TCMC M3 IM/FM TBL Series

TBL: Delirium & Dementia

The application excercise is a case reveal. Students should be instructed to view each part of the case without look forward to the next part.

Students will have prepared for this session by independent study of the following resources:

Essentials of Family Medicine (Sloane), Chapter 23- Dementia

Hazzard's Geriatric Medicine and Gerontology Chapter53- Delirium

Learning Objectives:

1. Diagnose postoperative delirium in a patient with dementia.

2. Describe interventions to prevent & treat delirium.

3. Describe outcomes of delirium.

4. Understand the pharmacologic treatment of Alzheimer’s Disease.

5. Differentiate mild cognitive impairment from Alzheimer’s disease

6. Apply principles of comprehensive care for dementia patients

Instructions:

iRAT/gRAT

This session is 1 hour. First students will take a quiz of these 10 questions alone (iRAT) then answer the same 10 questions in groups (gRAT) of 4-6 students. These questions are closed book. The iRAT will account for 40% of the grade (answers are recorded on a paper quiz sheet –partial credit is given) and the gRAT will account for 60% (answers are on a scratch off form, and partial credit is given). Students will take each portion of the RAT over 15-20 minutes, and the final 10-20 minutes of the session is devoted to discussion by each group. Following the gRAT there will be a facilitator-led discussion of each of the questions where students are encouraged to present the rationale for their answers as well as develop any question appeals. The iRAT should be scored while they are doing the gRAT. If a question was incorrect by the 15-20% or more of students then that question should be reviewed in the facilitator led discussion (preferably with question put up on powerpoint). Focusing

only on those questions has been shown to more time efficient and allow discussion of controversial questions.

If a group wishes to challenge an answer, this must be submitted in writing at the completion of the discussion session before the Application Exercise. It MUST include references to support their appeal. Students may take a few minutes to prepare appeals . No more than 1 question per group may be appealed during the entire CED afternoon session. Multiple groups can appeal the same question.

The application exercise is 1 hour. Questions are OPEN ENDED. Students work in their group to discuss and formulate answers to the questions after each case. Each group presents their answer via a spokes person for each group. The class should decide which group had the best answer to each question.

iRAT (about 15 min/gRAT about 45 min)

1. A 79-year-old woman was hospitalized 4 days ago after sustaining a right hip fracture in a fall at home. She underwent surgical repair with an open reduction external fixation 3 days ago and did not fully awake from general anesthesia until 12 hours after extubation. As her alertness has increased, she has become increasingly agitated and has been seeing children in her room who she does not know and who she is fearful about their well-being. The patient has a 4-year history of Alzheimer dementia now in the moderate stage. She has no other pertinent personal, psychiatric or family medical history. Medications are donepezil, memantine, and low-molecular-weight heparin.

She is inattentive and disoriented to time and place and exhibits combativeness alternating with hypersomnolence. The remainder of the neurologic examination is unremarkable, without evidence of focal findings or meningismus.

Which of the following is the most likely diagnosis?

(A) Acute stroke(B) Acute worsening of Alzheimer dementia(C) Postoperative delirium (D) Meningitis

Answer: CThe most likely diagnosis is postoperative delirium in a patient with dementia. Patients with delirium have acute, fluctuating mental status changes, with difficulty in focusing or maintaining attention and disorganized thinking.

The clinical presentation of delirium can take two main forms, either hypoactive or hyperactive. The hypoactive form of delirium is characterized by lethargy and reduced psychomotor functioning, and is the more common form in older patients.

Hypoactive delirium often goes unrecognized and carries an overall poorer prognosis. The reduced level of patient activity associated with hypoactive delirium, often attributed to low mood or fatigue, may contribute to its misdiagnosis or under recognition. By contrast, the hyperactive form of delirium presents with symptoms of agitation, increased vigilance, and often concomitant visual hallucinations; its presentation rarely remains unnoticed by caregivers or clinicians. Importantly, patients can fluctuate between the hypoactive and hyperactive forms—the mixed type of delirium—presenting a challenge in distinguishing the presentation from other psychotic or mood disorders. Moreover, recent recognition of partial or incomplete forms of delirium has brought attention to the persistence of symptoms among older patients, particularly during the resolution stages of delirium, when manifestation of the full syndrome may not be apparent. Partial forms of delirium also adversely influence long-term clinical outcomes. Delirium in elderly patients with dementia usually results from an acute medical problem. In addition, patients with dementia from almost any cause are at greater risk for delirium after surgery with general anesthesia (some agents bring more risk than others eg. Profanol), although even spinal anesthesia can be a precipitating factor.

