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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