Cognitive Impairment Mental Status Evaluation Hints

1. Cognitive Impairment & Mental Status Evaluation Hints Ted Johnson, M.D., M.P.H. Director, Atlanta Site Birmingham/Atlanta Geriatric Research Education and Clinical Center

2. Case #1 93 y.o. female NH resident who is transferred to the inpatient service Fever, cough, and hypoxemia Described as �acting differently� The pt has dementia and is uncooperative with history and exam The patient�s verbal output during the examination is mostly profanities

3. Case #2 72 yo male patient referred from urology clinic to continence clinic Sx: difficulty voiding with urgency, frequency, nocturia, poor stream. Pressure flow study: good bladder contractility but poor urinary flow Drug tx: finasteride, no alpha-blocker

4. Case #3 75 yo male patient misses an appointment for new evaluation in the geriatric clinic

5. Overview- Hands on practical Definitions �Screening� versus �evaluation� Properties of evaluation instruments and screening tests The role of neuro-imaging and serological evaluation Does �dementia� really reverse?

6. Prevalence of Dementia: Age and Setting

7. Should there be Screening for Dementia? Is it common? YES Is it morbid? YES Can you detect it early? PERHAPS Is there treatment for an early stage? MAYBE Is screening cost effective? PERHAPS

8. And the USPSTF says? The U.S. Preventive Services Task Force (USPSTF) concluded in June 2003 that the evidence is insufficient to recommend for or against routine screening for dementia in older adults.

9. Missed Dementia Williamson et al (British) 1964 87% of dementia unknown to GP Ross et al (Hawaii) 1997 60% of dementia in men not recognized by family Snowdon (Nuns) 1997 22% of caregivers failed to recognize dementia Sternberg et al (CSHA) 2000: 64% missed by caregivers and physician

10. Simulation of Clinical Screening for Dementia 1435 75-95 yo without dementia 3-step procedure �Do you currently have any problems with your memory?� one SD below mean on MMSE for age / education Neuropsychological testing

11. (In)Ability to Predict Word recall and verbal fluency had PPD for dementia of 85-100% Only 18% of future dementia cases were identified in preclinical phase 12% with no reported memory problems developed dementia 20% of participants without global cognitive impairment developed dementia

12. Evaluation versus screening Routine screening not recommended, yet clinicians should Assess cognitive function when cognitive impairment or deterioration is suspected Direct observation, Patient report, or Family members, friends, or caretaker concerns

13. Purpose of Evaluation for Cognitive Impairment Identify disease Offer treatment Cholinesterase inhibitors (mild-to-moderate) Donepezil, Galantamine, Rivastigmine NMDA Receptor Antagonists (mod-to-severe) Memantine Managing co-morbidities Advanced planning and expectations

14. Algorithm for Dementia Evaluation

15. Dementia criteria (DSM-IV) Short-term memory (learning skills) and long term memory impairment plus Functional decline plus Work and social activity impairments plus Normal consciousness plus One or more impairments in abstract thinking, problem solving or judgment; personality disturbance; aphasia, apraxia, agnosia, constructional abilities, or calculations

16. Symptoms of Dementia Amnesia: Can�t remember Apraxia: Can�t orchestrate complex actions Aphasia: Can�t use language Agnosia: Can�t understand visual stimuli

17. Delirium is different from Dementia Distinguishing criteria: Sudden onset of deficits; Waxing and waning cognitive impairment; Alteration in consciousness

18. Depression (DSM IVR) is Different from Dementia Dysphoria Anhedonia Guilt/ Self-reproach Fatigability Impaired concentration and cognition Appetite disturbance Sleep disturbance Suicidal thoughts, risk Agitation or retardation

20. Testing and Test Elements Folstein Mini Mental State Examination Single test elements Clock drawing

21. USPSTF Statements: MMSE MMSE best-studied screening instrument PPV only fair in unselected MMSE accuracy depends upon age & educational level: Arbitrary cut-point ? False (+) -older adults with low educational False (-) - younger adults with high educational Functional Activities Questionnaire (FAQ) comparable sensitivity and specificity

22. Using the Mini-Mental State Examination Test is a compilation of different memory and cognitive tasks Test results need to be adjusted with different levels of educational attainment <~21 abnormal for 8th grade education <~23 abnormal for high school education <~24 abnormal for college graduates

