PCA Regional Conference on Aging
October 2012
When It’s Not Dementia:
Other Conditions That Impair
Cognitive Performance
Christine Bradway, PhD, RN
Associate Professor of Nursing
School of Nursing
University of Pennsylvania
Joel E. Streim, MD
Professor of Psychiatry
Perelman School of Medicine
University of Pennsylvania
and
Philadelphia VA Medical Center
Disclosures
Dr. Streim receives salary support from grants funded
by:

National Institute on Aging
(NIA)

VA Health Services Research & Development
(VA HSR&D)

Health Resources and Services Administration (HRSA)

Donald W. Reynolds Foundation
Dr. Bradway receives salary support from

Health Resources and Services Administration (HRSA)
Learning Objectives

Identify cognitive domains that may become impaired in mental
disorders of late-life

Describe syndromes of cognitive impairment commonly seen in
older adults

Understand the importance of assessment for identifying
potentially reversible or treatable causes of cognitive
impairment; and for identifying the extent of cognitive disability
and need for assistance

Recognize the ways that cognitive impairment can affect
geriatric care, including behavioral health treatment and the role
of caregivers

Identify at least 3 elements of cognitive capacity required for
independent decision-making
Session Overview
1.
Lecture on cognitive conditions,
assessment, and management issues
(Streim)
2.
Interactive case presentations
(Bradway)
3.
Discussion of participant case experience
(Bradway, Streim, audience)
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
PCA Regional Conference on Aging
October 2012
When It’s Not Dementia:
Other Conditions That Impair
Cognitive Performance
Joel E. Streim, M.D.
Professor of Psychiatry
Perelman School of Medicine at the University of Pennsylvania
Geriatric Education Center
and
Philadelphia VA Medical Center
Mental Illness Research Education & Clinical Center
What is “cognitive impairment” ?
Deficits in various cognitive domains:
—attention
—memory
(amnesia)
—language
(aphasia)
—recognition
(agnosia)
—performing motor activities
(apraxia)
—initiating/executing tasks
(abulia)
—visual-spatial function
—insight
—judgment
Consequences of Cognitive Impairment
Cognitive impairment can interfere with

Communication
— Comprehension
— Ability to report symptoms, express needs

Social awareness, self-monitoring, behavior

Ability to follow directions

Self-care (basic ADLs)

Household management (instrumental ADLs)
Impairment in
Activities of Daily Living (ADLs)

Instrumental ADLs
(Household Management)

Basic ADLs
(Personal Care)
— Shopping
— Bathing
— Cooking
— Hygiene
— Cleaning
— Grooming
— Laundering
— Dressing
— Using Telephone
— Feeding
— Paying Bills
— Toileting
Other Consequences
Cognitive impairment can interfere with

Personal safety
— Eating (e.g. risk of choking or aspiration)
— Walking (e.g. risk of getting lost, falling)
— Household tasks (e.g. risk of fires, accidents)

Receipt of medical, nursing, and personal care
— Patient participation
— Delivery of care by providers & caregivers
Syndromes of Cognitive Impairment

Delirium = disturbance of
consciousness and attention
plus other cognitive domains
acute confusional state

Dementia = impairment of memory
plus other cognitive domains
(Dx requires interference
with everyday functioning)
chronic confusional state
Delirium: clinical features

Essential features:
— Disturbance of consciousness with impaired attention
(inability to focus, fix, or shift attention)
— Change in cognition (impaired memory, disorientation,
language disturbance), or
— Perceptual disturbance (hallucinations, illusions)
— Caused by a medical condition or medication effects

Associated features:
— Delusional thinking (psychosis)
— Sleep-wake cycle disturbance
— Agitated behavior, or hypoactivity
Delirium: clinical course and etiology

Abrupt onset (hours to days)

Fluctuating course

Caused by various medical or neurological
conditions, drug effects (intoxication, withdrawal),
or combination

