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Acove forms_r7

Cognitive
Patient Visit
Note

Impairment
To be completed by medical assistant
Reason for Visit:
Memory loss/confusion per patient and/or surrogate History of Present Illness: History given by:
1. Problems with memory? . . . . . . . . . . . . . If YES, duration of symptoms:
2. Patient has someone to help him/her . . If YES, primary caregiver:
3. Help is adequate for needs . . . . . . . . . . . If NO, patient needs more help with: (Check all that apply)
To be completed by physician
NO (If known diagnosis of dementia, complete items only as applicable)
4. Known diagnosis of dementia . . . . . . . . If YES, known dx, cause:
Anxiety/nervousness/agitation . . . . . . . . Violent/combative behavior . . . . . . . . . . . . . . . . . . . Insomnia/sleep problems . . . . . . . . . . . . Psychosis (delusions, hallucinations, paranoia) . . . . . . Wandering. . . . . . . . . . . . . . . . . . . . . . . . . Examination: (Complete as appropriate)
1. Cognition:
Memory, remote - What happened to Pres. Kennedy? Where? Who shot him?
(if this question is not culturally appropriate for your patient, substitute another question to check for remote memory)
Memory, recent - What happened 9-11-01? Buildings/cities affected? Who was responsible? Executive function - Bread is 75¢/loaf. Buy 2 loaves with $2. How much change? Fish is $8/lb. Buy 1/2 pound with $5. How much change? Language - Name animals in zoo/jungle/farm (Normal ≥10/min) Visual/Spatial - Draw clock, put hands at 10 to 2. (Normal = Correct number sequence, and position and hands display requested time)(clock face is on following page) Geriatric Depression
2. Affect:
Scale (GDS)
Often feel sad/blue/depressed? . . . . . . . *If YES, do GDS
GDS: (Positive screen= 2 or more with *)
3. Neurologic status:
Rigidity (e.g., cogwheeling) . . . . . . . . . . . . Tremor . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bradykinesia . . . . . . . . . . . . . . . . . . . . . . . 4. Decision-making capacity: Name of surrogate decision-maker:
Diagnosis/Treatment Plan:
Lab/Tests:

Impression:
Treatment: (the forms listed below can be printed from the ACOVE video program)
Patient education handouts:
Cognitive Impairment Patient Information Sheet Cognitive Impairment: Community Resources Alzheimer's Disease Treatment: Working with the Doctor Patient/surrogate counseled:
Clock Face Template
Directions: On the blank clock face below, fill in the numbers on the clock and then draw the hands of clock showingthe time, ten minutes to two (1:50 pm).
Patient: _________________________________ Date drawn: _____________________________ Cognitive
Impairment
Reason for Visit:
Cognitive symptoms/failed cognitive screen
History: (By patient/surrogate)
Problems with memory; duration of symptoms
Known diagnosis of dementia (cause?)
Primary caregiver (specify name)
Adequate help for needs? If NO, needs more help with:
Feeding
Current behavioral symptoms:
Anxiety/nervousness/agitation
Psychotic sx (e.g., delusions, hallucinations, paranoia)Other (specify) Examination: (complete as appropriate)
Cognition:
Memory:
Remote — What happened to Pres. Kennedy? Where?
Who shot him? (or other appropriate question)
Recent — What happened 9-11-01? Buildings/cities affected? Who was responsible? a) Bread is 75¢/loaf. Buy 2 loaves with $2. Change? b) Fish is $8/lb. Buy 1/2 pound with $5. Change? Language: – Name animals in zoo/jungle/farm (Normal ≥10/min) Visual/spatial: – Draw clock, put hands at 10 to 2.
(Normal = Correct number sequence, and position and handsdisplay requested time) Affect: Often feel sad, blue, or depressed? If YES ➔ GDS
GDS: (Positive screen= 2 or more with *)
Basically satisfied with life?
Neurologic status:
Tremor
Decision-making capacity:
Identify surrogate decision-maker
Impression:
Lab/Tests:
Treatment:
• Patient/surrogate counseling re: safety, caregiver support, • Cholinesterase inhibitor, memantine discussed• Vitamin E discussed• Mgmt of behavior problems discussed (medications needed?)• Driving cessation discussed• Psychiatry/psychology consult• Neurology consult Cognitive
Physician
Fact

