7/27/2017

1

Understanding Dementia and Cognitive Assessment

ANNA H. CHODOS, MD, MPH

DIVISION OF GERIATRICS

DIVISION OF GENERAL INTERNAL MEDICINE, ZSFG

CO-PI , OPTIMIZING AGING COLLABORATIVE

GERIATRICS WORKFORCE ENHANCEMENT PROGRAM

The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP28727.

DisclosuresI have nothing to disclose.

Outline

Dementia overview◦Definition◦Assessment

Behavioral issues in dementia

Dementia 

7/27/2017

2

“A Senior Moment”Is there age‐related decline?

Appear to decline with age:◦ conceptual reasoning

◦memory

◦ processing speed

Gradual, not enough to impair function

Dementia• 1 in 9 adults age 65+, and ~1 in 3 age 85+ have dementia 

Alzheimers Association Facts and Figures 2015; Yaffe K et al. BMJ 2013;347; Van Rensbergen G, Nawrot T. BMC Geriatrics 2010; Cordell Alz and Dementia 2013

Cognitive impairment unrecognized  in ~50% of affected patients in primary care. 

Dementia (Major Neurocognitive Disorder):

Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains:◦ Learning and memory◦ Language◦ Executive function◦ Complex attention◦ Perceptual‐motor◦ Social cognition = behavior

Part I

Dementia (Major Neurocognitive Disorder), cont’d:

The cognitive deficits interfere with independence in everyday activities. 

The cognitive deficits do not occur exclusively in the context of a delirium.

The cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia)

Diagnosis of dementia= acquired cognitive impairment+ acquired functional impairment

DSM‐V (2013)

Part II

Part III

Part III

7/27/2017

3

A Case

88 yo man, here for follow‐up.  

No complaints. 

PMH: hypertension, glaucoma, depression

Meds: HCTZ, eye drops

Says he takes the medicines. “You have my list.”

Our CaseMr. H’s probability is high given his age.◦ Early warning signs present?

◦ Sparse details during conversation and no memory for current news events.

Red flags for DementiaRepetition (not normal in span of a clinic visit)

Losing track of conversation

Frequently deferring to caregiver/family

Unexplained medical decompensation

Unexplained weight loss

Missing appointments

Inattentive to appearance, behavioral changes

Falls or injury, hospitalizations

Paucity of content, detail

Dementia Assessment:Part I

Cognitive:◦History and trajectory of:

◦Memory

◦ Executive Function

◦ Visuospatial

◦ Language

◦Motor

◦ Psychiatric/Behavioral

7/27/2017

4

Dementia Assessment: Part INeurologic exam: MS, motor, balance

Cognitive Testing◦What tools are you familiar with?

◦What do you have time to do?

Screening Method: Mini‐Cog1‐2 min

3 item recall (3 points)  

+ CLOCK DRAW (2 points)

Negative screen ≥3

Positive screen <3, consider DELIRIUM vs. DEMENTIA 

http://www.alz.org/documents_custom/minicog.pdf

MOCA Test10‐20min

• Positives: Many languages, Many cognitive domains• Negatives: +1 education < HS, unclear if this is enough• USE THE INSTRUCTIONS the first few times you use it 

www.mocatest.org (need to register)

GP‐COG5‐8 min 

Part 1‐ Patient (memory)

Part 2‐ Informant (function)

Available in Spanish, Chinese, Korean.

http://gpcog.com.au/

7/27/2017

5

Our CaseNeurologic exam normal.

Mr H’s MOCA test:  14/30 

What is his education?What is normal for 88yo?

Dementia Assessment: Part IIFunction:◦Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs)

How the person is doing is the most important part of this diagnosis.

Assessing FunctionADLs: Impacted late◦ Bathing

◦ Dressing

◦ Toileting, continence

◦ Transferring

◦ Feeding

IADLs: Impacted early◦ Driving/transportation

◦ Using phone

◦ Shopping for food

◦ Finances

◦ Cooking

◦ Housework

◦ Taking meds

Our CaseFunction: He reports no problems with ADLs or IADLs◦ In the clear?

