Cognition in Older Adults

Physiotherapy Alberta ConferenceSeptember 24th 2016

Lesley CharlesAssociate Professor and Program Director

Division of Care of the ElderlyDepartment of Family Medicine, University of Alberta

Disclosure

• I have no relationship that could be perceived as placing me in a real or apparent conflict of interest in the context of this presentation.

Learning Objectives

• Changes in cognition with age

• DSM 5 changes in diagnostic criteria

• Ruling out delirium, depression and reversible causes of dementia

• Types of dementia with case examples

• Treatment of dementia

• Capacity– Guiding Principles in assessment of capacity

– A Capacity Assessment process

• Normal aging – shot term memory loss

• Mild cognitive impairment - symptoms but no functional loss

• Dementia – 2 domains (memory, speech, praxis, recognition, executive functioning, spatial) with functional loss

• Always rule out delirium, depression drugs

Cognition

• Memory: STM, repetition, recalling names, losing, details

• Speech (aphasia): word finding, decreased fluency, spontaneous speech, reading, writing, comprehension

• Recognition (agnosia): people, places, things

• Praxis: using appliances around the home

Domains

• Executive function: decreased planning, initiation, sequencing and monitoring complex behavior e.g. planning a vacation, preparing formal dinners

• Visuospatial: disorientation e.g. day-night, getting lost, map reading, wandering

Domains

FunctionBADL IADL

• Washing

• Dressing

• Bathing

• Feeding

• Toileting

• Transfers

• Ambulation

• Shopping

• Cooking

• Cleaning

• Yard work

• Transport

• Finances

• Medications

DSM 5

• the term “dementia” has been eliminated and replaced with major or minor neurocognitive disorder

• the presence of memory impairment for all of the dementias is not a necessity

Minor Neurocognitive Disorder

• Evidence of modest cognitive decline from a previous level of performance in one or more of the domains –from patient, informant or clinician and a decline in neurocognitive performance (1-2 SD below norms)

• The cognitive deficits are insufficient to interfere with independence (e.g., instrumental activities of daily living, like more complex tasks such as paying bills or managing medications, are preserved)

• Not due to delirium or mental health disorder e.g. depression

• Old Mild cognitive impairment

Major Neurocognitive Disorder

• Evidence of substantial cognitive decline from a previous level of performance in one or more of the domains – from patient, informant or clinician and a decline in neurocognitive performance (≥2 SD below norms)

• The cognitive deficits are sufficient to interfere with independence (i.e., requiring minimal assistance with instrumental activities of daily living)

• Not due to delirium or mental health disorder e.g. depression

• Old dementia

• 8% at age 65 years

• 16% at age 75 years

• 35% at age 85 years

• 50% at age 90 years

Prevalence

• One of the most pressing problems facing health care

• 50% to 66% of dementias are ‘missed’ in the primary care setting

Dementia

Types of Dementia

• Alzheimer’s

• Vascular

• Mixed

• Dementia of Lewy Body

• Parkinson’s dementia

• Fronto temporal dementia

• Brain injury

• Substance abuse

Prevalence of 4 major types of dementia

AD Alzheimer dementia

VaD Vascular dementia

DLB Dementia of Lewy Body

FLD Fronto temporal Dementia

Other

60%

5%5%

15%

15%

Pure DLB 3%FLD

Other

DLB with AD, 12%

Mixed VaD andAD, 10%

Pure VaD 5%

• Memory loss affecting day-to-day function

• difficulty performing familiar tasks

• language/speech problems

• disorientation to time & space

• poor or decreased judgment

• problems with abstract thought

• misplacing objects

AD : 10 Warning Signs

15

• Mood & behaviour

• Personality alterations

• Loss of initiative

AD : 10 Warning Signs

16

• Differs from dementia in the it’s an acute change in cognition with fluctuations

• Difficulties with attention

• Disorganized thinking

• Change in level of consciousness

Delirium

• Common – 30%of those admitted to hospital

• Often a medical cause like infection, medication, metabolic abnormality, heart/lung disorder requiring oxygen, neurological e.g. stroke

Delirium

• Incredibly common

• Under diagnosed

• Can be hard to diagnosis

• Treatable and preventable

• Non-medication cognitive-behavioral therapies often effective

• Prone to relapse

Depression

Reversible Causes of Dementia

• Hypothyroidism

• B12/Folate deficiency

• Hypercalcemia

• Normal Pressure Hydrocephalus

• Depression (Pseudo-dementia)

• Medications

Dementia versus Delirium

• Dementia– Slow onset over months or

years

– Progressive course

– Speech normal

– Attention normal

– Memory: gradual and progressive loss

– Hallucinations possible

– Level of consciousness normal

• Delirium– Sudden onset over hours or

days

– Fluctuating course

– Speech rambling

– Inattentive

– Variable

– Hallucinations common

– Level of consciousness impaired

Features of Alzheimer’s

• Insidious onset over months, more often years

• Memory (STM) effected first then often speech/executive function

• May be FH

Vascular Dementia

• Also known as major vascular neurocognitive disorder in DSM 5/vascular cognitive impairment