Usually reversible if underlying condition is
treated successfully

High mortality rates, especially if not recognized
or treated
Delirium: common causes

Infection

Dehydration, electrolyte disturbances

Hypoglycemia

Hypotension (low blood pressure)

Hypoxemia (low blood oxygen levels)

Cardiac events

Respiratory illnesses

Neurological events (stroke, brain injury)

Medication effects
—
Anticholinergics, antihistamines
—
Narcotics
—
Alcohol or drug intoxication OR withdrawal
NB: An acute episode of delirium can be
superimposed on a chronic dementia
Recognition of Cognitive Impairment
Suspect delirium or dementia when

patient has self-care deficits

family has “taken over” responsibilities


patient doesn’t participate well in medical,
nursing, rehabilitative, or personal care
behaviors interfere with care delivery
Don’t blame “old age”
Symptom Overlap
in Delirium and Dementia
Common features of acute and chronic confusion:

Amnestic: forgetful, poor recall, misplacing things

Disoriented: confused about time and place

Aphasic: word-finding difficulty, impaired
comprehension

Perseverative: repetition of words, thoughts

Apraxic: difficulty dressing, grooming, hygiene

Dependent: need help from caregivers

Delusional: paranoid thoughts and fears

Agitated: picking at clothes/hair/objects, motor
restlessness, verbal or physical aggression
Recognition of Cognitive Impairment:
Barriers and Clues

Patient’s may not be aware of changes
— lack insight into memory problems
— deny disability

Get history from family, friends, or caregivers
— onset may be abrupt (days, weeks) or gradual (over
months, years)
— families may not notice gradual changes
— ask about change from baseline function, from
“usual self”

Look for discrepancy between self-reported
function and actual performance of ADLs

If patient has difficulty performing ADLs, ask for
OT evaluation (clinic or in-home)
Cognitive Impairment:
What are the obvious signs?

Forgetfulness
— Repetitious statements
— Misplacing things

Disorientation
— Getting lost

Speech deficits
— Word-finding difficulties
— Word substitutions

Diminished judgment
Recognizing more subtle signs

Visual complaints; impaired recognition

Trouble following directions

Difficulty performing familiar tasks

Family members take over usual roles

Loss of initiative
— Disengagement from usual activities
— Self-neglect
— Weight loss

Diminished social spontaneity
— Less conversation
Behavioral Disturbances

Wandering

Restlessness
—
Fidgeting
—
Pacing

Impulsivity

Inappropriate handling of objects
—
Rummaging / fiddling
— Hoarding

Verbal agitation
— Repetitious speech
— Verbal annoyance / aggression

Physical combativeness
Not all cognitive impairment meets
criteria for a diagnosis of dementia

When memory is not affected

When function is not affected
— Performance of ADLs is preserved

Can be associated with various
— Neurological conditions
— Medical illnesses
— Psychiatric disorders

Other contributing factors
— Chronic pain
— Impaired vision and hearing
Neurological conditions associated
with cognitive impairment

Mild cognitive impairment
— No significant functional deficits

Neurological disorders
— Stroke
— Parkinson’s disease

Traumatic brain injury (TBI)
Medical causes of cognitive impairment

Metabolic
— Vitamin deficiencies
— Hypo- or hyperglycemia
— Electrolyte disturbances (low Na, high Ca)

Hormonal
— Hypothyroidism

Infectious
— AIDS
— Syphilis
— Pneumonia
— Urinary tract infection
Some of these are
treatable and
potentially reversible
Psychiatric conditions associated
with cognitive impairment
Poor cognitive performance may be partially or wholly explained by


Anxiety
—
impaired concentration, distractibility
—
obsessional thinking, indecisiveness
Depression
—
lack of motivation, poor effort
—
fatigue
—
impaired concentration
—
executive dysfunction
—
indecisiveness
Most of these
are treatable
Cognitive performance may improve when anxiety or depression is
treated.
Other contributing factors

Chronic pain
— Osteoarthritis
— Peripheral neuropathy

Hearing impairment

Low vision
— Age-related macular degeneration
— Diabetic retinopathy
— Cataracts
Careful Evaluation is Essential
Up to 90% of individuals with acute and 20% with
chronic cognitive impairment may have a reversible
component
Need to identify treatable impairments. However,
most with dementia will have persistent deficits
Relationship of Depression and Cognitive
Impairment in Old Age: What’s New?