This patient with a hip fracture who underwent right hip surgery with general anesthesia and did not recover from the anesthesia until 12 hours after extubation most likely has postoperative delirium. Such delirium is highly predictable and often managed by identification and correction of any underlying disorders and the removal or reduction of contributing factors.

The possibility of acute stroke must be considered in a patient with a change in mental status. However, this patient has no clinical evidence of such an event, which makes this diagnosis extremely unlikely.

Surgery does not exacerbate Alzheimer dementia (or dementia of any other cause) but rather produces a superimposed delirium. Finally, dementia does not acutely worsen over several hours; the decline is steadily progressive over months to years.

This patient has had dementia for 4 years that has abruptly gotten worse after surgery. Although not impossible, meningitis is highly unlikely in this setting, especially given the absence of any supporting physical examination findings, including meningeal irritation.

Hazzard's Geriatric Medicine and Gerontology, 6e > Part III. Geriatric Syndromes > Chapter 53. Delirium > Definition >

Table 53-1 Diagnostic Criteria for Delirium

Diagnostic and Statistical Manual (DSM-IV) Diagnostic Criteria

A. A disturbance of consciousness (i.e., reduced awareness of the external environment) with reduced ability to focus, sustain, or shift attention.

B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting dementia.

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate over the course of a 24-hour period.

D. Evidence from the history, physical examination, or laboratory findings that the disturbance is caused by an underlying organic condition or is the direct physiologic consequences of a general medical condition or its treatment.

The Confusion Assessment Method (CAM) Diagnostic Algorithm*

Feature 1. Acute onset and fluctuating course

This feature is usually obtained from a reliable reporter, such as a family member, caregiver, or nurse, and is shown by positive responses to these questions: Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or did it increase and decrease in severity?

Feature 2. Inattention

This feature is shown by a positive response to this question: Did the patient have difficulty focusing attention, for example, being easily distractible, or have difficulty keeping track of what was being said?

Feature 3. Disorganized thinking

This feature is shown by a positive response to this question: Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Feature 4. Altered level of consciousness

This feature is shown by any answer other than "alert" to this question: Overall, how would you rate this patient's level of consciousness (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])?

*The ratings for the CAM should be completed following brief cognitive assessment of the patient, for example, with the Mini-Mental State Examination. The diagnosis of delirium by CAM requires the presence of features 1 and 2 and of either 3 or 4.

2. A 69 year old man is diagnosed with mild Alzheimer's disease. He needs to be started on treatment. The next best step would be which of the following?

(A) Start rivastigmine (B) Start memantine(C) Start memantine and when on a stable dose for one month start donepezil(D)

Start donepezil and when on a stable dose for one month start memantine

Answer: A

Medications approved by the FDA and indicated for mild stage Alzheimer's disease include only the acetylcholinesterase inhibitors (rivastigmine, donepezil, galantamine). The addition of memantine to an

acetylcholinesterase inhibitor once the patient is in the moderate stage of disease is then appropriate. The combination of an acetylcholinesterase inhibitor and memantine provides for a more robust response than monotherapy with an acetylcholinesterase inhibitor in the moderate stage of the disease. There is no evidence to support the use of memantine in the mild stage of Alzheimer's disease and it should not be used as monotherapy or combination therapy with an acetylcholinesterase inhibitor in this stage of disease.

3. An 80-year old woman living in a nursing home with history of dementia is admitted to the hospital with a fever. In the emergency department, a peripheral intravenous line was inserted, appropriate antibiotics were initiated, she was given oxygen by nasal cannula, and a urinary catheter was placed.

