Toolkit for Detection of Dementia. And. Safe DR(ive)

Transcription

1 Toolkit for Detection of Dementia And Safe DR(ive) Sudbury, Ontario October, 2007 Dr. J.K. Le Clair

2 Tools to Promote Common Language and Approach Physical: 5D s 1. Delirium 2. Disease 3. Drugs 4. Discomfort 5. Disability Social Social network, Life story Cultural heritage Pain Tool CAM 4M I Watch Death Mini Cog Clock Folstein Intellectual: 7 A s Amnesia, Aphasia, Apathy, Agnosia, Apraxia, Anosognosia, Altered Perception Environment Over/under stimulation Relocation Change in routine Noise, lighting, colours Understand Reflect Action Follow-up FAST GDS Capabilities ADLs IADLs Mood: Cornell/GDS Behaviour: DOS, Cohen Mansfield, 7Ds Psychosis: 7Ds, DOS Emotional: 4D s 1. Disorder Adjustment 2. Disorders of Mood 3. Delusional 4. Disorders of Personality - 2 -

3 1. What is the Confusion Assessment Method? Confusion Assessment Method (CAM) The CAM is a tool to assist with the identification of individuals who may be suffering from delirium/acute confusional state; it is particularly intended to be used with individuals who are at high risk for developing delirium. It is quick and can be done by non-psychiatric clinicians. It is not meant to be a diagnostic tool. The diagnosis of delirium requires: a comprehensive review of an individual's cognitive status and medical history, a physical examination, laboratory investigations, and a medication review. The ability of the CAM to identify delirium among those with marked dementia has been identified as a concern among some researchers. Other researchers, however, have suggested that the CAM can be a useful screening tool for delirium even among those with dementia if extra attention is given during the screening process. 2. How do we administer the CAM? Information is gathered from an interview with the person and from discussions with caregivers and family members, a review of the person's chart, as well as observations made by the interviewer. All of this information is used to make a determination about each feature in the delirium algorithm. Please note: it is not likely that you will administer and score the CAM but rather you use it as a framework for assessing the person. If in using the framework you identify a number of indications of delirium (particularly the 4 listed in the algorithm below) you should maintain a high index of suspicion and raise the possibility of a delirium to the care team. 3. What are the features of the CAM? The CAM has two parts, a nine-item questionnaire and a diagnostic algorithm for delirium. 1. Nine-item Questionnaire: The questions focus on features of delirium, all of which are part of the DSM-III-R diagnostic criteria for delirium. It can be used as a rating scale, but also includes open-ended questions if the person administering the scale would like to collect more detailed clinical information. 2. Diagnostic Algorithm for Suspecting Delirium: The algorithm includes four key features of delirium: 1. acute onset and fluctuating course 2. inattention 3. disorganized thinking 4. altered level of consciousness - alert (normal) - vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily) - lethargic (drowsy, easily aroused) - stupor (difficult to arouse) - coma (unarousable) - uncertain - 3 -

4 Delirium should be suspected if features (1) and (2) and either (3) or (4) are present. In such cases, further investigation, if warranted, to confirm a diagnosis of delirium. Delirium can be a life-threatening event. Remember the C s of Acute Confusion (Delirium): Change in short period Communication changes by caregiver Capabilities change over short time period - 4 -

5 1. Acute Onset 5. Disorientation Was the person disoriented at any time during the interview, such as thinking that she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? 6. Memory Impairment The Confusion Assessment Method Instrument (CAM) Is there evidence of an acute change in mental status from the person's baseline? 2. Inattention* A. Did the person have difficulty focusing attention, e.g., being easily distracted, or having difficulty keeping track of what was being said? not present at any time during interview present at some time during interview, but in mild form present at some time during interview, in marked form uncertain B. (If present or abnormal) Did this behaviour fluctuate during the interview, that is, does it tend to come and go or increase and decrease in severity? yes no uncertain not applicable C. (If present or abnormal) Please describe this behaviour. 3. Disorganized Thinking Was the person's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Altered Level of Consciousness Overall, how would you rate this person's level of consciousness? alert (normal) vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily) lethargic (drowsy, easily aroused) stupor (difficult to arouse) coma (unarousable) uncertain Did the person demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? - 5 -

