cognitive impairment in the elderly - recognition ... · 3 cognitive impairment in the elderly –...

BRITISHCOLUMBIA

MEDICALASSOCIATION

Cognitive Impairment in the Elderly – Recognition, Diagnosis and Management

Effective Date: July 15, 2007Scope

This guideline summarizes current recommendations for recognition, diagnosis and longitudinal management of cognitive impairment and dementia in the elderly. Where the guideline refers to “people affected by dementia”, this indicates not only the person with dementia but also the people in their “network of support”.

Summary recommendation Care Objectives

The primary care objectives are to encourage early recognition and assessment of cognitive impairment and to support general practitioners in the development of a comprehensive care plan that includes the identification of community resources for the people affected by dementia. A summary is provided for this guideline and can be used as a worksheet in the physician’s office.

Part I: Recognition and Diagnosis

recommendation 1 Recognition

a. General population screening in asymptomatic individuals is not recommended at this time.

b. Cognitive impairment should be suspected when there is a history that suggests a decline in occupational, social or day-to-day functional status. This might be directly observed or reported by the patient, concerned family members, friends and/or caregivers.

Symptoms of Cognitive Impairment

• Asksthesamequestionrepeatedly• Cannotrememberrecentevents• Cannotprepareanypartofamealormayforgetthattheyhaveeaten• Forgetssimplewords,orforgetswhatcertainobjectsarecalled• Getslostinownneighbourhoodanddoesnotknowhowtogethome• Dressesinappropriately(e.g.maywearsummerclothingonawinterday)• Hastroublefiguringoutabill,orcannotunderstandconceptssuchasbirthdays• Repeatedlyforgetswherethingswereleft;putsthingsininappropriateplaces• Hasmoodswingsfornoapparentreasonandespeciallywithoutpriorpsychiatrichistory• Hasdramaticpersonalitychanges;maybecomesuspicious,withdrawn,apathetic, fearful, or inappropriately intrusive, overly familiar or disinhibited• BecomesverypassiveandrequirespromptingtobecomeinvolvedAdapted from the Alzheimer Society of Canada: www.alzheimer.ca

Revised:January30,2008

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Cognitive impairment in the elderly – reCognition, diagnosis and management

revised January 30, 2008Cognitive impairment in the elderly – reCognition, diagnosis and management

revised January 30, 2008Diagnostic Code: 290

c. Atpresentation,differentiate,treat,andruleoutremediableand/orcontributorycause(s)ofcognitiveimpairmentsuchasthyroiddisorders,hypercalcemia,alcoholdependence,etc.(CanadianConsensusGuideline).Dementia,delirium,depressionandadversedrugeffectsarethemainconditionstoconsiderinthedifferentialdiagnosisofcognitiveimpairment(SeeTable1).

d. Completeacomprehensivereviewofmedicationhistory(type,dosageandcompliancefor bothprescriptionandover-the-counter).Anymedicationmaybeimplicated.

Table 1: Clinical Features of Dementia, Depression and Deliriuma

FEATURE DEMENTIA DELIRIUM DEPRESSION

Onset •Insidious • Acute •Gradual;maycoincide withlifechanges

Duration •Monthstoyears • Hourstolessthanonemonth, •Atleasttwoweeks, seldomlonger butcanbeseveral monthstoyears Course •Stableandprogressive • Fluctuates:worseatnight •Diurnal:usuallyworse VaD*:usuallystepwise • Lucidperiods inmornings,improves asdaygoeson Alertness •Generallynormal • Fluctuateslethargicorhyper-vigilant •Normal

Orientation •Maybenormalbutoften • Alwaysimpaired: •Usuallynormal impairedfortime/later time/place/person inthedisease,place

Memory •Impairedrecentand • Globalmemoryfailure •Recentmemorymaybe sometimesremotememory impaired •Long-termmemory intact

Thoughts •Slowed;reducedinterests •Disorganized,distorted,fragmented •Usuallyslowed, •Makespoorjudgements •Bizarreideasandtopicssuchas preoccupiedbysad •Wordsdifficulttofind paranoidgrandiose andhopelessthoughts; •Perseverates somaticpreoccupation •Moodcongruent delusions

Perception •Normal •Distorted:visualandauditory •Intact •Hallucinations(oftenvisual) •Hallucinationscommon •Hallucinationsabsent exceptinpsychotic depression

Emotions •Shallow,apathetic,labile • Irritable,aggressive,fearful •Flat,unresponsiveor •Irritable sadandfearful •Maybeirritable

Sleep •Oftendisturbed,nocturnal • Nocturnalconfusion •Earlymorningwakening wanderingcommon •Nocturnalconfusion

Otherfeatures •Poorinsightintodeficits •Otherphysicaldiseasemaynotbe •Pasthistoryofmood •Careless obvious disorder •Inattentive •Pooreffortoncognitive testing;givesupeasily

StandardTests •Comprehensiveassessment •ConfusionAssessmentMethod(CAM) •GeriatricDepression (history,physical,lab,SMMSE) seeAppendixA Scale(GDS)see AppendixB aAdaptedfromtheCentreforHealthInformaticsandMultiprofessionalEducation(CHIME),UniversityCollegeLondon.Dementiatutorial:Diagnosisandmanagementinprimarycare:Aprimarycarebasededucation/researchproject.www.ehr.chime.ucl.ac.uk/display/demcare/Home

*VaD: Vascular Dementia

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recommendation 2 Diagnosis

When delirium and depression have been treated and/or ruled out and cognitive impairment is still present, suspect dementia or mild cognitive impairment(MCI)astheunderlyingcause.Itmaybenecessary to complete the diagnostic evaluation over a few visits.

1. HISTORY– RECOGNIZING SIGNS OF DEMENTIA Inthediagnosticwork-upofpatientswithsuspectedmildcognitiveimpairmentordementia,itis

important to consider collateral information from family and caregivers.

Course of cognitive decline:Gradualandprogressive(usuallyAlzheimer’sdisease[AD]); suddenorstepwise(stroke,orpossiblyVaD);rapid(considerpriondisease)

Presence of day-to-day or intra-day fluctuations:Markedfluctuationincognitionoralertness maybeahallmarkofDementiawithLewyBodies(DLB)

Presence of amnesia(impairedmemory):Askforexamplesofthepatient’sforgetfulnessor disorientation

Presenceofdeficitsinexecutivefunctions:Problem-solving,sequencing,multi-tasking, conceptualizing,mentalflexibility,abstractthinking,etc.

Presence of language deficits: Difficulty finding words, loss of speech fluency, word substitutions, problems with verbal comprehension, etc.

Presence of agnosia(impairmentofrecognitionoffacesorobjects):Notcommonasa presenting feature of dementia

Presenceofapraxia(impairmentofperformingprogrammedmotortasks):Examples:playing an instrument, tying shoelaces or a tie, sewing or knitting

Presence of delusions:Examples:paranoiddelusionssuchasirrationalsuspiciousness, concerns of infidelity, etc.

Presence of hallucinations:VividhallucinationsaresuggestiveofDLB Gait abnormalities:AriselaterinAD;earlierinVaD,DLBandnormalpressurehydrocephalus

(NPH) Urinaryincontinence:Ifurinaryandgaitproblemsoccurearlyinthecourseofcognitive

impairment,considerNPH Impairedinstrumentalactivitiesofdailyliving:Aprerequisiteforthediagnosisofdementia

Examples:cannolongerperformjobsatisfactorily,unabletomanagefinances,trouble driving, cannot play bridge or keep score in golf, cannot cook from a recipe, unable to use public

transit, etc. Impairedbasicactivitiesofdailyliving: Declining ability to dress, toilet, groom, or attend to

hygiene or nutrition Other behavioural issues:Lackofinitiative,apathy,irritability,anger,andsocialdisengagement

orbehaviouraldisinhibition(inappropriatelyintrusiveoroverfamiliar)

2. PHYSICAL EXAM a.Identifymedicalconditionscontributingtocognitivedecline,and; b.Identifyneurologicabnormalitiesincludinglocalizingsigns,extrapyramidalsignsandataxia.

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3. LABORATORY TESTS ThefollowingtestsarerecommendedintheinitialworkupofsuspectedMCIordementia:

• Completebloodcount • Serumelectrolytes • Serumcalcium • Serumglucose • ThyroidStimulatingHormone(TSH) • B12*

*Observational studies suggest elevated total homocysteine levels are a risk factor for dementia and impaired cognitive function.1,2 These effects may be mediated by impaired function of the B vitamins involved in homocysteine metabolism (B12, folate and B6). Current data from systematic reviews of randomized double blind trials, however, do not provide evidence of improvement in cognition or dementia with B12 treatment.3

Othertestsmaybeaddedasindicatedbyclinicalsuspicion(e.g.SerologicalTestforSyphilis[STS],HIV,renalfunctiontests,liverfunctiontest).