Impairment
Dementia Syndrome
Definition
Chronic acquired decline in memory and in at least one other cognitive function (e.g., language, visual
spatial, executive) sufficient to affect daily activities.
Estimated Frequencies of Dementia Causes
• Other progressive disorders: 15% to 30% (e.g., vascular, Lewy body, frontotemporal) • Completely reversible dementia (e.g., drug toxicity, metabolic changes, thyroid disease, subdural hematoma, normal-pressure hydrocephalus): 2% to 5% Diagnosis of AD
• Not due to another physical, neurologic, • Deficits not occurring exclusively during or psychiatric condition or to medications Progression of AD
Mild Cognitive Impairment (preclinical)
MMSE: 26-30
• Report by patient or informant of memory loss • Some cases of mild cognitive impairment Early, Mild Impairment (yr 1-3 from onset of symptoms)
MMSE: 22-28
Middle, Moderate Impairment (yr 2-8)
MMSE: 10-21
Late, Severe Impairment (yr 6-12)
MMSE: 0-9
Noncognitive Symptoms
Psychotic Symptoms (e.g., delusions, hallucinations)
• Delusions may be paranoid (e.g., people stealing things, spouse unfaithful) • Hallucinations (approximately 11% of patients) are more commonly visual Depressive Symptoms
• Occur in up to 40% of AD patients; may herald onset of AD • May cause rapid acceleration of decline if untreated • Need to suspect if patient stops eating or withdraws Agitation or Aggression
• Occurs in up to 80% of patients with AD • A leading cause of nursing-home admission • Consider superimposed delirium or pain as a trigger Risk and Protective Factors for AD
Definite risks
Possible risks
Possible protectors
Antioxidants (eg, vitamin E, beta carotene) HypertensionLower educational levelDepression Clinical Features Distinguishing AD and Other Types of Dementia
• AD: Memory, language, visual-spatial disturbances, indifference, delusions, agitation • Frontotemporal dementia: Personality change, executive dysfunction, hyperorality, relative preserva- • Lewy body dementia: Visual hallucinations, delusions, EPS, fluctuating mental status, sensitivity to • Vascular dementia: Abrupt onset, stepwise deterioration, prominent aphasia, motor signs Evaluation
Although completely reversible dementia (e.g., drug toxicity) is rare, identifying and treating secondaryphysical conditions may improve function.
• Hx: Obtain from family or other informant • Evaluate mental status for attention, immediate and delayed recall, remote memory, executive function, and depression. Screening tests may include Mini-Cog, number of animals named in 1 minute,MMSE, GDS. Laboratory Testing
CBC, TSH, B12, folate, serum calcium, liver and kidney function tests, electrolytes, serologic test for
syphilis (selectively); at this time, genetic testing and commercial “Alzheimer blood tests” are not
recommended for clinical use.
Neuroimaging
The likelihood of detecting structural lesions is increased with:
• Focal (unexplained) neurologic signs or symptoms • Abrupt onset or rapid decline (weeks to months) • Predisposing conditions (e.g., metastatic cancer or anticoagulants) Neuroimaging may detect the 5% of patients with clinically significant structural lesions that wouldotherwise be missed.
FDG-PET scans approved by Medicare for atypical presentation or course of AD in which
frontotemporal dementia diagnosis is suspected.
See www.petscaninfo.com/portals/pat/medicare_guidelines_alzheimers
Treatment
Primary goals of treatment are to improve quality of life and maximize functional performance byenhancing cognition, mood, and behavior.
General Treatment Principles
• Identify and treat comorbid physical illnesses (e.g., HTN, diabetes mellitus) • Avoid anticholinergic medications, eg, benztropine, diphenhydramine, hydroxyzine, oxybutynin, • Limit prn psychotropic medication use • Specify and quantify target behaviors Nonpharmacologic Approaches
– Behavior modification, scheduled toileting, and prompted toileting for UI – Graded assistance (as little help as possible to perform ADLs), practice, and positive reinforcement – Simulate family presence with video or audio tapes – Speak at patient’s comprehension level – Bright light, “white” noise (i.e., low level, background noise) Pharmacologic Treatment of Cognitive Dysfunction in AD
• Patients with a diagnosis of mild or moderate AD should be offered treatment with a cholinesterase inhibitor that will increase the level of acetylcholine in the brain (see Cognitive Enhancers Table) – Controlled data show modest symptomatic benefit for cognition, mood, behavioral symptoms, and daily function of cholinergic drugs compared with placebo for 1 yr, and open trials demon-strate benefit for 3 yrs. – Only 10%-25% of patients taking cholinesterase inhibitors show clinical improvement, but 80% – Initial studies show benefits of these drugs for patients with dementia associated with Parkinson’s disease, Lewy body dementia, and vascular dementia.
– Cholinesterase inhibitors have not convincingly demonstrated that they slow progression of mild – Cholinesterase inhibitors may attenuate noncognitive symptoms and delay nursing-home – To evaluate response to cholinesterase inhibitor: • Elicit caregiver observations of patient’s behavior (alertness, initiative) and follow functional • Follow cognitive status (e.g., improved or stabilized) by caregiver’s report or serial ratings of • Memantine (Namenda) demonstrated modest efficacy compared with placebo in moderate to severe AD as monotherapy and when combined with donepezil (Aricept).
• Vitamin E at 1000 IU bid found to delay functional decline in AD (caution in those with cardiovascu- lar disease because ≥ 400 IU may increase mortality). • Ginkgo biloba is not generally recommended because clinical trial results are not definitive, and preparations vary because such nutriceuticals are not regulated by the FDA.
• Estrogen replacement therapy in older women may increase risk of developing AD.
Cognitive Enhancers
Formulations
Start at 5 mg qd, increase to 10 mg qd after 1 mo Start at 4 mg bid, increase to 8 mg bid after 4 wk; recommended dose 8 or 12 mg bid (CYP2D6, 3A4) Start at 1 capsle daily, preferably with food; titrate Start at 1.5 mg bid and gradually titrate up to 6 mg bid as tolerated; retitrate if drug is stopped (K) Start at 5 mg qd, increase by 5 mg at weekly intervals to maximum of 10 mg bid; reduce dose if * Cholinesterase inhibitors. Adverse effects increase with higher dosing. Continue if improvement or stabilization occurs; stopping drugs can lead to rapid decline. Possible adverse effects include nausea, vomiting, diarrhea, dyspepsia, anorexia, weight loss,leg cramps, bradycardia, insomnia and agitation.
*** Increased mortality found in controlled studies of mild cognitive impairment.
Treatment of Agitation
First, identify and examine context of behavior (is it harmful to patient or others), environmental
triggers (e.g., overstimulation, unfamiliar surroundings, frustrating interactions), exclude underly-
ing physical discomfort (e.g., illnesses or medication), consider nonpharmacologic strategies.
Agitation Treatment Guidelines
Formulations
impulse-control divalproexsymptoms in men * Use with caution in patients with cerebrovascular disease or hypovolemia; may increase risk of cerebrovascular adverse events compared with placebo; similiar comparative data not available for other atypical antipsychotics.
** May need to give higher doses in emergency situations; should be used for only short periods of time.
† Small divided daytime dosage and larger bedtime dosage; watch for sedation and orthostasis.
‡ Can be given bid; 2-4 wk for adequate trial.
§ Can monitor serum levels; usually well tolerated; check CBC, platelets for agranulocytosis, thrombocytopenia risk in older §§ Monitor serum levels; periodic CBCs, platelet counts secondary to agranulocytosis risk. Caregiver Issues
• Physical illness, isolation, anxiety, and burnout are common.
• Intensive education and support of caregivers may delay patient institutionalization.
• Adult day care for patients and respite services for caregivers may help.
• Alzheimer’s Association offers support, education; chapters are located in major cities throughout US.
• Family Caregiver Alliance offers support, education, information for caregivers. Additional References
Doody RS, Stevens JC, Beck C, et al. Practice parameter: management of dementia (an evidence-based
review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
Neurology 2001; 56(9):1154-1166.
Palmer K, Fratiglioni L, Winblad B. What is mild cognitive impairment? Variations in definitions andevolution of nondemented persons with cognitive impairment. Acta Neuro Scand. 2003; 107 (Suppl179): 14-20.
Adapted with permission from the American Geriatrics Society Source: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips:2005, 7th Edition. New York: The American Geriatrics Society; 2005: 41-45.
Cognitive
Management
Summary