6 7. Perceptual Disturbances Did the person have any evidence of perceptual disturbances, for example, hallucinations, illusions, or misinterpretations (such as thinking something was moving when it was not)? 8. a. Psychomotor Agitation At any time during the interview, did the person have an unusually increased level of motor activity, such as restlessness, picking at bedclothes, tapping fingers, or making frequent sudden changes of position? b. Psychomotor Retardation At any time during the interview, did the person have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a long time, or moving very slowly? 9. Altered Sleep-wake Cycle Did the person have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night? *The questions listed under this topic were repeated for each topic where applicable. Please note, The CAM Training Manual and Coding Guide is available on line at: Confusion%20Assessment%20Method%22 Diagnostic Algorithm for Suspecting Delirium The Algorithm includes four key features of delirium: 1. acute onset and fluctuating course 2. inattention 3. disorganized thinking 4. altered level of consciousness alert (normal) vigilant (hyperalert, overly sensitive to environemental stimuli, startled very easily) lethargic (drowsy, easily aroused stupor (difficult to arouse) coma (unarousable) uncertain Delirium should be suspected if features 1 and 2 and either 3 or 4 are present In such cases, further investigation if warranted to confirm a diagnosis of delirium

7 Searching for the Cause of Delirium Delirium Symptom list from CAM Sudden change in mental status Change in behaviour which fluctuates from normal to abnormal over a 24 hour period Difficulty in focusing attention Disorganized thinking and/or altered level of consciousness Begin your assessment with the highest probable risk for your client s situation? Drug Toxicity a. On more than six medications, especially: anticonvulsants barbiturates histamine H2 antagonist thiazide diuretics insulin/hypoglycemic agent anticholinergics antipsychotics antidepressants benzodiazepines cardiac glycosides narcotics anesthetic b. Receiving a medication for more than 5 years c. Age 75 or older d. Running drug levels beyond or at the high end of therapeutic range? Changes in Chronic Illness Physical and psychosocial assessment reveals exacerbation* of previously diagnosed condition, such as: Diabetes mellitus Hypo/hypertension COPD ASHD Cerebrovascular insufficiency Cancer Alzheimer disease Depression Pain Alcohol Hypoxia Request appropriate diagnostic tests? New Disease Process a) Cardio and cerebrovascular conditions 1. silent MI 2. TIA/CVA 3. CHF or b) GI conditions, GI bleed, if evidence of daily use of NSAIDS or steroids or c) Other medical conditions 1. hypo/hyperglycemia 2. hypo/hyperthyroidism 3. electrolyte imbalance 4. cancer 5. neurological conditions (e.g. normal pressure hydrocephalus) 6. pain 7. alcohol Request appropriate diagnostic tests (e.g. PE, pulse oximetry, EKG, hemoglobin and hematocrit, chemistry screen, electrolytes, TSH, specific test for cancer detection, CAT) or d) Psychiatric conditions, especially if evidence of family history Request psychiatric evaluation, dementia work up Adapted from: APA,1987 Inouye, SK, et.al. (1990). Clarifying Confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine, 113: Inouye, SK. (2006). Delirium in older persons. The New England Journal of Medicine, 354(11), Henry, M. (2002). Descending into delirium. ANJ, 102(3), p Delirium in the Older Person: A Medical Emergency. (2006). VIHA. Tools/Search for cause - V 1.1? Infection a. Elevation in baseline temperature, even less than C rectally b. History of lower respiratory infection or UTI more than twice per year c. History of any chronic infection d. Recent episode of falling Request appropriate diagnostic tests Most common: urinalysis, chest x-ray, sputum cultures? Elimination Problems a. Urinary problems 1) history of incontinence, retention, or indwelling catheter 2) signs or symptoms of dehydration, tenting, increased BUN 3) decreased urinary output 4) taking anticholinergic medication 5) abdominal distention b. Gastrointestinal problems 1) immobility for more than 1 day in persons previously mobile 2) abdominal distention 3) decreased number of bowel movements or constipated stool 4) decreased fluid intake dehydration 5) decreased food intake, especially bulk Request catheterization for postvoid residual and/or incontinence assessment, or both? Sleep Disturbance a) Assess baseline normal sleep pattern b) Identify causes of sleep disturbance, e.g. medications pain environment? Post Operative a) reaction to anesthetic b) analgesia c) opioids / anticholinergics Ensure elder friendly a) Inactivity b) Restraint Mobilize early? Psychosocial / Environmental a) grief, evident losses (family members, significant life items) b) alteration in personal space c) been recently admitted d) increase or decrease in sensory stimulation e) interpersonal difficulties f) dementia Initiate nursing management by environmental manipulation: a) low stimulation b) make environment user-friendly labels, pictures put orienting items in room c) provide client counselling or group work - 7 -