• Previously described as Multi-infarct dementia (MID) with step-wise progression with each vascular event felt to be main process

• Now chronic ischemia re-emerges as significant component and not necessarily a specific event

Mixed Dementia

• AD with cerebrovascular disease

• Increasingly felt to be a significant group of those with dementia

• In patients with dementia more likely to have co=pathologies than either AD/VaD alone

• Often difficult to distinguish AD and VaD

• Also difficult to distinguish which is more important when both pathologies are present

• As both are so prevalent co-occurrence is common

• On autopsy of pathologic AD patients 34-50% had vascular pathology

Fronto-temporal Dementia

• Relatively new entity fully articulated in ’86

• Used to be termed “Pick’s Disease”

• Behavioral characteristics appear early on in the disease (compared to AD) & include: -disinhibition & poor insight

- loss of social awareness

- personal neglect

- inertia and impulsivity

Lewy Body Dementia

• Meet criteria for minor or major neurocognitive disorder

• Probable LBD: 2 core or 1 core and 1 suggestive features

• Possible LBD: 1 core or 1 or more suggestive

Lewy Body Dementia

Core

• Fluctuation cognition with inattention

• Visual hallucinations typically well formed

• parkinsonism

Suggestive

• REM sleep disorder

• Neuroleptic sensitivity

• low dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET imaging

Case 1

• This 86 y.o. lady appears at your clinic in follow-up with her daughter. You had seen her 9 weeks ago for short-term memory loss (12-18 months’ duration), withdrawal from her usual recreational activities and failure to thrive. Because she had admitted to slight sadness and very poor sleeping with 12 lb weight loss in the previous 6 months, you had diagnosed major depression & treated her with Sertraline (Zoloft). Nine weeks later, she appeared again with improved spirits, more energy, and a weight gain of 5 lb. You extended her prescription.

Case 1

• On this visit, her daughter points out that her memory is still impaired, & worse than previously. In a recent game of bridge, she was not keeping up. The daughter was concerned about her driving ability on a trip to Westlock last week.

Case 1

• Which details on history would you pursue?

• Is lab work of help?

• Is a CT scan indicated? An MRI scan?

• What are the diagnostic possibilities?

Case 2

• This 81 y o lady presents to your office, anxious for an exam because she is convinced she has Alzheimer’s. In recent months she has noticed significant impairment in memory, as well as some difficulties with concentration. Her memory appears to affect STM and LTM. She used to be an avid reader but discontinued this when she found she was retaining very little. • She also describes symptoms of inner nervousness which have bothered her for 5 months. With prompting from her husband, she relates her belief that the police are watching her activities very carefully. She has noticed them parking outside her home and is worried they are going to convict her of a crime she did not commit.

Case 2

• She describes herself as a lifelong poor sleeper but that this has worsened. She has not experienced speech and language difficulties, problems in navigation, or difficulties in executive functioning. In terms of behavior she is much more anxious than previously and her husband describes her as more irritable.

• There is no FH of depression or dementia. There is no h/o head injuries but she did suffer a CVA with no sequlae.

Case 2

• Which further details would you seek?

• What is the likely diagnosis?

• Would you prescribe a drug at this point?

• Acetylcholinesterase Inhibitors – Aricept, reminyl, exelon

• Memantine

• All stabilise rather than “cure”/improve disease

Treatment

Summary of Management of Dementia

• Diagnosis – cognitive history, neurobehavior, function, cognitive testing, PE, labs +/- CT

• Medication – consider AchEI

• Function – look at ways need support

• Mood, behavior, psychosis, safety (driving/stove/wandering) - any issues

• Medicolegal

• Disposition

• Caregiver burden

Capacity Definition

• The ability to understand the information that is relevant to making of a personal decision and the ability to appreciate the reasonable foreseeable consequences of the decision

Guiding Principles

• Least Intrusive/least restrictive

– All adults presumed capable

– Taking away person’s right to liberty and freedom is a very serious step/last resort

– The onus is on the assessor to demonstrate lack of capacity, not on the patient to demonstrate capacity

Risk by Choice

• A risky decision is not necessarily incapable –

– Stockbrokers, soldiers, medical professionals and patients make them every day

• It is the process – or the lack of process – by which risky decisions are made that calls into question the capacity of a patient to make that decision

Common Pitfalls

• All or Nothing – the practitioner doesn’t understand that capacity is not “all or nothing”, but specific to a decision

• Practitioner fails to ensure that patient has been given relevant information about proposed treatment before making a decision

• As long as patient agrees with practitioner’s health care recommendations, practitioner fails to consider that patient may lack capacity for decisions

Development of a DMCA Model

• An Interdisciplinary Capacity Assessment Working Group was created in 2006 by Caritas (now Covenant Health)– reviewed literature, existing models, survey and interviews used to develop DMCA Model

Relevant Legislative Acts • Personal Directives Act

– Allows adult Albertans to create a Personal Directive to name people (agent) to make decisions and describes areas in which they want decisions made for them

