1. DEMENTIA, DELERIUM, AND DEPRESSION - DIFFERENTIATION Jessica L. Estes, DNP, APRN-NP Estes Behavioral Health, LLC KCNPNM – Annual Conference April 2014

2. Objectives Describe the current assessment tools for dementia, delirium, and depression Describe the current treatment protocols for dementia, delirium, and depression Describe the common side effect profile for anticholinergics and their benefits and risks.

3. DEMENTIA

5. Alzheimer’s Epidemic Epidemiological Concerns 5.2M Americans with AD in 2013 Growing epidemic expected to impact 13M Americans by 2050 and consume 1.1 trillion in healthcare spending AD Diagnostic Challenges Only 50% of pts receive formal dx Diagnosis delayed on average by 6+ Years Sig. impairment in function by time it is recognized

6. Base Rates 1 in 9 people 65+ (11%) 1 in 3 people 85+ (32%) Of those with Alzheimer’s disease: 4% <65 13% 65 -74 44% 75-84 38% 85+

7. Base Rates Almost 2/3 are women (longer life expectancy) Minority populations at higher risk (health/lifestyle factors) Older African Americans (2x as whites) Older Hispanics (1.5x as whites) AD 6 th leading cause of death in 2013 If disease could be detected earlier (pre-clinical stages) incidence would be much higher

8. Alzheimer’s Epidemic Numbers in Minnesota 201094,000 2025110,000 projected Projected % increase in AD between 2000-2025 is 25%

9. Today, Alzheimer’s Disease Is … Prevalent Expensive Fatal Misunderstood Under-diagnosed Under-treated Poorly Managed Stigmatized On the rise

10. Diagnostic Challenges

11. Cultural Ageism and defining “normal” aging MD will bring health problems to my attention Associated stigma Medical Heterogeneous baseline Many patients unaware of problem Time No lab test (only rule outs) Treatment options/efficacy Wrong diagnosis? Fear of delivering bad news Implications for physician/patient relationship

12. Fact: Most Americans want advanced notice Surveys of US adults Myth: Most people don’t want to know if they have Alzheimer’s disease %

13. Diagnostic Challenges Systemic/Institutional Low priority Few incentives Lack of procedural support Few specialists available (neurology, neuropsychology) Few community resources

14. Diagnostic Challenges International Alzheimer’s Disease Physician Survey Lack of definitive tests (65%, top barrier) Lack of communication between patients / caregiver and physicians 75% reported discussion initiated by patients/caregivers 44% “after they suspect the disease has been present for a while” 40% said patients/caregivers did not provide enough information to help them make a diagnosis Patient / Family denial (65%) & social stigma (59%) International Alzheimer’s Disease Physician Survey, 2012

15. Why Screen?

16. Does Screening Make Sense? Money Time Patient care / outcomes

17. Money Cost effectiveness of early assessment and treatment? Large scale studies ongoing Getsios et al (2012) Projections based on clinical trial and follow-up registry data Compared to no assessment / no treatment: Reduction in healthcare costs by $5,300 /pp Reduction in societal costs by $11,400 / pp

18. Time Physician does not administer screen Rooming nurse Length of screen varies Recommended tool takes 1.5 – 3 minutes Only conducted annually Mini-Cog does not disrupt workflow & increases capture rate of cognitive impairment in primary care Borson JGIM 2007

19. Patient Outcomes: Rationale for Early Detection 1. Improve quality of life  Early treatment is more effective  Stabilization vs. improvement  Delay functional decline  Patients can make decisions regarding care  Decrease burden on family and caregivers 2. Connection to services that promote independent (supported) living as long as possible  RTC support/counseling intervention (Mittelman et al. Neurology 2006)  Non-pharm interventions reduce NH placement by 30% and delay placement for others by 18+ months

20. Patient Outcomes: Rationale for Early Detection 3. Treat reversible causes  NPH, TSH, B12, hypoglycemia, depression 4. Improve management of co-morbid conditions  Underlying dementia = primary risk factor of poor compliance in the elderly  Affects management of ALL chronic diseases (diabetes, hypertension, anticoagulation)  Brain as 6 th Vital Sign

21. Patient Outcomes: Rationale for Early Detection 5. Reduce ineffective and expensive crisis-driven use of healthcare resources  “good” vs. “bad” healthcare  Prevent diagnosis during crises (wandering, hospitalization, car accidents, bankruptcy) 6. More time to participate in clinical trials and important scientific studies  Knowledge gap re: earlier stages  Find a cure

