Download Dementia In Primary Care - Hurley Graduate Medical Education

Myriam Edwards MD
Geriatrician, Assistant Professor, and
Geriatric Medicine Fellowship
Program Director
Hurley Medical Center /
Michigan State University
Geriatric Education Center of Michigan
activities are supported by a grant from the
U.S. Department of Health and Human
Services, Health Resources and Services
Administration, Public Health Service Act, Title
VII, Section 753(a).
This module was developed by
Define
• Delirium
• Dementia
• Decisionmaking
capacity
• Competence
Identify
Recognize:
• Tools to assess
cognitive status
• Decisionmaking ability
includes
• nature of the
decision
• cognitive
capabilities of
person
Cognition
Decisionmaking
capacity
Goal
Setting
Recall may be
delayed
Memory storage is
normal
Divided Attention Tasks
(more difficulty with
multi-tasking)
NORMAL AGING
●
No consistent, progressive deviations on
testing of memory
●
Some decline in processing and recall of new
information: slower, harder
●
Reminders work – visual tips, notes
●
Absence of significant effects on ADLs or
IADLs due to cognition
Slide 6
Memory Impairment
No Other Cognitive Deficits
Normal Daily Activities
Memory Impairment
Other Cognitive Problems
• Language (word finding, naming)
• Executive function (planning & organizing)
• Apraxia or Agnosia
Problems with Daily Activities
Stop, Look,
and Listen
Brief Screen
of Cognitive
Function
Arrange
Follow-up
Evaluation
Look for
Red Flags (
‘Triggers’ )
Listen to
Caregivers
Shopping
Transportation*
Finances*
Housework
Medication*
Meal Prep
Telephone*
■
■
■
Conversation
Clock Drawing Test
Mini-Cog
■
■
Three-Item Recall
Clock Drawing
1 pt 1 pt 1 pt 1 pt -
Draws a closed circle
Numbers in correct positions
All 12 correct numbers included
Hands placed in correct position
■ Negative Screen for Dementia
■ Score of 3 on 3-item recall
■ Normal Clock and a Score of 1 or 2
■ Positive Screen for Dementia
■ Score of 0 on 3-item recall
■ Abnormal Clock and a Score of 1 or 2
1. Memory impairment
2. Additional Cognitive Problems
3. Deficits cause significant impairment in social or
occupational function and represent a significant
decline from a previous level of function
4. Exclude Acute Confusion (delirium)
5. Exclude Depression
PHQ - 2
Other Good
Questions
• Do you feel sad or blue?
• Have you lost interest in doing
things that you have enjoyed?
• What are you looking forward to?
• What do you do for enjoyment?
Alzheimer’s
disease
Vascular
dementia
Lewy Body
disease
Other
THE EPIDEMIOLOGY OF
ALZHEIMER’S DISEASE
•
6%‒8% of people age 65+ have AD
•
Nearly 30% of those aged 85+ have AD
Slide 23
THE IMPACT OF DEMENTIA
•
Economic
$100 billion annually for care and lost productivity
Medicare, Medicaid, private insurance provide only
partial coverage
Families bear greatest burden of expense

Emotional
•
Direct toll on patients
Nearly half of caregivers suffer depression

•
•
•
Slide 24
RISK FACTORS FOR DEMENTIA
Definite
Possible
•
Age
• Head injury
•
Down’s syndrome
• Fewer years of education
•
Family history
•
Slide 25
APOE4 allele
• Late onset of major depression
• Cardiovascular risk factors
ASSESSMENT: HISTORY
Ask both the patient & a reliable informant
about the patient’s:
Slide 26
•
Current condition
•
Medical history
•
Current medications & medication history
•
Patterns of alcohol use or abuse
•
Living arrangements
ASSESSMENT: PHYSICAL

•
•
•

•
•
Slide 27
Examine:
Neurologic status
Mental status
Functional status
Include:
Quantified screens for cognition
 eg, Folstein’s MMSE, Mini-Cog
Neuropsychologic testing
ASSESSMENT: LABORATORY
•
Blood chemistries
•
CBC
•
Liver function tests
•
Urinalysis
• Serologic tests for:
 RPR
 TSH
 Vitamin B12 level
 Folate level
ASSESSMENT: BRAIN IMAGING

