Assessing Dementia: Review of a clinical case

1. Assessing Dementia:Review of a clinical case Zeina Chemali,M.D, MPH Capacity Building Workshop Lebanon, 2011

2. Case Discussion: Dementia Objectives: • Emphasize Alzheimer’s disease (AD), • Provide participants with the tools to identify, diagnose, and treat patients with progressive cognitive impairment. • Identify the need for appropriate early diagnosis and initiation of treatment • Preserve quality of life of patients for as long as possible.

3. Case discussion: Dementia • Chief Complaint: “My son thinks there is something wrong with me.”

4. Case discussion: Dementia • History of Present Illness: A 72-year-old white man comes to the neurology office accompanied by his son, who is concerned about his father’s recent memory lapses. The patient tells you he is just fine and is annoyed that his son insisted on this appointment. The son gently contradicts him and describes an incident when the patient said he had lost some checks; the son found the last 3 months’ worth of checks in his father’s top desk drawer, the son also tells you that during the past year his father has had increasing difficulty retaining new information; for example, last week he was unable to find a new restaurant where they were scheduled to meet. Lastly, the son notes that the patient has occasional trouble finding words when speaking.

5. Case discussion: Dementia • Risk factors: Hypertension • ROS: positive only for ; mild nocturia, mild joint pain, particularly in the knees and back after sitting for a while. He admits to feeling lonely at times, but denies crying spells and suicidal ideation. • Current Medications: • Hydrochlorothiazide, 25 mg PO q.d. ; aspirin, 81 mg PO q.d. ; one multivitamin PO q.d. • Allergies: No Known drug allergies

6. Case discussion: Dementia • Past Medical History: • Hypertension diagnosed at age 44 • depression” during his divorce at age 50: • one hospitalization for chest pain at age 67 years with no clear diagnosis. • Family History: • The patient’s father died at age 64 years of MI • Mother died at age 58 years of breast cancer. • One grandmother was “senile” when she died at age 80, and her cause of death is unknown. • No history of substance abuse or psychiatric illness in the family. • Social History: Nonsmoker. Daily alcohol consumption (2 to 6 ounces per day) for 40 years, although he says it never interfered with his ability to work and stopped drinking 10 years ago. He is divorced and lives alone. He walks one mile, 3 days a week. He follows a low-sodium diet. The patient is a college graduate, and retired from full-time employment at age 65 years. He now works part-time as a consultant for an advertising agency.

7. Case discussion: Dementia • Physical Examination (PE): • Vital signs: afebrile; BP 138/85mm Hg in both arms • Body mass index (BMI): 25 kg/m2 • Well-developed, well-nourished, well-groomed, cooperative with an appropriate social demeanor. PEERLA; oropharynx clear; both hearing and vision are grossly intact • Neck: Supple, full range of motion; no thyromegaly or lymphadenopathy; no bruits or jugular venous distention • Cardiac: Regular rate and rhythm; an S4 is heard, but there are no murmurs or rubs • Lungs: Clear to auscultation and percussion • Abdomen: Soft and nontender with normal active bowel sounds; no masses or distention • Extremities: No edema; pulses full and equal • Back: Full range of motion; no tenderness or deformity

8. Case discussion: Dementia • Neurological exam: He is oriented to person and place but is 2 days off on the date and says it is Wednesday rather than Thursday . He has a good general fund of knowledge but is uncertain when asked what year the graduated from college and the year he was married. He is able to name the current president and the two presidents who preceded him, but cannot name any vice presidents and is unable to provide any details about the birthday party for his grandson that he attended last week. He has no trouble subtracting 3 from 100 down to 88. There is no evidence of an anomia during conversation or with confrontational naming. He is able to name 8 animals in 60 seconds and states that the difference between a river and a canal is that a river is longer. Mini-Mental State Score: 24

9. Case discussion: Dementia • Cranial Nerves: II-XII intact • Cerebellar: Finger to nose and rapid alternating movements are normal bilaterally • Gait and Station: slightly shortened stride and a very mild stoop: turns using two steps and is stable on a pull-back test • Deep Tendon Reflexes: Normal; Babinski absent bilaterally • Muscle Strength: Normal bulk, tone, and strength throughout • Sensory: Intact to touch and vibration

