8/9/2019 Screening and Diagnosing Dementia in Primary Care Why is - - PowerPoint PPT Presentation

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8/9/2019 Screening and Diagnosing Dementia in Primary Care Why is - - PowerPoint PPT Presentation

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8/9/2019 Screening and Diagnosing Dementia in Primary Care Why is dementia important? Alzheimer Disease is the 6 th leading cause of death in the U.S. 5.4 million individuals affected Leah Karliner, MD, MAS 1 in 8 Americans aged 65

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Screening and Diagnosing Dementia in Primary Care

Leah Karliner, MD, MAS

Division of General Internal Medicine University of California, San Francisco

Why is dementia important?

  • Alzheimer Disease is the 6th leading

cause of death in the U.S.

  • 5.4 million individuals affected
  • 1 in 8 Americans aged 65 and older is affected by Alzheimer’s

Disease

  • In 2013, Americans provided 17.7 billion hours of unpaid care to

people with AD and other dementias

  • In 2014, AD cost Medicare and Medicaid ~$150 billion

What is dementia?

Pre-frontal: Executive function and behavior Temporal: Memory Parietal/temporal: Language and visuospatial Frontal and Motor Frontal and subcortical: Motor

  • An acquired, progressive, persistent impairment in

cognition or behavior

  • Involves 1 or more

cognitive domains

  • Sufficient to cause a

decline from a previous level of functioning

  • Dementia is no

longer a diagnosis of exclusion

Risk and protective factors

Risk Factors

  • Increased age
  • Vascular disease
  • Genetics (ie ApoE4)
  • Head injury
  • Lower education
  • Chronic inflammation

Protective Factors

  • Physical exercise
  • Social engagement
  • Mental activity
  • Education
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How do you currently screen patients for cognitive impairment or dementia?

  • A. I rarely or never screen my patients
  • B. I am inconsistent about how/if I screen patients
  • C. I screen all of my older patients regardless of symptoms or

risk factors

  • D. I screen all of my older patients with known risk factors only
  • E. I only screen patients with symptoms or whose

companion/caregiver brings up cognitive concerns

USPSTF Guideline

  • Last reviewed in 2014; current update in progress
  • USPSTF distinguishes between screening and early detection

– “I” or insufficient evidence for formal screening instruments in

community-dwelling adults in the general primary care population who are

  • lder than age 65 years and have no signs or symptoms of cognitive

impairment – Early detection and diagnosis of dementia through the assessment of patient-, family-, or physician-recognized signs and symptoms, some of which may be subtle, are not considered screening

  • clinicians should remain alert to early signs or symptoms of cognitive impairment (for

example, problems with memory or language) and evaluate as appropriate

Barriers to dementia screening and early detection in primary care

  • Concern re: offending patient
  • Unsure of who to screen
  • Time it takes away from other medical issues during visit
  • Not knowing what to do with the information
  • Sense of futility due to limited treatments
  • Challenges of screening / diagnostic testing; e.g., lack of familiarity

with screening tools, time, language barriers

Rationale for screening in primary care

  • Screening  identification of cognitive impairment
  • Identification allows

– Treatment of reversible causes of cognitive impairment – Treatment of conditions exacerbating cognition in dementia – Treatment that can mitigate dementia-related symptoms – PCP ability to contextualize screening for and treatment of other diseases and provide anticipatory guidance – Referral to community-based resources for both patients and caregivers

  • Educational, support, and skill-building services
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Where to begin?

KAER Model – Gerontological Society of America 2017 Kickstart the conversation Assess for cognitive impairment Evaluate for dementias Refer for community resources

https://www.geron.org/programs-services/alliances-and-multi- stakeholder-collaborations/cognitive-impairment-detection-and- earlier-diagnosis

KAER Step 1: Kickstart the Conversation

  • Discuss brain health

– Raise the issue; e.g., ‘brain ages like other parts of our bodies & is important for your overall health’ – Opens the door for patients to express any concerns

  • Observe for signs and symptoms of cognitive impairment

– “poor historian” – No-shows for appointments or comes at the wrong time or on the wrong day – Repeatedly and apparently unintentionally fails to follow instructions; e.g., changing medication – Defers to family member to answer questions directed to the patient

  • Listen for older adult and family concerns about cognition

Case

  • 80 yo retired chemist who is highly functional and living independently

with his wife mentions toward the end of a visit that he sometimes has trouble finding the right word, and then says ‘but of course everyone has that problem, right?’

What do you do next?

