Approach to Memory Loss

Approach to Memory Loss
Kevin Overbeck, DO Assistant Professor UMDNJ–SOM NJISA Campus image created by the University of Medicine & Dentistry of New Jersey School of Osteopathic Medicine

This medical student presentation is offered by the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

Geriatrics Pre-Session Question 1
Self-reported memory loss has been well correlated with subsequent development of dementia. True False Answer: (b) False Intended for Audience Response System Reference: Carr DB, Gray S, Baty J, Morris, JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology. 2000;55(11): Carr DB, Gray S, Baty J, Morris, JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology. 2000;55(11):

An elderly female who complains of a word finding difficulty thus displays a form of aphasia which is often exhibited during early stage Alzheimer’s disease. True False Answer: (b) False Intended for Audience Response System Reference: Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology. 1999;52(7): Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology.1999;52(7):

An 82 year old man presents acutely to the hospital and is noted to have a fever 100.5◦F. Which of the following is most suggestive of the diagnosis of delirium? Inability to stay focused on questions Word finding difficulty Mini-Mental State Exam Score: 18/30 Geriatrics Depression Scale Score: 6/15 Answer: (a) Inability to stay focused on questions Intended for Audience Response System

Learning Objectives The learner will be able to recognize the presentation of delirium and understand the etiology of delirium The learner will be able to approach the clinical manifestation of memory loss in a systematically and evidence based approach The learner will be able to compare and contrast the common geriatric cognitive syndromes of delirium, depression, and dementia

Approach to Memory Loss Cognitive Assessment Tools

Assessment Tool Overview
Dementia incidence 20-50% of those >85 yrs old Assessment Tools “AAO x 3” Clock Draw Test (CDT) Mini-Mental State Exam (MMSE) Sweet 16 Neuropsychological Testing The prevalence of dementia increases with age, affecting up to % of those > 85 years of age A goal is to have physicians go beyond simply documenting "AAOx3” (stands for “Awake, Alert, and Oriented x 3 [the “3” being person, place, time]). The modern physician must be ready to care for older adults and not simply recognize cognitive dysfunction but also be able to diagnose and assess a person’s mental status. As with all cognitive testing a neutral quiet environment should be maintained. Establish a rapport with the patient prior to beginning the test – be sure to avoid phrases such as “this is a silly test” or “easy test.”

Clock Draw Test (CDT) “Please draw the face of a clock and put the numbers in the correct positions. Draw in the hands at ten minutes after eleven.” Complete circle – 1 point All 12 numbers – 1 point Numbers in correct positions – 1 point Hands properly displaying “ten after eleven” – 1 point Maximum Score 4 out of 4 (4/4) Not nearly as rigorously tested in research. It is not sensitive for mild dementia, but remains a useful tool because of it’s ease of use at the bedside. It tests the domain of executive function. Clock Draw Test (CDT): Directions: “Please draw the face of a clock and put the numbers in the correct positions. Draw in the hands at ten minutes after eleven.” Scoring: Use the 0-4 point method of scoring, which is brief, sensitive and easy to apply. It should be noted that any cut off score is subjective and arbitrary – It is unlikely that a cognitively impaired person will produce a perfect clock. An abnormal score indicates need for further evaluation. Draws closed circle: Score 1 point Includes all 12 correct numbers: Score 1 point Places numbers in correct positions: Score 1 point Places hands in correct positions: Score 1 point Maximum Score (or “Perfect Clock”): 4/4 References: Tuokko H, et al. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer’s disease. J Am Geriatr Soc. 1992;40(6): Mendez MF, et al. Development of scoring criteria for the clock drawing task in Alzheimer’s disease. J Am Geriatr Soc. 1992;40(11): Tuokko H, et al. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer’s disease. J Am Geriatr Soc ;40(6): Mendez MF, et al. Development of scoring criteria for the clock drawing task in Alzheimer’s disease. J Am Geriatr Soc. 1992;40(11):

CDT: A Case How would you score this clock draw test?
(a) 4/4 – abnormal (b) 3/4 – abnormal (c) 2/4 – abnormal (d) 1/4 – abnormal (e) 0/4 – abnormal Answer: (c) 2/4 – Abnormal Intended for Audience Response System Scoring Correct – 1 point draws complete circle Correct – 1 point all 12 numbers present (despite one extra “twelve”) Incorrect – numbers are not in the correct positions Incorrect – hands are not properly placed Total Score: 2/4 – Abnormal References: Tuokko H, et al. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer’s Disease. J Am Geriatr Soc. 1992;40(6): Mendez MF, et al. Development of scoring criteria for the clock draw task in Alzheimer’s Disease. J Am Geriatr Soc. 1992;40(11):

CDT: Sample Documentation
“Clock Draw Test 2/4 – abnormal score suggestive of memory impairment” References: Tuokko H, et al. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer’s Disease. J Am Geriatr Soc. 1992;40(6): Mendez MF, et al. Development of scoring criteria for the clock drawing task in Alzheimer’s Disease. J Am Geriatr Soc. 1992;40(11):

Mini-Mental State Exam (MMSE)
Distribute MMSE forms to students Time Orientation (5 points) Place Orientation (5 points) Registration (3 points) Attention and Calculation (5 points) Recall (3 points) Naming (2 points) Repetition (1 point) Comprehension (3 points) Reading (1 point) Writing (1 point) Drawing (1 point) The Mini-Mental State Exam (MMSE) is the most widely used cognitive test for dementia in US clinical practice. This standardized test takes approximately seven minutes to complete and it assesses range of cognitive processes including orientation, recall, attention, calculation, language, and constructional ability. Registration – score only the first trial (repeat words if not retained to ensure that the recall portion of the test is valid) Attention & Calculation – score each correct answer (only perform the WORLD test if the respondent will not attempt to perform “serial sevens”). Comprehension – (give all directions at once – avoid giving 3 one step commands) Pentagons – All 10 angles must be present and two must intersect.

MMSE: Capacity Max Score: 30 points
<24 points: suggestive dementia or delirium <19 high correlated with incapacity (note: >23 denotes capacity) Using a cutoff of 24 points, the MMSE had a sensitivity of 87 percent and a specificity of 82 percent in a large population based sample. The use of higher cutoff scores on the MMSE improves sensitivity but lowers specificity. For research purposes, some investigators use a cutoff score of 26 or 27 in symptomatic populations in order to miss few true cases. The use of a “cutoff” score remains controversial for several reasons (1) the MMSE dose not diagnose dementia, rather it is an objective measure to assess cognition at that moment (2) those with limited education or those in whom English is not the primary language typically score perform lower on this cognitive test. The MMSE is helpful in assessing capacity in medical decision making. Studies suggest that high scores greater than 23 and low scores less than 19, can be highly predictive in discriminating competency from incompetency. Intermediate scores warrant more detailed competency evaluation. Again using the MMSE should only assist the clinician in making a judgment about competency – assessing competency remains a complex task – certainly a decision of an item from a menu is much different than the decision to understand consequences of having or not having surgery – participating or not participating in a drug trial, etc. Reference: Karlawish JHT, Casarett DJ, James BD, et al. The ability of persons with Alzheimer disease (AD) to make a decision about taking an AD treatment. Neurology. 2005;64(9): Karlawish JHT, Casarett DJ, James BD, et al. The ability of persons with Alzheimer disease (AD) to make a decision about taking an AD treatment. Neurology. 2005;64(9):