1/3 to 1/2 of patients with late-life depression have
at least mild cognitive impairment (MCI).1

Depression with onset in late-life is often
associated with vascular risk factors and
executive dysfunction.2

This has been called vascular depression, and is
distinct from pseudodementia, as cognition does
not improve with antidepressant treatment.2

Geriatric patients with depression have a higher
incidence of progression to MCI and dementia.1,3
1
Panza F et al. Am J Geriatr Psychiatry 2010; 18:98-116; 2 Alexopoulos GS et al. Am
Psychiatry 1997; 154:562-565; 3 Steffans DC et al. Arch Gen Psychiatry 2006; 63:130-138
Recognition of executive dysfunction
in clinical practice



1
2
History of observable functional and behavioral signs1
— Difficulty with initiation
— Inability to perform sequential tasks
— Poor task completion
— Disengagement from activities
— Task avoidance (BADL, IADL)
Referral for evaluation of functional status by
occupational therapist2
Consider referral for selective neurocognitive testing
Alexopoulos. J Clin Psychiatry. 2003;64(suppl 14):18-23.
Erez et al. Am J Occup Ther. 2009;63(5):634-640.
Executive function is crucial for both task
performance and decision-making
Encompasses:

Awareness of one’s situation (presence of
unmet needs, medical problems, disability,
danger) and what needs to be done

Planning solutions and actions

Initiation of tasks

Sequencing and performance of tasks
Self-reported abilities vs.
demonstrated performance
Individuals with executive dysfunction may be
able to describe how a task can be accomplished,
but unable to perform the task.
Therefore, a medical or psychiatric interview may
need to be complemented by observations of
actual task performance
Observations may be made during examination
by a psychiatrist, cognitive or neuropsychologist,
or occupational therapist
Individuals with executive dysfunction
or deficits in other cognitive domains
• may or may not meet criteria for
dementia or delirium
• may or may not have impaired
decision-making capacity
How do clinicians translate examination
findings into a clinical assessment of
decision-making capacity?
Evaluation of Decision-making
Capacity from a Clinical Perspective
Key elements of capacity

Awareness of the situation or need
(healthcare, financial, living arrangements)

Understanding of the treatment options /
available solutions

Appreciation of risks and benefits, or
consequences of a choice
(ability to reason and deliberate)

Ability to communicate the choice
Cognitive Impairment and Decision-making
Capacity: seeing clinical “shades of grey”
Pattern and severity of cognitive deficits usually includes areas
of spared cognitive function and impaired cognitive function.
Individual may have retained the capacity to
—
Recognize a basic need for help
—
Express wishes or preferences
which form the basis for participation in decision-making
…But same individual may have lost the capacity to
—
Appreciate the extent of disability
—
Recognize the type or magnitude of the assistance needed
—
Deliberate about risks, benefits
—
Appreciate potential consequences of a decision
which creates a need for assistance in decision-making
Basis for Assisted Decision-Making
Concept of substituted judgment


Effort to determine what the person wants or would
have wanted for him or herself
Duty to represent person’s advance directives, if
available
Need to educate and support caregivers and
surrogates to use

Substituted judgment in decision-making

Assisted decision-making, when possible
Training of Caregivers to Function as
Surrogate Decision-Makers
Concept of assisted decision-making:

Preservation of autonomy to the extent possible
— Identify areas of spared cognitive function and encourage
their continued use
— Help individual compensate for areas of impaired cognition

Take current wishes and preferences into account,
when consistent with realistic options