On physical examination, temperature is 38.3°C (101.0°F), blood pressure is 140/88 mm Hg, pulse rate is 100/min, and respiration rate is 16/min. Pulmonary exam reveals left lower lobe tubular breath sounds and egophony. Cardiac examination is normal. Moderate cognitive impairment is noted but no inattention or focal neurologic deficits.

She is provided access to her glasses and hearing aid, a large clock and low intensity night light are in place in her room and a family member stays with her during the nights.

Which of the following additional steps should be taken to prevent delirium in this patient?

(A) Administer haloperidol twice daily(B) Administer diphenhydramine for sleep(C) Remove her urinary catheter (D) Check vital signs every 4 hours through the night(E) Administer benzodiazepine, as needed

Answer: CElderly patients with a history of dementia are at very high risk for developing delirium during a hospitalization. Prevention involves addressing medical and environmental issues. Urinary catheters are associated with increased risk of delirium. In the absence of a medical indication for a catheter (e.g., relieve urinary retention, monitor fluid status in acutely ill patients when this directly impacts medical treatment, manage patients with stage 3 or 4 pressure ulcers on the buttocks/sacrum), it should be removed. Access to hearing aids, glasses, and canes and removal of unnecessary restraints and urinary catheters are basic procedures to reduce the risk of delirium in persons at risk.

Preventing delirium before it develops—is the most effective strategy for reducing delirium and its associated adverse outcomes, which range from functional disability to longer lengths of hospital stay, institutionalization, and death. Table 53-6 describes well-documented delirium risk factors and tested preventive interventions to address each risk factor. A controlled clinical trial demonstrated the effectiveness of a delirium prevention strategy targeted toward these risk factors. Compared with standard care, implementation of these preventive interventions resulted in a 40% risk reduction for delirium in hospitalized older patients. Please discuss these additional interventions with the students.

Benzodiazepines and diphenhydramine have sedating effects but can cause delirium in the elderly. In addition benzodiazepines can cause disinhibition, oversedation and, not uncommonly, a paradoxical effect in the elderly (especially those with a preexisting dementia) manifested as increased agitation. They should generally be avoided, unless a specific indication is present, such as benzodiazepines for alcohol withdrawal or diphenhydramine for an allergic reaction. Alternative nonpharmacologic methods for relaxation include music, massage, aroma therapy and meditation in appropriate settings.

In appropriately selected patients with severe delirium, low-dose haloperidol may lessen the severity and duration of delirium, but it is not indicated for the prevention of delirium. The use of antipsychotic medications (typical and newer second generation agents) in elderly patients with dementia is associated with an 1.6 increased risk of cardiovascular complications(MI, Stroke ect) and death, so use must involve a risk benefit analysis. In this case there is no consistent data to support use in primary prevention as opposed to acute treatment.

Assessing vs q 4 hours is not appropriate in this patient. A normal sleep-wake cycle should be maintained as much as possible, minimizing interruptions or unnecessary testing during the night. Having familiar people present during the hospitalization as much as possible, night light on and increasing stimulation during the day.

Hazzard's Geriatric Medicine and Gerontology, 6e > Part III. Geriatric Syndromes > Chapter 53. Delirium > Prevention >

Table 53-6 Delirium Risk Factors and Tested Interventions

RISK FACTOR INTERVENTION PROTOCOL

Cognitive impairment

Orienting communication, including orientation board Therapeutic activities program

Immobilization Early mobilization (e.g., ambulation or bedside exercises) Minimizing immobilizing equipment (e.g., restraints, bladder catheters)

Psychoactive medications

Restricted use of PRN sleep and psychoactive medications (e.g., sedative–hypnotics, narcotics, anticholinergic drugs)

Nonpharmacological protocols for management of sleep and anxiety

Sleep deprivation Noise-reduction strategies Scheduling of nighttime medications, procedures, and nursing activities

to allow uninterrupted period of sleep.