4. NEUROIMAGING4,5

Neuroimaging(CTorMRIofhead)isnotroutinelyindicatedbutmaybeusefulwhen:

• Thepatientislessthan60yearsold • Theonsethasbeenabruptorthecourseofprogressionrapid • Thereisahistoryofsignificantrecentheadinjury • Thepresentationisatypicalorthediagnosisisuncertain • Thereisahistoryofcancer • Therearenewlocalizingneurologicalsignsorsymptoms • Vasculardementiaissuspected • Thepatientisonanticoagulantsorhasableedingdisorder • Thereisahistoryofurinaryincontinenceandearlypresentationofgaitdisorder

5. COGNITIVE TESTING • Diagnosticcriteriarequirethatthereshouldbeobjectiveevidenceofamemorydeficitto support the diagnosis. • PerformanobjectivetestofcognitionsuchastheStandardizedMiniMentalStateExamination

(SMMSE).WhilethenormalrangeforSMMSEscoresis24-30,performanceonthistestmust be interpreted along with the other information gathered such as sensory impairment, educationattainment,languageandculturalissues.CognitivestatusindicatedbytheSMMSE isanimportantbenchmarkforfollowingthecourseofcognitiveimpairment(AppendixC).

• Supplementarytesttoconsider:ClockDrawingTest(AppendixD). 6. WORKING DIAGNOSIS Arriving at a specific dementia sub-type diagnosis will aid in treatment planning and counselling.

BroaderuseofDSM-IVTRcategoryof‘dementiaduetomultipleetiologies’isencouraged,withspecificationofthediseasescontributingtothedementiaroutinelyspelledout(ThirdCanadianConsensusConferenceontheDiagnosisandTreatmentofDementia,2006).5

The major clinical pathological subtypes of dementia are outlined in the list that follows, although mixedformsofdementiaarecommon(e.g.Alzheimer’sandVaD).Lesscommontypesofdementias,suchasTraumaticBrainInjury(TBI),shouldbeconsideredintheclinicalcontext.

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Table 2: Differential Diagnosis of Dementia

Alzheimer’sDisease(AD)

VascularDementia(VaD)

MixedAD/VaD

DementiaWithLewyBodies(DLB)

Parkinson’sDiseaseDementia(PDD)

Fronto-TemporalDementia

1. Slowprogressiveonset2. Multiplecognitivedeficitsmanifestedbyboth: • Memoryimpairment • Oneormoreadditionalcognitivedeficitssuchasaphasia,apraxia,agnosia,disturbancein executivefunctioning3. Associatedsignificantfunctionaldecline4. Notexplainedbyotherneurologicorsystemicdisorders

ThedegenerativechangesofADandthevascularchangesofVaDcommonlyco-exist.PresentationmorecommonlyofADpatternwithsignificantvascularriskfactors+/-smallvascularevents

1. Corefeatures: • Fluctuatingcognitionwithpronouncedvariationinattentionandalertness(memorydecline maynotbeanearlyfeature) • Recurrentvisualhallucinationsthatarewellformedanddetailed • SpontaneousmotorfeaturesofParkinsonism2. Featuressupportiveofdiagnosis: • Repeatedfalls • Syncopeortransientlossofconsciousness • Hypersensitivitytoantipsychotics(typicalandatypical) • Systematizeddelusions;non-visualhallucinations3. DLBhasreducedprevalenceofrestingtremorandreducedresponsetoL-dopacomparedtoidiopathicPDD4. PresenceofREMsleepdisorderinthesettingofadementiasuggestsDLB&relatedconditions5. DLBshouldoccurbeforeorconcurrentlywithonsetofParkinsonism

1. ThecognitivefeaturesmayappearsimilartoDLB(deficitsinattentionandalertness)2. LookformotorParkinsoniansymptomsthattypicallyarepresentmanyyearsbeforetheonsetofthe dementiaforPDD

1. Insidiousonsetandgradualprogression;tendstopresentinmiddle-agedpatients2. Characterchangespresentearlyandincludeapathy,disinhibition,executivefailurealoneorincombination3. Relativelypreservedmemory,perception,spatialskillsandpraxis4. Behaviouraldisordersupportiveofdiagnosis:declineinhygiene,mentalrigidity, distractibility,hyperorality,perseveration5. Prominentlanguagechangesfrequentlyoccurwithreductioninverbaloutput

1. Anumberofsyndromestypicallyassociatedwithcerebrovasculardisease2. Lookforabruptonset,step-wisedeclineandatemporalrelationshipbetweenthe vascularinsultandthecognitivechange3. Impairedexecutivefunctioningandearlydevelopmentofagaitdisturbanceareaddedfeatures4. Clinicalandneuroimagingevidencesupportsthediagnosis5. Commonlyseeperiventricularanddeepwhitematterchanges,howevertheymayalso beseeninothertypesofdementiaandinotherwisehealthyindividuals(usecaution)

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7. MILD COGNITIVE IMPAIRMENT (MCI) • AdiagnosisofMCIismadewhenothercausesofimpairedcognition(e.g.anxiety,depression,

deliriumorsubstanceabuse)havebeenexcludedandthepatientdoesnotmeetthe criteria for a diagnosis of dementia either because they lack a second sphere of cognitive impairment or because their deficits are not significantly affecting their daily living.

• Incaseswherethereisasuspicionofcognitiveimpairmentorconcernaboutthepatient’s cognitivestatus,andtheSMMSEscoreisinthe“normalrange”(24-30),theMoCA6 isrecommended[AppendixE](ThirdCanadianConsensusConferenceontheDiagnosisand TreatmentofDementia,2006).5

• PatientswithMCImayprogresstodementiaatarateof16%peryear.7 Once identified, patientswithMCIshouldbere-examinedperiodically(e.g.every6months)sothattreatment and counselling can be offered and incident dementia can be identified.

8. STAGING SomecliniciansstageADusingtheGlobalDeteriorationScale(SeeAppendixF).

recommendation 3 Diagnosis Disclosure

a. The disclosure of a diagnosis of dementia should be done as soon as possible, but can cause significantstress.Thetimingandextentofdisclosureshouldbeindividualizedandisbestcarriedoutoverafewvisitssupportedbyreferraltoothersupportresources(seePatient/CaregiverGuide).

•Ingeneral,thereareonlyafewexclusionstodisclosure,includingprobablecatastrophic reaction, severe depression or severe dementia

• Disclosureisfacilitatedthroughaninitialopen-endedapproach,e.g.asking:“What do you think the change in your memory and thinking is due to?”

b. Insettingupthevisitfordisclosure,considerpatientprivacyandaskwhetherthecaregivercanbeinattendance(theanswerwillbeyesinmostsituations).

c. At the initial disclosure visit highlight: • Dementiawithdementiasub-typeasaclinicaldiagnosis • Anticipatedprognosis • Indicatethatyouwillfollow-upandprovideongoingsupport • ProvidethePatient/CaregiverGuide,discussothersupportresourcesasappropriate • Provideascheduleofvisitsandbookthenextvisit

d. Atfollow-upvisitsdiscuss(atleastevery6months): • Informationneedsandconcerns • Advanceplanningwithrespecttofinancesandpatientpreferences • Safetyplanning • Availabilityofeducationandsupportresources

e. Disclosure when mild cognitive impairment is diagnosed needs to be carefully considered. Monitoringuntilprogressioninthecognitivedeficitisdemonstratedmaybereasonable,butdisclosure of the diagnosis with information about the risk of progression to dementia may allow the person to better understand their situation and participate in monitoring for further cognitive decline or associated functional changes or depression.

