Recognizing and Diagnosing Memory Loss

Recognizing and Diagnosing Memory LossBy Dania Phelps NPMental Health PractitionerBlack Hills Health Care SystemHot Springs VAMCI am a Psychiatric Nurse Practitioner working in Primary Care in the Memory Clinic.Focus of this clinic is early recognition of memory loss, diagnosis, and case management/support of veterans and their families coping with dementia.

1Credits:Dementia Demonstration ProjectDirected by Dr. Riley McCartenDirector or the Geriatric Research Education and Clinical Center at the Minneapolis Veterans Medical Center

Dementia Demonstration ProjectUtilized advanced practice registered nurses who were trained in screening, evaluating, and managing cognitive impairment.Embedded into the Primary Care Clinics at 7 VA centersThe APRNs functioned as Dementia Care Coordinators.

Dementia Demonstration ProjectAt the end of the 2 year project:8342 Veterans accepted memory screeningCriteria being 70 years of age or older with no previous diagnosis of dementia were offered the screening3 word recall and clock draw test was utilized97% acceptance rate Dementia Demonstration ProjectOut of 8342 Veterans 2081 (or 26%) failed the screen681 ( or 33 % )Veterans agreed to a comprehensive evaluationOf this group 95% had cognitive impairment which included 77% having full blown dementia

Dementia Demonstration ProjectMean cost of medical care in the year before diagnosis (minus the cost of evaluation) was $13,378.00

The year after diagnosis mean cost decreased to $11,636.00Course Objectives:1. Recognize how an undiagnosed memory problem effects medical outcomes vs. What a recognized memory diagnosis means to medical outcomesKnow what meets criteria for Dementia Know the common causes of DementiaKnow Criteria for Mild Cognitive Impairment (MCI) and Cognitive Disorder NOSKnow the Criteria for a Memory Work upBe able to put the data together to form a Diagnosis/and PlanTreatment for Alzheimers Disease and other Dementias.Statistics According to the 2011 Alzheimers Disease Facts and FiguresIt is estimated that 5.4 million Americans have Alzheimers Disease. 200,000 of those are under the age of 65.This translates to 13% or 1 in 8 Americans over the age of 65 have Alzheimers Disease.This means: 4% are under the age of 656% are 65-74 years old45% are 74-84 years old45% are 85 or olderStatistics ContinuedBy the time we reach 85 years of age we have a 50% chance of having Alzheimers Disease at some stage or another.Women develop Alzheimers Disease more often then men which is partially explained by the fact they still tend to live longer.Currently every 69 seconds someone in this country develops Alzheimers Disease. By mid century one in 33 will develop Alzheimers Disease.DSM IV Dementia CriteriaEvidence of memory impairmentNeuro/Psych evaluationMMSE , SLUMS, MoCA or other reliable testingPlus one of the following deficitsAphasiaApraxiaAgnosiaExecutive dysfunction

Cognitive deficits cause:Impairment in social or occupational functioningMust represent a decline in functioningDo not occur exclusively during deliriumAre not due to other CNS or systemic disease or substance induced.Are not better accounted for by another DSM-IV Axis 1 Disorder

Dementia is not a specific disease, but rather a descriptive term for a collection of symptoms. There are many disorders that can cause dementia.10Mild Cognitive ImpairmentMild cognitive impairment is evidenced by neuropsychological testing or clinical assessment. People with MCI function normally so therefore do not meet criteria for dementia. 45 50% of those diagnosed with MCI will develop Alzheimers Disease, the other 55-50% will improve or Stay the same.Cognitive Disorder NOS294.9 Per DSM-IV-TRThis category is for disorders that are characterized by cognitive dysfunction presumed to be due to the direct physiological effect of a general medical condition that do not meet criteria for any of the specific deliriums, dementias, or amnestic disorders.Delirium Is NOT dementiaPeople with dementia are more prone to developing deliriumOften associated with illnesses, hospitalization, surgery ,and medicationsCharacterized by:Rapid onset of confusion, disorientation, waxing and waning of attention, waxing and waning of consciousnessAssociated with higher mortality

Alzheimers Disease Accounts for 50-70% of all dementiasGenerally appears after the age of 60, but some early onset forms can appear as early as age 30. Most often we see this in people in their 70s and 80s.By the time someone is diagnosed the person may have had the disease 10-20 years.Memory changes occur initially, but as the disease progresses we start seeing problems with executive functioning, and eventually problems with movement and changes in perspective.Alzheimers Disease is a terminal diseaseNeuronHealthy brain cell and a diseased brain cellAlzheimers Disease: Unraveling the Mystery National Institute on Aging National Institute on Health

Brain cells in Alzheimers Disease develop neurofibrillary tangles and largely made up of the protein tau. Tau is normal in brain cells, but in AD the tau is changed. The tau is twisted into pairs of helical filaments that collect into tangles.This causes a collapse of the neurons transport system then death of the neuron.15Lewy Body DementiaAccounts for about 15% of all dementiasProgressiveStarts in the mid brain called the substantia nigra developing abnormal structures called Lewy Bodies. Lewy Bodies are made up of the protein call alpha synuclein, also linked to Parkinsons Disease and other disorders. Symptoms include hallucinations, Parkinsonism, memory impairment, poor judgment, confusion, shuffling, day to day fluctuations in attention, REM sleep disturbance, and autonomic dysfunction e.g. labile BPs.