Vision impairment Provision of vision aids (e.g., magnifiers, special lighting) Provision of adaptive equipment (e.g., illuminated phone dials, large-

print books)

Hearing impairment Provision of amplifying devices; repair hearing aids Instruct staff in communication methods

Dehydration Early recognition and volume repletion

Modified with permission from Inouye SK, Bogardus ST Jr., Charpentier PA, et al. N Engl J Med. 340:669, 1999.

4. You evaluate an 82-year-old man in your preceptor’s office for fluctuating confusion that began 2 weeks ago. He previously was independent in ADLs and IADLs and now requires assistance with dressing and both financial and medication management. He wanders aimlessly in the house, sometimes not recognizing his wife. He has visual hallucinations of his mother in the living room. He has occasional crying spells during the last 2 weeks. His medical history includes type 2 diabetes mellitus with painful peripheral neuropathy,urinary incontinence, coronary artery disease, depression. Medications are glyburide, nortriptyline, oxybutinin, digoxin, lorazepam, metoprolol, lisinopril, aspirin, and pravastatin. He does not remember how long he has been taking these medications or if there have been any recent dosage changes. The patient drinks alcohol 2-3 times per week, usually 1 glass of wine.

On physical examination, Vital signs are normal; oxygen saturation is normal with the patient breathing ambient air. He is inattentive and not oriented to time or place. His score on the Mini-Mental State Examination is 13/30 (28/30 6 months ago). Geriatric Depression Scale score is 6/15. Results of laboratory studies, including electrolyte levels and renal function studies, are normal. An MRI of the brain shows mild atrophy.

Which of the following is the most likely diagnosis?

(A) Alcohol hallucinosis(B) Alzheimer’s Disease(C) Schizophrenia (D) Depression(E) Medication induced delirium

Answer: E

The most likely diagnosis is toxic encephalopathy presenting as delirium. Notwithstanding the growing recognition of geriatric syndromes such as delirium, there is little evidence-based research that assesses the predictive value of laboratory and other diagnostic testing in the evaluation of delirium. Consequently, laboratory evaluation should be guided by clinical judgment, taking into account specific

patient characteristics and historical data. An astute history and physical examination, medication review, focused laboratory testing (e.g., complete blood count, chemistries, glucose, renal and liver function tests, urinalysis, oxygen saturation), and search for occult infection should help to identify the majority of potential contributors to the delirium.

The patient is taking several medications that might impair cognition and cause a delirium. Suspects are nortriptyline and oxybutinin, these drugs have anticholinergic properties and are likely to cause impairment in patients with a cholinergic deficiency (the elderly or patients with mild cognitive impairment, early dementia, or Parkinson disease). Digoxin and the benzodiazapine lorazepam may also contribute to cognitive impairment/delirium.

Symptoms of alcohol withdrawal most typically occur after cessation of prolonged, sustained alcohol intake. However, most people drink in an episodic fashion, as illustrated by this patient, and this pattern of drinking is not associated with sustained high blood alcohol levels that are requisite for withdrawal symptoms on abrupt cessation. Alcoholic hallucinosis develops 12 to 24 hours after the last drink and resolve within 24 to 48 hours, a symptomatic period much shorter than that experienced by this patient. Hallucinations are usually visual and are not associated with clouding of the sensorium. In patients with early Alzheimer dementia, delirium is produced more readily by anticholinergic medications. Alzheimer dementia cannot be ruled out in this patient, but inattentiveness would not be associated with Alzheimer’s disease and points strongly to a delirium and not dementia.

Depression may cause chronic cognitive impairment (pseudodementia) difficulty concentrating, and even psychotic symptoms but not an altered level of consciousness. Geriatric Depression Scale scores of 0-4/15 is not consistent with depression, 5-10/15 suggestive of depression, 11+/15 almost always associated with a major depression. Although he has a GDS score of 6 he has an altered level of consciousness and this is not associated with depression related cognitive impairment.

5. A 75-year-old man is brought to the office because he has recently had visual hallucinations of children in his living room which is very disturbing to him. He has a gait disturbance and minimal memory deficits. He was diagnosed with “dementia” about 6 months earlier. He is started on a low dose second generation antipsychotic agent, risperidone 0.25 mg q hs to alleviate his hallucinations. Shortly thereafter, the family calls because the patient is walking with great difficulty and has muscle stiffness and occasional tremors.

