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Dementia Evaluation

Learn how to identify common cognitive complaints and utilize screening tools for dementia in primary care settings. Discover the resources available in SFHN and San Francisco for patients with cognitive impairment.

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Dementia Evaluation

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  1. Dementia Evaluation for Primary Care Providers SFDPH Quarterly PCP Meeting Anna Chodos, MD MPH July 26, 2016 Optimizing Aging Collaborative A Community of Public, Human Services, and Academic Organizations

  2. Learning Objectives • 1) Describe common cognitive complaints and when to screen in your primary care patients. • 2) Demonstrate how to use a screening tool for dementia. • 3) List different resources in SFHN and San Francisco for your patients with cognitive impairment.

  3. Reflection and Evaluation • Throughout this talk and workshop, think about how this may impact your work with older adults. • At the end of this, commit to one change you will make in your practice. • Fill out our evaluation so we can keep teaching!

  4. The Burden of Dementia • 25-30% people over 85 years of age worldwide have some degree of cognitive decline. • 1-5% >60, but doubles every 5 years • Projected prevalence of people with Alz dementia is 14 million in US by 2050. • 5.4 million right now • In 2016, dementia will cost the US $236 billion. • Most is “informal care”.

  5. Should We Screen for Dementia in Primary Care? USPSTF recommendations:Insufficient evidence. “Although many uncertainties remain, the concept of detecting dementia at an early stage to allow interventions is a good one.” Cognitive impairment is unrecognized in 27%–81% of affected patients in primary care.

  6. Definitions • Mild cognitive impairment (MCI) or Minor Neurocognitive Disorder • Cognitive complaint with impaired neuropsychological test performance and intact activities of daily living (ADL)

  7. Definitions Dementia (Major Neurocognitive Disorder): • Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains: • Learning and memory • Language • Executive function • Complex attention • Perceptual-motor • Social cognition = behavior Deemphasizes memory impairment. Usually you only have a clinical history of decline.

  8. Definitions Dementia (Major Neurocognitive Disorder), cont’d: • The cognitive deficits interfere with independence in everyday activities. • The cognitive deficits do not occur exclusively in the context of a delirium. • The cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia) Diagnosis of dementia= acquired cognitive impairment + acquired functional impairment DSM-V (2013)

  9. Assessing Function… • ADLs: Impacted late • Bathing • Dressing • Toileting, continence • Transferring • Feeding • IADLs: Impacted early • Driving/transportation • Working/managing phone • Shopping for food • Finances • Taking meds • Cooking • Housework

  10. Types of Dementia

  11. SFHN Algorithm • Starts with screening or a complaint Mrs. Gutierrez, 76yo, who missed 3 appointments. Ms. Nguyen, 69yo, whose daughter says she is repeating herself all the time. Ms. Smith, 67yo who has a + screen (mini-cog). Mr. Xiao, 80yo, who shows you an eviction notice for failure to pay. Dr. Rapp’s patient...

  12. SFHN Algorithm

  13. Simple Screening Method: Mini-Cog Mini-Cog • 3 item recall Plus CLOCK DRAW • If normal, you are done…for a little while • If abnormal, consider DELIRIUM vs. DEMENTIA vs. other

  14. Screening: MOCA Test • Many languages • Many domains • Not as Alzheimer’s specific (like MMSE) • www.mocatest.org

  15. Test with GP-COG • Look at handout • Part 1- Patient • Part 2- Informant (function) • Available in Spanish, Chinese, Korean. • http://gpcog.com.au/ • Now PRACTICE IT with the person next to you!

  16. GP-COG results • If normal test, but no collateral information and high clinical concern, proceed with evaluation. Dr. Rapp’s patient…

  17. Assessment if + Test • Look for other treatable conditions that affect cognition. • Look for red flags that warrant urgent head imaging. • Ask about the primary cognitive symptom/s and ask about onset, length of symptoms and progression. • Could be behavioral. • Don’t need to do this all in one visit!

  18. If no functional impairment, monitor. • Bottom line is that no functional impairment (or no new functional impairment) is not dementia--- yet. • It is at the most severe a “mild neurocognitive disorder”. • So you can reassess and monitor.

  19. Diagnosis and Management • Strong history of acquired cognitive and functional impairment with objective findings of cognitive impairment = dementia • R/o reversible causes • Treat depression and reassess within 6 months. • Time can be a helpful diagnostic • Review Care Principles for Adults with Dementia

  20. If older and + functional impairment • Refer to care principles for adults with dementia. • Consider referral for further assessment and care planning, especially if other geriatrics issues. • Geriatrics or Geriatrics-Neurology

  21. If complex psych disease or needs conservatorship • Consider neuropsych testing in some form if complex psychiatric history and difficulty with your assessment or you want more extensive documentation of deficits. • Geriatrics-Neurology • Neuropsychology

  22. When is Neuropsychological Testing Helpful? • Complex differential, such as distinguishing serious mental illness or depression from dementia • To diagnose highly or marginally functional adults • May help with management, family recommendations, establishing a baseline

  23. If evidence of depression • Treat depression • See Geriatric Depression Algorithm • Consider referral to a Geriatrics Mental Health clinic in community. • If no improvement or cognitive symptoms not improving-> consider further evaluation or referral to Geriatrics Neurology or Geriatrics.