What Causes Dementia?Alzheimers DiseaseLewy Body DementiaFrontal Temporal DementiaParkinsons DementiaNormal Pressure HydrocephalyStrokeHead traumaBrain Mass (benign or malignant)Alcohol and other drugsTo name the most common.Frontal Temporal DementiaGenerally a spectrum of disorders that is sometimes hard to distinguish from Alzheimers Disease, Parkinsons or Amyotrophic lateral sclerosis (ALS)

Accounts for about 2-10 % of the dementiasSymptoms usually appear between the ages of 40 and 65Some people with FTD have a family hx indicating a strong genetic factorPeople live an average of 5-10 years after diagnosis.Frontal Temporal Disorders cont.Grouped into 3 types: 1. Progressive behavior/personality decline Picks Disease, Frontal Temporal variant Characterized by changes in behavior, personality, poor judgment, and emotional changes2. Progressive Language decline characterized by changes in language, speaking, understanding, reading and writing.3. Progressive motor decline characterized by difficulty in movement, shaking, difficulties with gate, frequent falls, and poor coordination.

Parkinsons DementiaBelieved to be part of the Lewy Body Spectrum of Disorders 60% of people with Parkinsons Disease will developDementia.

Normal Pressure HydrocephalusAbnormal accumulation of fluid in the ventricles of the brain.Can be found on CTCan be surgically correctedMemory loss , changes in executive functioningIncontinence new onsetShuffling gate/changes in coordinationSlowed processing

Vascular DementiaAccounts for up to 20% of all the dementiasCaused by cerebrovascular or cardio vascular problems Begin suddenly after a major stroke or multiple strokesshowing a stepwise progression. Those who have had a stroke may improve over timeKeep in mind cardio vascular problems are a vulnerability for Alzheimers DiseaseIf you have a sloping progression you may want to consider a mixed dementia

In Alzheimers Disease, Disease starts in the area of the hippocampus, progresses to the frontal brain and then through out the cortex.23Unmodifiable Risk Factors for dementiaAge (Number 1 risk factor for dementia)Family hx of Dementia (Genetics) Scientists have discovered variations that directly cause Alzheimers disease in the genes coding three proteins: amyloid precursor protein (APP), presenilin-1 (PS-1) and presenilin-2 (PS-2). APOE status APOE-e4 is one of three common forms of the APOE gene; the others are APOE-e2 and APOE-e3. Everyone inherits a copy of some form of APOE from each parent. Those who inherit APOE-e4 from one parent have an increased risk of Alzheimers. Those who inherit APOE-e4 from both parents have an even higher risk, but not a certainty.Female GenderAlzheimer's Association National Office 225 N. Michigan Ave., Fl. 17, Chicago, IL 60601Alzheimer's Association is a not-for-profit 501(c)(3) organization

24Modifiable Risk Factors for DementiaHypertensionElevated cholesterolHigh Homocysteine levels Diabetes-elevated insulin levelsHeart DiseaseCerebrovascular diseaseHead InjuryEnvironmental exposureObesityMultiple exposure to anesthesiaPTSDThe Alzheimers Answer 2008 by Marwin Noel Sabbach, MD Wiley and Sons PublishingHigh Homocysteine levels may also be related to low folate, B12, B6 25Recognized vs. Unrecognized DementiaUNRECOGNIZEDRECOGNIZEDForgets to refill medicationTakes medications incorrectly e.g. warfarinDoes not remember or understand medical directions or appointmentsMore falls and injuriesMore trips to ER/UCHigher cost for medical careUnrecognized driving concernsHigher risk for wandering

Providing more support for the patient with memory problems e.g. home care nurse, family involvement, meals on wheels, adult day care, financial helpAsking family to attend appointments. Monitoring for caregiver burn outDriving retirement/monitoringPlanning for the future and help with transitional support

What is normal aging vs. a memory concern?Normal aging does not cause dementia.We may not process information as quickly. We may not multitask as well. Sure we forget to pay a bill once in a while, perhaps forget to take our medication, and even have problems with remembering the names of familiar people (not close family or friends) but we are still able to cognitively manage our lives.

27What isnt normal agingMemory changes that disrupt daily lifeChallenges in planning or solving problemsDifficulty completing familiar tasks Confusion with time or place Trouble understanding visual images and spatial relationships New problems with words in speaking or writing Misplacing things and losing the ability to retrace steps Decreased or poor judgment Withdrawal from work or social activities Changes in mood or personality2009 Alzheimers Association

Memory Screening in the Clinical SettingWe routinely screen for many problems such as colo/rectal cancer, depression, PTSD, prostate testing etc. Memory needs to be assessed to.Assessing Mental Status is important to ensure you are receiving a reliable history and that the patient is able to comply with the recommended treatment.Dementia is common and age is the #1 risk factor. In the early stages it is hard to recognize in a 20-30 minute clinic visit.Pay attention:Are they reordering their medications in a timely basis according to how you have prescribed them (Have them bring in their prescriptions and OTC)Be alert to family/friend concerns of memory or behavior changesAre they reporting a recent car accident, falls, speech/language problems.Remember the patient may not notice they have a memory concern.Is there a change in their general hygiene?Do they seem more disorganized, irritable, vague in their hx, facts not adding up, confused?