Which of the following is the most likely diagnosis?

(A) Alzheimer's disease(B) Lewy body dementia(C) Vascular dementia (D) Mixed Dementia (Alzheimer's disease/vascular dementia)

Answer: B

First and second generation antipsychotic agents have high rates of adverse events yet some efficacy for psychotic symptoms/behavioral disturbances associated with dementia. Among the most prominent adverse events associated with the use of antipsychotics are extrapyramidal symptoms and tardive dyskinesia. Second generation antipsychotic agents (clozapine, risperidone, quetiapine, olanzapine, aripiprazole, ziprasidone) are less likely than first-generation antipsychotics to cause extrapyramidal symptoms however they still are capable of causing the symptoms.

Lewy body dementia has an especially striking association with very well-formed hallucinations frequently of children and animals but also people. Patients with Lewy body dementia are usually uniquely sensitive to antipsychotic agents and resulting adverse events. The sensitivity to neuroleptics is characterized by rigidity, cogwheeling, immobility, sedation, confusion and is singular enough to be included in consensus criteria for the diagnosis of Lewy body dementia. Because the risk of extrapyramidal symptoms is smaller with second than first-generation antipsychotics, second-generation agents specifically quetiapine (has the lowest extrapyramidal symptoms profile of all the second-generation agents) has been used to control psychotic symptoms in patients with Lewy body dementia. However again, even quetiapine can induce rigidity and immobility in patients with Lewy body dementia.

6. All of the following are abnormalities one would see in a patient with Alzheimer’s disease as the sole cause of their dementia except? (A) Hyperreflexia with a positive Babinski sign(B) Frontal Release signs(C) Abnormal clock drawing on the Mini-COG(D) Gait disturbance developing late in the course of the disease

Answer AHyperreflexia and a positive Babinski are upper motor neuron findings which are most likely due to a previous stroke which would preclude Alzheimer’s disease as the sole cause of the dementia in most cases. A diagnosis of a mixed dementia, vascular and AD is possible. All the other answers are common in AD in one stage of the disease or another.

7. Amnestic mild cognitive impairment (amnestic MCI), but not Alzheimer’s disease, is associated with which of the following?(A) Lack of impairment in delayed recall(B) Lack of significant functional impairment socially, occupationally or in ADLs or IADLs(C) Family members typically bring up a concern about memory which prompts a work up(D) All of the above

Answer BMCI is present when cognitive function is impaired more than what you would expect based on the patients age and education level but is not severe enough to cause significant impairment in function (socially, occupationally or with ADLs or IADLs). MCI is classified into two basic subtypes, amnestic (evident in testing of delayed recall) and non-amnestic. Normal aging has normal results on cognitive testing and no functional impairment. MCI has abnormal results on cognitive testing but no functional impairment. Alzheimer’s disease has both abnormal results on cognitive testing and significant functional impairment.

With normal aging usually only the patient notices changes in memory. In both MCI and Alzheimer’s disease family members notice the changes in memory or another cognitive domain and many times will bring this up at an office visit.

8.) Which of the following is true regarding pharmacological treatment of behavioral symptoms in Alzheimer’s disease?(A) Cholinesterase inhibitors have no effect on behavioral symptoms(B) Citalopram has been shown to have efficacy for managing behavioral symptoms(C) Benzodiazepines are generally a good choice for managing behavioral symptoms(D) Mood stabilizers have no role in managing behavioral symptoms such as aggression, impulsiveness and agitation

Answer B

There is evidence that cholinesterase inhibitors can delay the emergence of behaviors, improve existing behavioral symptoms and reduce the need for psychotropic drug use (antipsychotics, benzodiazepines ect) in management. Citalopram also has evidence for efficacy in management of agitation.

Benzodiazepines have a slew of negative outcomes when used in frail older patients in general but even more so in those that are cognitively impaired (falls, confusion ect). They should be a last resort for management.

Mood stabilizers (valproate) do have a role in managing aggression and impulsive behaviors specifically.

