Addressing Memory Concerns in Older Patients the Prevalence of Memory-Related Issues Increases with Age

Web audio at CurrentPsychiatry.com Dr. Wilcox: Strategies for addressing memory-related issues in older patients

Addressing memory concerns in older patients The prevalence of memory-related issues increases with age. So does concern about dementia. Be prepared to render the best evaluation and advice possible

James A. Wilcox, MD, PhD Professor of Clinical Psychiatry any older patients are concerned about their memory. The University of Arizona “worried well” may come into your office with a list of things Staff Psychiatrist they can’t recall, yet they remember each “deficit” quite well. Southern Arizona Veterans Administration M Health Care System Anticipatory anxiety about one’s own decline is common, and is most Tucson, Arizona often concerned with changes in memory.1,2 P. Reid Duffy, PhD, RN Patients with dementia or early cognitive decline often are oblivious Mental Health Research Coordinator to their cognitive changes, however. Of particular concern is progres- Southern Arizona Veterans Administration Health Care System sive dementia, especially Alzheimer’s disease (AD). Although jokes Tucson, Arizona about “senior moments” are common, concern about AD incurs deep- Disclosure seated worry. It is essential for clinicians to differentiate normal cognitive The authors report no financial relationships with any changes of aging—particularly those in memory—from early signs of company whose products are mentioned in this article or 3 with manufacturers of competing products. neurodegenerative disease (Table 1, page 30 ). In this article, we review typical memory changes in persons age >65, and differentiate these from mild cognitive impairment (MCI), an increasingly recognized prodrome of AD. Clinicians armed with knowledge of MCI are able to reassure the worried well, or recommend neuropsycho- logical testing as indicated.

Is memory change inevitable with aging? Memory loss is a common problem in aging, with variable severity. Research is establishing norms in cognitive functioning through the ninth decade of life.4 Controversy about sampling, measures, and methods abound,5 and drives prolific research on the subject, which is beyond the scope of this article. It has been demonstrated that there are a few

