1. Debra Bynum, MD Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH The University of North Carolina at Chapel Hill How to Teach about Dementia…. With Support from The Donald W. Reynolds Foundation ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.

2. 2 Does this Patient Have Dementia?  78 year old man is seen in the clinic for routine follow-up. He is a retired physician and is worried about memory loss. His MMSE is 27. His son has started helping him with his bills and other financial activities. On exam, he has difficulty with word finding and difficulty with “no ifs, ands, or buts….”

3. 3 Does this Patient Have Dementia?  82 year old woman with a 6 th grade education presents for follow up. Her eye sight is limited and the interview is challenging because of her severe hearing loss. Her MMSE is 20.

4. 4 Does this Patient Have Dementia?  91 year old man is admitted to the hospital with urosepsis. He is confused and upset. His MMSE is 23.

5. 5 Outline  What is dementia?  Risk factors and prevention  Dementia, delirium, and depression: Red flags  Assessment tools and strategies  Types of dementia  Treatments  Teaching about dementia….

6. 6 Objectives The learner will be able to:  Define dementia  Name risk factors/causes for dementia  Discuss why delirium and depression are predictors/red flags for dementia  Discuss assessment tools/strategies for identifying dementia  Name at least 5 types of dementia  Discuss the treatment options for dementia

7. 7 What is Dementia?  " I shall not today attempt further to define the kinds of material I understand to be embraced... but I know it when I see it...  Justice Potter Stewart, 1964, attempting to define pornography….

8. 8 DSM IV Definition  Memory impairment associated with (at least 1):  Aphasia (disturbance in language)  Apraxia (impaired motor ability)  Agnosia (inability to identify objects)  Disturbance in executive functioning (ie, planning, organizing, sequencing, and abstracting)  Impacts social, functional, or occupational activities  Decline from a previous level of functioning  Does not occur solely in the setting of delirium Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

9. 9 Key: Impact on Functional Status/Life  Mild Cognitive Impairment: memory loss that does not significantly impact daily functional status

10. 10 Key Point  The score on the MMSE (or any other assessment or screening instrument) is not a component of the definition  You can have a low MMSE and NOT have dementia. You can have a nearly normal MMSE and HAVE dementia

11. 11 Importance  Prevalence of dementia:  3% to 11% in those aged ~65 years  33% in those aged ~85 years  Over half of all skilled nursing home admissions in those aged >60 due to dementia

12. 12 19 th Century List of Causes of Dementia….

13. 13 2011: Risk Factors for Cognitive Decline  HTN (**)  Diabetes  Hyperlipidemia  Current smoking  HIV  ETOH abuse  Prior severe head trauma  Genetic factors

14. 14 Primary Risk Factor  Age

15. 15 Prevention?  No clear evidence to support preventing cognitive decline with Vitamin E, Gingko Biloba, leisure activities, fish oil, estrogen, NSAIDS…..  Observational studies looking at lifestyle changes, mental activity (crosswords, puzzles), etc all challenging because of potential selection bias  “Vitamin E is a drug looking for a disease….”  Dr. Zell Hoole

16. 16 Prevention  Preventing/treating HTN (*), DM, hyperlipidemia, obesity, smoking in mid-life  Prevention of both vascular and Alzheimer-type dementias

17. 17 The 3 D’s: (table from Postgraduate Medicine, Volume 122, Issue 4, July 2010) FeaturesDeliriumDementiaDepression OnsetAcuteInsidiousSubacute CourseFluctuatingProgressiveRelated to specific events DurationDays to weeks Months to years Variable ConsciousnessAlteredClear AttentionImpairedNormal, except in severe dementia Normal Psychomotor changes Increased or decreased Often normalDecreased ReversibilityUsuallyRarelyUsually

18. 18 Reality… FeaturesDeliriumDementiaDepression OnsetAcuteCan seem acute Can be vascular and acute CourseFluctuatingFunction can fluctuate (LBD) Can fluctuate DurationCan be months or more Can progress quickly Can last years ConsciousnessAlteredCan be alteredCan be altered (psychotic) AttentionImpairedImpaired when severe Can have psychoses Psychomotor changes Increased or decreased Can be altered (LBD) ReversibilityNot always (post CABG) RarelyCan be difficult