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Part II: Management of Dementia

recommendation 4 Practice Management

a. Organizationalinterventionswithinachronicdiseasemanagement(CDM)approachthatfacilitateproactive care and support are integral to improving care for people with dementia. Physicians are

encouraged to: • Establishadiseaseregisterandrecallpatientsforreviewinatimelymanner • Periodicallyreassesspatientsatplannedvisitsdedicatedsolelytothecareofdementia • Organizeandfocusbyuseofaclinicalactionplanaddressingdementiaandco-morbid

conditions(seeoptionalCognitive Impairment in the Elderly Flow Sheet,AppendixG) • Establisharelationshipwiththepersonwithdementia,family/caregiversandinvolvethemas

much as possible in setting goals and making decisions related to care and support

b. Consider referral to secondary services for the assessment of dementia in appropriate cases such as:

• Diagnosticuncertaintyoratypicalfeatures • Managementissuesthataredifficulttoresolve • Riskofharmtoselforothers • Requestoffamilyorcaregivers

c. Involvealliedhealthprofessionalsinthecareofthepatientwhenindicated(e.g.Homeand CommunityCarecasemanagers,mentalhealthteams,etc.).

recommendation 5 Driving

a. After early cognitive deficits are first diagnosed, consider entering into a discussion with the affected patient about eventual driving cessation. Assist the affected driver to make the necessary lifestyle changes early and to cease driving by choice rather than by compulsion. Encourage patienttoregisterwithHandyDart,HandyPASSandTaxiSavers(seeResourcessection).

b. An individual’s competence for driving should be assessed using both cognitive and non-cognitive criteria(e.g.othermedicalconditionsandspecialsensorydefects),andincludecollateralhistoryabout the individual’s driving habits from observers. On cognitive testing, deficits in attention, visuospatialabilitiesandjudgmentmaybepredictorsofdrivingrisk.Whendoubtexistsaboutapatient’s driving competence, physicians should recommend a performance-based evaluation suchasare-examroadtestbytheInsuranceCorporationofBritishColumbia(ICBC)oradriverfitnessreviewthroughtheOfficeoftheSuperintendentofMotorVehicles.

c. InaccordancewiththeBC Motor Vehicle Act,physiciansarerequiredtodocumentpatientsundertheir care who have a condition incompatible with safe driving and to instruct these patients to stopdriving.Ifthephysicianlearnsthatthepatientcontinuestodrivedespitethisinstruction,thephysicianisrequiredtonotifytheSuperintendentofMotorVehicles(Motor Vehicle Act section 230, subsections 1-3).

d. Notwithstandingtheseminimumrequirements,physiciansmayopttonotifytheSuperintendentofMotorVehiclesofanypatientwithaconditionincompatiblewithsafedriving.

e. When approached by friends or family members of individuals who may be driving unsafely due to a medical condition, but who do not attend a physician, those members of the public can be told tonotifytheSuperintendentofMotorVehiclesoftheirconcerns.

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recommendation 6 Self-Neglect, Neglect and Abuse

a. Physicians need to be aware of the potential risks for self-neglect, neglect and abuse by caregivers andothers(financialorpsychologicalabuse)

b. RefertoHomeandCommunityCareorgeriatricoutreachteams(wheretheyexist)inthehealthauthorities.Also,CommunityLivingBChasbeendesignatedunderguardianshiplegislationtoinvestigate situations of potential self-neglect, neglect and abuse

c. FormoreinformationfromthePublicGuardianandTrusteeofBC,seethepublication,Protecting Adults from Abuse, Neglect and Self-Neglect online at: www.trustee.bc.ca/reports_publications/index.html

recommendation 7 General Care and Support

Supportpatientfunctioningatthemaximumlevelofindependenceappropriateforhis/hercognitiveandphysicalcapabilities.Forpatientswithearlydementiawhoarestilllivinginthecommunity,itisimportantto identify the following issues and refer to support resources as appropriate:

a. Nutrition • Ifthepatientislivingaloneandisresponsibleforhisorherownfoodpreparation,weighthe

patient regularly to monitor for weight loss • ConsidertheuseofmealsupportsuchasMealsonWheelsorpre-preparedfrozenfoods b. Kitchen safety • Enquireaboutkitchenmishapssuchasfiresorburnedpots • Considerhavingthestovedisabledwhenthepatientcannolongeruseitsafely, especially if the patient is living in an apartment building • Thekitchenareashouldhaveafunctioningsmokedetector • Afamilymemberorcaregivershouldideallymonitortherefrigeratorforfoodsafety

c. Medication management • Strategiestoimprovemedicationsafetyandadherenceshouldbeexploredsuchastheuseof

blister packaging or Dossette trays and caregiver supervision of medications • ConsiderreferraltoHomeandCommunityCareformedicationmonitoring d. Hygiene • Considerabathingassistantorbathprogram(contactHomeandCommunityCare)

e. Wandering • Thepatientshouldalwayscarryidentificationwhenoutalone • ConsideranIDbraceletthroughtheSafely Home® – Alzheimer Wandering Registry Web site: www.alzheimer.ca/english/safelyhome/about.htm f. Socialization • Patientswithdementialivingaloneinthecommunitymaybecomesociallywithdrawn

• Considerreferraltoanadultdaycentre(contactHomeandCommunityCare)

g. Legal issues • Asearlyaspossibleinthecourseofdementia,engagethepatientinadiscussionofadvance planning issues • Encouragethepatienttohaveanup-to-datewill,afinancialrepresentative,ahealthcare

proxyandsomeformofadvancemedicaldirective • ARepresentationAgreementpermitsthepatienttoappointbothafinancialrepresentativeand ahealthrepresentative(guideavailableatwww.trustee.bc.ca).APowerofAttorney(withan eduringclause)istherecommendedlegaldocumenttoappointafinancialrepresentative

h. Other safety issues • Considerothersafetyhazards,suchasunsafesmoking,firearmsinthehome,etc. • Lifelineor911stickersonthetelephone

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recommendation 8 Co-Morbid Conditions

Address co-morbid conditions to prevent further unnecessary impairment of cognition in demented individuals. The underlying dementia has implications for management of other conditions, particularly with respect to tolerability and adherence to medication.

a. Cardiovascular disease • Addressvascularriskfactors,includingarterialhypertension,hypercholesterolemia,diabetes

mellitus, smoking, obesity, use of anticoagulation for atrial fibrillation and primary/secondary preventionoftransientischemicattacks(TIAs)andstroke

b. Depression • MoodsymptomsarecommoninmildtomoderateAD,butprevalenceinadvanceddementiais uncertain because recognition is more difficult • Depressioncoincidentwithdementiamaynotpresentasdepressedmood,butwithlackof interest, which along with other depression symptoms such as apathy, anhedonia, insomnia and agitation must be distinguished from the dementia itself • Ahighindexofsuspicionisrequiredtodetectdepressionindementedpatients • Atherapeutictrialofanantidepressantmayberequiredtodiagnosedepression • Managementincludes:antidepressant,mostoftenanSSRI,alongwithbehaviouralintervention, education and support for the caregivers • Foradditionalinformation,seeGPACguideline,MajorDepressionDisorder–Diagnosisand Management:www.BCGuidelines.ca

c. Delirium • Peoplewithdementiaaremoresusceptibletodelirium.Althoughtheagitatedtypeofdelirium with hallucinations is more easily recognized, hypoactive delirium presenting with inattentiveness and somnolence is more common and difficult to recognize • Approachdeliriumasamedicalemergencyduetothesignificantconditionsthatmaycausethe delirium,suchasinfectionsorCHF • Reviewandoptimizeallmedicationsastheycommonlycontributetodelirium

recommendation 9 Pharmacotherapy

Acetylcholinesterase Inhibitors (AChEIs)AChEIsincludedonepezil(Aricept®),galantamine(Reminyl®)andrivastigmine(Exelon®).TheyarecurrentlyapprovedbyHealthCanadaforthesymptomatictreatmentofmildtomoderatedementiaoftheAlzheimer’stype(AD).ThereisinsufficientevidencetorecommendthemforMCI.5

• EarlierstudieshavedemonstratedsmalltomodestefficacyofAChEIsincognitiveandglobaloutcome measures, while recent studies have included maintenance of activities of daily living and reductionofcaregiverburdenasoutcomes.Inameta-analysisofstudieswithglobaloutcomes(subjectiveassessmentbyclinicianand/orcaregiverofchangeoverall),thenumberneededtotreat(NNT)is12(3-6months)foroneadditionalpatienttoexperiencestabilizationorimprovementonglobal response.8Intheliterature,thereislittledefinitiveevidencefordurationofefficacybeyondtwo years.

• WhilesomeevidencesuggestsaroleforAChEIsinthetreatmentofsymptomsassociatedwithsevereADandinothertypesdementias(VaDandDLB),9,10 the clinical meaningfulness of randomizedcontrolledtrialoutcomemeasuresiscontroversialanddonepezilistheonlyAChEIcurrentlyapprovedbyHealthCanadafortheseindications.

• 8%morepatientsexperienceadverseeventsonAChEIscomparedtoplacebo(numberneededtoharm[NNH]=12)

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SummaryofthemostcommonadverseeventsbyAChEItype11

AChEI Common adverse effects NNH

donepezil Diarrhea 8 Nausea 20

rivastigmine Nausea 6 Vomiting 7

galantamine Nauseaat24mg/d 5

• Sleepdisturbances(nightmares/abnormaldreams)andmuscle/legcrampsmayalsobeobservedwithdonepezil.Slowtitrationofallthreemedicationsmayreduceadverseevents

• AttritionassociatedwithAChEItreatmentgroupsinclinicaltrialsisgreater(approximately29%)duetoadverseeventsthanthatofplacebogroups(18%)8,12

Deciding on a trial of AChEIs:

• Dothepatient/caregivershaveenoughclinicalinformation to understand their present condition and prognosis, and have they been able to participate in thedevelopmentofgoalsandrealisticexpectationsfortreatment?