Current Psychiatry

BRIAN STAUFFER Vol. 15, No. 5 29 Table 1 Mild cognitive impairment 8 Early warnings of dementia Since at least 1958, clinical observations and research have recognized a prodrome Difficulty following sequential tasks that differentiates cognitive changes predic- New-onset social withdrawal tive of dementia from those that represent An increase in word finding problems typical aging. Several studies and methods Inability to locate things due to confusion have converged toward consensus that Senior moments Trouble with spatial relationships MCI is a valid construct for that purpose, New memory deficits change the actions with ecological validity and sound predic- of daily life tive value. Clinical value is evident when Source: Reference 3 a patient does not meet criteria for MCI; in this case, the clinician can reassure the worried well with conviction. Revealing the diagnosis of MCI to “optimally aging” persons who avoid mem- patients requires sensitivity and assur- ory decline altogether.5,6 Most researchers ance that you will reevaluate the condition Clinical Point and clinicians agree, however, that memory annually. Although there is no evidence- Forgetfulness is change is pervasive with advancing age. based remedy for MCI or means to slow Memory change follows a gradient with its progression to dementia, data are rap- characteristic of recent memories lost to a greater degree idly accruing regarding the value of life- normal aging, and than remote memories (Ribot’s Law).7 style changes and other nonpharmacologic frequently manifests Forgetfulness is characteristic of normal interventions.9 with misplaced aging, and frequently manifests with Recognizing MCI most simply requires 2 misplaced objects and short-term lapses. criteria: objects and short- However, this is not pathological—as long term lapses as the item or memory is recalled within 24 The patient’s expressed concern about to 48 hours. decline in cognitive functioning from a Compared with younger adults, healthy previous level of performance. Alternately, older adults are less efficient at encod- a caretaker’s report is valuable because ing new information. Subsequently, they the patient might lack insight. You are not have more difficulty retrieving data, par- looking for an inability to perform activi- ticularly after a delay. The time needed to ties of daily living, which is indicative of learn and use new information increases, frank dementia; rather, you want to deter- which is referred to as processing inef- mine whether the person’s independence ficiency. This influences changes in test in functional abilities is preserved, although performance across all cognitive domains, less efficient. Patients might repeatedly with decreases in measures of mental report occurrences of new problems, processing speed, working memory, and although modest, in some cases. Although problem-solving. problems with memory often are the most Many patients who complain about frequently reported symptoms, changes “forgetfulness” are experiencing this nor- can be observed in any cognitive domain. mal change. It is not uncommon for a Uncharacteristic inability to understand patient to offer a list of things she has for- instructions, frustration with new tasks, and gotten recently, along with the dates and inflexibility are common. circumstances in which she forgot them. Discuss this article at Because she sometimes forgets things, but Quantified clinical assessment that the www.facebook.com/ remembers them later, there likely is noth- patient’s cognitive decline exceeds norms CurrentPsychiatry ing to worry about. If reminders—such of his age cohort. Clinicians are already famil- as her list—help, this too is a good sign, iar with many of these tests (5-minute recall, because it shows her resourcefulness in clock face drawing, etc.). For MCI, we recom- using accommodations. If the patient is mend the Montreal Cognitive Assessment managing her normal activities, reassur- (MoCA), which is specifically designed for Current Psychiatry 30 May 2016 ance is warranted. MCI.10 It takes only 10 minutes to administer. continued on page 32 continued from page 30 Multiple versions of the MoCA, and instruc- • normal pressure hydrocephalus, which tions for its administration are available for can be relieved by surgical placement of provider use at www.mocatest.org. a shunt. When these criteria are met—a decline in previous functioning and an objective clini- Take a complete history. What exactly cal confirmation—referral for neuropsycho- is the nature of the patient or caregiver’s logical testing is recommended. Subtypes complaint? You need to attempt to engage Senior moments of MCI—amnestic and non-amnestic— the patient in conversation, observing his have been employed to specify the subtype behavior during the evaluation. Is there (amnesic) that is most consistent with pro- notable delay in response, difficulty in dromal AD. However, this dichotomous attention and focus, or in understanding scheme does not adequately explain or cap- questions? ture the heterogeneity of MCI.11,12 The content of speech is an indicator of the patient’s information processing. Ask the patient to recite as many animals from Medical considerations the jungle as possible. Most people can Clinical Point Just as all domains of cognition are correlated come up with at least 15. The person with There is evidence that to some degree, the overall health status of MCI will likely name fewer animals, but a person influences evaluation of memory. may respond well to cueing, and perform subjective complaints Variables, such as fatigue, test anxiety, mood, better in recognition (eg, pictures or draw- of memory loss are motivation, visual and auditory acuity, edu- ings) vs retrieval. When asked to describe more frequently cation, language fluency, attention, and pain, a typical day, the patient may offer a vague, associated with affect test performance. In addition, clinician nonchalant response eg, “I keep busy watch- rapport and the manner in which tests are ing the news.” This kind of response may depression than with administered must be considered. be evidence of confabulation; with further cognitive impairment questioning, he is unable to identify current Depression can mimic MCI. A depressed issues of interest. patient often has poor expectations of him- self and slowed thinking, and might exag- Substance abuse. It is essential that clini- gerate symptoms. He might give up on tests cians recognize that elders are not exempt or refuse to complete them. His presentation from alcohol and other drug abuse that initially could suggest cognitive decline, but affects cognition. Skilled history taking, depression is revealed when the clinician including attention to non-verbal responses, pays attention to vegetative signs (insomnia, is indicated. A defensive tone, rolling of eyes, poor appetite) or suicidal ideation. There is or silent yet affirmative nodding are means growing evidence that subjective complaints by which caregivers offer essential “clues” to of memory loss are more frequently associ- the provider. ated with depression than with objective measures of cognitive impairment.13,14 A quick screening tool for the office is valuable; many clinicians are most familiar Other treatable conditions can present with the Mini-Mental State Examination or with cognitive change (the so-called revers- the Saint Louis University Mental Status

