Jane F. Potter, MD Chief Section of Geriatrics & Gerontology University of Nebraska Medical Center

1. Medical Evaluation of the Patient with Brain Failure Jane F. Potter, MD Chief Section of Geriatrics & Gerontology University of Nebraska Medical Center

2. Delirium • Clinical Presentation: A syndrome of acquired impairment of attention, level of consciousness, and perception.

3. Evaluation: Confusion Assessment Method (CAM) • Change in cognition that has both: • Acuteonset and fluctuating course • AND Inattention • And either • Disorganized thinking • OR altered level of consciousness

4. Acute Onset AND Fluctuation • Symptoms develop over hours to days (need a reliable informant; if not observed may present late) AND • Symptoms vary through out the day; characteristic lucid interval

5. AND Inattention • Difficulty focusing, sustaining, and shifting attention • Difficulty maintaining conversation or following commands

6. E.G. disorganized or incoherent thinking E.G. Rambling or irrelevant conversation (unpredictable switching subjects?) AND Either: Disorganized Thinking

7. OR: Altered Level of Consciousness • Vigilant (hyperalert, very easily startled) • Lethargic (drowsy, easily aroused) • Stupor (difficult to arouse) • Coma (unarousable)

8. Evaluation: CAM • Change in cognition that has both: • Acuteonset AND fluctuating course • AND Inattention • And either • Disorganized thinking • OR altered level of consciousness

9. Advanced age Dementia Depression Impaired physical function Sensory loss Decreased oral intake (food and fluids) Drugs (ETOH) Coexisting Medical Illness (severe, multiple, CKD, LD, fractures, stroke, neurological ds, HIV) Risk Factorsfor Delirium

10. Who Gets Delirious? Why? INSULTS VULNERABLE PATIENT # of RISK FACTORS

11. Dementia • Clinical Presentation: A syndrome of acquired impairment of memory and other cognitive domains sufficient to affect daily life • Etiology: Any disorder causing damage to brain systems involved in memory. Alzheimer’s disease is the most common cause in later life

12. Brain Failure • The most common cause of disability in later life • A focus for geriatric practitioners

13. Objectives: • Identify the common (non-dementia) causes of cognitive dysfunction. • Describe a basic approach to evaluate physical causes of cognitive dysfunction • Understand interdisciplinary contributions to evaluation of cognitive dysfunction

14. The Brain Failure Evaluation: What to Expect • Identification of reversible causes • Treatment of disabling conditions • Family information, counseling, and referral

15. Brain Failure:Evaluation CAREFUL CLINICAL OBSERVATION IS EVERYTHING!

16. Brain Failure:Evaluation • History/physical • Neurologic • Medications • Mood • Abilities • Social

17. The Brain Failure EvaluationHistory • Collateral Source • Onset, Course, Progression, Risk Factors • Characteristic Course of Alzheimer’s Disease

18. HISTORY OF SYMPTOMS • From a caregiver or someone close to the patient

19. HISTORY OF SYMPTOMS • What were the first symptoms? • How have things changed? • Is this typical for AD?

20. TYPICAL SYMPTOMS OF ALZHEIMER’S DISEASE Functional loss in reverse order to which skills were gained

21. Brain Failure: Case 1 An 83 year old widower is evaluated because his family is concerned that he is mildly cognitively slowed. He is still successfully maintaining homes in Arizona and Iowa. He describes a 9 month history of decline in his golf game, a 6 month history of unexplained falls, and a 1 month history of urinary incontinence.

22. Brain Failure:Recognition In patients or families presenting with a complaint of cognitive dysfunction a negative screening test does not exclude dementia.

23. The Brain Failure EvaluationPhysical • Special Senses • Heart / Lung / Liver / Kidney • Bladder / Bone / Mobility

24. Brain Failure: Special Senses • Vision • Hearing

25. Brain Failure:Case 2 • A 79 year old widower is a member of a multigenerational household. He has had progressive cognitive problems over the last 7 years. He is independent in all self care activities, but at night he wanders about knocking things over and urinating in trash cans

26. Brain Failure: Case 3 • A 68 year old married man suffers from AD. Despite successful treatment of an associated depression, he is inattentive and often does not respond to his wife or daughter.

