1. Assessing the Geriatric Psychiatric Patient in the Ambulatory Setting: Approach to Dementia Assessment
Stephen M. Scheinthal, DO, FACN
Associate Professor, Psychiatry
University of Medicine and Dentistry of New Jersey
School of Osteopathic Medicine (UMDNJ-SOM)
Image created by the University of Medicine & Dentistry of New Jersey School of Osteopathic Medicine

2. Assessing the Geriatric Psychiatric Patient in the Ambulatory Setting: Approach to Dementia Assessment
This Geriatric Psychiatry presentation for General Psychiatry residents is offered by the New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

3. Learning Objectives
To identify the major components of a dementia assessment and their role in determining an appropriate diagnosis and treatment strategy
To distinguish and diagnose four major types of dementia including Alzheimer’s, Vascular, Frontal Temporal and Lewy Body
To appropriately recognize and diagnose dementia and depression in older patients

4. Approach to the Geriatric Patient in the Ambulatory Setting
Chief Complaint
History of Chief Complaint
Past Psychiatric History
Past Medical History
Social History
Functional Assessment
Medication Review
Mental Status Exam
Diagnosis and Plan
Follow Up

5. History Components Chief Complaint History of Chief Complaint
What the patient reports
What the family/caregiver reports
Patient’s understanding of visit
History of Chief Complaint
Time line is important
How problem is impacting daily function
Collateral information may or may not be available
Best to see patient alone first
Establish doctor-patient relationship
Avoid family dynamic during history taking
Privacy

6. History Components Past Medical History Past Psychiatric History
Look for correlation with physical and mental illness
Past Psychiatric History
Prior patterns of disease
Risk factors
Suicide attempts
Hospitalizations
Treatment history

7. Case of Mrs. B.
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8. Case of Mrs. B History Chief Complaint History of Present Illness
“I am upset about coming here, but my daughter made me come. She thinks I am losing my mind.”
History of Present Illness
72 year old female who is very angry and tearful when describing her history
Patient admits to losing things and getting lost driving once. “I got lost because of construction.”
She states, “I am able to do the cooking,” although she admits to leaving a pot burning on the stove on more than one occasion.
Patient does not know how long this has been happening

9. Things to Think About What is confabulation?
Confabulation is the creation of false memories commonly seen in Alzheimer’s Disease. It fills the gaps in the patient’s memory. It can be difficult to distinguish from lying or delusions.

10. Things to Think About Why is collateral information important?
Collateral history becomes very important when a patient is confused, since the history from the patient is not always reliable. When evaluating someone with cognitive issues, family and friends can be helpful in verifying the accuracy of the patient’s report.

11. Case of Mrs. B History History Past Medical History
Patient’s daughter reports increasing confusion and anger
Confusion has been escalating over past year
Forgetting names, missing birthdays
Making up stories that are not true
Got lost coming home twice
Burned several pots on stove
Not sleeping well
Poor appetite, picks at food
Past Medical History
Hyperlipidemia
Breast CA, s/p lumpectomy
Hysterectomy
Osteoporosis
Migraine
Past Psychiatric History
No history of depression

12. Case of Mrs. B History Social History Widowed for 10 years
Retired teacher with college education
Widowed for 10 years
3 children and 7 grandchildren
Lives alone
Drug and alcohol
Wine 2-3 glasses a week with dinner
Denies other drug usage
No advance directive
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13. Case of Mrs. B Medications Medication Review Tums Lipitor 20 mg po QD
Prescriptions:
Lipitor 20 mg po QD
Fosamax 10 mg po QD
Imitrex 50 mg QD (1-2 x a month)
Ambien 10 mg QHS
Over-the-Counter/Herbal Agents
Tums
Multivitamin
Vitamin C
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14. Common Prescribing Cascades
Medication Side Effects
Prescribing Cascade
Selective Serotonin Reuptake Inhibitors (SSRIs)
Serotonin Syndrome
Agitation
Restlessness
Insomnia
Appetite change (increase or decrease)
Can lead to prescribing anti- psychotics or benzodiazepines
Can lead to prescribing of sleep aids
Can lead to prescribing appetite stimulants
Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry 67(1):26-36, 2010.