10. Case discussion: Dementia

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15. Case discussion: Dementia • Differential DX: • Age associated memory impairment (AAMI) • Mild Cognitive Impairment • Alcoholic dementia • Alzheimer’s Disease • Other Dementias : PD, DLB, FTD,VD • Depression • Hypothyroidism • Intracranial mass lesion

16. Case discussion: Dementia Work-up: feasible in community CBC and metabolic profile CT or Brain MRI Geriatric Depression Scale RPR B12 level TSH More sophisticated…. Refer to MDU

17. Case discussion: Dementia • Complete blood count and complete metabolic profile • Rule out conditions such as infections and metabolic disorders that can cause or contribute to cognitive dysfunction (Knopman 2001, 1143-1153).

18. Case discussion: Dementia • Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain Highly appropriate part of the diagnostic workup American Academy of Neurology’s 1994 Practice Parameters for AD: Results of neuroimaging studies: changed the diagnosis 19% - 28% of patients affected management in 15% of patients (Chui and Zhang 1997)

19. Brain MRI

20. SPECT

21. Differential Diagnosis Mild cognitive impairment: • memory impairment, normal general cognitive function, and independence in all activities of daily living • Patients with mild cognitive impairment are at high risk of progressing to dementia, and longitudinal studies report an annual rate of conversion to Alzheimer’s disease of 6% to 25% annually. • Clinical trials are underway to determine whether there are treatments that will slow the rate of progression from mild cognitive impairment to dementia (Petersen 2001)

22. Case discussion: Dementia • Geriatric Depression Scale • It is highly appropriate to administer a depression screening test to this patient with cognitive impairment, as depression could be the cause of these symptoms or may be a co-morbid condition.

23. Geriatric Depression Scale • 30 questions • Best answer for • “ how you felt over the past week”: Y/N • Scale can be administered or read

24. Short form of GDS • 1. Do you worry? In the past month? • 2.Have you been sad or depressed in the past month? • 3.Are you hopeful about the future • 4.During the past month, have you ever felt that life is not worth living? • 5.During the past month, did you feel you would rather be dead? • 6. Do you enjoy things as much as you used to? • 7. Is it because you depressed that you don’t enjoy things as much? • 8. Are you very happy, fairly happy , not very happy, not happy at all?

25. Behavioral Problems with AD • Many patients with Alzheimer’s disease will experience behavioral problems during the course of the disease. Psychoses and delusions are common • Atypical antipsychotics (e.g., risperidone, olanzapine, quetiapine) may work as well as typical antipsychotics (e.g., haloperidol), and with fewer side effects (Mayeux and Sano 1999) • Use always lowest dose

26. Case discussion: Dementia • Rapid plasma reagin (RPR)- Indolent infection work-up • This patient reports no risk factors for syphilis infection and does not live in a high-risk geographic area. According to the American Academy of Neurology’s 2001 Practice Parameter: No longer considered appropriate without suspicion of high-risk behavior.

27. Case discussion: Dementia • Serum B12 Level • This patient has memory loss but lacks any other neurological symptoms of vitamin B12 deficiency. • He also reports taking a daily multivitamin. Nevertheless, low vitamin B12 levels are common in the elderly and should be recognized and treated when appropriate (Knopman 2001).

28. Case discussion: Dementia • Thyroid-stimulating hormone (TSH) • This test is appropriate because hypothyroidism is common in the elderly population and can cause or contribute to cognitive dysfunction.

29. Case discussion: Dementia • Management Plan: • Education for patient and family Anti-inflammatory agent • Antidepressant agent • Anti-inflammatory • Gingko Biloba and/or other Vitamins • No treatment • Referral to geriatric psychiatry • Referral to memory disorder unit- Cholinesterase Inhibitors • Repeat cognitive testing in 6 months

30. Anti-inflammatory agent Anti-inflammatory agents can cause adverse effects and have not been proven to benefit patients with Alzheimer’s disease. Treating this patient with an anti-inflammatory drug is inappropriate.

