Medical Evaluation of the Patient with Brain

Failure

Jane F. Potter, MDJane F. Potter, MD

Chief Section of Geriatrics & GerontologyChief Section of Geriatrics & Gerontology

University of Nebraska Medical CenterUniversity of Nebraska Medical Center

DeliriumDelirium

• Clinical Presentation: A syndrome of acquired impairment of attention, level of consciousness, and perception.

Evaluation: Confusion Assessment Method (CAM)

■ Change in cognition that has Change in cognition that has bothboth::◆ AcuteAcute onset and fluctuating courseonset and fluctuating course◆ AND InattentionAND Inattention

■ And eitherAnd either◆ Disorganized thinkingDisorganized thinking◆ OR altered level of consciousnessOR altered level of consciousness

Acute Onset AND Fluctuation

■ Symptoms develop over Symptoms develop over hours to dayshours to days

(need a reliable informant; if not observed (need a reliable informant; if not observed may present late) may present late) ANDAND

■ Symptoms Symptoms varyvary through out through out the day; characteristic the day; characteristic lucid interval lucid interval

AND Inattention

■ Difficulty focusing, sustaining, and shifting Difficulty focusing, sustaining, and shifting attentionattention

■ Difficulty maintaining conversation or Difficulty maintaining conversation or following commandsfollowing commands

AND Either: Disorganized Thinking

■ E.G. disorganized E.G. disorganized or incoherent or incoherent thinkingthinking

■ E.G. Rambling or E.G. Rambling or irrelevant irrelevant conversation conversation ((unpredictable switching unpredictable switching subjects?)subjects?)

OR: Altered Level of Consciousness

■ Vigilant (hyperalert, very easily startled)Vigilant (hyperalert, very easily startled)

■ Lethargic (drowsy, easily aroused)Lethargic (drowsy, easily aroused)■ Stupor (difficult to arouse)Stupor (difficult to arouse)■ Coma (unarousable)Coma (unarousable)

Evaluation: CAM

■ Change in cognition that has Change in cognition that has bothboth::◆ AcuteAcute onset AND fluctuating courseonset AND fluctuating course

◆ AND Inattention AND Inattention

■ And eitherAnd either◆ Disorganized thinkingDisorganized thinking◆ OR altered level of consciousnessOR altered level of consciousness

Risk Factorsfor Delirium

■ Advanced ageAdvanced age■ DementiaDementia■ DepressionDepression■ Impaired physical Impaired physical

functionfunction■ Sensory lossSensory loss■ Decreased oral intake Decreased oral intake

(food and fluids)(food and fluids)

■ Drugs (ETOH)Drugs (ETOH)■ Coexisting Medical Coexisting Medical

Illness (severe, multiple, Illness (severe, multiple, CKD, LD, fractures, CKD, LD, fractures, stroke, neurological ds, stroke, neurological ds, HIV)HIV)

Who Gets Delirious? Why?

VULNERABLE PATIENT

# of RISK FACTORS

INSULTS

DementiaDementia

• Clinical Presentation: A syndrome of acquired impairment of memory and other cognitive domains sufficient to affect daily life

• Etiology: Any disorder causing damage to brain systems involved in memory. Alzheimer’s disease is the most common cause in later life

Brain Failure■ The most common The most common

cause of disability in cause of disability in later lifelater life

■ A focus for geriatric A focus for geriatric practitionerspractitioners

Objectives:

■ Identify the common (non-dementia) causes Identify the common (non-dementia) causes of cognitive dysfunction. of cognitive dysfunction.

■ Describe a basic approach to evaluate Describe a basic approach to evaluate physical causes of cognitive dysfunctionphysical causes of cognitive dysfunction

■ Understand interdisciplinary contributions Understand interdisciplinary contributions to evaluation of cognitive dysfunctionto evaluation of cognitive dysfunction

The Brain Failure Evaluation: What to Expect

■ Identification of reversible causesIdentification of reversible causes

■ Treatment of disabling conditionsTreatment of disabling conditions

■ Family information, counseling, and referralFamily information, counseling, and referral

CAREFULCAREFUL

CLINICAL OBSERVATION CLINICAL OBSERVATION

IS EVERYTHING!IS EVERYTHING!

