Screening For Geriatric Syndromes

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Texas Elder Abuse and Mistreatment Institute
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Module 3SCREENING FOR GERIATRIC
SYNDROMESDementia, Delirium, and Depression

• E. Lee Poythress, M.D.
• Baylor College of Medicine

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Objectives

• At the end of this module, participants will be
  able to
• conduct a standard assessment for cognitive
  dysfunction in the elderly.
• discuss the various instruments available for
  screening mental capacity, their differences, and
  the conditions for which each has been developed.
  
• evaluate the cost effectiveness of the clock test
  vs. the Mini-Mental State Exam (MMSE).
• distinguish between depression, dementia, and
  delirium.

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Pre-Test Questions

• 1.  Which of the following is true with regard
  to the elderly population in the United States?
•  a. The fastest growing segment consists of
  people who are over the age of 60 years.
• b. After 2050, the number of U.S. citizens who
  are over the age of 65 will decline by 5.
• c. The prevalence of dementia doubles every 2
  years after the age of 65.
• d. One third of all health care expenditures are
  for the elderly.

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Pre-Test Questions

• 2.  The clock drawing test evaluates which of the
  following?
•  
• Functional status
• Cognitive status
• Affective status
• Hand-eye coordination
• Vision

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Pre-Test Questions

• 3.   What percentage of patients with dementia
  have Alzheimers disease?
•  
• 30
• 40
• 50
• 70
• 90

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Introduction

• Geriatric Assessment and Intervention (GAI)
• Comprehensive method used for evaluating and
  treating elderly patients.
• Uses an interdisciplinary approach.
• Proven effective in randomized, controlled trials
  in various settings.

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Introduction

• Components of GAI
• History and physical examination
• Cognitive testing
• Functional assessment
• Social evaluation

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3 Ds of Geriatrics

• Dementia, Delirium, and Depression
• These common disorders can look alike.
• GAI often helps uncover or differentiate them.
• All are associated with elder mistreatment.

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Scope of the Issues

• Dementia
• Population trends.
• 8 of patients over 65 years old have dementia.
• Incidence doubles every 5 years 2 at 65 and 32
  at 85 years.
• 3.5 million cases in 1999 will be 14 million in
  40 years.
• Cost of AD alone is 90-100 billion per year.

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Definitions and Initial Approach

• The Dementia Workup

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Dementia

• Dementia is a progressive decline in cognitive
  and functional abilities with associated
  psychiatric disturbances.
• Normal aging leads to a slowing of performance
  but not decreased cognition.

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Differential Diagnosis General

• Dementia
• Depression
• Delirium

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Differential Diagnosis Specific

• Alzheimers
• Diffuse Lewy Body
• Vascular
• Parkinsons
• Ethanol abuse

• Normal Pressure Hydrocephalus
• Huntingtons
• Frontal Lobe
• Shy Drager/ Progressive Supranuclear Palsy
• CJ

Reversible Causes
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Approach to the Demented Patient

• Comprehensive GAI
• Team Approach MD, PA, NP, SW, NCM, PT/OT,
  psychiatry, and others

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Initial Evaluation

• Office-based adjustments
• History and physical
• Screening tests
• Reversible causes

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History and Physical

• Acute vs. chronic change Get a timeline of their
  cognitive and functional status
• Family/friend/provider
• Physical signs and symptoms
• Social issues
• Medications

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Delirium

• 1. Acute change in mental status and
• 2. Inattention
• With either
• 3. Disorganized thinking or
• 4. Altered level of consciousness

Inouye et al. Ann Int Med, 1993
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Delirium

• It is a medical emergency.
• 15-20 of medical patients are delirious upon
  admission.
• 25-60 of patients over 65 years old develop
  delirium after admission.
• 32-67 of physicians fail to recognize the
  disease.

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Differential Diagnosis

• Always consider dementia and depression as
  competing diagnoses.
• Other post-ictal state, psychiatric disorders,
  nonconvulsive epilepsy.

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Differential Diagnosis

• Three types of delirium
• Organic (medical)
• Post-operative
• Terminal restlessness

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Differential Diagnosis

• The initial evaluation is primarily an acute
  workup in search of the underlying cause(s).
• Use of the Confusion Assessment Method (CAM) is
  essential in identifying delirium.

Inouye et al. Ann Int Med, 1993
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Depression

• Prevalence in older adults
• Community 1 (27)
• Inpatients 11 (40)
• Nursing home 10-25 (45)
• Inflated numbers due to inclusion of patients
  with less severe symptoms.

