Cognitive Impairment – AFP2011

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.

Hx – from the pt supported with collateral from the caregiver & Document:
  1. Memory decline / impairment
    • Difficulty learning new info
    • Difficulty recall previously learned info, eg. forgetting the name of a relative(s)
    • Frequent repetition of stories and/or statements
  2. AND One of
    • Aphasia – language disturbance – early AD
    • Apraxia – difficulty in carrying out learned motor activities despite intact motor function – Moderate AD
    • Agnosia – difficulty recognizing people, places, or objects previously familiar despite intact sensory function – often subtle and unnoticed
    • Disturbance in executive function (SOAP)- difficulty Sequencing, Organizing, Abstracting, Planning
  3. Geriatric giants
    • Confusion / incontinence / falls / polypharmacy
    • Safety: wandering, leaving doors unlocked, leaving stove on, losing objects
    • Behavioural / mood: anxiety, psychosis, SI, personality changes, aggression, agitation, apathy, disinhibition
  4. Level of functional decline / impairment
    • ADLs – basic activities of daily living:
      • transfers, toileting, washing, dressing, feeding
    • IADLs – instrumental activities of daily living:
      • shopping, cooking, housework, laundry, banking, travel beyond walking distance. taking medications properly
    • Becoming lost while driving familiar routes
  5. Other cognitive areas (i.e., language, orientation, difficulty in performing familiar tasks)
    • Exercising poor judgement
  6. EtOH, smoking, OTCs, herbal remedies, medications (sedative hypnotics, antipsychotics, antidepressants, anticholinergics) – compliance, accessibility
  7. Hx of vascular dz, head trauma, CV, endocrine, neoplastic, renal ROS
  8. Perform objective test of cognition – MMSE
    • screening test for cognition
    • influenced by age and education level
    • Good for comparison in serial tests

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

Diagnosis of Dementia (DSM-IV)
  1. A syndrome characterized by: (4 As of Dementia)
    1. Amnesia – Memory impairment (difficulty learning new information or recalling previously learned information)
    2. One of the following:
      i. Aphasia – language
      ii. Apraxia – visuospatial ability
      iii. Agnosia
      iv. Disturbance in executive functioning – reasoning
  2.  The cognitive deficits above cause significant impairment in functioning (work or socially) and represent a decline from previous functioning.
  3. Symptoms do not occur exclusively during delirium and are not better accounted for by another mental illness.

Subtypes: With or without behavioural disturbance: Wandering, agitation, early onset (<65) or late onset (>65)


Dx Criteria for probable AD
  1. Criteria for dementia are met
  2. Gradual onset over months/years & clear worsening of cognition.
  3. Initial & most prominent cognitive deficits are amnestic (learning & recall of recently learned info) & less commonly nonamnestic (language) – word-finding difficulties
  4. Deficits occur in other domains, visuospatial abilities (face or obj recognition), executive function (reasoning, judgement, problem solving).
  5. Probable AD should not be applied when substantial concomitant cerebrovascular dz is present
Dx criteria for possible AD
  • Criteria for possible AD are met but follows an atypical course, eg. sudden onset, or
  • Criteria for AD are met but ? mixed presentation, eg. concomitant cerebrovascular dz, or features of dementia with Lewy bodies, another comorbidity (medical or neurologic), or on med with substantial cognitive effect
MCI (Mild Cognitive Impairment) Dx
  1. Concern regarding a decline in cognition reported by the patient, information, or clinician + objective evidence of cognitive deficits in ≥ 1 domains (typically memory)
  2. Preservation of independence in functional abilities – at work or in usual daily activities (clinical judgement)
    • IADLs are not affected in MCI
  3. Further evaluation to r/o vascular, traumatic, medical causes & AD genetic factors
  4. represents an intermediate stage between dementia and normal aging
Early-onset dementia (Onset before 65yo)
  1. refer to a memory clinic with genetic counselling (auto dominant mutation – presenillin 1/2, amyloid precursor protein)
  2. sensitive to issues eg. loss of employment & access to support services
RPD (Rapidly Progressive Dementia)
  1. develops within 12 months after the appearance of 1st cognitive symptoms
  2. Exclude delirium then refer to specialist
  3. AD pt with a delcine of ≥ 3 points on the MMSE in 6 months – worse prognosis, need to explore comorbid conditions & reviews meds

Physical Exam:

  • BP, hearing and vision
  • Focal or lateralizing neurological signs – signs of parkinsonism
  • Gait disturbances
  • Evidence of EPS (extra pyramidal symptoms), which are not seen in AD until late in the course
  • CV exam
  • MMSE (MoCA for high functioning)

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.