MMSE: Limitations Influenced by auditory, visual, and motor impairments Not sensitive for mild dementia Limited ability to assess progressive decline due to practice effect The MMSE has limitations for assessing progressive cognitive decline in individual patients over time. Changes of two points or less are of uncertain clinical significance as they may represent measurement error, regression to the mean, or a practice effect1. Reference: Hensel A, Angermeyer MC, Riedel-Heller SG. Measuring cognitive change in older adults: reliable change indices for the Mini-Mental State Examination. J Neurol Neurosurg Psychiatry. 2007;78(12): Hensel A, Angermeyer MC, Riedel-Heller SG. Measuring cognitive change in older adults: reliable change indices for the Mini-Mental State Examination. J Neurol Neurosurg Psychiatry. 2007;78(12):

MMSE: Sample Documentation
“MMSE Total Score of 25/30 Time Orientation: 4/5 (deficit season) Location Orientation: 4/5 (deficit county) Attention/Calculation : 4/5 (serial sevens) Repetition: 0/1 (missed first attempt but got it on the second attempt) Drawing: 0/1 MMSE suggestive of cognitive impairment with deficits in orientation, attention, repetition, and drawing”

Cognitive Testing: The “Sweet 16”
Time Orientation (4 points) Location Orientation (4 points) Registration (3 points) Digit Span Testing (2 points) Recall (3 points) Registration – score only the first trial (repeat words if not retained to ensure that the recall portion of the test is valid) Digit Span – Score only numbers backwards (must perform trial of numbers forwards and give instructions for numbers in reverse – do not score these however) Reference: Fong TG, Jones RN, Rudolph JL, et al. Development and validation of a brief cognitive assessment tool, the Sweet 16. Arch Intern Med. 2011;171(5): Fong TG, Jones RN, Rudolph JL, et al. Development and validation of a brief cognitive assessment tool, the Sweet 16. Arch Intern Med. 2011;171(5):

Sweet 16: Sample Documentation
“Sweet 16 Score of 9/16 1/4 – Time Orientation (deficit year, date, day) 3/4 – Location Orientation (deficit town) 3/3 – Registration 1/2 – Digit Span 1/3 – Recall Sweet 16 cognitive test suggestive of cognitive impairment and correlates with an MMSE of 16.9/30)” Reference: Fong TG, Jones RN, Rudolph JL, et al. Development and validation of a brief cognitive assessment tool, the Sweet 16. Arch Intern Med. 2011;171(5):

The Case of Mrs. Roberts

A Case: Mrs. Roberts Mrs. Roberts is a 75 year old widowed female who sustained a fall and hip fracture 2 weeks ago with a subsequent adult failure to thrive presentation pattern highlighted by poor participation in rehabilitation efforts. Not only is she not eating, but she is sleepy during the day and restless at night The son is upset about this and wants to know why she is not improving and what you are doing about it. Lisinopril 10mg daily Sertraline 100mg daily Lorazepam 2mg qHS PRN Acetaminophen 650mg q4h PRN mild pain Celecoxib 100mg po daily Oxycodone/acetaminophen 5mg/325mg one tablet po q4h prn severe pain

A Case: Mrs. Roberts The concerned son reports that his mother is confusing him for her deceased husband (i.e. son’s father). He goes on to report that he has been diligently trying to be present during meal time to support her intake but she falls asleep while he’s trying to have a conversation with her. Although her son witnessed this behavior since the surgery, he reports, “I thought it would’ve gone away by now.” During the day she has been kept in a recliner chair by the nurse’s station because of poor safety awareness (i.e. getting up out of bed without assistance). Nurse’s notes indicate that she has been agitated at night – demanding to go home and threatening to call the police if she is not taken home immediately.

A Case: Mrs. Roberts Her son admits that she was forgetful before the surgery, but “never to this degree.” His mother moved in to live with him after the death his father (her spouse). Functional History ADLS – preoperatively independent [6/6 Katz ADL Scale] IADLS – preoperatively dependent on shopping, transportation, finances [5/8 Lawton IADL Scale] Upon further review her son reports that she was still capable of cooking basic meals but less frequent and less fancy. She has complaints of fatigue and naps a lot. She seems to have no desire to leave the house.

A Case: Mrs. Roberts Mrs. Roberts has had a history of depression and had previously taken anti-depressants intermittently. She has been taking sertraline (Zoloft®) 100mg since his death just over a year ago. Due to her grief, she moved in with her son shortly after the funeral. Prior to her hip fracture, her appetite had been fair; he also admits that she was an avid reader but had become “more of a television watcher since my dad died.” She has a long history of insomnia taking lorazepam at bedtime nearly every night “for as long as I can remember.” He agrees that she has been taking this medication to help her sleep “for more than 10 years.”

A Case: Mrs. Roberts Time Orientation: 1/5 Location Orientation: 2/5
Registration: 1/3 Attention: serial sevens 0/5 Naming: 2/2 Short-term Memory: 0/3 3-step Command: 2/3 Read and Obey: 1/1 Sentence: 1/1 Visual Spatial: 0/1 SERIAL SEVENS versus the “WORLD” Note: “WORLD backwards” should only be performed if the patient refuses to do the “serial sevens task.” This is a common mistake and should be recognized as such – remember that the serial sevens task is more difficult (and may require more education to perform the task correctly than the DLROW task) and therefore patient’s are getting “let off easy.” Example Take for example the brilliant engineer who was hired by NASA to develop the original space suit and then spent the rest of his career improving radar systems and eventually satellite technology who presents to the office as patient with his spouse for concern about memory. This patient informs you that he has an identical twin who has been diagnosed with a moderate to severe Alzheimer’s Disease and states, “He can no longer care for himself.” The spouse defensively reports, “They lived very different lives… his brother didn’t take good care of his himself.” During this office visit, the patient was able to perform all memory tests correctly with the exception of the serial sevens – he made two errors out of the five total response for a score 3/5. He was able to perform the WORLD task without difficulty among others. This is a significant finding in a brilliant engineer who is noted for is excellent math skills. TOTAL SCORE=10/30

A Case: Mrs. Roberts Her hip incision is clean, dry, well-approximated and without evidence of cellulitis. During your performance of standardized cognitive testing instruments, you note Mrs. Roberts to be difficult to engage with questioning. At times you must repeat the instructions 3-4 times to get her to respond. You have the opportunity to watch her during physical therapy and note that she requires considerable assistance and cuing in order to stand but she performs this task she is able to do so without pain. In between exercise sets she is noted to be picking and readjusting her clothing.