Brain Failure:Evaluation

Brain Failure:Evaluation

■ History/physicalHistory/physical■ NeurologicNeurologic■ MedicationsMedications■ MoodMood■ AbilitiesAbilities■ SocialSocial

The Brain Failure EvaluationHistory

■ Collateral SourceCollateral Source

■ Onset, Course, Progression, Risk FactorsOnset, Course, Progression, Risk Factors

■ Characteristic Course of Alzheimer’s DiseaseCharacteristic Course of Alzheimer’s Disease

HISTORY OF SYMPTOMS

■From a From a

caregiver or caregiver or

someone close someone close

to the patientto the patient

HISTORY OF SYMPTOMS

■ What were the What were the first symptoms?first symptoms?

■ How have things How have things changed?changed?

■ Is this typical Is this typical for AD?for AD?

TYPICAL SYMPTOMS OF ALZHEIMER’S DISEASE

Functional loss in reverse order to Functional loss in reverse order to which skills were gainedwhich skills were gained

Brain Failure: Case 1

An 83 year old widower is evaluated because An 83 year old widower is evaluated because his family is concerned that he is mildly his family is concerned that he is mildly

cognitively slowed. He is still successfully cognitively slowed. He is still successfully maintaining homes in Arizona and Iowa. maintaining homes in Arizona and Iowa.

He describes a 9 month history of decline in He describes a 9 month history of decline in his golf game, a 6 month history of his golf game, a 6 month history of

unexplained falls, and a 1 month history of unexplained falls, and a 1 month history of urinary incontinence.urinary incontinence.

Brain Failure:Recognition

In patients or families presenting with a In patients or families presenting with a complaint of cognitive dysfunction a complaint of cognitive dysfunction a

negative screening test does not exclude negative screening test does not exclude dementia. dementia.

The Brain Failure EvaluationPhysical

■ Special SensesSpecial Senses

■ Heart / Lung / Liver / KidneyHeart / Lung / Liver / Kidney

■ Bladder / Bone / MobilityBladder / Bone / Mobility

■ VisionVision

■ HearingHearing

Brain Failure: Special Senses

■ A 79 year old widower is a member of a A 79 year old widower is a member of a multigenerational household. He has had multigenerational household. He has had progressive cognitive problems over the last progressive cognitive problems over the last 7 years. He is independent in all self care 7 years. He is independent in all self care activities, but at night he wanders about activities, but at night he wanders about knocking things over and urinating in trash knocking things over and urinating in trash canscans

•Brain Failure:Case 2

Brain Failure: Case 3■ A 68 year old married man suffers from A 68 year old married man suffers from

AD. Despite successful treatment of an AD. Despite successful treatment of an associated depression, he is inattentive and associated depression, he is inattentive and often does not respond to his wife or often does not respond to his wife or daughter.daughter.

Brain Failure: organ system dysfunction■ Heart and Lung: hypoxic encephalopathyHeart and Lung: hypoxic encephalopathy■ Hepatic encephalopathyHepatic encephalopathy■ Renal encephalopathyRenal encephalopathy■ Thyroid disordersThyroid disorders■ HyperparathyroidismHyperparathyroidism

Brain Failure: Case 4■ A 75 year old widow is evaluated at the A 75 year old widow is evaluated at the

request of her family for progressive request of her family for progressive cognitive impairment over the last 9 cognitive impairment over the last 9 months. Her MMSE is 18. During the months. Her MMSE is 18. During the interview she admits to exertional fatigue, interview she admits to exertional fatigue, and lack of energy. On exam she has and lack of energy. On exam she has diffuse expiratory wheezing in all lung diffuse expiratory wheezing in all lung fields.fields.

Brain Failure = Disability

■ Families/Patients are complaining of the Families/Patients are complaining of the disabilitydisability caused by brain dysfunction.caused by brain dysfunction.

■ The population at risk is characterized by a The population at risk is characterized by a burden of burden of co-morbiditiesco-morbidities..

■ Look for Look for un or under-treatedun or under-treated comorbidities causing dysfunction.comorbidities causing dysfunction.

■ High yield for disorders of bladder, bone, High yield for disorders of bladder, bone, mobility.mobility.

