Medical Evaluation of the Patient
with
Brain Failure
Jane F. Potter, MD
Chief Section of Geriatrics & Gerontology
University of Nebraska Medical Center
Delirium
• Clinical Presentation: A syndrome of acquired
impairment of attention, level of consciousness, and
perception.
Evaluation: Confusion Assessment
Method (CAM)

Change in cognition that has both:
 Acute
onset and fluctuating course
 AND Inattention

And either
 Disorganized
thinking
 OR altered level of consciousness
Acute Onset AND Fluctuation

Symptoms develop over hours to days
(need a reliable informant; if not observed
may present late)
AND

Symptoms vary through out
the day; characteristic
lucid interval
AND Inattention
Difficulty focusing, sustaining, and shifting
attention
 Difficulty maintaining conversation or
following commands

AND Either: Disorganized Thinking
 E.G.
disorganized
or incoherent
thinking
 E.G. Rambling or
irrelevant
conversation
(unpredictable switching
subjects?)
OR: Altered Level of Consciousness

Vigilant (hyperalert, very easily startled)
Lethargic (drowsy, easily aroused)
 Stupor (difficult to arouse)
 Coma (unarousable)

Evaluation: CAM


Change in cognition that has both:
 Acute
onset AND fluctuating course
 AND
Inattention
And either
 Disorganized
thinking
 OR altered level of consciousness
Risk Factors
for Delirium






Advanced age
Dementia
Depression
Impaired physical
function
Sensory loss
Decreased oral intake
(food and fluids)


Drugs (ETOH)
Coexisting Medical
Illness (severe, multiple,
CKD, LD, fractures,
stroke, neurological ds,
HIV)
Who Gets Delirious? Why?
VULNERABLE
PATIENT
# of RISK
FACTORS
I
N
S
U
L
T
S
Dementia
• Clinical Presentation: A syndrome of acquired
impairment of memory and other cognitive domains
sufficient to affect daily life
• Etiology: Any disorder causing damage to brain systems
involved in memory. Alzheimer’s disease is the most
common cause in later life
Brain Failure
 The
most common
cause of disability in
later life
 A focus
for geriatric
practitioners
Objectives:
Identify the common (non-dementia) causes
of cognitive dysfunction.
 Describe a basic approach to evaluate
physical causes of cognitive dysfunction
 Understand interdisciplinary contributions
to evaluation of cognitive dysfunction

The Brain Failure Evaluation:
What to Expect

Identification of reversible causes

Treatment of disabling conditions

Family information, counseling, and referral
Brain Failure:
Evaluation
CAREFUL
CLINICAL OBSERVATION
IS EVERYTHING!
Brain Failure:
Evaluation
History/physical
 Neurologic
 Medications
 Mood
 Abilities
 Social

The Brain Failure Evaluation
History

Collateral Source

Onset, Course, Progression, Risk Factors

Characteristic Course of Alzheimer’s Disease
HISTORY OF SYMPTOMS
From
a
caregiver or
someone close
to the patient
HISTORY OF SYMPTOMS
 What
were the
first symptoms?
 How
have things
changed?
 Is
this typical
for AD?
TYPICAL SYMPTOMS OF
ALZHEIMER’S DISEASE
Functional loss in reverse order to
which skills were gained
Brain Failure: Case 1
An 83 year old widower is evaluated because
his family is concerned that he is mildly
cognitively slowed. He is still successfully
maintaining homes in Arizona and Iowa.
He describes a 9 month history of decline in
his golf game, a 6 month history of
unexplained falls, and a 1 month history of
urinary incontinence.
Brain Failure:
Recognition
In patients or families presenting with a
complaint of cognitive dysfunction a
negative screening test does not exclude
dementia.
The Brain Failure Evaluation
Physical

Special Senses

Heart / Lung / Liver / Kidney

Bladder / Bone / Mobility
Brain Failure: Special Senses
 Vision

Hearing
•Brain Failure:Case 2

A 79 year old widower is a member of a
multigenerational household. He has had
progressive cognitive problems over the last
7 years. He is independent in all self care
activities, but at night he wanders about
knocking things over and urinating in trash
cans
Brain Failure: Case 3

A 68 year old married man suffers from AD.
Despite successful treatment of an
associated depression, he is inattentive and
often does not respond to his wife or
daughter.
Brain Failure: organ system
dysfunction
Heart and Lung: hypoxic encephalopathy
 Hepatic encephalopathy
 Renal encephalopathy
 Thyroid disorders
 Hyperparathyroidism

Brain Failure: Case 4

A 75 year old widow is evaluated at the
request of her family for progressive
cognitive impairment over the last 9
months. Her MMSE is 18. During the
interview she admits to exertional fatigue,
and lack of energy. On exam she has
diffuse expiratory wheezing in all lung
fields.
Brain Failure = Disability
Families/Patients are complaining of the
disability caused by brain dysfunction.
 The population at risk is characterized by a
burden of co-morbidities.
 Look for un or under-treated
comorbidities causing dysfunction.
 High yield for disorders of bladder, bone,
mobility.

NEUROLOGICAL EXAM

Cortical- frontal,
parietal, temporal,
occipital lobes

Sub-cortical- internal
capsule, basal ganglia,
thalamus
NEUROLOGICAL EXAM

Apraxia, agnosia,
aphasia, focal motor or
sensory signs

Gait disturbance,
rigidity, tremor
Frontal Lobe Release signs
MovieClips\Glabellar.movGlabellar tap
 Palmomenttal
 Grasp

Gait

Cortical

Subcortical
Sutton’s Law:

“Gee, Willy, why do you rob banks?
“BECAUSE
THAT’S
WHERE THE
MONEY IS”
Geriatrician’s Law:
Go for the MEDS
Because that’s where the money is
Inspect the Drug Bag

Three or more
drugs increase the
likelihood of an
adverse effect or
drug interaction
Drugs and Brain Failure
 Many
drugs can do this, e.g.
Sedatives, anxiolytics, anticholinergics, H2blockers, centrally acting antihypertensives
(clonidine, alpha-methyl dopa) antiarhythmics,
beta blockers, digoxin, sinemet, selegeline.
 Check
all for CNS S.E.s
 Try a “Drug Holiday”
Alcohol and Brain Failure

Volume of
distribution for ETOH
with age

No more than one/day
after age 65; stop all if
cognition impaired
Brain Failure: Case 4

An 83 year old widow presents with a
history of progressive cognitive failure.
During interview she admits to a long term
pattern of one drink before dinner. On
questioning, her daughter feels that she
likely exceeds one drink per day.
Depression as Brain Failure

Emotional illness
slows cognitive
function
Depression as a Cause of Brain Failure
Dementia
Depression
Insidious onset
Long duration
No psychiatric history


Conceals disability (often
unaware of memory loss)

Highlights disabilities (may
complain of the memory loss)

“Near-miss” answers

“Don’t know” answers

Day-to-day fluctuation in
mood

Diurnal variation in mood,
but generally more consistent





Abrupt onset
Short duration
Previous psychiatric history
The Brain Failure Evaluation
UNDERSTAND THE NORMAL
AGE-RELATED CHANGES IN
BRAIN AND MEMORY
Brain Failure vs Normal Aging

Normal aging
does not cause
dysfunction
The Brain Failure Evaluation
Laboratory
B-12, Folate, TSH
 Chem profile, UA, ?O2 sat
 CBC
 Other as indicated

The Brain Failure Evaluation
Radiology & Other
Head CT, ? Head MRI
 Chest X-ray
 EKG, EEG

Things that Cause the Brain to Fail
(whether or not an underlying dementia is present)
D
E
M
E
N
T
I
A
Drugs
 Emotional Illness (including depression)
 Metabolic/endocrine disorders
 Eye/ear/environment
 Nutritional/neurological
 Tumors/trauma
 Infection
 Alcoholism/anemia/ atherosclerosis

Therapy for AD
Cholinesterase inhibitors
 Vitamin E
 NMDA inhibitor- Memantine
 ? Vaccination
 Not Estrogen
 Not Anti-inflammatories
