Cognitive Impairment in the Emergency Department

1. Cognitive Impairment in the Emergency Department Jin H. Han, MD, MSc Assistant Professor Department of Emergency Medicine Research Division Center for Quality Aging Vanderbilt University School of Medicine

2. What We Will Cover… • Define cognitive impairment • Delirium • Dementia • Screening for cognitive impairment in the emergency department

3. Cognitive Impairment in the ED Up to 25% of older emergency department (ED) patients will have cognitive impairment Hustey et al. Ann Emerg Med. 2002;39:248-53

4. Two Main Flavors Hustey et al. Ann Emerg Med. 2002;39:248-53 Han et al. Ann Emerg Med. 2011:57:662-71 Carpenter et al. AcadEmerg Med 2011: 18: 374–84 Elie et al. CMAJ. 2000:163:977-81 • Delirium – acute loss of cognition • Affects 5 - 18% of older ED patients1,2,3 • Recognized 20 - 50% of the time1,4 • Dementia – chronic loss of cognition • Affects 15 - 40% of older ED patients1,2,3 • Documented in medical record in 3 – 13% of cases.2,3 • Delirium and dementia often occur concurrently

5. What is delirium? A disturbance of consciousness (i.e. inattention) that is accompanied by a acute change (hours to days) in cognition that cannot be better accounted for by a preexisting or evolving dementia. This disturbance tends to fluctuate throughout the course of the day. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

6. What is dementia? • Gradual (months to years) loss of cognition that causes significant impairment in social or occupational functioning. It is manifested in memory impairment and one or more of the following: • Aphasia • Apraxia • Agnosia • Disturbance in executive function Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

7. Delirium ≠ Dementia What’s the difference?

8. Delirium versus Dementia Dementia is an important predisposing factor to delirium Characteristic Delirium Dementia Onset Hours to days Months to years Course Fluctuating Stable Inattention Yes Rarely Altered LOC Typically Rarely Disorganized thinking Sometimes Rarely Reversible Typically Rarely

9. Precipitating Factors of Delirium • Systemic • Infection / sepsis • Dehydration • Hypo- or hyperthermia • Trauma • Inadequate pain control • Medications / Drugs • Adverse drug reaction • Recreational drug or withdrawal • CNS • Infection • Hemorrhage / hematoma • CVA • Metabolic • Thiamine deficiency • Renal or liver failure • Hypo- or hypernatremia • Hypo- or hypercalcemia • Hypo- or hyperglycemia • Hypo- or hyperthyroidism • Cardiopulmonary • Shock • Hypoxemia • Hypercarbia • Acute heart failure • Acute myocardial infarction • Hypertensive encephalopathy

10. Reversible Causes of Dementia Hypothyroidism Normal pressure hydrocephalus Vitamin B12 deficiency Depression can mimic dementia-like symptoms Reversible causes of dementia are rare

11. Rationale for Cognitive Screening 1. Han et al. Ann of Emerg Med. 2011; 57:662-71 • Delirium and dementia in the ED is frequently unrecognized • Potential safety concern • Inaccurate history1 • Cannot comprehend discharge instructions1 • Decisional capacity • Safe to go home?

12. Rationale Delirium Screening Delirium may be the first manifestation of a underlying illness and can occur prior to any vital sign abnormalities.

13. Rationale for Delirium Screening If you miss delirium, you may miss the underlying illness. Reeves et al. South Med J. 2010; 111 - 5

14. Rationale for Delirium Screening Kakuma et al. J Am Geriatr Soc. 2003 Lewis et al. Am J Emerg Med. 1995 Han et al. Ann Emerg Med. 2010 Han et al. Acad Emerg Med. 2011 • Delirium is associated with: • Mortality1,2,3 • Accelerated cognitive and functional decline • Prolonged hospitalizations4 • Increased hospital complications • Increased institutionalization • Higher health care costs

15. Global Tests of Cognition

16. Global Tests of Cognition These tests in and of itself cannot differentiate between dementia and delirium

17. Global Tests of Cognition • 10-15 minutes • Mini-mental state examination • Montreal Cognitive examination • 5 minutes • Abbreviated Mini-Cog • Short Blessed Test • < 5 minutes • Six Item Screener • Mini-Cog • Ottawa 3DY • Brief Alzheimer’s Screen

18. Trade Off Accuracy Brevity

19. Ottawa 3DY Month Year Spell “WORLD” backwards Molnar et al. Clin Med Geriatrics. 2008:2:1-11

20. Ottawa 3DY Carpenter CR. AcadEmerg Med. 2011; 18:374-84 • In older ED patients • 95% sensitive • 51% specific

21. Six-Item Screener Ask patient to remember 3 objects Ask patient the day, month, and year Ask patient to recall the 3 objects Callaham et al. Med Care. 2002;40:771-81

22. Six-Item Screener • In older ED patients, 2 or more errors • 63% to 74% sensitive • 77% to 81% specific Wilber et al. AcadEmerg Med.2008;15:613-6 Carpenter et al. Ann Emerg Med. 2011; 57:653-61

23. Delirium Assessment Tools

24. Confusion Assessment Method Feature 1 Fluctuation and change in mental status + Feature 2 Inattention 94 - 100% sensitive and 90 - 95% specific Feature 3 Disorganized thinking and either Feature 4 Altered level of consciousness Inouye et al. Ann Intern Med. 1990; 113:941-8

25. CAM’s Diagnostic Accuracy Pooled Sensitivity: 86% Pooled Specificity: 93% Wong et al. JAMA. 2010.

26. Brief Confusion Assessment Method (B-CAM) 84% sensitive and 98% specific in older ED patients Han et al. Ann Emerg Med 2013 (In press).