19. 19 Dementia, Delirium, and Depression  Much emphasis in past made on differentiation  Key points:  1. Often tied together, can have overlap  2. Delirium and depression are markers for underlying cognitive impairment and the development of dementia

20. 20 Late Life Depression: Predictor of Dementia  Women’s Health Initiative Study: Depressive disorder at baseline associated with double risk of incident MCI and dementia  HYVET: Patients with baseline depression had increased risk of mortality, CV mortality, stroke, and dementia (the higher the GDS score, the higher the risk)*  Late life depression may be early manifestation of cognitive impairment *Hypertension in the Very Elderly Trial, coordinated by scientists from Imperial College London, March 2008

21. 21 Should We Screen?  Prevalence of dementia in primary care settings 6-15% in patients over age of 65 (increases with increasing age)  <20% of patients with confirmed dementia on screening had documentation of dementia

22. 22 Assessment Tools for Dementia

23. 23 If You Have 10 Minutes:  MMSE  GPCOG (General Practitioner Assessment of Cognition)

24. 24 MMSE  Commonly used and standardized  Helpful when used repeatedly in same patient  30 total points  Does not assess executive function, judgment, insight  Does not differentiate dementia, delirium, learning disabilities  Dependent upon age and education: Does NOT perform as well in the very educated/high functioning or the poorly educated/lower SES

25. 25 GPCOG (General Practitioner Assessment of Cognition)  Brief cognitive screening for general practice  9 item cognitive assessment (memory of recent events and orientation)  Plus 6 item informant questionnaire  6 minute test  Sensitivity and specificity 85%

26. 26 GPCOG: Patient Examination  1. Repeat name and address (John Brown, 42 West Street, Kensington): 0 points  2. What is the date?: 1 point  3/4. Clock Draw Test (CDT): Draw clock and show 10 minutes past eleven: 2 points  5. Can you tell me something that happened in the news this week?: 1 point  6. What was the name and address?: 5 points  Score: x/9 (0-4 suggest cognitive impairment, 5-8?, 9= normal)

27. 27 GPCOG: Informant Examination (If Patient Score 5-8)  1. Does the patient have more trouble remembering things that have happened recently?  2. Does the patient have trouble remembering conversation a few days later?  3. Does the patient have more difficulty finding the right word or tend to use the wrong words more often?  4. Is the patient less able to manage money and financial affairs?  5. Does the patient need more assistance with transport?  Scores 0-3 suggest cognitive impairment

28. 28 If You Have Only 3 Minutes…  Mini-Cog

29. 29 Mini-Cog  3 minute test to screen for cognitive impairment in older adults in the primary care setting  3 item recall plus scored Clock Drawing Test (CDT)  Normal clock  Hand placed on correct time (10 minutes after 11)  Untrained clinicians good at assessing normal vs abnormal  Faster and less affected by ethnicity, language, and education than MMSE  Can detect Mild Cognitive Impairment (MCI)

30. 30 Mini-Cog: Scoring  1 point for each recalled word  CDT: normal or abnormal  Score:  0: positive for cognitive impairment  1-2 abnormal CDT: positive for CI  1-2 and normal CDT: negative for CI  3: negative screen for dementia (no need to score CDT)

31. 31 If You Have 15 Minutes…  MMSE or GPCOG plus  Trails testing  Categories and letters  Clock drawing

32. 32 Trails B Testing  1-A-2-B-3-C…  Score based upon total time to complete task correctly (seconds)  Mean times  70-74: 111 seconds  75-79: 119 seconds  80-85: 152 seconds

33. 33 Categories and Letter Naming  Score number of animals or letters named in 60 seconds  Mean scores:  70-79: 16 animals  80-89: 14 animals  90-95: 13 animals  Animals: Alzheimer’s disease  F words:  Fronto-temporal dementias  May elicit F-bombs….

