The Cognitive Assessment Toolkit...The Cognitive Assessment Toolkit Southlake Geriatric Conference...
Transcript of The Cognitive Assessment Toolkit...The Cognitive Assessment Toolkit Southlake Geriatric Conference...
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The Cognitive Assessment Toolkit
Southlake Geriatric Conference April 2012
Dr. William DalzielAssociate Professor, Geriatric Medicine
University of OttawaMedical Director, Geriatric Day Hospital
The Ottawa Hospital
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Disclosure
1.
Member Aricept Advisory Board (Pfizer).2.
Honoraria for CME/design of educational programs and projects (Pfizer/Novartis/Lundbeck/JOI)
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Grey’s Anatomy – FIRST
Episode
Izzie
Stephens:
“Maybe I should have gone into geriatrics. No one minds when you kill an older person.”
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Grey’s Anatomy – FIRST
Episode
Alex Karev: “Geriatrics is for freaks who live with their mothers and never had sex.”
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The Silent EpidemicThe facts …
A new case in Canada every 4 minutes (100,000 new cases per year)
Now (450,000) to 750,000 by 2025
3rd most expensive disease in the Canadian Healthcare System
1 in 4 Canadians has a family member affected by the disease and half of all Canadians know someone diagnosed with Dementia
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Case Study: Mrs. Green
A 80 year old female with BP 165/85 and no family history of dementia
Question #1:Do you screen this type of patient ALREADY?
Question #2: IS HER RISK OF DEMENTIA1.
<10%
2. 10-20%
3. 20-30%
4. Over 30%
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•
Prevalence 8% N = 30-40•
Incidence 2% per year N = 8-10
Not Diagnosed
50%
Diagnosed not treated 25%
Diagnosed and treated 25%
A Typical GP Practice (65+ = 400-500)
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How is dementia currently
“recognized”?
…A Sentinel Event
OR
…Normalization Fails
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Dementia Early Warning SymptomsFor Professionals:
Frequent phone calls/appointments –
missing/wrong day
Poor historian, vague, seems “off”, repetitive questions or stories
Poor compliance meds/instructions
Appearance/mood/personality/behaviour
Word-finding/Decreased social interaction
Subacute
change in function without clear explanation/frequent visits to ER
Confusion -
surgery/illness/meds
Weight loss/dwindles/ “failure to thrive”
Driving –
accident/problems/tickets/family concerns
Head-turning sign (turning to caregiver for answer)
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Why do dementia screening?
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Patients with Dementia Have Other Chronic Conditions
•
Heart disease 31%•
Arthritis 23%
•
Hypertension 25%•
Diabetes
16.5%
•
Respiratory Disease 11%
Management is Affected
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Patients with AD Have More Injuries – 1 year
1.
Fractures
12%2.
Head injuries
20%
3.
Contusions
35%4.
Falls
45%
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Why should we do Dementia Screening?
Social
Social/financial planning
Early caregiver education
Safety: compliance, driving, cooking
Advance directives planning
Right/Need to know
Medical
Reversible cause/component
Vascular risk factor treatment
Compliance strategies
Treatment of other diseases
AChEI treatment
Crisis avoidance
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•
50% of dementia is NOT “diagnosed”.
•
What % of dementia diagnosed is diagnosed in the early/mild stage?–
10%
–
20%–
40%
–
60%–
80%
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Stage of Dementia At Time of Diagnosis –
55% are
Moderate/Severe
45% mild45% moderate10% severe
First Symptom to Dx
= 2.5 years
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1.
What are risk factors for Dementia?2.
How would you calculate an individual patient’s risk? (Mrs. Green 80, female, BP 165/85).
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Dementia Risk Calculator
< 65 1%65 2%70 4%75 8%80 16%85 32%
Overall risk = age risk _____% x family hx
risk multiplier___x
vascular risk multiplier ___= ___%
Risk Doubles every 5 years of Age
Each additional vascular risk factor approximately doubles the risk
Positive family history doubles the risk
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Question #3:•
? In a busy office/clinic/ ER Hospital situation what screening “tests”
could
you use?
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Dementia Quick Screen
3 item recall (0-1 correct: OR 3.1)
Animals in 1 minute (<15: OR 20.2)
Clock drawing (abnormal: OR 24)
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Mrs. G’s DQS is Positive:
•
6 animals in 1 minute•
1/3 recall
•
Abnormal clock (hands to 10 & 11)
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Dementia Quick Screen
3 item recall (0-1 correct: OR 3.1)
Animals in 1 minute (<15: OR 20.2)
Clock drawing (abnormal: OR 24)
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Mrs. G’s DQS is Positive:
•
6 animals in 1 minute•
1/3 recall
•
Abnormal clock (hands to 10 & 11)
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So What’s Next?
Pathway 1
Pathway 2DQS +
CG/patientcomplaints
Collateral History(ABC)
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•
Husband admits he has seen some forgetfulness, slowly worsening over the past year and has observed some irritability and apathy
•
He has not observed any problems in shopping, cooking, cleaning, banking, driving etc.
Case History: Mrs. Green
1.DOES SHE HAVE EARLY DEMENTIA?
2.WHAT WOULD YOU DO NEXT?
