Disclosures Delerium and Dementia Sadly, I still have nothing new to disclose since early this week John Engstrom, M.D. Professor of Neurology Using the ARS for this talk August 2018 MOCA reproduced at end of slides

Mental Status Assessment Screening Mental Status

• If the patient can give a completely • Orientation-time, place, person coherent history, then the mental status • Attention-Digit span forward (nl > 6-7) examination is probably normal • Language-repetition, naming, comprehend • If history suggests a cognitive problem, • Memory-Recall of 3 common objects at 5 then a methodical mental status exam minutes; if misses an answer give a prompt is necessary • Abstractions-Similarities and differences (e.g.-apple vs. orange; lake vs. river)

1 Q1: Which part of an abnormal mental status exam negates testing for memory? Screen Attention First A. Abstractions • Attention-requires input of numbers, immed 33% B. Attention span 28% recall, and verbal output of numbers – Everyone must remember a numerical sequence C. Orientation 22% 17% – Exceptions: deafness, ESL, no education D. Visual fields • Memory-input of objects, hold memory of objects for five minutes, then verbal recall • Screen attention first (or after orientation)

s n s n o ld io ti ie ct ta f a n al tr e u s ri is b O V A Attention span

Pathological Basis of Delerium: Delerium-Defining Features Impaired Attention • Inattention-malfunction cerebrum/brainstem • Poor attention-Digit span forward < 6-7 • Arousal and attention centers in the • Subacute onset brainstem (RAS) • Other cognitive abnl (e.g.-disorientation) • Bilateral cerebral regions that receive • Not explained by another neurologic dz sensory inputs, process and interpret • Evidence that the delirium is caused by a information, react to inputs, and result in “metabolic” disorder expressive or motor outputs in response

2 Delerium-Clinical Accompaniments Delerium-Practical Clinical Features • Fluctuation over minutes-hours-lethargy or • History provided by family, friends, or co- hyperactivity based on many observations workers who know the patient well • Vital signs – Establish pre-morbid mental baseline – Tachycardia/hypersympathetic state-infection, substance use, substance withdrawal – Review medications and “substances” – New hypertension/hypotension – Review medical comorbidities – Fever-risk of infection • Initial test of choice if often to call or interview someone who knows history • Meningismus-Resistance to neck flexion • Exam features above normal in dementia

Q2: Which neuro exam finding helps Neurologic exam findings that help distinguish delerium from dementia? distinguish delerium from dementia A. Fine, postural tremor • Fine postural tremor-Acute/subacute onset- B. Asterixis 73% often sign of hypersympathetic state C. Myoclonus • Asterixis-Loss of tone with wrist extension D. Focal neurol findings – Classic with renal or hepatic failure – Seen in many metabolic conditions (hemiparesis) 8% 8% 6% 4% E. All of the above • Myoclonus-sudden discharge of motor cells r is . e o ix .. v m r o e te s b r s g a producing an asymmetric jerk-metabolic t l A in e ra d th u Myoclonus in f t f o os l ll ro , p A eu ne n Fi l ca o F

3 Delerium-Metabolic Causes/Evaluation-I Delerium-Metab Causes/Evaluation-II

Metabolic Causes Laboratory Studies Metabolic Causes Laboratory Studies Hypo/hypernatremia Na Substance use/withdrawal Toxicology screen Renal failure BUN, Cr Alcohol intox/withdrawal Alcohol level Medication overuse/withdrawal Review meds; consider drug level Hypoxia, ischemia PO2 Hypercalcemia, Hyper Mg Calcium, magnesium Hypo/hyperglycemia Glucose Hyperphosphatemia Phosphate Hypo/hyperthyroidism, Thyroid function tests Hepatic Failure LFTs; ammonia

Delerium – Common Causes and Pitfalls in the Outpatient Evaluation Assessment of Delerium Infectious Causes Laboratory Studies • The delerium is a post-ictal state and the Sepsis Cultures, CBC, Chest X-Ray, UA intermittent seizures are not obvious Meningitis Lumbar puncture (LP), – Get more history from observers re poss sz Cultures, CBC, CXR, UA Neurologic Causes – Patient has pre-existing brain dz (e.g.-stroke)

Subarachnoid hemorrhage Head CT, LP • The patient is malnourished and has

Cerebral infarction Head CT or MRI thiamine deficiency (e.g.-Wernicke’s) Seizures, post-ictal state Consider head CT/MRI, EEG • Neuro exam in uncooperative patient?