23. Annual Wellness Visit: Medicare Took effect January 1, 2011 Affordable Care Act Medicare will cover an annual wellness visit which will include the creation of a personalized prevention plan For first time, “detection of cognitive impairment” is core feature of the exam However, no guidance regarding: What screening tools to use What to do if patient fails screening

24. National Alzheimer’s Project Act (NAPA) Law signed into effect January 4, 2011 US Dept of Health and Human Services responsible for: Creating national plan to address Alzheimer’s disease epidemic Improve early diagnosis, care coordination and treatment Recommendations include: Physician education Dissemination of assessment tools Collaboration at state and local level to advance awareness and readiness across public and private sectors

25. Local Health Systems Numerous systems already screening HealthPartners Annual Wellness Visit Pilot Neurology, Ophthalmology, Pharmacy Allina 30,000+ screens to date Essentia Health (Duluth) Piloting with plans to roll out across entire system ACMC Piloting in one clinic with plans for expansion

26. Easy Practice Tips

27. Practice Tips Raise your expectation of the older patient Clinical interview Let patient answer questions without help Remember: Social skills remain intact Easy to be fooled by a sense of humor, irritability, reliance on old memories, or quiet/affable demeanor Subjective interviews FAIL to detect dementia in early stages

28. Practice Tips Red flags Repetition (not normal in 7-10 min conversation) Tangential, circumstantial responses Losing track of conversation Frequently deferring to family Over reliance on old information/memories Inattentive to appearance Unexplained weight loss or “failure to thrive”

29. Practice Tips Family observations: ANY instances whatsoever of getting lost while driving, trouble following a recipe, asking same question repeatedly, mistakes paying bills Ask: “Let’s suppose your family member was alone on a domestic flight across the country and the trip required a layover with a gate change. Would he/she be able to manage that kind of mental task on his/her own?”

30. Practice Tips Intact older adult should be able to: Describe 2 current events in some detail Describe what happened on 9/11, New Orleans disaster Name the current President and 2 immediate predecessors Describe medical history and names of some medications

31. Cognitive Screening Tools

32. Screening Initial considerations Research findings re: early detection Balance b/w time and sensitivity/specificity How will your practice incorporate screening? Who will administer tests? MDs, nurses, social workers, allied health professionals What happens when screen is positive?

33. Screening Measures Wide range of options Mini-Cog (MC) Mini-Mental State Exam (MMSE) St. Louis University Mental Status Exam (SLUMS) Montreal Cognitive Assessment (MoCA) All but MMSE free online in public domain

34. Screening Measures Do NOT Allow patient to give up prematurely or skip questions Deviate from standardized instructions Offer multiple choice answers Bias score by coaching Be soft on scoring Score ranges already padded for normal errors Deduct points where necessary – be strict

35. Mini-Cog Contents Verbal Recall (3 points) Clock Draw (2 points) Advantages Quick (2-3 min) Easy High yield (executive fx, memory, visuospatial) Subject asked to recall 3 words Leader, Season, Table Subject asked to draw clock, set hands to 10 past 11 +3 +2

37. Mini-Cog Pass > 4 Fail 3 or less Borson S., Scanlan J, Brush M et al. 2000. The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15, 1021-1027.

38. Mini-Cog Pros  Easy to administer  Minimal time commitment  Clock sensitive to visuospatial & executive dysfunction  Simple scoring and interpretation Cons  Not as sensitive for MCI or early dementia when compared to longer screens  Brevity means less information to interpret

39. Mini-Cog

45. Performance unaffected by education or language Borson Int J Geriatr Psychiatry 2000 Sensitivity and Specificity similar to MMSE (76% vs. 79%; 89% vs. 88%) Borson JAGS 2003 Does not disrupt workflow & increases rate of diagnosis in primary care Borson JGIM 2007 Failure associated with inability to fill pillbox Anderson et al Am Soc Consult Pharmacists 2008

46. Screen Failure MiniCog = <4 OR memory complaints by patient/family Schedule follow-up appt Insist on family collateral Perform more complex test (MOCA, SLUMS, MMSE)

47. MMSE

48. Pass > 26 Fail 25 or less

49. Pros  Widely accepted and validated for dementia screening  30-point scale well known and score easily interpretable  Measures orientation, working memory, recall, language, praxis Cons  Scale developed 40 years ago, before MCI criteria and when early dementia less well understood  Lacks sensitivity to MCI and early dementia  Takes 7+ min. to administer  Copyright issues MMSE

