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

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

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

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

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

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

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)

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

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

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)

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

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

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

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

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”

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?”

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

Questions ??? Discussion

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

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

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

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

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

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

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?

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.

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

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.

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

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”.

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?

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?

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?

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

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 38-41.

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

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?

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

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.

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.

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

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

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?

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?

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…

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