ible dementias). A deficiency of vitamin B12, Examination, which are known to be sen- thiamine, or folate often is seen because qual- sitive in detecting memory problems and ity of nutrition generally decreases with age. other cognitive defects. As we noted, the Hyponatremia and dehydration can present MoCA is now recommended for differen- with confusion and memory impairment. tiating more subtle changes of MCI.10,15 It Other treatable conditions include: is important to remember that common • cerebral vasculitis, which could improve conditions such as an urinary tract infec- with immune suppressants tion or trauma after anesthesia for routine • endocrine diseases, which might procedures such as colonoscopy can cause respond to hormonal or surgical cognitive impairment. Again, eliciting his- Current Psychiatry 32 May 2016 treatment tory from a family member is valuable continued on page 33 continued from page 32 because the patient may have forgotten Table 2 vital data. Recommendations for reducing effects of cognitive aging, from A good physical exam is important when the Institute of Medicine evaluating for dementia. Look for any neurologic anomaly. Check for disinhibition of Engage in physical activity primitive reflexes, eg, abnormal grasp or Reduce and manage cardiovascular risk factors snout response or Babinski sign. Compare the symmetry and strength of deep tendon Regularly review health conditions and medications that might affect cognitive health reflexes. Look for neurologic soft signs. The committee suggested 3 additional actions Any pathological reflex response can be an supported by some scientific evidence to important clue about neurodegeneration or suggest positive effects on cognition: space-occupying lesions. We recall seeing • Pursue intellectual engagement, with a 62-year-old man whose spouse brought ongoing opportunities to learn him for evaluation for new-onset reckless • Get adequate sleep driving and marked inattention to personal • Avoiding the risk of cognitive changes due hygiene that developed over the previous to delirium if undergoing procedures or Clinical Point hospitalization 3 months. On examination, he appeared Source: Reference 22 Cerebral atrophy, disheveled and had a dull affect, although disinhibited and careless. His mentation space-occupying and gait were slowed. He denied distress of lesions, and shifting any kind. Frontal release signs were noted Always check for arrhythmia and hyper- of the ventricles on exam. An MRI revealed a space-occu- tension. These are significant risk factors often correspond pying lesion of the frontal lobe measuring for ischemic brain disease, multiple-infarct with cognitive 3 cm wide with a thickness of 2 cm, which stroke, or other forms of vascular demen- pathology confirmed as a benign tumor. tia. A shuffling gait suggests Parkinson’s decline Labs. The next level of evaluation calls for Related Resources a basic laboratory workup. Check complete • American Psychological Association. Memory and Aging. blood count, liver enzymes, thyroid func- www.apa.org/pi/aging/memory-and-aging.pdf. tion tests, vitamin D, B and folate levels; • Desai AK, Schwarz L. Subjective cognitive impairment: 12 when to be concerned about ‘senior moments.’ Current perform urinalysis and a complete meta- Psychiatry. 2011;10(4):31,32,39,40,42,44,A. bolic panel. Look at a general hormone Drug Brand Names panel; abnormal values could reveal a pitu- Senior moments Donepezil • Aricept Memantine • Namenda itary adenoma. (In the past 33 years, the Galantamine • Reminyl Rivastigmine • Exelon first author has found 42 pituitary tumors in the workup of mental status change.) We use imaging, such as a CT or MRI of the brain, in almost all cases of suspected disease, or even Lewy body dementia, or dementia. Cerebral atrophy, space-occupy- medication-related conditions, for example, ing lesions, and shifting of the ventricles from antipsychotics. often correspond with cognitive decline.

Clinical Point Take a medication history. Many com- Other than for mon treatments for anxiety and insomnia Treatment can cause symptoms that mimic dementia. Effective treatment of dementia remains the ‘reversible Digitalis toxicity results in poor recall and elusive. Other than for the “reversible dementias,’ confusion. Combinations of common med- dementias,” pharmacotherapy has shown pharmacotherapy icines (antacids, antihistamines, and oth- less progress than had been expected. has shown less ers) compete for metabolic pathways and Donepezil, galantamine, rivastigmine, and lead to altered mental status. Referencing memantine could slow disease progres- progress than had the Beers List16 is valuable; anticholiner- sion in some cases. There have been many been expected gics, benzodiazepines, and narcotic anal- studies for dementia preventives and gesics are of special concern. The latter treatments. Extensive reviews and meta- could still be useful for comfort care at the analyses, including those of randomized end of life. controlled trials17-19 abound for a variety It is common for seniors to take a variety of herbs, supplements, and antioxidants; of untested and unproven supplements in none have shown compelling results. Table the hope of preventing or lessening memory 2 (page 33) lists Institute of Medicine recom- problems. In addition to incurring significant mendations supported by evidence that costs, the indiscriminate use of supplements could reduce effects of cognitive aging.20 poses risks of toxicity, including unintended Recommendations from collaboration interactions with prescribed medications. between the National Institute on Aging Many older adults do not disclose their use and the Alzheimer’s Association21 state of these supplements to providers because that research should focus on biomarkers, they do not consider them “medicine.” such as neural substrates or genotypes. continued on page 40