A Case: Mrs. Roberts Would you diagnose Mrs. Roberts with delirium?
Yes No Intended for Audience Response System

A Case: Mrs. Roberts Would you diagnose Mrs. Roberts with depression?

A Case: Mrs. Roberts Would you diagnose Mrs. Roberts with dementia?

A Case: Mrs. Roberts Would you order “discontinue lorazepam?” Yes No
Intended for Audience Response System

A Case: Mrs. Roberts Would you order “discontinue oxycodone/ acetaminophen?” Yes No Intended for Audience Response System

A Case: Mrs. Roberts Reduce and taper lorazepam
Discontinue oxycodone/acetaminophen (Percocet®) Continue sertraline (Zoloft®) Discontinue celecoxib (Celebrex®) Continue acetaminophen PRN Continue lisinopril Ensure (nutritional supplement) daily Next week (after taper lorazepam) consider start of mirtazapine at bedtime Benzodiazepines Lorazepam can contribute to withdrawal or depression/fatigue – this drug requires tapering or she may develop withdrawal. She may need an alternate sleep medication. Mirtazapine or trazodone are medications that can not only be helpful in cases of depression but also in cases in which poor sleep is causing significant concern. Pain Management Clearly Mrs. Roberts is justified having the necessary pain medication needed to get through her physical therapy session but you observe that she has essentially no pain and a reduction of her pain medications is indicated. Consider acetaminophen toxicity as a possibility. She has been ordered acetaminophen as needed in addition to a combination pill that contains both oxycodone and acetaminophen (Percocet®). The medications orders are written such that she could theoretically be given 5200mg of acetaminophen in a 24 hours period: 6 doses of acetaminophen at 650mg = 3900mg of acetaminophen in 24 hours + 6 doses of oxycodone/acetaminophen 5mg/325mg = 1950mg of acetaminophen in 24 hours TOTAL 5850mg acetaminophen The best plan in this case is to simplify the regimen – for example, if an opiate is necessary for the patient to be able to complete physical therapy then order “oxy IR” (also known as “oxycodone instant release” which contains just oxycodone alone) to avoid the “acetaminophen portion” of the Percocet® [a combination medication]. Continue acetaminophen PRN but then change to scheduled as first line intervention if patient develops pain that affects her participation in physical therapy. Celebrex-may contribute to dyspepsia/anorexia – discontinue if possible

Delirium, Dementia, Depression
ALL presentations of ‘memory loss’ are due to one (and sometimes combinations) of the following conditions: DELIRIUM DEPRESSION DEMENTIA NORMAL AGING Dementia Delirium It’s rare that in medicine that we can say “all” or “never” but this instance we can say this about memory loss – that all memory loss presentations are due to one of the four conditions (or combinations of those conditions). Note that these pathological conditions exist within the context of normal aging but are distinctly different and set apart – dementia is not normal aging. Very commonly these co-exist and it’s the intersection of these domains that presents the greatest clinical challenge. Depression Normal Aging

Dementia, Depression, Delirium
We’ve come a long way… but we have much further to go Image of restraint chair from Wellcome Images Collection, Wellcome Library, London. © Wellcome Trust (Under the terms of the Creative Commons License, anyone is free to copy, distribute, and display the image, providing that the image is fully attributed to Wellcome Images and used solely for non-commercial purposes.) Wellcome Images. Wellcome Library , London © Wellcome Trust

Delirium, Dementia, Depression
Distinguishing Feature(s) Associated Symptoms Course Delirium Acute Onset and Fluctuating Levels of Confusion/ Consciousness Inattention, Memory Loss, Disorientation, Agitation, Delusions, Apathy, Withdrawal, Disturbed Sleep Cycle, Disorganized Thinking Acute, Due to an Underlying Condition Dementia Memory Impairment Disorientation, Agitation, Disturbed Sleep Cycle Chronic, Insidiously Progressive Depression Sadness, Loss of Interest Disturbed Sleep Cycle, Appetite, Difficulty Concentrating, Decreased Energy, Hopelessness, Worthlessness, Suicidal Ideation/Attempt(s) Single Episode or Recurrent/Chronic Episodes “Slowly progressive” suggests memory loss over months – memory loss year by year making it seem like “normal aging” to lay people (family/friends) because of it’s insidious nature but memory loss is not normal aging.

Self Reporting versus Informant
Most demented patients do not present with a chief complain of “memory loss” Most often spouse/daughter/son brings it to the attention of the clinician Family are often delayed in recognizing the dementia signs (i.e. cooking/finances) “Memory loss” is rarely the chief complaint of individuals who present to a clinical setting. The majority of cases reach the physician’s attention via a spouse or son/daughter. Self-reported memory loss is poorly correlated with the subsequent development of dementia; however, informant-reported memory loss is a much better predictor of the current presence and future development of dementia. Therefore, family member concern is should prompt a more in depth cognitive assessment. It should further be noted that family members often attribute signs of dementia to “aging” and often are late (rare than early) in detecting cognitive impairment. Because of dementia’s insidious nature, informants have difficulty determining the onset of symptoms. Example(s) of “delayed recognition of the signs of dementia” “mom stopped cooking because her arthritis was getting so bad … you know she couldn’t stand in the kitchen for a long amount of time.” “dad was having trouble reading the bills and writing the checks because of his continued deterioration in his vision.” Patients with depression are more likely to complain about memory loss than those with dementia; the latter are frequently brought to physicians by their families, while depressed patients often present by themselves. Reference: Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology. 2000;55(11): Carr DB, Gray S, Baty J, Morris JC. The value of informant versus individual's complaints of memory impairment in early dementia. Neurology. 2000;55(11):

Aging Masquerading as Disease
Encoding (slowed speed of processing; slightly less able than normal to concentrate and more easily distracted by external stimuli) Storage (unchanged) Retrieval (word-finding difficulty) New learning is intact/possible but greater effort Retrieval from short term memory may not be quite as rapid NORMAL AGING cognitive changes are similar to those presentations found in pathological conditions (i.e. delirium, depression, dementia) but not as severe – for example, daily activity / function is intact and unaffected – this is an opportunity to re-emphasize the concept of homeostenosis as it applies to the cognitive domain. An insult that disrupts the delicate homeostasis found in the elderly – even those without any cognitive impairment can throw them into a delirious state (i.e. easily distracted, decreased concentration … etc). “The Filing Cabinet” Example Use your imagination to think of your brain as a filing cabinet – imagine that every year you add a new filing cabinet of memories. After 85 years, you will 85 filing cabinets of data sort through before you find the right piece of information. There can be an increase in the amount of time that it takes to find that retrieve that single piece of information. Image: Filing cabinet image is from the Microsoft ClipArt Library. Reference: Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology. 1999;52(7): Small SA, Stern Y, Tang M, Mayeux R. Selective decline in memory function among healthy elderly. Neurology. 1999;52(7):

