Diagnosis and Initial Management of Cognitive Disorders

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1 Diagnosis and Initial Management of Cognitive Disorders January 29, 2016 Kelly Garrett, PhD Cathleen Obray, MD, MHS Neurosciences Clinical Program Cognitive Care Team

2 None Disclosures

3 Neurosciences Clinical Program Cognitive Care Team Cognitive care development team established June 2015 Multidisciplinary team led by Meg Skibitsky, geriatrician 2016 goal: develop a standardized approach to identify, diagnose, and treat cognitive disorders. Strategy: Leverage existing resources to enable primary care providers to efficiently meet the needs of cognitively impaired patients and their caregivers.

4 Primary care needs for cognitively impaired patients Survey of 150 Intermountain primary care providers 40% response rate (35 Internal Medicine, 25 Family Medicine) support for patients with cognitive impairment/dementia as a Top 5 need for 63% of Internal Medicine and 20% of Family Medicine respondents Survey and data thanks to Justin Poll, Ph.D., Strategic Planning & Research

5 Primary care needs for cognitive care Additional training Clear process for cognitive impairment Not helpful Slightly Somewhat Very Extremely Not helpful Slightly Somewhat Very Extremely

6 Primary care needs for cognitive care Access to psychologist Access to a physician specialist Not at all Somewhat Very Extremely Not helpful Slightly Somewhat Very Extremely

7 1. Review definition of dementia and mild cognitive impairment Objectives 2. Know how to make a diagnosis of dementia and use the appropriate ICD 10 diagnostic codes 3. Know how to screen for dementia using the Mini-Cog 4. Know when to order brain imaging, neurology consultation, and neuropsychological assessment in the evaluation of cognitive complaints 5. Appreciate the role of non-pharmacologic interventions as first line treatment for cognitive impairment

8 Cost of care in the last 5 years of life Dementia No dementia 42,000 Utahns living with probable Alzheimer s in 2025 Mean total spending $287,038 $183,001 The looming epidemic 127% Prevalence in US 11% 65yrs 32% 85 yrs 2/3 women

9 Dementia: a syndrome with multiple etiologies Etiologies of dementia in order of prevalence Alzheimer s disease: 60-80% of cases Mixed or vascular etiology Lewy body disease or Parkinson s dementia Frontotemporal dementia, normal pressure hydrocephalus, neurosyphilis, others

10 Mild cognitive impairment Cognitive impairment Decline from previous level Not due to delirium Not due to another diagnosis Functional impact Cognitive deficits do not interfere with IADLs Dementia SAME Screening tool MoCA Mini-Cog Terminology Cognitive deficits interfere with IADLs

11 Mrs. P 82 year old retired college professor whom you last saw 5 years ago Scheduled today for her Annual Medicare Wellness Visit PMH: hypertension, hypothyroidism, osteoporosis, macular degeneration, borderline vitamin B12 deficiency Listed medications: losartan, levothyroxine, alendronate, calcium + vitamin D, ocuvite, vitamin B12 Social history: Her 56 year old son died from pancreatic cancer last year. She lives with her husband. Family History: Her sister died at 87 with Alzheimer s dementia.

12 What are you going to do about her cognitive concerns? Refer to Neurology? Start on donepezil and advise her to come back in 6 months? Reassure? Take her car keys? Send her for a brain PET scan? Do a complete evaluation for dementia now. Your other patients can wait?

13 Mini-Cog in icentra Got icentra? see HELP2 Hot Text in the purple Cognitive Care Swag Bag

14 Word Recall (max 3) : 1 point for each word spontaneously recalled without cueing. Clock Draw: 2 or 0 points. A normal clock has numbers placed in sequence and approximately correct position (e.g., 12, 3, 6 & 9 in anchor positions) with no missing or duplicate numbers. Hands pointing to 11 and 2. Hand length not scored. Total score = Word Recall + Clock Draw Interpretation: 0-3 positive, indicates a need for further evaluation 4-5 negative for dementia, but not sensitive for mild cognitive impairment Mini-Cog: Your Scoring? Your interpretation: a) 5 points, not impaired b) 4 points, not impaired c) 3 points, not impaired d) 3 points, impaired e) 2 points, impaired

15 Word Recall: 1 point for each word spontaneously recalled without cueing. (max 3) Clock Draw: 2 or 0 points. A normal clock has all numbers placed in the correct sequence and approximately correct position (e.g., 12, 3, 6 and 9 are in anchor positions) with no missing or duplicate numbers. Hands are pointing to the 11 and 2. Hand length is not scored. Total score = Word Recall + Clock Draw Interpretation: 0-3 positive, indicates a need for further evaluation 4-5 negative for dementia, but not sensitive for mild cognitive impairment Mini-Cog: Your Scoring? Your interpretation: a) 5 points, not impaired b) 4 points, not impaired c) 3 points, impaired d) 2 points, impaired

16 Diagnosis Scan Clock Drawing!

17 Diagnosis Scan MoCA!

18

19 Referral to Neurology Refer AFTER initial evaluation has been completed (delirium addressed) in cases where: Atypical presentation or rapid progression Neurologic deficits or findings Strong patient or family preference Possible benefit in counselling family members Opportunity to enroll patients in research studies Order non contrast brain MRI at time of Neurology referral for indication: cognitive decline

20 Neuroimaging Do not reimage if neuroimaging in last 3 years Non contrast brain MRI is test of choice Dementia remains a clinical diagnosis NOT radiological Role of neuroimaging is to rule out other etiologies Vascular, hydrocephalus, chronic subdural hematoma, tumor Non contrast MRI should always be obtained for any cases with: atypical presentation rapid progression focal neurologic deficit or gait disturbance when a question of vascular burden would change management Non contrast CT if MRI cannot be obtained

21 Needed in situations where: Concern by neurologist Neuropsychology assessment Consider in situations where: Physician, patient, or family wants full work-up Question of MCI versus dementia or subtype of MCI Initial testing normal in a highly educated patient but cognitive concerns persists Formal, objective screening for driving needed or if you prefer to outsource the driving conversations Question on decision making capacity Question of pseudodementia

22 Initial Management for Mrs. P: probable Alzheimer s disease Current visit Quarterly follow-up Plan for Care Manager Refer to Mental Health Integration. Goals: process bereavement, increase meaningful activity pattern Consider neuropsychology consult Encourage physical activity, social engagement, mental stimulation Review progress on anticholinergics Review MHI & Neuropsych impressions & response to Tx Share Dx impressions with Mrs. P Order home safety evaluation (OT) Consider driving evaluation (OT) Consider starting slow titration of Aricept Set up a family meeting: goals of care & advanced planning Provide information about the Alzheimer s Association Mediterranean diet Quarterly follow-up with PCP and care manager until cognitive care plan is implemented/stable

23 On behalf of Cognitive Care Development Team

24

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