4 Neuro Exam for Focality in the Delerium Neuro Exam for Focality in the (Uncooperative) Patient Delerium (Uncooperative) Patient • Cranial Nerve Examination -Facial asymmetry on command or with grimace • Motor-grade best strength; note asymmetry -Lower 2/3 face-upper motor neuron – Moves arms/legs symmetrically vs. gravity? -Entire face-facial nerve or brainstem – Able to stand with/without assistance? • Brainstem reflexes – Able to walk with/without assistance – Pupils-midbrain: asymmetric, reactive? – If unable to stand/walk-due to focal weakness, focal sensory loss, or focal leg imbalance – Corneals-pons: asymmetric, reactive? – Breathing/pulse-medulla: normal/abnormal • Sensory-Symmetry of withdrawal of arms or legs to pain stimulus of equal intensity

Q3: What is Not Routinely Useful in More Pitfalls in the Outpatient Managing Improving Delerium after Assessment of Delerium Hospital Discharge • Delerium dx as depression in setting of somnolence or reduced responsiveness A. Use of anti-psychotic to control 92% behavior – Use vitals, gen exam, neurologic signs as above B. Use of prescribed eyewear – EEG nl depression, diffusely slow in delerium C. Use of prescribed hearing aids • An undiagnosed neurodegenerative disease D. Frequent reorientation of the patient in is already present (e.g.-AD) a familiar environment 1% 2% 4% 2%

r a .. .. E. Encourage falling asleep on a .. e . . . ng o – Slower recovery from delerium/post-ictal state o ew i n t y ar io ic e e t t d h ta ho e d n schedule c ib e ie y r ib r s sc r o -p e sc re – Establish baseline mental function ti r e t n p r a f p en f o f u o e o q s e e se U s r U U F Encourage falling asleep ..

5 Non-Pharmacologic Prevention Delerium-Conclusions and Management of Delerium • Especially at hospital discharge to home • If the patient can give a completely coherent • Frequent reorientation of the patient history, then the mental status examination • Using eyeglasses and hearing aids is almost always normal • Early PT/mobiliz-restore baseline function • Initial assessment of suspected delerium should include: • Sleep hygiene – Establish pre-morbid mental baseline – Prevent daytime naps – Rev medication or substance use and disuse – Encourage falling asleep on a schedule – Review medical comorbidities

Delerium-Conclusions

• Screen attention first • Have your list of screening labs for delerium at the ready • Beware of outpt traps-baseline depression, neurodegen dz, post-ictal state, thiamine def • Non-pharmacologic measures are proven to enhance mental functioning in delerium pts

6 Dementia Goals of Dementia Assessment

• Dementia–a decline in cognition interfering with • Establish the presence/absence of dementia daily function and independence • Understand areas of cognitive impairment – No disturbance of consciousness and the severity of the impairment – Best assessed as an outpatient • Impairment in at least one cognitive domain: • Understand the functional consequences of – Memory and learning areas of cognitive impairment/preservation – Language • Determine the likely etiology – Executive function-judgment, planning, reasoning – Social cognition, perceptual-motor function

Approach to Patient/Family: Visit One Q4: Which one of the following is important in a dementia history? • Best history from pt and family or sig other • General/neuro exams and limited lab testing A. Recent memory function 96% • May need separate input from others if patient is defensive or argumentative B. Executive function C. Language • Patients often lack insight into the problem D. Assessing impact of cognition on – Denial or excuses-remembering something is safety risks 0% 0% 0% 4% not important anymore or too old for an activity

