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DEMENTIA

Dementia is NOT a normal part of aging Symptoms of dementia can be caused by different diseases Some symptoms of dementia may include:

1. Memory loss The individual may repeat questions or statements, misplacethings or lose items, forget names of others, forget appointments or to takemedications/pay bills. The person may begin to forget recent events with

progression to forgetting events/people/history from longer ago. The individual

may show increasing forgetfulness and disorientation (person, place, time).

Learning new ideas/tasks and remembering new information is often difficult.

2. Difficulty with understanding language and/or using language Theindividual usually displays decreased ability to write or speak. Sometimes theperson may not be able to find the right word to use in a sentence. They may

substitute any word or may wait for someone to assist them or fill the spot with

an appropriate word. Terms often associated with language deficits may include:word-finding problems, echolalia, confabulation and perseveration.

3. Motor skills may become impaired The individual may experience difficultywith movement, especially fine coordination and control of the hands and arms.If the individual does show signs of in-coordination and lack of control with

movement, deficits may be seen in dressing tasks, eating, writing, opening and

closing small/tight containers, etc. Sometimes, a persons brain doesnt alwaystell the hands/body what to do and this can lead to problems as discussed above as

well as difficulty with walking, balance, and planning movements.

4.

Executive functions/Cognitive and perceptual skills decline The individualmay show problems with judgment, reasoning, problem-solving and planning.

Often the person loses the ability to think abstractly and requires concrete orspecific messages. A person may require assistance to plan more unfamiliar tasks

and organize things to ensure safety/thoroughness. A person with dementia maybegin to lose insight regarding consequences of certain actions or non-actions.

Mathematical skills often show decline due to attention and concentration as well

as the above, making it more difficult to do finances, shopping, money

management without assistance. Learning new skills is usually difficult.Familiar, repetitive tasks are often performed more accurately and appropriately

for longer periods from the onset of the disease.

5. Emotional/personality changes may appear -- An individual may showdecreased awareness of or an inability to recognize stimuli (and at other times an

emotional response is likely due to the persons awareness of the changes goingon in and around them). There are many behaviors that can be associated with the

above including: irritability, anxiety, depression, aggression, withdrawal,

paranoia, new/increased confusion, incontinence, and/or changes in personalhygiene, sleep or sexual activity.


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BASIC POINTS TO CONSIDER

Most people do NOT have dementia:

Before age 65, less than to 1% are affected (and of those, it is more commonlydue to head injuries, although Alzheimer Disease can occur before age 65).

After 65, prevalence of dementia increases to about 5-10% of the population.

After 75, the rate increases to 18-20% of the population. After age 85, the rate goes up to 35-40% (some estimates go as high as 50%). After age 65, 50-70% of the dementia cases are thought to be caused by

Alzheimers disease.

These low percentages translate into a high number of people with dementia.Currently, approximately 4.5 million people in the U.S. have Alzheimers (the most

common form of later life dementia). This is likely to increase as the population

continues to age.

Dementia is NOT a disease:

Dementia is a diagnostic category representing some/all of the following symptomswhich are severe enough to interfere with daily functioning, noticeable in a person

who is awake or alert, and typically progressive if untreated (the pattern of losses may

be uneven):

Memory Loss Loss of Judgment Loss of Abstract Reasoning Loss of Sense of Time Change in Emotional Responses Problems with Speech and Communication Loss of Coordination

Many other things can CAUSE dementia-like symptoms BESIDES dementia:

Stress/Fatigue Malnutrition Medications Other Medical Conditions (e.g. Depression, Delirium, Stroke, Fever) Motivation (or lack thereof) Sensory Deficits Ageist Expectations

HOW CAN YOU TELL WHAT IS NORMAL (AND WHAT IS NOT?)

Signs and symptoms which SHOULD trigger consideration of an evaluation:

Progressive cognitive changes (new forgetfulness) Psychiatric symptoms (withdrawal, apathy) Personality changes (inappropriate friendliness, blunting) Problem behavior (wandering, agitation) Changes in day to day functioning (difficulty driving, etc)


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A complete evaluation can give you information regarding:

The nature of the persons illness Whether the condition can be medically treated/reversed The extent of the disability The areas where a person may still function successfully Other health problems to be treated The social and psychological needs/resources of the patient and his/her family Changes which may be expected in the future

Some evaluative procedures:

Complete physical medical exam Blood tests (e.g., infection, electrolytes) Neurological tests (e.g., MRI, CT, PET) Cognitive tests (e.g. MMSE)

WHAT IF ITIS DEMENTIA?

What is the cause of the symptoms?Many diseases lead to dementia and they differ in the areas they affect and their

symptoms. There are about 100 or so diseases associated with the clinical symptoms of

dementia, including:

Alzheimer Disease Prion Dementias (CJD, GSS, etc.)Vascular Dementia/Multi-Infarct Lewy Body Dementia

Frontotemporal Degeneration (Picks) AIDS/Syphilis Paresis, etc.

Huntington Disease

What are the possible treatments?

Medical (depends upon cause) EnvironmentalBehavioral FamilialPsychosocial Palliative

Things to Remember:

People with dementia are still people People in the early stages have many remaining abilities People are often AFRAID of dementia Care giving can be stressful Being cared for can be stressful Cognitive losses can impact family relationships and roles There IS help available

HOW DO I TALK TO A PERSON WITH DEMENTIA?

Improving Your Communication Strategies:

Communication involves both the sending of messages to others (production) and the

understanding of messages sent by others (comprehension). Communication includes notonly the words we use, but also our tone and body language. Ways to improve

communication include:

Stop and Receive the Other Persons Communication:


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Pay close attention listen and watch their body language Be patient (allow time to respond do not interrupt or rush) Focus on the emotional (nonverbal) cues Double check your understanding of what the individual has communicated

If a Person Can Not Find the Right Word: Encourage the individual to act out the meaning Encourage the person to talk around what they are trying to say Say what you think they are trying to communicate (a person with dementia may

be able to recognize words they can not generate on their own)

Be cautious about correcting wrong words (this may only serve to frustrate orembarrass a person)

If a Person Digresses or Loses Their Train of Thought:

Repeat the last words said Summarize what has been discussed so far Ask relevant questions Show respect for the feelings expressed, even if the facts are wrong If you do not understand, it may be best to say so

Improve Your Own Verbal Communication:

Think before you speak Begin each intervention by introducing yourself, giving your name and your role;

explain why you are there; socialize a little

Explain what is going to happen Use short, simple sentences

Do not use conjunctions (e.g., and but) Be specific, direct and explicit about what you mean Use concrete and common words (avoid abstract and fancy words) Avoid clichs, idioms, sayings, generalizations, and colloquialisms Use proper names and common nouns (avoid pronouns) Give the most important information at the end of sentences (e.g. Do you want to

drink coffee or tea?)

If a Person is Having Trouble Understanding You:

Repeat what you said twice Revise and restate using different words Avoid logical discussions or debates (instead, respond to feelings the individual is

expressing)

Provide immediate feedback, reassurance and rewards Assume that the person can understand more than they can express Remember that people with dementia will probably forget, so you may need to

repeat yourself

When Asking Questions:

Avoid open-ended questions Limit the number of choices possible to two


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Give lots of time for a response If needed, repeat or reword questions

When Giving Instructions:

Break instructions into small steps Give one direction at a time Allow time for completion of each direction before going on Give directions close to when they must be followed Give positive directions (what to do rather than not do)

Improving Your Nonverbal Communication:

Gently get the persons attention by being sure he/she can see you before sayinganything

Approach from front so he/she can see you Use more than one of the five senses (e.g., say their name and touch their

shoulder)

Use a calm, pleasant, low-pitched tone of voice Use open, friendly, relaxed body language Move slowly and gently Maintain appropriate eye contact Use positive facial gestures Respect personal space (do not stand too close or too far away from the person) Converse at eye level beside or in front of the person (never behind) Use objects and pictures to illustrate your message Use physical action to illustrate your message When giving instructions, demonstrate action Be aware of the persons culture Be sure that your verbal and nonverbal communication matches Keep trying

Additional Things to Remember:

A person with dementia is still a person with thoughts, feelings, and needs A person in the early stages of dementia has many remaining abilities A person with dementia may understand much more than they can communicate A person with dementia will often understand non-verbal cues long after they can

understand verbal communication (so tone and expression matter!)

