dementia eval by yangxichun

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									Differentiating Dementia,
Mild Cognitive Impairment,
and Depression:
Neuropsychological Perspective


Emily Trittschuh, PhD
Geriatric Research Education and Clinical Center (GRECC)
VA Puget Sound Health Care System
emily.trittschuh@va.gov

Dept of Psychiatry and Behavioral Sciences
University of Washington
Learning Objectives
   Characterize Dementia, Mild Cognitive Impairment,
    and Depression in Older Adults
   Recognize warning signs and initiate diagnostic
    work-up
   Understand components of a Neuropsychological
    Evaluation
   Cognitive Profiles – unique/overlapping features
   Utilizing this information to guide treatment and
    care planning
    The Aging Population
   Older Americans represent ~12 % of the population.
       26% percent of physician office visits
       A third of all hospital stays and of all prescriptions
       Almost 40 % of all emergency medical responses
       90 % of nursing home residents
   In 2011, the first baby boomers will reach their 65th
    birthdays.
       By 2029, all baby boomers will be at least 65 years old.
       This group will join the rest of older adults to total an estimated
        70 million people aged 65 and older.
                                      *As reported by the Alzheimer’s Association in 2010
“Typical” Cognitive Aging
   Autobiographical memory
   Recall of well-learned information
   Procedural and Episodic Memory
   Emotional processing
               Encoding of new memories
                  Slower to learn new tasks
               Working memory
                  May need more repetitions to learn new info
               Processing speed
                  Slower to respond to novel situations
What you might hear in clinic
   I can’t focus
   She’s not interested in her usual activities
   I can’t come up with the word I want
   My energy is low
   My short-term memory is shot
   I lost my car in the parking lot
   My husband’s “selective attention” is worse – he
    doesn’t listen to me
Dementia
A decline of cognitive ability and/or
 comportment . . .
    primary and progressive
    due to a structural or chemical brain disease
    Not secondary to sensory deficits, physical
     limitations, or psychiatric symptomatology.
    to the point that customary social, professional and
     recreational activities of daily living become
     compromised.
Probable Alzheimer’s Disease
   Dementia established by clinical and
    neuropsychological examination.
       Explicit memory impairment plus at least 1 other area of
        dysfunction.
       Activities of daily living have been affected.
   Insidious onset and progressive course.
   Risk increases with age; rare onset before age 60
   Other diseases capable of producing a dementia
    syndrome have been ruled out.
                  NINCDS-ADRDA Criteria from 1984 consensus group
Causes that Mimic Dementia
(*but are treatable)


                                           Medications, B12 deficiency,
 Toxic/metabolic                           hypothyroidism


                                           Infections, cardiovascular
Systemic illnesses                         disease, pulmonary


                                           Depression, sleep apnea,
         Other
                                           psychosocial stressors, drugs

                       *Treatment may improve, but not fully reverse, symptoms
                       Prevalence of AD in the US
                     9.0
                     8.0
                     7.0
Millions of people




                     6.0
                                                                                 65-74
                     5.0
                                                                                 75-84
                     4.0
                                                                                 85+
                     3.0
                     2.0
                     1.0
                     0.0
                           2000   2010   2020    2030      2040      2050

                                          Hebert, et al, 2003, Archives of Neurology
Is it always Alzheimer’s disease?
Lim, et al. J Am Geriatr Soc. 1999 May;47(5):564-9.
Mild Cognitive Impairment
 Objectively measured deficits in memory and/or
  other thinking abilities
 Subjective memory complaint
 Normal ADLs
 Prevalence rates vary widely depending on age and
  community vs clinic sample
 ** Conversion to dementia is significantly higher in
   people with MCI
            MCI            12 - 15% per year
            Normal controls 1 - 2% per year
                                        (Petersen et al., 1999, 2001)
Depression in Older Adults
   Mood disorder characterized by:
       Sadness
       Guilt, negative self-regard
       Apathy – loss of motivation, loss of interest
       Vegetative Symptoms: sleep, appetite, energy
       Psychomotor changes – agitation or slowing
       Trouble thinking, concentrating
       Loss of interest in life; suicidal ideation
   Must occur for at least 2 weeks and interfere with daily living
   Higher prevalence rates of mood disorder in the elderly

                                          DSM-IV and ICD-10 criteria
When the Veteran has concerns or
you notice a change . . .