Delirium, Depression, Dementia: Memory Loss Responding to Treatment
Disease n Depression 40 Drugs 31 Metabolic 27 NPH 16 Neoplasm 11 Subdural hematoma 10 Alcohol 8 Infection 4 Not Specified/Other 21 Depression Drugs Weytingh and colleagues performed a meta-analysis of studies published between with a total of 1551 individual cases of dementia that met inclusion criteria in which memory loss was documented and then followed those cases to determine which cases were reversible (either partially or fully reversed). In there study published in 1995, they noted that at approximately 11% of all cases responded at least partially to intervention (168/1551 = 10.8%). It should further be noted that studies published earlier showed a greater number of reversible cases than those published a later date suggesting that Metabolic – includes thyroid disease, B12, Hepatic, Folate deficiency, hyperparathyroidism NPH – Normal Pressure Hydrocephalus SDH – Subdural Hematoma Not Specified/Other – included (but not limited to) cases of rheumatoid vasculitis, Parkinson’s disease, lead intoxication, intoxication of an unknown agent, congestive heart failure, “cerebral hypoperfusion,” rheumatoid arthritis, iron-deficiency anemia, sensory deprivation, unstable living arrangements' Reference: Weytingh MD, Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol. 1995;242(7): Metabolic Data from: Weytingh MD, Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol. 1995;242(7):

Delirium, Depression, Dementia: Fully Reversed Memory Loss
Disease n Depression 4 Drugs 13 Metabolic 2 NPH 1 Neoplasm Subdural hematoma Alcohol Infection Not Specified/Other Depression Drugs The authors conclude in their discussion, “So reversible dementia is not a myth; but it is rare. This has important implications for the investigation of patients with dementia. The clinician with such a patient faces a dilemma: full investigation offers a small chance of a large benefit1.” More than ½ the of the fully reversed cases were attributed to “drugs” as the etiology. Reference: Weytingh MD , Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol. 1995;242(7): Data from: Weytingh MD, Bossuyt PM, van Crevel H. Reversible dementia: more than 10% or less than 1%? A quantitative review. J Neurol. 1995;242(7):

Algorithm Patient with Known or Suspected Memory Loss CAM Abnormal
Identify Underlying Cause of Delirium & Treat No Delirium Equivocal or Inconsistent with Depression Consistent with Depression GDS Treat Depression or Discuss Options SWEET 16/ MMSE Great opportunity to involve medical students into the plan of care – medical students are well able to perform standardized cognitive testing on elderly patients or patient’s presenting with cognitive impairment (especially after completing SP cases that evaluate their performance of a MMSE, Sweet 16, GDS, CDT). Algorithm The “Algorithm” is the way to approach a case in which memory loss is a key sign/symptom/confounder. This algorithm describes the way in which cases should be “thought out” BUT NOT THE ORDER IN WHICH THE TESTS ARE PERFORMED. Refer to the Comprehensive Geriatric Assessment (CGA) in which the GDS (Geriatric Depression Scale) and MMSE (Mini-Mental State Exam) and/or Sweet 16 are performed on every patient as a routine nature when a new patient is evaluated. The cognitive tests above should be performed as a battery of tests and then use this algorithm by putting in the data and using a clinical judgment to define the best practice to care for the individual. As we will see the CAM (Confusion Assessment Method) is a tool best used immediately following the GDS + cognitive assessment. Impaired Not Impaired Re-evaluate After Treatment Lab Brain Imaging No Action

A Case: Mrs. Windfelder Day 1: Mrs. Windfelder is an 81 year old female who continues to live independently despite ambulating with a rolling walker. She presents to the emergency room for an evaluation of chest discomfort. She feels a chest pressure that lasts for just a few moments but wanted to get it checked despite having a recent negative stress test. She goes on to admit “I lives alone and I thought I should get checked out.” Triage: 180/70 mmHg BP 30 minutes later: 150/70 mmHg [prior to any treatment] EKG: normal sinus rhythm 1st Set Cardiac Biomarkers: “negative” Anderson JL, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007;50(7):e1-e157. Patients with chest pain and intermediate to high risk features such as dynamic ischemic ECG changes or elevated cardiac biomarkers, such as troponins, are likely to be having an ACS event and thus noninvasive imaging for triage purposes is unnecessary. These patients require hospital admission and usually undergo early cardiac catheterization, followed by coronary revascularization, if appropriate. In such patients, noninvasive testing will not alter the proposed triage and treatment strategy. According to ACC/AHA 2007 practice guidelines, age greater than 70 places a patient at “intermediate risk” and age greater than 75 places a patient at “high risk.” Reference: Anderson JL, et al. ACC/AHA 2007 Guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2007;50(7):e1-e157.

A Case: Mrs. Windfelder She is treated with O2, aspirin, metoprolol, nitroglycerine, morphine, and omeprazole. A bladder catheter is ordered because she has been ordered “bed rest” until cleared by cardiology. Should Mrs. Windfelder get a cardiac catheterization? Yes No

A Case: Mrs. Windfelder Day 2: Despite a third negative set of cardiac biomarkers, Mrs. Windfelder had a similar episode of vague chest discomfort during the early morning and agrees with her treating cardiologist that a cardiac catheterization is the next best plan of care. Day 3: Cardiac catheterization results in essentially normal coronary vasculature . In evening, Mrs. Windfelder develops confusion and begins pulling at IV lines and insisting that she needs to urinate. Despite reassurance that the catheter is collecting her urine she is unable to be re-directed. She is managed with restraints, lorazepam and haloperidol.

A Case: Mrs. Windfelder Day 4: Mrs. Windfelder develops urinary tract infection with fever and increased confusion. Bladder catheter discontinued; patient incontinent. Day 9: Patient remains incontinent, but is unable to walk safely due to deconditioning. She is transferred to subacute rehabilitation; sacral breakdown is noted on the transfer paperwork.

Delirium DSM-IV Criteria - Delirium
Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. Develops over a short period of time (usually hours to days) Mental status tends to fluctuate during 24 hour period Evidence the disturbance is caused by a medical condition, substance intoxication, or medication side effect. Despite DSM-IV criteria cited above, this “acute” confusion is firmly a medical diagnosis due to an underlying condition (and NOT a primarily psychiatric diagnosis). Delirium is very often unrecognized. Delirium is an expression of limited “cognitive reserve capacity”. There is again an opportunity to highlight normal aging/homeostenosis. Delirium is among the most prevalent mental disorder in older individuals – especially those with a underlying medical illness. Delirium and confusion have primarily been studied in hospital settings. It has been estimated that approximately 30% of elderly hospitalizes patients experience delirium1. Among elderly surgical patients studies have shown that the risk for delirium varies from 10-50% or more. Although delirium is considered potentially reversible, it is often the harbinger of future problems for frail, elderly persons. It has been cited by experts that signs of delirium may persist in up to 12 months in individuals who have experienced an insult. Reference: Francis J. Delirium in older patients. J Am Geriatr Soc. 1992;40(8):