Often times the experience (e.g., a pleasant conversation) is more important thanthe content (accuracy and reality can be overrated!)


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Clinical Diagnosis of Dementia

Developed by the Geriatric Education Center of Michigan (GECM), and the Michigan Primary Care DementiaNetwork. All GECM activities are funded through a grant from the Bureau of Health Professions of the HealthResources and Services Administration as authorized through Section 777(a), Title VII of the U.S. Public HealthService Act, as amended.Rev. 04.02.07

1

In this module, learn about clinical diagnosis of dementia and:

The important components of the history and exam Methods of evaluating cognitive function

The relevant diagnostic studies

The differential diagnosis of dementia

When the clinical triggers described in Dementia in Primary Care raise suspicion ofpossible dementia, evaluation of the patient should include a history and physicalexam that focus on specific areas of concern. Various diagnostic studies can be usedas well to confirm the problem and assess the differential diagnosis. The physicianalso needs to know when referral is appropriate, and to understand that the slowprogression of dementia may mean that a definitive diagnosis can only be made overan extended period of time.

HISTORY

The history should be obtained from the patient as well as an additional reliableinformant. When diagnosing dementia, the important components of the historyinclude:

History of cognitive impairment signs and symptoms, including timing of earliesteffects and rate of progression

Current and past medical problems, including systemic diseases, neurologicaldisorders, head trauma, alcohol or substance abuse, infectious or metabolicillnesses

Functional status, focused on ADLs and IADLs see Table A for the ADL andIADL forms, and Table Bfor the Functional Activities Questionnaire

Current medications, with special attention to both prescription and non-prescription medications that have anti-cholinergic properties

Family history, especially any early-onset dementia, neurological conditions,and vascular diseases

Social history, including:o

Family and social supportso Educational backgroundo Literacyo Preferred languageo Alcohol, tobacco, and other substance use


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PHYSICAL EXAM

The key elements of the physical exam include: General appearance and behavior, including hygiene, affect, and alertness

Pulse and blood pressure, including any orthostatic changes

Cardiac and pulmonary auscultation Neurologic exam

o Focal deficits, including cranial nerves, motor and sensory exam of theextremities, coordination, balance and gait

o Signs of Parkinsons disease, including cogwheeling, masked facies,bradykinesia, rigidity, and resting tremor

DIAGNOSTIC TESTING

The routine laboratory workup for dementia generally includes: CBC with differential,

chemistry profile (with electrolytes, creatinine, calcium, glucose, and liver functiontests), TSH, and vitamin B12 levels. Other laboratory tests may be indicated inselected patients, including urinalysis, serologic tests for syphilis and/or HIV, tests forautoimmune diseases and vasculitis, and toxicology screens. Chest x-rays, EEGs,and exams of CSF (cerebrospinal fluid) are occasionally helpful.

Brain imaging (CT or MRI) is generally recommended in the evaluation of early ormiddle stage dementia. The American Academy of Neurology has stated that,structural neuroimaging with either a noncontrast CT or MR scan in the routine initialevaluation of patients with dementia is appropriate. (Level of Evidence is Guidelineonly.) When dementia is diagnosed in the late stage and is typical for Alzheimers, it

may not be necessary to perform imaging studies.

Studies have been mixed about the value of brain imaging in dementia patients, andclinicians should bear in mind not only that abnormalities found may be unrelated tothe patients status but also that interventions may not lead to any improvement insymptoms. Evaluation of possible interventions related to abnormal imaging studiesshould involve experienced experts with a healthy dose of skepticism about the valueof such interventions.

COGNITIVE TESTING

There is no single tool perfect for use in diagnosing dementia. All of the instrumentsthat have been proposed have limitations. One of the biggest issues is that a tool withsufficient sensitivity to diagnose early dementia will also have a relatively lowspecificitythat is, a high false negative rate. A second major issue is the brevity of


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the tool an instrument short enough to use in clinical practice by necessity gives upa certain level of both sensitivity and specificity.

The Mini-Mental Status Exam (MMSE) (Table A) is the tool most widely used byhealthcare professionals in the U.S., and it is the most comprehensive of the short

tools available for evaluation as it tests multiple domains of cognitive function. TheBlessed Information Memory Concentration (BIMC), Blessed Orientation MemoryConcentration (BOMC), and the Short Test of Mental Status (STMS) are roughlyequivalent to the MMSE though less widely used. It is important to note that all ofthese tests require adjustment for educational status, ethnicity, and socioeconomicstatus, and that there is no absolute cutoff for distinguishing normal from abnormalscores in individual patients.

The diagnosis of dementia requires identification of both memory loss and decline inan additional domain of cognitive function. The MMSE and the other short tests areexcellent for identifying more advanced disease, but may fall short in assessing earlier

symptoms. By necessity, each domain is tested only briefly. Tests of recent memoryare the most discriminating measures overall in identifying dementia, but reliance onthis criterion alone may miss those people for whom loss in another cognitive domainis the most prominent symptom. Declines in domains such as language ability,psychomotor performance, or executive function may also be early symptoms ofdementia.

A comprehensive review of instruments was performed by the Agency for Health CarePolicy and Research (now the Agency for Research in Health Care Quality) (Pfeffer etal, 1982), demonstrating that the presence of cognitive and functional decline can bedocumented in many different ways. Key points from that review include:

The Functional Activity Questionnaire is the single best test for dementia, but itrequires the presence of a reliable informant, usually a family member.

The MMSE, BIMC, BOMC, and STMS are roughly equivalent.

Experts in the Michigan Primary Care Dementia Network have found a variety ofindividualized tests to be helpful in early assessment of dementia. None of theseapproaches have been rigorously tested in clinical trials:

Testing category fluency asking the patient to name as many items as

possible in one minute, in a category like fruits and vegetables or animals.Experts suggest that a person with normal cognitive function should be able toname at least 18 in one minute. Ten or fewer is definitely abnormal. Numbersin between are questionable.

Asking the patient to recall three objects as in the MMSE, but making theobjects less common and attaching adjectives to them.


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Asking the patient to name and describe the function of a more complex objectthan used in the MMSE. For example, instead of a pen, use typewriter.

Using a ten-word list with each word on a separate card. The examiner showsone card at a time and has the patient repeat each word individually, and thenasks the patient to recite as many words as are recalled. A normal score is a

recall of 5-6 words. The cards are then shuffled and the process repeated, witha normal result of 7-8 words recalled. Another shuffle and repeat can beperformed, and people with no impairment usually recall 9-10 words at thispoint. While memory-impaired patients do learn across the trials, theimprovement is much less that in those with no deficits.

Expanding on the previous test 15-20 minutes later, asking the patient to nameas many of the words as can be recalled. The number of correct recalls istypically close to the score on the third trial above. Finally, the examiner canshow twenty cards that include the first 10, asking the patient to identify whichwere reviewed before. A normal result is 100% recognition of the words.