9.) Which of the following is true regarding Delirium :(A) It results in an increased rate of nursing home placement but not functional and cognitive decline (B) As few as 20% of patients attain complete resolution at 6 months follow-up.(C) A very low percentage of hospital patients that enter the post acute care setting (Skilled Nursing Facility) have delirium meeting the full CAM-criteria(D) Lucid intervals are not characteristic

AnswerBDelirium is an important independent determinant of prolonged length of hospital stay, increased mortality, increased rates of nursing home placement, and functional and cognitive decline—even after controlling for age, gender, dementia, illness severity, and baseline functional status.

Delirium has long been thought to be a reversible, transient condition. Recent research on the duration of delirium symptoms, however, provides evidence that delirium may persist for much longer than previously recognized. In fact, delirium symptoms generally persist for a month or more; as few as 20% of patients attain complete symptom resolution at 6-month follow-up. In addition, those patients with extant cognitive impairment may experience greater deleterious effects than comparable patients without dementia. The chronic detrimental effects are likely related to the duration, severity, and underlying cause(s) of the delirium, in addition to the baseline vulnerability of the patient.

The patient population in nursing homes can be divided into two distinct groups: postacute patients who receive short-term rehabilitative care in nursing homes after an acute hospitalization, and long-

term care patients who reside in nursing homes as a result of severe cognitive and functional impairments. Both are high-risk groups for delirium, though the epidemiology differs between the two populations.

For the postacute population, persistent delirium after an acute hospitalization is the major issue. A recent study demonstrated that 16% of new admissions to postacute care met full CAM-criteria for delirium, while another 50% demonstrated signs of subsyndromal (partial) delirium. Patients with delirium on admission to postacute care experience more complications such as falls, have higher rehospitalization rates, and higher mortality. Delirium among postacute patients is also persistent—of those admitted with delirium, over 50% are still delirious 1 month later. Persistence of delirium prevents functional recovery in the postacute setting; only those patients whose delirium cleared within 2 weeks of admission recovered to their prehospitalization functional status. Persistent delirium is also associated with higher mortality.

Lucid intervals are characteristic of delirium

10) Which of the following is not a standard nonpharmacologic management strategy for delirium ?(A) A glass of warm milk or herbal tea, relaxation music or tapes and back massage(B) Ensure a low level of noise at night, including minimizing hallway noise, overhead paging, and staff conversations(C) Keeping overhead lights on in the room at night to improve orientation during the night(D) Avoiding physical restraints because they lead to decreased mobility, increased agitation, pressure ulcers and greater risk of injury.(E) Encourage family to be with the patient as much as possible including sleeping in the hospital

Answer C

Nonpharmacological approaches for relaxation and sleep can be effective for management of agitation in delirious patients and for prevention of delirium through minimization of psychoactive medications. The nonpharmacological sleep protocol includes three components: (1) a glass of warm milk or herbal tea, (2) relaxation music or tapes, and (3) back massage. This protocol was demonstrated to be feasible and effective. Use of the protocol reduced the use of sleeping medications from 54% to 31% (P <.002) in a hospital environment.

Nonpharmacological approaches are the mainstays of treatment for every delirious patient. These approaches include strategies for reorientation and behavioral intervention, such as ensuring the presence of family members, use of sitters, and transferring a disruptive patient to a private room or closer to the nurse's station for increased supervision. Orienting influences such as calendars, clocks, and the day's schedule should be prominently displayed, along with familiar personal objects from the patient's home environment (e.g., photographs and religious artifacts). Personal contact and communication are critical to reinforce patient awareness and encourage patient participation as much as possible. Communication should incorporate repeated reorientation strategies, clear instructions, and frequent eye contact. Correction of sensory impairments (i.e., vision and hearing) should be maximized as applicable for individual patients by encouraging the use of eyeglasses and hearing aids during the hospital stay. Mobility and independence should be promoted; physical restraints should be avoided because they lead to decreased mobility, increased agitation, and greater risk of injury. Patient involvement in self-care and decision-making should also be encouraged. Other environmental interventions include limiting room and staff changes and providing a quiet patient care setting with low-level lighting at night. An environment with decreased noise allowing for an uninterrupted period for sleep at night is of crucial importance in the management of delirium. This may require unitwide

changes in the coordination and scheduling of nursing and medical procedures, including medication dispensing, vital sign recording, and administration of intravenous medications and other treatments. Hospital-wide changes may be needed to ensure a low level of noise at night, including minimizing hallway noise, overhead paging, and staff conversations.

