Arif Nazir MD Assistant Professor, IU School of Medicine Medical Director, Extended care Service IU Geriatrics

 Can be highlighted by using the following as an example

 Mrs. DM admitted to the hospital in 7/07 confused and covered with feces  Diagnosed with cellulitis, CHF and delirium  Labeled to have MCI by physician on admission to LTC  Ended up on Aricept in 1/08  Admitted to the hospital 3/08 with CHF and returned with diagnosis of Dementia

 Assessment on return revealed reasonable cognition (aware of date, day, year and 2/3 recall)  Complained of nightmares for last few weeks  Staff reported mild forgetfulness but no other cognitive issues  Aricept discontinued and patient’s nightmares resolved  No worsening in cognition since then

 Mr WB seen in LTC and found to have reasonable cognition  Medications included Aricpet  Old chart showed that resident admitted to the hospital in 2003 with UTI and delirium  Started on Aricept 15mg at that hospitalization without any formal testing  Aricept discontinued without adverse effects

Mangino M., Middlemiss C. Alzheimer's disease: preventing and recognizing a misdiagnosis. Nurse Pract Oct;22(10):58-9

 Depression is frequently misdiagnosed as dementia, with up to 32% of those referred for dementia evaluation actually suffering from depression  Sixty percent of the times this leads to use of inappropriate medications Crigger N, Forbes W: Assessing neurologic function in older patients. AJN 1997; 97( 3): 37–41 Marin D, Sewell M, Schlechter A: Alzheimer’s disease. Accurate and early diagnosis in the primary care setting. Geriatrics 2002; 57:427–33. Maynard, Carolyn K. RN, PhD, CS, FNP Differentiate Depression From Dementia. Nurse Practitioner. 28(3):18-19,23-27, March 2003.

 Patient stress, depression and suicide Rohde K, Peskind E, Raskind M. Suicide in two patients with Alzheimer's disease. J Am Geriatr Soc 1995;43(2):187-9  More established risks of receiving the diagnosis of dementia are difficulty obtaining medical or life insurance, or acceptance into assisted-living communities. U.S. Preventive Services Task Force  Loss of patient autonomy  Inappropriate medications use with side effects

 Factors contributing to misdiagnosis:  Failure to obtain collateral history  Failure to apply widely accepted diagnostic criteria  Over-reliance on structural brain imaging  Lack of longitudinal follow-up McDaniel LD et al. J Geriatr Psychiatry Neurol Oct-Dec;6(4):230-4 Lamer AJ. Int J Clin Pract Nov;58(11):1092-4

 Scrutinize every resident admitted with the “Dementia” label  Educate the LTC providers/ staff to closely assess cognition on admission  Equip the nursing home staff with simple tools to assess cognition at regular intervals  Advocate formal testing or specialist consultations for LTC residents diagnosed with dementia  Encourage a culture change to refrain from diagnosing dementia in hospital setup

 Discover care- issues regarding residents with cognitive impairment and dementia  Utilize the Complex Adaptive system/ Reflective adaptive processes to come up with possible solutions, and  Pilot research projects to recommend interventions to achieve these solutions  Networking of the stakeholders in order to:  Deliver and disseminate these tools

 Submitting a grant proposal for a Seminar “Towards excellence in Dementia care: Implementing an effective and locally sensitive quality dementia care in your nursing home facility”  Finding a valid and user friendly delirium assessment tool for nursing home staff  Creation of a “transfer form” for better communication of residents’ mental and physical status to the ED or Primary care physician  A Pilot project to assess the appropriateness of diagnosis of dementia in nursing homes

 Patrick Healey  Arif Nazir  Cindi Moon  Dave Mccarroll  Pat Russell  Mary Roeslinger