NEUROPSYCHOLOGICAL TESTING

Neuropsychological testing is the most definitive standard for diagnosis of earlydementia. Such testing may be especially useful in patients who present early in thedisease process, when the usual brief cognitive tests discussed above may lacksufficient sensitivity and specificity for diagnosis. It can also be helpful when dementiaand depression are difficult to separate, or when atypical symptoms are present. Inaddition, clearer identification of specific cognitive deficits may be helpful in designingindividualized coping strategies and behavior management.

Performance on neuropsychological testing is influenced by many factors, includingeducation, cultural background, and co-morbid illnesses. A referral source withspecial expertise in dementia evaluation is particularly helpful when questions aboutsuch influences arise.

We are likely to use neuropsychological testing more often in the future, as patients,families, and physicians increasingly appreciate the benefits of early diagnosis andtreatment for dementia. Currently, referral for neuropsychological testing should beconsidered when:

1. MMSE or other cognitive assessment is normal, but a family member

expresses concerns2. Patient has an unusually high or low educational status, literacy level, orintelligence

3. Patient is from a minority racial or ethnic background4. MMSE is abnormal, but the functional assessment is normal


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DIAGNOSIS OVER TIME

It may be difficult to be certain about the diagnosis of dementia in the early stages,and even the results of neuropsychological testing may be ambiguous. A clearerpicture often emerges over time with repeated assessments. The primary care

physician is in an ideal position for follow-up appointments that can include updatedfunctional assessments and cognitive evaluation, making progression of disease mucheasier to identify.

REFERRAL TO SPECIALISTS

Referral to a clinician with dementia expertise (geriatrician, neurologist, or psychiatrist)should be considered in patients with any of the following:

Age less than 65

Atypical presentation or unclear diagnosis Rapid progression or deterioration Strong family history of dementia Any focal neurological symptoms or signs, including movement disorders

Gait disturbance or urinary incontinence in the early stages of dementia, Prominent language symptoms or personality change

Referral is also indicated when the primary care physician does not feel comfortablewith evaluation or management, or if the patient or family strongly desire consultation.

STAGING DEMENTIA

Clinical Diagnosis Differential Diagnosis

Dementia can be broadly defined as a syndrome in which memory loss isaccompanied by acquired impairment in at least one other cognitive domain, includingthe areas of language, motor function, personality, reasoning, and executive function(ability to plan and organize). Formal diagnostic criteria for dementia can be found inthe Diagnostic and Statistical Manual of Mental Disorders.

Criteria for the two most common types of dementia can be found in the NINCDS-

ADRDA for Alzheimers and NINDS-AIREN for vascular dementia.

Alzheimers http://neurology.org/cgi/content/abstract/34/7/939

Vascular dementia http://neurology.org/cgi/content/abstract/43/2/250
http://neurology.org/cgi/content/abstract/34/7/939http://neurology.org/cgi/content/abstract/43/2/250http://neurology.org/cgi/content/abstract/43/2/250http://neurology.org/cgi/content/abstract/34/7/939


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Identifying dementia is usually of greater importance to the primary care physicianthan differentiating the precise type and cause of the disease. By far, most cases ofdementia the primary care clinician sees will be caused by Alzheimers disease, eitheralone or in combination with another underlying cause like vascular dementia.

But in highly unusual cases, the sole source of dementia will be found to be areversible condition, and somewhat more commonly, such a condition will coexist withAlzheimers. Those disorders should be recognized and treated separately, evenwhen Alzheimers or another irreversible disease is present. Practitioners shouldknow that truly reversible dementias are quite rare, especially in those over 65 in theprimary care setting, with one meta-analysis estimating that less than 1% of cases ofdementia have causes that lead to even partial reversibility (Clarfield MA, 2003).

Mild Cognitive Impairment vs. Dementia

In addition to knowing the difference between signs of dementia and changes thatrelate to normal aging, we need to be able to distinguish dementia from mild cognitiveimpairment (MCI).

Signs of Normal Aging Compared with Signs of Dementia

NORMAL AGING DEMENTIAOccasional short-term memory lapses (lostdetails can be restored by prompts)

Increasing short-term memory problemsthat get in the way of daily living(unresponsive to prompts because newmemories are not being formed and cannot

be retrieved)Awareness of memory lapses No awareness of memory problems

Often needs reminders aboutappointments, medication schedule, etc.

Forgetting where you left the car keys Forgetting what car keys are for

Occasionally misplacing items Frequently misplacing itemsLeaving things in unusual places (e.g., milkin the breadbox)

Occasionally forgetting a word Frequent inability to come up with words,communicate clearly, understand what is

being saidForgetting someones name Difficulty identifying a close friend or

relativeTaking longer to perform tasks Inability to perform familiar tasksTaking longer to solve problems Problems with abstract thinking


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Additional symptoms that should berecognized as possibly signs of dementia:Withdrawal, loss of interestMood and behavior changesDecreased ability to make good judgmentsTrouble remembering the date, time orplace

The diagnosis of MCI recognizes that beyond a certain point, cognitive changes inaging individuals should not be considered normal, even when they do not meet all theaccepted criteria for dementia.

A patient with MCI typically reports problems with short-term memory such as notremembering the names of new people, not recalling the flow of a conversation, ormisplacing an object. While these problems are seen in dementia, MCI presents cleardifferences. Significant among these is the likelihood that the patient will be the one to

complain of the problem, something that is rarely true in cases of dementia, even inthe early stage. Corroboration from another informant, however, should be taken as asign that the patient has MCI rather than memory changes associated with normalaging. In addition, the patient:

Performs poorly on formal memory tests, even in comparison to people ofcomparable age and education

Shows normal general cognitive functions otherwise Experiences no interference with the activities of daily living and does not

require added assistance in these areas beyond the previous level of need

As in the case of Alzheimers and related disorders, physicians should be careful toevaluate for coexisting or confounding depression. See the information aboutdepression in the Depression and Dementia section that follows in this module.

MCI may be a transitional stage. It is estimated that people diagnosed with MCI willprogress to Alzheimers at a rate of 10-15% per year as opposed to 1-2% in a healthycontrol group. But the cognitive changes found in MCI may never progress to clear-cut dementia in some cases. In light of the high conversion rate of MCI toAlzheimers, it is especially important to recall that when signs that suggest dementiaare present, reassessment may be needed in order to make a diagnosis over time,discussed above.


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Delirium and Dementia

Delirium represents the acute or subacute impairment of brain function due to theeffects of physical illness. The Diagnostic and Statistical Manual provides criteria fordelirium.

Delirium occurs with increasing frequency in advancing age, and dementia is asignificant underlying risk factor for the development of delirium. In fact, thedevelopment of delirium may be the first sign of dementia in an elderly patient. Inaddition, delirium may be confused with dementia, especially in milder forms ofdelirium, when acute onset is not apparent. The chart below describes keydifferences that can help distinguish between the two:

Delirium DementiaOnset Acute or

subacute

Gradual, insidious

Reversibility Reversible Irreversible;Progressive

Orientation Disoriented Not impaired(until advanced)

Consciousness Fluctuates;Clouded

Intact(until advanced)

Attention Impaired Normal(until advanced)

Memory Confused Short-term losses

Cognitive deficits Variable Consistent

Psychomotorstatus

Hyperactiveor hypoactive

Normal(until advanced)

Subacute delirium is more common in the elderly than in any other age group. Thissubacute presentation can easily cause it to be confused with dementia. Metabolicdisturbances and drug effects are the most common causes of subacute delirium inthe elderly population.