7/27/2017

6

Dementia Assessment: Part IICollateral‐ family, 

caregiver/sMemory

Executive fxn

Language

Visuospatial

Motor 

Behavior

FUNCTION

Our Case

Collateral‐◦ His wife’s children ‐unaware anything serious was going on, says he drives daily. 

◦Wife says he is more forgetful, forgets bills.

Dementia assessment: Part IIIR/o reversible causes

◦Delirium: acute, fluctuating, inattentive

◦Substance Use

◦Depression

◦Labs: TSH, B12, RPR and HIV 

◦Medication review

Medications Causing Cognitive Symptoms

BenzodiazepinesAnti‐cholinergics: diphenhydramine, hydroxyzine, chlorpheniramine◦ Including OTC combination meds‐ tylenol PM

Sleep medications: Z‐drugsMuscle relaxants (cyclobenzaprine, carisoprodol) Antispasmotics: oxybutynin, tolterodineTCA anti‐depressantsAnti‐psychotics

7/27/2017

7

Dementia: Head imagingWhen should I order head imaging?

Feldman HH, et al. CMAJ. 2008 Mar 25;178(7):825‐36Cordel CB, et al. Alzheimers Dement. 2013 Mar;9(2):141‐50

• <65• Rapid onset• Other diagnoses: cancer, HIV

• Head injury• Focal neurologic findings• Meds: anti‐coagulants

Our caseLabs wnl

Diagnosed mild/moderate dementia–informed patient and CDPH (mandated reporter) ‐> they will inform DMV

Dementia: the take home

Suspect it– Recognize red flags and symptoms

Diagnosis it:◦ Part I Cognitive history

◦ Part II Functional history ◦ Get collateral

◦ Part III R/o reversible causes

Get specialist help when you are not sure

Types

• Alzheimer disease

• Vascular dementia

• Dementia with Lewy Bodies

• Parkinson’s disease with dementia

• Frontotemporal dementia

• Normal pressure hydrocephalus

• Alcohol-related dementia

• HIV-related dementia

• Syphilis-related dementia

• Progressive supranuclearpalsy

• Corticobasal degeneration

• Primary progressive aphasia

• Creutzfeldt-Jakob disease

• Huntington disease

7/27/2017

8

Types of Dementia

Type MCI Alzheimers Vascular Lewy Body FTD

Onset Gradual Gradual Sudden, or stepwise

Gradual Insidious, younger

Cognitive Features

Memory MemoryLanguage

Depends on injury

MemoryVisuaspatialHallucinationsFluctuating

ExecutiveDisinhibitionHyperorality<memory

Motor Features

Rare early Rare earlyApraxia-late

Depends on injury

Parkinsonian None

Other May progress to AD

Gradual Decline

Stepwise decline

Caution with antipsychotics-

Preserving cognition • Intellectually engaging activities

• Physical Activity

• Social Engagement

Harada, Clin Geriatr Med. 2013 Nov; 29(4): 737–752.

Behavioral symptoms of dementiaNeuropsychiatric symptoms of dementia

“Agitation” (nonspecific), aggression, arguing, irritability, delusions, hallucinations, wandering, depression, apathy, disinhibition, repetitive behaviors, sleep disturbances

Most patients have some NPS.◦ ~80% at some point, especially later in disease course

Panza F, et al. (2015) Expert Opinion on Pharmacotherapy 16:17, pages 2581‐2588. ; Lyketsos CG, et al. JAMA. 2002 Sep 25;288(12):1475‐83.

7/27/2017

9

NPS

Why are they important?◦Worse daily function◦Worse quality of life◦Burden on caregivers◦ Behavioral symptoms > physical needs

◦More institutionalizationAllegri RF, Neuropsychiatr Dis Treat. 2006;2:105–110.; Lyketsos CG, et al. Alzheimers Dement. 2011 Sep; 7(5): 532–539.Torti FM, Alzheimer Disease & Associated Disorders 200418(2), pp 99‐109

A Case: Neuropsychiatric Symptoms in Dementia

Ms. L who lives in a board and care, spends many afternoons banging on the chairs causing a lot of noise. 