23. Test Components Orientation 10 points Registration and Recall 6 points Attention and Calculation 5 points Language/Figure Design 9 points Total points: 30

24. Some Common Errors Non-components Correctly saying your name Reason for your admission 3 Common errors Orientation Attention Scoring

25. Case Presentations: Why I hate A & O x 4! Often means no assessment done What time & place elements were tested? Oriented to self? Little cause disorientation to self Insulting question? Oriented to situation May be complex or simple

26. 3 Common Errors in Test Administration- Orientation Ask all 5 time components: day, date, month, year, and season Location elements: state; county; city; hospital; floor Re-orient patients for later testing if incorrect Issues Where�s the VA? Decatur? Atlanta? In which county is Grady located?

27. 3 Common Errors in Test Administration- Serial 7�s Begin with 100 and count backwards by 7 Stop after 5 subtractions Do not reorient patient to task once started If cannot or will not, ask to spell the word WORLD backwards

28. 3 Common Errors in Test Scoring-Serial 7�s Correct sequence is 93, 86, 79, 72, 65 Score the total number of correct subtractions 93, 86, 79, 72 = 4 points 93, 76, 69, 62 = 4 points Do not reorient patient to task once started If cannot or will not, ask to spell the word WORLD backwards

29. 3 Common Errors in Overall Test Scoring Do not take off for sections where other disability renders patient unable to complete, I.e. poor vision Report score as 26/28, where patient was unable to complete x and y because of z Report score as patient only able to recall 1/3 objects, could not see to attempt x and y

30. Utility of Single Test Elements Serial subtraction Clock Drawing Time orientation

31. Single Test in Cognitive Screening- Serial 7�s

32. Single Test in Cognitive Screening- Clock Draw

33. Short Test of Mental Status

34. ROC for MCI versus Normals

35. Clock Drawing Test Instructions: Draw a clock, put all the details in and show that it is 10 minutes after 11. Normal Correct spacing, numbering, rotation Almost normal Missing number, inappropriate spacing Abnormal Perseveration, counterclockwise rotation, irrelevant patterns

42. Single Test in Cognitive Screening- Orientation

43. Further Evaluation Elements Identifying underlying contributing factors The �reversible� dementia Serological testing Neuro-imaging

44. Evaluating Dementia Hoping to alter dementia, potentially through co-morbidities History is the most important factor!!! Take drug history Characterize symptoms and their duration Active medical problems and current physical status Assess functional status Assess social support

45. Search for �reversible� causes Clinical series show that most dementias are not reversible. Food for thought Are �reversible dementias� truly �dementia�, or are they �delirium� states?

46. Most common causes of "reversible dementias": Medications Depression Metabolic disorders Thyroid B12 Calcium Hepatic

47. Case Reports of Reversible Dementia

48. Potential vs. Actual Reversal 305 consecutive memory clinic patients History; Physical Examination; lab tests Neuropsychological testing; CT scan 196 with definite or suspected dementia 45/196 �potentially� reversible 4 improved; 3 reversed (3.6% of total)

49. Find co-morbid illness Chemistry Electrolytes Calcium Complete blood count

50. Co-morbid illness: Subclinical hypothyroidism Thyroid replacement has slight, mild effect on cognition Equivalent of improvement of 5 points on a standard IQ test Proven benefit in depression

51. Co-morbid illness: B-12 Several observational studies have shown an association between cognitive impairment and low B12 levels Dementia/ B-12 deficiency both common Bronx Longitudnal Study on Aging: B-12 deficiency not associated with development of cognitive impairment 3/22 subjects with low B12 levels 57/388 subjects with normal B12 levels

52. Co-morbid illness: B-12 Memory clinic: 170 consecutive patients 26 cases with low B-12 levels Replacement of B-12 over 6 months No change in dementia versus controls in Activity of daily living disability Cognition Care-giver burden

53. Benefit of B-12 Treatment Dementia evaluation and had low serum B-12 but no obvious consequences Evaluation for hematologic, neurologic, metabolic consequences Mild neuropathies, EEG abnormalities, serum MMA/homocysteine & evoked potentials improved with treatment Dementia did not improve in 13 patients

54. Neurosyphilis ($$) FTA-Abs indicated RPR can revert to negative In younger, HIV +: Abrupt change over days to weeks in mental status Treatment in these patients is highly likely to improve function.

