Dust off your dementia playbook and re-evaluate your approach as Dr. Josh Uy walks us through this common (yet perplexing) condition. Dr. Uy (@joshuy) is the geriatric fellowship director at University of Pennsylvania in addition to a nursing home director and shares his skills in simplifying dementia screening, management, and treatment. Set your chairs up for the “triad visit” and prepare to ‘stew in the milieu’ of dementia!
Free CME for this episode at curbsiders.vcuhealth.org!
Join the American College of Physicians today! Post-training physicians can take advantage of a special limited-time $100 dues discount. Visit acponline.org/acp100 and use the code CURBSIDERS. Membership discount is available only until May 31, 2021.
Go to GreenChef.com/90curb and use code 90curb to get $90 off including free shipping!
Let’s define some terms…
Cognitive impairment is impairment at any time, including congenital.
Dementia is acquired cognitive impairment which impairs function (functional impairment is key to diagnosis!). Epidemiology: more common with increasing age. Ask about instrumental activities of daily living, particularly medication and financial management, which are the most cognitively taxing iADLs and subtle impairments often present first by impacting these functions.
Mild cognitive impairment is typically used when there is a cognition change that does not impair function. Dr. Uy notes this distinction is rather arbitrary, and varies widely between patients and what their daily activities are. Approximately 10% (range 7-15%) of MCI cases/year will advance to dementia (Oh, 2019).
Dr. Uy recommends a “triad visit”, where there is attention to both the caregiver and the patient. He particularly prioritizes this on new patient visits, and sets ground rules for everyone to contribute. For example, family members should not interrupt the patient.
Providers should feel comfortable communicating openly and set the emotional tone of not being fearful or embarrassed to name ‘dementia’ and discuss it. Starting with a gentle question can help: “Tell me about your memory- do you feel it is not as good as it used to be?”
Dr. Uy roughly ballparks dementia types by assessing a patient’s speed of movement & speaking; and considering age.
-Dr. Uy on his approach to dementia based on patient’s speed of speech and movement
For a patient with rapidly progressing dementia or who is “young” (e.g. <65), Dr. Uy refers the patient immediately to a specialist (neurology or neuropsychology) to do systematic testing. Quirky personalities/mental health overlap may be harder to tease out, and he sends for formal neuropsychology evaluation. These or other atypical cases warrant a more specialized evaluation.
Dr. Uy orders CBC, BMP, B12, and TSH for his basic evaluation (Oh, 2019).
The MiniCog or Clock Drawing test are binary screening tools.
MMSE, MOCA, and SLUMS are all validated assessment tests to consider (Oh, 2019). Dr. Uy suggests MOCA for patients who have mild symptoms or the history/physical do not indicate a clear diagnosis, as the MOCA is challenging and was designed to pick up mild cognitive impairment. MMSE is copyrighted and SLUMS is not. Both of these are useful tools to show more of the spectrum of cognitive impairment.
The Functional Assessment Staging of Alzheimer’s Disease (FAST) is validated for staging Alzheimer’s Disease and is helpful to follow patients over time. Dr. Uy also checks a Geriatric Depression Scale and evaluates psychiatric symptoms, which may complicate the diagnosis/exacerbate cognitive symptoms.
Look for prior imaging from any previous visits. If Dr. Uy sees a patient with “typical dementia” without red flags he may not order imaging. If he does order imaging, a non-contrast head CT may be used to rule out larger, common structural issues.
Prioritize safety at home, ask about ADL and iADL impairment, offer management suggestions, and address caregiver needs. It’s helpful to enlist home health aid support and build a schedule.
Dr. Uy encourages that patients continue to live their life as fully as possible and keep healthy habits. Healthy eating, good sleep, intellectual stimulation, social interaction, physical activity are important! (Livingston 2020)
Caregiver education helps prevent or delay institutionalization and is meaningful for both caregiver and patient (Vandepitte, 2016)
The American College of Physicians’ evidence review is a succinct summary (though slightly older) (Raina et al, 2008):
Treatment of dementia with cholinesterase inhibitors and memantine can result in statistically significant but clinically marginal improvement in measures of cognition and global assessment of dementia.
As an example, 14 studies examined 2459 patients on donepezil with MMSE and showed a 1.14 (95% CI 0.76-1.53) point decrease compared to placebo; however >3 is considered a clinically significant change. A 2018 meta-analysis also did not reach clinical significance, showing an average improvement in MMSE score of 1.0 for acetylcholinesterase inhibitors and less for memantine (Knight, 2018) at 6 months. Another recent review similarly concluded that the efficacy of pharmacological therapy remains limited (Arvanitakis, 2019).
For acetylcholinesterase inhibitors, the number needed to harm is ~12. Side effects include gastrointestinal symptoms (e.g. diarrhea) and cardiac issues (e.g. bradycardia), so the benefit often does not justify the harms (Lanctot, 2003). Notably, these medications (acetylcholinesterase inhibitors and memantine) do not have FDA approval for MCI.
A recent Cochrane review showed some decline in function upon stopping anti-dementia medications, but these results did not reach clinical significance (Parsons, 2021).
Antipsychotic medications can be dangerous for patients with dementia, with a number needed to harm 26-50 to cause one death (Maust, 2015). But, suppose these medications are needed to manage dangerous dementia-related behaviors. In that case, Dr. Uy uses them at the lowest dose and for the shortest amount of time if he believes it could help avoid institutionalization. Then, he targets a specific outcome. Notably, Dr. Uy always optimizes non-pharmacologic management before prescribing medical therapy.
Communication with patients with dementia must be concrete and complete. While talking to the patient, assess mood, thought content, and process to evaluate for an affective or psychotic component. Stew with the patient. This gives the individual dignity and allows them to be comfortable.
Healthy habits could prevent an estimated 40% of dementia (Livingston 2020). Show note special: Dr. Uy’s favorite article on prevention shows a high level of fitness in midlife among a Swedish women cohort had an 88% decrease in dementia over a 44-year follow-up! (Horder, 2018)
*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.
Listeners will build a framework to confidently approach dementia assessment and its basic management.
After listening to this episode listeners will…
Dr. Uy reports no relevant financial disclosures. Drs. Okamoto, Watto, Brigham, and Williams report no relevant financial disclosures.
Okamoto EE, Uy J, Williams PN, Brigham SK, Watto MF. “#268 Dementia with Dr. Josh Uy”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list April 12, 2021.
Got feedback? Suggest a Curbsiders topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.