31. Antidepressant agents • This patient’s Geriatric Depression Scale indicates borderline depression. Depression could be contributing to cognitive dysfunction. • Depression can be an early symptom of Alzheimer’s disease (Kawas 1999) and it coexists in 5%- 8% of Alzheimer patients (Small and Mayeux 2000) A trial of an antidepressant might prove helpful. Selective serotonin reuptake inhibitors may be the antidepressant of choice. (Doody et al 2001)

32. Cholinesterase inhibitors • At MDU clinic- Start medication • Economic analyses of cost-effectiveness ? • Data remains inadequate on cost-effective analysis • Some benefit in favor of treatment compared to placebo. • Rate of withdrawal > treatment groups • Little direct difference from comparisons between the three drugs • On a different review, memantine w/same benefit as compared to cholinesterase inhibitors.

33. Case Discussion The patient begins a trial of a cholinesterase inhibitor. Dosage is titrated appropriately. Six months later, his Mini-Mental State score is unchanged. The medication is continued.

34. Case discussion:Education • Educating patients and family members about dementia and helping them plan for the future are extremely important aspects of care. Educational and support programs aimed specifically at early diagnosis patients and their families stand to ease the emotional adjustment required of both patient and caregivers (Post and Whitehouse 1995) • The patient takes home educational materials regarding advance directives. His son contact the local Alzheimer’s Association and learn about local support groups. Call Alzheimer Disease Lebanon (Ms. Diane Mansour)

35. Ginkgo Biloba • There is no clear evidence to date that ginkgo biloba benefits patients with Alzheimer’s disease, but research is ongoing. • This is not appropriate first-line therapy for this patient, although it is commonly used by many for its perceived positive effects on circulation and neuropsychological function. • Beware of CNS bleed

36. High-dose vitamin E Single study showed modest delay in disease progression with moderate to severe disease the High-dose vitamin E (2000 IU/d) was used Patient’s outcome following treatment • Vitamin E is begun and titrated to 1000 IU twice daily. After 6 months, the patient’s cognitive function is unchanged. The medication was discontinued per patient’s request

37. Vitamin E • Edgar Miller et al. published a review in the Annals of Internal Medicine, January 2005 stating that there is an increase risk of death(4%) in one to several years follow-up for people taking Vitamin E at doses >400IU compared to a tiny decrease in risk(2%) for those taking lower doses • *problems with data collection ( 20,000 s)

38. Observation and no treatment Beginning pharmacologic treatment ? slow the progression of the disease: Discuss with patient and family. Initiating non-pharmacologic interventions at this point would also be optimal. Patient’s outcome following treatment • The patient and his son are reassured and instructed to follow up with the patient’s primary care physician. Eight months later, the patient’s son calls you because his father was found wandering the streets after failing to find his neighborhood grocery store.

39. The role of Geriatric Psychiatry Patient’s outcome following treatment The patient visits a geriatric psychiatrist, who confirms an impression of Alzheimer’s disease with possible mild coexistent depression. She does not recommended antidepressants at this point, refers the patient back to you for further management, and offers to be available as the clinical situation deteriorated

40. Role of memory disorders clinics • This referral may be particularly useful when the diagnosis is not entirely clear. • Many memory clinics use a multidisciplinary approach that addresses all aspects of patient care. • Present an opportunity for patients and families to participate in research studies.

41. Case discussion: Dementia • Repeat cognitive testing in 6 months • Follow-up cognitive testing is appropriate in order to track the progression of disease. Cognitive testing can also objectively evaluate the efficacy of other treatment choices in patients with Alzheimer’s disease (Salmon and Lange, 2001). Patient’s outcome following treatment • The patient is instructed to return in 6 months. On his follow-up visit, his Mini-Mental State score has declined to 22.

42. Case discussion: Dementia • Two years later, son has assumed full responsibility for his father’s household, including financial management and food shopping. The patient has in-home care for daily checkups and meal preparation. Mini-Mental State score= 18. He remains on the cholinesterase inhibitor.