                Medical Evaluation
                     History, physical
                     Blood tests, brain scans


                Formal Cognitive Testing
                     Evaluate relative to others in
                      the same age group
Diagnostic Challenges
 If dementia, changes can begin up to 20 years
  before noticeable by self & others
     importance of prevention …
 Is this “normal aging”? Is it a change?
 Clinical presentations can be similar
   may not be detectable using screening tests
 Comprehensive assessment is essential
   rule out other treatable causes
Clinical Neuropsychology
   Integrative approach – psychology, psychiatry, and
    neurology
   Record review
   History is often the most important diagnostic tool
   Collateral information is helpful
   Objective cognitive testing to aid in diagnosis
       Multiple domains of cognitive function must be evaluated
   Importance of using appropriate measures and
    appropriate normative data
Geriatric Neuropsychology
    Tests
        Consider age of subject and overall health/energy
        Consider adjusting measures administered based on
         referral question (e.g., first diagnosis vs. current function)
    Normative populations
        Limited normative information for 90+
        Non-native English speakers
        Ethnicity/Cultural differences
    Premorbid estimates
        Individualized benchmark
    What is “impaired”?

      “Gold” standard:
   premorbid baseline data

      Standard benchmark:
     Compare to the average
performance within an age group
-3   -2.5   -2   -1.5   -1   -.5   0   .5   1   1.5   2   2.5   3

                        Standard deviations
   What is “impaired”?

     “Gold” standard:
  premorbid baseline data

     Personal benchmark:
  Compare test results to an
estimate of premorbid abilities
-3   -2.5   -2   -1.5   -1   -.5   0   .5   1   1.5   2   2.5   3

                        Standard deviations
Clinical Symptoms of Cognitive Decline

       Memory loss is often the most commonly
        reported symptom:
           Forgetfulness
           Repeats self in conversation
           Asks the same questions over and over
           Gets lost in familiar areas
           Can’t seem to learn new information (routes, tasks,
            how to use a new appliance or electronics)
Clinical Symptoms cont . . .

     Presenting symptoms can also consist of
      changes in one or more of these areas:
         Attention
         Language
         Visuospatial abilities
         Executive function
         Personality/judgment/behavior
Impairments in Attention

  • Starting jobs but not finishing them
  • Absentmindedness
  • Difficulty following a conversation
  • Distractibility
  • Losing train of thought
Impairments in Language

• Problems expressing one’s thoughts in
  conversation (can’t find the right words)
• Consistently misusing words
• Trouble spelling and/or writing
• Difficulty understanding conversation
Impairments in Visuospatial Function

   • Getting turned around (even in one’s own home)
   • Trouble completing household chores (using
     knobs or dials)
   • Difficulty getting dressed
   • Trouble finding items in full view
   • Misperceiving visual input
Impairments in Executive Function

  • Disorganization
  • Poor planning
  • Decreased multi-tasking
  • Perseveration
  • Decreased ability to think abstractly
Changes in Personality or Comportment

   Quantitative change in behavior:
        Increase- disinhibition, impulsivity, poor self-
         regulation, socially inappropriate
        Decrease- flat affect, reduced initiative, lack of
         concern, lack of interest in social activities (often
         initially mistaken for depression)
        Behavior not typical of premorbid personality
Case Example: Key Features

    68-year-old, r-handed, AA female
    Master’s degree; Associate dean
    No significant past medical history
    Referred from primary care MD for complaints
     of memory loss
        Insidious onset, seems progressive
Symptom History at Initial Visit

   2 year decline in memory
   Social skills maintained
   Living alone, independent in all ADLs
   Collateral endorsed a change
      Neurocognitive Profile - MCI
  SEVERE


MODERATE



    MILD



 NORMAL
           Mood Attention   Lang      Spatial   Memory Executive ADLs


                 Initial:
                 (2 yr after onset)
Changes at Second Visit

   Sense of progression
   Social skills maintained
   Still living alone; independent for basic ADLs

