Case Presentation. Cognition: changes with Normal Aging? Synonyms

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2 Case Presentation 78 yr old new patient presenting for new PCP after discharge from hospital stay Discharged 3 days ago Summary : admitted with new atrial fibrillation, with history of DM, CHF. In hospital, she was rate controlled with amiodarone and warfarin added for anticoagulation. Discharge summary is reviewed, she cannot tell you her medications or much about hospital stay She reports mild SOB and swelling in legs. PE: HR 100 irreg, sat 95% RA, BP good, LE edema 2+, mild crackles bilaterally on chest exam Pt did not pick up new medications: amiodarone and warfarin Line was too long at CVS What questions to ask? How have you been feeling since you left the hospital? Problems with breathing, sleep? How has your thinking been doing since leaving the hospital, do you feel groggy or not as sharp? Does anyone live with you? Is anyone here with you today? Do you get all your medications filled at CVS? (then you can call for information on refill history) Is it difficult to fill your prescriptions due to cost or getting to the pharmacy? Do you remember getting any information about needing to get laboratory studies to monitor your blood while taking warfarin? Have you had problems remembering things in the last few months? Ask informant changes in way they think or act in last 2 weeks, since New Years? Cognition: changes with Normal Aging? Normal cognitive issues associated with aging: Mild changes in memory and the rate of information processing Usually do not affect daily function. Knowledge or experience accumulated over time, remains stable. Abilities not based on experience or education tend to decline. Traditional ways of approaching solutions are maintained in older persons. Problems that have not been encountered during your life may take extra time to figure out. Synonyms Delirium Encephalopathy Metabolic / Toxic / Toxic Metabolic Some neurologists subgroup delirium as agitated state of encephalopathy but geriatricians and leading experts feel delirium and encephalopathy are synonyms Either has hypoactive or hyperactive subgroups skills normal aging.html Delirium is a Key Sign of Illness: Your Canary in the Coal Mine Frail elders may present with confusion as first sign of illness It is critical to understand normal baseline so that we do not miss signs of delirium or other neurologic emergencies. Delirium Acute onset Inattention May change level of alertness Fluctuating: minutes to hours REVERSIBLE vs. Gradual onset Memory disturbance Usually does not change alertness Fluctuating: none or days to weeks Irreversible Common: Delirium superimposed on 10

3 Delirium Screening Confusion Assessment Method (CAM) Feature 1: Acute change in mental status with a fluctuating course Feature 2: Inattention Feature 3: Disorganized thinking Feature 4: Altered level of consciousness Diagnosis of Delirium: requires presence of Features 1 and 2 and either 3 or 4. Inouye, SK 1990 Testing Attention Inattention is always present in delirium but not in dementia or chronic impairments alone. Attention as ability to stay on task Patients that look normal are often inattentive Formal methods: Digit Span: 5 forwards, 3 backwards Days of Week, Months of Year backwards Vigilance Letter A Test (if not speaking) Screening for Delirium CAM Delirium Screening - Disorganized Thinking Is patient disoriented, confused or delusional? May include: disorientation; jumbled thoughts; rambling or irrelevant conversation; hallucinations; delusions; inappropriate behavior; misidentification of people or objects Have you seen or heard anything that seems scary or unusual today? Delirium What does Delirium look like to us? Hyperactive Agitation Restlessness Removing tubes or lines Subtypes of Delirium Hypoactive Withdrawal Flat Affect Apathy Lethargy Decreased Responsiveness Mixed Patient fluctuates between Hyperactive and Hypoactive In Elderly Patients > 50% Cases are Hypoactive Top Causes of Delirium Medications Sedatives, Muscle Relaxants, Sedating Antihistamines, and Opioids Infection Delirium frequently first sign of sepsis Hypoxia / Hypercarbia Abnormal electrolytes Sodium, Calcium Workup History: time course of mental status changes association with other events New medications OTC, or Rx, illness Physical examination: Vital signs: HR, BP, temp, oxygen sat, glucose General medical: cardiac, pulmonary Neuro: new focal signs Slide used w permission of C Wasynski, Hartford Hospital

4 Back to New Patient IF she had positive screen for delirium Needs full laboratory panel & close supervision possible readmission Fortunately, she had a negative screen for delirium Good attention, alertness, daughter has not noted changes recently Daughter frustrated for last few years with mother losing items, repeating questions Doesn t seem to be taking care of herself well Needs evaluation for chronic cognitive impairment is a general term, a clinical syndrome of persistent intellectual deterioration that is severe enough to interfere with social or occupational functioning. Memory deficit may be main feature, other cognitive and personality disturbances are present to different degrees. DSM V Major Neurocognitive Disorders include dementia, must have significant cognitive decline in memory or another cognitive ability, that interferes with everyday life. Mild Neurocognitive Disorders include Mild Cognitive Impairment evidence of cognitive decline but not interfering with function. Ex., with more effort, still pay bills and take medications Executive Function Executive Function refers to the higher level cognitive skills used to control and coordinate other cognitive abilities and behaviors Dysfunction may include: Inability to apply consequences from past actions Difficulty with risk benefit decisions Difficulty with abstract concepts Difficulty in planning and initiation (getting started) Inability to multitask Loss of interest in activities Unawareness or denial that their behavior is a problem Trouble planning for the future Cognitive Assessment Screening for Mini Cog ( Cog.com) MOCA (Montreal Cognitive Assessment) AD8 Eight item Informant Interview Alzheimer s Association Professionals Tab (download free app) care professionals/cognitive tests patientassessment.asp#cognitive_screening Association with Frontal Lobe Problems, Association with Vascular/Small Vessel Ischemic Disease, Diabetes, Heart Failure Folstein MMSE has no measure of executive function Mini Cog Screen Screening Tool for 3 minutes Not Diagnosis Cochrane Review 2015 Older adults, multiple languages, ethnicities, & literacy levels tested ( Cog.com) Sensitivity 76 99%, Specificity 89 93%, Office staff can Administer Instructions Listen carefully, give patient 3 unrelated words & patient repeats back Suggested Banana, Sunrise, Chair or River, Nation, Finger Give large circle, ask patient to draw a clock Place the numbers and set time ten minutes after eleven 3 minute limit on clock draw task Ask patient to recall previous words Cog.com Mini Cog Scoring Algorithm 3 item recall = 0 Clock Draw Abnormal=0 Borson, 2000 Mini Cog 1pt per word recalled 3 item recall = 1 2 Clock Draw Normal=2 3 item recall = 3 No Score 4 5 Normal Range Score 3 Possible MCI Score <2 Possible

