COGNITIVE ALTERATIONS IN CHRONIC KIDNEY DISEASE K K L E E

COGNITIVE ALTERATIONS IN CHRONIC KIDNEY DISEASE K K L E E

Attention Problem Solving Language Cognitive Domains Decision Making Memory Reasoning

The Cardiovascular Health Cognition Study shows higher S Cr was associated with vascular-type dementia but not Alzheimer-type. Moderate renal impairment is associated with an excess risk of incident dementia among individuals in good excellent health. STEPHEN SELIGER et al. J Am Soc Nephrol 2004 15: 1904 1911 Decline in renal functioning is associated with longitudinal decline in global cognitive functioning, abstract reasoning and verbal memory. Adam Davey et al. Nephrol Dial Transplant 2013 28: 1810 1819

COGNITIVE IMPAIRMENT Can be understood as a decline in patient baseline functions possibly at a level severe enough to interfere with the performance of activities of daily living. Cognitive involvement and dementia are commonly seen in patients with CKD, particularly in subjects with advanced stage disease,

PROBLEMS Individuals with disease in any stage are susceptible to cognitive disorders associated with 1. Increased risk of death, 2. Lower levels of compliance to proposed treatment, 3. Higher incidence of cerebrovascular disease, and 4. Prolonged hospitalization

The mechanisms involved have not been fully established yet, but some factors may play a critical role in neuronal damage. Uremic toxins Cerebrovascular Ischemic lesions Chronic inflammation & Oxidative stress Anemia & Vitamin B12 deficiency Hyperhomocysteinemia Endothelial dysfunction

CORRECT ANY REVERSIBLE CAUSES The prevalence of depression symptoms in ESRD ranges between 20% and 25% Potentially treatable conditions such as depression and delirium.

CKD AND DEMENTIA Compared to the general population, the prevalence of cognitive impairment is higher in individuals with renal failure and even more significant in patients on dialysis. CKD has been strongly correlated with vascular dementia Dementia appears to complicate the management of patients with ESRD and has been correlated with poorer prognosis.

PWD (PATIENTS WITH DEMENTIA) Present deficits in at least 2 of the following : 1. Memory, 2. Executive function, 3. Attention, 4. Visuo-spatial skills, 5. Speed of information processing 6. Language

Murray looked into the neuropsychological performance of 338 hemodialysis patients through memory, language, and executive function tests and found that over a third of the subjects had 3 x prevalence of dementia estimated for the general population. Murray AM et al. Cognitive impairment in hemodialysis patients is common. Neurology 2006;67:216-23.

Dementia is not limited to cases of advanced kidney disease. Patients initially diagnosed with moderate renal disease without dementia had higher incidences of vascular dementia over 6 years of follow-up in association with higher serum creatinine levels.

COGNITIVE FUNCTION AND HEMODIALYSIS Individuals on hemodialysis had low scores in logical reasoning, verbal learning, motor skills, verbal fluency, visuo-spatial, memory tests. The risk of multi-infarct dementia in elderly patients on hemodialysis appears to be 7 times greater than in the general population, possibly due to increased prevalence of comorbidities such as diabetes mellitus, atherosclerosis, and hypertension.

COGNITIVE FUNCTION AND PERITONEAL DIALYSIS Individuals on peritoneal dialysis have moderate to severe cognitive impairment, especially in areas related to executive function, decision-making, and capacity for abstraction. Such impairment may interfere with the self-administration of dialysis and compliance with complex medication regimens.

DIALYSIS Neuropsychological performance tends to improve and patients on dialysis have lesser cognitive deficits than untreated individuals and patients with uremia. Short-term memory improves with maintenance hemodialysis Persistence of other cognitive dysfunctions in the domains of attention, cognitive flexibility, memory, and learning

COGNITIVE FUNCTION AND KIDNEY TRANSPLANTATION Studies have described memory improvements after renal transplantation and reversion of some neuropsychological deficits, memory impairments in particular, detected during dialysis. May still have to endure deficits in verbal memory and executive function.

TAKE HOME MESSAGES Depression, delirium and dementia are commonly seen in any stage of CKD, and are generally associated with complications and poorer prognosis CKD appears to be a risk factor for cognitive impairment and dementia. Renal disease severity walks hand in hand with loss of neurocognitive function

TAKE HOME MESSAGES Evidence suggests that hemodialysis improves cognition in patients with CKD, a significant, yet underestimated, portion of the individuals on hemodialysis presents moderate to severe cognitive impairment. There appears to be no difference in the cognitive disorders affecting patients with CKD treated with hemodialysis or peritoneal dialysis

Identification of cognitive impairment is an important step in the process to improve quality of life and mitigate the morbidities associated with this condition The ideal time to assess cognitive function and the choice of screening scale must take the patient s clinical status into account. Evaluations should take little time, MMSE, the best known and studied screening test for dementia A more thorough investigations of the cognitive domains requires neuropsychological testing requires more time.

COGNITIVE ASSESSMENT MMSE AMT What day of the week is it? (1) What is the date today? (1) What is the month? (1) What is the year? (1) (1) About what time is it? (within 1 hr) (1) (1) What is your age? (1) What is your Date of Birth? (1) What is your home address? (1) Where are we now? (1) (1) What floor are we now? (1) In which estate are we? (1) In which region are we now? (N/S/E/W/C) (1) What day of the week is it? (1) What is the date today? (1) What is the month? (1) What is the year? (1) (1) About what time is it? (within 1 hr) (1) (1) What is your age? (1) What is your Date of Birth? (1) What is your home address? (1) Where are we now? (1) (1) What floor are we now? (1) In which estate are we? (1) In which country are we? (1) Who is our country s PM? (1) What is his / her job? (show picture) (1) * Repeat the following words: Lemon. Key. Balloon. (3) Subtract $7 from $100 and make 5 subtractions (5) * Can you recall the three words? (3) What is this? (show pencil) (1) What is this (show watch) (1) Repeat the following: (1) (a) No ifs, ands or buts (English) (b) Forty-four stone lions. (Chinese) Count backwards from 20 to 1 (1) ^ Memory phrase: 37 Bukit Timah Road Follow a 3-stage command: Take this piece of paper, fold it in half and put it on the floor. (3) Say a sentence of your choice (1) Read & obey what is written on this piece of paper: Raise your (1) hands. Copy this drawing on a piece of paper (1) ^ Recall memory phrase (1) TOTAL SCORE / 30 / 10