• Isthepatientasuitablecandidate(considerthepresence of serious co-morbidity and reduced life expectancywithdementia)?

• Isthepatientlikelyabletotakemedicationsasprescribed(consideringcurrentsupportsandleveloffunction)?

If a trial of AChEIs is initiated:

• Developandimplementafollow-upplan• Caregiversmaybeaskedtokeepawrittenrecordofpersonalimpressions,commentonadverse

drug reactions, sleep disturbances etc., to support assessment• Afterinitiationofthemedication,theinitialvisitschedulewillbedeterminedbythetitration

schedule(i.e.every2-6weeksuntildosereached)• Areviewforsideeffectsshouldbecarriedoutwithinthefirst3months,usuallyatthetitration

visit(s)• Every6months, monitor for changes from baseline in stabilization or deterioration of cognition,

function, behaviour and global assesment of change• Usepatient-specificinformationtoinformreassessment of continued drug therapy• Currentliteratureiscontroversialwithrespecttoadverseeffectsfromdiscontinuingtreatment

Effective October 22, 2007, PharmaCare, through the Alzheimer's Drug Therapy Initiative,willprovidecoverageofdonepezil, rivastigmine and galantamine for eligible individuals diagnosed with mild to moderate Alzheimer's disease, including patients with Alzheimer's disease with a vascular component or Parkinsonianfeatures.Fordetailsonthisinitiative please visit: http://www.health.gov.bc.ca/pharme/adti

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Table 3. Starting dose and titration schedule of AChEIs

Drug* Starting Titration Dose Increase Usual Effective Dose Period Per Titration Max Dose donepezil 5mgdaily** 4-6wks 5mgdaily 10mgdaily

rivastigmine 1.5mgb.i.d. 2-4wks 1.5mgb.i.d. 3-6mgb.i.d.

galantamine 8mgERdaily 4-6wks 8mgERdaily 16mgERdaily-24mgERdaily

Potential Drug Interactions

ToxicityofdonepezilandgalantaminemaybeINCREASEDbytheconcomitantuseofcytochromeP450inhibitors(e.g.,paroxetine,erythromycin,prednisone,grapefruitjuiceandnefazodone).EffectivenessofdonepezilandgalantaminemaybeDECREASEDbytheconcomitantuseofcytochromeP450inducers(e.g.,carbamazepine,phenytoinandrifampin).Rivastigmineismainlymetabolizedthroughhydrolysis;thereforecytochromeP450druginteractionsarenotexpected.

*AChEI cost approximately $5.00/day Adapted from Hsiung, G., Loy-English, I. BCMJ 2004;46(7):338-343**Consider 2.5 mg daily in very frail patients

AChEI Relative ContraindictionsPeptic ulcer disease, hepatic or renal disease, significant bradycardia or AV block, significant bronchospastic disease, obstructive urinary disease, epilepsy or history of seizure.

Strategies to Reduce Side Effects of AChEIs

a. TakeAChEIwithmeals(specificallyindicatedforrivastigmine)

b. Usealongertitrationperiod,temporarilyreducethedoseorplanskippeddoses

c. Ifabovemeasuresareineffective,takeanti-emeticsforlimitedperiodsduringthetitration periode.g.domperidone(avoidOTCanti-emeticswiththeiranti-cholinergiceffectsthatcan worsencognitionand/orcausedelirium)

d. Avoid sleep disturbances with donepezil by morning dose administration e. ConsideranotherAChEIifthefirstisnottolerated(taperfirstagentover1-2weeksandstart

newagentatlowestpossibledose).AnalternateAChEImaybeofferedforissuesof tolerabilityandadverseeffects.ThereisinsufficientevidencetorecommendswitchingAChEIs due to ineffectiveness

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Memantine(Ebixa®):HealthCanadahasgrantedmemantineaNotice of Compliance with Conditions as monotherapy or as adjunctive therapy with cholinesterase inhibitors for the symptomatic treatment of patients with moderate to severe Alzheimer’s Disease. The product monograph advises against the use of memantine in patients with renal disease, cardiovascular disease and seizure disorders. Adverseeffectsofmemantinemayinclude:fatigue,pain,dizziness,constipation,anxietyandhallucinations.

Table 4. Starting dose and titration schedule of memantine

Drug Starting Titration Dose Increase Usual Effective Dose Period Per Titration Max Dose

memantine 5 mg 4 wks 5 mg 10 mg b.i.d.

Potential Drug Interactions

MajordruginteractionsassociatedwithmemantineincludedrugswhichincreasethepHinurine(e.g.carbonicanhydraseinhibitors).Exercisecautionwhenprescribingmemantinewithotherdrugswhichundergo renal tubular secretion. Dofetilide is considered a very severe risk, due to the potential for causing arrhythmias. The effects of dopamine agents will be increased when co-administrated with memantine.

OtherAgents:UseofGinkgoBiloba,VitaminE,anti-inflammatorydrugs(suchasNSAIDs),estrogenand statins is not recommended. There is insufficient evidence of treatment efficacy and/or concerns have been raised about possible increased risk of negative health impacts.

recommendation 10 Behavioural and Psychological Symptoms of Dementia (BPSD)a. Symptoms • Psychosis(hallucinationsordelusions) • Depression • Anxiety • Sleepdisturbances • Behaviouralproblemsofaggressionoragitation

b. AssessmentUponsymptomonset,establishanunderstandingoftheoriginsofbehavioursbeforedevelopingamanagement strategy.

• Assessandtreatmedicalconditions(considertheinfluenceofpain,dysuria,dyspnea, abdominaldiscomfortandpruritus) • Reviewandoptimizecurrentmedications • Assessandtreatconcurrentpsychiatricconditions

c. Management Treatment goals should include: • Decreasingorremovingthesymptom(s)entirelywhilepreservingmaximalfunction • Reducingcaregiverburden

Potential Interventions a. Environmental and behavioural modifications are recommended as first line management. • Identifyandminimizeenvironmentalandbehaviouralprecipitants(userecord keeping by caregivers to identify potential triggers such as physical treatments, meal time,bathingandcompany)

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b. Psychosocial interventions are recommended. • Offerpsychosocialsupportandeducationforcaregivers • Suggestactivitiessuchasmusictherapy,pettherapy,walkingorotherformsoflightexercise

c.PharmacotherapeuticinterventionsforBPSD: • Treatdepressionoranxietywithantidepressants • Treatsleepdisorderswhennecessarywithtrazodone25-75mgatthehourofsleep (*Benzodiazepinesarenotrecommendedduetotheirhighpotentialforadverseeventssuchas

confusionandfalls) • Treatpsychosis(hallucinationordelusions)withantipsychoticmedicationsonlywhenthe

patient is particularly disturbed by these symptoms • Treataggressionoragitationwith: - Cholinesterase inhibitors, or - Trazodone 25-50 mg does up to 200 mg a day, or - Antipsychotics:typical(Loxapine)oratypical(risperidone,olanzapineorquetiapine)only

afterenvironmentalandpsychosocialinterventionshavebeenconsidered,exceptinurgent situations

Exercise caution when prescribing antipsychotic medications.All antipsychotics have side effects and a risk-benefit assessment

needs to be carefully adjudicated in each case. Antipsychotic medications are only recommended when: • Alternatetherapiesareinadequateontheirown • Thereisanidentifiableriskofharmtothepatientandothers • Symptomsaresevereenoughtocausesufferinganddistress

When using antipsychotics, initiate a careful trial of a low dose antipsychotic and slow upward titration(e.g.risperidone0.125mginveryfrailpatientswithslowupwardtitrationto1.5–2mgmaximumaday).InpatientswithDLBandPDD,considersensitivitytomedication(e.g.increasedriskofextrapyramidialsideeffectswhenusingantipsychotics).Monitortheeffectscloselyandreviewtodeterminewhetheramaintenancedosemaybeneeded(itmaybepossibletodiscontinuemaintenancedoseovertime).

• Atypicalantipsychoticsinclude:risperidone,quetiapineandolanzapine.Risperidonehasbeen favouredasthemostefficaciousforagitationindementia,butwithmodestoutcomes.Itisthe only atypical antipsychotic approved for the short-term treatment of aggression or psychosis in patients with severe dementia.