5 Patient Mini Cog Results Steps to Take MiniCog Score = 1 / 5 Recall one of three words Case Management Note Before Discharge- independent, no self-care needs identified, will discharge home without home-health Abnormal Mini-Cog Independent predictor of CHF readmissions -Circ Heart Fail. 2015;8:8 16. Executive Function and Working Memory Key Issues in self management of chronic illness Disclose concerns to patient and family if present that they may have some problems with thinking or memory, needs further investigation If family member not present, ask if they can come on follow up visit Discuss if they have noted any concerns or problems Review medical history and medications More In depth Cognitive Testing, Laboratory investigations and Imaging May Refer to Neurologist, or Geriatrician Determine if functional impairments and concerns of impaired capacity for living independently Evaluate Functional Status What supports could be helpful MoCA Montreal Cognitive Assessment MoCA is a brief cognitive test (approx. 10 minutes) designed to assist health care professionals in detecting mild cognitive impairment. It may be administered by anyone, but results should be interpreted by an individual with expertise in the cognitive field. In multiple languages, validated for adults 55 to 85 years old. It tests memory, attention, language, abstract, recall, orientation, as well as visuospatial skills by incorporating a shorter Trails B and a clock making task. The highest possible score is 30, with a score of 26 or above considered normal. Average MoCA score for MCI (Mild Cognitive Impairment) is 22 (range 19 25) Average MoCA score for Mild Alzheimer s is 16 (range 11 21) One point should be added for individuals with 12 years or fewer of formal education. A score of 18 or less should raise concerns about driving safety. Can she manage independently? (Ask Patient and Informant) Activities of Daily Living (ADL s) Ability to dress self Toilet manage continence Transfer from Bed to Chair / Ambulate Bathe Feed self Try This Series Hartford Institute for Geriatric Nursing Katz Scale ADL s, Lawton Scale IADL s Instrumental Activities of Daily Living (IADL s) Finances Transportation Meal preparation Shopping Performing light housework Using a telephone Medication management Can she manage independently? Capacity Evaluations Capacity for safe and independent living when concerns of safety and possible guardianship needs involves assessment of two types of capacity: Decision Making Capacity Ability to make a decision Executive Capacity Ability to carry out a decision, execute a plan Slide: Naik & Whitney, BCM 2012 Evaluation of Independent Living Skills Occupational Therapy Consults Independent Living Skills (ILS) evaluation KELS (Kohlman s Evaluation of Living Skills) Comprehensive Assessment of Decision making and Executive Capacity Referral to Neuropsychological Testing, Geriatrician, Neurologist Tools Available for Study MedEd Portal Geriatrics 2008 Naik Assessing Capacity in Suspected Cases Self Neglect

6 Back to Case MoCA Test Score 18 concerning for Physical Exam normal no evidence of movement disorders, gait abnormalities Laboratory Studies evidence of poor nutrition and not taking vitamin D supplement, low albumin Functional Assessment Independent in ADL s no need for nursing home or constant assistance Dependent in IADL s not functioning well in managing finances, managing medications, not keeping house well KELS Assessment able to recognize safety hazards in home, but unable to pay a bill and do simple calculations to manage checkbook Needs more support and assistance from family or paid caregivers She accepted assistance with managing bills and medications and housekeeping /meals Initiated Advanced Care Planning Health Care & Financial Proxies Summary Points Cognitive Impairment Evaluation Time Course Acute/Subacute vs Chronic vs Acute Superimposed on Chronic Delirium must be considered first a sign of severe illness Look for Medications and Medical Illness Yielding Confusion Evaluation for Chronic Cognitive Impairment should include Memory Ability to Learn new Information Executive Function Ability to Manage Complex Tasks / Decisions Functional Status Ability to Manage Issues in Daily Life Must have Functional Impairment for Diagnosis of Critical to place meaningful supports for patient well being Alertness and Attention Alertness and Attention are typically intact in patients with. Alertness and Attention are typically impaired in Delirium. Alertness patient may present with hyperactive or hypoactive levels of alertness Attention the ability to stay on task, to sustain attention Tested with Months of the Year Backwards, Days of the Week Backward, Digit Span tests, Spelling World Backwards Mini Cog Mini Cog is the best rapid screening tool to help understand his readmissions and his non compliance. Mini Cog tests Memory and Executive Function with Clock Draw Task Both are associated with Medication Compliance Executive Function is Necessary for complex regimens like CHF & DM Executive Dysfunction is Extremely Common & Associated with Small Vessel Ischemic Disease common in Cardiovascular disease and Diabetes If deficits are noted, increased supports could be put in place to support patient and improve compliance Resources Alzheimers Association Professionals Tab (download app) care professionals/cognitivetests patient assessment.asp#cognitive_screening American Geriatrics Society GeriatricCareOnline Driving Guide to Assessing and Counseling Older Drivers. guide to assessing andcounseling older drivers 3rd edition/b022/