Med 4- Dementia

1
Med 4- Dementia

• Cognitive assessment, evaluation, tests and
  interpretation.
• Dr. Frank Molnar
• Associate Professor of Medicine
• University of Ottawa Division of Geriatric
  Medicine. Medical Director, The Ottawa Hospital
  Geriatric Day Hospital

2
Objectives

1. Describe the principles related to screening for
   cognitive impairment in high risk elderly and
   simple tests or tools that can be used.
2. Compare and contrast common assessment tools in
   dementia in terms of their utility, advantages
   and limitations.
3. Describe an approach to the evaluation of an
   elderly person with dementia in terms of
   differential diagnosis of potential cause(s).

3
Objective 1

• Describe the principles related to screening for
  cognitive impairment in high risk elderly and
  simple tests or tools that can be used.

4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
The Preliminary Event

• In order to truly understand the results of the
  studies to be reviewed we need to understand
• The definitions of sensitivity and specificity
• How sensitivity and specificity are affected by
• Cut-off values employed
• Overlap of cognitive scores
• Choice of test

9
Definitions

• Sensitivity
• of diseased persons identified as diseased
  (score below cut-off)
• Specificity
• of normal persons identified as normal (score
  above cut-off)

10
1. Sensitivity and specificity are affected by
the cut-off score employed
11
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
Specificity 25
xx x x xx x xxx x x xx xx xx xxx x x x
xx xxx xx x xx x x
Sensitivity 100
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
12
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 50
Sensitivity 87.5
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
13
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 75
Sensitivity 75
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
14
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx xx x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 100
Sensitivity 62.5
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
15
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx xx x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 100
Sensitivity 35
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
16
Take Home Message 1

• Sensitivity and Specificity for any given test
  are dependent on cut-off score studied
• For scales where high scores are good and low
  scores are bad (MMSE, MOCA)
• When cut-off is lowered
• Sensitivity decreases
• Specificity increases
• When cut-off is raise
• Sensitivity increase
• Specificity decreases

17
Sensitivity vs. Specificity
18
2. Sensitivity and specificity are affected by
the population in which the test is being used
- Overlap of cognitive scores (spectrum of
disease)
19
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 75
Sensitivity 62
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
20
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 75
Sensitivity 75
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
21
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
Specificity 75
Sensitivity 87.5
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
22
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxx x x x x x x x xx x x x x x x x x
Specificity 75
Sensitivity 100
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
23
MOCA or MMSE
Scores for persons with normal cognition
Scores for persons with dementia
xxxx x x x x x x xxx x xx x xxx
Specificity 100
Sensitivity 100
xx x x x xxxx x x xxx x xxxxxx xx xxx xxxxx
xxx x x x xx x
1) Sensitivity with disease who are
identified as diseased by test (i.e. of
diseased that fall below cut-off score) 2)
Specificity of normals who are identified as
normal by test (i.e. of normals that score
above cut-off)
0
24
Less overlap higher combined sensitivity and
specificity
0
30
10
20
Greater overlap lower combined sensitivity and
specificity
0
10
20
30
25
Correct population distribution
0
30
10
20
Incorrect distribution resulting in exaggerated
sensitivity and specificity
0
10
20
30
26
Take Home Message 2

• The sensitivity and specificity depend on the
  amount of test score overlap between normal and
  diseased
• Sensitivity and specificity depend on sample /
  population
• Since the populations we take care of clinically
  are different from those in studies
• The Sensitivity and Specificity of a test in
  clinical practice will likely not match that in
  studies (we cannot know if it does)

27
Objective 2

• Compare and contrast common assessment tools in
  dementia in terms of their utility, advantages
  and limitations.
• Sensitivity and Specificity are dependent on the
  test employed

28

• Choosing the right tool for the job
• For more information on the MOCA go to
  www.mocatest.org

29
MOCA validation process

• Developed based on clinical intuition of main
  author (ZN)
• Iterative modification based on 5 years of
  clinical use
• Tested on 46 MCI / AD with MMSE gt 24 vs. 46
  normal
• 5 items replaced weighting adjusted
• Clinical distribution
• We are now in the stage of validation
• Ongoing process
• Main dementia / MCI articles to be reviewed.