• Atypicalantipsychoticshavebeenassociatedwithsevereadverseeventssuchasincreased riskoffalls,cerebrovascularevents*(strokeandtransientischemicattacks),andincreased mortality in the elderly†. While recent population based observational studies have shown that there is a similar risk of stroke, cerebrovascular events and drug-induced movement disorders with typical antipsychotics as with atypicals, reviews of randomized controlled trials indicatethatatypicalantipsychotics,atlowerdosesareassociatedwithfewerextrapyramidal sideeffectsandlesssomnolencethantypicalantipsychoticsinthetreatmentofBPSD.13-15

* HealthCanada/JanssenOrthoreleasedaDrugSafetyUpdatein2002detailingreportsofstrokesandstroke-like events in elderly patients taking risperidone in clinical studies.

† TheUSFoodandDrugAdministrationissuedahealthadvisoryinMarch2005reportingincreasedmortality(1.6-1.7foldincreaseinrelativerisk,1.9%increaseinabsoluterisk,NNH:52)inelderlypatientstakingatypi-calanti-psychoticstotreatBPSD.

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recommendation 11 End-of-Life Care

a. Reviewpatient/familyexpectationsforqualityoflifeandintensityofcareandsupportb. Discuss initiation or revision of advance care planning with patient and family c. Clarify specific care decisions pertaining to: • Pain(commonlyoccursinthisphaseofthelifecourse).Ahighindexofsuspicionisnecessary withagitationorotherbehaviouralchanges;mayneedacloselymonitoredtherapeutictrial • Nutritionandhydration • Treatmentofrecurrentinfections • Provisionforincreasedservicesathome • Indicationsfortransfertohospitalortoahigherlevelofcare

recommendation 12 Caregiver Support

Caregivers need to be well supported. Determine your capability to provide ongoing, regular support, and/orreferouttootheragencies(SeeRecommendation13forworkingwithcommunityandhealthcareservices). • Askaboutthecaregiver’sneeds,copingstrategies,supportsystemandburden • Educatepatientsandcaregiversaboutthediseaseandhowtocope,includingadvancecare planning(considerculturalcontextforunderstandingandacceptanceofdementia;seePatient &CaregiverGuide) • Coordination,communicationandplanningduringtransitionbetweencareenvironments • Respiteforcaregiversincludingadultdaycentrereferralforpatientetc.

recommendation 13 Community Care, Mental Health and Specialty Services Resources a. TimelyreferraltotheAlzheimerSocietyofBC(ASBC).TheASBCassistspeoplewithalltypesof

dementia and their caregiver’s particularly: • Peoplewithearlystagedementia • Caregiversforpeoplewithdementiaatanystage Note: Disclosure of the diagnosis or suspected diagnosis of dementia should occur before referral to ASBCb. Asktheopinionofadementiaspecialist(geriatrician,neurologist,psychiatrist)whendiagnosisor

management is problematicc. RefertoHomeandCommunityCareservicesineachoftheHealthAuthoritiesforlong-termcase

management, home support, home safety assessment, respite care, adult day care or transitions to alternate living situations

d. RefertoCommunityMentalHealthServicesforsignificantandcomplexmentalhealthconditionsaffecting the health and care of the patient and caregiver

Rationale

Alzheimer’sdisease(AD)andrelateddementiasareprogressive,irreversibledegenerativebraindiseases that lead to a decline in memory and other cognitive functions sufficient to affect daily life inanalertperson.ADisthemostcommontypeofdementiarepresentingapproximately67%ofallcasesnationally.Examplesofrelateddementiasinclude:vasculardementia(VaD),mixeddementia(ADandVaDtogether),dementiawithLewyBodies(DLB),fronto-temporaldementia,andCreutzfeldt-Jakob disease.16

d. Follow-upOncesymptomsarecontrolled,regularlyevaluatetheneedforcontinuingtreatment(ongoingreviewforadverseeventsandeffectiveness)andconsiderwithdrawalofmedicationwithclosemonitoringforre-emergence of symptoms.

15



ItisestimatedthatADandrelateddementiasaffect8%ofCanadiansovertheageof65.Nationally,thistranslatestoapproximately420,000people.PendingavalidateddementiaregistryinBritishColumbia,itisestimatedthatbetween51,000and64,000peoplearecurrentlyaffected,approximately41,000ofwhomarefemale.Dementiaprevalenceispositivelycorrelatedwithage.Historically,2.4%ofpeopleage65to74,11.1%ofpeopleage75to84,and34.5%ofthose85yearsandolderinCanadahavesomeformofdementia.OstbyeandCrosse(1994)estimatedthetotalannualnetcostofdementiainCanada(healthcareandpaid/unpaidcaregiving)tobe$3.9billion.17Basedonthisstudy,theAlzheimerSocietyofCanadarecentlyupdatedthisfigureto$5.5billiontoreflect2003dollars.18

ThecurrentandprojectedburdenofADandrelateddementiashasledtheNationalAdvisoryCouncilonAgingandtheAlzheimerSocietyofCanadatocallforthedevelopmentandimplementationofanationalstrategydealingwithdementia.Theirpositionpaperoutlines30recommendationswhichinclude increased research into the causes, prevention and treatment of progressive cognitive impairment, increased allocation of resources for long term care facilities, caregiver support and home care, increased physician training and education in AD and related dementias.

List of Abbreviations

AChEI AcetylcholinesteraseInhibitorAD Alzheimer's diseaseASBC AlzheimerSocietyofBritishColumbiaBPSD BehaviouralandPsychologicalSymptomsofDementiaCAM ConfusionAssessmentMethodCDM chronicdiseasemanagementCDT Clock Drawing TestCHF congestiveheartfailureCT (CAT)computerizedaxialtomographyDLB DementiawithLewyBodiesDSMIV-TR DiagnosticandStatisticalManualofMentalDisorders,FourthEd.,TextRevisionGDS GeriatricDepressionScale(Yesavageetal.)GDS GlobalDeteriorationScale(Reisbergetal.)MCI mildcognitiveimpairmentMDD majordepressivedisorderMoCA MontrealCognitiveAssessmentMRI magneticresonanceimagingNNH numberneededtoharmNNT numberneededtotreatNPH normalpressurehydrocephalusNSAID non-steroidalanti-inflammatorydrugOTC over-the-counterPDD Parkinson’s Disease DementiaSMMSE StandardizedMiniMentalStateExamSR slowreleaseSSRI SelectiveSerotoninReuptakeInhibitorTBI traumaticbraininjuryTIA transientischemicattackTSH thyroidstimulatinghormoneVaD Vascular Dementia

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Resources

DriveSafe TheBCMedicalAssociation’sGuideforPhysiciansinDeterminingFitnesstoDriveaMotorVehicle(withupdates)canbeaccessedonlineat:www.drivesafe.com.Thissitecontainsanumberoflinkstoresources for physicians such as:• British Columbia: Report a Medical Condition Affecting Fitness and Ability to Drive,MV2351, updatedNovember2003;• AMA Physician’s Guide to Assessing and Counselling Older Drivers

Drive ABLE Assessment Centres Inc. Foranassessmentcentreinyourregion,pleasecall1-877-433-1494orgoto:www.driveable.com or www.candrive.ca.

HandyDART is a door-to-door, share ride, custom transportation service. This service is for people who are unable to use the regular transit service some or all of the time due to mobility issues associated with a permanent or temporary physical or cognitive disability: www.busonline.ca/regions/vic/accessible/handydart.cfm

TaxiSaversprovidesgreaterconvenienceforone-timetripswhenhandyDARTcannotaccommodateyourtravelneeds:www.busonline.ca/regions/vic/accessible/taxi_saver.cfm

Community Living BC has been designated under guardianship legislation to investigate situations of potential self neglect, neglect and abuse: www.communityliving.bc.ca

Alzheimer Society of BC assists people with all types of dementia and their caregivers 1-800-667-3742orgoto:www.alzheimerbc.org/

Alzheimer's Drug Therapy InitiativeAllquestions,clinicalandadministrative,canbedirectedtoHealthInsuranceBCat1800663-7100orgo to: www.health.gov.bc.ca/pharme/adti

References

1. WrightCB,LeeHS,PaikMC,etal.Totalhomocysteineandcognitioninatri-ethniccohort:theNorthernManhattanStudy.Neurology2004;63:254-60.

2. GarciaA,ZanibbiK.Homocysteineandcognitivefunctioninelderlypeople.Canadian MedicalAssociationJournal2004;171:897-904.3. MaloufR,AreosaSastreA.VitaminB12forcognition.CochraneDatabaseofSystematic Reviews2003;(3):CD004326.4. PattersonC,GauthierS,BergmanH,etal.Therecognition,assessmentandmanagement

of dementing disorders: Conclusions from the Canadian consensus conference on dementia CanadianJournalofNeurologicalScience2001;28(Suppl1):S3-S16.

5. ThirdCanadianConsensusConferenceonDiagnosisandTreatmentofDementia,Montreal,March9-11,2006.Officialconferencepublicationforthcoming.

