When It’s Not Dementia: Other Conditions That Impair Cognitive Performance

1. PCA Regional Conference on AgingOctober 2012 When It’s Not Dementia: Other Conditions That Impair Cognitive Performance Joel E. Streim, MD Professor of Psychiatry Perelman School of Medicine University of Pennsylvania and Philadelphia VA Medical Center Christine Bradway, PhD, RN Associate Professor of Nursing School of Nursing University of Pennsylvania

2. Disclosures Dr. Streim receives salary support from grants funded by: National Institute on Aging (NIA) VA Health Services Research & Development (VA HSR&D) Health Resources and Services Administration (HRSA) Donald W. Reynolds Foundation Dr. Bradway receives salary support from Health Resources and Services Administration (HRSA)

3. Learning Objectives • Identify cognitive domains that may become impaired in mental disorders of late-life • Describe syndromes of cognitive impairment commonly seen in older adults • Understand the importance of assessment for identifying potentially reversible or treatable causes of cognitive impairment; and for identifying the extent of cognitive disability and need for assistance • Recognize the ways that cognitive impairment can affect geriatric care, including behavioral health treatment and the role of caregivers • Identify at least 3 elements of cognitive capacity required for independent decision-making

4. Session Overview • Lecture on cognitive conditions, assessment, and management issues (Streim) • Interactive case presentations (Bradway) • Discussion of participant case experience (Bradway, Streim, audience)

5. PCA Regional Conference on AgingOctober 2012 When It’s Not Dementia: Other Conditions That Impair Cognitive Performance Joel E. Streim, M.D. Professor of Psychiatry Perelman School of Medicine at the University of Pennsylvania Geriatric Education Center and Philadelphia VA Medical Center Mental Illness Research Education & Clinical Center

6. What is “cognitive impairment” ? Deficits in various cognitive domains: • attention • memory(amnesia) • language (aphasia) • recognition (agnosia) • performing motor activities (apraxia) • initiating/executing tasks (abulia) • visual-spatial function • insight • judgment

7. Consequences of Cognitive Impairment Cognitive impairment can interfere with • Communication • Comprehension • Ability to report symptoms, express needs • Social awareness, self-monitoring, behavior • Ability to follow directions • Self-care (basic ADLs) • Household management (instrumental ADLs)

8. Instrumental ADLs (Household Management) Shopping Cooking Cleaning Laundering Using Telephone Paying Bills Basic ADLs (Personal Care) Bathing Hygiene Grooming Dressing Feeding Toileting Impairment in Activities of Daily Living (ADLs)

9. Other Consequences Cognitive impairment can interfere with • Personal safety • Eating (e.g. risk of choking or aspiration) • Walking (e.g. risk of getting lost, falling) • Household tasks (e.g. risk of fires, accidents) • Receipt of medical, nursing, and personal care • Patient participation • Delivery of care by providers & caregivers

10. Syndromes of Cognitive Impairment • Delirium = disturbance of consciousness and attention acute confusional state • Dementia = impairment of memory chronic confusional state plus other cognitive domains plus other cognitive domains (Dx requires interference with everyday functioning)

11. Delirium: clinical features Essential features: Disturbance of consciousness with impaired attention (inability to focus, fix, or shift attention) Change in cognition (impaired memory, disorientation, language disturbance), or Perceptual disturbance (hallucinations, illusions) Caused by a medical condition or medication effects Associated features: Delusional thinking (psychosis) Sleep-wake cycle disturbance Agitated behavior, or hypoactivity

12. Delirium: clinical course and etiology Abrupt onset (hours to days) Fluctuating course Caused by various medical or neurological conditions, drug effects (intoxication, withdrawal), or combination Usually reversible if underlying condition is treated successfully High mortality rates, especially if not recognized or treated

13. Delirium: common causes Infection Dehydration, electrolyte disturbances Hypoglycemia Hypotension (low blood pressure) Hypoxemia (low blood oxygen levels) Cardiac events Respiratory illnesses Neurological events (stroke, brain injury) Medication effects Anticholinergics, antihistamines Narcotics Alcohol or drug intoxication OR withdrawal

14. NB: An acute episode of delirium can be superimposed on a chronic dementia

15. Recognition of Cognitive Impairment Suspect delirium or dementia when • patient has self-care deficits • family has “taken over” responsibilities • patient doesn’t participate well in medical, nursing, rehabilitative, or personal care • behaviors interfere with care delivery Don’t blame “old age”

16. Symptom Overlap in Delirium and Dementia Common features of acute and chronic confusion: • Amnestic: forgetful, poor recall, misplacing things • Disoriented: confused about time and place • Aphasic: word-finding difficulty, impaired comprehension • Perseverative: repetition of words, thoughts • Apraxic: difficulty dressing, grooming, hygiene • Dependent: need help from caregivers • Delusional: paranoid thoughts and fears • Agitated: picking at clothes/hair/objects, motor restlessness, verbal or physical aggression