50. SLUMS

51. Pass > 26 Fail 25 or less

52. Pros  More measures of executive functioning  Good balance between easy and difficult items  More sensitive than MMSE in detecting MCI and early dementia  30-point scale similar to MMSE  Score range for MCI and dementia  Free online Cons  Takes 10 min. to administer  Slightly more complex directions than MMSE  Less name recognition than MMSE SLUMS

53. MoCA

54. Pass > 26 Fail 25 or less

55. Pros  Much more sensitive than MMSE for MCI and early dementia  More content tapping higher level executive fx  30-point scale similar to MMSE  Translations available in 35+ languages  Free online Cons  Takes 10-14 min. to administer  More complex administration and directions than MMSE MoCA

56. Screening Tool Selection Montreal Cognitive Assessment (MoCA) Sensitivity: 90% for MCI, 100% for dementia Specificity: 87% St. Louis University Mental Status (SLUMS) Sensitivity: 92% for MCI, 100% for dementia Specificity: 81% Mini-Mental Status Exam (MMSE) Sensitivity: 18% for MCI, 78% for dementia Specificity: 100% Larner et al Int Psychogeriatr 2012; Nasreddine et al J Am Geriatr Soc 2005; Tariq et al Am J Geriatr Psychiatry 2006; Ismail et al Int J Geriatr Psychiatry 2010

59. Diagnostic Workup History & physical Objective cognitive measurement Diagnostics Labs Imaging ? More specific testing (e.g., neuropsychological exam)? Diagnosis Family meeting

60. Diagnosis Alzheimer’s disease: 60-80 % Includes mixed AD + VD Lewy Body Dementia: 10-25 % Parkinson spectrum Vascular Dementia: 6-10 % Stroke related Frontotemporal Dementia: 2-5 % Personality or language problems

62. Intervention / Management Medication treatment Small component of care plan Referrals Senior LinkAge Line ® the 1-stop shop for MN Seniors Alzheimer’s Association and other community organizations Goals Provide education Connect to programs and services Increase dementia competence For patient AND family

63. Care Coordination Tools Care Coordinators in Health Care Homes Care Coordination Checklist Cognitive Status / Dx ID Care Partner Care Plan Checklist Disease Stages

65. EMR Tools Use EMR to automate: Screening Work-up AVS with dementia education Internal orders and referrals Community supports

66. Pharmacolgical Treatment

67. Pharmacological Treatment

69. CASE STUDY 1

70. DELERIUM

71. 71 SymptomsParameterDeliriumDementia Onset Short, rapid, hours/days Insidious and gradual Presentation Disoriented, fluctuating moods Vague symptoms, loss of intellect, agitated, aggressive Course Hours, weeks, or longer Slow and continuous Sleep/Wake Worse at night in darkness and on awakening, insomnia Worse in evening; “sundowning”, reversed sleep Duration Hours to < month Month to years Affect Labile variable; fear / panic, euphoria, disturbed Easily distracted, inappropriate anxiety, labile to apathy

72. 72 SymptomsParameterDeliriumDementia Judgment Impaired; difficulty separating facts and hallucinations Impaired, bad / inappropriate decisions, denies problems Psychotic symptoms Delusions Misperceives people and events as threatening; late delusions, hallucinations Level of Consciousness DisturbedIntact Recent Memory Impaired, but remote memory is intact Short term memory deficit in early course, progresses to long-term deficits, confabulation, perseveration

73. 73 Assessment of Delirium History and Physical Current medication Tests: chemistries, EKG, CXR, ABGs, oxygen saturation, u/a, thyroid function tests, cultures, drug levels, folate levels, pulse oximetry, EEG, lumbar puncture, serum B12

74. 74 Treatment of Delirium Failure to treat delays recovery and can worsen the older person’s health and function. Psychiatric Management: identify and treat underlying etiology, intervene immediately for urgent medical conditions; ongoing monitoring of psychiatric status Environmental and supportive interventions:  all environmental factors that exacerbate delirium; make environment more familiar; reorient; reassure, and inform to  fear or demoralization Somatic Interventions: antipsychotic; benzodiazepines

75. CASE STUDY 2

76. DEPRESSION

77. 77 Definition of Depression Clinical syndrome characterized by lower mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss and / or guilt. Diagnostic labels: minor depression, major depression, adjustment disorder with depressed mood, dysthymia, bipolar depression, seasonal affective disorder

