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Geriatric Medicine. Jenny Basran MD, FRCPC Associate Professor & Head, Division of Geriatric Medicine University of Saskatchewan. Meet Mrs. B. 81 year old woman presents to ER with chest pain, not responsive to NTG, ST changes with trop leak. Past history angina.

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Geriatric Medicine


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    1. Geriatric Medicine Jenny Basran MD, FRCPC Associate Professor & Head, Division of Geriatric Medicine University of Saskatchewan

    2. Meet Mrs. B • 81 year old woman presents to ER with chest pain, not responsive to NTG, ST changes with trop leak. Past history angina. • Goes to cath lab  PTCA, but no stent required • Paged to see Mrs. B on ward because she is confused and does not want to take her medications. What are you thinking about as you go up to see her?

    3. WHAT IS COGNITIVE IMPAIRMENT? • Change in how you think • Change from baseline • Often the body’s only way of telling you there is something wrong • Rather than classical signs and symptoms

    4. What should be your first question?

    5. FIRST QUESTION – ACUTE VS CHRONIC?

    6. How can you tell? • Patient usually can’t tell you • Ask the family and other caregivers – nursing home, GP, home care, etc • If you don’t know, must assume acute • Treatable • Can be life threatening

    7. Past history & Meds • Type 2 diabetes X 10 years • HgbA1c 6%, chemstrips checked OD (4-8) • Metformin 500 mg bid (Cr Cl 65 ml/min) • No proteinuria, neuropathy; yearly optho • Hypertension X 20 years • BP 130/70 lying & 120/60 standing; no SXS • Diovan (Valsartan) / HCTZ 160/12.5 mg OD • Hyperlipidemia X 8 years – lipitor 20 mg OD • Osteoporosis – vertebral fracture 1 year ago • fosavance 70 mg OD, Calcium 500 mg BID • eats dairy regularly • Macular degeneration – 5 years, vitalux

    8. Past Medical History & Meds • Urinary incontinence X 1 year • Urge with nocturia once/ night, on detrol • Previous CAD – LV OK; ASA 81 mg OD  plavix added • Insomnia – clonazepam prn (almost daily) • OA knees / hands – occas tylenol prn • OTCs – gingko OD, Vitamin E 400 IU • Previously on HRT for menopause

    9. Social History & Fxnal History • Lives alone in bungalow. Widowed 5 years ago • 2 children – both live in Alberta, but regular contact by phone • Lifetime nonsmoker and glass of wine at night with supper. • Functionally • Occasional falls – vague re: situation • Independent with ADLs & IADLs • Uses hearing ai • Family History – mom – 90’s – memory probs

    10. What do you need now? • Labs – CBC, e’lytes, BUN, CR • Extended labs – Ca, Mg, PO4, albumin • Drug levels if appropriate – ie: digoxin, lithium, etc • Drug tox screen if worried about overdose or errors • Liver panel • TSH, B12, glucose • ECG – need baseline anyway, but could be cardia • CXR – especially if clinically warrants • U/A – will be positive often, so can’t stop here • Others – as warrants

    11. Mrs. B • Her vitals are stable but she is clearly disoriented and starting to get agitated. She is easily distracted. • Her daughter is concerned because her mother is not usually like this. • The nurses are concerned because she seems to be getting worse, although notes periods when she seems OK • You review her meds – only prn BZDP & tylenol not ordered on admission • Lab work normal, U/A suggests UTI (pt has foley) • ? Diagnosis

    12. Key Features of Delirium • Acute onset and fluctuating course • Usually develops over hours to days or may be abrupt • Unpredictable fluctuations (within interview or over day) with periods of lucidity • Often worse at night • Inattention • Easily distractable • Disorganized thinking • Illogical, bizarre; delusion of persecution common • Altered level of consciousness Confusion Assessment Method (CAM) = 1 + 2 + (3 or 4)

    13. Mrs. B • What predisposing and precipitating factors for delirium are present? • Predisposing – older age, polypharmacy, sensory impairment • Precipitating – cardiac disease, foley, UTI, BZDP suddenly stopped, OA pain (not getting tylenol)

    14. What is your Plan? • Plan • rule out other causes of delirium, especially cardiac • restart low dose BZDP – was taking daily at home • scheduled tylenol – while awake • Prevention – non pharmacological interventions • hearing aid, glasses • mobilizing, eating, limited daytime naps • family to sit with her at bedtime – back rub, music

    15. Mrs. B • What if the Mrs. B had been really agitated and pulling out her IV along with refusing to take her meds? • Is the approach any different?