15. Common Prescribing Cascades
Medication Side Effects
Benzodiazepines
Lethargy
Agitation
Depression
Acetylcholinesterase Inhibitors
Restlessness
Insomnia
Bradycardia
Weight Loss
Prescribing Cascade
Can lead to prescribing psychostimulants
Can lead to prescribing antipsychotics
Can lead to the prescribing antidepressants
Can lead to prescribing antipsychotics or benzodiazepines
Can lead to prescribing sleep aides
Can lead to cardiac workup & pacer placement
Can lead to use of appetite stimulants
Mojtabai R, Olfson M. National trends in psychotropic medication polypharmacy in office-based psychiatry. Arch Gen Psychiatry 67(1):26-36, 2010.

16. Case of Mrs. B. Appearance Speech Affect/Mood Thoughts
Exam
Mental Status Exam
Appearance
Speech
Affect/Mood
Thoughts
Sensorium/ Cognition
71 yo female who appears much younger than stated age, nicely dressed and well groomed. Ambulates with a steady gait. No tremor.
Speech clear, spontaneous, goal directed, no pressure.
Mood, angry with an angry/upset affect.
No suicidal or homicidal ideation, no auditory or visual hallucinations, no looseness of associations, no flight of idea, no ideas of reference, no paranoia.
AAOX 2 (self and place, not date); Memory: short term memory=limited, long term memory=good, registration 3/3, recall 1/3. MMSE 21/30 insight and judgment – Fair.

17. Screening Tests
Test
Sensitivity
Specificity
Mini Mental Status Exam
79%
88%
Mini-Cog
76%
89%
Clock Drawing
81%
77%
Six Item Screen
Montreal Cognitive Assessment (MoCa)
100%
87%
Steve: Moved content to notes for audio. What is citation for table. Need copyright??? Pam, I made table. Multiple sources, how to handle?
Dementia should never be diagnosed based on a screening test.
Dementia is a clinical diagnosis
Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Int Med 122(6): , 1995.
Borson S, Scanlan JM, Chen P, et al. The Mini-Cog as a screen for dementia: Validation in a population-based sample. J Am Geriatric Soc 51(10): , 2003.
Kirby M, Denihan A, Bruce I, et al. The clock drawing test in primary care: Sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry 16(10): , 2001.
Callahan CM, Unverzagt FW, Hui SL, et al. Six Item Screener to identify cognitive impairment among potential subjects for clinical research. Med Care 40(9): , 2002.
Nasreddine ZS, Philips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatric Soc 53(4): , 2005.

18. Case of Mrs. B Labs Laboratory Results CBC: WNL BMP: WNL LFT: WNL
Thyroid: WNL
B12 :WNL
Folate: WNL
UA C&S: WNL
RPR: Neg
Total Cholesterol: 210, LDL 130, HDL 30
CT-Head: no focal lesions, age related atrophy
Discuss work-up for dementia.

19. Role of Neuroimaging Neuroimaging could also include:
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET)
Co-Registration is also available where CT and PET are integrated in the same machine allowing for anatomic and metabolic imaging.
Discuss role of neuroimaging in dementia.

20. Does the patient have dementia?
Case of Mrs. B
Does the patient have dementia?
Patient has progressive memory loss
She is having impairment in IADL’s
There is impairment in planning
Impairments are affecting function
Need to rule out other medical illness
Chow TW, Binns MA, Cummings JL, et al. Apathy symptom profile and behavioral association in frontotemporal dementia vs dementia of Alzheimer type. Arch Neurol 66(7): , 2009.

21. Dementia Subtypes
Cortical (e.g. Alzheimer’s, Frontotemporal, Lewy Body)
Focal symptoms
Language difficulties
Aphasia
Anomia
Visual spatial difficulties
Apraxia
Agnosia
Difficulty learning new information

22. Dementia Subtypes Subcortical (e.g., Vascular, Parkinson’s)
Memory deficits
Slowing of processing
Change in personality
Difficulty retrieving information

23. What Type of Dementia? Alzheimer’s Most common type of dementia
Insidious onset
Progressive
Apathy
Executive dysfunction
Problems planning
Problems organizing
Confabulation
Aphasia
Agnosia
Apraxia
Anomia
Visuospatial impairment
Late in disease
Rigidity
Gait disturbance
Seizures
Total aphasia
Dysphagia
Reichman WE, Cummings JL. Dementia. In: Duthie EH, Katz PR, Malone ML (Eds.). Practice of Geriatrics, 4th Edition. Philadelphia, PA: Saunders Elsevier, 2007:

24. DSM-IV TR Criteria for Dementia of the Alzheimer’s Type
A. The development of multiple cognitive deficit manifested by both
Memory impairment (impaired ability to learn new information or to recall previously learned information)
One (or more) of the following cognitive disturbances:
aphasia (language disturbance)
apraxia (impaired ability to carry out motor activities despite intact motor function)
agnosia (failure to recognize or identify objects despite intact sensory function)
disturbance in executive function (i.e. planning, organizing, sequencing, abstracting)
The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

