Transcript Dementia
COGNITIVE ASSESSMENT IN THE ELDERLY PATIENT AGS Jennifer Breznay, MD, MPH Division of Geriatrics Department of Medicine Maimonides Medical Center November 2, 2009 THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. DEMOGRAPHICS Population: 1960 to 2050 (in millions) 90 78.9 80 75.2 Elderly Oldest Old 70 60 69.4 53.2 50 39.4 40 34.7 31.1 30 20 25.6 20 18.2 16.6 13.6 10 0.9 1.4 2.2 3 4.3 5.7 6.5 8.5 0 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 US Bureau of the Census Slide 2 WHY ARE THE ELDERLY AN IMPORTANT POPULATION? • 20th century: <65-year-olds tripled >65-year-olds increased 11 • 35% of surgeries • 20 million surgeries/year • Present later for care • More comorbidities • Tend to need more emergent care Slide 3 30-DAY SURGICAL MORTALITY 10 9 8 7 6 5 4 3 2 1 0 8.4 All ages 60 -69y 70-79y >80y >90 y 6 2.9 2.2 1.2 30 Day Percent mortality Emergency abdominal surgery > 80 years: 10% Major procedure mortality over 90 years: 20% Jin & Chung. Br J Anaesth. 2001; 87:604-624. Slide 4 CORTICAL FUNCTIONS • • • • • • • • • Level of consciousness Orientation/perceptual ability Memory Attention/concentration Language Motor functions/praxis Visuospatial skills Executive function Judgment/abstraction Slide 5 WHAT IS DEMENTIA? • Acquired syndrome of decline in 2 or more cognitive functions • Decline in function from baseline • Different from normal cognitive lapses; not due to delirium, psychiatric illness, or other medical diagnoses • Not an inherent aspect of aging 1 in 10 persons aged 65+ have dementia 1 in 2 persons aged 85+ have dementia Slide 6 CONSENSUS STATEMENT First International Workshop on Anesthetics and Alzheimer’s Disease • University of Pennsylvania, University of California at San Francisco, Harvard University, University of Wisconsin, University of Virginia, Columbia University, Mount Sinai School of Medicine • May, 2008 • Interest in onset of Alzheimer’s and exposure to anesthetics Slide 7 SCREENING FOR COGNITIVE DECLINE • Mini-Cog 3-item recall Clock drawing test • MMSE • Animal naming • Digit span • Orientation questions Slide 8 DELIRIUM VS. DEMENTIA • Delirium and dementia often occur together in older hospitalized patients • The distinguishing signs of delirium are: Acute onset Cognitive fluctuations over hours or days Impaired consciousness and attention Altered sleep cycles Slide 9 MORTALITY OF DELIRIUM In medical units at YaleNew Haven Hospital: • Mortality of in-hospital delirium: 25%33% • Unrecognized by physicians in 30%50% of cases Inouye et al. Am J Med. May 1999. Slide 10 POST-OP DELIRIUM (1 of 2) • Incidence 10%15% after age 65 • Increases risk of mortality and longer hospital stay • Numerous risk factors besides advanced age: Dementia Depression Anemia Alcohol and drug withdrawal Metabolic derangement Acute MI Infection Emergency surgery Slide 11 POST-OP DELIRIUM (2 of 2) Often due to: • Medications • Hypoxia • Pain • Infection • Sleep deprivation Slide 12 EVALUATION: CAM (CONFUSION ASSESSMENT METHOD) Acute onset & AND fluctuating course Inattention plus either Disorganized Altered LOC thinking DELIRIUM Inouye et al. Ann Intern Med. 1990;113:941-948. Reprinted with permission. Slide 13 AVOID INPATIENT DELIRIUM! • Orientation strategies • Maintain day/night schedule • Avoid restraints • Avoid sedative/hypnotics • Ensure assistive devices are working (eyes and ears) • Avoid immobility • Avoid dehydration Slide 14 Slide 15 ACKNOWLEDGMENTS • Sheila R Barnett, MD, Assistant Professor of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School • Barbara Paris, MD, Chief of Geriatrics, Maimonides Medical Center • Kalpana Tyagaraj, MD, Program Director, Department of Anesthesiology, Maimonides Medical Center • Dennis Feierman, MD, PhD, Vice Chairman, Department of Anesthesiology, Maimonides Medical Center Slide 16 THANK YOU FOR YOUR TIME! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatricssociety Slide 17