17. Recognition of Cognitive Impairment:Barriers and Clues • Patient’s may not be aware of changes • lack insight into memory problems • deny disability • Get history from family, friends, or caregivers • onset may be abrupt (days, weeks) or gradual (over months, years) • families may not notice gradual changes • ask about change from baseline function, from “usual self” • Look for discrepancy between self-reported function and actual performance of ADLs • If patient has difficulty performing ADLs, ask for OT evaluation (clinic or in-home)

18. Cognitive Impairment: What are the obvious signs? • Forgetfulness • Repetitious statements • Misplacing things • Disorientation • Getting lost • Speech deficits • Word-finding difficulties • Word substitutions • Diminished judgment

19. Recognizing more subtle signs • Visual complaints; impaired recognition • Trouble following directions • Difficulty performing familiar tasks • Family members take over usual roles • Loss of initiative • Disengagement from usual activities • Self-neglect • Weight loss • Diminished social spontaneity • Less conversation

20. Behavioral Disturbances • Wandering • Restlessness • Fidgeting • Pacing • Impulsivity • Inappropriate handling of objects • Rummaging / fiddling • Hoarding • Verbal agitation • Repetitious speech • Verbal annoyance / aggression • Physical combativeness

21. Not all cognitive impairment meets criteria for a diagnosis of dementia • When memory is not affected • When function is not affected • Performance of ADLs is preserved • Can be associated with various • Neurological conditions • Medical illnesses • Psychiatric disorders • Other contributing factors • Chronic pain • Impaired vision and hearing

22. Neurological conditions associated with cognitive impairment • Mild cognitive impairment • No significant functional deficits • Neurological disorders • Stroke • Parkinson’s disease • Traumatic brain injury (TBI)

23. Medical causes of cognitive impairment • Metabolic • Vitamin deficiencies • Hypo- or hyperglycemia • Electrolyte disturbances (low Na, high Ca) • Hormonal • Hypothyroidism • Infectious • AIDS • Syphilis • Pneumonia • Urinary tract infection Some of these are treatable and potentially reversible

24. Psychiatric conditions associated with cognitive impairment Poor cognitive performance may be partially or wholly explained by Anxiety impaired concentration, distractibility obsessional thinking, indecisiveness Depression lack of motivation, poor effort fatigue impaired concentration executive dysfunction indecisiveness Cognitive performance may improve when anxiety or depression is treated. Most of these are treatable

25. Other contributing factors • Chronic pain • Osteoarthritis • Peripheral neuropathy • Hearing impairment • Low vision • Age-related macular degeneration • Diabetic retinopathy • Cataracts

26. Careful Evaluation is Essential Up to 90% of individuals with acute and 20% with chronic cognitive impairment may have a reversible component Need to identify treatable impairments. However, most with dementia will have persistent deficits

27. Relationship of Depression and Cognitive Impairment in Old Age: What’s New? • 1/3 to 1/2 of patients with late-life depression have at least mild cognitive impairment (MCI).1 • Depression with onset in late-life is often associated with vascular risk factors and executive dysfunction.2 • This has been called vascular depression, and is distinct from pseudodementia, as cognition does not improve with antidepressant treatment.2 • Geriatric patients with depression have a higher incidence of progression to MCI and dementia.1,3 1 Panza F et al. Am J Geriatr Psychiatry 2010; 18:98-116; 2 Alexopoulos GS et al. Am Psychiatry 1997; 154:562-565; 3 Steffans DC et al. Arch Gen Psychiatry 2006; 63:130-138

28. Recognition of executive dysfunction in clinical practice • History of observable functional and behavioral signs1 • Difficulty with initiation • Inability to perform sequential tasks • Poor task completion • Disengagement from activities • Task avoidance (BADL, IADL) • Referral for evaluation of functional status by occupational therapist2 • Consider referral for selective neurocognitive testing 1 Alexopoulos. J Clin Psychiatry. 2003;64(suppl 14):18-23. 2 Erez et al. Am J Occup Ther. 2009;63(5):634-640.