Delirium (Epidemiology)
Delirium Rates1 Hospital: • Prevalence (on admission) 14-24% • Incidence (in hospital) 6-56% Postoperative: 15-53% Intensive care unit: 70-87% Nursing home/post-acute care: 20-60% Palliative care up to 80% Mortality Hospital mortality2: 22-76% One-year mortality3: 35-40% Pathogenesis Acetylcholine plays an fundamental role in the pathogenesis of delirium. Anticholinergic drugs have a high risk of causing delirium in frail elderly persons – it has also been shown that delirium can be precipitated in healthy volunteers who are given an anticholinergic medication. Many drugs not “classically” considered as anti-cholinergic have cross-reactivity and binding with muscarinic receptors and thus induce a delirium – again the frail elderly are at highest risk in this regard. The anticholinergic mechanism is illustrated in studies that have shown a concurrence between a decrease in CNS acetylcholine synthesis and common medical conditions (i.e. hypoxia, hypoglycemia, and thiamine deficiency). Serum anticholinergic activity measured from venous blood samples from hospitalized non-surgical delirious patients correlates had “significantly elevated SAA levels compared with levels in nondelirious controls. Also, subjects whose delirium resolved showed a significant decline in SAA compared with their initial SAA level. The present data suggest a significant association between SAA levels and the presence or absence of delirium in medical patients5.” Authors admit the study had a small sample size and did not have a control for the “severity of medical illness.” To draw a comparison, the pathogenesis of Alzheimer disease has been characterized by a loss of cholinergic neurons; individuals with this condition are well known to have an increased risk of developing delirium when prescribed anticholinergic medications. Unfortunately, the pathological mechanism of delirium is more complicated than that stated above – in fact it is believed to result from a combination of interactions from multiple neurotransmitters, inflammatory cytokines, and even hypothesized an impaired cerebral oxidative metabolism. Risk Factors: Rarely is delirium caused by a single factor; rather, it is a multi-factorial syndrome, resulting from the interaction of vulnerability on the part of the patient. Advanced age Underlying dementia/cognitive impairment Severe/Acute medical illness Alcohol abuse Male gender Depression Malnutrition Terminal illness ICU stay (up to 80%) Visual Impairment BUN/Creatinine Ratio > 18 Physical Restraints Bladder Catheter >3 Medications Added to Regimen EEG (Electroencephalography): the typical feature seen in EEG studies is “slowing;” One note worthy exception is found in sedative / alcohol withdrawal in which there is a majority of “low voltage, fast-wave activity.” Never-the-less there limited utility of EEG for the diagnosis of delirium – unless its use serendipitously identifies the underlying cause (i.e. seizure). References: Inouye SK. Delirium in older persons. N Engl J Med ;354(15): American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(Suppl 5):1-20. Moran JA, Dorevitch MI. Delirium in the hospitalized elderly. Aust J Hosp Pharm. 2001;31(1):35-40. Mach JR Jr, et al. Serum anticholinergic activity in hospitalized older persons with delirium: a preliminary study. J Am Geriatr Soc. 1995;43(5): Inouye SK. Delirium in older persons. N Engl J Med ;354(15): American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(Suppl 5):1-20. Moran JA, Dorevitch MI. Delirium in the hospitalized elderly. Aust J Hosp Pharm. 2001;31(1):35-40.

Confusion Assessment Method (CAM)
Symptoms Symptoms Rating 1 Acute onset or Fluctuating Course Neg Pos 2 Inattention AND 3 Disorganized Thinking OR 4 Altered Level of Consciousness CAM: (Confusion Assessment Method) “The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.1” Instructions The physician can complete the CAM instrument immediately upon completion of the patient history and physical. The items noted above are answered based on what the physician observed during the interview2 (the interview should include either the MMSE and/or Digit Span Testing - recall that the Digit Span Test is a portion of the Sweet 16). “Some formal cognitive assessment is recommended, since the validity of using CAM for non-standardized observations (e.g., routine clinical care) is poor3.” Note that the CAM is at the top of the Algorithm because the algorithm is most simply a schematic that shows way in which cases are to be “thought out” and not the order in which the tests are performed. The CAM is actually a “reflection tool” – complete the CAM after you have performed some type of standardized cognitive assessment of the patient [see noted above or reference #3]. 1. Acute Onset of Fluctuating Course This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity1? 2. Inattention This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention (i.e. being easily distractible, having difficulty keeping track of what was being said, perseverates answers, answers inappropriately) 1? Inattention is easily identifiable clinically (all physicians should have the skill to recognize delirium when it exists – comfort in testing for attention should be comparable auscultation of heart tones). There are a variety of standard tests that could be performed to test a patient’s attention or inattention as the case may be – digit span tests (i.e. like those noted on the Sweet 16), days of the week backward, or months of year backward. 3. Disorganized Thinking “This feature is shown by a positive response to the following question: Was the patient thinking incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? At times, respondent gives lucid, coherent answers, and at other times, gives nonsensical, incoherent answers1” 4. Altered Level of Consciousness "This feature is shown by an answer other than 'alert' to the following question: overall, how would you rate this patient's level of consciousness? [alert (normal), vigilant (hyperalert), lethargic (drowsy, easily aroused), stupor (difficult to arouse), or coma (unarousable)]. At times, respondent is alert and responsive to all questions, while at other times respondent is lethargic, unresponsive, and difficult to arouse.1” It should be further noted that even a patient who is lethargic at times may be able to give attention during an arousal period1. Examples: Lethargy The patient repeatedly dozes off while you are asking questions – difficult to keep respondent awake for interview, but does respond to voice or touch2. Stupor The patient is very difficult to arouse and keep aroused for the interview, requiring shaking and/or repeated shouting2. Coma The patient cannot be aroused despite shaking and shouting2. Historical Background for CAM The Confusion Assessment Method (CAM) was originally developed in , to improve the identification and recognition of delirium. CAM was intended to provide a new standardized method to enable non-psychiatrically trained clinicians to identify delirium quickly and accurately in both clinical and research settings1 . When validated against the reference standard ratings of geriatric psychiatrists based on comprehensive psychiatric assessment, the CAM had a sensitivity of %, specificity of 90-95%, and high inter-observer reliability1. The CAM is a widely used standard tool for clinical and research purposes – it has been translated into at least 12 languages and used in over 250 original published studies to date4. References: Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med 1990;113(12): Inouye SK. The Confusion Assessment Method (CAM): Training Manual and Coding Guide. 2003;Yale University School of Medicine. Inouye SK, et. al; Arch Int Med. 2001;161: Wei LA et al. J Am Geriatr Soc. 2008;56: Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):

Delirium Perceptual disturbances Psychomotor agitation
Psychomotor retardation Altered-sleep wake cycle In addition to direct observations particularly during formal mental status testing please also consider these other common clinical manifestations. Clinical Manifestations Perceptual Disturbances are manifested as hallucinations and/or delusions

A Clinical Question A stuporous patient can also have psychomotor agitation. True False Answer: (a) True Intended for Audience Response System