30
3 MOCA Validation Studies in area of Dementia

• Nasreddine et al. The Montreal Cognitive
  Assessment, MOCA A brief Screening Tool For Mild
  Cognitive Impairment. Journal of the American
  Geriatrics Society 2005 53 695-699
• Smith et al. The Montreal Cognitive Assessment
  validity and Utility in a Memory Clinic Setting.
  The Canadian Journal of psychiatry 2007 52
  329-332
• Luis et al. Cross validation of the Montreal
  Cognitive Assessment in community dwelling older
  adults residing in the Southern US. International
  Journal of Geriatric Psychiatry 2008

31
Nasreddine et al - Results

• MOCA (cut-off 25/26)
• 90 SENS to detect MCI
• 100 SENS to detect AD
• MMSE (cut-off 25/26)
• 18 SENS to detect MCI
• 78 SENS to detect AD
• MOCA seems to win on SENS (particularly for MCI)

32
Nasreddine et al - Results

• SPEC Normals 26 (correctly identified as
  normal
• MOCA (cut-off 25/26)
• 87 SPEC to normals
• Mislabelled 13 as impaired
• MMSE (cut-off 25/26)
• 100 SPEC to normals
• MMSE seems to win on SPECS

33
Nasreddine Results (my interpretation)

• The results only describe part of the story
• If you lowered the MOCA cut-off, its specificity
  would improve and sensitivity will drop
• If you raise the MMSE cut-off, its sensitivity
  would improve and specificity will drop
• SENS / SPEC are very dependent on cut-offs and on
  populations studied

34
Tests may have differential sensitivity in
different ranges of cognitive decline
MOCA
MMSE
30
30
Normal
25
MCI
20
Mild dementia
25
15
Moderate dementia
20
10
15
10
Severe dementia
5
5
0
0
35
Nasreddine et al recommendations

• If patients have cognitive complaints and
  functional impairment then likely dementia
• MMSE first
• MOCA if MMSE 26 (MCI, Mild dementia)
• If patients have cognitive complaints but no
  functional impairment then likely normal or MCI
• MOCA first

36
Screening COSThow to read studies select
tests

• Cut-off
• Sensitivity and Specificity for any given test
  are dependent on cut-off score
• Objective
• - screen for MCI dementia in community (high
  cut-off)
• - screen for dementia (not MCI) in community
  (lower cut-off)
• - NOT for diagnosis
• - on inpatient setting can only screen for
  cognitive impairment (delirium, depression, MCI,
  dementia)
• Sample
• Sensitivity and Specificity depend on sample /
  population. Since the populations we take care of
  clinically are different from those in studies
  the Sensitivity and Specificity of a test in
  clinical practice will likely not match that in
  studies
• Test Characteristics
• Sensitivity and Specificity are dependent on the
  test employed. MOCA has high sensitivity but low
  specificity (relative to MMSE)

37
Objective 3

• Describe an approach to the evaluation of an
  elderly person with dementia in terms of
  differential diagnosis of potential cause(s).

38
3 Step Approach

• Use DSM criteria to
• 1. Rule Out Depression
• 2. Rule Out Delirium
• 3. Assess for Dementia vs. Mild Cognitive
• Impairment (MCI)

39
Step 1 Rule Out Depression

• M Persistent low mood or anhedonia gt 2 weeks
• S Sleep Impairment
• I Interests decreased
• G Guilty ruminations / regrets
• E Energy decreased
• C Concentration decreased
• A Appetite decreased
• P Psychosomatic complaints / Psychomotor
  retardation or agitation
• S Suicidal ideation (Passive vs. Active)

40
Step 2 Rule Out Delirium

• Delirium Dementia
• Onset Abrupt Gradual
• Course Short Long
• Fluctuation Present Absent
• Hallucinations Present Absent
• Attention Impaired Normal
• LOC Altered Normal
• Psychomotor Altered Normal
• It is common for Delirium to be superimposed on
  Dementia!

41
This table oversimplifies so let us look at
exceptions to the rules as well as the most
reliable signs of Delirium
42
Onset Duration (exceptions)

• Delirium
• May have prolonged low grade delirium with
  chronic ETOH, BDZ, Narcotic, Anticholinergic
  (e.g. TCA, Ditropan) use
• Dementia
• Can have rapid onset with strokes or
  Creutzfeldt-Jakob Disease (see Health Canada CJD
  website describing rapid progression with changes
  in balance / mobolity)

43
Fluctuation

• Delirium
• New onset unpredictable fluctuation (hour by
  hour not day by day)
• Depression
• Predictable diurnal variation (worse in morning)
• Dementia
• Predictable diurnal variation (worse in afternoon
  or evening)

44
Hallucinations

• Delirium
• Especially if family describe new onset
  hallucinations
• Dementia / Psychiatric Disorders
• Long-standing hallucinations
• E.g. Lewy Body disease, Psychotic Depression,
  Bipolar disease

45
Attention, Concentration, LOC

• Delirium
• Attention, Concentration and altered Level of
  Consciousness - LOC (i.e. drowsy, somnolent, slow
  mentation)
• Depression
• Can alter Attention, Concentration but not LOC
• Dementia
• Normal Attention, Concentration, LOC

46
Patterns of Psychomotor Change in delirium

• Hyperactive ("wild man!") 25
• Hypoactive (out of it!, snowed, pleasantly
  confused) 50
• Mixed delirium (features of both), with reversal
  of normal day-night cycle (sundowning) 25

47
Confusion Assessment Method (CAM)

• 1. History of acute onset of change in patients
  normal mental status fluctuating course?
• AND
• Lack of attention?
• AND EITHER
• 3. Disorganized thinking?
• Altered Level of Consciousness?