Tools for Screening MemoryMini Mental State Exam: Fairly common, has a copy write, and takes more than 5 minutes to perform perhaps not as sensitive to dementiaMoCA (Montreal Cognitive Assessment) again takes more than 5 minutes to perform and time is limited in the clinic setting though more sensitive to dementia and can be used in clinical setting without permission. I like using the MINI Cog It is a 3 word recall and clock draw test. It doesnt diagnose, it is a screening tool only but it provides immediate recall, visual spatial/executive function, and delayed recall information. Takes about 2 minutes to perform.

Please see sample MINI Cog and MoCA.30MINI COG ScoringScoring is 1 point for each word recalled2 points for a correct clock, must have a circle, #s 1-12 in fairly accurate axis.Hands pointing to the correct time. Hands do not have to be of correct length.Negative score is 4-5 points (In my clinic)Positive score is 3 points or less. At this point you recommend or start a memory evaluation. Memory EvaluationSee Hand out:Identifying Data: Name/Age/SSN/Sex/Marital Status and Home Status/Occupation/Dominant Hand/ and who accompanies them for the evaluation and are they reliable.Chief Complaint: Patients view of their memory Often they do not recognize a problem.History of Present Illness Precipitating factor? Past Medical History (Stroke, exposures (radiation, heavy metals, chemicals), surgeries, accidents, head trauma etc)

Provide copy of a H&P format and MoCA32Evaluation cont.AllergiesCurrent Medication and verify against medical chartBe sure to look at bottles and when they were last filledIs compliance good? Who sets up and reorders the meds?Are there any medication that cause cognitive effect?For example: hypnotics, anticholinergics, pain medications, atypical antipsychotics, antidepressants, antileptics,

Evaluation Cont.Family History: CNS disorders, Stroke/TIA, MH issues Dementia, seizure disorders etc. Status of Family members: Father, Mother, Siblings,childrenSocial History:Alcohol Occupation SpiritualTobacco Armed forces Service Gambling Hobbies Education Level Street Drugs Exercise

Evaluation cont.Review of Systems: Neurologic examCognitive Test: MoCA, MMSE, SLUMS (I use the MoCA. Geriatric 15 question depression scaleFunctional Assessment Staging (FAST Score)Labs : CBC, Lytes, BUN/CR, Hepatic Panel, Magnesium, Calcium, RPR, UA, Glucose/HgA1C, TSH, B12, Folate, Vitamin D, Heavy Metals if indicated.Brain Imaging: CT of Head without or with/without Contrast or Brain MRICognitive Performance Test and Driving ScreenSometimes a Neurology consult, Neuro Psych, Speech Therapy consult etc.

Rapid Plasma Reagin (RPR) refers to a type of test that looks for non-specific antibodies in the blood of the patient that may indicate that the organism (Treponema pallidum) that causes syphilis is present.

35Making Sense out of the DataMaking a diagnosis is a process of ruling in and ruling out differential diagnosis.At this time there is no definitive test to diagnose Alzheimers Disease other than autopsy.This includes frontal temporal dementiaLewy body dementiaParkinsons Dementia

MRI and CT of Head can pick up stroke, masses, NPH.Staging DementiaFAST Copyright 1984 by Barry Reisberg, M.DReproduced by permission from Barry Reisberg, MD

Professor of Psychiatry Director, Fisher Alzheimers Disease ProgramClinical Director, Aging & Dementia Clinical Research CenterDirector, Clinical Core, NYU Alzheimers Disease CenterCenter of Excellence on Brain Aging New York University Langone Medical Center

Case Studies1st Case Study 2nd Case Study 3rd Case Study

Read case studies and discuss38

TreatmentMedications: For Alzheimers Disease , Parkinsons Dementia, Lewy Body dementia, or Mixed Dementia (Vascular and Alzheimers Disease)Cholinesterase InhibitorsAricept (donepezil)Razadyne (galantamine)Exelon (Rivastigmine)

Namenda (memantine) N-Methyl D-Aspartate antagonist. Blocks toxic effects ofGlutamate and regulates Glutamate activation

Co existing Depression Start antidepressant such as SSRI

Behaviors: Behavior management through behavior modification preferredtypical and atypical antipsychotics (Be very cautious due to increase risk of death. If so start low and go very slow) ConclusionDementia is a functional diagnosis.

There are many causes, vulnerabilities, and diagnosis that lead to dementia.

To determine the cause of dementia allows for proper treatment, support, and education to your patients and their support systems/family.Questions?