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It is important for the primary care physician to be able to identify delirium as an acuteresponse to a medical problem that requires urgent treatment. The clinician shouldalso recognize that delirium can accompany dementia, and effective treatment for theunderlying cause of delirium may still leave dementia that needs to be addressedseparately. Delirium can also be a warning sign for dementia, and should be a trigger

for the physician to investigate possible dementia.

Any patient with delirium should be evaluated for underlying dementia when stable.

Depression and Dementia

Depression in an older patient can be easily mistaken for dementia, and vice versa.Many of the early presenting symptoms and signs are similar in both conditions:apathy, neglect of self-care, memory loss, and other impaired cognitive functioning. A

personal or family history of depression may be helpful in recognizing depression; afirst-ever depression after age 60 is unusual in the absence of a clear precipitant liketrauma or grief. However, there are also important differences that can help theclinician distinguish between depression and dementia as shown in the chart below.

Depression DementiaOnset More discrete onset Insidious

Mood Low most of the day,Sadness may be

maskedby physical symptoms

Fluctuates withoutpattern;

Mood changes inadditionto depression arecommon

Physicalsymptoms

May be prominent aches and pains, GIsymptoms, headache,etc.

Uncommon

Cognitive loss Fluctuates Stable and progressive

Memory loss Apathy short andlong-term bothaffected

Short-term memorymuch more impaired

Presentation Patient likely topresent concerns

Relative or friend likelyto present concerns


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Patientperception

Complains aboutmemory loss

Unaware of memoryloss;Underestimatesproblems

Answers toQuestions Dont know;Incomplete answers Inappropriateor near miss

Effort on tasks Low Normal

The Geriatric Depression Scale is a valuable screening tool for depression in theelderly.

Geriatric Depression Scale (Short Form)

Choose the best answer for how you felt the past week:

Are you basically satisfied with your life? Yes No*Have you dropped many of your activities and interests? Yes* NoDo you often feel that your life is empty? Yes* NoDo you often get bored? Yes* NoAre you in good spirits most of the time? Yes No*Are you afraid that something bad is going to happen to you? Yes* NoDo you feel happy most of the time? Yes No*

Do you often feel helpless? Yes* NoDo you prefer to stay at home rather than going out and doing new things? Yes* NoDo you feel you have more problems with memory than most? Yes* NoDo you think it is wonderful to be alive now? Yes No*Do you feel pretty worthless the way you are now? Yes* NoDo you feel full of energy? Yes No*Do you feel your situation is hopeless? Yes* NoDo you think most people are better off than you are? Yes* NoEach answer marked by an asterisk counts as one point.

(Public Domain)

The GDS has 15 yes-or-no questions on a form designed to be self-administered andit takes only 5-10 minutes to complete. A score between 5 and 9 suggests


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depression, while a score greater than 9 correlates very strongly to depression.Further assessment is needed to confirm the diagnosis if the GDS is positive.

The primary care physician needs to be able to identify treatable depression in olderpatients. Treatment with antidepressants may alleviate all of the symptoms that mimic

dementia, but the clinician should know that depression is also a common co-morbidity of Alzheimers. Depression is a recognized risk factor for dementia as well;therefore, underlying dementia should be suspected in all elderly patients withdepression. In cases where dementia and depression coexist, it is important to identifyand treat both.

Any patient with depression should be evaluated for underlying dementia.

Major Types of Dementia

Although dementia has many causes, the three major causes account for almost all ofthe cases seen and managed by primary care physicians (see referral criteria above):Alzheimers disease; vascular dementia; and dementia with Lewy bodies.

Alzheimers Disease

Alzheimers disease should always be suspected when signs of dementia areidentified. It is the predominant cause of dementia and often coexists with otherdisorders that contribute to the dementia syndrome. Key elements of Alzheimersdementia are:

Insidious onset Progressive course

Impaired memory (both in recalling previously learned information and inlearning new information)

Impairments in one or more of the areas of :o Languageo Orientationo Ability to carry out motor activities (apraxia)o Ability to recognize or identify objects (agnosia)o Executive function (ability to plan and organize, to abstract this may

be subtle)

A patient may also be apathetic and emotionally withdrawn.


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Vascular Dementia

The symptoms of vascular dementia are not easily distinguishable from the symptomsof Alzheimers disease, and a significant number of individuals who have dementiafrom cerebrovascular causes also have Alzheimers. There are differences that can

be identified, however:

Onset can be abrupt, but is more often subtle

Progression may be stepwise

Focal neurological signs may be present Cognitive deficits correlate with lesions on imaging

Gait disturbances and urinary incontinence may be present Risk is higher in patients with hypertension, diabetes, and coronary artery

disease

Most significantly, vascular dementia has a temporal association between the

development of cognitive impairment and either clinical or imaging evidence of effectsof vascular disease.

However, dementia without sudden onset often goes undiagnosed following a CVA(cerebrovascular accident, or stroke). In many studies, the rate of dementia after aCVA is around 30%. And studies have demonstrated that many people diagnosedwith vascular dementia also have clear evidence of Alzheimers disease at autopsy.

Dementia with Lewy Bodies (DLB) / Dementia from Parkinsons Disease

It is unclear whether dementia with Lewy bodies and dementia associated withParkinsons disease, which has many features similar to Alzheimers, are two separateentities or simply variants of one type. Like Alzheimers, DLB is insidious in onset andprogressive, but it may be distinguished by:

Fluctuations in cognitive function with varying levels of alertness andattention

Visual hallucinations that may become evident early in the course ofdisease

Parkinsonian motor features, especially rigidity and bradykinesia

Nighttime behavioral disturbances and daytime drowsiness

Less prominent memory loss early in the course of the illness More prominent executive dysfunction early in the course of the illness Sensitivity to neuroleptic side effects

These three types of dementia Alzheimers disease, vascular dementia, anddementia with Lewy Bodies have significant overlap in clinical presentation and


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treatment: cholinesterase inhibitors are valuable in slowing the progression of all threeand control of vascular risk factors is important in all three. The clinical importance ofmaking a clear distinction among them has been overemphasized.

Identification of dementia is far more important than precise identification of itscause.


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TABLE AThe Mini-Mental Status Exam

Standard version Folstein, Folstein, McHugh, 1975(To be completed by a trained clinician)

Patient Name: __________________________________________

Date: _______________ Time: _________________

Birth Date: __________

Sex: Male Female

Education (years): ____

Race: Caucasian

Black Hispanic Asian Other

Orientation Questions:

Question Right Wrong

1. What is todays date?

2. What is the month?

3. What is the year?

4. What day of the week is today?

5. What season is it?

6. What is the name of this clinic (place)?

7. What floor are we on?

8. What city are we in?9. What county are we in?

10. What state are we in?

Immediate Recall: Ask the subject if you mat test his/her memory. Then say ball, flag, tree clearlyand slowly, about one second for each. After you have said all three words, ask him/her to repeat them.The first repitition determines the score (0-3), but keep saying them until he/she can repeat all three, up tosix tries. If he/she does not eventually learn all three, recall cannot be meaningfully tested:

11. Ball

12. Flag

13. Tree

Note the Number of Trials: ___________

Attention:

A. Ask the subject to begin with 100 and count backwards by 7. Stop after 5 subtractions. Score thecorrect subtractions.

14. 93

15. 86

16. 79


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17. 72

18. 65

Serial 7s Total: ___________

Patient Name:______________________________________________

B. Ask the subject to spell the word WORLD backwords. The score is the number of letters in the

correct position. For example, DLORW is 3, LROWD is 0.