55. Neurosyphilis Evaluation: Routine Testing Retrospective review: 672 hospitalized patients evaluated for dementia Lumbar Puncture on 402 patients 333 with AFB, fungal, and bacterial cultures 4 meningitis - 2 crypto, 1 TB, 1 coag (-) staph All meningitis cases with sub-acute mental status changes, fever, or meningismus

56. Imaging CT or MRI scan Truly reversible lesions are few: NPH Subdural hematomas Intra-cranial tumors 1/59 of patients with these processes will present with isolated dementia of > 1 year duration

57. Neuroimaging Presentation of surgically treatable brain lesions Acute/subacute dementia (6 - 12 months) Headache and nausea Gait disturbance Urinary incontinence Focal neurologic findings

58. Rules for Neuroimaging Timing Rapid onset or progression Neurological signs or recent unexplained symptoms Early age

59. More Recent Guidelines

60. Neuroimaging Rules: Limitations If a low prevalence of reversibility: 1% Applying the highest-sensitivity rule (Dietch) would miss only 1 patient of 10 in a cohort of 1000 patients with dementia. If a higher prevalence of reversibility: 10% Number of missed cases is 13 of 50. Small proportion (3.6%) of all patients with rule-negative findings. Unacceptably high? For rules to work, docs must be proficient in Eliciting a neurologic history Performing a neurologic examination

61. Wrap up on Dementia Routine screening not recommended by USPSTF, but evaluation encouraged Historical information about the duration and time course will direct your evaluation as will the presence or absence of physical findings Reversibility for depression, metabolic, and medications MMSE is a useful standardized tool, yet test elements may be more efficiently used in certain situations

62. Nominal Benefits Seen in Drugs for Alzheimer'sNY Times, 4/07/04 "You can name 11 fruits in a minute instead of 10," said Dr. Thomas Finucane, a professor at Johns Hopkins and a geriatrician. "Is that worth 120 bucks a month?� Dr. DeKosky said the "data are overwhelming" that the drugs help patients stay functional a bit longer. In addition, he said, family members often tell him that patients improve with the medicines, or at least seem to decline less steeply. The moderator summed up, saying: "For us to tell you what to do, I think would be wrong. All you can do is look at your soul and do the best you can."

63. Case #1 93 year old female Nursing Home resident with fever, cough, and hypoxemia Could not coherently speak, perform any self-care MMSE is 11/30 from one year ago Outcome I.V. antibiotic treatment initiated and oral therapy continued Patient returned to NHCU, returned to baseline

64. Case #2 72 year old male patient referred from urology clinic to geriatric continence clinic Patient showed poor clock drawing all numbers & hands present Poor spacing of numbers One failed attempt Patient unaware he was no longer taking terazosin Alternative medication / assistance?

65. Case #3 75 year old male patient misses an appointment for new evaluation in the geriatric primary care clinic Son offered to drive patient to the VA for the appointment, but patient refused. Patient had agreed to meet son at the VA, but when son arrived, the patient was nowhere to be found Patient had showed up at VAMC, but could not remember where to go Information clerk asked patient why he was here; patient responded �I have a hernia� Patient transport took individual to outpatient surgery Patient sent home from outpatient surgery when no appointment found

66. High Homocysteine Levels High homocysteine levels associated with age, renal function, and B12 deficiency 128 persons with prevalent AD and 109 with incident AD in 3,206 person-years of follow-up. The adjusted OR of prevalent AD for the highest quartile of homocysteine compared to the lowest was 1.3 (95% CI = 0.7, 2.3; p for trend = 0.25). High homocysteine levels were not related to a decline in memory scores over time.

67. Neurosyphilis Evaluation: Routine Testing Retrospective review: Patients greater than >60 years in acute care setting 79 with (+) serology 8 had lumbar puncture; 71 had no LP performed 51 had no follow-up at all

68. Biological Markers: Abnormal in AD Several abnormalities The APOE [epsilon]4 allele Hippocampal atrophy on magnetic resonance imaging Cerebrospinal fluid (CSF) assays of tau protein a marker of neuronal and axonal damage that follows neurofibrillary tangle deposition Lower [beta]-amyloid 42 (A[beta]42) protein levels Cortical defects of perfusion or metabolism on single-photon emission tomographic or PET scans Biological markers have no incremental diagnostic value for AD over expert clinical diagnosis

69. Lists of Animals and Words that Begin with �F�

70. Guideline and Position Statements on Neuroimaging