Dementia and Decision-Making: Functional Assessment of the Older Adult I

1. Dementia and Decision-Making: Functional Assessment of the Older Adult I Myriam Edwards MD Geriatrician, Assistant Professor, andGeriatric Medicine Fellowship Program Director Hurley Medical Center / Michigan State University Geriatric Education Center of Michigan

2. 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 Mark Ensberg, MD Geriatric Education Center Michigan State University

3. Learning Objectives

5. What is Normal?

6. 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

7. What is MCI?(Mild Cognitive Impairment)

8. What is Dementia?

9. Dementia is Sneaky

10. Daily Activities: IADLs Instrumental Activities of Daily Living • * * relevant to the medical office visit

11. ‘Ten Warning Signs’ • Memory loss • Difficulty performing familiar tasks • Problems with language • Disorientation to time and place • Poor or decreased judgment • Problems with abstract thinking • Misplacing things • Changes in mood or behavior • Changes in personality • Loss of initiative Alzheimer’s Association

12. Brief Screens: Cognitive Function • Conversation • Clock Drawing Test • Mini-Cog • Three-Item Recall • Clock Drawing

13. JAGS 1993; 41: 576.

14. Clock-Drawing: 4-Point Scoring 1 pt - Draws a closed circle 1 pt - Numbers in correct positions 1 pt - All 12 correct numbers included 1 pt - Hands placed in correct position

15. Mini-Cog • 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

16. Follow-Up Evaluation • Mini-Mental State Examination (MMSE) • Montreal Cognitive Assessment (MoCA) • Functional Activities Questionnaire - Bills & Checks - Prepare Meals - Organizing Papers - Current Events - Shopping - TV Magazines - Games & Hobbies - Appointments - Making Coffee - Transportation

20. DSM IV Criteria for Dementia • Memory impairment • Additional Cognitive Problems • Deficits cause significant impairment in social or occupational function and represent a significant decline from a previous level of function • Exclude Acute Confusion (delirium) • Exclude Depression

21. Screening for Depression

22. Types of Dementia

23. THE EPIDEMIOLOGY OF ALZHEIMER’S DISEASE • 6%‒8% of people age 65+ have AD • Nearly 30% of those aged 85+ have AD

24. 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

25. RISK FACTORS FOR DEMENTIA • Possible • Head injury • Fewer years of education • Late onset of major depression • Cardiovascular risk factors Definite • Age • Down’s syndrome • Family history • APOE4 allele

26. ASSESSMENT: HISTORY Ask both the patient & a reliable informant about the patient’s: • Current condition • Medical history • Current medications & medication history • Patterns of alcohol use or abuse • Living arrangements

27. ASSESSMENT: PHYSICAL • Examine: • Neurologic status • Mental status • Functional status • Include: • Quantified screens for cognition • eg, Folstein’s MMSE, Mini-Cog • Neuropsychologic testing

28. ASSESSMENT: LABORATORY • Serologic tests for: • RPR • TSH • Vitamin B12 level • Folate level • Blood chemistries • CBC • Liver function tests • Urinalysis

29. 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

30. 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)

31. DELIRIUM vs DEMENTIA Delirium and dementia often occur together in older hospitalized patients; the distinguishing signsofdelirium are: • Acute onset • Cognitive fluctuations over hours or days • Impaired consciousness and attention • Altered sleep cycles

32. DEPRESSION vs DEMENTIA (1 of 2) The symptoms of depression and dementia often overlap: • Impaired concentration • Lack of motivation, loss of interest, apathy • Psychomotor retardation • Sleep disturbance

33. 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

34. ALZHEIMER’S DISEASE • Onset:gradual • Cognitive symptoms:primarily memory with difficulty learning new information • Motor symptoms:rare early, apraxia later • Progression:gradual, over 8–10 yrave. • Lab tests:normal • Imaging: possible global atrophy, small hippocampal volumes

35. 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)

36. VASCULAR DEMENTIA • Onset:may be sudden/stepwise • 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

37. 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

38. LEWY BODY DEMENTIA • Onset:gradual • Cognitive symptoms:memory, visuospatial, hallucinations, fluctuations • Motor symptoms:parkinsonism • Progression:gradual, but usually faster than AD • Lab tests:normal • Imaging:possible global atrophy

39. FRONTOTEMPORAL DEMENTIA • Onset:gradual, usually age <60 • 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

40. PRIMARY GOAL OF TREATMENT To enhance quality of lifeand maximize functional performanceby improving cognition, mood, and behavior

41. 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

42. PHARMACOLOGIC MANAGEMENT • Treatment should be individualized • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine • Memantine • Other cognitive enhancers • Antidepressants • Psychoactive medications

43. We determine decision-making capacity Courts determine competence

44. Decision-Making

45. Decision-making Capacity

46. 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 ASSESSMENT OFDECISIONAL CAPACITY

47. 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 ELEMENTS OF CAPACITY TO MAKEMEDICAL DECISIONS

48. Ability to care for oneself or Ability to accept the needed help to keep oneself safe ELEMENTS OF CAPACITY TO MAKEDECISIONS ABOUT SELF-CARE

49. Ability to manage bill payment Ability to appropriately calculate and monitor funds ELEMENTS OF CAPACITY TO MAKEFINANCIAL DECISIONS

50. Ability to identify the individuals involved Ability to remember estate plans Ability to express the logic behind choices ELEMENTS OF CAPACITY TO MAKEA LAST WILL AND TESTAMENT