Sensitivity 94-100 Specificity 90-95 Kappa
0.81

• Inouye SK Ann Intern Med 1990113(12)941-8
• Arch Intern Med. 1995 155301

48
Step 3 - Dementia vs. Mild Cognitive Impairment

• Once again employ the DSM criteria look for a
  deficit in each of the following categories (5 As
  function progression) base on history,
  physical examination, cognitive testing
• Amnesia
• Aphasia, Apraxia, Agnosia, And Executive
  dysfunction
• Progressive
• Impacts on social and / or occupational
  functioning
• If do not have 1 deficit in each of 4 categories
  then have Mild Cognitive Impairment
• (MCI). Be practical If MMSE very low (e.g. 20)
  then Dementia more likely than
• MCI. 10-15 of persons with MCI progress on to
  dementia over 5 10 years for a
• total of 60-70 so follow-up is recommended.
  Amnestic MCI (memory problems)
• more likely to progress to dementia.

49
Amnesia Short-term memory loss

• Look for changes from baseline
• Repeating questions or stories
• Losing items (keys, purse )
• Forgetting details of important events
• Trouble recalling names
• Mixing up relatives and friends
• Increased use of compensatory strategies (lists,
  calendars, memory cues)

50
Aphasia (expressive)

• Ask if patient has word finding problems (words
  on the tip of their tongue)
• Word searching
• Mixing up languages
• Losing last language learned first
• Patterns
• Sudden loss then stable or improving suggests
  stroke, bleed
• Progressive word finding problems (more frequent
  and more severe / noticeable) suggests
  Alzheimers
• Severe and more pronounced than memory problems
  suggests stroke, bleed, Semantic Dementia,
  Primary Progressive Aphasia
• Later develop reading and writing difficulty

51
Apraxia

• Difficulty executing a motor task despite intact
  motor and sensory function
• May notice during dressing post examination
• On exam can ask patient to show how to
• Comb hair
• Brush teeth
• Cut paper with a scissor
• Sometimes difficult to differentiate from
  executive dysfunction (use of stove, TV, remote)

52
Agnosia

• Difficulty identifying objects despite an intact
  sensory function
• Difficulty recognizing family members or close
  friends
• Differentiate this from difficulty recalling
  names. In agnosias they cannot recall the
  persons role in their life.

53
And Executive Dysfunction

• Instrumental Activities of daily Living (IADLs)
  change from baseline due to cognition
• S Shopping
• H Housekeeping / Hobbies
• A Accounting / finances
• F Food preparation
• T Telephone / Tool use
• Transportation (Driving)

54
And Executive Dysfunction

• ADLs (lose after IADLs)
• D Dressing
• E Eating
• A Ambulation
• T Transfers
• H Hygiene

55
And Executive Dysfunction

• Driving (see Geriatrics and Aging article)
• Think of this as a super-IADL
• The only IADL that can result in death if patient
  is too slow (driving is unforgiving there may
  not be a second chance to do the task right)
• If patient has problems with lower level IADLs
  due to cognition then have to consider
  fitness-to-drive
• CMA guidelines If patient has problems with 2 or
  more lower level IADLs due to cognition then
  likely have a moderate dementia and should stop
  driving

56
Working through the DDX of dementia

• Common presenting features

57
Alzheimer disease

• Progressive short-term memory loss
• Encoding problem so cues do not help
• MAY present with progressively more frequent /
  noticeable word-finding changes. When present
  this is highly suggestive of AD
• Limited insight not fully aware of presence of
  memory loss and impact on function

58
Vascular dementia

• 3 levels of evidence
• Neuroimaging performed in the course of the
  dementia demonstrating cerebrovascular disease
  (more than mild microangiopathic ischemia)
  significant enough and in locations to account
  for deficits (i.e. not pure motor areas)
• Established arterial disease (stroke, carotid
  stenosis, CAD, RAS, PVD) consider the arterial
  tree as a single organ. If these are present will
  treat vascular risk factors
• Vascular risk factors.