Consider imaging when:
•
•
Onset occurs at age <65 years
Symptoms have occurred for <2 years
Neurologic signs are asymmetric or focal
Clinical picture suggests normal-pressure hydrocephalus
Patient has had recent fall or other head trauma

Consider:
•
Noncontrast computed topography head scan
Magnetic resonance imaging
Positron emission tomography
•
•
•
•
•
Slide 29
DIFFERENTIAL DIAGNOSIS
•
Normal aging
•
Mild cognitive impairment
•
Delirium
•
Depression
•
Alzheimer’s disease
•
Vascular (multi-infarct) dementia
•
Dementia associated with Lewy bodies
•
Other (alcohol, Parkinson's disease, Pick’s disease,
frontal lobe dementia, neurosyphilis)
Slide 30
DELIRIUM vs DEMENTIA
Delirium and dementia often occur together in older
hospitalized patients; the distinguishing signs of
delirium are:
 Acute
onset
 Cognitive fluctuations over hours or days
 Impaired consciousness and attention
 Altered sleep cycles
Slide 31
DEPRESSION vs DEMENTIA (1 of 2)
The symptoms of depression and dementia
often overlap:
Slide 32
•
Impaired concentration
•
Lack of motivation, loss of interest, apathy
•
Psychomotor retardation
•
Sleep disturbance
DEPRESSION vs DEMENTIA (2 of 2)
•
Patients with primary depression are generally
unlike those with dementia in that they:

•
Demonstrate  motivation during cognitive testing

Express cognitive complaints that exceed measured
deficits

Maintain language and motor skills
Effective treatment of depressive symptoms may
improve cognition
Slide 33
ALZHEIMER’S DISEASE
•
Onset:
•
Cognitive symptoms: primarily memory with
difficulty learning new
information
•
Motor symptoms:
rare early, apraxia later
•
Progression:
gradual, over 8–10 yr ave.
•
Lab tests:
normal
•
Imaging:
possible global atrophy, small
hippocampal volumes
Slide 34
gradual
DSM-IV DIAGNOSTIC CRITERIA FOR AD
•
Development of cognitive deficits manifested by:


Impaired memory and
Aphasia, apraxia, agnosia, disturbed executive function
•
Significantly impaired social, occupational function
•
Gradual onset, continuing decline
•
Not due to CNS or other physical conditions
(eg, PD, delirium)
•
Not due to an Axis I disorder (eg, schizophrenia)
Slide 35
VASCULAR DEMENTIA
•
Onset:
•
Cognitive symptoms: depend on anatomy of
ischemia
•
Motor symptoms:
correlates with ischemia
•
Progression:
stepwise with further
ischemia
•
Lab tests:
normal
•
Imaging:
cortical or subcortical
changes on MRI
Slide 36
may be sudden/stepwise
DSM-IV DIAGNOSTIC CRITERIA
FOR VASCULAR DEMENTIA
•
Development of cognitive deficits manifested by:


Impaired memory and
Aphasia, apraxia, agnosia, disturbed executive function
•
Significantly impaired social, occupational function
•
Focal neurologic symptoms & signs or evidence of
cerebrovascular disease
•
Deficits occur in absence of delirium
Slide 37
LEWY BODY DEMENTIA
•
Onset:
•
Cognitive symptoms: memory, visuospatial,
hallucinations, fluctuations
•
Motor symptoms:
parkinsonism
•
Progression:
gradual, but usually faster
than AD
•
Lab tests:
normal
•
Imaging:
possible global atrophy
Slide 38
gradual
FRONTOTEMPORAL DEMENTIA
•
Onset:
•
Cognitive symptoms: executive: disinhibition,
apathy, behavior changes
•
Motor symptoms:
none; may be associated
with ALS in rare cases
•
Progression:
gradual but faster than AD
•
Lab tests:
normal
•
Imaging:
atrophy in frontal and
temporal lobes
Slide 39
gradual, usually age <60
PRIMARY GOAL OF TREATMENT
To enhance quality of life
and maximize functional performance
by improving cognition, mood, and behavior
Slide 40
NONPHARMACOLOGIC MANAGEMENT
•
Cognitive rehabilitation
•
Individual and group therapy
•
Physical and mental activity
•
Regular appointments
•
Family and caregiver education and support
•
Environmental modification
•
Attention to safety
Slide 41
PHARMACOLOGIC MANAGEMENT
•
Treatment should be individualized
•
Cholinesterase inhibitors:
donepezil, rivastigmine, galantamine
•
Memantine
•
Other cognitive enhancers
•
Antidepressants
•
Psychoactive medications
Slide 42
IADLs ( medications and finances)
Live safely at home
Drive a car
Informed Consent
Appoint DPOA –HC
Transact business
Make a will
Communication
Culture
Circumstances
Consequences
Choices
Consistency
ASSESSMENT OF
DECISIONAL CAPACITY