8 MEDICINES Causes for Delirium Checklist Prescribed Medication : New ones Yes No : Withdrawn recently Yes No : Syndrome of sudden compliance Yes No : Adherence problems (mixing up meds) Yes No Over-the-Counter Meds Yes No (Remember over the fence) Substance Misuse Alcohol Yes No Others Yes No MEDICAL ILLNESS Myocardial infarction Yes No Respiratory Yes No Hypoxia Yes No Previous and current chronic illnesses Yes No MICROBIALS Infection, i.e., UTI Yes No METABOLIC Hydration Yes No Others Yes No Remember! Usually multiple causes. Remember! One cause, then another. Remember! Many times, it is delirium and no cause is found

9 Dementia Risk Calculator The recognition of cognitive impairment and the diagnosis of dementia are often delayed for up to 2 to 3 years from the time of the first symptoms. It is therefore useful to use a brief screening test for cognitive impairment in those elderly who are at high risk (ε 15%). The dementia risk calculator is based on age, vascular risk factors, and family history of dementia (the doubling rule) and gives a rough approximation of possible risk for cognitive impairment. Age % < RISK DOUBLES WITH EVERY FIVE YEARS Risk = % (Age) Family history (Risk doubles for each first-degree relative) Mother Father X 1 (No family history) Brother Risk = X 2 (1 relative) Risk = % Sister X 4 (2 relatives) (Age + family history) Vascular risk factors (VRFs) (Risk doubles for each vascular risk factor) Atrial fibrillation Diabetes Heart disease (MI/CAD) Hyperlipidemia X 1 (No VRFs) Risk = % Hypertension Risk = X 2 (1 VRF) (Age + family history Smoking X4 (2 VRFs) + vascular risk factors) Stroke Obesity Overall risk % A risk 15% is high risk for cognitive impairment and justifies full cognitive assessment. The higher the risk of cognitive impairment by using the dementia risk calculator, the higher the chance that screening tests will reflect true positives rather than false positives. References: 1. Gauthier S, Panisset M, Nalbantoglu J, Poirier J. Alzheimer s disease: current knowledge, management and research. CMAJ 1997;157: de la Torre JC. Is Alzheimer s disease a neurodegenerative or a vascular disorder? Data, dogma, and dialectics. Lancet Neurol 2004;3: (Developed by and used with the permission of Dr. W. Dalziel) - 9 -

10 Checklist for the Practitioner Detecting Dementia Checklists for Providers High Risk Population for Dementia Family history of dementia and family history, particularly, of early onset dementia Age greater than 80 (Prevalence 20%) Consider key vulnerable populations (Parkinson s, AIDS, Huntington s) History of delirium/post depression, particularly late onset depression and depression associated with cognitive changes Post stroke, 30% risk of dementia in 3 months Those with multiple vascular risk factors MCI, Particularly amnestic MCI (Note conversion rate 15% year up to 45%) Red Flags; Changes in Thinking, Feeling, and Behaving (ABC) Affect/Emotion Irritability Apathy Emotional lability Anxiety Loss of Initiative Marital conflict *Personality Change Depression Somatization Behaviour Difficulty performing familiar task (change is key) Judgement/disinhibition Lost in unfamiliar environments Restricting, increasing activity IADL (SHAFT): What I do through the day, i.e. Shop, Household tasks, Accounting, Food preparation, Transportation Cognition Forgetting more than usual Excuses, near misses, confabulation Communication problems (word finding) Delusion of stealing Perseveration (going over the same content)