25. DSM-IV TR Criteria for Dementia of the Alzheimer’s Type
The course is characterized by gradual onset and continuing cognitive decline.
The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure, hydrocephalus, brain tumor)
systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)
substance-induced condition

26. DSM-IV TR Criteria for Dementia of the Alzheimer’s Type
E. The deficits do not occur exclusively during the course of delirium.
F. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia).
DSM IV TR References:
1. Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1): , 2001.
2. Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

27. What Type of Dementia?
Frontotemporal Dementia (FTD) and Pick’s Disease
Behavioral changes
Disinhibition
Impulsivity
Intrusiveness
Executive dysfunction
Judgment changes
Anomia
Aphasia
Reichman WE, Cummings JL. Dementia. In: Duthie EH, Katz PR, Malone ML (Eds.). Practice of Geriatrics, 4th Edition. Philadelphia, PA: Saunders Elsevier, 2007:

28. What Type of Dementia? Lewy Body Dementia (LBD) Sleep disturbance
Auditory hallucinations
Visual hallucinations
Masked face
Rigidity
Parkinsonism
Symptoms worsen with antipsychotics
Serby M, Samuels S. Diagnostic criteria for dementia with Lewy bodies reconsidered. Am J Geriatr Psychiatry 9(3): , 2001.

29. What Type of Dementia? Vascular Note vascular risk factors
Abrupt in onset
Stepwise progression
Psychomotor slowing
Depressive features
Focal neurologic symptoms
Urinary incontinence
Preserved awareness of surroundings
Gait disturbance
Depression
Psychosis
Knopman DS. An overview of common non-alzheimer dementias. Clin Geriatr Med 17(2): , 2001.

30. What Type of Dementia? Parkinson’s Disease 40% develop dementia
Apathy/depression
Psychomotor slowing
Gait disturbance
Visual hallucination
Typically small animals or human forms
Delusions
Patients may respond well to ACHEI’s
Clozaril treatment of choice for psychosis
Start at 12.5 mg QHS
Weintraub D, Hurtig HI. Presentation and management of psychosis in Parkinson’s disease and dementia with Lewy bodies. Am J Psychiatry 164(10): , 2007.

31. Things to Think About Is the dementia reversible?
0.29% are partially reversible
0.31% are fully reversible
Some reversible causes include; medication, infection, tumors, normal pressure hydrocephalus, nutritional deficiencies, hypothyroidism and hypoglycemia
50-60% of dementias are of the Alzheimer’s type which is the most common form of dementia
Almost 50% of people in their 80s will develop some type of cognitive disorder
Clarfield AM. The decreasing prevalence of reversible dementias: An updated meta-analysis. Arch Int Med 163(18): , 2003.

32. Depression versus Dementia
Symptom
Depression
Dementia
Memory
Trouble concentrating
Trouble storing new information
Orientation
Normal
Impaired
Language
Word finding deficits
Using objects
Apraxias
Thoughts
Negativity
Confabulation

33. Is there a Relationship between Dementia and Depression
Untreated depression may progress to dementia
Depression may be a risk factor for dementia
Depression may be a prodromal symptom of dementia
Note:
Cognitive impairment is part of depression criteria
Apathy is a common feature of depression and dementia
Can be difficult to distinguish from one another
Depression often seen in subcortical dementia
More research is required on the relationship between depression and dementia.
Ownby RL, Crocco E, Acevedo A, et al. Depression and risk for Alzheimer disease: Systematic review, meta-analysis, and metaregression analysis. Arch Gen Psych 63(5): , 2006.

34. Case of Mrs. B Is the patient depressed?
While the patient is angry, upset and frustrated, she has acute reason for this.
Missing are the DSM-IV TR criteria for depression.
Patient denies symptoms of depression, but admits to tearfulness.
Collateral information does report decreased sleep and decreased appetite.
The Tearfulness alone is not an indication of depression
Depression is often linked to subcortical cerebral vascular disease
There is a high correlation between vascular dementia and depression
case slides should be easy to distinguish – this is unclear again – perhaps have a similar title or appearance for the case slides to help learner
Chow TW, Binns MA, Cummings JL, et al. Apathy symptom profile and behavioral association in frontotemporal dementia vs dementia of Alzheimer type. Arch Neurol 66(7): , 2009.