   Changes in IADLs
       Having trouble driving (minor accidents; got lost)
       Trouble managing medications
 Neurocognitive Profile - Dementia
  SEVERE


MODERATE



    MILD



 NORMAL
           Mood Attention   Lang      Spatial   Memory Executive ADLs


                 Initial:                  1st F/U:              2nd F/U:
                 (2 yr after onset)        (3 yr after onset)    (5 yr after onset)
      Neurocognitive Profile - MCI
  SEVERE


MODERATE



    MILD



 NORMAL
           Mood Attention   Lang      Spatial   Memory Executive ADLs


                 Initial:                  1st F/U:              2nd F/U:
                 (2 yr after onset)        (3 yr after onset)    (5 yr after onset)
Symptom History at Initial Visit
   2 year decline in memory; collateral notes change
   Affective Changes
       Loss of interest in normal activities
       Sadness and decreased social network

   Living alone, independent in basic ADLs
   IADLs
       Sometimes forgets medication dosages
       a few examples of inattention while driving
Neurocognitive Profile - Depression
  SEVERE


MODERATE



    MILD



  NORMAL
           Mood Attention   Lang      Spatial   Memory Executive ADLs


                 Initial:                  Tx x 1 yr:               Tx x 1 yr:
                 (2 yr after onset)        (Incomplete remission)   (Effective)
Complicating issues
   Chronic depression is a risk factor for dementia
   Reported rates of depression in dementia range from
    0-86% of cases
   Recent meta-analysis found 50% prevalence
   Discriminating depression from dementia is even more
    challenging in non-AD dementias
   With the trajectory of MCI unknown, the relationship to
    depression is less clear
   Depression may indicate prodromal dementia
Treatment and Care Planning
   Dementia
     No cure and the causes are not entirely
      understood
     Effective intervention = improve functional
      status to a degree discernable to caregivers
      or health care providers
     In the case of a progressive disorder,
      “improvement” = slower decline
       Current FDA-Approved Medications
Acetylcholinesterase
Inhibitors
                         tacrine Cognex®          hepatotoxic

                      donepezil Aricept®          1 month

                    galantamine Razadyne®         4 months

                    rivastigmine Exelon®          4 months; patch

NMDA receptor antagonist
                     memantine Namenda®           1 month; approved
                                                  for mod-severe AD
Adjunct Therapies (off label)   Antidepressants   SSRIs, mirtazapine
                                Antipsychotics    risperidone, quetiapine
                      AGE
                Head Injury, Depression,
Environment             Female,              Genetic
               Presence of APOE e4 allele
                     Chronic Illness



                                   Amyloid
                                   Plaques

        Alzheimer’s
         pathology                NFTs


              Neuronal and Synaptic
                   dysfunction

           Cognitive Decline
     Alzheimer’s Disease Diagnosis
 Mild Cognitive Impairment

Normal          MCI          Dementia




         An ideal point of
          intervention?
Risk Factors that can be Managed or
               Avoided

Medical Conditions      Behavioral Factors
 High Blood Pressure    Nutrition/Diet
 High Cholesterol       Alcohol / Tobacco
 Type II Diabetes       Exercise
                         Stress
                         Socialization
Type II Diabetes

         Older adults (>55 yrs) with diabetes
         have a 65% increased risk of
         developing Alzheimer’s disease
         (compared to those without diabetes)

         Adults with diabetes have
         lower scores on cognitive tests
         Bennett, et al. Religious Orders Study. Archives of Neurology, 2004
Depression in the Elderly

   Depression is not a normal part of aging
   Estimated that only 10% of Older Adults with
    depression receive treatment
   Suicide rates – higher in the elderly and higher
    in Veteran populations
   Risk of cognitive decline should be monitored
                  Dang! . . .
                  Now where
                 was I going?

Dementia?

Mild Cognitive
 Impairment?

Depression?

                         Superman in his later years
Thank you
     Questions?
Please also email me at
emily.trittschuh@va.gov

								
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