Question Right Wrong

19. D

20. L

21. R

22. O

23. W

DLROW Total: __________ Greater Score A or B:__________

Delayed Verbal Recall: Ask the subject to recall the three words you previously asked him/her toremember.

24. BALL?25. FLAG?

26. TREE?

RECALL: ___________

Naming: Show the subject a wrist watch and ask him/her what it is. Repeat for pencil.

27. WATCH

28. PENCIL

29. REPITITON

Three Stage Command: Give the subject a plain piece of paper and say, Take the paper in your hand,fold in half, and put it on the floor.

30. TAKES

31. FOLDS32. PUTS

Reading: Hold up the card reading, Close your eyes, so the subject can see it clearly. Ask him/her toread and do what it says. Score correctly only if the subject actually closes his/her eyes.

33. CLOSES EYES

Writing: give subject a piece of paper and him/her to write a sentence. It is to be written spontaneously. Itmust contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary.

34. SENTENCE LANGUAGE

Pentagons: Ask the subject to draw they the two pentagons as they appear on the paper.


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35. PENTAGONS


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MMSE

Patient Name:_____________________________________________________

Calculations:

Total the number of correct responses: __________

(MMSE maximum score = 30)

24-30 normal, depending on age, education and complaints20-23 mild10-19 moderate1- 9 severe0 profound

(Public Domain; MMSE HTML @ MEDAFILE.COM)


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TABLE BFlow Chart for Recognition and Initial Assessment of

Alzheimers Disease and Related Dementias1

1Source: Agency for Health Care Policy and Research, 1996.


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References

Agency for Health Care Policy and Research. (1996). Early Identification ofAlzheimers Disease and Related Dementias, AHCPR Archived Quick ReferenceGuide No. 19.Note: AHCPR (Agency for Health Care Policy and Research) wasrenamed and is now known as AHRQ (Agency for Healthcare Research and Quality).

Clarfield AM. (2003). The decreasing prevalence of reversible dementias: an updatedmeta-analysis. Arch Intern Med, 163(18):2219-29.

Folstein MF, Folstein SE, McHugh PR. (1975). Mini-mental state. A practical methodfor grading the cognitive state of patients for the clinician. J Psychiatr Res, 12:189-98.

Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. (1963). Studies of illness inthe aged. The index of ADL: A standardized measure of biological and psychosocialfunction, JAMA, 185:914-9.

Lawton MP, Brody EM. (1969). Assessment of older people: self-maintaining andinstrumental activities of daily living. Gerontologist, 9(3):179-86.

McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. (1984).Clinical diagnosis of Alzheimers disease: report of the NINCDS-ADRDA work groupunder the auspices of Department of Health and Human Services Task Force onAlzheimers Disease. Neurology, 34(7):939-44.

Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S. (1982). Measurement offunctional activities in older adults in the community. J Gerontol, 37:323-9.

Roman GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JH,Amaducci L, Orgogozo JM, Brun A, Hofman A. (1993). Vascular dementia: diagnosticcriteria for research studies. Report of the NINDS-AIREN International Workshop,Neurology, 43:250-60.


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experts recommend four week intervals. It comes in 1.5, 3, 4.5, and 6mg capsules, so titration can be quite slow when needed. It isrecommended that it be taken with food to slow down the rate ofabsorption to decrease the GI side effects. The lowest effective dose is3 mg BID, and the maximum dose is 6 mg BID. There is a good

possibility that an Exelon patch may be available towards the end of2007.

Galantamine (Razadyne -- renamed from Reminyl because ofconfusion with Amaryl) has a starting dose of 4 mg BID, which can beincreased to the minimum effective dose of 8 mg BID after a minimumof 4 weeks. A further increase to 12 mg BID should be attempted afteranother four weeks, if the patient is tolerating the medication. For renalinsufficiency, the maximum dose should be kept at 16 mg/day.Galantamine is also available in an extended release form (RazadyneER) that can be dosed once a day. It is recommended that Razadyne

be taken with food.

Tacrine (Cognex) is rarely used because of its high GI side effects andsignificant hepatotoxicity. Tacrine is not suitable for use by mostprimary care physicians, and has very limited use even in the hands ofdementia specialists.

Common Side Effects of ChEIs

It is worth noting that even the common side effects of ChEIs are relatively

infrequent, but are seen most often during the titration periods. ChEIs are overallwell tolerated, especially when a slow approach to dose titration is used.Specialists in dementia report quite low rates of discontinuation of ChEIs becauseof side effects in clinical practice. Adverse effects may be gastrointestinal,cardiovascular, neuromuscular, or related to the central nervous system:

Gastrointestinal: Nausea, vomiting, diarrhea or abdominal pain mayresult in anorexia and weight loss.

Cardiovascular: Bradycardia, tremor or dizziness may result in astheniaand fatigue.

Neuromuscular: Muscle cramps and weakness may result in falls.

Central Nervous System: Insomnia, nightmares, agitation or a panic-likestate.

Developed by the Geriatric Education Center of Michigan (GECM), and the Michigan Primary Care DementiaNetwork. All GECM activities are funded through a grant from the Bureau of Health Professions of the HealthResources and Services Administration as authorized through Section 777(a), Title VII of the U.S. PublicHealth Service Act, as amended.Rev. 08.14.07

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Adverse event profiles reported in the Physicians Desk Reference suggest themost frequent side effect is nausea. Vomiting and diarrhea were reported morefrequently than anorexia, dizziness or fatigue.Other side possible side effects are:

Sleep disturbances, including insomnia and vivid dreams/nightmares Muscle cramps, fatigue, syncope

Worsening of peptic ulcer disease

We should use caution giving any cholinesterase inhibitor to patients with severeasthma or COPD as these drugs can cause bronchoconstriction. Closemonitoring of the pulmonary condition will keep serious problems from developingin most patients. These pulmonary problems are NOT absolute contraindicationsto the use of ChEIs we need to consider the potential benefits as well as thepossible risks. Symptomatic bradycardia is a possible side effect, especiallywhen combined with digoxin or calcium channel blockers that also slow the

conduction through the AV mode.

With slow dosage titration, ChEIs are generally well tolerated.

Comparing the Three Commonly Prescribed ChEIs

A meta analysis (Ritchie 2004) of many of the trials done comparing the threecommonly prescribed ChEIs found that all three drugs showed beneficial effects

on cognitive tests, as compared with placebo. For donepezil and rivastigmine,larger doses were associated with larger effect. This was not the case withgalantamine. The odds of clinical global improvement demonstrated superiorityover placebo for each drug, with no dose effects noted. Dropout rates weregreater with galantamine and rivastigmine. There was little difference in dropoutrate for each drug at each dose-level, except with high-dose donepezil. Insummary, all three drugs had similar cognitive efficacy, with donepezil andrivastigmine showing a dose effect across the dosing levels studied. However,both galantamine and rivastigmine were associated with a greater risk of trialdropout than placebo, especially at higher dosing levels.

Prices are comparable for all three agents. Donepezil is slightly cheaper by AWPpricing and slightly higher by Red Book data. As with all drug choices, we need toconsider individual formulary requirements in our selection.


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Donepezil has some perceived advantages over rivastigmine and galantamine:as the agent longest on the market, it has the most data available. It has thesimplest titration schedule and the lowest GI side effects according to datapresented in the PI.

The percentages of adverse events from monotherapy titration reported in the2006 Physicians Desk Reference were highest in every category (diarrhea,nausea, vomiting, anorexia, dizziness, and fatigue) for rivastigmine (6-12 mg).Galantamine (16-24) percentages were higher than donepezil (5-10 mg), exceptfor diarrhea, but the differences between galantamine and donepezil were lesssubstantial than the difference between rivastigmine and the other two. The datado not represent a head-to-head comparison.