Delirium: Documentation
Example 1 Incorrect - “patient disoriented to place.” Correct - “patient thought she was at a bowling alley” Example 2 (perseveration) Incorrect - “patient repeated answers.” Correct - “patient ‘1922’ to each of the orientation questions on cognitive function testing (i.e. month, date, day, state, town).” Describe the actual observed behavior(s) or statement(s) by the respondent and describe them in detail. For an observed behavior, do not write only an impression/interpretation of a behavior – but rather record actual behavior observed: Example 1 Incorrect - “patient disoriented to place.” Correct - “patient thought she was at a bus station” Example 2 (perseveration) Incorrect - “patient repeated answers.” Correct - “patient stated ‘1922’ to each of the orientation questions on cognitive function testing (i.e. month, date, day, state, town).” Example 3 Incorrect - “patient seemed inattentive.” Correct - “patient’s attention given to noises/voices in the environment; eye contact was poor; patient required questions to be repeated 4 times in order to generate a response that was not due to hearing loss” Reference: Inouye SK. The Confusion Assessment Method (CAM): Training Manual and Coding Guide. Yale University School of Medicine. Vancouver Island Health Authority website. Published Accessed October 5, 2011.

Delirium: Etiology Dementia Electrolytes
Lungs, liver, heart, kidney, brain Infection Rx - Treatment & withdrawal (ETOH, Benzos, Sleepers) Injury, pain, stress Unfamiliar environment Metabolic Addressing the multi-factorial etiology is key to managing delirium. Primary prevention of delirium likely to be the most effective treatment strategy1. Non-Pharmacological Sleep Protocol3 (study N=111; reduced sleep medication from 54% to 31% [p<0.002]) 1. Five minute back rub 2. Give a warm drink (choice of herbal tea or warm milk) 3. Use relaxation tapes 4. Allow one hour before re-evaluating effectiveness Schedule Meds/Vital checks allow for uninterrupted sleep Lights off/decrease noise level Avoidance of daytime naps References: Inouye SK. Talks&slides/AGS Henderson Lecture henderson/s_inouye_henderson.pdf Inouye SK. Delirium in hospitalized elderly patients: recognition, evaluation, and management. Connecticut Medicine. 1993;57(5): McDowell JA et.al. J Am Geriatr Soc. 1998;46: Inouye SK. AGS Henderson Lecture, Delirium: applying research to transform care at the bedside, Talks & Slides presented at: American Geriatrics Society, 2010; henderson/ s_inouye_henderson.pdf. Accessed October 5, 2011.

Delirium: High Yield Rx
Sedatives Hypnotics “sleepers” Barbiturates Opiates Anticholinergics (including benztropine) Digoxin Steroids Psychotropics Anticonvulsants Benztropine (Cogentin®) This medication is indicated for the treatment of Parkinsonism, Acute Dystonia, and drug-induced extrapyramidal symptom. It possesses both anti-cholinergic and anti-histaminic properties. In vitro anti-cholinergic activity approximates that of atropine; in vivo it is only about half as active as atropine.

Delirium: Yale Delirium Prevention Program
Risk Factor Intervention Cognitive Impairment Reality orientation Therapeutic activities protocol Sleep deprivation Nonpharmacologic sleep protocol Sleep enhancement protocol Immobilization Early mobilization protocol Minimizing immobilizing equipment Vision impairment Vision aids Adaptive equipment Hearing impairment Amplifying devices Adaptive equipment and techniques Dehydration Early recognition and volume repletion Background “Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium1.” Methods1 “We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge1.” Orientation Protocol (all patients once daily; memory impairment 3x daily): board with names of care-team members and day’s schedule; communication to reorient to surroundings1 Therapeutic-activities protocol (all patients once daily; memory impairment 3x daily): cognitively stimulating activities three times daily (e.g., discussion of current events, structured reminiscence, or word games)1 Nonpharmacologic sleep protocol (All patients; need for protocol assessed once daily): at bedtime, warm drink (milk or herbal tea), relaxation tapes or music, and back massage1 Sleep-enhancement protocol (all patients; unit wide): unit-wide noise-reduction strategies (e.g., silent pill crushers, vibrating beepers, and quiet hallways) and schedule adjustments to allow sleep (e.g., rescheduling of medications and procedures)1 Early-mobilization protocol (All patients; ambulation whenever possible, and range-of-motion exercises when patients chronically non-ambulatory, bed or wheelchair bound, immobilized): ambulation or active range-of-motion exercises three times daily; minimal use of immobilizing equipment (e.g., bladder catheters or physical restraints)1 Vision protocol (Patients with <20/70 visual acuity): visual aids (e.g., glasses or magnifying lenses) and adaptive equipment (e.g., large illuminated telephone keypads, large-print books, and fluorescent tape on call bell), with daily reinforcement of their use1 Hearing protocol (Patients hearing <6 of 12 whispers on Whisper Test): portable amplifying devices, earwax disimpaction, and special communication techniques, with daily reinforcement of these adaptations1 Dehydration protocol (Patients with ratio of blood urea nitrogen to creatinine>18),: early recognition of dehydration and volume repletion (i.e., encouragement of oral intake of fluids)1 References: Inouye SK. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340: Inouye SK. A practical program for preventing delirium in hospitalized elderly patients. Cleve Clin J Med. 2004;71(11): Table 3 here replicated appears on page 895. Inouye SK. Cleve Clin J Med. 2004;71(11):

Delirium: Yale Delirium Prevention Trial Results
Outcome Intervention Group (N=426) Usual Care Group (N=426) Matched OR (CI) or p-value Incident delirium, n (%) 42 (9.9%) 64 (15.0%) .60 ( ) p=.02 Total delirium days 105 161 p=.02 # delirium episodes 62 90 p=.03 Delirium severity score 3.9 3.5 p=.25 Recurrence rate 13 (13.0%) 17 (26.6% p=.62 Conclusions “The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy1.” “This controlled clinical trial provides evidence that a multicomponent, targeted intervention strategy, the [Hospital] Elder Life Program, is effective for the prevention of delirium in hospitalized older medical patients. The intervention prevented the initial development of delirium and reduced the total number of days of delirium. It was most effective in patients who were at intermediate risk for delirium at base line. Once an initial episode of delirium had occurred, however, the intervention had no significant effect on the severity of delirium or on the likelihood of recurrence1.” HELP = Hospital Elder Life Program Limitations “Logistic constraints precluded random assignment of the patients to the two treatment groups. However, the prospective, individual-matching strategy allowed balanced assignment of the patients to the two groups. Furthermore, a contamination effect in the usual-care group probably decreased the overall rates of delirium. Contamination was evident in the rates of delirium, which were substantially lower than anticipated on the basis of earlier studies in the same study population and it was also evident in the substantial reduction in risk factors that occurred in the usual-care group. Although efforts were made to avoid contamination, some intervention protocols were disseminated by word of mouth to staff members in usual-care units1.” Reference: Inouye SK. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9): Inouye SK. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):

Hospital Elder Life Program (HELP)
Delirium is the leading risk factor for falls in hospital HELP instituted at 29 hospitals – falls reportedly reduced at 95% of sites Hospital at Home Other interventions not included in the Yale Delirium Prevention trial were part of HELP [Hospital Elder Life Program]…. Scheduled toileting (i.e. having the patient walk to toilet every 2 hours), lower mattress height1 At 3 HELP sites (Maine, Cornell, Moses Taylor), data documents fall reduction1,2: – Site 1: 11.4 to 3.8 per 1000 patient-days – Site 2: 4.7 to 1.2 per 1000 patient-days – Site 3: 4.2% to 2.4% in 4000 patients/1 yr HELP instituted at 29 hospitals – falls reportedly reduced at 95% of sites2 Hospital at Home3 Patients cared for at home had lower rates of delirium Ongoing research Does delirium lead to dementia? Or does delirium identify those at risk (again, speaking of homeostenosis concept and the “cognitive reserve capacity”). Are we still able to build cognitive reserve? References: Inouye SK. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. N Engl J Med. 2009;360(23): Inouye SK. AGS Henderson Lecture, Delirium: applying research to transform care at the bedside, Talks & Slides presented at: American Geriatrics Society, 2010; s_inouye_henderson.pdf. Accessed October 5, 2011. Gianluca I, et al. Delirium in elderly home-treated patients: a prospective study with 6-month follow-up. Age. 2009;31(2):109–117. Inouye SK. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. N Engl J Med. 2009;360(23): 2. Inouye SK. AGS Henderson Lecture, Delirium: applying research to transform care at the bedside, Talks & Slides presented at: American Geriatrics Society, 2010; s_inouye_henderson.pdf. Accessed October 5, 2011.

Identify Underlying Cause of Delirium & Treat No Delirium Equivocal or Inconsistent with Depression Consistent with Depression GDS Treat Depression or Discuss Options SWEET 16/ MMSE Impaired Not Impaired Re-evaluate After Treatment Lab Brain Imaging No Action

PHQ-2 Adapted from the PHQ-9
A score of 3 or more had a sensitivity of 83% and specificity of 92% for major depression GDS is better suited for elderly patients Depression is not part of normal aging. Physical Signs/Symptoms of Depression – weight loss, insomnia, pain, fatigue – should trigger a screening for depression The PHQ-9 is not as well-validated as the GDS in the elderly population. Studies have included patients older than 65 but no dedicated studies. Also, the rating scale may be even more difficult than the GDS for patients with cognitive deficits. The items on the questionnaire are the nine signs and symptoms of depression in the DSM-IV with a question on functional impairment from the symptoms (as also required in the DSM-IV). Because of the direct relationship to the nine DSM-IV depression signs and symptoms it is called the PHQ-9. PHQ point rating scale: Not at all: 0 Several days: 1 More than half the days: 2 Nearly every day: 3 PHQ-2 also uses a three point scale (not at all to every day): a score of 3 or more had a sensitivity of 83% and specificity of 92% for major depression Geriatric Depression Scale The 15 point scale takes about 5 minutes at most to complete and has an 92% sensitivity and 89% specificity (short form correlates with long form r=0.89)1 Depression significantly increases morbidity and mortality. Relative to dementia which has an insidious onset, depression in the elderly usually has a more rapid onset and individuals have intact but possibly sluggish cognitive processing. Suicidal Ideation Assessment: Consider asking patients if they have ever felt that they were a burden to their family or if their family would be better off without them. Follow these open ended questions with more direct questions to investigate active suicidal ideation1. References: Thibault JM, Prasaad Steiner, RW. Efficient identification of adults with depression and dementia. Am Fam Physician. 2004;70(6) Kroenke K et al. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):  Pfizer, Inc. Thibault JM, Prasaad Steiner RW. Efficient identification of adults with depression and dementia. American Family Physician. 2004;70(6). Kroenke K et al. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):

Geriatric Depression Scale (GDS) 15 “Yes/No” Items
Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with memory than most? Do you think it is wonderful to be alive now? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are? The GDS was originally a 30-item questionnaire in which participants are asked to respond “yes” or “no” in reference to how they felt over the last week. The questions that had the highest correlation with depressive symptoms in were selected and validated in the “short form” 15-item questionnaire1. Reference: Sheikh JI et al. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In TL Brink (Ed), Clinical Gerontology: A guide to Assessment and Intervention , NY: The Haworth Press, 1986. Sheikh JI et al. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In TL Brink (Ed), Clinical Gerontology: A guide to Assessment and Intervention , NY: The Haworth Press, 1986.

Geriatric Depression Scale (GDS)
A score > 5 points is suggestive of depression A score > 10 pints is almost always indicative of depression Any score greater than 5 should prompt a discussion about suicidal ideation Reference: Sheikh JI et al. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In TL Brink (Ed), Clinical Gerontology: A guide to Assessment and Intervention , NY: The Haworth Press, 1986. Sheikh JI et al. Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In TL Brink (Ed), Clinical Gerontology: A guide to Assessment and Intervention , NY: The Haworth Press, 1986.

Depression Depressed mood
Loss of interest or pleasure in most or all activities Insomnia or hypersomnia Change in appetite or weight Psychomotor retardation or agitation Low energy Poor concentration Thoughts of worthlessness or guilt Recurrent thoughts about death or suicide A major depressive syndrome or episode manifests with five or more of the following symptoms, present most of the day nearly every day for a minimum of two consecutive weeks. At least one symptom is either depressed mood or loss of interest or pleasure1. And don’t forget that depression can present as psychosis=Psychotic depression…it has fooled many a practitioner! (not a student level question) Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000.

Dementia Defined “A disorder that is characterized by impairment of memory and at least one other cognitive domain (aphasia, apraxia, agnosia, executive function). These must represent a decline from previous level of function and be severe enough to interfere with daily function and independence.” Clock Draw and Trail Making test executive function Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000.

Dementia (Diagnosis) DSM-IV Criteria - Dementia Memory Impairment
One of the following: Apraxia Aphasia Agnosia Disturbance in executive function Disturbance in effects work, social activities, relationships Disturbance does not occur exclusively during delirium Alzheimer’s Disease (AD) is a clinical diagnosis; there are no laboratory tests that confirm the presence of this disorder. Bilateral hippocampal atrophy on an MRI suggests AD, but is not specific or sensitive. The clinical diagnosis of AD is reasonably accurate. In an autopsy study, for example, 92 of 106 cases (87 percent) of clinically diagnosed AD were confirmed pathologically2. Definitions Apraxia – loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements. Aphasia – produce and/or comprehend language Agnosia – loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss References: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000. Gearing M, et al. The consortium to establish a registry for Alzheimer's disease (CERAD). Part X. Neuropathology confirmation of the clinical diagnosis of Alzheimer's disease. Neurology. 1995;45: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 1994, 2000.