Impairment
Is there a specific treatable cause?
• Has a reversible causes evaluation been conducted? (CBC, biochemical panel, TSH, B12, and perhaps syphilis serology, folate, and neuroimaging study)? • Is this patient likely to have Alzheimer’s disease (prominent memory, language, and visual-spatial impairment)? Consider a cholinesterase inhibitor and/or memantine. Also consider vitamin E at 1000 IU bid.
• Is this patient likely to have vascular dementia (stepwise course frequently with focal neurologic signs). If so, consider aspirin or other antiplatlet agent.
• Is this an atypical dementia (visual hallucinations and Parkinsonian features suggest Lewy body dementia; personality changes such as poor boundary setting, hyperorality suggest frontotemporaldementia)? If so, consider referring to a psychiatrist or neurologist.
Is there a non-specific treatable condition?
• Does patient have behavioral symptoms? If yes, consider the following therapies (in parentheses) and monitor response during subsequent visits: – Agitation in the context of non-acute psychosis (atypical antipsychotic, but remember to review – Agitation in the context of depression (SSRI antidepressants) – Hallucinations or delusions (atypical antipsychotic) – Insomnia or sleep problems (sleep hygiene measures or trazodone) • Is the patient depressed? Consider SSRI antidepressant.
• Is the patient drinking too much? Insist that the patient stop drinking.
• Is there caregiver stress? If yes, refer to community resources (give handout). Consider social work • If all else fails, consider psychiatry referral.
Geriatric
Depression
Scale
5-item