11 Dementia Risk Calculator AGE < % Family history (Risk doubles for each first degree relative) Mother Father X 1 (no family history) Risk = Brother X 2 (1 relative) Sister X 4 (2 relatives) Vascular risk factors (Risk doubles for each vascular risk factor) Atrial Fibrillation Diabetes Heart Disease (MI/CAD) Hyperlipidemia Hypertension Smoking Stroke Obesity Risk = X 1 (no vascular risk factors) X 2 (1 vascular risk factor) X 4 (2 vascular risk factor2) Risk = % (age) Risk = % (age + family history) Risk = % (age + family history + vascular risk factors) Overall risk = %

12 Checklist for Practitioner; Interactions with Family Physician Practice Frequent phone calls (family) or no contact Poor historians (vague) Poor adherence to Meds/Instruction Appearance/Hygiene Word finding Appointments-- no show, wrong time Head turning sign, i.e., when asking the person questions they look to family for answers Family presents with concerns, not necessarily the patient Remember - -it is a change that counts (Adapted from Champlain Dementia Network Toolkit; Ottawa, Canada) Checklist for the Practitioner, Caregiver Questions Difficulty performing familiar tasks Problems with language Disorientation of time and place Poor/Decreased judgment Problems with abstract thinking Misplacing things; change in mood/behaviour Change in personality Memory loss affecting day-to-day activities Repetition Remember -- Change is Key (Adapted From Champlain Dementia Network Toolkit; Ottawa, Canada)

13 10 Behavioural Flags for Healthcare Professionals Frequent phone calls, visits to doctor or emergency room Poor historian, vague, seems off, repetitive questions and/or stories Poor understanding or compliance with medications and/or instructions Changes in appearance/mood/personality/behaviour Word-finding problems / decreased social interaction Appointments missing, coming on the wrong day Confusion: postsurgery, with illness or with new medications Loss of ADLs, weight loss, dwindles, failure to thrive Driving: accident/problems/tickets / family concerns Head-turning sign (turning to caregiver for answers)

14 Mini Cog Plus - Probing all Lobes It is important to have sensitive tests that will reveal the functioning of the major parts of the brain. Parietal Visuospatial Clock Occipital Visual Memory Frontal -Word Generation -Paired Associate Learning Temporal (Hippocampal) Recall - see visual clues - provide to person for sec - take away - ask them to draw what they saw (see attached)

15 The Mini Cog; Components, Instructions, and Relevance A. What year is this? (O.R. 37) B. Repeat these 3 words: House, Tree, Car (Registration) C. Name as many 4 legged animals as you can in 1 min (Should get approximately 12-15; if <15, 20X odds ratio of cognitive impairment) o Observe for (1) categorization and (2) perservation o Recall the 3 words (2/3 Normal) (O.R. < 2/3 approx. 3X) D. Clock; Provide the Circle (O.R. 24) 1. Make it look like a clock 2. If wrong, ask patient if it is correct. If not, allow patient to do again, instructing him or her to concentrate. Put numbers on exactly where they should be. 3. Ask patient to make the clock; say 10 after 11. If unable to do so, ask patient to put the hand on the clock for 10 after 11. E. Visual Memory Tasks. Present visual cue. Tell patient that you want him or her to remember the diagram and that you will be removing it and asking him or her to draw what he or she says

16 Interpretation of Mini Cog Plus Components Any of the following is a positive screen indicating the need for a full cognitive assessment: 1. 0 or 1 on 3-item recall (2 of 3 is not a positive screen) on animal naming is a positive screen 10 animals suggests dementia 10 to 14 suggests mild cognitive impairment (MCI) 3. Abnormal clock drawing Test Negative Screen Positive Screen Odds Ratio 3-item recall 2 or 3 words recalled 0 or 1 word recalled 3.1 times Animal naming 15 animals < 15 animals 20.2 times Clock drawing Normal clock or only minor irregularities in number placement with hands in the correct position Abnormal clock: hand and/or number placement 24 times The odds ratio is the number of times more likely it is for a person who has screened positive to have cognitive impairment versus someone who has screened negative. For example, if someone names 12 animals, they are 20.2 times more likely to have cognitive impairment than someone who names 18 animals. References: 1. Siu, AL. Screening for dementia and investigating its causes. Ann Intern Med 1991;115: Canning SJ, Leach L, Stuss D, Ngo L, Black SE. Diagnostic utility of abbreviated fluency measures in Alzheimer disease and vascular dementia. Neurology 2004;62:

17 Mini Cog Plus Form Apply the P.I.E.C.E.S. Approach Patient Name Date

18 Family Physician Form for Mini Cog For Primary Care Patient Name: What year is it (O.R. 37) Registration: House (0-1; O.R. 3:1) Tree Car Date Completed: Animal 4 legged in 1 min (N) 15 (<15 O.R. 20.2) Recall House Tree Car Spontaneous Cueing 1/3 (3X O.R.) Clock (See attached) (O.R. 24) Visual Memory Cue 1 Cue

19 Date Patient s Name Sample

20 Date Patient s Name Sample

21 Visual Memory (1) Visual Cue 1 Instructions: -Provide visual for 30 seconds then remove -Ask patient to draw what he or she saw

22 Date of Assessment Patient s Name Sample 1 Visual (1) Cue Response by Patient

23 Visual Memory (2)

24 Date of Assessment Patient s Name Sample 2 Visual (2) Cue Response by Patient

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30 Folstein Mini-Mental State Examination (MMSE) The Test The MMSE was developed 30 years ago as a rapid screening test for cognitive function. It emphasizes the typical changes seen in Alzheimer s disease (memory/orientation) as opposed to the early changes seen in the non-alzheimer s dementias (vascular, Lewy body, frontotemporal which are: executive function problems - frontal lobe: putting the hands on the clock, animal naming, Trails A and B which test SOAP Strategizing, Organizing, Abstract thinking, Planning). Strengths: Widely used, short (7 minutes), tests memory, orientation, naming, visuospatial, and attention. Weaknesses: Focuses on few domains (little visuospatial, no executive function) Poor at upper end of cognitive ability (ie, poor discrimination of normal vs MCI vs early dementia) Cut-off norms require adjustments based on the patient s age and especially education particularly with a less than grade nine education The MMSE is much more suitable to assess domains affected by Alzheimer s disease than by non-alzheimer s dementias Interpretation A score < 24 is suggestive of cognitive impairment/dementia. Serial 7s vs spelling world backwards: The instructions call for the use of serial 7s unless the person refuses, in which case spelling world backwards is a substitute. Alternatively, both tests can be done and recorded separately. Typically, patients score 1 to 2 points better with spelling world backwards. Based on the person s history and functional issues, you may expect a certain MMSE (e.g. 17 to 18), but if the person scores much higher (e.g, 22 to 23 or more), suspect non-alzheimer s dementia. This is because the MMSE does not test the common problem areas seen in the non- Alzheimer s dementias (executive function / visuospatial). In this situation, the MOCA is a much superior test. Age Mean MMSE Scores Years of Education College Reference: 1. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA 1993;269:

31 The Self Test Name: Date : Side 1 You may get help with instructions ONLY. Instructions: 1. In the space below, please draw the face of a clock and put the numbers in the correct positions. Now draw in the hands at ten minutes after eleven. 2. Remember these words (Take a few minutes to commit them to memory) House Story Judgment 3. Turn page over and keep it on Side

32 Side 2 4. Write down the name of TEN animals. 5. What are the three words you were asked to remember? 6. What is the year? What is the month? What is the day of the week? Thanks, you are finished!

