1. Dementia: Early Assessment Early Diagnosis Early Treatment Janice Knoefel, MD MPH Geriatrics, Internal Medicine, Neurology University of New Mexico

2. Dementia Definition Impairment in at least 2 cognitive domains: Impairment in at least 2 cognitive domains: –Memory –Language –Visuospatial –Executive/attention –Social/behavior function A decline from previous level of function A decline from previous level of function Impairs daily function and independence Impairs daily function and independence Absence of other psychiatric, neurologic or systemic disease and delirium Absence of other psychiatric, neurologic or systemic disease and delirium

3. Subtypes of Dementia Alzheimer’s disease 50-60% Alzheimer’s disease 50-60% Vascular dementia 10% Vascular dementia 10% Dementia with Lewy bodies 10-20% Dementia with Lewy bodies 10-20% Parkinson’s Disease Dementia 5% Parkinson’s Disease Dementia 5% Frontotemporal dementia 5% Frontotemporal dementia 5% Mixed dementias (usually AD and vascular) 10-20% Mixed dementias (usually AD and vascular) 10-20% Alcohol-associated Dementia 1-2% Alcohol-associated Dementia 1-2% Creutzfeld-Jakob (mad cow) disease.001% Creutzfeld-Jakob (mad cow) disease.001% Normal Pressure Hydrocephalus (NPH).1% Normal Pressure Hydrocephalus (NPH).1% Huntington’s Disease with dementia.1% Huntington’s Disease with dementia.1% Depression with dementia-like symptoms-unknown Depression with dementia-like symptoms-unknown

4. Screening for Dementia Different from assessment of dementia Different from assessment of dementia Offered to persons without symptoms Offered to persons without symptoms Offered to persons with complaints Offered to persons with complaints Performed by anyone with training Performed by anyone with training Variety of tools available Variety of tools available How can screening be used? How can screening be used?

5. Tools for Screening MoCA: Montreal Cognitive Assessment MoCA: Montreal Cognitive Assessment –Samples all cognitive domains in 10 min. –Normative data online –Versions for illiterate, blind, 52 languages –Excellent website, includes training video –Free app for healthcare professionals –App for electronic administration –www.mocatest.org

6. Tools for Screening MMSE: Mini-Mental Status Exam MMSE: Mini-Mental Status Exam –Oldest test in use (40 years) –Heavily weighted to language (18/30 pts) –No test of executive function –Poor discrimination for mild impairment –Fallen out of use due to profiteering –Not free to use = $1 per test –www.minimental.com

7. Tools for Screening SLUMS: St Louis University Mental State SLUMS: St Louis University Mental State Not in such widespread use Not in such widespread use Tests immediate recall more than recent Tests immediate recall more than recent Education adjusted norms Education adjusted norms But still an acceptable test But still an acceptable test aging.slu.edu/index.php?page=saint- louis-university-mental-status-slums- exam aging.slu.edu/index.php?page=saint- louis-university-mental-status-slums- exam

8. Tools for Screening Other, brief (5 minute) tests: Other, brief (5 minute) tests: –Clock draw –Mini-cog –3 item recall –General Practitioner Assessment of Cognition (GPCOG) –Memory Impairment Screen (MIS)

9. Who to Screen for Dementia Persons reporting: Persons reporting: –Forgetfulness –Repeating self, questions –Misplacing items –Confusion –Inability to carry out daily routine –Difficulty driving, getting lost Older persons: dementia is age-related Older persons: dementia is age-related

10. 10 Warning Signs Memory loss Memory loss Challenges in planning Challenges in planning Difficulty completing familiar tasks Difficulty completing familiar tasks Confusion with time or place Confusion with time or place Trouble with spatial relationship Trouble with spatial relationship Words problems in speaking or writing Words problems in speaking or writing Misplacing items Misplacing items

11. 10 Warning Signs Poor judgment Poor judgment Withdrawal from work/social activities Withdrawal from work/social activities Changes in mood and personality Changes in mood and personality alz.org/alzheimers_disease_10_signs_ of_alzheimers.asp?type=alzchptfooter #signs alz.org/alzheimers_disease_10_signs_ of_alzheimers.asp?type=alzchptfooter #signs

12. When to Screen for Dementia Welcome to Medicare visit(age 65-66): Welcome to Medicare visit(age 65-66): –Introductory visit in the first 12 months –Review of medical and social history –Education about preventive services –Certain screenings, shots, and referrals –Height, weight, blood pressure, vision –Discussion about advance directives –Review of depression and safety risk –May included cognitive screening

13. When to Screen for Dementia Medicare Annual Wellness visit: Medicare Annual Wellness visit: –Lifestyle: diet, exercise, tobacco, alcohol –Cancer screening & immunizations –Update current providers & prescriptions –Height, weight, blood pressure, others –Detection of cognitive impairment –Annual depression screening = new! –Assessment of community/home function –Review of advance directives, POA

14. Why would Seniors want a Screen for Dementia? It’s free! It’s free! No Medicare B copay cost to senior if done during: No Medicare B copay cost to senior if done during: –Welcome to Medicare visit –Medicare Annual Wellness visit