6. NasredddineZ,PhillipsN,BedirianV,etal.TheMontrealCognitiveAssessment,MoCA:Abriefscreeningtoolformildcognitiveimpairment.JournaloftheAmericanGeriatricsSociety2005;53:695-699.

7. PetersonRC,ThomasRG,GrundmanM,etal.fortheAlzheimer’sDiseaseCooperative StudyGroup.VitaminEanddonepezilforthetreatmentofmildcognitiveimpairment.New EnglandJournalofMedicine2005:352:2379-2388.8. LanctôtK,HerrmannN,YauKK,etal.Efficacyandsafetyofcholinesteraseinhibitorsin

Alzheimer’sdisease:ameta-analysis.CanadianMedicalAssociationJournal2003;169(6):557-64.9. FeldmanH,GauthierS,HeckerJ,etal.andtheDonepezilMSADStudyInvestigatorsGroup.

A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer’s disease.Neurology2001;57:613-620.

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10. WinbladB,KilanderL,ErikssonS,etal,fortheSevereAlzheimer’sDiseaseStudyGroup.Donepezil in patients with severe Alzheimer’s disease: double-blind, parallel-group, placebo-controlledstudy.Lancet2006;367:1057-65.

11. TherapeuticsInitiativeEvidenceBasedDrugTherapy.Therapeuticsletter#56:Drugsfor Alzheimer’sDiseaseApril-August2005,UniversityofBritishColumbiaDepartmentof Pharmacology & Therapeutics.12. BirksJ.CholinesteraseinhibitorsforAlzheimer’sDisease.CochraneDatabaseofSystematic

Reviews2006;(1):CD005593.13. VanIerselMB,ZuidemaSU,KoopmansRT,etal.Antipsychoticsforbehaviouralandpsychological

problems in elderly people with dementia: A systematic review of adverse events. Drugs and Aging 2005;22(10):845-858.

14. WangPS,SchneeweissS,AvornJ,etal.Riskofdeathinelderlyusersofconventionalvsatypicalantipsychoticmedications.NewEnglandJournalofMedicine2005;353:2335-2341.

15. SchneeweissS,SetoguchiS,BrookhartA,etal.Riskofdeathassociatedwiththeuseofconventionalversusatypicalantipsychoticdrugsamongelderlypatients.CanadianMedicalAssociationJournal2007;176(5):627-632.

16. BritishColumbiaMedicalAssociation’sCouncilonHealthPromotion.Buildingbridges:A callforacoordinateddementiastrategyinBritishColumbia.April2004. http://www.bcma.org/public/patient_advocacy/Building%20Bridges.pdf17. OstbyeT,CrosseE.NeteconomiccostsofdementiainCanada.CanadianMedical AssociationJournal1994;151:1457-64.18. Theeconomiccostsofdementia.Onlineresource,accessedFebruary9,2006.www.alzheimer.

ca/english/disease/stats-costs.htm Revised Date:January30,2008

This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the BritishColumbiaMedicalAssociationandadoptedbytheMedicalServicesCommission.

Contact InformationGuidelines and Protocols Advisory CommitteePOBox9642STNPROVGOVTVictoriaBCV8W9P1

Phone: 250952-1347 E-mail:[email protected]: 250952-1417 Website: www.BCGuidelines.ca

AppendicesAppendixA TheConfusionAssessmentMethod(CAM)DiagnosticAlgorithmAppendixB GeriatricDepressionScale(GDS)AppendixC StandardizedMini-MentalStateExam(SMMSE)AppendixD ClockDrawingTestAppendixE MontrealCognitiveAssessment(MoCA)AppendixF GlobalDeteriorationScaleAppendixG CognitiveImpairmentintheElderlyFlowSheet(Optional)

The principles of the Guidelines and Protocols Advisory Committee are to:

• encourageappropriateresponsestocommonmedicalsituations• recommendactionsthataresufficientandefficient,neitherexcessivenordeficient• permitexceptionswhenjustifiedbyclinicalcircumstances.

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18




Associated Documents The following documents accompany this guideline: • Summary • PatientandCaregiver'sGuide


revised January 30, 2008

The Confusion Assessment Method (CAM) Diagnostic Algorithm

Feature 1: Acute Onset and Fluctuating Course

This feature is usually obtained from a family member or nurse and is shown by positive responses to thefollowingquestions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?

Feature 2: Inattention

Thisfeatureisshownbyapositiveresponsetothefollowingquestion:

Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

Feature 3: Disorganized Thinking

Thisfeatureisshownbyapositiveresponsetothefollowingquestion:

Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Feature 4: Altered Level of Consciousness

Thisfeatureisshownbyanyanswerotherthan“alert”tothefollowingquestion:

Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])

ThediagnosisofdeliriumbyCAMrequiresthepresenceoffeatures1and2andeither3or4

Adapted from:InouyeVD,AlessiC,BalkinS,etal.Clarifyingconfusion:theconfusionassessmentmethod.AnnalsofInternalMedicine1990;113(12):941-948.

AppendixA



GERIATRIC DEPRESSION SCALE (GDS)*

Directions to Patient: Please choose the best answer for how you have felt over the past week

DirectionstotheExaminer: Readthequestionstothepatientandrecordtheirresponses. Ifappropriate,allowtheclienttocompletetheformonhis/herown.

1. Areyoubasicallysatisfiedwithyourlife? ❏ Yes ❏ No2 Haveyoudroppedmanyofyouractivitiesandinterests? ❏ Yes ❏ No3 Doyoufeelthatyourlifeisempty? ❏ Yes ❏ No4 Doyouoftengetbored? ❏ Yes ❏ No5 Areyouingoodspiritsmostofthetime? ❏ Yes ❏ No6 Areyouafraidthatsomethingbadisgoingtohappentoyou? ❏ Yes ❏ No7 Doyoufeelhappymostofthetime? ❏ Yes ❏ No8 Doyouoftenfeelhelpless? ❏ Yes ❏ No9 Doyouprefertostayathome,ratherthangoingoutanddoingnewthings? ❏ Yes ❏ No10 Doyoufeelyouhavemoreproblemswithmemorythanmost? ❏ Yes ❏ No11 Doyouthinkitiswonderfultobealivenow? ❏ Yes ❏ No12 Doyoufeelprettyworthlessthewayyouarenow? ❏ Yes ❏ No13 Doyoufeelfullofenergy? ❏ Yes ❏ No14 Doyoufeelthatyoursituationishopeless? ❏ Yes ❏ No

15 Doyouthinkthatmostpeoplearebetteroffthanyouare? ❏ Yes ❏ No

Ascoregreaterthan5issuggestiveofdepression,however,fullscoringinformationfortheGDSisavailableat:http://www.stanford.edu/~yesavage/GDS.english.long.html

Yesavage:TheuseofRatingDepressionSeriesintheElderly,inPoon(ed.):Clinical Memory Assessment of Older Adults,AmericanPsychologicalAssociation,1986.

SheikhJI,YesavageJA:GeriatricDepressionScale(GDS):Recentevidenceanddevelopmentofa shorter version. Clinical Gerontology: A Guide to Assessment and Intervention 165-173,NY:TheHaworthPress,1986.

ThefollowingWebsiteallowsyoutodownloadtheGDSinEnglishorotherlanguages.http://www.stanford.edu/~yesavage/GDS.html

NAMEOFPATIENT DATE

AppendixB

*This is the Yesavage et al. short form – 1983/86

Total Score:

(PLEASE✓)



/1

Directions for administration of the SSMSE:

1. Beforethequestionnaireisadministered,trytogetthepersontositdownfacingyou.Assesstheperson’sabilitytohearandunderstandverysimpleconversation,e.g.What is your name?Ifthepersonuseshearingorvisualaids,providethesebeforestarting.

2. Introduceyourselfandtrytogettheperson’sconfidence.Beforeyoubegin,gettheperson’spermissiontoaskquestions,e.g.Would it be alright to ask you the same questions about your memory?Thishelpstoavoidcatastrophicreactions.

3. Askeachquestionamaximumofthreetimes.Ifthesubjectdoesnotrespond,score0.

Iamgoingtoaskyousomequestionsandgiveyousomeproblemstosolve.Pleasetrytoanswerasbestasyoucan.

4. Ifthepersonanswersincorrectly,score0.Acceptthatansweranddonotaskthequestionagain,hint,orprovideanyphysicalcluessuchasheadshaking,etc.

5. Thefollowingequipmentisrequiredtoadministertheinstrument:Awatch,apencil,Page3ofthisSMMSEwithCLOSEYOUREYESwritteninlargelettersandtwofive-sidedfiguresintersectingtomakeafour-sidedfigure,andPage4,ablankpieceofpaper.

