Transcript dementia eval - University of Washington

Differentiating Dementia,
Mild Cognitive Impairment,
and Depression:
Neuropsychological Perspective
Emily Trittschuh, PhD
Geriatric Research Education and Clinical Center (GRECC)
VA Puget Sound Health Care System
[email protected]
Dept of Psychiatry and Behavioral Sciences
University of Washington
Learning Objectives
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Characterize Dementia, Mild Cognitive Impairment,
and Depression in Older Adults
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Recognize warning signs and initiate diagnostic
work-up
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Understand components of a Neuropsychological
Evaluation
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Cognitive Profiles – unique/overlapping features
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Utilizing this information to guide treatment and
care planning
The Aging Population
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Older Americans represent ~12 % of the population.
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26% percent of physician office visits
A third of all hospital stays and of all prescriptions
Almost 40 % of all emergency medical responses
90 % of nursing home residents
In 2011, the first baby boomers will reach their 65th
birthdays.
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By 2029, all baby boomers will be at least 65 years old.
This group will join the rest of older adults to total an estimated
70 million people aged 65 and older.
*As reported by the Alzheimer’s Association in 2010
“Typical” Cognitive Aging
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Autobiographical memory
Recall of well-learned information
Procedural and Episodic Memory
Emotional processing
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 Encoding of new memories
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 Working memory
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Slower to learn new tasks
May need more repetitions to learn new info
 Processing speed
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Slower to respond to novel situations
What you might hear in clinic
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I can’t focus
She’s not interested in her usual activities
I can’t come up with the word I want
My energy is low
My short-term memory is shot
I lost my car in the parking lot
My husband’s “selective attention” is worse – he
doesn’t listen to me
Dementia
A decline of cognitive ability and/or
comportment . . .
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primary and progressive
due to a structural or chemical brain disease
Not secondary to sensory deficits, physical
limitations, or psychiatric symptomatology.
to the point that customary social, professional and
recreational activities of daily living become
compromised.
Probable Alzheimer’s Disease
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Dementia established by clinical and
neuropsychological examination.
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Explicit memory impairment plus at least 1 other area of
dysfunction.
Activities of daily living have been affected.
Insidious onset and progressive course.
Risk increases with age; rare onset before age 60
Other diseases capable of producing a dementia
syndrome have been ruled out.
NINCDS-ADRDA Criteria from 1984 consensus group
Causes that Mimic Dementia
(*but are treatable)
Toxic/metabolic
Systemic illnesses
Other
Medications, B12 deficiency,
hypothyroidism
Infections, cardiovascular
disease, pulmonary
Depression, sleep apnea,
psychosocial stressors, drugs
*Treatment may improve, but not fully reverse, symptoms
Millions of people
Prevalence of AD in the US
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
65-74
75-84
85+
2000
2010
2020
2030
2040
2050
Hebert, et al, 2003, Archives of Neurology
Is it always Alzheimer’s disease?
Lim, et al. J Am Geriatr Soc. 1999 May;47(5):564-9.
Mild Cognitive Impairment
 Objectively measured deficits in memory and/or
other thinking abilities
 Subjective memory complaint
 Normal ADLs
 Prevalence rates vary widely depending on age and
community vs clinic sample
** Conversion to dementia is significantly higher in
people with MCI
MCI
12 - 15% per year
Normal controls 1 - 2% per year
(Petersen et al., 1999, 2001)
Depression in Older Adults
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Mood disorder characterized by:
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Sadness
Guilt, negative self-regard
Apathy – loss of motivation, loss of interest
Vegetative Symptoms: sleep, appetite, energy
Psychomotor changes – agitation or slowing
Trouble thinking, concentrating
Loss of interest in life; suicidal ideation
Must occur for at least 2 weeks and interfere with daily living
Higher prevalence rates of mood disorder in the elderly
DSM-IV and ICD-10 criteria
When the Veteran has concerns or
you notice a change . . .
Medical Evaluation
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History, physical
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Blood tests, brain scans
Formal Cognitive Testing
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Evaluate relative to others in
the same age group
Diagnostic Challenges
 If dementia, changes can begin up to 20 years
before noticeable by self & others
 importance of prevention …
 Is this “normal aging”? Is it a change?
 Clinical presentations can be similar
 may not be detectable using screening tests
 Comprehensive assessment is essential
 rule out other treatable causes
Clinical Neuropsychology
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Integrative approach – psychology, psychiatry, and
neurology
Record review
History is often the most important diagnostic tool
Collateral information is helpful
Objective cognitive testing to aid in diagnosis
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Multiple domains of cognitive function must be evaluated
Importance of using appropriate measures and
appropriate normative data
Geriatric Neuropsychology
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Tests
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Normative populations
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Consider age of subject and overall health/energy
Consider adjusting measures administered based on
referral question (e.g., first diagnosis vs. current function)
Limited normative information for 90+
Non-native English speakers
Ethnicity/Cultural differences
Premorbid estimates
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Individualized benchmark
What is “impaired”?
“Gold” standard:
premorbid baseline data
Standard benchmark:
Compare to the average
performance within an age group
-3
-2.5
-2
-1.5
-1
-.5
0
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1
Standard deviations
1.5
2
2.5
3
What is “impaired”?
“Gold” standard:
premorbid baseline data
Personal benchmark:
Compare test results to an
estimate of premorbid abilities
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-2.5
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Standard deviations
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Clinical Symptoms of Cognitive Decline
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Memory loss is often the most commonly
reported symptom:
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Forgetfulness
Repeats self in conversation
Asks the same questions over and over
Gets lost in familiar areas
Can’t seem to learn new information (routes, tasks,
how to use a new appliance or electronics)
Clinical Symptoms cont . . .