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Depression

• Duration
• 31-50 years 9-18 months
• gt50 years 3-5 years
• Recurrence
• 50 after first episode
• 70 after second episode
• 90 after third episode

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Depression

• Treatable in 75 of cases.
• Untreated cases associated with 15 mortality.
• Suicide rate in elderly is double the rate for
  all other age groups.
• Workup is identical for that of dementia.
  Dementia and depression often coexist.

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Cognitive and Depression Testing and Reversible
Causes
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Cognitive and Depression Testing

• Commonly found to be too time consuming.
• Utilize validated tests.
• DO NOT require physician administration.
• Multiple new tests.
• Neuropsychological testing.

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Cognitive and Depression Testing

• First line Mini-Mental Status Exam (MMSE)1,
  Clock Drawing Test (CDT)2, and Geriatric
  Depression Scale (GDS)3.
• Second line Trails B4 and other tests for
  further evaluation of cognition.
• Third line Neuropsychological testing referral.

1Folstein 1975, 2Wolf-Klein,3Yesavage 1983,
4Army Individual Test Bat. 1944
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MMSE

• Tests major domains of cognitive functioning.
• Not sensitive in patients with a higher level of
  functioning or higher education.
• Patients with lower education levels or
  minorities may score low without actual
  impairment.

Folstein et al. J Psych Res, 1975
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MMSE

• Establishes a baseline and measures decline over
  time.
• Use 26 as a strict upper cutoff for normal.
• 21-25 gray area.
• 20 or less associated with cognitive dysfunction.
• Clinical acumen is key for patients scoring 26 or
  higher (check the drawing).

Folstein et al. J Psych Res, 1975
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Clock Test

• Excellent initial screening test.
• Tests executive functioning.
• Easy to administer.

Wolf-Klein et al. JAGS, 1989
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Clock Test

• Two types of scoring systems will be presented.
• Ten-point scale by Wolf-Klein et al1 is validated
  and has been shown to be more sensitive than MMSE
  baselines of 21 or higher in predicting cognitive
  decline over time2.
• Wolf-Klein system includes a cutoff scale.
• It utilizes a predrawn circle.

1Wolf-Klein et al. JAGS, 1989 2Ferrucci et al.
JAGS, 1996
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Clock Test

• The Pfizer method1 is well recognized but not
  validated in the literature.
• It uses a 0-4 scale and requires some
  interpretation.
• No cutoff is given, but typically a 3-4 of a 4
  point scale is considered normal.
• It is done completely freehand.

1Pfizer Inc.
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Geriatric Depression Scale

• 15-point or 30-point scale.
• More than 5 or 10 negative responses suggests
  depression.
• Used in conjunction with the patients history
  and observation.

Yesavage et al. J Psy Res, 1983 Sheikh et al.
Clin Geron, 1986
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Confusion Assessment Method

• Diagnosis of delirium with 94-100 sensitivity
  and 90-95 specificity

Inouye et al. Ann Int Med, 1993
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Confusion Assessment Method

• Patients must have
• acute onset and fluctuating course AND
• 2. inattention
• With either
• 3. disorganized thinking OR
• 4. altered level of consciousness

Inouye et al. Ann Int Med, 1993
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Functional Assessment

• History
• Activities of daily living (ADL)1
• Instrumental activities of daily living (IADL)2
• ADLs correlate with MMSE scores

1Katz et al. JAMA, 1963 2OARS/MFAQ. Duke Univ,
1978
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Functional Assessment

• AVG MMSE SCORE
• 20
• 14
• 11
• 7

• ADL LOSS
• Use telephone, obtain
• own meal
• Travel, use home appliance
• Dress, groom
• Walk, eat

Galasko et al. Alz Dis Assoc Discord, 1997
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Neuropsychological Testing

• More sensitive than screening tools for detecting
  early dementia.
• Helpful in characterizing the pattern of
  cognitive impairment (i.e., depression,
  alcoholism, type of dementia).
• Referral required.

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Reversible Causes

• TSH/Free T4
• B12
• Folate
• RPR
• HIV
• (PTH/CA)

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Imaging

• Not needed in most cases (delirium cases often
  require it).
• History and physical are key determinants.
• MRI best for vascular dementia.
• CT best for atypical presentations and/or
  atypical dementias.
• PET and SPECT scans not recommended.