NEUROLOGICAL EXAM

■ Cortical- frontal, Cortical- frontal, parietal, temporal, parietal, temporal, occipital lobesoccipital lobes

■ Sub-cortical- internal Sub-cortical- internal capsule, basal ganglia, capsule, basal ganglia, thalamusthalamus

NEUROLOGICAL EXAM

■ Apraxia, agnosia, Apraxia, agnosia, aphasia, focal motor or aphasia, focal motor or sensory signs sensory signs

■ Gait disturbance, Gait disturbance, rigidity, tremorrigidity, tremor

Frontal Lobe Release signs

■ MovieClips\Glabellar.movMovieClips\Glabellar.movGlabellar tapGlabellar tap■ PalmomenttalPalmomenttal■ GraspGrasp

Gait

■ CorticalCortical

■ SubcorticalSubcortical

Sutton’s Law:

■ ““Gee, Willy, why do you rob banks?Gee, Willy, why do you rob banks?

“BECAUSETHAT’S

WHERE THEMONEY IS”

Geriatrician’s Law:

Go for the MEDSBecause that’s where the money is

Inspect the Drug Bag

■ Three or more Three or more drugs increase the drugs increase the likelihood of an likelihood of an adverse effect or adverse effect or drug interactiondrug interaction

Drugs and Brain Failure

■ Many drugs can do this, e.g. Sedatives, anxiolytics, anticholinergics, H2-blockers, centrally acting antihypertensives (clonidine, alpha-methyl dopa) antiarhythmics, beta blockers, digoxin, sinemet, selegeline.

■ Check all for CNS S.E.s■ Try a “Drug Holiday”

Alcohol and Brain Failure

■ Volume of

distribution for ETOH

with age

■ No more than one/day

after age 65; stop all if

cognition impaired

Brain Failure: Case 4■ An 83 year old widow presents with a An 83 year old widow presents with a

history of progressive cognitive failure. history of progressive cognitive failure. During interview she admits to a long term During interview she admits to a long term pattern of one drink before dinner. On pattern of one drink before dinner. On questioning, her daughter feels that she questioning, her daughter feels that she likely exceeds one drink per day.likely exceeds one drink per day.

Depression as Brain Failure

■ Emotional illness

slows cognitive

function

Depression as a Cause of Brain Failure

Dementia■ Insidious onset■ Long duration■ No psychiatric history

■ Conceals disability (often unaware of memory loss)

■ “Near-miss” answers

■ Day-to-day fluctuation in mood

Depression■ Abrupt onset■ Short duration■ Previous psychiatric history

■ Highlights disabilities (may complain of the memory loss)

■ “Don’t know” answers

■ Diurnal variation in mood, but generally more consistent

The Brain Failure Evaluation

UNDERSTAND THE NORMAL UNDERSTAND THE NORMAL

AGE-RELATED CHANGES IN AGE-RELATED CHANGES IN

BRAIN AND MEMORYBRAIN AND MEMORY

Brain Failure vs Normal Aging

■ Normal aging Normal aging does not cause does not cause dysfunction dysfunction

The Brain Failure EvaluationLaboratory

■ B-12, Folate, TSHB-12, Folate, TSH■ Chem profile, UA, ?OChem profile, UA, ?O2 sat sat

■ CBCCBC■ Other as indicated Other as indicated

The Brain Failure EvaluationRadiology & Other

■ Head CT, ? Head MRIHead CT, ? Head MRI■ Chest X-rayChest X-ray■ EKG, EEGEKG, EEG

Things that Cause the Brain to Fail (whether or not an underlying dementia is present)

■ DrugsDrugs■ Emotional Illness (including depression)Emotional Illness (including depression)■ Metabolic/endocrine disordersMetabolic/endocrine disorders■ Eye/ear/environmentEye/ear/environment■ Nutritional/neurologicalNutritional/neurological■ Tumors/traumaTumors/trauma■ InfectionInfection■ Alcoholism/anemia/ atherosclerosisAlcoholism/anemia/ atherosclerosis

DEMENTIA

Therapy for AD■ Cholinesterase inhibitorsCholinesterase inhibitors■ Vitamin EVitamin E■ NMDA inhibitor- MemantineNMDA inhibitor- Memantine■ ? Vaccination? Vaccination■ Not EstrogenNot Estrogen■ Not Anti-inflammatoriesNot Anti-inflammatories