Overarching factor is the patient’s ability to
understand the consequences of a decision

Evaluate each patient individually, considering his
or her beliefs, values, and goals of care

Avoid assuming on the basis of ethnic background
that a patient holds certain beliefs
Slide 46
ELEMENTS OF CAPACITY TO MAKE
MEDICAL DECISIONS

Ability to understand:





The disease process
The proposed therapy and alternative therapies
The advantages, adverse effects, and potential
complications of each therapy
The possible course of the disease without intervention
Ability to communicate a decision
Slide 47
ELEMENTS OF CAPACITY TO MAKE
DECISIONS ABOUT SELF-CARE

Ability to care for oneself
or

Ability to accept the needed help
to keep oneself safe
Slide 48
ELEMENTS OF CAPACITY TO MAKE
FINANCIAL DECISIONS

Ability to manage bill payment
Ability to appropriately calculate and
monitor funds

Slide 49
ELEMENTS OF CAPACITY TO MAKE
A LAST WILL AND TESTAMENT

Ability to identify the individuals involved

Ability to remember estate plans

Ability to express the logic behind choices
Slide 50
STANDARDIZED TESTS
OF DECISIONAL CAPACITY

Mini-Mental State Examination (limited utility)

Executive Interview 25-item examination
(EXIT 25) of executive function

Capacity to Consent to Treatment Instrument

MacArthur Competency Assessment Tool –
Treatment
Slide 51
HIERARCHY
OF DECISION-MAKING STRATEGIES

Use substituted judgment

Respect the patient’s last competent indication
of their wishes

Use the principle of beneficence
Slide 52
LAST COMPETENT
INDICATION OF WISHES

Most relevant when patients can foresee that they will
become incapacitated, as when entering the terminal
phase of an illness

Patients should be encouraged to give detailed advance
directives (called advanced care plans in some contexts)

As long as the circumstances remain substantially as
predicted, other persons should not be allowed to reverse
these decisions
Slide 53
SUBSTITUTED JUDGMENT

Defined as the process of constructing what the person
would have wanted if he or she had been able to
foresee the circumstances and give direction for care

A patient can appoint someone to hold durable power
of attorney for health affairs (called a health care agent
or health care proxy)

A person granted durable power of attorney takes
precedence over the next of kin
Slide 54
PRINCIPLE OF BENEFICENCE

Making medical decisions for an incapacitated
person on the basis of the benefits and burdens of
treatment and interventions

The analysis is best done by someone who is very
aware of:



What gives that patient pleasure
What causes agitation, fear, pain, or discomfort
How the patient reacts to a change in setting, use of
restraints, and similar matters
Slide 55
CONSERVATORS



Appointed by a court in the absence of next of kin or
durable power of attorney
Called guardians in some states
Two types:


Conservator of finance
Conservator of person (the patient can no longer make
personal decisions, such as medical decisions, or endangers
himself and cannot understand or accept the need for help)
Slide 56
ADVANCE DIRECTIVES
(LIVING WILLS)

Attempt to demonstrate what decisions a person would
make in hypothetical clinical situations (eg, vegetative
state, terminal illness)

Limited utility because of vagueness and lack of
generalizability to decisions that commonly need to be
made

Can be used by surrogate decision maker as evidence of
preferences
Slide 57
Identify Decision-maker
(include person)
Understand Patient as a
Person (QoL)
The Condition/Diagnoses
(prognoses)
Review Plan
Establish Plan of Care
• Discuss ‘Best Guess’ transitions
and/or decision points
Make sure goals are shared goals
Make goals as explicit as possible
and be sure all involved understand
them
Make sure you make time to
review (and revise if necessary)
goals, especially when
condition changes.