6. Ifthepersonanswers:Whatdidyousay?,donotexplainorengageinconversation.Merelyrepeatthesamedirectionsamaximumofthreetimes.

7. Ifthepersoninterrupts(e.g.Whatisthisfor?),reply:I will explain in a few minutes, when we are finished. Now if we could proceed please… we are almost finished.

1. Time: 10 seconds for each reply: a) What year is this?(acceptexactansweronly).b) What season is this?(accepteither:lastweekoftheoldseasonorfirstweekofanewseason).c) What month is this?(accepteither:thefirstdayofanewmonthorthelastdayofthepreviousmonth).d) What is today’s date?(acceptpreviousornextdate).e) What day of the week is this?(acceptexactansweronly).

2. Time: 10 seconds for each reply:a) What country are we in?(acceptexactansweronly).b) What province are we in?(acceptexactansweronly).c) What city/town are we in?(acceptexactansweronly).d) (Inhome)What is the street address of this house?(acceptstreetnameandhousenumberorequivalent inruralareas). (Infacility)What is the name of this building?(acceptexactnameofinstitutiononly).e) (Inhome)What room are we in?(acceptexactansweronly). (Infacility)What floor of the building are we on?(acceptexactansweronly).

3. Time: 20 seconds Say: I am going to name three objects. When I am finished, I want you to repeat them. Remember what they

are because I am going to ask you to name them again in a few minutes.(Saythefollowingwordsslowlyatapproximatelyone-secondintervals):Ball / Car / Man.

Forrepeateduse:Bell,jar,fan;Bill,tar,can;Bull,bar,pan. Please repeat the three items for me.(scoreonepointforeachcorrectreplyonthefirstattempt.) Ifthepersondidnotrepeatallthree,repeatuntiltheyarelearnedoruptoamaximumoffivetimes (butonlyscorefirstattempt).

/1/1

/1

/1/1

/1/1

/1

/3

/1

NAMEOFPATIENT DATE

STANDARDIZED MINI-MENTAL STATE EXAMINATION (SMMSE)AppendixC



4. Time: 30 seconds Spell the word WORLD.(youmayhelpthepersontospellthewordcorrectly)Say: Now spell it backwards

please.Ifthesubjectcannotspellworldevenwithassistance,score0.RefertoPage3forscoringinstructions.

5. Time: 10 seconds Say: Now what were the three objects I asked you to remember? (scoreonepointforeachcorrectanswerregardlessoforder)

6. Time: 10 seconds Show wristwatch. Ask: What is this called? (scoreonepointforcorrectresponse:accept“wristwatch”or“watch”;donotaccept“clock”or“time”,etc.).

7. Time: 10 seconds Show pencil. Ask: What is this called? (scoreonepointforcorrectresponse;accept”pencil”only;score0forpen)

8. Time: 10 seconds Say: I would like you to repeat a phrase after me: No ifs, ands or buts. Scoreonepointforacorrectrepetition.Mustbeexact,e.g.noifsorbuts,score0).

9. Time: 10 seconds Say: Read the words on this page and then do what it says.Then,handthepersonthesheetwithCLOSEYOUR

EYESonit.Ifthesubjectjustreadsanddoesnotcloseeyes,youmayrepeat:Read the words on this page and then do what it says(amaximumofthreetimes).Scoreonepointonlyifthesubjectcloseseyes.Thesubjectdoesnothavetoreadaloud.

10. Time: 30 seconds Handthepersonapencilandpaper(Page3).Say: Write any complete sentence on that piece of paper. Scoreonepoint.Thesentencemustmakesense.Ignorespellingerrors.

11. Time: 1 minute maximum Placedesign,eraserandpencilinfrontoftheperson.Say: Copy this design please.Allowmultipletries.Wait

untilthepersonisfinishedandhandsitback.Scoreonepointforacorrectlycopieddiagram.Thepersonmusthavedrawnafour-sidedfigurebetweentwofive-sidedfigures.

12. Time: 30 seconds Ask thepersonifheisrightorlefthanded.Takeapieceofpaper,holditupinfrontofthepersonand say: Take this paper in your right/left hand(whicheverisnon-dominant),fold the paper in half once with both

hands and put the paper down on the floor.Scoreonepointforeachinstructionexecutedcorrectly.

TakespaperincorrecthandFoldsitinhalfPutsitonthefloor

Total Test Score:

Adjusted Score

/5

/3

/1

/1

/1

/1

/1

/1

/1/1/1

/30

/22

Pleasenote:ThistoolisprovidedforuseinBritishColumbiawithpermissionbyDr.D.WillamMolloy.ThisquestionnaireshouldnotbefurthermodifiedorreproducedwithoutthewrittenconsentofDr.D.WilliamMolloy.MolloyDW,AlemayehuE,RobertsR.ReliabilityofastandardizedMini-MentalStateExaminationcomparedwiththetraditionalMini-MentalStateExamination.AmericanJournalofPsychiatry,1991;148(1):102-105.



Close your eyes

D L R O W

D L R O W

D L R O W

L O W R O

D L R O W

L R R W O

D L R O W

D R W O D

D L R O W

L

D L R O W

=Score3

=Score1

=Score5

=Score3

=Score3

ScoringWORLDbackwards(instructionsforitem#4)

Write the person’s response below the correct response.Draw lines matching the same letters in the correct response and the response given.TheselinesMUSTNOTcrosseachother.Drawonlyonelineperletter.Theperson’sscoreisthemaximumnumberoflinesthatcanbedrawnwithoutcrossingany.

Examples:

=Score0

Foldalongthislineandshowinstructionstoperson

Foldline

Item11

Item9



Sentence Writing

Item10



AppendixC

Standardized Mini Mental State Examination (SMMSE) Cont’d

Table 1. Stages of Cognitive Impairment as Defined by SMMSE Scores

SCORE DESCRIPTION STAGE DURATION (Years)

30-26 Couldbenormal Couldbenormal Varies25-20 Mild Early 0to2319-10 Moderate Middle 4-79-0 Severe Late 7-14

Table 2. Areas of Functional Impairment

SMMSE SCORE ACTIVITIES OF DAILY LIVING COMMUNICATION MEMORY 30-26 Couldbenormal Couldbenormal Couldbenormal

25-20 Driving,finances,shopping Findingwords,repeating, Three-itemrecall, goingofftopic orientationtotimethenplace

19-10 Dressing,grooming,toileting Sentencefragments,vague SpellingWORLDbackward, terms(i.e:this,that) language,andthree-step command

9-0 Eating,walking Speechdisturbancessuch Obviousdeficitsinallareas asstutteringandslurring

Adaptedfrom:VertesiA,LeverJA,MolloyDW,etal.Standardizedmini-mentalstateexamination:Useandinterpretation.CanadianFamilyPhysician2001;47:2018-2023.



AppendixD

Clock Drawing Test

Theclockdrawingtest(CDT)isaveryappealingsupplementtotheSMMSEbecauseitdrawsonanumberofcognitivedomainssuchasworkingmemory,executivefunctioning(planning,conceptualizing),andvisuoconstructionalskills.Itisalsolessaffectedbylanguage,cultureandeducation than many other tests.

The CDT may be completed and scored according to one of many different protocols, or more commonly, it can be administered and rated in an informal and subjective manner such as the following:

• Presentthepatientwithapre-drawncircleabout10cmindiameter• Askthepatienttoplacethenumbersonthecirclelikeaclock.Notewhetherthepatientuses

appropriate planning in distributing the numbers properly, or whether the patient perseverates or forgets the task and continues numbering past 12

• Askthepatienttoplacehandsontheclockshowingthetimetobe10minutesafter11.Patientswith faulty conceptualization may be drawn to placing the hands at 10 and 11 rather than at 11 and 2, or they may fail the task completely

Foldalongthislinetoadminister



POINTS

TOTAL

M E M O R Y

N A M I N G

VISUOSPATIAL / EXECUTIVE

ATTENTION

LANGUAGE

ABSTRACTION

DELAYED RECALL

ORIENTATION

Read list of words, subject must repeat them. Do 2 trials. Do a recall after 5 minutes.

Subject has to repeat them in the forward order [ ] 2 1 8 5 4 Subject has to repeat them in the backward order [ ] 7 4 2

Read list of letters. The subject must tap with his hand at each letter A. No points if ≥ 2 errors

[ ] F B A C M N A A J K L B A F A K D E A A A J A M O F A A B

Serial 7 subtraction starting at 100 [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65

Repeat : I only know that John is the one to help today. [ ]The cat always hid under the couch when dogs were in the room. [ ]

Similarity between e.g. banana - orange = fruit [ ] train – bicycle [ ] watch - ruler

Draw CLOCK (Ten past eleven)Copy cube

__/5

__/3

Nopoints

1st trial

2nd trial

FACE VELVET CHURCH DAISY RED

__/5

__/2

__/1

__/3

__/2Fluency / Name maximum number of words in one minute that begin with the letter F _____ [ ] (N ≥ 11 words) __/1

__/2

__/6

__/30

B

Begin

End

5

E

1

A

2

4 3

C

D

Read list of digits (1 digit/ sec.).