34. 34 Standard Workup….  B12, HIV, RPR, TSH  If more acute, think of encephalitis or more atypical diseases  Most recommend imaging if never done before (unless longstanding dementia with slow, typical decline)  Rule out subdural  Rule out NPH

35. 35 Types of Dementia  Alzheimer’s Disease  Vascular Dementia  Overlap (AD/Vascular)  Fronto-Temporal Dementia  Dementia with Lewy Body  Dementia due to Parkinson’s Disease  Other Parkinson Plus Processes  ETOH  HIV, Neurosyphilis, Prion Disease

36. 36 Alzheimer’s Disease  Gradual short term memory loss  Personality changes  Visuospatial problems: difficulty with clock drawing  Apraxia  Medial temporal lobe atrophy on MRI  Difficulty with naming categories (animals, vegetables)

37. 37 Vascular Dementia  Classic: Step wise decline

38. 38 Overlap  Reality: Most cases of dementia in older patients are mixed AD and Vascular (largest risk factor for both is age)  Vascular risk factors increase risk for AD as well as vascular dementia  Cholinesterase inhibitors work just as well (or poorly) in patients with vascular dementia and AD

39. 39 Frontotemporal Dementia (FTD)  Behavioral symptoms (disinhibition)  Executive function problems  Language dysfunction  Frontal release signs  Can occur in patients with motor neuron diseases (ALS)  Can have earlier onset and more often familial than AD

40. 40 Dementia with Lewy Body (DLB)  15-25% cases of dementia in patients >65  Early visual (vivid) hallucinations  Prior sleep disorders (may precede dementia by years)  Parkinsonian features (not overt tremor, but some stiffness, cogwheeling)  More rapid decline  Decline with antipsychotics (especially typical agents) AVOID!  Fluctuating course (can resemble delirium with good days and bad days)

41. 41 Dementia with Parkinson’s  30 % or more of patients with Parkinson’s disease will develop cognitive decline and dementia

42. 42 Parkinson Plus Syndromes  DLB  Multiple Systems Atrophy (Shy-Drager)  Progressive Supranuclear Palsy

43. 43 ETOH Related Dementia  Can have associated cerebellar degeneration  ETOH abuse often unrecognized in older people

44. 44 Impact of Dementia…  Driving, loss of autonomy  Loss of independence (IADLs, ADLs)  Caregiver stress  Wandering, behavioral problems, agitation, sleep disturbances  Risk for elder mistreatment  Risk of placement (falls, incontinence, behavioral)  Falls and fractures

45. 45 Treatment Options

46. 46 Cholinesterase Inhibitors  Benefits overall small: slowing of progression of disease  Similar benefits for AD and Vascular and overlap  No one agent better than another  No evidence to justify use with MCI

47. 47 Cholinesterase Inhibitors  Donepezil 5 mg-10 mg  Rivastigmine pill: 1.5 mg BID – 6 mg BID  Rivastigmine patch: 4.6 mg/24 hrs – 9.5 mg/24 hrs  Galantamine: 4 mg BID or 8 mg ER QD – 12 mg BID or 24 mg ER QD

48. 48 Cholinesterase Inhibitors: Side Effects  Nausea (11-47%)  Vomiting (10-31%)  Diarrhea (5-19%)  Anorexia (4-17%)  Lesser known:  hallucinations/odd dreams/nightmares  Bradycardia  Dizziness, tremor, leg cramps  Urinary Incontinence

49. 49 Memantine (Namenda)  NMDA receptor antagonist/ neuroprotective  Starting dose: 5 mg/day; goal 20 mg (10 mg BID)  Used in combination with cholinesterase inhibitors for patients with moderate-severe dementia  Slowing of progression of disease, benefits limited  Costly, but few side effects or medication interactions

50. 50 Beware Antipscyhotics….  FDA Black Box warning: increased mortality and strokes  Bottom line: may help with symptoms of psychosis and aggression in selected patients, but use with caution and recognize risks  Similar risk and warning with both typical and atypical antipsychotics  Side effects: orthostasis, lethargy, confusion, QT prolongation, edema

51. 51 Clinical Teaching  See one (sometimes), do one, teach one  Lectures  Role modeling  Clinical teaching

52. 52 Role Modeling  Informal (hidden, unwritten) curriculum  Professionalism  Teamwork  Culture of the institution  You are being watched…