APPLICATION EXERCISE (1 hour)

Case: Part 1:

BJ is a 81 year old Caucasian female with no prior psychiatric history, who is brought to your family medicine clinic by her only daughter, who is concerned about the patient’s memory problems. The patient, who is widowed and lives alone, initially stated that she does not think she needs to see a doctor: “What is all the fuss about? My memory is fine, everyone’s memory is off at my age.” The daughter reports that she has noticed that “she’s just not the same person anymore.” The daughter has noticed that while her mother’s memory of distant events is remarkably intact (she can tell stories of her youth with great detail included), she often cannot recall things that happened earlier in the day, or a few days before. “She’ll forget things I just told her a few minutes ago, and ask me the same question three times in ten minutes,” the daughter says. The daughter was also concerned about the state of her mother’s house on a recent visit because it has been quite cluttered and dirty when she visits about every other week (she lives 2 hours away). There are multiple bottles of the same medications which are full, on her kitchen counter. There is spoiled food in the refrigerator and a burned tea pot on the stove. She reports that her mother used to be very organized and meticulous about cleanliness, but now her house is a mess, and “I have to remind her to eat.” She says it appears her mother has lost weight, though the patient denies this. The daughter reports also that the patient is more irritable and short-tempered than usual.

The patient denies having often felt sad during the last 2 weeks, a sense of helplessness, hopelessness or worthlessness and, reports that her appetite and sleep are normal for her. She admits that while she used to enjoy gardening, she does not do it much anymore, but cannot explain why. She admits also that her energy level has declined over the past year: “I am getting older, you know.” She does miss her husband, who died four years ago, but says, “The nice young man down the street comes by from time to time to keep me company.” The remainder of her psychiatric and medical review of systems was unremarkable. Physical exam: There were word finding difficulties and a palmer mental reflex noted but no other neurologic signs. MiniCog 1/3 recall items correct, clock draw abnormal.

Medications: atorvostatin , hydrochlorthiazide. FH: HTN Mother

Part 1 Discussion Questions

1.) What is your differential diagnosis list and which 2 diagnoses are most likely?

The differential diagnosis for cognitive impairment in a case like this can be extensive MCI, AD, Vascular, Lewy Body, Frontotemporal dementias, several psychiatric conditions (e.g., dementia, depression, delirium, long standing Bipolar disorder and schizophrenia), conditions secondary to general medical conditions (e.g., hypothyroidism, hyperthyroidism, calcium, B 12 deficiency, neuropsyphylis), trauma (subdural hematoma from a fall)several neurological conditions (e.g., CVA, lyme disease, ALS, MS), or substance-induced or substance-related conditions (e.g., various alcohol-related cognitive disorders such as Korsakoff’s syndrome or simply chronic alcohol exposure over years), normal pressure hydrocephalus(NPH). For purposes of the case presented here, the most likely conditions is major depressive disorder and/or one of the dementias most likely AD since the findings for the other forms of dementia are absent.

2.) What would you do next?

CMP, TSH, CBC, B12, urinalysis, RPR, MMSE or MOCA, more complete functional assessment, Geriatric depression scale, MRI

Primary dementia would be a diagnosis of exclusion, made only after disorders secondary to general medical conditions, substance-induced disorders, or other neurological disorders are ruled out. Screening labs, including B12 and Folate levels, TSH, and syphilis screening, biochemical screen and CBC are warranted here. Head imaging is also indicated to rule-out CVA or other neurological processes (recent fall/subdural, NPH) that may not be picked up on exam. Neuropsychological testing can be helpful for determining dementia and differentiating subtypes, but the diagnosis can also be made by a thorough case history and clinical presentation, with basic cognitive testing (MMSE or MOCA), labs, imaging and functional assessment. With an abnormal MinCog (a quick simple screening test for cognitive impairment) either an MMSE or MOCA should be performed to further assess cognitive deficits.

