#268 Dementia Made Simple with Dr. Josh Uy

April 12, 2021 | By Emi Okamoto

A memorable dive into office evaluation and management

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!

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Credits

• Producer, cover art, infographic: Emi Okamoto MD, FACP
• Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Leah Witt MD (written materials); Clair Morgan of nodderly.com
• Guest: Josh Uy MD

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner and picks of the Week*
• Case from Kashlak
• Definitions of dementia and cognitive impairment
• Subtyping dementia
• Cases to refer and basic laboratory testing
• Potential imaging
• Management of dementia
• Take-home points, Outro

Dementia Pearls

1. The pillars of dementia prevention and treatment rest on maintaining an overall healthy lifestyle, good physical health/optimal comorbidity management, and adequate social support (notice we didn’t say medications…)
2. Standard assessments for dementia include the MOCA, MMSE, and SLUMS. While MOCA is sensitive for picking up mild deficits, it is a longer test and may be challenging for those with a higher symptom burden.
3. Removing the stigma and shame of dementia is important. The clinician should ameliorate this by respecting patients and offering ways to achieve their overall goals for a good quality of life.
4. Keep things simple. If you are scratching your head about ordering complex tests or imaging for atypical cases (e.g., younger patients or people with rapidly progressive dementia), these patients should be referred.
5. Acetylcholinesterase inhibitors and memantine show marginal clinical improvement in trials and the number needed to harm for acetylcholinesterase inhibitors is 12. 
6. In rare cases, antipsychotics are needed to manage dangerous dementia-related behaviors (though this is not the first-line treatment!) If needed, use at the lowest dose possible for the shortest duration. The number needed to harm (where harm is an associated death) is 26-50.

Dementia Show Notes 

Cognitive Impairment and Dementia

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). 

The triad and approaching the topic

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?”

Subtyping Dementia

Dr. Uy roughly ballparks dementia types by assessing a patient’s speed of movement & speaking; and considering age.

• Alzheimer’s dementia: Speed unaffected, older or younger (if younger, could be frontotemporal dementia (FTD)
• Frontotemporal dementia (FTD): Speed unaffected, younger-onset often before 65
• Vascular: Slower speed, with vascular risk factors
• Parkinson’s disease dementia: Slower speed with cogwheeling, tremors, or rigidity; motor symptoms precede memory symptoms by more than a year (and thus patients often diagnosed with Parkinsonism before dementia)
• Lewy body dementia (LBD): Slower speed with cogwheeling, tremors, or rigidity; memory symptoms appear concurrently with motor symptoms

“If it’s fast and they’re older, most likely Alzheimer’s. Fast and they’re younger 50/50 Alzheimer’s, FTD. If it’s slow with afib, HTN, diabetes – vascular dementia. And if it’s slow with Parkinson’s type features then it’s either PD or Lewy Body dementia. And as a non-neurologist that gets me in the ballpark. No one will laugh me out of the room.” 

-Dr. Uy on his approach to dementia based on patient’s speed of speech and movement

Referring atypical cases

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.

Evaluation of Dementia

Laboratory

Dr. Uy orders CBC, BMP, B12, and TSH for his basic evaluation (Oh, 2019). 

Quick Binary Screeners

The MiniCog or Clock Drawing test are binary screening tools.

Assessments

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.

Imaging

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. 

Management of Dementia

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) 

Education for the family

Caregiver education helps prevent or delay institutionalization and is meaningful for both caregiver and patient (Vandepitte, 2016)

Medication

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. 

Discontinuation 

A recent Cochrane review showed some decline in function upon stopping anti-dementia medications, but these results did not reach clinical significance (Parsons,  2021).

Antipsychotics

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. 

This was also reviewed in episode #82 (Dementia Dos and Don’ts), and other geri-psych pharmacologic management for sleep and behavior were covered in episode #110,

Talk to the patient!

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.

Prevention

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)

Links*

1. The Chronicles of Narnia, book series by C.S. Lewis. 
2. Pretending I’m a Superman: The Tony Hawk Video Game Story, movie

*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.

Goal

Listeners will build a framework to confidently approach dementia assessment and its basic management.

Learning objectives

After listening to this episode listeners will…

1. Define mild cognitive impairment (MCI) and dementia
2. Build a toolkit of questions and cognitive tests to uncover even subtle cognitive impairment 
3. Develop an approach to recognizing dementia subtypes
4. Educate patients and families on key lifestyle management that can help with dementia prevention and management
5. Recognize the limitations of benefit and potential harms of  medications for dementia treatment

Disclosures

Dr. Uy reports no relevant financial disclosures. Drs. Okamoto, Watto, Brigham, and Williams report no relevant financial disclosures. 

Citation

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.