    16. HalDOL Bridge(only if Patient harming themselves or others) • Severe delirium: 0.5-1.0 mg IM or po (IV short acting) – NOTE DOSE • Repeat dose Q30 – 60 minutes until calm achieved • Max dose 3-5 mg / 24 hours • Maintenance = 50% loading dose in divided doses (ie: TID) over the next 24 hour. Taper asap over next few days • Ie: 3 mg given to calm  give 1.5 mg next day in divided doses (0.5 mg TID)  then 0.5 BID  then 0.5 OD  then discontinue • Bridge to keep them safe while the treatment takes effect • If gets worse  you missed something, keep looking

    17. Haldol • Never PRN • Never give to patient with parkinsonism • Monitor • Daily ECG – prolonged QTc • Tardive dyskinesis – increased stiffness first sign

    18. Why is it important to treat delirium? • Mortality & morbidity the same as: • Having a MI in hospital • Being septic in hospital • Often missed because can be: • Hyperactive – hallucinations, agitation, paranoid • Hypoactive – sleeps all the time, wont eat, wont move • Combination of both - fluctations

    19. Mrs. B – 8 weeks after discharge • 81 year old woman presents to ER with chest pain, not responsive to NTG, ST changes with trop leak. Past history angina. • Goes to cath lab  PTCA, but no stent required • Course in hospital – delirium  UTI treated & BZDP restarted, scheduled tylenol. Cardiac status stable  back to cognitive baseline on discharge. Discharged on same meds plus plavix and higher dose of lipitor (80 mg OD) • Sees you 8 weeks after discharge with her daughter. Daughter is visiting but going back to Alberta in 2 weeks and is concerned about her mother’s memory & her ability to manage.

    20. History – Most important • Must discuss with family / caregiver. Patient often has limited insight. • Time course & functional impairments • Ask for specific examples - • What are they forgetting? • Names of close friends or family? • Appointments, medications (irregular refill periods) • Repeatedly asking same question • Visual hallucinations? Unexplained falls? • Personality changes? Unusual behavior? • Safety issues • Do they ever leave the stove on or water running? • Do they eat healthy and regularly? • Have they had any problems driving or getting lost in familiar areas • Have they become aggressive? • Legal issues – do they have POA, will and living will in place?

    21. History: 10 WARNING SIGNS • Memory loss that affects day to day function • Short term more than long term • Difficulty performing familiar tasks • Preparing meals, forget you ate it • Problems with language • Forgetting simple words, substituting words • Disorientation of time and place • Lost on own street, unable to get home • Poor or decreased judgment • Dress inappropiate for weather • Problems with abstract thinking • Balance checkbook, not understanding what a birthday is • Misplacing things • Put in inappropriate place • Change in mood or behavior • Mood swings for no reason • Changes in personality • Confused, suspicious, withdrawn • Apathy, acting inappropriately • Loss of initiative • Needs prompting to become involved Alzheimer Society of Canada

    22. Physical Exam • May be completely normal • Focal neurological signs • Up-going plantar  stroke • Peripheral neuropathy  rule out B12 deficiency • Slow reflexes  hypothyroidism • Primitive reflexes  frontal or advanced cerebral atrophy • Cognitive Testing • Mini – Cog - part of normal neuro exam • 3 word registration, clock & 3 word recall • MMSE and Clock Drawing Test – if abnormal Mini-Cog • MOCA can be used for mild cognitive impairment • The score does NOT make diagnosis • Adjust for age, education • How much of a struggle is it for them to complete?