E. All of the above n n ... e io io n ov t t g b nc nc o a u u c e – Social and interpersonal skills preserved early f f Language f h y e o t r iv ct f o t a o m u p ll e c m A m xe i t E g n in ce ss e e R ss A

7 Dementia History-Memory Dementia History-Language

• Age Associated Memory Challenges • Expressive aphasia-Reduced volume of – Forgetting words or names language but perservation of content words – Slowing of cognitive processing • Paraphasic errors-substituting one word for – Increased difficulty with multitasking another that sounds similar but has a different meaning (e.g.-cow for car) • Worrisome Memory Deficits – Forgetting recent conversations • Neologisms-word sounds that are not words – Forgetting appointments and plans • Receptive aphasia-word salad, nonsensical – Not paying bills on time words, paraphasic errors, neologisms

Dementia History-Functional Dementia History-Executive Function Assessment • Performing complex tasks • Basic ADLs preserved until late-bathing, • Initiating plans eating, dressing, grooming, continence • Following multistep directions-using a • Safety risks-driving, climbing stairs, falling remote control or computer or near falls, car accidents, getting lost in • Visuospatial deficits-difficulty using hands familiar surroundings for a complex task or misjudging the • Food preparation, household maintenance position of objects in space • Keeping appointments, managing finances

8 Dementia-Role of Comorbidities Screening Mental Status + Physical/Psychosocial factors? • Attention-Digit span forward (nl > 6-7) • Special senses-Diminished hearing or vision • Orientation-time, place, person • Conditions limiting mobility-CHF, hip • Language (aphasia testing)-repetition, arthritis, balance (medications, alcohol) naming, comprehension • Physical • Memory-Recall of 3 common objects at 5 – Steps into or inside house; stairs in home? minutes; if misses an answer give a prompt – Is the home filled with debris or tidy? • Abstractions-Similarities and differences • Psychological state-home alone; social (e.g.-apple vs. orange; lake vs. river) function; help with challenging home tasks

Cognitive Testing-the MoCA Mild Cognitive Impairment (MCI) • 30 point test-takes 10 minutes to administer • Normal score > 25; adjust education level • Cognitive limitations severe enough to be noticed by patient or others • Improvement detecting MCI (mild cognitive impairment) or AD from MMSE – Not interfering with ADLs – Higher risk of devel AD; road to biomarker? • Assesses memory, executive function, – Most often recent memory, occ exec function language, visuospatial ability – Some pts never get worse or improve • When abnl may suggest AD but other – Advanced directives structural neurologic dz must be considered • MOCA scores less than 26 sensitive and • www.mocatest.org electronic copy of test specific for AD and MCI

9 Dementia-Motor/Sensory Exam Dementia-Cranial Nerve Exam • Rigidity or cogwheeling tone-Parkinsonism • Cranial nerve palsy unexpected in dementia • Spasticity/UMN weakness-Descending – Diplopia/impaired eye movts (CN III, IV, or motor tracts (stroke, brain tumor, MS) VI)-brainstem • Diffuse LMN Weakness-motor neuron dz – Weakness lower 2/3 face (CNS) or entire face (CN VII palsy or brainstem) • Unilateral ataxia limb-cerebellum – Difficulty swallowing, aspiration, voice (CN X) • Gait ataxia-cerebellum, sensory loss, severe – Abnormal brainstem reflexes (pupils, corneals) focal weakness – Any other CN palsy-much less common • Unilat sensory loss-ascending sensory tracts