  24. Reasons to get head imaging • f • If concerning features: Order a head CT and treat reversible findings. • Consider a head MRI if referring to a consult service. • Dr. Rapp’s patient…

  25. Assistance with Diagnosis and Management • Consult services through Geriatrics eReferral: • Geriatrics: Older adults with cognitive complaints and/or other geriatrics conditions • Geriatrics-Neurology Cognitive Clinic: Geriatrics + Neurology + Neuropsychology in one visit • Neurology • Neuropsychology for neuropsych testing • Community: IOA neuropsychology, Memory and Aging Center @ UCSF

  26. Treatment • Treat underlying pathophysiology -> Not possible yet • Treat neurotransmitter abnormalities • Acetylcholinesterase inhibitors (e.g donepezil) and NMDA receptor antagonists have modest benefit • Treat the environment • Change environment rather than patient (e.g. disable stove, make all clothes pull-on sweats in matching colors, circular corridors) • Activity, socialization. • Break down complex activities into simple tasks, structured activities and routines, simple words and sentences • Treat the caregiver • Recognize burnout and depression • Connect to education: Alzheimer’s Association, Family Caregiver Alliance, support groups • LHH respite

  27. Following the Patient & Caregiver • Follow-up: Patient • Some tests, such as MOCA could be more helpful to follow • Functional assessment q6-12 months • Hearing and vision • Behavioral interview with each visit (sleep, wandering, eating, hallucinations) • Driving (mandated reporters to DPH) • Safe Return program ($$) • Follow-up: Caregiver • Depression, coping, sleep • Referrals: Alzheimer Association, Family Caregiver Alliance • Abuse potential • Need for placement: community resources

  28. Dementia and Behavioral Symptoms • Very common in dementia • Disruptive: Sleep Disturbance, Appetite Change, Irritability, Disinhibition, Wandering, Hoarding • Mood: Anxiety, Apathy, Depression • Aggression: Agitation, Verbal Disruptions, Physical Aggression • Psychosis: Delusions, Hallucinations

  29. Addressing Behaviors • Ask about precipitants: basic needs, medical issues • Behavioral interventions are 1st line • Caregivers need to get support and education • Need to know it takes trial and error, creativity Ms. G: “I know it’s Mom’s dementia, but she just won’t listen.” • Medication, i.e. anti-psychotics, should be weighed against risks of sedation, cerebrovascular injury, EPS, metabolic side effects and death

  30. Take home points • Assess cognitive complaints and look for reversible causes • Use our algorithm. • Dementia = acquired cognitive impairment + acquired functional impairment • Refer to outside services for further diagnostic assistance if needed.

  31. Reflection and Evaluation • What change you will make in your practice? • Fill out our evaluation!

  32. A Partnership Of: For more information contact: GWEP@ucsf.edu Optimizing Aging Collaborative at UCSF – SFHN Training

  33. Extra slides

  34. References • “World Alzheimer Report 2010: the Global Economic Impact of Dementia.” Alzheimer’s Disease International. September 21, 2010. • Alzheimer’s Association 2016 Facts and Figures. • BoustaniM et al. Ann Internal Med 2003; 138: 927-37 • ChodoshJ, Physician recognition of cognitive impairment: evaluating the need for improvement. JAGS 2004. • GP-COG: http://gpcog.com.au/ • MOCA: www.mocatest.org • Brodaty, H., et al., The GPCOG: a new screening test for dementia designed for general practice. Journal of the American Geriatrics Society, 2002. 50(3): p. 530-4.

  35. Summary of Screening Tools21, 22, 23, 24, 25, 26

  36. Mini-Cog: 3 item recall/clock draw Mini-Cog Recall=3 Recall=0 No Cognitive Impairment Cognitive impairment Recall=1-2 Clock Normal Clock Abnormal Cognitive impairment No Cognitive Impairment **Can be used in multiethnic and multilingual populations Sensitivity 76-97% Specificity 89-95%

  37. Overlapping Symptoms of Depression and Dementia DEPRESSION DEMENTIA Mood changes Anhedonia Sleep disturbances Poor concentration Memory changes Agitation Persistent sadness Worthlessness Suicidal ideation Aphasia Agnosia Apraxia

  38. Questions of Capacity and Competence • Assessing CAPACITY is often part of every medical encounter • Capacity is DECISION-specific • It can change • Some patients with dementia can retain capacity for *some* decisions which is why it is important to assess • Capacity and Competence are DIFFERENT concepts • Competence is defined by the COURTS, not by a physician, though physicians are asked to fill out a “capacity declaration” which further specificies if individuals retain the ability to make decisions to the person or to the estate • Adults are assumed to have capacity unless otherwise defined by the courts

  39. Rationale for Screening • Advance care planning • Protection of assets • Widera JAMA 2011 • Public health safety (driving) • Involvement from other providers (SW, RN, APS) • Helps guide management of comorbidities • Med management may deviate from standard of care • Hospice for end-stage dementia • Initiate medications early (maybe) • No evidence that this improves outcomes • If this changes, would argue for screening for MCI

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