Although some experts have suggested switching from one ChEI to another if theexpected benefit is not realized, this practice is not supported by either clinicaltrials or expert consensus. Switching is sometimes done when one CHEI is not

tolerated over the other, so in essence it may be done for safety purposes.

Other ChEI Considerations

Keep in mind that many drugs have anticholinergic effects (drugs for overactivebladder, antihistamines, antidepressants, etc.) that can not only decrease theefficacy of cholinesterase inhibitors but also independently worsen dementia,cause delirium and other CNS side effects. Studies suggest that serumanticholinergic activity (SAA) can be detected in most older persons in thecommunity and that even low SAA is associated with cognitive impairment(Mulsant 2003). Many patients with dementia are also using many othermedications for comorbidities. The risks of prescribing cholinesteraise inhibitorsalong with anticholinergic drugs needs to be diligently evaluated and monitored. Itis important to consider medications with mild anticholinergic effects along withthose with stronger effects since the anticholinergic burden is cumulative. Thecumulative anticholinergic burden is associated with higher incidence of deliriumand cognitive impairment.

Summary

ChEIs have been shown in prospective, randomized, double-blind, and placebo-controlled trials to:

Reduce the rate of cognitive decline for 6-12 months

Reduce the rate of functional decline for 6-12 months Stabilize or improve the clinician global impression of change

after 6-12 months


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patients yielded a 92 minutes per day reduction in caregiver time (compared tothe 52.4 and 32 minutes for donepezil and galantamine respectively). There isalso data to support the use of the two-drug combination (donepezil andmemantine) as being superior to donepezil alone for some domains of theNeuropsychiatric Inventory (NPI) for behavior.

Some experts are using memantine for the mild stage of disease, both alone andin combination with a ChEI. However, its use for the mild stage is off label sincethe FDA has not approved its use for mild disease and is unlikely to do so in thefuture. One U.S.-based trial has suggested it is valuable earlier in the dementiaprocess, but European studies have been negative.

Memantine seems to be even better tolerated than the cholinesterase inhibitors,both as a single agent and in combination with donepezil. In some patients,memantine causes dizziness, headache, or constipation. Less common adverseevents may include fatigue, pain, hypertension, vomiting, confusion or

somnolence, hallucinations, coughing, and dyspnea.

Start patients on 5 mg QD and slowly increase by 5 mg each week until a dose of10 mg BID is reached. It may be taken with or without food. Dose reductions(total dose of 5 mg/BID) for patients with moderate renal dysfunction (est CrCl 5-29 ml/min) should be considered, and it is not recommended for patients withsevere renal dysfunction. When starting therapy with both memantine and aChEI, consider starting the memantine first to reduce the likelihood of adverse GIeffects from the ChEI.

Use of memantine with other NMDA receptor antagonists (amantadine,dextromethorphan, ketamine, etc.) has not been evaluated in clinical trials, butcould be assumed to be problematic on theoretical grounds after prolonged orhigh-dose use.

OTHER AGENTS

Other potential treatment agents or supplements have been suggested, andpatients or family members may ask about them.

Vitamin E: A single trial showed controversial benefit with 2,000 IU/dayvs. placebo and selegiline. (Sano) The researchers concluded thatVitamin E was shown to delay nursing home placement and functionaldisability, but not cognitive decline. Critics of the study have noted that thestudy population did not reflect the general Alzheimers population:


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subjects were younger, had more severe dementia, and were not takinganypsychoactive medications.

A Cochrane review reported that there was insufficient evidence torecommend Vitamin E, and the AAN says that its use should be

considered. A recent meta-analysis of the risk of Vitamin Esupplementation (in all users, not just those with dementia) concluded thatsupplements higher than 400 mg per day were associated with a significantincrease in all-cause mortality (Miller ER, Annals of Internal Medicine 2005;142: 37-46). Subsequently, another large study showed no difference incardiovascular events or cancer and related mortality, but a possibleincrease in heart failure (Lonn 2005).

If you decide to use Vitamin E treatment, exercise caution in patientsalready taking antiplatelet or anticoagulant drugs because of the possibleincrease in the risk of bleeding.

Estrogen: Despite several descriptive studies that had shownpostmenopausal women taking estrogen supplements to have a lower rateof dementia, a large prospective trial has now shown that use of estrogencombined with progestin may actually increase the rate of dementia andstroke (Shumaker 2003). And in a related large prospective trial, therapywith estrogen alone showed an adverse effect on cognition that wasgreater among women with lower cognitive function at treatment outset(Espeland 2004).

Anti-inflammatories: Inflammation around the beta amyloid plaques andsubsequent neuronal destruction has been thought to be a key factor in thepathogenesis of Alzheimers disease, and several observational studieshave demonstrated that people who regularly use NSAIDs have adecreased incidence of Alzheimers. However, neither NSAIDs norprednisone have been shown to have any benefit in the treatment of thoseidentified with Alzheimers in prospective, randomized, placebo-controlledtrials.

Statins: Observational studies have shown a decrease in Alzheimersdisease as well as slowing of its progression with the use of statins. Alarge cooperative randomized controlled trial of simvastatin is underway,but results may be delayed. Researchers have found that so manypatients are now already on statins or have strong indications for their use,that recruitment of subjects eligible for randomization has been slower thananticipated.


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Complementary/alternative therapies: There is insufficient evidence tosupport the use of any other treatments for dementia. A large NIA trial withhuperizine (an acetylcholinesterase inhibitor found in Chinese Club Moss)is underway.

STOPPING PHARMACOLOGIC TREATMENT

There is no clear consensus regarding how or when to stop any of thepharmacologic agents for dementia. As with most clinical decision-making, thismust be evaluated on an individual basis. We need to assess and weigh thebenefits and burdens (including cost and side effects) of treatment in light of thepatients earlier expressed wishes and with the caregiver or decision-maker.

Some experts recommend that pharmacologic therapy should be continued untilthere are no meaningful social interactions and quality of life has irreversibly

deteriorated (Farlow & Cummings). This recommendation assumes that thepatients cognitive and functional status are monitored at six-month intervals.

When considering withdrawal of treatments aimed at altering the course ofdementia, we need to consider what function the patient still has that is worthpreserving. The answers, of course, vary according to individual values andsituations.

Most experts do agree that ChEIs and memantine should be stopped at thepoint that the patient no longer has meaningful function and/or when thepatient is enrolled in hospice services. Is this patient doing anything that

we want to preserve?

Do NOT perform a trial off medication. Prior level of benefit is unlikely tobe regained and there may be a precvipitous decline after stopping.

After a patient has been hospitalized and needs to be re-initiated on theChEI, the drug should be re-titrated from the starting dose. This isespecially true for rivastigmine and galantamine; even a 2-week stoppinginterval necessitates restarting therapy at the lowest dose.


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References

American Academy of Neurology. AAN Guideline Summary for Patients and TheirFamilies: Alzheimers Disease. (Accessed 08/08/05 at http://www.aan.com/.)

Beier MT. Cholinesterase inhibitors and anticholinergic drugs: Is thepharmacologic antagonism myth or reality? J Am Med Dir Assoc2005;6(6):413-4.

Bentu-Ferrer D, Tribut O, Polard E, Allain H. Clinically significant druginteractions with cholinesterase inhibitors: A guide for neurologists. CNS Drugs2003;17(13):947-963.