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Lumbar Puncture

• Indications
• Acute or subacute onset (lt8 weeks).
• Immunosuppression.
• Atypical presentation of dementia (seizure,
  cranial neuropathy).
• Positive RPR.
• Evidence of normal pressure hydrocephalus.

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Summary Workup

• History and physical.
• Cognitive tests.
• Reversible causes.
• Can be done over several visits.

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Dementia and Depression

• Pseudo-dementia patients with complete recovery
  of high intellectual functioning will develop
  irreversible dementia at 20 per year.
• Late-onset depression has a higher prevalence of
  dementing disorders.
• Demented elderly develop depression at a higher
  rate.

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Dementia vs. Delirium

• Chronic
• Irreversible
• Long course
• Day to day
• Vague onset

• Acute
• Reversible
• Short course
• Hour to hour
• Precise onset

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Executive Function

• The cognitive processes that orchestrate
  relatively simple ideas, movements or actions
  into goal directed behaviorswithout executive
  functions, behaviors important for independent
  living can be expected to break down into their
  components parts

Royall, Exp Aging Res, 1994-quoting various
authors
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Executive Function

• direction and purpose are lost undermining
  independence, which can lead to problem behaviors
  in a number of settings

Royall, Exp Aging Res, 1994-quoting various
authors
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Executive Function

• Includes
• Direction
• Planning
• Execution
• Sequencing
• Supervision of behavior
• Abstraction/insight

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Executive Function

• Executive function integrates more traditional
  cognitive domains (memory, praxis, motor skills).
• Forms goal-directed behaviors cooking, cleaning,
  and self-care.

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Executive Dysfunction

• Breakdown of Goal-Directed Behaviors
• You can wash a dish, but cannot do the dishes.
• You can write a check, but cannot pay the
  bills.
• You can shower, but cannot shower, get dressed,
  catch the bus, and do the shopping.

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Executive Dysfunction

• Medical Diagnoses Associated with Executive
  Dysfunction
• Dementia Depression
• Diabetes Psychosis
• Parkinsons Brain trauma
• Alcohol/drug use Age related

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Executive Dysfunction

• Executive dysfunction can occur in the absence
  of other cognitive dysfunction.
• 50 of elderly retirees failed the EXIT test but
  had normal MMSEs.1
• 20 of septuagenarians failed the EXIT test but
  passed the MMSE.2

1 Royall et al. Neuro N Behav Neurol, 1993 2
Royall et al. Exp Aging Res, 1997
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Effects of Executive Dysfunction

• Functional disability.
• Requirement for supervision/care.
• Neuropsychiatric disturbances.

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Effects of Executive Dysfunction

• Study of patients in the community compared
  with patients in a retirement center.
• Center with three levels of care.
• Study showed executive dysfunction was most
  important factor in determining level of care.

Royall et al. JAGS, 1998
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Effects of Executive Dysfunction

• Community
• EXIT 9.4
• MMSE 28.4
• GDS 1.3

• Level 1
• 16.3
• 27.3
• 2.9

Royall et al. JAGS, 1998
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GAI and Executive Function

• GAI will help identify executive dysfunction and
  allow for better planning of care for patients,
  especially after inpatient discharge.
• Executive function is an important component of
  the capacity assessment.

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Neuropsychological Testing and Executive Function

• Neuropsychological testing is often required for
  patients with some clinical evidence of executive
  dysfunction but normal cognitive testing on GAI
  screening.

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Conclusions

• Screening for geriatric syndromes can be done
  quickly and efficiently.
• Dementia, delirium, and depression can all be
  significant factors in elder mistreatment cases.
• Subtle forms of cognitive impairment may need
  neuropsychological testing.

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Post-Test Questions

• 1. Which of the following is true with regard to
  the elderly population in the United States?
•  
• a. The fastest growing segment consists of people
  who are over the age of 60 years.
• b. After 2050, the number of U.S. citizens who
  are over the age of 65 will decline by 5.
• c. The prevalence of dementia doubles every 2
  years after the age of 65.
• d. One third of all health care expenditures are
  for the elderly.

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Post-Test Questions

• 2. The clock drawing test evaluates which of the
  following?
•  
• Functional status
• Cognitive status
• Affective status
• Hand-eye coordination
• Vision

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Post-Test Questions

• 3.   What percentage of patients with dementia
  have Alzheimers disease?
•  
• 30
• 40
• 50
• 70
• 90

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64
Texas Elder Abuse and Mistreatment Institute
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