyloid Abnormal
No Cognitive
Symptoms
Amyloid +
Neurodegeneration
Mild Cognitive
Symptoms
No Symptoms
Biomarkers Normal
Mild Symptoms
Biomarkers Abnormal
No Symptoms
Amyloid +
Neurodegeneration
Dementia
Dementia Biomarkers
Abnormal
Dementia
Mild Cognitive Impairment (MCI)
Intermediate stage between the expected cognitive decline of normal aging
and the more-serious decline of dementia
Can Involve problems with memory, language, thinking and judgment
that are greater than normal age-related changes.
Forms of MCI prodromal AD
Amnesic MCI (aMCI) early stage of AD
Impairment in Executive Function-Inattention (eMCI) progressed into
AD
Not all patients with MCI go on
to develop Alzheimer’s,
but almost all cases of Alzheimer’s
start with MCI.
Why is identifying MCI important?
In primary care 25% of patients with MCI will progress
into dementia within 3 years
By diagnosing MCI early this will Identify patients at risk for dementia
Education of caregivers
Psychological Components
Reduced patient and family anxiety
Uncertainty and stress
improved family understanding of demented patient
reduced caregiver burden
Reduce blame & denial
Promote safety
driving, medication compliance, cooking,
Patient’s and family’s right to know especially about genetic risks
Promote advocacy for research and treatment development
Early Pharmacological Therapy
Temporarily improve cognitive dysfunction
Temporarily improve function (ADLs)
Delay conversion from MCI to Alzheimer’s disease
Decrease development of behavior problems
Delay nursing home placement
Advance planning while patient is competent
Screening for MCI
MMSE vs MoCA
Who to Screen?
When to Screen?
Starting at age 65, the risk of developing the disease
doubles every 5 years
By age 85 years and older, between 25% and 50% of
people will exhibit signs of Alzheimer's disease
Up to 5.3 million Americans currently have
Alzheimer's disease
By 2050, the number is expected to more than
double due to the aging of the population
Alzheimer's disease is the sixth leading cause of
death in the United States
Fifth leading cause among persons age 65 and older
Mortality Rates
Average 4.5 years from diagnosis of dementia
>80 at time of diagnosis years as little as 3 or 4
years
New research shows that if diagnosed before
age 70 increases to 10 years
Common Screening Tools
MMSE
Assesses mental status created in 1975
11 questions
Test 5 areas of cognition:
Orientation
Registration
attention and calculation
Recall
language
Max score 30
Score <23=cognitive impairment
5-10 minutes to perform
Target population
Older
community dwelling
hospitalized
institutionalized adults
MoCA
Assesse MCI
8 components
Tests 8 cognitive domains
attention and concentration
executive functions
Memory
Language
visuoconstructional skills
conceptual thinking
Calculations
Orientation
Max score 30
Score <17 impairment
Score >26 normal
10 minutes to perform
Target population
Older adults
Primary care
Any acute care setting
Diverse populations
For any educational background
Validity & Reliability
MMSE
MoCA
Detection of MIC
Detection of MCI
Sensitivity 66%
Specificity of 99%
89% confidence interval
Sensitivity 90%-96%
Specificity of 87%
95% confidence interval
The MoCA detected 100% of Alzheimer’s dementia with
a specificity of 87%.
MoCA
http://www.mocatest.org/pdf_files/instructions/MoCA-Instructions-English_2010.pdf
Making a Difference
Dementia Work-Up
References
http://www.healthline.com/health/types-dementia#overview1
https://www.technologyreview.com/s/428480/an-alzheimers-warning-25-years-before-symptoms-show/
Executive Dysfunction in MCI: Subtype or Early Symptom. International Journal of Alheimer’s Disease, Vol. 2012, ID 936272.
Evaluation of cognitive impairment and dementia. https://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia
DIAGNOSTIC CRITERIA FOR DEMENTIA https://www.fightdementia.org.au/files/helpsheets/Helpsheet-DementiaQandA11-DiagnosticCriteriaForDementia_english.pdf
Prognosis of Mild Cognitive Impairment in General Practice: Results of the German AgeCoDe Study
doi: 10.1370/afm.1596Ann Fam Med March/April 2014 vol. 12no. 2 158-165
Ashford JW, Borson S, O’Hara R, et al. Should older adults be screened for dementia? It is important to screen for evidence of dementia! Alzheimer’s & dementia : the journal of the Alzheimer’s
Association. 2007;3(2):75-80. doi:10.1016/j.jalz.2007.03.005.
About Alzheimer's Disease: Alzheimer's Basics
https://www.nia.nih.gov/alzheimers/topics/alzheimers-basics
Trzepacz PT, Hochstetler H, Wang S, Walker B, Saykin AJ, for the Alzheimer’s Disease Neuroimaging Initiative. Relationship between the Montreal Cognitive Assessment and Mini-mental State
Examination for assessment of mild cognitive impairment in older adults. BMC Geriatrics. 2015;15:107. doi:10.1186/s12877-015-0103-3.
DETECTION, DIAGNOSIS AND MANAGEMENT OF DEMENTIA http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf