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Differentiating Dementia, Mild Cognitive Impairment, and Depression: Neuropsychological Perspective Emily Trittschuh, PhD Geriatric Research Education.

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Presentation on theme: "Differentiating Dementia, Mild Cognitive Impairment, and Depression: Neuropsychological Perspective Emily Trittschuh, PhD Geriatric Research Education."— Presentation transcript:

1 Differentiating Dementia, Mild Cognitive Impairment, and Depression: Neuropsychological Perspective Emily Trittschuh, PhD Geriatric Research Education and Clinical Center (GRECC) VA Puget Sound Health Care System emily.trittschuh@va.gov Dept of Psychiatry and Behavioral Sciences University of Washington

2 Learning Objectives Characterize Dementia, Mild Cognitive Impairment, and Depression in Older Adults Recognize warning signs and initiate diagnostic work-up Understand components of a Neuropsychological Evaluation Cognitive Profiles – unique/overlapping features Utilizing this information to guide treatment and care planning

3 The Aging Population Older Americans represent ~12 % of the population. 26% percent of physician office visits A third of all hospital stays and of all prescriptions Almost 40 % of all emergency medical responses 90 % of nursing home residents In 2011, the first baby boomers will reach their 65th birthdays. By 2029, all baby boomers will be at least 65 years old. This group will join the rest of older adults to total an estimated 70 million people aged 65 and older. *As reported by the Alzheimer’s Association in 2010

4 “Typical” Cognitive Aging Autobiographical memory Recall of well-learned information Procedural and Episodic Memory Emotional processing  Encoding of new memories Slower to learn new tasks  Working memory May need more repetitions to learn new info  Processing speed Slower to respond to novel situations

5 What you might hear in clinic I can’t focus She’s not interested in her usual activities I can’t come up with the word I want My energy is low My short-term memory is shot I lost my car in the parking lot My husband’s “selective attention” is worse – he doesn’t listen to me

6 Dementia A decline of cognitive ability and/or comportment... primary and progressive due to a structural or chemical brain disease Not secondary to sensory deficits, physical limitations, or psychiatric symptomatology. to the point that customary social, professional and recreational activities of daily living become compromised.

7 Probable Alzheimer’s Disease NINCDS-ADRDA Criteria from 1984 consensus group Dementia established by clinical and neuropsychological examination. Explicit memory impairment plus at least 1 other area of dysfunction. Activities of daily living have been affected. Insidious onset and progressive course. Risk increases with age; rare onset before age 60 Other diseases capable of producing a dementia syndrome have been ruled out.

8 Causes that Mimic Dementia (*but are treatable) Toxic/metabolic Medications, B 12 deficiency, hypothyroidism Systemic illnesses Infections, cardiovascular disease, pulmonary Other Depression, sleep apnea, psychosocial stressors, drugs *Treatment may improve, but not fully reverse, symptoms

9 Millions of people Prevalence of AD in the US Hebert, et al, 2003, Archives of Neurology

10 Is it always Alzheimer’s disease?

11 Lim, et al. J Am Geriatr Soc. 1999 May;47(5):564-9.

12  Objectively measured deficits in memory and/or other thinking abilities  Subjective memory complaint  Normal ADLs  Prevalence rates vary widely depending on age and community vs clinic sample Mild Cognitive Impairment (Petersen et al., 1999, 2001) ** Conversion to dementia is significantly higher in people with MCI MCI 12 - 15% per year Normal controls 1 - 2% per year

13 Depression in Older Adults Mood disorder characterized by: Sadness Guilt, negative self-regard Apathy – loss of motivation, loss of interest Vegetative Symptoms: sleep, appetite, energy Psychomotor changes – agitation or slowing Trouble thinking, concentrating Loss of interest in life; suicidal ideation Must occur for at least 2 weeks and interfere with daily living Higher prevalence rates of mood disorder in the elderly DSM-IV and ICD-10 criteria

14 Medical Evaluation  History, physical  Blood tests, brain scans Formal Cognitive Testing  Evaluate relative to others in the same age group When the Veteran has concerns or you notice a change...

15  If dementia, changes can begin up to 20 years before noticeable by self & others  importance of prevention …  Is this “normal aging”? Is it a change?  Clinical presentations can be similar  may not be detectable using screening tests  Comprehensive assessment is essential  rule out other treatable causes Diagnostic Challenges

16 Clinical Neuropsychology Integrative approach – psychology, psychiatry, and neurology Record review History is often the most important diagnostic tool Collateral information is helpful Objective cognitive testing to aid in diagnosis Multiple domains of cognitive function must be evaluated Importance of using appropriate measures and appropriate normative data

17 Geriatric Neuropsychology Tests Consider age of subject and overall health/energy Consider adjusting measures administered based on referral question (e.g., first diagnosis vs. current function) Normative populations Limited normative information for 90+ Non-native English speakers Ethnicity/Cultural differences Premorbid estimates Individualized benchmark

18 What is “impaired”? “Gold” standard: premorbid baseline data Standard benchmark: Compare to the average performance within an age group

19 -2 -1.5 -.5 0.5 1 1.52 -2.5 2.5 3 -3 Standard deviations

20 What is “impaired”? “Gold” standard: premorbid baseline data Personal benchmark: Compare test results to an estimate of premorbid abilities