Investigations:

Routine b/w in patients with suspected dementia.
  • CBC, complete metabolic panel, TSH, serum electrolytes, calcium, glucose, Vit B12, folate
  • Renal function, LFTs, lipids

Additional testing (e.g., neuroimaging, cerebrospinal fluid analysis, human immunodeficiency virus testing, Lyme titer, rapid plasma reagin test) can be performed in patients with suspected dementia and specific risk factors or symptoms

CT head only if
  1. pt ≥ 60yo,
  2. abrupt onset, rapid decline (1-2 mo) of unexplained decline in cognition / function, short duration
  3. Focal neurological S/Sx – hemiparesis / babinski reflex
  4. unexplained neurologic symptoms (Sz, new severe headache)
  5. Unusual or atypical cognitive symptoms – progressive aphasia, gait disturbance
  6. Predisposing conditions
    • Prev malignancy, recent sig. head trauma,
    • bleeding disorder or use of anticoagulants
  7. Urinary incontinence + gait disorder early in the course of dementia (NPH)
Neuroimaging:
  • CT/MRI to assess cognitive impairment & unsuspected cerebrovasculardz if it would change the clinical Rx
    • In addition to the structural imaging
  • Amyloid test alone can’t dx AD or MCI. Advice pt against the test
  • CSF amyloid B and T level not recommended

Alzheimer disease (AD) is a clinical dx, but aware of neuroimaging & biomarkers (amyloid-B/T, hyperphosphorylated T)


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

Determine dx of dementia (Formulate etiological dx)
  1. gradual onset & progression over time with a normal CNS exam suggests AD
  2. Abrupt onset & stepwise decline suggests vascular dementia
  3. Early behavioural problems & ↓ interpersonal skills with loss of social awareness suggests frontotemporal dementia
  4. Fluctuating cognition where dementia is followed by development of spontaneous EPS including falls suggest dementia with Lewy Bodies. 
  5. EPS preceded the dementia usually by several years suggests Parkinson’s dementia (opposite from Lewy Bodies)
  6. Early gait disturbance with urinary incontinence + mild cognitive impairment suggests possible NPH

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).

F/U – Plan f/u with pt and caregiver to review Info
  • MCI – Q3-6mo as pt may progress to dementia, usually AD within a short time (10-15% /yr)
  • Dementia – f/u within 1mo with pt and caregiver for info exchange then Q3-6mo
    • Average survival for AD ~ 10 yr (2-20)
    • Stage – GDS 
    • Safety planning including driving evaluation
    • Tx systolic HTN, encourage exercise routine, caution re change in environment or elective hospitalization

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

Issues to consider:
  • Failure to cope
  • Caregiver education and stress
  • Ask caregiver about concerns/problems/feeling stressed by care responsibilities
  • Re-explore safety issues: driving, stove, finances, falls, meds, nutritions
  • Power of attorney, legal will, advanced medical directive

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

Physician-reporting to the Ministry of Transportation is mandatory in all provinces and territories
  • Not an issue unique to geriatrics
  • Moderate to severe dementia is a contraindication to driving: defined as the inability to independently perform 2 or more IADLs or any basic ADL
    • defined as the inability to independently perform 2 or more IADLs or any basic ADL
  • Pt with mild dementia should be assessed;
    • if indicated, refer to specialized driving testing centre; if deemed fit to drive, re-evaluate pt Q6-12mo
  • Poor MMSE, clock drawing suggests a need to Ix driving ability further
  • MMSE alone is insufficient to determine fitness to drive

Key factors to consider in Older drivers – SAFEDRIVE
  • Safety record
  • Attention (concentration lapses, episodes of disorientation)
  • Family observations
  • Ethanol abuse
  • Drugs
  • Reaction time
  • Intellectual impairment
  • Vision / visuospatial function
  • Executive functions: planning, decision-making, self-monitoring behaviours

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.