27. Modified Richmond Agitation Sedation Scale In hospitalized patients Single mRASS:64% sensitive and 93% specific Serial mRASS: 74% sensitive and 92% specific Chester et al. J Hosp Med 2011

28. Nursing Delirium Screen Scale (NuDESC) 86% sensitive and 87% specific in hospitalized patients Gaudreau et al. Gen Hosp Psychiatry 2005.

29. Single Question in Delirium Sands et al. Palliat Med 2010. • “Do you think [name of patient] has been more confused lately?” • 80% sensitive • 71% specific • Validated in an oncology inpatient population

30. Suggested Algorithm Ottawa 3DY Positive Negative B-CAM No Cognitive Impairment No delirium and no dementia Positive Negative Yes delirium MMSE or MOCAor Referral

31. Cognitive and Mood Assessment in the Emergency Department Roger D. Williams, Ph.D. Zablocki VA Medical Center Associate Professor of Psychiatry & Behavioral Medicine Medical College of Wisconsin

32. Who Should be Evaluated for Dementia? People with identified risk factors People with memory impairment or cognitive complaints, with or without functional impairment Informant complaint, with or without patient concurrence People with psychiatric complaints, with or without cognitive complaints

33. Diagnosis of Dementia The diagnosis of Alzheimer’s disease (AD) and related dementias remains a clinical process Efforts to detect dementia in the Emergency Department improves clinician decision-making, treatment planning and eventual disposition Since memory impairments are often the earliest signs of dementia, use of cognitive screening is helpful to the diagnostic process

34. Is There Cerebral Impairment? Level of performance Pattern of performance Right-left differences Pathognomonic signs

35. Brain-Behavioral Correlates Output ConceptFormation Reasoning LogicalAnalysis Language Skills VisuospatialSkills Attention, Concentration, Memory Input After Reitan & Wolfson, 1993

36. Brief Cognitive Assessment in the Emergency Department • Mini-Cog • Mini Mental Status Examination (MMSE) • Cut-off 23/30 • Montreal Cognitive Assessment (MoCA) • Cut-off 23/30 • St. Louis University Mental Status Exam (SLUMS) • Cut-off 20/30 or 19/30 depending on education

37. Clinical Dementia Rating (CDR) • Determines the stage of AD by scoring 6 cognitive/functional areas from 0 (none) to 3 (severe): • Memory • Orientation • Judgment and problem solving • Community affairs • Home and hobbies • Personal care After Morris. 1993

38. Functional Assessment

39. Mood Assessment • Depression (GDS, PHQ-2, PHQ-9) • Low motivation and energy, poor appetite • Substance abuse (Audit-C) • Psychotic Disorders • Paranoia, delusions • Personality Style • Highly value independence

40. Mood Assessment • Geriatric Depression Scale • 30, 15 & 5 item versions available • Administration • Scoring • Cut-off scores (11 or 12/30, 5 or 6/15 & 2/5) • Interpretation

41. Putting it All Together Brief structured screening tools Account for sensory-perceptual factors Consider physical limitations Weigh demographic factors (e.g., age, education, ethnicity, & background) Avoid level of performance errors Close inspection of individual items

42. References Morris JC. The Clinical Dementia Rating (CDR): Current version and scoring rules. Neurology 1993; 43:2412-2414. Reitan, R.M., & Wolfson, D. 1993. The Halstead-Reitan Neuropsychological Test Battery: Theory and clinical interpretation (2nd ed). Tucson, AZ: Neuropsychology Press. Strauss, E., Sherman, E. M. S., & Spreen, O. 2006. A compendium of neuropsychological tests: Administration, norms, and commentary (3rded). New York: Oxford University Press. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression rating scale: a preliminary report. J Psych Res. 1983; 17:37-49.

43. Assessing Capacity By Steven M. Crocker, Ph.D.

44. What is Capacity Capacity to make decisions Decision making capacity Capability Competency Often referred to as global capacity

45. Capacity to Make Medical Decisions Medical “Capacity” refers to an individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate health-care decisions. (Uniform Health-Care Decisions Act of 1993, 1994).

46. Capacity Decisional Capacity the capacity to decide Executable Capacity the capacity to implement the decision

47. Assessing Capacity • Assessing capacity typically consists of • Assessing cognitive functioning Neuropsychological assessment • Assessing psychiatric and/or Emotional functioning Assessing for Delusions and/or hallucinations, severe mood impairments • Assessing functional elements

48. Assessing Capacity Functional Elements • The functional elements for medical capacity are primarily cognitive and include: • Expressing Choice • Understanding • Appreciation • Reasoning

49. Assessing Decision Making • Clinical Interview • Medical history • Social history • Objective measures (at a minimum) • Dementia Rating Scale (global cognitive functioning assessed) • Mini Mental Status Examination (brief screen) • St. Louis University Mental Status Examination (brief screen) • Montreal Cognitive Assessment (brief screen) • Independent Living Scales (functional Assessment) • RBANS (Global cognitive functioning assessed)

50. Cognitive Assessments for Capacity Testing • May be useful if you are already collecting this data • Mini-mental State Examination • MMSE scores < 19 likely to be associated with lack of capacity1,2 • MMSE scores > 23 to 26 likely to be associated with presence of capacity1,2,3,4 • Other cognitive assessments (e.g., MOCA) not well studied • Kim et al. PsyciatrServ2002;54:1322-4. • Karawish et al. Neurology 2005; 53:1514-9. • Etchells et al. J Gen Intern Med 1999;14:27-34. • Raymont et al. Lancet 2004;364:1421-7.