Positive screen: 2 or more asterisked (*) responses
1. Are you basically satisfied with your life? 4. Do you prefer to stay at home rather than going out 5. Do you feel pretty worthless the way you are now? Used with permission from The Journal of the American Geriatrics Society.
Source: Hoyt MT, Alessi CA, Harker JO, et al. Development and Testing of a Five-Item Version of the Geriatric DepressionScale. Journal of the American Geriatrics Society 1999 Jul; 47(7):873-8.
Cognitive
Physician’s
Responsibilities

Impairment
and Driving

As of 2003, the following 11 states REQUIRE that physicians report patients with disorders characterized by lapses of consciousness, such as dementia, Alzheimer’s, or other related conditions: California
Delaware
Kentucky
New Jersey
Pennsylvania
Two states REQUIRE that patients provide physicians with permission before allowing them to submit their health One state, Alaska, reviews all medical information submitted to the DMV, but does not expect physicians to report
One state, Indiana, REQUIRES the reporting of handicapping conditions to the state Board of Health within 60 days of
diagnosis, treatment or provision of care by a physician.
The 35 other states and the District of Columbia ENCOURAGE and PERMIT reporting of health problems that could affect a person’s ability to safely operate a motor vehicle, but they DO NOT REQUIRE it.
Source:Wang CC, Kosinski CJ, Schwartzberg JG, Shanklin AV. Physician’s Guide to Assessing and Counseling Older Drivers.
Washington, DC: National Highway Traffic Safety Administration; 2003. Chapter 8.

Source: http://www.med.illinois.edu/depts_programs/sciences/clinical/internal_med/Document/All%20Cognitive%20Impairment%20Physician%20Materials.pdf

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