Diagnosis Dementia:
Diagnosis, Assessment, and
Referral
Soo Borson MD
University of Washington
Department of Psychiatry and Behavioral Sciences,
School of Medicine
Department of Psychosocial and Community
Health, School of Nursing
New Cases of Alzheimer’s Disease
Hebert et al. Neurology 2004
National Priorities for Dementia Care
• Detect cognitive impairment
• Diagnose dementia when it’s present
– Dementia is…
• A medical problem caused by specific disease processes,
and a target for medical treatment
• A risk factor for other problems, and a modifier of other
conditions and treatments
• A (usually) progressive condition with changing, stagespecific problems and needs
• Provide dementia-specific, relevant, proactive , and
comprehensive patient care
The Broad Impact of Dementia
• Health care
– Delirium (OR 3.96, 95% CI 1.1-14.2) 1
– Low health literacy/adherence to pre-op instructions (OR
4.0, 95% CI 1.6-9.8) 2
– Med management deficits3
– More hospitalizations for ambulatory care sensitive
conditions (OR 1.8, p < 0.0001)4
• Public safety
– Driving risk 5
• At home, in the community
– Need for everyday support and assistance 6
1.
Alagiakrishnan et al. JAGS 2007. 2. Chew et al. Am J Surg 2004. 3. Lakey et al. Ann
Pharmacother 2009.
4. Phelan et al (in prep). 5. AMA Driver Guide, http://www.amaassn.org/ama/pub 6. Scanlan et al. Am J Geriatr Psychiatry 2007
© 3-11 Soo Borson MD
New Opportunities for Detecting
Dementia in Primary Care
• The Medicare Annual Wellness Visit
–
–
–
–
New benefit - January 2011
Voluntary for patients and providers
No patient co-pay; Level 4 E/M for provider
Two assessment components
• Cognitive checkup – objective assessment
• Health risk assessment
• One key goal: personal prevention plan
• Missed opportunity
– Only 3-4% of seniors used the benefit in 1st half of 2012
Cognitive Assessment in the Annual
Wellness Visit
• Many approaches
– Ask the patient about problems with memory
or needing help to do things that used to be
easy (e.g. paying bills)
– Ask someone else who knows the patient well
– Give a screening test
• Some health care systems have adopted
routine, systematic screening
– Simple, uniform, quality control possible
Case Study: Mini –Cog™
1)
GET THE PATIENT’S ATTENTION, THEN SAY: “I am going to say three words that I want you to remember.
The words are:
Banana
Sunrise
Chair
Please say them for me now.” (Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item.)
(Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the memory words. Hand the patient a pencil/pen).
2)SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: “Please draw a clock (provide paper, pencil). Start by drawing a large
circle.” (When this is done, say) “Put all the numbers in the circle.” (When done, say) “Now set the hands to show 11:10 (10 past 11).”
SAY: “What were the three words I asked you to remember?”
___________________
___________________
Score the clock (see other side for instructions):
____________________
Normal clock
Abnormal clock
(Score 1 point for each)
3-Item Recall Score
2 points
0 points
Clock Score
TOTAL SCORE = 3-ITEM RECALL PLUS CLOCK SCORE
Total score of 0, 1, or 2 possible impairment; 3, 4, or 5 suggests no impairment.
Mini-Cog™. Copyright Soo Borson MD All rights reserved.
Mini-Cog™
A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:
All numbers 1-12, each only once, are present in the correct order
and direction (clockwise) inside the circle.
Two hands are present, one pointing to 11 and one pointing to 2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED
ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED
ABNORMAL.
Abnormal Hands
Abnormal Spacing
Mini-CogTM . Copyright Soo Borson MD. All rights reserved.
Abnormal
Spacing/Numbers
Detecting Dementia with the MiniCog™
Recognition Rate,
N (%)
Total N
(%‡)
by
Mini-Cog
by
Physicians
112 (47)
111 (99)
69 (62) **
AD + vascular
22 (10)
20 (91)
15 (56) *
Vascular dementia
15 (6)
15 (100)
6 (40) **
Other dementia types
11 (6)
9 (82)
5 (45) *
Mild Cognitive Impairment
71 (32)
39 (55)
4 (6) **
231
194 (84%)
94(41%)
Diagnosis
Dementias
Probable AD
Total
* p < 0.05; ** p < 0.01
Borson et al. Int J Geriatric Psychiatry 2006
Moving from Screening to
Diagnosis
• Screening for cognitive impairment
– Identifies the majority of patients with
dementia
– Cannot diagnose dementia or its cause
• Diagnostic assessment appropriate after
– Positive screen
– Negative screen but high clinical suspicion
Components of the Diagnostic Workup
•
•
•
•
Thorough medical and family history
Mental status testing
Physical and neurological examination
Laboratory examination
History
FIRST
SYMPTOMS/SIGNS
• Forgetfulness
• Executive
impairment
• Psychiatric or
behavioral
• Neuromotor
COURSE
•Insidious vs
sudden onset
•Smooth vs
stuttering
•Short term
stability vs daily
fluctuation
OTHER
•Diseasespecific features
•Comorbid
conditions
•Medications
•Alcohol and
other substance
use
•Family history +
Mental Status Testing
• To establish presence of cognitive disorder
– Comparison with
• Patient’s prior cognitive level
• Normative expectations for the person
– Two or more core cognitive abilities affected
• Memory and learning
• Executive abilities
• Language, cognitive control of motor acts, recognition of
objects, people
• Visuospatial functions, navigation
– Everyday life affected by deficits
• To look for non-dementia causes, e.g.