Bottom Line Variations in cognition occur over the lifespan. Be aware that mild cognitive impairment (MCI) is not a benign change but a harbinger of dementia for most affected people. We are able to differentiate the worried well from patients with MCI. The importance of early treatment for reversible forms of dementia is vital to reducing patient suffering and the overall burden on caregivers. Early identification of MCI will assist further research toward prevention or delay of progression to Current Psychiatry 34 May 2016 Alzheimer’s dementia. continued from page 34 Indicators of oxidative stress (cytokines) 6. Negash S, Smith GE, Pankratz SE, et al. Successful aging: definitions and prediction of longevity and conversion and inflammation (isoprostanes) show to mild cognitive impairment. Am J Geriatr Psychiatry. promise as measures of brain changes that 2011;19(6):581-588. 7. Ribot T. Diseases of memory: an essay in the positive correspond with increased risk of AD or psychology. London, United Kingdom: Kegan Paul Trench; other dementias. 1882. 8. Kral VA. Neuropsychiatric observations in old peoples home: studies of memory dysfunction in senescence. J Gerontol. 1958;13(2):169-176. 9. Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic Senior moments Summing up management of behavioral symptoms in dementia. JAMA. Older adults are a heterogeneous group. 2012;308(19):2020-2029. 10. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Intellectual capacity does not diminish with Cognitive Assessment, MoCA: a brief screening tool for mild cognitive assessment. J Am Geriatr Soc. 2005;53(4): advancing age. Many elders now exceed 695-699. expectations for productivity, athletic abil- 11. Clark LR, Delano-Wood L, Lisbon DJ, et al. Are empirically- derived subtypes of mild cognitive impairment consistent ity, scientific achievement, and the creative with conventional subtypes? J Intl Neuropsychol Soc. arts. Others live longer with diminished 2013;19(6):1-11. 12. Ganguli M, Snitz BE, Saxton JA, et al. Outcomes of mild quality of life, their health compromised by cognitive impairment by definition: a population study. progressive neurodegenerative disease. Arch Neurol. 2011;68(6):761-767. Clinical Point 13. Bartley M, Bokde AL, Ewers M, et al. Subjective memory Age-associated memory change often complaints in community dwelling older people: the is exaggerated and feared by older adults influence of brain and psychopathology. Intl J Geriatr The worried well are Psychiatry. 2012;27(8):836-843. and, regrettably, is associated with inevi- anxious, although 14. Chung JC, Man DW. Self-appraised, informant-reported, table functional impairment and is seen as and objective memory and cognitive function in mild cognitive impairment. Dement Geriatr Cogn Disord. the stigma associated heralding the loss of autonomy. The wor- 2009;27(2):187-193. with cognitive ried well are anxious, although the stigma 15. Tsoi KK, Chan JY, Hirai HW, et al. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA decline may preclude associated with cognitive decline may pre- Intern Med. 2015;175(9):1450-1458. clude confiding their concerns. 16. American Geriatrics Society 2012 Beers Criteria Update confiding their Expert Panel. American Geriatrics Society updated Providers need the tools and acumen to Beers Criteria for potentially inappropriate medication concerns treat patients along an increasingly long use in older adults. J Am Geriatr Soc. 2012;60(4): 616-631. continuum of time, including conveyance 17. May BH, Yang AW, Zhang AL, et al. Chinese herbal of evidence-based encouragement toward medicine for mild cognitive impairment and age associated memory impairment: a review of randomised controlled optimal health and vitality. trials. Biogerontology. 2009;10(2):109-123. 18. Loef M, Walach H. The omega-6/omega-3 ratio and References dementia or cognitive decline: a systematic review on human studies and biological evidence. J Nutr Gerontol 1. Serby MJ, Yhap C, Landron EY. A study of herbal remedies Geriatr. 2013;32(1):1-23. for memory complaints. J Neuropsychiatry Clin Neurosci. 2010;22(3):345-347. 19. Solfrizzi VP, Panza F. Plant-based nutraceutical interventions against cognitive impairment and dementia: 2. Jaremka LM, Derry HM, Bornstein R, et al. Omega-3 meta-analytic evidence of efficacy of a standardized supplementation and loneliness-related memory problems: Gingko biloba extract. J Alzheimers Dis. 2015;43(2): secondary analyses of a randomized controlled trial. 605-611. Psychosom Med. 2014;76(8):650-658. 20. Institute of Medicine. Cognitive aging: progress in 3. Depp CA, Harmell A, Vania IV. Successful cognitive aging. understanding and opportunities for action. Washington, In: Pardon MC, Bondi MW, eds. Behavioral neurobiology of DC: National Academies Press; 2015. aging. New York, NY: Springer-Verlag; 2012:35-50. 21. Albert MS, DeKosky ST, Dickson D, et al. The diagnosis 4. Invik RJ, Malec JF, Smith GE, et al. Mayo’s older Americans of mild cognitive impairment due to Alzheimer’s disease: normative studies: WAIS-R, WMS-R, and AVLT norms for recommendations from the National Institute on Aging- ages 56 to 97. Clin Neuropsychol. 1992;6(suppl 1):1-104. Alzheimer’s Association workgroups on diagnostic 5. Powell DH, Whitla DK. Profiles in cognitive aging. Boston, guidelines for Alzheimer’s disease. Alzheimers Dement. MA: Harvard University Press; 1994. 2011;7(3):270-279.

Current Psychiatry 40 May 2016