• Powers of Attorney Act– Allows adult Albertans to create an Enduring Power of

Attorney to name people (attorney) to make decisions in financial matters for them

• Adult Guardianship and Trusteeship Act – Continuum of Decision–making– Legal process for granting powers of surrogate decision

making

Personal Directive Act• Schedules

• A process for determining incapacity

• Expanded scope of Service Providers in healthcare such as Registered Nurses, Psychiatric Nurses, SW, OT to act as the second signature

• Allow for re-assessment of capacity or determination of regained capacity

• Complaints process via OPG (similarly under AGTA)

• The assessor forms an opinion about the ability of the maker to:

Understand the information that is needed to make a decision

Retain information that is relevant to making a decision Identify and appreciate the consequences of making or

not making a decision Communicate his/her decision about specific personal

matters (checked off in the schedule)Specific to the decision at hand.

Declaration of Incapacity: Schedule 2 and 3

Process of Capacity Assessment

• Tailored to different levels of capacity• Designed to provide as much autonomy as possible

Range of Capacity

Specific Decision-Making and

Emergency Decision-Making

Has CapacitySignificant

Capacity

Impairment

Temporary lack

of Capacity

Lacks Capacity

Long Term

SupportedDecision-making

Authorization

Guardianship, Trusteeship and

Protection

Temporary Guardianship/

TrusteeshipAdult Makes

Decisions

Co-Decision-

Making

AGTA has multiple decision-making options

Goals of Capacity Assessment Process

• Concentration on more front-end screening and pre-assessment (problem-solving)

• Development of a well-defined and standard process

• Definition of team members’ roles

• Documentation and organization of information collected

• Education and mentoring

Capacity Assessment Care Map

Initial Assessment:

Identifying Reasons

for Assessment,

Domains and Risks

Assessment in Depth:

Problem-Solving Using

Cognitive and Functional

Testing

Formal Capacity Ax:

When Problems Cannot

be Solved by Less

Intrusive Means

Validating Reasons and Identifying Domains

Valid Reasons for Assessment

A formal capacity assessment may be necessary if the reason for assessment meets the following criteria:

1. An event or circumstance which potentially places a patient, or others, at risk that

2. seems to be caused by impaired decision-making which

3. Necessitates investigation, problem-solving (and possibly action) on the part of a health care professional

Identifying Domains

• Decisions can be categorized into functional “Domains”

• Domains help guide your information gathering.

• Incapacity in one domain does not necessarilysignify incapacity in other domains

• Each domain must be assessed separately

Domains of Decision-Making

Health care Participation in social activities

Accommodation Participation in educational activities

With whom to live & associate Participation in employment activities

Legal matters Financial and Estate

Identifying Domains

Care Map – Assessments and problem solving

Assess Risk• Investigate and document risky and unsafe

situations prior to admission

• Determine how long the risks have existed

• Explore ways to reduce risk that might resolve the issue without resorting to formal capacity assessment

• Assess the severity of the risk: the higher the risk to the patient or others, the stricter the standards

A Word on Problem-solving• Be creative !!

• Involve patients and families in problem-solving

• Seek perspectives from other team members

• Consider formal resources

• Mobilize informal resources

• Issue may be resolved by problem solving without formal capacity assessment

Cognitive Assessment

• There is no cognitive test that will determine capacity

• Assessment of a person’s cognition is not necessarily equivalent to their abilities

• Not solely used to determine one’s capacity for decision making.

Summary

• If solution is acceptable to patient and

family/caregivers addressing specific issues

proceed with plan

• If solution is unacceptable may need to

proceed to capacity interview.

Reasons for Formal Capacity Interview

• No adequate solutions from problem-solving

• Risk to patient / others too high

• Other, less intrusive methods, have failed

• Appointment of legal decision-maker may solve the problem

• Problem persists or becomes worse

• Remember: a determination of incapacity may do nothing to fix the problem

Care Map – Capacity Interview

Anatomy of a Competent Decision

• The decision-maker is aware of the choices that are available.

• The decision-maker understands the reasonably foreseeable effects or consequences of each choice.

• The decision-maker makes a choice after weighing the relative benefits and disadvantages of the choices available.

Capacity Interview Worksheet

Capacity Assessment Process Worksheet

Who’s involved in the assessment of Decision Making Capacity?

Specialty service

Designated capacity assessors

OT,SW,RN,RPN

Physicians/ Psychologist

_ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __

Mentoring Team

SW/ OT/ RN

Attending / interdisciplinary teams

MD- Hospitalist/ OT/ RN/ SW

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Front line clinical staff

•Pre-assessment and

problem solving (step 1&2)

•Recognition of issues

• Support/ mentor the interdisciplinary

teams

• Provide education (initial /ongoing)

Supportive organization

•Provide expertise for complex cases

•Support mentoring teams and DCA’s

•Complete formal assessment

of capacity (as mandated by

specific Acts)

Capacity Assessment Brochure

Questions

• Contact information:

• Lesley.Charles@albertahealthservices.ca