Risk tolerance may reflect the persons life-long values

Responsibility for the final decision rests with the
surrogate
Assisted Decision-Making:
Practical Approaches to Communication
Caregivers and surrogate decision-makers
should be encouraged to:
— Use simple language to explain situation, options, etc.
— Present information slowly
— Repeat information, check for comprehension
— Point out consequences
— Ask about wishes and preferences
— Ask about priorities (values)
e.g., “What’s most important to you?”
Essentials of Family-Caregiver Education

Explain functional limitations due to confusion

Set expectations for
— Recovery from delirium; risk of recurrence
— Progression of dementia

Clarify care needs
— Provide a safe environment
— Communication strategies (optimize vision & hearing)
— Supervision / assistance with ADLs

Encourage medical follow-up
— Optimize treatment of other conditions
— Reduce and manage co-morbidity
Questions ???
Discussion
Standardized cognitive screening
instruments: Short and Shortest

Mini Cog
— 3 recall items
— Clock drawing

3 minutes to administer

Scoring quick, simple

Less affected by education, ethnicity,
language than other, longer tools
Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual
elderly. Int J Geriatr Psychiatry 2000; 15(11):1021
Mini-Cog Scoring Algorithm
http://geriatrics.uthscsa.edu/tools/MINICog.pdf
Montreal Cognitive Assessment
(MoCA)

Tests multiple cognitive domains
— Attention
— Memory
— Language
— Visuospatial
— Executive function
— Abstract thinking

10 minutes to administer

Score range 0-30

<26 is abnormal
Nasreddine ZS, et al. The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For
Mild Cognitive Impairment. J American Geriatr Soc 53:695-699, 2005.
Montreal Cognitive Assessment
(MoCA)
http://www.mocatest.org/
Case #1


Mrs. T. is 90 and has just been discharged
to home after a 5 day hospital stay
Came to the hospital with “confusion” at
home
—Did not recognize daughter
—Not eating
—Fearful of burglars in house
Case #1: Continued

Hospital diagnoses/problems included:
— Urinary tract infection
• Dehydration
— Delirium
— Deconditioning
— She is ordered home physical/occupational
therapy to determine her ability to continue to
live at home
Case #1: Continued

1. What pre-hospital information is
important to know about Ms. T?

2. What assessments are essential when
she returns home from the hospital?

3. What factors need to be considered
when making Ms. T.’s plan of care?

4. What caregiver information/support
should be initiated?
Case #2

Mr. R is an 81 year-old widower now at home after a 3day hospitalization for acute pneumonia. He has
underlying mild COPD.

Mr. R worked as a mechanic and retired at age 62. His
wife died 3 years ago and he sold his home and now
lives with his daughter.

Mr. R.’s daughter has noticed he is less physically
active and seems to interact less and less with family
and friends for the past 6 months.
Case #2: Continued
At home you note that Mr. R:
 Requires oral antibiotics for 5 more days to
complete pneumonia treatment
 Has lost 10lbs. within last month
 Had unreported diarrhea during hospitalization
 Began a medication, Amitriptyline, for
depression
—Was given a sleep medication, Ambien, while
hospitalized and to take at home
Case #2: Continued

On interview, Mr. R is a little
lethargic and has slowed
speech. He is also unsteady
and nearly falling with walking.
He has increased confusion at
night; he had some mild
memory loss before being
hospitalized. He has had
diarrhea since coming
home and his appetite is poor.
Case #2: Continued
What else would you like to know about
Mr. R’s memory and cognition?
Case #2: Continued