    23. Investigations- Canadian Guidelines • Labs – RULE OUT reversible causes • CBC, electrolytes, TSH, B12, serum Calcium, serum glucose • If warranted: liver function (ETOHic), CXR – lung Ca • Indications for Neuroimaging • Structural Imaging – CT / MRI – reasonable per Clarfield Criteria • Functional Imaging – PET / SPECTin the differential diagnosis of dementia, particularly those with questionable early stage dementia or those with frontotemporal dementia • fMRI and MRS scanning are not recommended, but promising

    24. Clarfield criteria for CT: • age < 70 • new onset dementia , < 1 year • atypical presentation • rapid unexplained deterioration • unexplained focal signs, symptoms • head injury • incontinence, gait ataxia • need for reassurance of patient, family 1.Clarfield, CMAJ, (1991), vol.144(7), 851-853 2.Patterson et al., (1999) CMAJ, vol.160,(Supp.12),S1-15

    25. Atrophy in Alzheimer’s disease Atrophy of the brain in AD: Medial temporal lobes are affected first and most severely Figure from: 8. http://pathology.ouhsc.edu/DeptLabs/diagnostic_center_for_alzheimer.htm

    26. Mrs. B - Clinic Visit • Patient not really concerned about her memory and thinks she is OK • Daughter • Progressive memory last year – repeats herself, trouble names and birthdays. • Low mood, mother up at night – easily confused • Eats mostly frozen dinners, but rotting food in fridge. • Eats lots of blueberries • Not sure taking her meds correctly and found a few overdue bills around the house. • Concerned about her driving. Was driving to Market Mall but not recently.

    27. Clinic Visit • Vitals stable, BP 130/70, HR 80 • Physical exam - unremarkable • MMSE 22/30 (-2 orientation, -3 recall, -1 WORLD, -2 language) • Clock – hands placed wrong, slight spacing errors • FAQ = 26 • Geriatric Depression Scale – 3/15

    28. What is the differential diagnosis? • Delirium – in hospital, but daughter agrees back to baseline • Depression – possible – widowed, post-MI, but GDS 3/15 and patient denies • Dementia – progressive loss memory and function • reversible loss of cognition • Mild cognitive impairment or true dementia

    29. DEPRESSION vs DEMENTIA The symptoms of depression and dementia often overlap; patients with primary depression: • Demonstrate  motivation during cognitive testing • “I don’t know” – ie: results in loss of points on MMSE • Tell us that memory problems are a lot worse than we find on testing. • Language and motor skills remain normal If you suspect depression  need to treat first before diagnosis of dementia can be made

    30. What is the differential diagnosis? • Delirium – in hospital, but daughter agrees back to baseline • Depression – possible – widowed, post-MI, but GDS 3/15 and patient denies • Dementia – progressive loss memory and function • reversible loss of cognition • Mild cognitive impairment or true dementia

    31. IS IT reversible? • Medication side effects • Depression • Vitamin B12 deficiency • Chronic alcoholism • High calcium levels • Neurological disorders – normal pressure hydrocephalus • Certain tumors or infections of the brain • Metabolic imbalances, including thyroid, kidney or liver disorders

    32. What medications could be affecting her cognition? • Detrol – anticholinergic • Clonazepam – BZDP  sedating • Added risk of falls • ? Wine – need to confirm the amount • ? Metformin – ? hypoglycemia, falls • ? Diovan (Valsartan) – low blood pressure, orthostatic hypotension

    33. Is IT Dementia? • A decline from a previous level of cognitive function • memory • language (naming) • Executive abilities – planning, abstract thinking, organization, conceptual shift • construction/visuospatial function • Personality change • Insidious and progressive • KEY QUESTION: • Impairment is sufficient to interfere with function and Activities of Daily Living.

    34. Mild Cognitive Impairment • Memory complaints • Memory impaired for age ( generally 1.5 SD) • General cognitive function: normal for age • Normal activities of daily living • Not meeting dementia criteria = Function Not Affected Petersen RC et al Arch Neurol 56(3)303-308 1999

    35. Common Risk Factors for Developing MCI • Elevated systolic BP • Hypertension • Elevated cholesterol in mid-life • Low level of education • African-American descent • Cerebral infarcts evident on MRI • Depression • Mechanisms may be vascular atherosclerotic mechanisms, or directly through hastening the pathophysiology of AD. 1 Launer LJ et al. JAMA, 1995; 2 Carmelli D et al. Neurology, 1998; 3 Kivipelto M et al. Neurology, 2001;4 Lopez OL et al. Arch Neurol, 2003.