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Presenting symptoms can also consist of
changes in one or more of these areas:
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Attention
Language
Visuospatial abilities
Executive function
Personality/judgment/behavior
Impairments in Attention
• Starting jobs but not finishing them
• Absentmindedness
• Difficulty following a conversation
• Distractibility
• Losing train of thought
Impairments in Language
• Problems expressing one’s thoughts in
conversation (can’t find the right words)
• Consistently misusing words
• Trouble spelling and/or writing
• Difficulty understanding conversation
Impairments in Visuospatial Function
• Getting turned around (even in one’s own home)
• Trouble completing household chores (using
knobs or dials)
• Difficulty getting dressed
• Trouble finding items in full view
• Misperceiving visual input
Impairments in Executive Function
• Disorganization
• Poor planning
• Decreased multi-tasking
• Perseveration
• Decreased ability to think abstractly
Changes in Personality or Comportment
Quantitative change in behavior:
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Increase- disinhibition, impulsivity, poor selfregulation, socially inappropriate
Decrease- flat affect, reduced initiative, lack of
concern, lack of interest in social activities (often
initially mistaken for depression)
Behavior not typical of premorbid personality
Case Example: Key Features
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68-year-old, r-handed, AA female
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Master’s degree; Associate dean
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No significant past medical history
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Referred from primary care MD for complaints
of memory loss
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Insidious onset, seems progressive
Symptom History at Initial Visit
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2 year decline in memory
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Social skills maintained
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Living alone, independent in all ADLs
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Collateral endorsed a change
Neurocognitive Profile - MCI
SEVERE
MODERATE
MILD
NORMAL
Mood Attention
Lang
Initial:
(2 yr after onset)
Spatial
Memory Executive ADLs
Changes at Second Visit
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Sense of progression
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Social skills maintained
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Still living alone; independent for basic ADLs
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Changes in IADLs
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Having trouble driving (minor accidents; got lost)
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Trouble managing medications
Neurocognitive Profile - Dementia
SEVERE
MODERATE
MILD
NORMAL
Mood Attention
Lang
Spatial
Memory Executive ADLs
Initial:
1st F/U:
2nd F/U:
(2 yr after onset)
(3 yr after onset)
(5 yr after onset)
Neurocognitive Profile - MCI
SEVERE
MODERATE
MILD
NORMAL
Mood Attention
Lang
Spatial
Memory Executive ADLs
Initial:
1st F/U:
2nd F/U:
(2 yr after onset)
(3 yr after onset)
(5 yr after onset)
Symptom History at Initial Visit
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2 year decline in memory; collateral notes change
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Affective Changes
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Loss of interest in normal activities
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Sadness and decreased social network
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Living alone, independent in basic ADLs
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IADLs
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Sometimes forgets medication dosages
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a few examples of inattention while driving
Neurocognitive Profile - Depression
SEVERE
MODERATE
MILD
NORMAL
Mood Attention
Lang
Spatial
Memory Executive ADLs
Initial:
Tx x 1 yr:
Tx x 1 yr:
(2 yr after onset)
(Incomplete remission)
(Effective)
Complicating issues
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Chronic depression is a risk factor for dementia
Reported rates of depression in dementia range from
0-86% of cases
Recent meta-analysis found 50% prevalence
Discriminating depression from dementia is even more
challenging in non-AD dementias
With the trajectory of MCI unknown, the relationship to
depression is less clear
Depression may indicate prodromal dementia
Treatment and Care Planning
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Dementia
 No cure and the causes are not entirely
understood
 Effective intervention = improve functional
status to a degree discernable to caregivers
or health care providers
 In the case of a progressive disorder,
“improvement” = slower decline
Current FDA-Approved Medications
Acetylcholinesterase
Inhibitors
tacrine Cognex®
hepatotoxic
donepezil Aricept®
1 month
galantamine Razadyne®
4 months
rivastigmine Exelon®
4 months; patch
NMDA receptor antagonist
memantine Namenda®
Adjunct Therapies (off label)
Antidepressants
Antipsychotics
1 month; approved
for mod-severe AD
SSRIs, mirtazapine
risperidone, quetiapine
AGE
Environment
Head Injury, Depression,
Female,
Presence of APOE e4 allele
Chronic Illness
Genetic
Amyloid
Plaques
Alzheimer’s
pathology
NFTs
Neuronal and Synaptic
dysfunction
Cognitive Decline
Alzheimer’s Disease Diagnosis
Mild Cognitive Impairment
Normal
MCI
An ideal point of
intervention?
Dementia
Risk Factors that can be Managed or
Avoided
Medical Conditions
 High Blood Pressure
 High Cholesterol
 Type II Diabetes
Behavioral Factors
 Nutrition/Diet
 Alcohol / Tobacco
 Exercise
 Stress
 Socialization
Type II Diabetes
Older adults (>55 yrs) with diabetes
have a 65% increased risk of
developing Alzheimer’s disease
(compared to those without diabetes)
Adults with diabetes have
lower scores on cognitive tests
Bennett, et al. Religious Orders Study. Archives of Neurology, 2004
Depression in the Elderly
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Depression is not a normal part of aging
Estimated that only 10% of Older Adults with
depression receive treatment
Suicide rates – higher in the elderly and higher
in Veteran populations
Risk of cognitive decline should be monitored
Dang! . . .
Now where
was I going?
Dementia?
Mild Cognitive
Impairment?
Depression?
Superman in his later years
Thank you
Questions?
Please also email me at
[email protected]