1. 3D Geriatrics Dementia Delirium and Depression Gerry Gleich MD Geriatrics Interclerkship April 26, 2013

2. Goals Understand common causes of cognitive dysfunction in the elderly Understand key diagnostic features of dementia, delirium and depression Differentiate between dementia, delirium and depression Understand the use of cognitive assessment tools

3. Case # 1 75 y/o woman brought to the ER by police found confused trying to use her front door key on an apartment door in her building but on the wrong floor. She became abusive confused and frightened, looked pale and agitated and since the police couldn’t establish her address at the time, they brought her to the ER. On examination, it takes several attempts to gain her attention to answer any questions at all but once focused on a question she rambles on in a disorganized way, her speech becoming incoherent at times. She is drowsy at times and falls asleep during the interview. When awake, she seems to be talking about things that are in the room with her and is unable to describe where she is, who she is, or where she lives. Her pulse is 96 and regular, BP145/90, and she is at times agitated and diaphoretic, and at other times quiet, withdrawn, and near sleep.

4. Questions There is no family member or witness present to get more history What physical exam, laboratory studies and other diagnostic tests should be performed and why?

5. Questions When a family member or friend is contacted what specific questions should be asked?

6. Questions The police officer accompanying her has mentioned Alzheimer’s. Other patients are backing up in the ER. Can this patient wait until the ER quiets down?

7. Diagnostic Features of Delirium Disturbance of consciousness with reduced ability to focus, sustain, or shift attention A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre- existing established, or evolving dementia The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day There is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition

8. The Confusion Assessment Method (CAM) Diagnosis requires features 1 and 2 and either 3 or 4 1. Acute change in mental status and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness

9. Delirium Medical emergency High mortality associated with it Find the underlying cause and treat it. Re-orient the patient Minimize sedatives and disorienting stimuli

10. Case # 1 continued The workup reveals a UTI and after treatment with antibiotics, fluids for dehydration and a few days in the hospital her mental status returns to her baseline with no evidence of dementia. Because of the immobility during her illness she is deconditioned and requires rehabilitation to regain her ability to ambulate for 10 days prior to returning home

11. Case # 2 72 y/o man brought to see MD by daughter. He lives alone. Wife died 3 years ago. Daughter notes that he took care of himself well for a time after his wife died but now his house is now in disarray with uneaten rotted food in the refrigerator, and dirty laundry around the house. The patient denies that there is any problem but says his daughter is just fussing over him. The daughter says that the decline in her father’s self care has occurred over the last 6-12 months. On physical exam the pt. has no significant abnormalities with the exception of a score of 20/30 on the MMSE with poor orientation and short term memory

12. Questions What are the diagnostic considerations? What workup should be performed?

13. Diagnostic Features for Dementia Progressive deterioration of higher cortical function Usually insidious in onset No disturbance of consciousness No other explainable cause of deficits Deficits in two areas of cognition Memory impairment Aphasia Apraxia Agnosia Disturbance in executive functioning

14. Differential Diagnosis of Dementia CNS conditions Alzheimer’s Lewy Body Dementia Vascular Dementia Frontotemporal Dementia Normal pressure hydrocephalus Tumors Systemic conditions Hypothyroidism Vitamin B12 deficiency Neurosyphilis HIV Substance abuse Delirium Psychiatric conditions Depression Schizophrenia

15. Types of Dementia

16. Diagnostic Tools Mini Mental Status Exam Mini – Cog Montreal Cognitive Assessment

17. Mini Mental Status Exam Dependent on education and language Screening is more useful in patients with functional decline Give directions clearly in optimized setting accounting for hearing and vision difficulties No help from the peanut gallery Be a stickler for the correct answer and scoring 26-30 mild cognitive impairment 21-25 early dementia 11-20 moderate dementia 0-10 severe dementia

18. MINI-COG Dementia Screen Get patient’s attention and have them repeat 3 unrelated words to you. You may present the 3 words to the patient up to 3 times Ask the patient to draw a clock face with all the numbers on it then ask them to add hands with the time 8:20 or 11:10 2 pts if correct 0 if incorrect Recall 3 words 1 pt for each correctly recalled word Interpretation 0-2 = positive screen 3-5 = negative screen

19. Montreal Cognitive Assessment MoCA Useful for earlier stages of cognitive dysfunction and dementia www.mocatest.org Detailed instructions and test available

20. Depression Prevalence rates In ambulatory population 6-10% In nursing home population 12-20% Variable rates in patients requiring inpatient medical care of 11-45%

21. Depression Elderly under report and may be less likely to recognize Assessment tools can help diagnosis PHQ-2 if positive go to PHQ-9 Geriatric Depression Scale - 15 item test 0-5 is normal >5 depression Cognitive decline with depression can mimic dementia Bereavement can mimic depression

22. Scaled PHQ-2 Answer key for 2 questions below Not at all: 0, Several days: 1, More than half the days: 2, Nearly every day: 3 In past 2 weeks, how often have you been bothered by: 1. Little interest or pleasure in doing things? 2. Feeling down, depressed or hopeless? Interpretation Positive if 3 or more points Administer PHQ-9 if positivePHQ-9 Efficacy Test SensitivityTest Sensitivity: 83% Test SpecificityTest Specificity: 92%

23. Dementia vs. Delirium Dementia Onset gradual No fluctuation in consciousness No other medical problem accounting for the cognitive decline Delirium Onset more rapid (hours to days) Fluctuations in consciousness Caused by a general medical condition

24. Conclusion about confusion Depression and Dementia often co-exist Delirium is more common in patients who have Dementia Making the diagnosis is the first step to successful treatment