29. Executive function is crucial for both taskperformance and decision-making Encompasses: Awareness of one’s situation (presence of unmet needs, medical problems, disability, danger) and what needs to be done Planning solutions and actions Initiation of tasks Sequencing and performance of tasks

30. Self-reported abilities vs. demonstrated performance Individuals with executive dysfunction may be able to describe how a task can be accomplished, but unable to perform the task. Therefore, a medical or psychiatric interview may need to be complemented by observations of actual task performance Observations may be made during examination by a psychiatrist, cognitive or neuropsychologist, or occupational therapist

31. Individuals with executive dysfunction or deficits in other cognitive domains • may or may not meet criteria for dementia or delirium • may or may not have impaired decision-making capacity

32. How do clinicians translate examination findings into a clinical assessment of decision-making capacity?

33. Evaluation of Decision-making Capacity from a Clinical Perspective Key elements of capacity Awareness of the situation or need (healthcare, financial, living arrangements) Understanding of the treatment options / available solutions Appreciation of risks and benefits, or consequences of a choice (ability to reason and deliberate) Ability to communicate the choice

34. Cognitive Impairment and Decision-making Capacity: seeing clinical “shades of grey” Pattern and severity of cognitive deficits usually includes areas of spared cognitive function and impaired cognitive function. Individual may have retained the capacity to Recognize a basic need for help Express wishes or preferences which form the basis for participation in decision-making …But same individual may have lost the capacity to Appreciate the extent of disability Recognize the type or magnitude of the assistance needed Deliberate about risks, benefits Appreciate potential consequences of a decision which creates a need for assistance in decision-making

35. Basis for Assisted Decision-Making Concept of substituted judgment Effort to determine what the person wants or would have wanted for him or herself Duty to represent person’s advance directives, if available Need to educate and support caregivers and surrogates to use Substituted judgment in decision-making Assisted decision-making, when possible

36. Training of Caregivers to Function as Surrogate Decision-Makers Concept of assisted decision-making: Preservation of autonomy to the extent possible Identify areas of spared cognitive function and encourage their continued use Help individual compensate for areas of impaired cognition Take current wishes and preferences into account, when consistent with realistic options Risk tolerance may reflect the persons life-long values Responsibility for the final decision rests with the surrogate

37. Assisted Decision-Making:Practical Approaches to Communication Caregivers and surrogate decision-makers should be encouraged to: Use simple language to explain situation, options, etc. Present information slowly Repeat information, check for comprehension Point out consequences Ask about wishes and preferences Ask about priorities (values) e.g., “What’s most important to you?”

38. Essentials of Family-Caregiver Education • Explain functional limitations due to confusion • Set expectations for • Recovery from delirium; risk of recurrence • Progression of dementia • Clarify care needs • Provide a safe environment • Communication strategies (optimize vision & hearing) • Supervision / assistance with ADLs • Encourage medical follow-up • Optimize treatment of other conditions • Reduce and manage co-morbidity

39. Questions ??? Discussion

40. Standardized cognitive screening instruments: Short and Shortest Mini Cog 3 recall items Clock drawing 3 minutes to administer Scoring quick, simple Less affected by education, ethnicity, language than other, longer tools Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11):1021

41. Mini-Cog Scoring Algorithm http://geriatrics.uthscsa.edu/tools/MINICog.pdf

42. Montreal Cognitive Assessment (MoCA) Tests multiple cognitive domains Attention Memory Language Visuospatial Executive function Abstract thinking 10 minutes to administer Score range 0-30 <26 is abnormal Nasreddine ZS, et al. The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For Mild Cognitive Impairment. J American Geriatr Soc 53:695-699, 2005.

43. Montreal Cognitive Assessment (MoCA) http://www.mocatest.org/

44. Case #1 • Mrs. T. is 90 and has just been discharged to home after a 5 day hospital stay • Came to the hospital with “confusion” at home • Did not recognize daughter • Not eating • Fearful of burglars in house

45. Case #1: Continued • Hospital diagnoses/problems included: • Urinary tract infection • Dehydration • Delirium • Deconditioning • She is ordered home physical/occupational therapy to determine her ability to continue to live at home

46. Case #1: Continued • 1. What pre-hospital information is important to know about Ms. T? • 2. What assessments are essential when she returns home from the hospital? • 3. What factors need to be considered when making Ms. T.’s plan of care? • 4. What caregiver information/support should be initiated?

47. Case #2 • Mr. R is an 81 year-old widower now at home after a 3-day hospitalization for acute pneumonia. He has underlying mild COPD. • Mr. R worked as a mechanic and retired at age 62. His wife died 3 years ago and he sold his home and now lives with his daughter. • Mr. R.’s daughter has noticed he is less physically active and seems to interact less and less with family and friends for the past 6 months.

48. Case #2: Continued At home you note that Mr. R: • Requires oral antibiotics for 5 more days to complete pneumonia treatment • Has lost 10lbs. within last month • Had unreported diarrhea during hospitalization • Began a medication, Amitriptyline, for depression • Was given a sleep medication, Ambien, while hospitalized and to take at home

49. Case #2: Continued • On interview, Mr. R is a little lethargic and has slowed speech. He is also unsteady and nearly falling with walking. He has increased confusion at night; he had some mild memory loss before being hospitalized. He has had diarrhea since coming home and his appetite is poor.

50. Case #2: Continued What else would you like to know about Mr. R’s memory and cognition?