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

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

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

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: ; 3 Steffans DC et al. Arch Gen Psychiatry 2006; 63:

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):

29. Executive function is crucial for both task performance 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

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: , 2005.

43. Montreal Cognitive Assessment (MoCA)

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?

51. Case #2: Continued
Mr. R’s daughter’s main concern is her father’s changed behavior. Prior to hospitalization Mr. R was functioning with minimal assistance at home, was forgetful, but mostly independent. Mr. R’s hearing aid was lost during hospitalization and so, until his daughter can secure another, Mr. R’s hearing is quite impaired. The Mini-Mental State Examination pre-hospitalization is unavailable. Mr. R’s current MMSE is 21 (normal 24-30). Since discharge he has been quite dependent, more short of breath than normal, and is often “not making sense”.

52. Case #2: Continued
What are the risk factors Mr. R has for the development of delirium?
What are the risk factors Mr. R has for depression?
What concerns do you have for Mr. R. now that he is at home?

53. Case #2: Continued
What further information might be helpful in terms of Mr. R.’s nutritional and fluid intake?
How might this affect Mr. R.’s cognitive abilities?

54. Case #2: Continued
What interventions would you suggest implementing for Mr. R’s plan of care?
How should Mr. R’s depression be addressed?
Are there interventions that could have been implemented in the hospital to prevent/minimize the delirium?

55. Case #2: Continued
What other strategies might be helpful to support Mr. R’s daughter?

56. Case #3: Ms. W* 75 y.o. In good health; lives alone in the community
No history of dementia or psychiatric illness
Comes to office with left face/eye pain
Diagnosed with temporal arteritis and started on oral steroids
Long term steroid treatment is appropriate for temporal arteritis
* Cipriani, et al (July 2012). Reversible dementia from corticosteroid therapy. Clinical Geriatrics, pp

57. Case #3: Clinical Course
After 7 months of steroid treatment Ms. W:
Became forgetful
Developed insomnia and impaired memory
Family noted anxiety, labile mood
Decreased motivation to perform IADLs/ADLs
Bathing
Driving
One month later she was unable to care for herself

58. Case #3: Additional Data at 7 Months
MMSE 22/30
EEG and labs normal
Why is dementia probably not what is happening to her now?

59. Case #3: Follow-Up Ms. W was diagnosed with steroid-induced delirium
Steroids were tapered and then discontinued over a 20-day period
15 days after the steroids were stopped, memory and cognitive deficits improved
Two months after stopping the steroids her MMSE was 28/30 and ADL/IADL function much improved

60. Case #4: Mr. H.G. Patient is an 89 year old male
Is the caregiver for his wife, who has dementia and low vision.
Mr. H.G. was ambulatory, driving, shopping for groceries, cooking, doing light housekeeping, and paying the bills until the last couple of months.
His daughter brings him to see his primary care provider after her mother complains that she’s tired of eating microwaved hotdogs every night. Daughter also notices spoiled food in the refrigerator.

61. Case #4: Continued
Patient complains of pain in his back, shoulders and knees that prevents him from standing in the kitchen and preparing meals. He says he doesn’t need any help with shopping or other household tasks, except maybe with meal preparation.

62. Case #4: Continued
What else do you want to know about Mr. H.G.’s health and function?

63. Case #4: Continued Physical exam: Cognitive exam:
Weight is down 23# since his doctor’s visit 3 months ago.
He has arthritic changes in both hands and knees, with muscle wasting in arms and legs.
His hearing aids are not working, even with new batteries
Cognitive exam:
He can recite all the names and doses of his wife’s medications
MMSE=19/30 (below 24 is abnormal)
Laboratory and x-ray findings:
Anemia
Spinal stenosis
Severe degenerative changes in both knees R>L

64. Case #4: Continued What else do you want to know?
What factors might be causing or contributing to Mr. H.G.’s decline in functioning?

65. Case #4: What might you learn from doing a home visit at this point?
What would you look for?
What else would you ask about?
What might you recommend?

66. Case #4: Follow-up Management included:
Discontinuation of NSAIDs that were thought to be causing gastritis and GI blood loss
A regular pain medication regimen
Physical therapy
Replacement of hearing aids
Nutritional supplements
He gained 6#, anemia resolved, strength and ambulation improved, with increased ability to stand in the kitchen…

67. Case #4: Follow-up
…But executive dysfunction persisted and the couple needed a home health aid to help with grocery shopping and meal preparation
Over the next 12 months, his short-term memory became worse, and he could no longer supervise his wife’s medications