Espeland MA, Rapp SR, Shumaker SA, Brunner R, Manson JE, Sherwin BB, HsiaJ, Margolis KL, Hogan PE, Wallace R, Dailey M, Freeman R, Hays J. Conjugated

equine estrogens and global cognitive function in postmenopausal women:Womens Health Initiative Memory Study. JAMA 2004;291(24):2959-68.

Farlow MR, Cummings JL. Effective pharmacologic management of Alzheimersdisease. Am J Med 2007;120(5):388-97.

Feldman H, Gauthier S, Hecker J, Vellas B, Emir B, Mastev V, Subbiah P.Efficacy of donepezil on maintenance of activities of daily living in patients withmoderate to severe Alzheimers disease and the effect on caregiver burden. J AmGeriatr Soc2003;51(6):737-44.

Lonn E, Bosch J, Yusuf S, Sheridan P, Pogue J, Arnold JM, Ross C, Arnold A,Sleight P, Probstfield J, Dagenais GR.. Effects of long-term vitamin Esupplementation on cardiovascular events and cancer: A randomized controlledtrial. JAMA 2005;293(11):1338-47.

Miller ER 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E.Meta-analysis: High-dosage vitamin E supplementation may increase all-causemortality. Ann Intern Med2005;142(1):37-46.

Mulsant BH, Pollock BG, Kirshner M, Shen C, Dodge H, Ganguli M. Serumanticholinergic activity in a community-based sample of older adults: relationshipwith cognitive performance. Arch Gen Psychiatry, 2004. 60(2):198-203.

Ritchie CW et al. Meta analysis of randomized trials of the efficacy and safety ofDonepezil, Galantamine, and Rivastigmine for the treatment of Alzheimerdisease. Am J Geriatr Psychiatry2004;12:358-69.


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Sano M, Wilcock GK, van Baelen B, Kavanagh S, The effects of galantaminetreatment on caregiver time in Alzheimers disease. Int J Geriatr Psychiatry2003;18(10):942-50.

Sano M, Ernesto C, Thomas RG, Klauber MR, Schafer K, Grundman M,

Woodbury P, Growdon J,Cotman CW, Pfeiffer E, Schneider LS, Thal LJ. Acontrolled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimersdisease. The Alzheimers Disease Cooperative Study. N Engl J Med1997;336(17):1216-22.

Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, Hendrix SL,Jones BN 3rd, Assaf AR, Jackson RD, Kotchen JM, Wassertheil-Smoller S,Wactawski-Wende J, WHIMS Investigators. Estrogen plus progestin and theincidence of dementia and mild cognitive impairment in postmenopausal women:The Womens Health Initiative Memory Study: A randomized controlled trial.JAMA 2003;289(20):2651-62.

Wimo A, Winblad B, Stoffler A, Wirth Y, Mobius HJ. Resource utilization and costanalysis of memantine in patients with moderate to severe Alzheimers disease.Pharmacoeconomics2003;21(5):327-40.


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1

Dementia in Primary Care

Developed by the Geriatric Education Center of Michigan (GECM), and the Michigan Primary Care Dementia

In this module, learn about:

Epidemiology and under-diagnosis of dementia

Barriers to diagnosis

Benefits of early diagnosis

Signs that should trigger an investigation of possible dementia

DEMENTIA A GROWING HEALTH CONCERN

Diagnoses of Alzheimers disease and other dementia causing disorders have

grown rapidly in the last twenty-five years. It is estimated that 4.5 millionAmericans now have Alzheimers - more than twice the number in 1980. Thosenumbers are only expected to rise in the years to come, with projections of a 44%increase by 2025, and perhaps a tripling of todays number by 2050. Even inMichigan, with a rate of growth in the elderly population significantly lower thanthat of the Sunbelt states, a 12% increase in people living with Alzheimers isprojected for the next two decades.

The impact of dementia can also be seen in its incidence, which rises rapidly asan older adult ages. Studies have shown that from age 65, incidence doublesevery five years, and that up to 50% of those over age 85 are suffering from

dementia.

Today, Alzheimers disease and other dementias account for at least 40% and, bysome estimates, up to 60% of nursing home admissions. Dementia is the thirdmost expensive disease to treat in the United States, after cancer and heartdisease. However, generally diagnoses of dementia are still not made untilpatients are quite far into the course of the disease, even though helpfulinterventions could be startedmuch earlier.

THE ROLE OF THE PRIMARY CARE PHYSICIAN

The symptoms of Alzheimers disease (and many other dementias) develop soslowly that they can go unnoticed for a very long time. Or, if they are observed,changes may seem so slight that their significance is not recognized.Additionally, the lack of self-awareness that is part of dementia makes it less likelythat patients will report their own problems.

Network. All GECM activities are funded through a grant from the Bureau of Health Professions of the HealthResources and Services Administration as authorized through Section 777(a), Title VII of the U.S. PublicHealth Service Act, as amended. Rev. 02.28.07


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Despite these and other impediments to the timely assessment of cognitiveimpairment, current knowledge and assessment tools can lead to earlierdiagnoses of dementia than is now the norm. The primary care physician whoknows what signs to look for in elderly patients and what follow-up tools areavailable can act as an effective early warning system. In fact, the physician who

routinely assesses elderly patients for early signs of dementia is often the key todetermining whether patients and families will receive information, guidance, andappropriate interventions when they can help the most.

The effects of those interventions should not be underestimated. Many primarycare physicians are unaware of recent changes in treatments for Alzheimers andrelated disorders, and of the effective medications that are available. Thesemedications can be successfully prescribed and managed in a primary caresetting. In general, the earlier they are started, the better.

Given the prevalence of Alzheimers in patients over age 65, dementia is a

possibility that ought to be in the forefront of our thinking when seeing olderpatients. As primary care physicians, we can familiarize ourselves with thecommon triggers that should raise the suspicion of dementia. These triggersinclude communication problems, missed appointments, medication managementissues, a history of delirium, and more, discussed in detail later in this module.

Dementia is a significant problem for elderly patients, their families and societyas a whole. Primary care physicians can improve the rate of early diagnosis and treatment.

COMMON BARRIERS TO DIAGNOSIS

Early diagnosis of dementia can make a significant difference in the lives ofpatients and their families and caregivers, but it is relatively rare that a diagnosisis made early in the course of the disease. Most diagnoses are made much later,at a point when the patient is suffering from serious functional as well as cognitivedecline.

The insidious onset of dementia is not the only reason it goes undiagnosed.There are also barriers to diagnosis that relate to patients and their families,

physicians and their practices, and the attitudes of the larger culture. Forexample, there are individuals who may be so frightened by symptoms of mentaldecline that they deny them, or busy office practices for which the timecommitment to diagnose and manage dementia might seem overwhelming. Andto the degree that the subject of dementia is considered taboo in our society, it iseasy to respond to barriers with silent acquiescence. But to a large extent, theseobstacles and the concerns that lie behind them can be addressed througheducation of practitioners and the public.

Developed by the Geriatric Education Center of Michigan (GECM), and the Michigan Primary Care DementiaNetwork. All GECM activities are funded through a grant from the Bureau of Health Professions of the HealthResources and Services Administration as authorized through Section 777(a), Title VII of the U.S. PublicHealth Service Act, as amended. Rev. 02.28.07


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One of the biggest concerns is that making the diagnosis of dementia will open awhole Pandoras Box of troubles a series of problems that will only expand andnever be resolved. Given the degenerative course of the disease and itsincurable nature, this attitude understandably gives rise to the feeling that the

topic is best avoided. But while the frightening diagnosis of dementia mightsuggest a state of affairs that is beyond control, there are steps that can be takento improve a difficult situation.

Understanding the facts about barriers and misconceptions is a good place tostart.