Ascending paresthesias, tongue soreness, limb weakness, weight loss

Vitamin B12 deficiency

Broad-based shuffling gait, urinary incontinence

Normal pressure hydrocephalus

Current use of psychoactive drugs, such as benzodiazepines or anticholinergics

Adverse effects from medication

Depressed mood, anhedonia, feelings of worthlessness, flat affect, slowed speech

Depression

Fatigue, cold intolerance, constipation, weight gain, reduced body hair

Hypothyroidism

Head trauma within the previous three months, headache, seizures, hemiparesis, papilledema

Subdural hematoma

History of alcoholism, nystagmus or extraocular muscle weakness, broad-based gait and stance

Wernicke-Korsakoff syndrome

History of high-risk sexual behavior or drug use, hyperreflexia, incoordination, peripheral neuropathy

Human immunodeficiency virus–associated dementia

History of high-risk sexual behavior or drug use, hyporeflexia, papillary abnormalities, decreased proprioception

Neurosyphilis

Recent hospitalization or acute illness, inattention, fluctuating behavioral changes, altered level of consciousness

Delirium


Differentiate:  depression, delirium, dementia


Depression features
  1. Mood – sad / depressed most of the time & Memory problems (same duration as other symptoms, wk – mo, not years)
  2. Sleep disturbed
  3. Interests decreased – anhedonia (↓ capacity to enjoy)
  4. Guilty
  5. Energy reduced
  6. Concentration poor
  7. Appetite ↓ & wt loss (10% in 6mo)
  8. Psychomotor agitation / anxiety (can be prominent)
  9. Atypical common in the elderly
    1. psychotic features (paranoid delusions), somatization, the dwindles
  10. Issues in depressed elderly
    1. ↑suicide risk, depression co-exist with dementia (not usually sole cause of cognitive impairment)

The Geriatric Depression Scale (GDS-15) is a series of 15 yes/no questions; a score of 5 or greater is considered positive


Delirium features – medical emergency
  1. Acute onset
  2. Fluctuation course
  3. Attention ↓
  4. Consciousness ↓
  5. Thoughts disorganized
Risk factors & causes
  • Advance age
  • Pre-existing cognitive impairment/ psychiatric comorbidity eg dementia
  • Sensory deprivation / over stimulation / environmental changes / use of physical restraints
  • Medications (4+ meds, anticholinergics, opoids, sedative-hypnotics, drug withdrawal, drug intoxication)
  • Trauma / surgery / infection – UTI / respiratory
  • cardiopulmonary disorders (MI, HoTN, hypoxia)
  • Metabolic/dehydration/nutritional factors, electrolytes abn, malnutrition / hypoalbuminemia
  • CNS – dementia, stroke
  • GI – ulcer, bleeding, constipation
  • GU – retention

Dementia features
  • Memory loss with at least one of aphasia, apraxia, agnosia, disturbance in executive function
  • Decline from previous level of function with significant impact on the pt’s life
  • Not explained by other causes, eg. delirum or depression
  • Be vigilant for imminent, serious potential risks to self / others
  • identify sources of collateral info and plan timely f/u for more complte assessment with collateral info
  1. AD: memory impairment, Aphasia, apraxia, agnosia
  2. Dementia with Lewy bodies: VH, Parkinsonism, Fluctuating cognition
  3. Frontotemporal dementia (Pick’s dz): 
    • Behavioural presentation: disinhibition, perserveration, decreased social awareness, mental rigidity, memroy relatively spared
    • Language presentation: Progressive non-fluent aphasia, semantic dementia
  4. Huntington’s dz: chorea
  5. Vascular Dementia
    • Multi-infarct dementia: abrupt onset, stepwise deterioration is classive but progressive is most common, dysexecutive syndrome, focal neurological findings
    • CNS vasculitis: systemic S/Sx of vasculitis

