Comprehensive Cognitive Assessment and Management for Elderly Patients

1. Cognitive Assessment Dr Robert Tobiansky

2. Preliminary issues • History is essential (onset, duration, examples of complaint, ADLs, associated factors) • Communication (language barrier) • Correct any sensory deficits (glasses, hearing aid, personal hearing amplifier) • Note mood, anxiety, pain, discomfort • Avoid use of word “test”

3. Which instrument? • AMTS • 6-CIT • MMSE • MOCA • ACE • RUDAS • etc

4. Cognitive domains • Orientation • Attention & Concentration • Immediate recall (registration) • Delayed Recall • Remote Memory (long term) • Language • Praxis • Recognition • Executive/frontal

5. Note the main features of the MSE on the DVD clip

6. Discussion & case Vignette

7. A man with dementia recently admitted to a care home (example from Lancet commission Dec 2017) Problem Mr Smith moved to a care home when his son, with whom he had lived, moved abroad. Mr Smith continually asked when he would go home and see his son and could not remember his son had moved. Staff avoided Mr Smith because they did not know how to reply. He became increasingly agitated, refused personal care, and was sometimes physically aggressive and resistive to care. His skin began to break down through neglect.

8. A man with dementia recently admitted to a care home Assessment He was referred to mental health services and a nurse met with staff and talked to his son. Staff discovered that team members had each been responding in different ways—some saying his son was on holiday and he would go home soon, others saying that this was his home now, and others not answering him. His son told the nurse that he felt guilty and had avoided calling his father because he thought his calls would disrupt him from settling in the home.

9. A man with dementia recently admitted to a care home Management The care staff and nurse worked out that saying his son loved him and encouraging him to talk about his son helped Mr Smith, and they agreed to give that consistent message. They reassured his son that regular contact would help and he started regular video calls. Staff worked with family to add personal possessions and photographs to his room making it more home-like. Staff also talked to him during personal care, gently explaining what they were doing, and played music that he liked. They planned that staff members he trusted would, whenever possible, give personal care. He began to accept personal care again. The staff maintained these strategies when things were better.

10. 78 year old man 78 year old man lives with his wife. She reports that he has a 1 year history of increasing forgetfulness. He gets upset as he claims that he can see strange people, including children, entering his bedroom at various times. He has poor mobility and frequent falls. He has episodes of marked confusion but at other times can be more lucid.

11. 78 year old man What is the most likely diagnosis and DDx? What neuroimaging might be useful here? What medication would you consider for the hallucinations?

12. 78 year old man Dx: DLB DDx: Vascular Dementia / Alzheimer’s Neuroimaging: DAT scan for DLB ; MRI for Vad / AD Medication: cholinesterase inhibitor eg donepezil

13. GP referral 84 year old woman 84 year old woman with no past psychiatric history. She lives alone at home , supported by her daughter who visits 3x weekly. She is brought to A & E as the daughter reports that her mother has been very confused over the past 2 days, is disorientated, irritable and accusing her cleaner of stealing her purse.

14. What is the most likely diagnosis? Depression Late onset schizophrenia Dementia Delirium Anxiety disorder

15. What is the most likely diagnosis? Depression Late onset schizophrenia Dementia Delirium Anxiety disorder

16. Cases for discussion: Case 3 You receive a letter from a solicitor, “your patient wishes to make a new will… does he have Testamentary Capacity?” “Could you also please tell me if he has capacity to donate Lasting power of Attorney?” How do you proceed?

17. Testamentary Capacity Banks v Goodfellow (1870) “Nature of the act” - concept of a will Give instructions Extent of their property / assets Who would have a valid claim? Decision not affected by mental disorder Not subject to undue influence by 3rd party

18. Capacity to donate LPOA Must understand that: The Attorney/s will be able to assume complete control of their affairs once LPOA registered Attorney will be able to do anything with affairs that they themselves could have done The authority will continue if s/he becomes mentally incapable The power can only be revoked by the court

19. Driving & Dementia When a diagnosis of dementia is made, the Patient / carer should inform DVLA If not you must Medical report On-road driving assessment may be required