27. Brain Failure: organ system dysfunction • Heart and Lung: hypoxic encephalopathy • Hepatic encephalopathy • Renal encephalopathy • Thyroid disorders • Hyperparathyroidism

28. Brain Failure: Case 4 • A 75 year old widow is evaluated at the request of her family for progressive cognitive impairment over the last 9 months. Her MMSE is 18. During the interview she admits to exertional fatigue, and lack of energy. On exam she has diffuse expiratory wheezing in all lung fields.

29. Brain Failure = Disability • Families/Patients are complaining of the disabilitycaused by brain dysfunction. • The population at risk is characterized by a burden of co-morbidities. • Look for un or under-treated comorbidities causing dysfunction. • High yield for disorders of bladder, bone, mobility.

30. Cortical- frontal, parietal, temporal, occipital lobes Sub-cortical- internal capsule, basal ganglia, thalamus NEUROLOGICAL EXAM

31. Apraxia, agnosia, aphasia, focal motor or sensory signs Gait disturbance, rigidity, tremor NEUROLOGICAL EXAM

32. MovieClips\Glabellar.movGlabellar tap Palmomenttal Grasp Frontal Lobe Release signs

33. Gait • Cortical • Subcortical

34. Sutton’s Law: • “Gee, Willy, why do you rob banks? “BECAUSE THAT’S WHERE THE MONEY IS”

35. Geriatrician’s Law: Go for the MEDS Because that’s where the money is

36. Inspect the Drug Bag • Three or more drugs increase the likelihood of an adverse effect or drug interaction

37. Many drugs can do this, e.g.Sedatives, anxiolytics, anticholinergics, H2-blockers, centrally acting antihypertensives (clonidine, alpha-methyl dopa) antiarhythmics, beta blockers, digoxin, sinemet, selegeline. Check all for CNS S.E.s Try a “Drug Holiday” Drugs and Brain Failure

38. Alcohol and Brain Failure • Volume of distribution for ETOH with age • No more than one/day after age 65; stop all if cognition impaired

39. Brain Failure: Case 4 • An 83 year old widow presents with a history of progressive cognitive failure. During interview she admits to a long term pattern of one drink before dinner. On questioning, her daughter feels that she likely exceeds one drink per day.

40. Depression as Brain Failure • Emotional illness slows cognitive function

41. Dementia Insidious onset Long duration No psychiatric history Conceals disability (often unaware of memory loss) “Near-miss” answers Day-to-day fluctuation in mood Depression Abrupt onset Short duration Previous psychiatric history Highlights disabilities (may complain of the memory loss) “Don’t know” answers Diurnal variation in mood, but generally more consistent Depression as a Cause of Brain Failure

42. The Brain Failure Evaluation UNDERSTAND THE NORMAL AGE-RELATED CHANGES IN BRAIN AND MEMORY

43. Brain Failure vs Normal Aging • Normal aging does not cause dysfunction

44. The Brain Failure EvaluationLaboratory • B-12, Folate, TSH • Chem profile, UA, ?O2 sat • CBC • Other as indicated

45. The Brain Failure EvaluationRadiology & Other • Head CT, ? Head MRI • Chest X-ray • EKG, EEG

46. Things that Cause the Brain to Fail (whether or not an underlying dementia is present) D E M E N T I A • Drugs • Emotional Illness (including depression) • Metabolic/endocrine disorders • Eye/ear/environment • Nutritional/neurological • Tumors/trauma • Infection • Alcoholism/anemia/ atherosclerosis

47. Therapy for AD • Cholinesterase inhibitors • Vitamin E • NMDA inhibitor- Memantine • ? Vaccination • Not Estrogen • Not Anti-inflammatories