Her daughter is asking if there is “anything we can give her to calm her down” so the staff will stop calling her?

Example: www.teepasnow.com‐‐“About Videos”: Challenging Behaviors

What can we do? An Approach to NPS

Identify and describe the behavior 

Identify triggers

Identify if it’s a problem and if it is leading to potential harm

7/27/2017

10

Identify the behaviorMs. L– Behavior‐‐ repetitive behavior, argumentative

Examples:

Yelling, vocalizing

Repetitive behaviors‐ cleaning, reorganizing 

Hitting

Identify triggers

Needs: thirst/hunger, pain, toileting, boredom, tired, comfort

Environment: Attendant gender, bathing, undressing

Over or understimulated◦ Isolation and loneliness

◦ Unwanted interaction, fear

Depression, anxiety

Our Case: NPS in dementiaMs. L was a housekeeper prior to retirement. 

In reviewing her needs, staff noticed she was not taken to the toilet enough during the afternoon because she was resistant. 

Identify if it’s a problemWhat is the consequence of this behavior?◦Caregiver stress

◦Harm to others/self

What has been tried?

7/27/2017

11

Identify the behavior to identify solutions

Common NPS Interpretations/solutions

Toileting issues Timed voiding

Agitated, upset, restless

Overstimulation, unrealistic expectations, delirium? Provide structure, calm, pets, music

Repetitive behavior Give outlet for activity, safe environment, substitutions

Argumentativeness Agree, avoid debates, calm environment

Adapted from Kathryn Eubank, MD

Educate caregivers

Alzheimers Association

Family Caregiver Alliance

Companies/programs, e.g. teepasnow.com

UCSF Memory and Aging Center videos (Alz Dis)

Choosing Wisely Campaign Geriatrics Rec #2 (2013)

Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia

7/27/2017

12

Treatment with antipsychoticsAre modestly effective.◦ Agitation, aggression, psychosis

1 in 3 nursing home residents and 1 in 7 community‐dwelling adults with dementia◦ Use goes up with age

GAO Antipsychotic Drugs and Older Adults 2012 Olfson M., et al. J Clin Psychiatry. 2015 Oct;76(10):1346‐53

CATIE‐AD RCT421 outpatients 

Risp (1mg) > olanz (5mg) > quet (50mg) 

Affected: Paranoia, hostility, aggression, mistrust, psychosis 

No change in function, care needs, QOL 

Withdrawal from treatment high

Olanz: worsening ADL function

Sultzer DL et al. Am J Psych 2008 Jul;165(7):844‐54. Schneider L, N Engl J Med 2006;355:1525‐38. 

Side effects of anti‐psychotics for NPS

1.5‐1.7x increased risk of mortality◦risk of death occurs as early as <6mo 

2‐3x increased stroke risk◦CV and metabolic effects (obesity, glucose) 

Extrapyramidal symptoms

Worsening cognition and falls

HospitalizationsTampi RR, et al. Ther Adv Chronic Dis 2016, Vol. 7(5) 229–245 ; Maust et al. JAMA Psychiatry 2015; GAO Antipsychotic Drug Use, Jan 2015; Jeste DV J Comp EffRes. 2013 Jul; 2(4): 355–358. 

Approach for NPS: Medication

Try dementia medications and antidepressants first.

Consider an antipsychotic if it’s a severe problem:◦ Quetiapine > risperidone > olanzapine 

◦ Record target symptom

◦ Schedule it, lowest dose possible

◦ Record response, trial off after 3‐6 months

7/27/2017

13

Our CaseFor Ms. L, staff put cleaning cloths in easy reach and would clean next to her.  This would get her to use cloths to clean the chairs instead of hitting them and so no one would have to try to get her to stop. 