    36. MILD COGNITIVE IMPAIRMENT • Areas of brain begin to shrink • Cognitive problem (usually memory) but does not interfere with activities • Memory storage & retrieval problem • Executive function • apathy • Treatment – monitor patient and vascular risk factors • 10-25% progress to dementia per year (vs 1-2% non-MCI)

    37. Course of Aging, MCI and AD Brain Aging Brain Aging “Brain”AD Mild MCI Cognitive Decline Moderate Moderately Severe Clinical AD Severe Time (Years) (Ferris, 4/03)

    38. DEMENTIA IN CANADA • 8% of all individuals > 65 years old • Incidence / Prevalence  with age • 1 in 10 over the age of 75 • 1 in 3 over the age of 85 • Annual cost = 3.9 billion dollars • AD = 747/1125 (66%) of dementia cases (CSHA) • 95% sporadic Canadian Study of Health & Aging. CMAJ 1994:150:899-913

    39. 850 750 650 550 450 350 250 150 0 Projected Prevalence of AD 300,000 Alzheimer’s Cases Today - > 750,000 Projected Within a Generation 750 500 000’s 300 2031 2000 2011 Canadian Study of Health & Aging Working Group. CMAJ 1994; 150:899-913

    40. The 5/50 plan: Delaying the onset of AD by 5 years would be associated with a reduction in AD prevalence of 50% A modest delay, such as 1 year, would reduce AD/dementia prevalence by 5%. Brookmeyer, Gray & Kawas, Am J Publ Health 88 (9), 1337-1342 1998 .

    41. Benefits of Early Intervention • Drug therapy – slows down progression of dementia • Not appropriate to expect an improvement • Improve family / caregiver stress • Plan for change before need becomes urgent • Education – anticipate change and have some ways to cope • Allows time to prepare for taking over roles of dementia patient • Enhance patient’s sense of control • If early, can participate in management decisions • Future planning – POA, will, living will, end of life care • Promote safety – medications, wandering, driving, falls

    42. DIFFERENT TYPES OF DEMENTIA Other dementias Frontal lobe dementia Creutzfeldt-Jakob disease Corticobasal degenerationProgressive supranuclear palsy Many others Vascular dementiasMulti-infarct dementiaBinswanger’s disease Dementia with Lewy bodies Parkinson’s disease Diffuse Lewy body disease Lewy body variant of AD Vascular dementias and AD AD and dementia with Lewy bodies AD 5% 10% 65% 5% 7% 8% CSHA - CMAJ 1994; Small et al, 1997; APA, 1997; Morris, 1994.

    43. 4 major types of dementia • Alzheimer’s Disease (AD) • Includes Mixed-AD • Vascular Dementia (VaD) • Includes large & small vessel disease • Frontotemporal Dementia (FTD) • Includes Pick’s disease, progressive nonfluent aphasia, & semantic dementia • Dementia with Lewy Body (DLB) • Includes Parkinson’s disease dementia

    44. ~105 years ago… • 51 yo German woman admitted Nov 25, 1901 to psychiatry under Dr. Alois Alzheimer • Hx – cog impairment (memory, language, orientation) & behavioral probs (paranoia, agitation) • Progressive decline  died Apr 6, 1906  neuropathology showed plaques & tangles • Dr. Alzheimer reported case 1907 Auguste D Lancet, 1997;349:1546-49

    45. DSM Criteria for AD • 1. Insidious Onset with progressive decline • 2. Memory Impairment and at least one of the following: • Aphasia (language) • Apraxia (unable to carry out directed movement) • Agnosia (unable to recognize specific items in environment) • Disturbance in executive functioning • 3. Interferes with daily function • 4. Does not occur exclusively during delirium and not due to other neurological, psychiatric, toxic, metabolic or systematic diseases