Barriers- Uncertainty about the Diagnosis

Because the symptoms of the most common dementia disorders reveal

themselves so slowly, over the course of months and years, it can be difficult forphysicians to identify dementia in its earliest stage. It may be hard to recognizethat a problem even exists especially when our encounters with a patient areisolated and relatively brief, and concerns are not raised by family members oroffice staff. Unless a patient comes in with a specific complaint related to memoryor confusion, its quite possible that no immediate cause for concern in thoseareas will present itself.

But even when the suspicion is raised by a patient, family or office staff, orthrough the use of screening tools, thisis only a first step in diagnosis. We mustthen ask if dementia really is involved. Or is, perhaps, a condition whosesymptoms mimic dementia, like depression or delirium, involved? Furtherevaluation will be required to resolve these questions.

Physicians might also ask whether a patients dementia results from Alzheimersdisease or some other cause of dementia. Again, additional evaluation can helpprovide answers, and these answers will sometimes influence treatmentdecisions. But it is important to note that Alzheimers is by far the leading causeof dementia in the population aged 65 and older. Alzheimers alone or incombination with vascular dementia accounts for 70% of dementia in that agegroup. A consensus panel representing the American Association for GeriatricPsychiatry, the Alzheimers Association, and the American Geriatrics Society hasrecommended Alzheimers be considered a diagnosis of inclusion. That is,unless specific, positive findings indicate another form of dementia or a disorderthat mimics dementia, it is appropriate for the physician to make a clinicaldiagnosis of Alzheimers. It should also be noted that Alzheimers disease is ofteninvolved even when other causes of dementia are identified. Clinicians who seedementia in elderly patients can reasonably assume that Alzheimers is what theyshould always suspect.



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Alzheimers is by far the most common cause of dementia in the elderlypopulation, and is often present even when other causes are identified.

The primary care physician can accurately diagnose Alzheimers and otherdementias in an office setting. We simply need to be alert to common triggersand warning signs of dementia, and to employ easy-to-use cognitive screeningtools (both triggers and tools are discussed in the Clinical Diagnosis section ofthis module). When findings are ambiguous, repeated observations and testingover time will lead to a clear answer. Given dementias slow onset, it cannot beoveremphasized that this diagnosis over time is central to our ability to correctlyidentify and treat it in the primary care setting.

Barriers Mistaking Signs of Dementia for Normal Aging

Instances of mild memory loss and cognitive slowing are common as we growolder and include: forgetting where we placed the car keys, occasionally failing toremember a name, andslowing down on some problem solving tasks. It may behard to distinguish these common losses from the earliest stage of dementia.

However, as dementia progresses, the distinctions between disease and normalsigns of aging are apparent.

Signs of Normal Aging Compared with Signs of Dementia

NORMAL AGING DEMENTIAOccasional short-term memory lapses(lost details can be restored byprompts)

Increasing short-term memoryproblems, which interfere with dailyliving (unresponsive to promptsbecause new memories are not beingformed and cannot be retrieved)

Awareness of memory lapses No awareness of memory problemsOften needs reminders aboutappointments, medication schedule,etc.

Forgetting where car keys were left Forgetting what car keys are for

Occasionally misplacing items Frequently misplacing itemsLeaving things in unusual places (e.g.,milk in the breadbox)

Occasionally forgetting a word Frequent inability to come up withwords, communicate clearly,



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understand what is being saidForgetting someones name Difficulty identifying a close friend or

relativeTaking longer to perform tasks Inability to perform familiar tasksTaking longer to solve problems Problems with abstract thinking

Additional symptoms that should berecognized as possible signs ofdementia:Withdrawal, loss of interestMood and behavior changesDecreased ability to make good

judgmentsTrouble remembering the date, time orplace

A person might forget the location not only of keys, but of valuable objects.Failure to recall names becomes common, and the patient may have troubleremembering the names of close family members. Even simple tasks begin tocause difficulties. As these problems increase, along with declines inorganizational ability and reading comprehension, they become more noticeableto family members. Additionally, those close to the patient may see signs ofbehavior changes that include paranoia, withdrawal or poor hygiene. Thesesymptoms are not signs of normal aging but of illness, and we ought to replaceold assumptions about what is normal aging with increased clinical suspicion ofdementia.

Barriers Lack of Appreciation for the Impact of Early Intervention

It stands to reason that if we see no ready benefit, we will be less likely to movequickly toward a diagnosis of dementia. Thats why it is important to know thataddressing dementia early in its course can have a substantial positive impact onthe lives of patients and families. This applies not only to drug therapies thatmight slow disease progression, but to the psychosocial aspects of the illnesssuch as family stress and the patients sense of control, and to physical safetyissues. See the Benefits of Early Intervention section in this module for additional

information.

Barriers Pessimism about Disease Progression and Outcome



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Without a clear understanding of the benefits that drug treatments and otherinterventions can bring to patients with dementia and their families, it is easy toview dementia disorders in an extremely pessimistic light. That the disease isincurable and irreversible may come to seem the only facts that count.

Thus, physicians may act or rather fail to act, on the unspoken assumption thatdiagnosis does not matter because theres nothing to be done. This messagemay in turn be conveyed to patients and families even when it is not explicitlydiscussed. A pessimistic outlook leads physicians not to want to talk aboutdementia, and families not to want to ask.

Barriers Inadequate Reimbursement

The familiar issue of reimbursement that rewards procedures more than thoroughdoctor-patient communication can be a disincentive to evaluation and treatment of

dementia. In addition, there are ICD-9 coding issues unique to dementia.Physicians generally tend to under-code for complex office visits, and aretherefore under-reimbursed. If physicians do not overlook aspects of theevaluation and management of dementia patients that increase the complexity ofvisits, many of visits may qualify for a higher E/M code.

Barriers Patient and Family Awareness

People who begin to experience memory loss and confusion in the initial stage ofdementia can find the experience frightening. Yet it may be hard for them toshare their feelings and worries with family members or health professionalsbecause they have a sense, as we all have, that naming out loud the thing wefear will make it so. This is the well-known phenomenon of denial, a defensemechanism that can certainly play a positive role in peoples lives, allowing themto digest unpleasant facts at a manageable pace. But when denial becomes fixedand allows no room at all for reality to settle in, it stands in the way of a timelydiagnosis, and getting the help the patient needs

Just as individuals who suffer from the onset of dementia try to hide the facts fromthemselves and others, family members may also practice denial. They too fearfor their loved ones future, and so they see but refuse to acknowledge the signsof dementia. They might even compensate for the ill persons increasing deficits,offering to share tasks but in fact taking them over because the individual is nolonger competent. This can go on for months and years, as the problem onlycontinues to worsen.



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BENEFITS OF EARLY DIAGNOSIS

A diagnosis of dementia is most likely to be made well into the course of the

disease, when the patient has begun to have serious trouble carrying out theactivities of daily living and is showing impaired judgment. The disease hasreached a point where family members can no longer ignore or deny it.

What this means in practical terms is that by the time the illness is recognized forwhat it is, the family is already in crisis. There may have been an accident orhospitalization, or a scary episode in which the ill person has become lost. Thepatients ability to do basic self-care may in practical terms be gone. Patient andfamily are understandably confused and frightened, but hardly have room torespond emotionally because there are decisions that must be made decisionsthey are totally unprepared to face.

At the same time, the physician will realize that the value of medications thatmight have slowed the patients decline has diminished, and that time has beenirretrievably lost.

When the diagnosis is made early, at a time when symptoms are present put lesssevere, it is possible to:

Reduce family stress and burden

Empower the person with dementia Use medications more effectively