15. What to do with a Positive Screen Referral for diagnostic evaluation Referral for diagnostic evaluation –Thorough medical history –Mental status testing –Physical and neurological exam –Blood tests and brain imaging to rule out other causes of dementia-like Alzheimer's and dementia specialists: Alzheimer's and dementia specialists: –Neurology, psychiatry, geriatricians

16. How Difficult is It?

17. If not Dementia, What? Depression – number 1 Dx in my clinic Depression – number 1 Dx in my clinic Delirium Delirium Drugs, drugs, a multitude of drugs Drugs, drugs, a multitude of drugs Mild Cognitive Impairment Mild Cognitive Impairment Normal, usual aging Normal, usual aging Low vitamin B12 Low vitamin B12 Low or high thyroid Low or high thyroid Many others: cardiac, respiratory, etc Many others: cardiac, respiratory, etc

18. If not Alzheimer’s, What? Alzheimer’s disease 50-60% Alzheimer’s disease 50-60% Vascular dementia 10% Vascular dementia 10% Dementia with Lewy bodies 10-20% Dementia with Lewy bodies 10-20% Parkinson’s Disease Dementia 5% Parkinson’s Disease Dementia 5% Frontotemporal dementia 5% Frontotemporal dementia 5% Mixed dementias (usually AD and vascular) 10-20% Mixed dementias (usually AD and vascular) 10-20% Alcohol-associated Dementia 1-2% Alcohol-associated Dementia 1-2% Creutzfeld-Jakob (mad cow) disease.001% Creutzfeld-Jakob (mad cow) disease.001% Normal Pressure Hydrocephalus (NPH).1% Normal Pressure Hydrocephalus (NPH).1% Huntington’s Disease with dementia.1% Huntington’s Disease with dementia.1% Depression with dementia-like symptoms: unknown Depression with dementia-like symptoms: unknown

19. Why Diagnose Early? Better chance of treatment benefit Better chance of treatment benefit Time to plan for the future Time to plan for the future –Future care preferences and options –Financial and legal matters Less anxiety about unknown problems Less anxiety about unknown problems Participation in clinical trials, research Participation in clinical trials, research Develop relationship with providers and care partners Develop relationship with providers and care partners Benefit from support – Alz Association Benefit from support – Alz Association

20. Why Diagnose Early? Prevention of complications: Prevention of complications: –Sleep disturbance –Mood disturbance –Protect finances, avoid financial scams –Prevent driving accidents/errors –Safety measures: Firearms Firearms Substance and alcohol use Substance and alcohol use Becoming lost Becoming lost

21. Why Diagnose Early? Avoidance of inappropriate, aggressive medical procedures Avoidance of inappropriate, aggressive medical procedures Streamline medications Streamline medications Optimize time with family, leisure, etc Optimize time with family, leisure, etc Work on your bucket list Work on your bucket list Enjoy the time remaining Enjoy the time remaining “I always wanted to….” “I always wanted to….”

22. Is the Diagnosis Certain? May not be certain in early stages May not be certain in early stages Routine testing, at least annual Routine testing, at least annual If diagnosis correct, progression of decline will be present in: If diagnosis correct, progression of decline will be present in: –Cognitive –Function

23. Summary Liberal use of screening tools Liberal use of screening tools Refer often and early for suspected decline, document with screen Refer often and early for suspected decline, document with screen Always consider depression Always consider depression –Annual depression screening Monitor progression, complications Monitor progression, complications Establish support and future plans Establish support and future plans

24. UNM Health Sciences Center Announces New Memory and Aging Center “UMAC” The establishment of a new Memory and Aging Center at the University of New Mexico Health Sciences Center will consolidate programs and coordinate professionals to provide enhanced diagnosis, treatment, research and education in New Mexico. The establishment of a new Memory and Aging Center at the University of New Mexico Health Sciences Center will consolidate programs and coordinate professionals to provide enhanced diagnosis, treatment, research and education in New Mexico. Dr. Gary Rosenberg MD, Chair of the Department of Neurology and Dr. Janice Knoefel MD, Professor of Geriatrics and Neurology are conceptualizing and creating the new UNM Health Sciences Memory and Aging Center (UMAC) at the request of the Dean. Dr. Gary Rosenberg MD, Chair of the Department of Neurology and Dr. Janice Knoefel MD, Professor of Geriatrics and Neurology are conceptualizing and creating the new UNM Health Sciences Memory and Aging Center (UMAC) at the request of the Dean. Three distinct services answering three distinct needs: Three distinct services answering three distinct needs: –Diagnosis and Treatment –Research –Education and Outreach Started the 1st of January 2016, updates will be coming Started the 1st of January 2016, updates will be coming

25. Resources www.mocatest.org www.mocatest.org www.mocatest.org www.minimental.com www.minimental.com www.minimental.com aging.slu.edu/index.php?page=saint- louis-university-mental-status-slums- exam aging.slu.edu/index.php?page=saint- louis-university-mental-status-slums- exam alz.org/alzheimers_disease_10_signs_ of_alzheimers.asp?type=alzchptfooter #signs alz.org/alzheimers_disease_10_signs_ of_alzheimers.asp?type=alzchptfooter #signs