53. 53 Strategies for Clinical Teaching  Canned 10 minute talks  Condense this talk and save  Thinking out loud/demonstrating  Use the tools discussed/practiced here in front of learners  Can be useful in acute or busy situations  One Minute Preceptor

54. 54 One Minute Preceptor  Get a Commitment: What do you think is going on?  Probe for supporting evidence: Why?  Reinforce what was done well: You have a thorough differential…  Give guidance/correct errors: It is also important to consider….  Teach a general principle: When you see this, you should always think of…  Conclusion: Let’s go see…

55. 55 One Minute Preceptor  Assess the patient  Assess the learner  Focus teaching on one key point/pearl you want to get across  Give feedback

56. 56 30 Second Preceptor….  WHAT  What do you think is going on?  WHY  Why do you think that?  WHEN….  When you see this, you need to think of ….  Feedback

57. 57 Practice Teaching Cases  Pair up  Take turns role playing the resident/learner and the faculty/preceptor; Use one minute preceptor skills to teach key points about dementia  Spend 10 minutes working through the 3 cases  Wrap up discussion

58. 58 Case 1  78 year old man is seen in the clinic for routine follow-up. He is a retired physician and is worried about memory loss. His MMSE is 27. His son has started helping him with his bills and other financial activities. On exam, he has difficulty with word finding and difficulty with “no ifs, ands, or buts….”  You are precepting in the clinic  The resident tells you that based on the MMSE, the patient has Mild Cognitive Impairment…  Does this patient have MCI? What teaching point do you make to the resident and how?

59. 59 Case 2  82 year old woman with a 6 th grade education presents for follow up. Her eye sight is limited and the interview is challenging because of her severe hearing loss. Her MMSE is 20.  Your resident is worried that the patient has dementia and can no longer live at home.  Does this patient have dementia? How would you assess this? What would you tell your resident?

60. 60 Case 3  91 year old man is admitted to the hospital with urosepsis. He is confused and upset. His MMSE is 23.  Your resident is worried that the patient has dementia and will not be able to return home after discharge.  What do you tell your resident? What teaching points can be made in this case?

61. 61 Group Discussion

62. 62 Case 1: Teaching Strategies  “What do you think is going on? Why do you think the patient has MCI and not dementia?”  “What is the definition of dementia? Could this patient meet that definition?”  “When you see a high functioning, well educated patient, the MMSE may not work well. The diagnosis of dementia is not based upon a number on the MMSE, but an assessment that a patient’s memory loss and cognitive impairment are affecting his overall functional status”.

63. 63 Case 2: Teaching Strategies  “What do you think is the cause of her low MMSE?”  “Why do you think she has dementia? Are there alternative reasons she may have done poorly on the MMSE?”  Feedback: You did a nice job in performing an MMSE on this patient, and recognizing that dementia may be a problem. But remember that MMSE scores may be low for other reasons….  When you see a patient with a low MMSE, think about other factors such as vision, hearing, and educational status that may be playing a role.

64. 64 Case 3: Teaching Strategies  “Why do you think this patient has dementia? What else could be going on?”  “What other diagnoses could account for his MMSE score? Does the MMSE perform well in this setting?”  Feedback: It is important to assess cognitive impairment in older patients who are acutely ill, but remember that acute delirium clouds the picture – you cannot diagnose dementia in the setting of delirium alone. But you are correct to be concerned because the presence of delirium is a red flag for an underlying dementia.  When you see cognitive problems in a patient who is acutely ill, think about delirium. When you see delirium, it is a red flag for possible underlying dementia as well.

65. 65 Key Points:  Dementia is common and often missed  Vascular disease and dementia are intertwined  Red flags for dementia: Age, depression, delirium  Screening tools are quick and easy to use and teach  Think about the different types of dementias…  Dementia has incredible impact on functional status  Treatment options are still limited and do have side effects  Avoid antipsychotics if at all possible

66. 66 Key Point  Take what you have learned and teach…in the clinic, in the ED, on the wards, by modeling, by showing, by talking out loud…

67. 67 Acknowledgements and Disclaimer This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and Health and the UNC Division of Geriatric Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian. 67

68. 68 ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.