78. 78 Prevalence of Depression The most common emotional disorder found in older people (2% - 10%) 8% to 15% of community-dwelling older adults 30% among institutionalized older persons Suicide risk factors: - psychiatric illness, serious medical illness, living along, recent bereavement, divorce, or separation, unemployment or retirement, advanced age, and substance abuse

79. 79 Prevalence of Depression Herbal, nutritional, vitamins, and supplement consumed in large doses Highest rate of completed suicide is among older white men. Risk of suicide is higher in older adults than in younger people. Herbal, nutritional, vitamins, and supplement consumed in large doses Highest rate of completed suicide is among older white men. Risk of suicide is higher in older adults than in younger people.

80. 80 Assessment Instruments for Depression Hamilton Rating Scale for Depression Zung Self-rating Depression Scale Montgomery-Asberg Depression Rating Scale Yesavage Geriatric Depression Scale Cornell Scale for Depression in Dementia Hamilton Rating Scale for Depression Zung Self-rating Depression Scale Montgomery-Asberg Depression Rating Scale Yesavage Geriatric Depression Scale Cornell Scale for Depression in Dementia

81. 81 Symptoms of Depression Depressed mood Associated psychological symptoms Somatic manifestations Psychotic symptoms

82. 82 Treatment Strategies for Depression Pharmacologic – SSRI, Tricyclic antidepressants, MAO inhibitors Electroconvulsive Therapy Group and Individual Psychotherapy

83. 83 Points to consider…… Comorbidities Monitor every 1 – 2 weeks Assess response every 4 – 6 weeks Assess “SIG-E-CAPS” symptoms

84. 84 Depression: “SIG-E-CAPS” “SIG-E-CAPS” is the acronym used for evaluating the patient’s progress over time S Sleep disturbance (insomnia or hypersomnia) I Interests (anhedonia or loss of interest in usually pleasurable activities) G Guilt and/or low self-esteem E Energy (loss of energy, low energy, or fatigue) C Concentration (poor concentration, forgetful) A Appetite changes (loss of appetite or increased appetite) P Psychomotor changes (agitation or slowing/retardation) S Suicide (morbid or suicidal ideation)

85. 85 Interventions Institute safety precautions for suicide risk Monitor / promote nutrition, elimination, sleep, rest, comfort, pain control Enhance physical function and social support Maximize autonomy Structure and encourage daily participation in therapies Remove etiologic agents Monitor / document responses Provide practical assistance, such as problem-solving Provide emotional support

86. CASE STUDY 3

87. QUESTIONS ????

88. References Bischkopf J Busse A Augemeyer M 2002 Mild cognitive impairment - A review of prevalence, incidence and outcome according to current approaches.Bischkopf, J., Busse, A., & Angermeyer, M. (2002). Mild cognitive impairment - A review of prevalence, incidence and outcome according to current approaches. ACTA Psychiatrica Scandinavica, 106(3), 403- 414. Borsutzky, S., Fujiwara, E., Brand, M., & Markowitsch, H.J. (2008). Confabulation in alcoholic Korsakoff patients, Neuropsychologia, 46(13), 3133-3143. Retrieved from www.elsevier.com/locate/neuropsychologia. www.elsevier.com/locate/neuropsychologia Brodaty, H., & Moore, C. M. (1997). Clock Drawing Test for dementia of the Alzheimer's type: A comparison of three scoring methods in a memory disorders clinic. International Journal of Geriatric Psychiatry, 12(7), 619-627.

89. References – Cont. Fillenbaum G Hughes D Heyman A George L Blazer D 1988 Relationship of health and demographic characteristics to Mini- mental state Examination score among community residents.Fillenbaum, G., Hughes, D., Heyman, A., George, L., & Blazer, D. (1988). Relationship of health and demographic characteristics to Mini-mental state Examination score among community residents. Psychological Medicine, 18(18), 719-726. Flherty J H Shay K Weir C Kamholz B Boockvar K Shaughnessy M Stein J Rudolph J 2009 development of a mental status vital sign for use across the spectrum of care.Flherty, J. H., Shay, K., Weir, C., Kamholz, B., Boockvar, K., Shaughnessy, M., Stein, J., & Rudolph, J. (2009). development of a mental status vital sign for use across the spectrum of care. Journal of the American Medical Directors Association, 10(6), 379-380. doi:10.1016/j.jamda.2009.04.001