depression
Clinical Differential Diagnosis
Dementia
present
Neuro exam
normal
AD
Neuro exam
abnormal
FTD
VaD
PDD, ‘Park+’
DLB
Diagnostic Testing
• Routine “rule out” labs
• Psychometric testing
• Structural and functional neuroimaging
Pure AD
AD with severe cerebral amyloid angiopathy
Mild AD with vascular involvement
AD with vascular lesions
AD with CVD
VaD with AD changes
VaD with small-vessel disease
Pure VaD
Agüero-Torres H, Winblad B. Ann NY Acad Sci. 2000;903:547-552.
Common Patterns of Ischemic Vascular
Dementia
Cortical
Cortico-subcortical
occipito-temporal infarct
Subcortical White Matter
White matter lesions predominate
Strategic
Thalamic infarct
Subcortical Lacunar
Lacunar infarcts predominate
Courtesy of T. Erkinjuntti.
DIAGNOSIS
MRI
SPECT/PET
Alzheimer Disease
Med temporal, parietal
atrophy; later, diffuse atrophy
and ventricular enlargement
Parietotemporal assoc
cortex, posterior cingulate;
sensorimotor preservation
Frontotemporal
Dementia
Frontal and/or lateral
temporal atrophy
Prefrontal and temporal
Dementia with Lewy
Bodies
Hippocampus, medial
temporal preserved; putamen
atrophy
Parietotemporal plus
occipital
Vascular Dementia
Bilateral micro and/or
macrovascular disease, no
set pattern
Asymmetric cortical,
subcortical, cerebellar;
watershed; crossed
cerebellar diaschisis;
lateralized hemispheric
deficit
Pure AD
CONVENTIONAL SPECT
IMAGES
3D – SSP PROCESSED IMAGES
Pure AD
FUSED MRI/SPECT IMAGES
AD + Vascular Disease
Lewy Body Dementia
Contribution of Combined
MRI/SPECT to Diagnosis
• Findings significant for diagnosis in 78.5%
• Pre-imaging diagnosis of neurodegenerative disease
rejected by imaging in 2.5%
• Vascular component identified in 41 patients (51% of
sample)
– 30% exclusively vascular
– 53% AD + vascular
– 7% FTD + vascular
• Imaging most helpful:
– When diagnosis is difficult due to atypical features
– To test clinical impression
– To clarify complex etiologies
Research and Clinical Trials
• CSF biomarkers as indicators of AD risk
– Amyloid beta
, Tau
• Novel PET imaging compounds
– FDA approval of amyloid imaging agents
• Not currently approved for clinical diagnostic use
• Genetic testing
• Preclinical diagnosis of AD
Clinical Trials
• Primary pathway to therapeutic progress
• Depend on referrals from practicing
physicians and other providers
• You can help!
– Check out Alzheimer’s Association Trial
Match
http://www.alz.org/research/clinical_trials/find
_clinical_trials_trialmatch.asp
Specialist Referrals
• Neuropsychologist (psychometric testing)
– Very mild impairment in highly intelligent persons
– Atypical cognitive impairment mixed with psychiatric symptoms
– Medicolegal indications (e.g. medical disability determinations)
• Neurologist
– Difficult differential diagnosis
– Rare disease suspected, e.g. CJD, NPH
• Geriatric psychiatrist
– Difficult neurobehavioral problems
– Ongoing management of patient + family
• Geriatrician
– Frailty, falls
• Social worker
– Care planning, caregiver support and community resources
• Psychologist
– Psychotherapy for family members
An Integrative Framework
for Dementia Care
Differential
Diagnosis
and
Staging
Medical Comorbidity,
Safety and Risk
Management
Patient
and Family
Care
Partner
Caregiver
Assessment,
Counseling,
Services, and
Planning
Neuropsychiatric
Symptom Assessment
& Management
© 2008 Soo Borson MD
Evaluating the Quality of Dementia Care:
New Measures
• AMA PCPI with AAN, AGS, AMDA, APA/AAGP, Alz Assoc, others
• 10 quality measures, grouped into key domains
– Dementia assessment: cognition, stage, everyday
functional deficits
– Screening for depressive symptoms
– Neuropsychiatric symptom assessment and
management
– Counseling about safety (falls, medications) and
driving
– Comprehensive advance care planning and end of life
counseling
– Caregiver education and support