USPSTF Screening 9 The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. >4 >2 Epidemiology of Dementia 5 percent of individuals over age 65 years and 35 to 50 percent of persons over age 85 years have dementia USPSTF “The USPSTF found good evidence that some screening tests have good sensitivity but only fair specificity in detecting cognitive impairment and dementia. There is fair to good evidence that several drug therapies have a beneficial effect on cognitive function (equivalent to delaying the natural progression of Alzheimer's disease from 2 to 7 months), but the evidence of their beneficial effects on instrumental activities of daily living is mixed, with the benefit being small, at best. There is insufficient evidence to determine whether the benefits observed in drug trials are generalizable to patients whose disease would be detected by screening in primary care settings. The accuracy of diagnosis, the feasibility of screening and treatment in routine clinical practice, and the potential harms of screening (e.g., labeling effects) are also unknown. The Task Force therefore could not determine whether the benefits of screening for dementia outweigh the harms1.” Example: “labeling” effect Imagine a physician who is reviewing a patient’s medical record and reads “dementia” or during a medication review notes that “donepezil,” and/or “memantine” are present in the patient’s medication regimen – does that change the way the clinician approaches the patient/patient’s illness? Does that cause harm (or good)? The physician may weigh historical data provided by a family member/nurse more than the patient’s. Reference: Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: A summary of the evidence for the U.S. Preventive services task force. Ann Intern Med. 2003;138(11): Year Boustani M, Peterson B, Hanson L, et al. Screening for dementia in primary care: A summary of the evidence for the U.S. Preventive services task force.. Ann Intern Med. 2003;138(11):

Cognitive Testing: A Review
Clock Draw Test (CDT) Mini-Mental State Examination (MMSE) Sweet 16 Neuropsychiatric Testing

Cognitive Testing Neuropsychological Testing
Distinguish mild dementia from age-associated memory loss Detect focal neuropsychological manifestations Distinguish organic dementia from depression Fully characterize cognitive capacity Make appropriate recommendations regarding competence (i.e. financial responsibility, vehicle operation) Provide longitudinal assessment (i.e. rates of decline, efficacy of medical interventions) Complex cases of dementia warrant standardized neuropsychological testing. This slide illustrates the purpose of neuropsychological testing. The neuropsychological instruments that emphasize memory function were considered most useful. In particular, five subtests (Animal naming, Modified Boston Naming Test, MMSE, Constructional Praxis, and Word List Memory) were identified by a consortium of experts to be a valid, reliable measure of cognition in normal aging and AD.

Cognitive Testing Example Assessment of Pre-morbid Ability
Ache Thyme Debt Bouquet Heir Nausea Chord Psalm Depot NART Scores (National Adult Reading Test) Pronunciation of 50 Irregular English Words The more words a patient can read the higher the estimate of pre-morbid ability If initial IQ is controlled, scores to do not differ between those with and without mild to moderate dementia The National Adult Reading Test (NART) involves pronunciation of 50 irregular English words such as "ache" and "thyme.” The more words a patient can read, the higher the estimated of pre-morbid ability. In a study of elderly individuals (about 80 years old) and after calculating using IQ scores documented at age 11, the mean NART scores did not differ in those with and without mild to moderate dementia1. Reference: McGurn, B, Starr, JM, Topfer, JA, et al. Pronunciation of irregular words is preserved in dementia, validating premorbid IQ estimation. Neurology. 2004;62(7): McGurn B, Starr JM, Topfer JA, et al. Pronunciation of irregular words is preserved in dementia, validating premorbid IQ estimation. Neurology. 2004;62(7):

Cognitive Testing Example: Trail-making Executive Function Testing
Ability to comprehend all details of an activity AND Convert that information to an adequately perform a given behavior Deficits in executive function are common to all dementias but are particularly distinctive of vascular dementia; measurable deficits often occur prior to a diagnosis of dementia and correlate with neuro-imaging findings.

Cognitive Assessment Incongruent with History
Cog Suggests Dementia History Suggests Dementia Acute Confusion (Delirium) Low Intelligence/ Education Primary Language not English Inadequate recognition by informants Mild Dementia High Intelligence/ Education Depression Misrepresentation by informants Neuropsychological assessment (psychometric testing) may be useful in these difficult situations; re-evaluation at a later time is often helpful. Reference: Knopman, DS. The initial recognition and diagnosis of dementia. Am J Med. 1998;104(4A):2S-12S. Knopman, DS. The initial recognition and diagnosis of dementia. Am J Med. 1998;104(4A):2S-12S.

Identify Underlying Cause of Delirium & Treat No Delirium Equivocal or Inconsistent with Depression Consistent with Depression GDS Treat Depression or Discuss Options SWEET 16/ MMSE Impaired Not Impaired Re-evaluate After Treatment Lab Brain Imaging No Action

Laboratory & Radiological Studies
An 80 year old male brought for an evaluation by his son for a progressive deterioration has an MMSE 22/30 and GDS 4/15. He has even experienced delusions in which he accused his son of stealing his important VA papers. He exhibits no focal deficits on neurological exam and takes only an aspirin every day. Which of the following items can be omitted from the initial work up of this patient’s progressive memory loss? Serum TSH Radiological brain imaging Carotid Doppler B12 Level Folate Level Answer: (c) Carotid Doppler Intended for Audience Response

Laboratory & Radiological Studies
BMP CBC LFTs B12/Folate TSH Brain imaging (MRI preferred) +/- RPR The American Academy of Neurology (AAN) recommends screening for B12 deficiency and hypothyroidism in patients with dementia. The AAN recommends structural neuroimaging with either a noncontrast head CT or MRI in the routine initial evaluation of all patients with dementia1. There are no clear data to support or refute ordering "routine" laboratory studies such as a complete blood count, electrolytes, glucose, and renal and liver function tests. Screening for neurosyphilis is not recommended unless there is a high clinical suspicion. The cost effectiveness has been questioned because the yield is significantly low; in a 2006 community-based series, none of the 560 patients with dementia screened had a treatable metabolic cause2. Patients with an atypical syndrome, e.g., young patients (< 60 years) or those with rapidly progressive dementia, may benefit from a more extensive evaluation Genetic testing for the apolipoprotein E epsilon 4 allele is not currently recommended3. MRI findings in AD include both generalized and focal atrophy as well as white matter lesions. In general, these findings are nonspecific. However, a number of investigators have correlated changes in hippocampal volume with cognitive decline. References: Knopman DS, et al. Practice parameter: Diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9): Knopman DS, et al. Incidence and causes of nondegenerative nonvascular dementia: A population-based study. Arch Neurology ;63(2): Statement on use of apolipoprotein E testing for Alzheimer disease. American College of Medical Genetics/American Society of Human Genetics Working Group on ApoE and Alzheimer disease. JAMA. 1995;274(20): Knopman DS, et al. Practice parameter: Diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9): Knopman DS, et al. Incidence and causes of nondegenerative nonvascular dementia: A population-based study. Arch Neurology. 2006;63(2):

Other Testing Other considered studies – RPR, UDS, EtOH level, EEG, CXR, EKG, HIV

Approach to Memory Loss

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