33 Safety and Alzheimer s and Related Dementia Functional Evaluation Driving Review SAFE - DR Driving Assessment and Package

34 SAFE-DR Dementia Drive Assessment Summary Date: Re-appt 4-6 mos: Type of Dementia: Severity of Dementia: Safe Unsafe Specialized Assess Road Test If unsafe Letter to Ministry Letter to Person/Family Potential Problem Areas OK Concerns Capabilities IADL Multiple, Probably unsafe ADL: if ADL due to dementia, probably unsafe Physical Medication, Substance Vision, Hearing Mobility, Reaction Time (Ruler Test) Emotional Insight Judgement Emotional lability/ Impulsivity Intellectual Type of Dementia Lewy Body Frontal significant visuospatial Folstein MoCA Trail A, B Clock Questions: Patient Score: Score: A: B: Family Adapted from Dr. Dalziel

35 Driving Assessment (Top 10) 1. Driving Record Concern Yes No Reported and by whom 2. Questions For Patient Yes No Any changes in driving skills Any accidents, near misses, tickets Have you restricted your driving Other drivers irritated 3. Questions for Family Yes No Do you feel uncomfortable driving with the person Has the person had any near misses, accidents tickets Has the person restricted his/her driving Would you be concerned if the grandchildren were alone with the person Environmental scan (garage, poles, car dents) Family drive test recommendable 4. Vision/Hearing Abnormal Normal Vision Hearing 5. Reaction Time/Mobility Ruler Test R L Head turning ability Mobility (stop test) Adapted from Dr. Dalziel

36 6. Medications/Substances Yes No Concern Adapted from Dr. Dalziel Psychotropics Over the counter Alcohol Medical drugs 7. Emotion/Behaviour of Concern (Under Stress or Multitasking) Yes No Impulsivity Agitation Hallucination Depression with attention, concentration problems Apathy Manic-like Symptoms 8. Type of Dementia (concern necessary) Yes No Lewy Body Frontal Lobe Vascular with Frontal/Executive, Visuospatial Other Dementia

37 9. Cognitive Tests Abnormal Normal Folstein Score MoCA Score Mini Cog Plus Trail Making A Clock Arrow (Note <20 unsafe) Trail B 10. Function IADL, ADL Ability Impaired Yes No IADL SHAFT Shopping Household Accounting Food Preparation Transportation (other) (Taking Meds) (Telephone Use) ADL DEATH Dressing Eating Ambulation Transfer Hygiene Yes No Summation Unsafe -- See checklist Safe to drive (Re-test 4-6 months) Road Test Recommended Specialized Assessment

38 Adapted from Dr. Dalziel A Dementia Education Physician Teaching (A.D.E.P.T) Program for Family Physicians The Mini-Mental State Examination (MMSE) and Driving Capacity Conceptually: Only patients with dementia severity of very mild are potentially safe to drive. The risk of a crash increases eight times with mild dementia (50% serious crash rate within 2 years of diagnosis). Driving risk correlates better with instrumental ADL impairment than MMSE score. Remember that the MMSE must be adjusted for age and education, but can provide a rough framework for assessing driving safety. Patients scoring under 20 on the MMSE are definitely unsafe to drive. STOP! The CMA Guidelines state Individuals showing a score of less than 24 on the MMSE are ineligible to hold a driver s license of any class pending complete neurological assessment. STOP CAUTION 1. MMSE < 20* Unsafe to drive MMSE 20-23* Probably unsafe to drive Unless other factors are entirely normal. If so, and continued driving is being considered, suggest referral to specialized assessment** including road testing. GO 2. MMSE 24-26* Unsure safe to drive Depends on other factors. If unsure refer to specialized assessment** & road testing 3. MMSE 27-29* Probably safe to drive Unless concern with other factors. If so, consider referral to specialized assessment & road testing * MMSE score assuming > grade 8 education and age 85. Early on, even with mild disease severity, Lewy body, and frontotemporal dementia patients often score surprisingly high on the MMSE but are more unsafe to drive because of visuospatial problems, altered attention, hallucinations or poor judgement. ** Specialized assessment includes such services as geriatric / psychogeriatric / memory disorder clinics or day hospitals, usually involving physician and occupational therapy testing. Ref: Practical Case Management: DVD Series Driving Assessment from ADEPT Program (Dr. W. Dalziel)

39 Name: Date: A Dementia Education Physician Teaching (A.D.E.P.T) Program for Family Physicians NOTIFICATION ABOUT DRIVING Address: You have undergone assessment for memory/cognitive problems. It has been found by comprehensive assessment that you have dementia. The severity is. Even with mild dementia, compared with people your age you have an eight-times higher risk of a car accident in the next year. With even mild dementia, the risk of a serious car accident is 50% within 2 years of diagnosis. Additional factors in your health assessment raising concerns about driving safety include: As your doctor, I have a legal responsibility to report potentially unsafe drivers to the transportation authorities. Even with a previous safe driving record, your risk of a car accident is too great to continue driving. Your safety and the safety of others are too important. MD