59
Vascular dementia

• Presentation not suggestive of AD
• Good insight
• Early apraxia / agnosia with ischemia in relevant
  regions
• Retrieval rather than encoding problem memory
  loss responds to cues
• Step-wise decline?
• Beware of False Negatives many cannot recall
  stepwise decline
• Beware of False Positives recurrent deliriums
  with incomplete recovery can give AD a saw
  toothed pattern that looks like a step-wise
  decline. Search for neurological changes
  suggestive of stroke that occurred during period
  of decline
• Do not use the term vascular dementia with
  patients they do not know what this means. Call
  it Stroke dementia.

60
Mixed dementia (Alzheimers vascular)

• Moving ratio concept.
• When you first see patient they may be 99
  vascular and 1 AD (so look like pure vascular)
• A few years later the ratio will shift and they
  will be lt 50 vascular and gt 50 AD. This does
  not mean you were wrong when you first saw them.
  The AD component required more time to declare
  itself so follow your vascular dementia patients
  carefully.

61
Lewy Body dementia

• McKeith et al. neurology 1996 47 1113-1124
• Dementia occurring at the same time as mild
  parkinsonian features
• Long-standing Hallucinations (visual, auditory)
• Long-standing Fluctuation (cognition, attention,
  alertness)
• Supportive features
• Vivid nightmares due to changes in REM sleep
  (lack of muscle paralysis kick, punch and run
  in sleep)
• Neuroleptic sensitivity
• Cognitive profile (memory responds to cuing,
  early executive dysfunction, early visuospatial
  dysfunction driving skills)

62
Parkinsons Dementia

• Common in patients who have passed through the 5
  10 year honeymoon period (motor symptoms
  only) of Parkinson's disease
• Similar cognitive profile to Lewy body Disease
• memory responds to cuing, early executive
  dysfunction, early visuospatial dysfunction
  (driving skills)
• Emre et al. Clinical diagnostic criteria for
  dementia associated with Parkinsons disease.
• Movement Disorders 2007 22(12) 1689-1707

63
Frontotemporal Lobar Degeneration (FTLD)

• Behavioural type
• Classic Frontal Lobe dementia with early loss of
  executive function (relevant to driving)
• Earlier onset
• Presenting symptoms can be positive
  (impulsiveness, anger control problems) or
  negative (withdrawal looks depressed). More
  commonly referred to Psychiatry.
• Test well (MMSE 30/30) but function more poorly
  than screens (that do not test executive function
  well) would suggest
• Neuropsychology helpful in diagnosis

64
Frontotemporal Lobar Degeneration

• Language types
• Semantic dementia
• PPA Primary (non-fluent) Progressive Aphasia
• Severe early expressive aphasia with no obvious
  cause on neuroimaging
• Test poorly (MMSE 5/30 - because testing is
  language based) but function much better than
  test results would predict
• Neuropsychology and Speech-language Pathology
  helpful in diagnosis

65
Normal Pressure Hydrocephalous (NPH)

• AD is a cortical dementia
• NPH can look more like subcortical dementias
  (e.g. subcortical vascular, LBD, Parkinsons
  dementia )
• 3Bs Brain (cognition), Balance (falls), Bladder
  (incontinence)
• Diagnosis with CSF Flow study or LP drain (Do not
  accept simple LP with fluid withdrawal as prone
  to False Negative results)

66
Treatments

• Alzheimer
• CIs /- Memantine (in place of CI or if continue
  to progress on CI
• Vascular
• Usual vascular risk factor modification ASA /
  Ticlid / Plavix / Coumadin /- ACEi
• Lewy Body
• Exelon, Aricept, Galantamine
• Parkinsons
• Exelon, Aricept
• Frontotemporal
• Avoid CIs
• SSRI, Trazadone in behavioural variant
• NPH
• Shunt
• Follow for emergence of AD

67
Why do all of this!!

• If you ignore these issues as being beneath you
  or outside your scope of practice (outside your
  specialty area) then you do so at your (and your
  patients) peril because identification of
  dementia, delirium, depression
• Allows you to create medical care plans that will
  actually be followed (relevant to all
  specialties)
• Helps with discharge from hospital (relevant to
  all specialties)
• Prevents ER visits and hospitalization (or return
  to hospital after discharge)
• Other benefits of diagnosing dementia, delirium,
  depression
• Allows you to start treatment early and maintain
  function and safety of your patients.
• Allows you to counsel families and help them with
  future planning.
• If you cannot assess dementia, delirium,
  depression (at least to the point of identifying
  the presence of one of these) then you cannot be
  a complete and optimally effective physician no
  matter what specialty you are in.

68
GOOD LUCK

• To learn more about dementia, delirium,
  depression and other medical issues consider
  joining the Canadian Geriatrics Society (CGS).
  Medical Students can join the Canadian Geriatrics
  Society (CGS) for free and get full electronic
  access to CGS educational materials
• To join the CGS click on https//www.canadiangeria
  trics.com/ssl/membrappl.asp