35. Things to Think About Highest risk group for completed suicide
What is the potential risk of suicide?
Highest risk group for completed suicide
Often will not report or minimize feelings
Red Flags
Older white male
Single, no close friends or family
Multiple medical illnesses
History of prior suicide or depression
Helpless/Hopeless
Alcohol or other substance use
Heisel MJ, Duberstein PR, Lyness JM, et al. Screening for suicide ideation among older primary care patients. J Am Board Fam Med 23(2): , 2010

36. Case of Mrs. B Assessment Is the course subacute or chronic? Chronic
Is the course of decline steady or stepwise?
Is the syndrome cortical (impaired language, memory, visual spatial) or subcortical (impaired motor function, apathy, personality)?
Was the first symptom cognitive or noncognitive?
Are extrapyramidal symptoms present?
Chronic
Steady
Cortical
Cognitive No
The case slides should be easy to distinguish – this is unclear again – perhaps have a similar title or appearance for the case slides to help learner

37. Case of Mrs. B
Assessment
Axis I Dementia NOS, probable dementia of the Alzheimer’s type with depression
Axis II Defer
Axis III Hyperlipidemia, Osteoporosis, migraines by history, probable Alzheimer’s disease
Axis IV Social (widowed, lives alone), financial
Axis V
The case slides should be easy to distinguish – this is unclear again – perhaps have a similar title or appearance for the case slides to help learner

38. Things to Think About Will she require services to stay at home?
She is having significant dysfunction of her IADL’s.
She is getting lost driving and has burned pots on the stove.
Patient should be referred for driving evaluation.
Cooking should only be done under supervision.
Patient admits to drinking.
Is she safely administering her own medications?
Social service consult is critical to addressing safety issues with patient and family.

39. Case of Mrs. B Neuropsych testing within the month Plan
Short Term Plan
Neuropsych testing within the month
Cognitive baseline
Identify specific deficits
Driving evaluation
Patient getting lost
The case slides should be easy to distinguish – this is unclear again – perhaps have a similar title or appearance for the case slides to help learner

40. Case of Mrs. B Plan Short Term Plan Social work assessment
Assess in home safety
Medication safety
Access community social service agencies
Advance care planning

41. Case of Mrs. B Consider acetylcholinesterase inhibitor Long Term Plan
To slow decline and to aid function
Minimum trial of 6 month
Start:
Aricept 5 mg QAM x 30 days then
Aricept 10 mg QAM
Monitor for:
Change in sleep
Decreased appetite
Increased agitation
Bradycardia/syncope
The case slides should be easy to distinguish – this is unclear again – perhaps have a similar title or appearance for the case slides to help learner
Rabins PV, APA Work Group on Alzheimer’s Disease and Other Dementias. Practice guideline for the treatment of patients with Alzheimer's disease and other dementias, 2nd edition. Am J Psych 164(12 Suppl):5-56, 2007.

42. Case of Mrs. B Long Term Plan Recommend decreasing Ambien to:
5mg po QHS
Monitor for change in sleep
Reassess need at next follow-up visit
4-6 weeks

43. Things to Think About
Should the patient be on psychoactive medication?
Not every patient needs psychoactive medication
Resist temptation to place people on medication without clear indication and diagnostic criteria for medication
In the elderly side effect risk always has to be considered against benefit
Avoid prescribing cascades
Other question slides you repeated the question at the top. Why did you use a different format for this?
Should this be deleted. Move to the end?

44. Case of Mrs. B Long Term Plan Anger may or may not be situational
Patient did not want to come to doctor
Friction with daughter
Behavior/mood may be related to current situation or may be depressive symptoms/frustration due to dementia.
The case slides should be easy to distinguish – this is unclear again – perhaps have a similar title or appearance for the case slides to help learner
Rabins PV, APA Work Group on Alzheimer’s Disease and Other Dementias. Practice guideline for the treatment of patients with Alzheimer's disease and other dementias, 2nd edition. Am J Psych 164(12 Suppl):5-56, 2007.

45. Case of Mrs. B Long Term Plan Follow-up visit in four to six weeks
Reassess mood symptoms at that time
Consider need for antidepressant
If necessary:
Celexa 10mg po QAM
Will take days to see effect

46. Pearls
Due to cognitive impairment patient may be limited source of information
Collateral information
Confirm or dispel patient’s report
Provide additional history
History and timeline of decline are important
Dementia is a clinical diagnosis
Need to exclude reversible causes of dementia

47. Pearls Distinguishing between Depression and Dementia can be difficult
Note level of functioning
Safety assessment is important
Engage social services to help provide a support system for patients and their family