40 A Dementia Education Physician Teaching (A.D.E.P.T) Program for Family Physicians HOW TO TELL THE PATIENT HE/SHE IS UNSAFE TO DRIVE 1. Discuss your concerns about driving. Give the evidence supporting driving cessation in an empathetic way, but be firm and non-negotiable that he/she not drive. Avoid arguing. 2. Be understanding in dealing with the patient s emotional reaction. Speak to the safety of the person and others no the road ( you wouldn t want to hurt yourself or someone else ). 3. Explain that despite a perfect driving record in the past, the presence of mild dementia predicts significant future risk, and increases the risk of a crash by eight-fold. There is a 50% risk of a serious car crash within 2 years. 4. Speak to other medical diseases (CVD/TIA/heart disease, diabetes, etc.) or physical limitations (slowed reaction time, weakness, decreased neck range of motion, etc.). These may be more palatable reasons to the patient than the diagnosis of dementia. 5. Refer to results of testing, especially critical cognitive domains including judgement, visuospatial, and executive function. Show the patient and family the tests and demonstrate problems/defects (MMSE, MOCA, clock, Trails A and B, etc.). 6. Provide a written statement to the patient/family as to why the patient can not drive. 7. Communicate in writing to your provincial Ministry of Transport. 8. Explain that the savings of not driving can be considerable ($ per year = a lot of taxes). Explore other options (family, friends, volunteer drivers, professionals). Ref: Practical Case Management: DVD Series Driving Assessment from ADEPT Program (Dr. W. Dalziel)

41 Red Flags (Clinical features which, if present, should make you consider a diagnosis other than Alzheimer s). THINK OF Cognitive decline within 3 months of CVA / TIA Focal neurological symptoms Vascular Focal neurological signs Dementia Abrupt onset / stepwise decline Previous CVA or TIA. AD with CVD Multiple vascular risk factors Visual hallucinations (detailed / recurrent) Lewy Body Pronounced fluctuation in cognition over hours / days Dementia Parkinsonism (especially rigidity) / bradykinesia Executive function worse than memory. Neuroleptic sensitivity. Unexplained falls / loss of consciousness

42 Red Flags THINK OF Behavioral changes: disinhibition / apathy Impulsivity / poor judgment Frontotemporal Self neglect / socially inappropriate. Dementia Executive function worse than memory. Language problems. Abnormal gait Normal Incontinence early in course of dementia Pressure Rapidly progressing dementia. Hydrocephalus (NPH)

43 Table 2. Clinical red flags to suggest a possible diagnosis other than Alzheimer s dementia Mixed Dementia (Alzheimer s Dementia with Cerebrovascular Disease) Progressive, gradual decline suggestive of Alzheimer s disease but also with superimposed vascular events Cognitive decline within 3 months of CVA/TIA Focal neurological symptoms Focal neurological signs Abrupt onset / stepwise decline Previous CVA or TIA Alzheimer s dementia with cerebrovascular disease Non-Alzheimer s Dementias Cognitive decline within 3 months of CVA/TIA Pure vascular dementia Focal neurological symptoms Focal neurological signs Abrupt onset / stepwise decline Previous CVA or TIA Visual hallucinations: detailed/recurrent Lewy body dementia Pronounced fluctuation in cognition over hours/days Parkinsonism (especially rigidity) / bradykinesia Executive function worse than memory Neuroleptic sensitivity Unexplained falls / loss of consciousness Behavioural changes: disinhibition/apathy Frontotemporal dementia Impulsivity / poor judgement Self-neglect / socially inappropriate Executive function worse than memory Language problems Abnormal gait (magnetic apraxia) Normal pressure Incontinence early in course of dementia hydrocephalus (NPH) Rapidly progressing dementia (NPH) Adapted from: Patterson CJ, Gauthier S, Bergman H, et al. The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia. CMAJ 1999;160(12 Suppl):S1-S