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Dementia Interview Guide
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Dementia Interview Guide
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Dementia Interview Guide
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Dementia Interview Guide
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Dementia Interview Guide
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Dementia Interview Guide
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Summary of Assessment
Cognitive Testing Results:
MMSE ________/30 (serial 7’s) ________/30 (world) _________
MoCA /30
Clock #s: Normal /Abnormal Hands: Normal/Abnormal _________
Animal Naming in 1 Minute
Need to Rule Out (check if any present)
Delirium (see CAM)
Unstable medical illness
Drug side effect/concerns: (see drug checklist)
Alcohol
Depression (Consider “SIG E CAPS” or GDS)Red Flags:
Negative (likely Alzheimer’s)
Positive for:
Vascular
Mixed/vascular
Lewy Body
Frontotemporal
NPHStill Driving?
No
Yes (see Trails A and B) (Also can do Appendix 3: Driving Checklist)
Trails A – errors
Normal
Abnormal – errors
Time
Seconds Observation: _______________
Trails B - errors
Normal
Abnormal – errors
Time
Seconds Observation: _______________
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IMPRESSION ACTION
Cognitive Decline with NO Functional decline due to Cognitive reasons
→
likely MCI (Mild Cognitive Impairment)
Cognitive Decline WITH Functional decline possible DementiaNeed to Rule Out-
Delirium (see CAM)
Unstable medical illness
Drug side effect/concerns: (review drug checklist)
Alcohol
Depression
Other ____________________________________
Other issues:
1.
2.
3.
Consider referral to specialized geriatric services if :Unclear Diagnosis Unaddressed Management Issues Multidisciplinary Assessment
What: Depression Who:
What: Delirium work up indicated Who:
What: Dementia work up indicated Who:
What: Optimize Vascular Risk Factors Who:
What: Caregiver Support Who:
What: Driving Safety Who:
What: Refer to Alzheimer’s Society Who:
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MMSE
30-point scale
Focus on memory/orientation (16/30 points) -
good for
AD, poor for non-Alzheimer’s dementias
Poor at upper end at discrimination between normal (especially highly educated) and MCI
Poor with those < grade 5 education (cut off = 20 for 80 y/o, 19 for 85 y/o)
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MoCA
30-point scale
Available free of charge in multiple languages at www.mocatest.org
Comprehensive: Many more domains than MMSE (good for AD and non AD)
Minor: adjustment for education (add 1 point if ≤
grade 12) IS WRONG
MCI = MOCA <26?
Using a cut-off score <26 provides sensitivity of 80%, and specificity of 91% to distinguish MCI from normal
Much better discrimination betweenNormal
vs
MCI
and
Dementia≥
26 < 26
< 26(usually 21-25)
(usually < 20)(function OK) (function affected)
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MCI vs Dementia
•
MCI = cognitive changes but no functional changes
•
Dememtia
= cognitive change CAUSING functional changes.
(Not scores on tests)
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No the patient does NOT
have dementia. Mrs. Green has Mild Cognitive Impairment (MCI).
Mrs. Green: COG ∆
→ NO Fn ∆
BUT…
• Rx VRFs
• Lifestyle
• Yearly F/U (15%)
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•
Mrs. G. had shown increasing forgetfulness and repetitiveness. Her husband has seen some problems with banking, shopping and cooking. Her MMSE is now 21, MOCA 18.
•
What is the diagnosis?•
What should be done next?
1 Year Later
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Causes that must be ruled out
Delirium
Depression
Alcohol
Hypothyroid
Drug side effects (including OTC/herbals)
Significant hearing/vision problem
Recent head injury/fall
Poorly controlled medical conditions
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Examination/Lab/CT
1.
Neuro/CVS focus2.
CBC, electrolytes, blood sugar, calcium, TSH, creatinine, B12
3.
CT for “other”
reason
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Investigations•
Lab normal CBC, electrolytes, Cr, Ca, BS, TSH, B12
•
CT: 1 old lacune
and moderate PVWM changes
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•
Mild mixed AD with CVD (cerebrovascular disease) or mixed AD/VAD
•
How would you manage/treat her mild dementia?
Mrs. Green has:
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Triple Therapy In Dementia
Prevent the Preventable
•
Lifestyle changes
•
Antihypertensive•
Antidiabetic
•
Antiplatelet•
Antilipemics
•
Anticoagulants•
Antidepressant
Treat the Treatable
A trial in all patients with a cholinesterase inhibitor
A trial with Ebixa in mod-severe disease
Care for the Caregivers
Referral to Alzheimer Society
Home support
Respite
Recognize and change caregiver burden/stress/
depression
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How Dementia Drugs Work
Cholinesterase inhibitor = + cholinergicADD CI
ADD Memantineto CI
GABA receptor antagonist = ↓
excitotoxicity
Normal Alzheimer’s
Alzheimer’s
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Expectations
25%
25%50%
Responder
Average response = mild improvement or same for 1 year (Brain Cancer)
Non-Responder
(Continued worsening)
Super Responder(Much better)
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Memantine
(EBIXA)
•
Approved in Canada for treatment of AD (moderate to severe)
•
Non-competitive inhibitor of NMDA receptor
•
Now indicated for treatment of moderate and severe AD
•
Primarily for use in combination with CI’s
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Dementia Interview Guide
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