NAME :Education :

Sex :Date of birth :

DATE :

© Z.Nasreddine MD Version November 7, 2004

www.mocatest.orgNormal ≥ 26 / 30

Add 1 point if ≤ 12 yr edu

MONTREAL COGNITIVE ASSESSMENT (MOCA)

[ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City

[ ]Contour

[ ] ] [] [Numbers

[ ]Hands

] [] [] [

4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2 pts, 1 correct: 1 pt, 0 correct: 0 pt

( 3 points )

Category cue

Points for UNCUED

recall onlyWITH NO CUE

Optional

Has to recall words

Multiple choice cue

FACE VELVET CHURCH DAISY RED[ ] [ ] [ ] [ ] [ ]

Administrationandscoringinstructionsavailableatwww.mocatest.org(English,French,Dutch&Spanish)

AppendixE



Nosubjectivecomplaintsofmemorydeficit.Nomemorydeficitevidentonclinicalinterview.

Subjectivecomplaintsofmemorydeficit,mostfrequentlyinfollowingareas:(a)forgettingwhereonehasplacedfamiliarobjects;(b)forgettingnamesoneformerlyknewwell.Noobjectiveevidenceofmemorydeficitonclinicalinterview.Noobjectivedeficitsinemploymentorsocialsituations.Appropriateconcernwithrespecttosymptomatology.

Earliestclear-cutdeficits.Manifestationsinmorethanoneofthefollowingareas:(a)patientmayhavebecomelostwhentravelingtoanunfamiliarlocation;(b)co-workersbecomeawareofpatient'srelativelypoorperformance;(c)wordandnamefindingdeficitbecomesevidenttointimates;(d)patientmayreadapassageorabookandretainrelativelylittlematerial;(e)patientmaydemonstratedecreasedfacilityinrememberingnamesuponintroductiontonewpeople;(f)patientmayhavelostormisplacedanobjectofvalue;(g)concentrationdeficitmaybeevidentonclinicaltesting.Objectiveevidenceofmemorydeficitobtainedonlywithanintensiveinterview.Decreasedperformanceindemandingemploymentandsocialsettings.Denialbeginstomanifestinthepatient.Mildtomoderateanxietyaccompaniessymptoms.

Clear-cutdeficitoncarefulclinicalinterview.Deficitsmanifestinfollowingareas:(a)decreasedknowledgeofcurrentandrecentevents;(b)mayexhibitsomedeficitinmemoryofonespersonalhistory;(c)concentrationdeficitelicitedonserialsubtractions;(d)decreasedabilitytotravel,handlefinances,etc.Frequentlynodeficitinfollowingareas:(a)orientationtotimeandplace;(b)recognitionoffamiliarpersonsandfaces;(c)abilitytotraveltofamiliarlocations.Inabilitytoperformcomplextasks.Denialisdominantdefensemechanism.Flatteningofaffectandwithdrawalfromchallengingsituationsfrequentlyoccur.

Patientcannolongersurvivewithoutsomeassistance.Patientisunableduringinterviewtorecallamajorrelevantaspectoftheircurrentlives,e.g.,anaddressortelephonenumberofmanyyears,thenamesofclosefamilymembers(suchasgrandchildren),thenameofthehighschoolorcollegefromwhichtheygraduated.Frequentlysomedisorientationtotime(date,dayofweek,season,etc.)ortoplace.Aneducatedpersonmayhavedifficultycountingbackfrom40by4sorfrom20by2s.Personsatthisstageretainknowledgeofmanymajorfactsregardingthemselvesandothers.Theyinvariablyknowtheirownnamesandgenerallyknowtheirspouse’sandchildren’snames.Theyrequirenoassistancewithtoiletingandeating,butmayhavesomedifficultychoosingtheproperclothingtowear.

Mayoccasionallyforgetthenameofthespouseuponwhomtheyareentirelydependentforsurvival.Willbelargelyunawareofallrecenteventsandexperiencesintheirlives.Retainsomeknowledgeoftheirpastlivesbutthisisverysketchy.Generallyunawareoftheirsurroundings,theyear,theseason,etc.Mayhavedifficultycountingfrom10,bothbackwardand,sometimes,forward.Willrequiresomeassistancewithactivitiesofdailyliving,e.g.,maybecomeincontinent,willrequiretravelassistancebutoccasionallywillbeabletotraveltofamiliarlocations.Diurnalrhythmfrequentlydisturbed.Almostalwaysrecalltheirownname.Frequentlycontinuetobeabletodistinguishfamiliarfromunfamiliarpersonsintheirenvironment.Personalityandemotionalchangesoccur.Thesearequitevariableandinclude:(a)delusionalbehavior,e.g.,patientsmayaccusetheirspouseofbeinganimpostor,maytalktoimaginaryfiguresintheenvironmentortotheirownreflectioninthemirror;(b)obsessivesymptoms,e.g.,personmaycontinuallyrepeatsimplecleaningactivities;(c)anxietysymptoms,agitationandevenpreviouslynonexistentviolentbehaviormayoccur;(d)cognitiveabulia,i.e.,lossofwillpowerbecauseanindividualcannotcarryathoughtlongenoughtodetermineapurposefulcourseofaction.

Allverbalabilitiesarelostoverthecourseofthisstage.Frequentlythereisnospeechatall,onlyunintelligibleutterancesandrareemergenceofseeminglyforgottenwordsandphrases.Incontinentofurine,requiresassistancetoiletingandfeeding.Basicpsychomotorskills,e.g.,abilitytowalk,arelostwiththeprogressionofthisstage.Thebrainappearstonolongerbeabletotellthebodywhattodo.Generalizedrigidityanddevelopmentalneurologicreflexesarefrequentlypresent.

Level Clinical Characteristics

Reisberg B, Ferris SH, Leon MJ, et al. The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry 1982;139:1136-1139.

1. Nocognitive decline

2. Verymildcognitive decline (Forgetfulness)

3. Mildcognitive decline (EarlyConfusional)

4. Moderatecognitive decline (LateConfusional; MildDementia)

5. Moderatelysevere cognitivedecline (EarlyDementia; Moderate Dementia)

6. Severecognitive decline (MiddleDementia; ModeratelySevere Dementia)

7. Verysevere cognitivedecline (LateDementia; SevereDementia)

Global Deterioration ScaleAppendixF

Functionalstatus(Baseline&reviewateachvisit)

IADLs::•Housework•Mealprep•Shopping•Transportation•Finances•ManagingmedsSupports(homecare,family,casemanager,livingsituation)Caregiverissues(behaviour/sleep/mood)Livingwill/DNRdiscussion

COGNITIVE IMPAIRMENT IN THE ELDERLY FLOW SHEET

NAMEOFPATIENT

ThisoptionalFlowSheetisbasedontheGuideline, Cognitive Impairment in the Elderly – Recognition, Diagnosis and Management

Website:www.BCGuidelines.ca

DATEOFBIRTH

DIAGNOSIS

SEX

MF

RISKFACTORSANDCO-MORBIDCONDITIONSDefinemanagementgoals(Riskfactorreduction;Treatco-morbidconditions;casemanagement)

DATE BP WEIGHTLbs Kg

VISITS

ANNUALLY

CARE OBJECTIVES

HLTH/BCMA6009(06/07)

SELF MANAGEMENT (Discuss with patient & caregiver)

Diabetes

HTN

CAD

Atrial fib

Asthma

COPD

Renaldisease

Depression

FBG

TSH

eGFR

CBC

B12

Ca

STS

Obesity

Smoker

AlcoholECG

Other

SMMSE Score: Date:

MoCA Score: Date:

BaselineInvestigations(✓whendone;normaloraddvaluesprn)

Other:

AnnualFlu: Pneumovax:VACCINATIONS

DATE DATE DATE

BASELINE

HR

EDUCATION

OCCUPATIONDATEOFDIAGNOSIS

ADLs:•Bathing/Toileting•Dressing•Mobility

REVIEWCLINICALACTIONPLAN

(Review care objectives, management goals, functional status, symptoms, medications/pharmacy)

*Forinformationonbillingincentivefees,pleasevisitwww.health.gov.bc.ca/phc

DIAGNOSTICCODE(Dementia):290

Guidelines &ProtocolsAdvisoryCommittee

BRITISHCOLUMBIA

MEDICALASSOCIATION