Mr. R’s daughter’s main concern is her father’s
changed behavior. Prior to hospitalization Mr. R
was functioning with minimal assistance at home,
was forgetful, but mostly independent. Mr. R’s
hearing aid was lost during hospitalization and
so, until his daughter can secure another, Mr. R’s
hearing is quite impaired. The Mini-Mental State
Examination pre-hospitalization is unavailable.
Mr. R’s current MMSE is 21 (normal 24-30). Since
discharge he has been quite dependent, more
short of breath than normal, and is often “not
making sense”.
Case #2: Continued
What are the risk factors Mr. R has for
the development of delirium?
What are the risk factors Mr. R has for
depression?
What concerns do you have for Mr. R.
now that he is at home?
Case #2: Continued
What further information might be helpful in
terms of Mr. R.’s nutritional and fluid
intake?
How might this affect Mr. R.’s cognitive
abilities?
Case #2: Continued
What interventions would you suggest
implementing for Mr. R’s plan of care?
How should Mr. R’s depression be
addressed?
Are there interventions that could have been
implemented in the hospital to
prevent/minimize the delirium?
Case #2: Continued
What other strategies might be helpful to
support Mr. R’s daughter?
Case #3: Ms. W*

75 y.o.

In good health; lives alone in the community

No history of dementia or psychiatric illness

Comes to office with left face/eye pain

Diagnosed with temporal arteritis and started
on oral steroids
 Long term steroid treatment is appropriate
for temporal arteritis
* Cipriani, et al (July 2012). Reversible dementia from corticosteroid
therapy. Clinical Geriatrics, pp 38-41.
Case #3: Clinical Course

After 7 months of steroid treatment Ms. W:
— Became forgetful
— Developed insomnia and impaired memory
— Family noted anxiety, labile mood
— Decreased motivation to perform IADLs/ADLs
• Bathing
• Driving

One month later she was unable to care for
herself
Case #3: Additional Data at 7 Months

MMSE 22/30

EEG and labs normal

Why is dementia probably not what is
happening to her now?
Case #3: Follow-Up

Ms. W was diagnosed with steroid-induced
delirium

Steroids were tapered and then
discontinued over a 20-day period

15 days after the steroids were stopped,
memory and cognitive deficits improved

Two months after stopping the steroids her
MMSE was 28/30 and ADL/IADL function
much improved
Case #4: Mr. H.G.

Patient is an 89 year old male

Is the caregiver for his wife, who has dementia
and low vision.

Mr. H.G. was ambulatory, driving, shopping for
groceries, cooking, doing light housekeeping, and
paying the bills until the last couple of months.

His daughter brings him to see his primary care
provider after her mother complains that she’s
tired of eating microwaved hotdogs every night.
Daughter also notices spoiled food in the
refrigerator.
Case #4: Continued

Patient complains of pain in his back,
shoulders and knees that prevents him
from standing in the kitchen and preparing
meals. He says he doesn’t need any help
with shopping or other household tasks,
except maybe with meal preparation.
Case #4: Continued

What else do you want to know about Mr.
H.G.’s health and function?
Case #4: Continued

Physical exam:
— Weight is down 23# since his doctor’s visit 3 months ago.
— He has arthritic changes in both hands and knees, with
muscle wasting in arms and legs.
— His hearing aids are not working, even with new batteries

Cognitive exam:
— He can recite all the names and doses of his wife’s
medications
— MMSE=19/30 (below 24 is abnormal)

Laboratory and x-ray findings:
— Anemia
— Spinal stenosis
— Severe degenerative changes in both knees R>L
Case #4: Continued

What else do you want to know?

What factors might be causing or
contributing to Mr. H.G.’s decline in
functioning?
Case #4:

What might you learn from doing a home
visit at this point?
— What would you look for?
— What else would you ask about?

What might you recommend?
Case #4: Follow-up

Management included:
— Discontinuation of NSAIDs that were thought to be
causing gastritis and GI blood loss
— A regular pain medication regimen
— Physical therapy
— Replacement of hearing aids
— Nutritional supplements

He gained 6#, anemia resolved, strength and
ambulation improved, with increased ability to
stand in the kitchen…
Case #4: Follow-up


…But executive dysfunction persisted and
the couple needed a home health aid to
help with grocery shopping and meal
preparation
Over the next 12 months, his short-term
memory became worse, and he could no
longer supervise his wife’s medications