If groups fail to suggest additional functional assessment questions ask them: what are the essential components to making the diagnosis of any dementia? Obtaining a more detailed functional history with more specific questions regarding ADL/IADLS is essential in establishing the diagnosis (there must be significant functional impairment to make the diagnosis of any form of dementia), assessing safety risk, abuse risk, appropriateness of current living setting, need for other community services.

Waiting for the results of the workup is the best approach. Pharmacological treatment for dementia does not reverse the process of cognitive decline, but can slow the rate of progression and improve symptoms in many patients for a limited period of time. Treatment includes acetylcholinesterase inhibitors (e.g., donepezil, rivastigmine, galantamine) or NMDA receptor antagonists ( memantine). Rivastigmine and donepezil are FDA approved for all stages of dementia, and memantine for moderate to severe stages of dementia. In this patient an acetylcholinesterase inhibitor should be started first.

Based upon history and mental status exam, this woman does not appear to be suffering from depression. However, it is important to note that depression in the elderly often presents with symptoms that can be mistaken for delirium (e.g., poor concentration or other cognitive symptoms of depression can look like memory impairment). A Geriatric Depression Scale should be performed. Individuals with delirium have high rates of co-occurring depression, which may be superimposed upon the delirium. One could consider assessment with the CAM (Confusion Assessment Method) as well.

Part 2

An MRI that you order shows enlarged ventricles, widened sulci and generalized atrophy, but is otherwise unremarkable (A Normal, B Your patient). A complete metabolic panel, TSH, CBC, B12, urinalysis, RPR in normal range. MMSE score is 20. Geriatric Depression Scale score is 3 (inconsistent with depression) You start donepezil at the next office visit 1 week later.

A A

B B

The patient misses her follow-up appointment two months later, and so it is four months before she returns to your clinic, at the urging of her daughter. Knowing that she no longer drives, you ask how she got to the clinic, and she says she does not remember. On MMSE, her score has dropped to 18 (missed an additional point on orientation to time and three step command). Her sleep, appetite, energy, and level of activity are unchanged since her first visit. When asked whether she is taking her donepezil, the

patient claims that you never prescribed her a medication. On mental status exam, she appears somewhat more disheveled, is wearing urine stained clothes and is poorly groomed compared to the first visit.

Part 2 Discussion Questions:

1. Is the patient, in your judgment, able to care for herself living alone at home? If not why not? If not, what other options should be discussed with the patient and her daughter?

2. Would you add or stop any medications? If so what would you do?

In addition to attending to her cognitive problems, the physician has responsibilities to take into account and address her psychosocial difficulties, which in this case are closely bound up with her cognitive difficulties. Assessing the safety and suitability of her living condition is an important part of the physician’s psychosocial assessment (and not an issue that can be entirely relegated to a case manager or social worker, even when such staff is available). The physician must assess not just her cognitive or neuropsychiatric condition, but also the ways in which such impairments are affecting her daily functioning (ADL/IADLs, safety, abuse potential, self management of medical problems). Clearly this patient is not capable of independent living due to self care issues, medication management issues, safety issues, elder abuse issues. She would need 24 hour care to continue to age in place or placement in assisted living preferably with specific dementia care services.

A patient that lacks the ability to adequately provide food, clothing, or shelter for herself (or avail herself of resources to do this) due to a medical or neurological condition is legally considered “gravely disabled”. Most states have legal measures in such cases to allow family members or friends to take on the role of conservator and assist the patient. The process for assigning a conservator is often triggered by a medical evaluation, and clinicians should be familiar with their state’s process in regards to conservatorships, in order to advise families regarding how to proceed.

Normally one would consider adding memantine to her donepezil since she is in the moderate stage of the disease (MMSE 11- 21). However there is medication noncompliance and an increased likelihood of adverse events with her current regimen. The best course is getting someone to assist with daily medication management either at home or by moving to an assisted living setting.