GDC (global deterioration scale)
  • Level 1 – no cognitive decline
  • Level 2 – forgetfulness
  • Level 3 – Early confusional – earlier clear-cut deficit –
    • (a) patient may have gotten lost when traveling to an unfamiliar location;
    • (b) co-workers become aware of patient’s relatively poor performance;
    • (c) word and name finding deficit becomes evident to intimates;
    • (d) patient may read a passage or a book and retain relatively little material;
    • (e) patient may demonstrate decreased facility in remembering names upon introduction to new people;
    • (f) patient may have lost or misplaced an object of value;
    • (g) concentration deficit may be evident on clinical testing.
  • level 4 – Late Confusional
    • (a) decreased knowledge of current and recent events;
    • (b) may exhibit some deficit in memory of one’s personal history;
    • (c) concentration deficit elicited on serial subtractions;
      (d) decreased ability to travel, handle finances, etc. Frequently no deficit in following areas: (a) orientation to time and person; (b) recognition of familiar persons and faces (c) ability to travel to familiar locations.
  • Level 5 – Early dementia
    • Patient can no longer survive without some assistance.
  • Level 6 – Middle Dementia
    • Delusional behaviour
    • Obsessive symptoms
    • Anxiety, agitation, violent behaviour
    • Cognitive abulla – loss of willpower because can’t think long enough to determine a purposeful course of action
  • Level 7 – Late Dementia
    • All verbal abilities are lost.

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).

Risk Factors of AD:
  • Age
  • Family Hx
  • Smoking,
  • head injury
  • low education level
  • Down’s syndrome
    • predisposes to early onset of AD (~ 40) due to 3 copies of the amyloid gene (APP)

Dementia considerations for management: ABCDS
  • Affective disorders and ADLs
  • Behavioural problems
  • Caretaker, cognitive medications and stimulation
    • Provide education and support for pt and family: day programs, respite care, support groups, home care
  • Directives, Driving
    • Consider long-term care plan (nursing home) and power of attorney / living will
  • Sensory enhancement (glasses/ hearing aides)
    • Provide orientation cues for pt (clock, calendar)
Med Tx

ChEIsDonepezil – (Aricept) A trial is recommended for most AD pt

  • Tx mild-moderate AD, AD w/ cerebrovascular dz, Parkinson dementia, all stages of AD.
  • Valproate should not be used for agitation / aggression in AD
  • Recommended for AD with cerebrovascular dz, dementia with Parkinson dz, and mild-severe AD
    • Inconsistent evidence for Vascular dementia
    • Combination of a ChEI and memantine is rational (insufficient evidence tho)
  • ↑ central & peripheral cholinergic stimulation
  • S/E: ↑ GIB (↑ in PUD pt or NSAIDs use), bradycardia / heart block, exacerbate asthma / pulmonary dz, urinary outflow obstruction, ↑ risk of Sz, prolong succinylcholine (muscle relaxant)
  • Discontinuation (s/e and cost) if
    • Pt, caregiver, substitute decision maker decide to stop (informed about risks & benefits)
    • Pt is nonadherent & Rx would be useless
    • Pt’s rate of cognitive, functional, behavioural decline ↑ on Tx compared with that before Tx
      • monitor over the next 1-3 mo & restart if observable decline
    • Pt’s comorbidities make the agent risky or futile, eg. terminal illness
    • End stage with no meaningful benefit from Tx, eg. Global deterioration Scale stage 7
    • Taper before stopping.
Agitation / aggression in Dementia
  • Recognition & management of potentiating factors (medical, psychiatric, medications, environmental)
  • A trial of antidepressant if pt has an inadequate response to nonpharmacologic interventions or has MDD, severe dysthymia, severe emotional lability
  • Risperidone, olanzapine, aripiprazole for severe agitation, aggression, psychosis associated with dementia where there is a risk of harm to thept or others.
    • + substantial risk: cerebrovascular adverse events and mortality
    • Quetiapine, SSRI, trazadone – insufficient evidence

References:

 

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Posted in 23 Dementia, 99 Priority Topics, FM 99 priority topics, Neuro

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