21 -2 -1.5 -.5 0.5 1 1.5 2 -2.5 2.5 3 -3 Standard deviations

22 Clinical Symptoms of Cognitive Decline Memory loss is often the most commonly reported symptom: Forgetfulness Repeats self in conversation Asks the same questions over and over Gets lost in familiar areas Can’t seem to learn new information (routes, tasks, how to use a new appliance or electronics)

23 Clinical Symptoms cont... Presenting symptoms can also consist of changes in one or more of these areas: Attention Language Visuospatial abilities Executive function Personality/judgment/behavior

24 Impairments in Attention Starting jobs but not finishing them Absentmindedness Difficulty following a conversation Distractibility Losing train of thought

25 Problems expressing one’s thoughts in conversation (can’t find the right words) Consistently misusing words Trouble spelling and/or writing Difficulty understanding conversation Impairments in Language

26 Impairments in Visuospatial Function Getting turned around (even in one’s own home) Trouble completing household chores (using knobs or dials) Difficulty getting dressed Trouble finding items in full view Misperceiving visual input

27 Impairments in Executive Function Disorganization Poor planning Decreased multi-tasking Perseveration Decreased ability to think abstractly

28 Changes in Personality or Comportment Quantitative change in behavior: Increase- disinhibition, impulsivity, poor self- regulation, socially inappropriate Decrease- flat affect, reduced initiative, lack of concern, lack of interest in social activities (often initially mistaken for depression) Behavior not typical of premorbid personality

29 Case Example: Key Features 68-year-old, r-handed, AA female Master’s degree; Associate dean No significant past medical history Referred from primary care MD for complaints of memory loss Insidious onset, seems progressive

30 Symptom History at Initial Visit 2 year decline in memory Social skills maintained Living alone, independent in all ADLs Collateral endorsed a change

31 MILD NORMAL SEVERE AttentionMoodLangSpatialMemoryADLsExecutive Neurocognitive Profile - MCI MODERATE Initial: (2 yr after onset)

32 Changes at Second Visit Sense of progression Social skills maintained Still living alone; independent for basic ADLs Changes in IADLs Having trouble driving (minor accidents; got lost) Trouble managing medications

33 MILD NORMAL SEVERE AttentionMoodLangSpatialMemoryADLsExecutive Neurocognitive Profile - Dementia MODERATE Initial: (2 yr after onset) 1st F/U: (3 yr after onset) 2nd F/U: (5 yr after onset)

34 MILD NORMAL SEVERE AttentionMoodLangSpatialMemoryADLsExecutive Neurocognitive Profile - MCI MODERATE Initial: (2 yr after onset) 1st F/U: (3 yr after onset) 2nd F/U: (5 yr after onset)

35 Symptom History at Initial Visit 2 year decline in memory; collateral notes change Affective Changes Loss of interest in normal activities Sadness and decreased social network Living alone, independent in basic ADLs IADLs Sometimes forgets medication dosages a few examples of inattention while driving

36 MILD NORMAL SEVERE AttentionMoodLangSpatialMemoryADLsExecutive Neurocognitive Profile - Depression MODERATE Initial: (2 yr after onset) Tx x 1 yr: (Incomplete remission) Tx x 1 yr: (Effective)

37 Complicating issues Chronic depression is a risk factor for dementia Reported rates of depression in dementia range from 0-86% of cases Recent meta-analysis found 50% prevalence Discriminating depression from dementia is even more challenging in non-AD dementias With the trajectory of MCI unknown, the relationship to depression is less clear Depression may indicate prodromal dementia

38 Treatment and Care Planning Dementia No cure and the causes are not entirely understood Effective intervention = improve functional status to a degree discernable to caregivers or health care providers In the case of a progressive disorder, “improvement” = slower decline

39 Current FDA-Approved Medications Acetylcholinesterase Inhibitors tacrine Cognex ® hepatotoxic donepezil Aricept ® 1 month galantamine Razadyne ® 4 months rivastigmine Exelon ® 4 months; patch NMDA receptor antagonist memantine Namenda ® 1 month; approved for mod-severe AD Adjunct Therapies (off label) Antidepressants Antipsychotics SSRIs, mirtazapine risperidone, quetiapine

40 EnvironmentGenetic AGE Neuronal and Synaptic dysfunction Cognitive Decline Alzheimer’s Disease Diagnosis Alzheimer’s pathology NFTs Amyloid Plaques Head Injury, Depression, Female, Presence of APOE e4 allele Chronic Illness Risk Factors

41 Normal MCI Dementia An ideal point of intervention? Mild Cognitive Impairment

42 Risk Factors that can be Managed or Avoided Medical Conditions  High Blood Pressure  High Cholesterol  Type II Diabetes  Nutrition/Diet  Alcohol / Tobacco  Exercise  Stress  Socialization Behavioral Factors

43 Older adults (>55 yrs) with diabetes have a 65% increased risk of developing Alzheimer’s disease (compared to those without diabetes) Adults with diabetes have lower scores on cognitive tests Type II Diabetes Bennett, et al. Religious Orders Study. Archives of Neurology, 2004

44 Depression in the Elderly Depression is not a normal part of aging Estimated that only 10% of Older Adults with depression receive treatment Suicide rates – higher in the elderly and higher in Veteran populations Risk of cognitive decline should be monitored

45 Dementia? Mild Cognitive Impairment? Depression? Superman in his later years Dang!... Now where was I going?

46 Thank you Questions? Please also email me at emily.trittschuh@va.gov


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