Staff started to regularly offer her bathroom trips. She seemed more comfortable afterward and would spend less time cleaning the chairs and “annoying” the staff. 

NPS: the take home

Identify the behavior, triggers, if it’s a problem. 

NONPHARMACOLOGIC approaches first

Educate caregivers

If decided, plan a medication trial carefully. 

https://www.healthcare.uiowa.edu/igec/iaadapt/

Thank youHelen Kao, MD

Kathryn Eubank, MD

Stephanie Rogers, MD

Stefanie Bonigut, LCSW, Alz Association

Kirby Lee, PharmD

Kate Radcliffe

For more information contact: GWEP@ucsf.edu

THE OPTIMIZING AGING COLLABORATIVE AT UCSF IS SUPPORTED BY THE UCSF GERIATRICS WORKFORCE ENHANCEMENT PROGRAM: HEALTH RESOURCES AND SERVICES ADMINISTRATION

(HRSA) GRANT NUMBER U1QHP28727.

7/27/2017

14

EXTRA SLIDESQuestions you can ask to elicit history about cognitive impairment in the various cognitive domains

Cognitive Symptoms: MemoryProblems with recent events – Trouble remembering conversations, repeating things

Remote events (generally remain intact until later in disease)

Misplacing objects 

Repetitive Questions

Missing appointments

Objective findings: Repeats complaint stated earlier in visit, unable to do short‐term recall exercise

Cognitive Symptoms: Executive FunctionDifficulty with planning or organization

Multi‐tasking

Concentration/attention span

Problem Solving

Impulsivity (acting without thinking)

Mental rigidity/inflexibility

Objective findings: Difficulty following complex instructions, difficulty with clock draw or trails 

Cognitive Symptoms: LanguageWord finding trouble

Poor articulation

Impaired comprehension

Impoverished speech (e.g. “thingie” instead of specific word)

Impaired reading/writing/spelling

Mutism/ Decreased speech output

Objective findings: Can name <11 words in 1 minute, poor score on Boston Naming Test (doesn’t know names of high frequency words)

7/27/2017

15

Cognitive Symptoms: VisuospatialLost in familiar environments

Difficulty recognizing faces

Difficulty driving

Difficulty parking

Objective finding: Trouble drawing a cube

Cognitive Symptoms: BehavioralChanges in emotional expression (blunting/labile)

Changes in personality/behavior

Apathy/decreased motivation

Obsessive/compulsive behaviors

Agitation/aggression

Depression

Delusions/Hallucinations

Impaired Hygiene/eating

Changes in sleep

Cognitive Symptoms: MotorDifficulty with walking or balance

Trouble using utensils (apraxia)

Change in handwriting

Tremor

Weakness

Involuntary movements

Trouble Swallowing

Objective findings: Falls, cannot demonstrate how to brush teeth or hair (apraxia)

EXTRA SLIDESManagement of Dementia

7/27/2017

16

Pharmacological ManagementDepends on the type of dementia

Treatment of risk factors for stroke and cardiovascular disease

Tailor to patient’s goals of care

Setting realistic expectations◦ Most treatments don’t have a big effect on cognition or function

Pharmacological ManagementCHOLINESTERASE INHIBITORS

MILD/MODERATE DEMENTIA

Donepezil

Rivastigmine

Galantamine

General side effects: nausea, diarrhea, anorexia, insomnia

NMDA RECEPTOR ANTAGONIST

MODERATE/SEVERE DEMENTIA

Memantine

Minimal impact on function and quality of life.Do not really change the disease course.

What works?

Effect sizes are: small = 0.2; moderate= 0.5; large= 0.8

Address the environmental, social factors and engage caregivers

Future Drug TherapiesAnti-beta amyloid◦ Solanezumab & bapineuzumab- no improvement in

cognition or function in Phase 3 study

Many other still in early phase studies◦ Beta-secretase (BACE) inhibitors- prevents

formation of beta-amyloid◦ Preservation of tau protein- maintain neuronal

structures◦ Anti-inflammatory medication