Dementia-Lab Assessment Q5: Which statement regarding • B12, TSH, BUN, Cr, CBC Alzheimer’s disease (AD) is false? • Consider RPR, HIV, methylmalonic acid A. Most common form of dementia 45% • Brain MRI-subdural hematoma, strokes, B. Prevalence is constant in the population white matter disease, microhemorrhages after age 70 26% 18% • Amyloid PET imaging-amyloid lesion C. Uncommon before age 60 11% burden and distribution in brain D. Impaired recent memory is the most – No routine clinical use-diagnosis of AD vs. common deficit at presentation . 0 .. . .. 6 y .. in e r f t ag o other dementias, prognosis, research biomarker o n m a re e rm st o m o n f t f o e n n c b e o is n c m o re ce m m n ed o e om ir c al c a st v n p o re U M P Im

10 AD-Epidemiology Mild-Mod AD-Donepezil Rx • Genetic forms are uncommon, except in patients with early age of onset • Depletion of cortical choline acetyl transferase leads to decreased acetylcholine • Prevalence increases with age-up to 40% of and impaired cholinergic function patients over the age of 90 years have AD – Donepezil (rivastigmine, galantamine) • “The Silent, Slow Epidemic”-As life – Donepezil 5 mg po/day x 4 weeks, then 10 po expectancy continues to increase the – Small benefit MMSE scores incidence of AD will skyrocket, especially – Contraind-heart block, SSS, bradycardia in developing countries – Diarrhea, nausea, emesis transient in 20% • Quality of life decried by family members – Effect washes out when drug discontinued

Mod-Sev AD-Memantine Rx AD-Other Drug Rx • Memantine-NMDA receptor antagonist – Poss Neuroprotective-Blocks pathologic • Vitamin E-2000 U/day-mixed results stimulation NMDA receptors (vasc dem, AD) • Patients and families will ask you about – Trials show reduced rates of deterioration on what they read on the internet clinical efficacy scales and possibly useful as • No role for selegiline, estrogen replacement, add-on to donepezil in moderate to severe AD antiinflammatory drugs, ginkgo biloba, – Infreq side effects-HA, dizziness, confusion statins, vitamin B, omega-3 fatty acids – 5 mg/day x 1 week, then increase by 5 mg/wk until taking 10 mg bid

11 Dementia Management Issues Dementia-Other Considerations • Nutrition-Malnutrition common; oral supplements may be useful • Control risk factors for cardiovascular • Exercise-slows functional decline disease and stroke – No clear effect on cognitive decline • If parkinsonism present, avoid Sinemet – Less depression • Try to manage disruptive behaviors without • Occup Rx-individual sessions training anti-psychotics pts/caregivers on coping strategies and use • Attend to family caregivers-how are they of aids improved function at 3 months avoiding burnout?

Dementia-Quality of Life and Survival Dementia and Sleep Disturbance • Mean survival if dx at age 65 is 9 years • Mean survival if dx at age 90 is 3 years • Insomnia and irregular sleep-wake rhythm • Prognostication affects eligibility for • Restless legs syndrome hospice Medicare benefit-only estimated • Periodic limb movements of sleep survival of < 6 months are eligible • REM sleep disorder-acting out dreams • Palliative care access should not be guided • Obstructive sleep apnea by prognosis but dz trajectory and family/pt • Excessive daytime somnolence wishes for comfort and quality of life • Refer sleep center consultation/sleep study

12 Approach to Patient/Family: Visit Two Dementia Conclusions-I • Discuss test results and what they mean • Describe working dx + etiology (if known) • Dementia is a decline in cognition interfer- • Encourage activities patient still enjoys ing with daily function and independence • Discuss management • The most common domains of impairment – ADLs including driving, finances, safety risks are recent memory, language, and executive function – Drug and non-drug management strategies – Community and social resources • Gen/neurologic exams establish presence or – Quality of life and advanced directives absence of other medical/neurologic contributions to altered mental status

Dementia Conclusions-II

• Approved drug treatments for Alzheimer’s disease are of modest benefit • Personalize care by addressing safety risks, management of ADLs, minimizing treatable medical problems (e.g.-hearing loss, CHF) • Address quality of life issues with the patient and caregivers (advanced directives and continue activities that give pleasure)

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