  • A. Reassure patient that yes everyone has that problem

& it is completely normal

  • B. Explore further, asking about other signs/symptoms
  • f cognitive impairment
  • C. Do a formal cognitive screen in the office
  • D. Send for formal neuro-cognitive testing

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2% 2% 9% 87%

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KAER Step 2: Assess for Cognitive Impairment

  • Normal brain aging can affect word-retrieval
  • It can also be a sign of mild cognitive impairment, or – if affecting

function – early dementia

  • The patient’s concern merits further assessment by history
  • A formal cognitive screen in the office may be reassuring or highlight

cognitive deficits in specific domains

KAER Step 2: Assess for Cognitive Impairment

  • For a review of how to do this in context of Medicare Annual Wellness Visit:

Cordell et al. Alzheimer’s & Dementia 9 (2013) – Review functional deficits (e.g. managing medications, schedule, money) – Make your own assessment during the visit – Elicit patient and caregiver (if present) concerns If from above, signs or symptoms of cognitive impairment, then do formal cognitive screen

  • Many screening tools available all with advantages and disadvantages

Screening Tools

Tool Advantages Limitations

Mini-Cog

http://mini-cog.com/ Score ≤3 is positive

Developed for and validated in primary care and with multiple languages and cultural groups Little or no education/language/cultural bias Short administration time Use of different word lists may affect failure rates MMSE

www.parinc.com Score <25 is positive

Most widely used and studied worldwide Required for some drug insurance coverage Education/age/language/cultural bias Ceiling effect (highly educated impaired patients pass) Proprietary – unless used from memory needs to be purchased MoCA

www.mocatest.org Score <26 is positive

Designed to test for mild cognitive impairment Multiple languages accessible on website Tests many separate domains Lacks studies in primary care Education bias (≤12 years) Admin time ≥ 10 min

Case

  • Because it was designed to catch mild cognitive

impairment, you decide to screen your patient (80 year old chemist) for dementia using the MoCA, so you schedule him for a follow-up visit for just this purpose.

  • He scores 25/30 – scores normally except for memory
  • He recalls 0/5 words on delayed recall
  • With category prompting he recalls 4/5
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  • This positive screening test merits further diagnostic

evaluation

  • Many patients (~50%) with cognitive impairment never get a

diagnostic evaluation for dementia

– PCP may not do evaluation – Family may not want evaluation – Patient may not want / follow-through on evaluation

Boustani et al 2005 Fowler et al 2015 Kotagal et al, 2014 McCarten et al, 2012

Phenotyping dementias is important for appropriate treatment and anticipatory guidance

Courtesy Howard Rosen Adapted from Plassman et al., 2007

  • Lewy Body Disease
  • Frontotemporal dementia
  • Progressive supranuclear palsy
  • Corticobasal degeneration
  • Multiple system atrophy
  • Amyotrophic lateral sclerosis
  • Triplet repeat disease

(ie Huntington’s Disease)

  • Paraneoplastic disorders
  • Hashimoto’s encephalopathy
  • CNS lymphoma
  • Rapidly progressive dementias (ie

Creutzfeld-Jakob disease)

Evaluate for Dementia

In the context of a medical history with patient and informant assessing for

  • -onset, course and nature of memory & other cognitive impairments
  • -associated behavioral, medical, psychological issues
  • -recent illness, falls & head injury, medications, OTC/herbals, substance use
  • -vision and hearing problems, depression
  • 1. determine if there is a non-dementia condition causing cognitive

impairment

  • 2. Determine if patient meets diagnostic criteria for neuro-cognitive disorder
  • 3. identify the cause of neurocognitive impairment

Evaluate for Dementia

  • 1. determine if there is a non-dementia condition causing cognitive

impairment

  • Medication/substance evaluation

– Opioids, TCAs, benzos, non-benzo hypnotics, muscle relaxants, antihistamines, anti-epilectics – Substances: alcohol, drugs

  • Sensory & Mood assessment: Vision, hearing, depression
  • Labs: exclude underlying infection, uremia, liver and thyroid disease;

check B-12, folate, calcium, fasting glucose, HIV

  • Neuro-imaging: MRI (or non-con CT) to exclude tumors, subdural

hematomas, hydrocephalus

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Evaluate for Dementia

  • 2. Determine if patient meets diagnostic criteria for neuro-cognitive

disorder

  • DSM-V (American Psychiatric Association, 2013): Impairment(s)

– in 1 or more of 6 cognitive domains:

  • Complex attention, executive function, learning and memory, language,

perceptual-motor, social cognition – must be a decline from previous level of functioning – Interfere(s) with independent functioning – do not occur solely in course of delirium

Evaluate for Dementia

  • 2. Determine if patient meets diagnostic criteria for neuro-cognitive

disorder

  • Functional Assessment

–Activities of Daily Living:

  • bathing, dressing, toileting, transferring, continence and feeding

–Instrumental Activities of Daily Living:

  • using the telephone, shopping, food prep, housekeeping, laundry, transportation, ability

to manage medications and finances

  • Cognitive impairment interference with function – key distinguishing

factor between mild cognitive impairment (MCI) and Dementia

Evaluate for Dementia

  • 3. identify the cause of neurocognitive impairment
  • Neurologic exam

– Gait disturbance (Parkinsonism, FTD, NPH, stroke) – Lateralizing signs on cranial nerve exam or indolent HA – consider space-occupying lesion – Focal weakness (vascular, Parkinson’s) – Bradykinesia, rigidity or tremor (Parkinsonism) – Assess for neuropathy due to toxins or vitamin deficiencies

  • Neuropsychological Testing helpful for

– Very early stage dementia – Evaluating atypical presentations – Comprehensive, objective info re: which cognitive functions are affected – Provides a baseline for future re-evaluations

Case Study: A 76 yo Chinese-American woman with forgetfulness

  • CC: “My memory is not as good as it used to be, but overall it’s fine.”
  • HPI: (from patient and informant)
  • Over last 2 years, has forgotten to take her pills and missed

appointments

  • Family is concerned about her riding buses in the city by herself as she

got lost and was missing for several hours.

  • Has had several falls in the last 1-2 years
  • Family worries that she is depressed
  • PMH: Hypertension, hyperlipidemia
  • Neurological exam:
  • Socially intact but with a paucity of spontaneous speech
  • Gait instability
  • MoCA: 21/30 missing points for orientation, memory, copy of cubes

Depression? Fall risk Executive, memory and visuospatial Insight?

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What is the Diagnosis?

  • A. Normal aging
  • B. Alzheimer’s Disease (AD)
  • C. Vascular dementia (VaD)
  • D. Alzheimer’s Disease + Vascular dementia

N

  • r

m a l a g i n g A l z h e i m e r ’ s D i s e a s e ( A D ) V a s c u l a r d e m e n t i a ( V a D ) A l z h e i m e r ’ s D i s e a s e + V a s c u l . .

1% 33% 29% 37%

Answer: It depends on the MRI

For vascular dementia, look on T2 or FLAIR sequences for… Periventricular white matter (PVWM) changes (FLAIR image) Lacunar infarcts

In AD, look for hippocampal atrophy

Normal hippocampus Atrophy of hippocampus

Alzheimer’s Disease (AD)

  • 1st symptom: Difficulty encoding new memories (due to

hippocampal atrophy)

  • Will spread to include other cognitive domains
  • Usually social graces and motor functions are spared until late in

disease

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AD symptoms mirror its spreads through connected neuronal circuits

Early Middle Late

  • 1st symptom: Difficulty retrieving memories (sub-cortical

pattern of memory impairment)

  • Stepwise progression
  • Oftentimes accompanied by executive dysfunction,

parkinsonism, psychiatric disturbance (paranoia, hallucinations)

  • Vascular dementia is distinct from stroke

Vascular Dementia (VaD) Diagnosis of vascular dementia

  • Can be difficult

– Symptoms and impairments similar to AD – Research shows that physicians don’t always agree

  • Presence of peri-ventricular white matter (PVWM) changes on MRI

does not rule out AD

  • Absence of PVWM changes makes AD more likely
  • Problems with balance and walking are more common in early

vascular dementia

  • Differs from stroke in non-acute onset and progressive impairment

without recovery over time

Current Treatment of AD and VaD are similar

  • Acetylcholinesterase inhibitor (ie donepezil)
  • SSRI for depression and/or irritability
  • Exercise regimen +/- physical therapy
  • Home safety evaluation to prevent falls, accidents
  • Planning for the future
  • Caregiver support
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Refer to Resources in the Community

  • Area Agencies on Aging

– Network of ~620 organizations nationwide – Serve elderly populations of their local areas – Receive federal funding under Older American Act – Provide services: nutrition, caregiver support, information & referral, long term care ombudsmen, insurance counseling, transportation – No hands on care, no Medicaid planning, no Veterans benefits planning

Refer to Resources in the Community

  • Community Resource Finder

https://www.communityresourcefinder.org/ – Patients/families can identify needs and find specific resources

  • Alzheimer’s Association https://www.alz.org/

– Focus on Alzheimer’s Disease care, support, and research – Website has patient and caregiver centered resources

  • Diagnosis, treatment, research
  • Help & Support, including finding local chapters

Refer to Clinical Trials

  • NIA’s ADEAR Center website, Find Alzheimer’s Disease and Related

Clinical Trials https://www.nia.nih.gov/alzheimers/clinical-trials

– free online resource that allows users to search for relevant clinical trials being conducted in their geographic area

  • The Alzheimer’s Association’s Trial Match https://www.alz.org/alzheimers-

dementia/research_progress/clinical-trials/about-clinical-trials – free, online resource that matches persons with dementia, caregivers, and healthy volunteers to clinical trials in their geographic area