Dementia Clinical Sciences PDF

RS3330 Clinical Sciences for medical and neurological conditions Neurocognitive Disorder (Dementia) Presenter Dr Hoe Lee  Learning Goals / Objectives On completion of this Lecture, the participants should Know what is NeuroCognit...

RS3330 Clinical Sciences for medical and neurological conditions Neurocognitive Disorder (Dementia) Presenter Dr Hoe Lee  Learning Goals / Objectives On completion of this Lecture, the participants should Know what is NeuroCognitive Disorders (NCD) – a new term for “Dementia” and related conditions according to DSM-5 (2013), including its, o Definition, & Epidemiology, Symptoms (Cognitive & other Behavioral & Psychological Symptoms) For personal use only o Terms related to Cognitive Domains Know the Steps & Workflow in Diagnosis of Dementia, including o Assessment Cognitive assessment Functional Assessment Assessment of BPSD o Other Common Clinical Investigation o Assessment on Staging of Dementia Have a glance of the Current Pharmacological management of Dementia o Antidementia Drugs (Cognitive enhancers) o Drugs for BPSD, including antipsychotics, antidepressants, sedatives, anxiolytics All rights reserved  Getting older What’s normal and what’s not? Inevitable effects of ageing ST memory loss Skin is affected by dryness Wrinkles Move about slower Not as active Stiffer joints Need less sleep Eyesight and hearing decline Fertility declines Multiple changes to many organs and systems Q: Old people have memory problems? A: Yes and no: Age-associated memory impairment is typically accepted. Short term memory, episodic (LT) and working memory are typically affected due to structural changes in the brain BUT experience and knowledge may reduce the effects of this. May be reductions on some cognitive capacities problem solving, reasoning, adaptation, attention and executive functioning HOWEVER This does not typically affect the individual functionally as processes such as neuroplasticity allow the individual to create compensatory pathways and neuronal connections. When there is functional impairment it is generally because of a disease process or neurological insult such as stroke, dementia, traumatic brain injuries or tumour. Put simply, if a person’s day-to-day function is causing problems then you might need to have the cause investigated. A good example might be if a an older person ‘gets lost’ on a walk or cant find where they’ve parked their car a couple of times doesn’t mean that they are at risk of dementia. However, if this occurs repeatedly and is associated with other atypical behaviours then you might need to obtain some advice.  Older people are more likely to fall over 25% >70yo & 50% 80yo will fall at least once a year Some of the reasons might be that older people are more likely to fall Poly pharmacy (regular use of 5 or more medications at the same time) Mobility problems associated with normal ageing and abnormal ageing e.g. Parkinson's Chronic health conditions eg diabetes, Sensory impairments, balance problems Environmental hazards- dogs, mats, items in excess Footwear Cognition not planning for movement Touch: Changes in vascularisation of skin + decrease in number of Meissner’s corpuscles the ability to sense light/deep touch, vibration and pressure all reduce -> an increased incidence of burns, injuries and accidents to hands and feet Pain: Changes occur to PNS may alter the reception of pain May be more likely to experience chronic pain due to illnesses associated with age and are more likely to under-report pain Vision: Deterioration normally occurs with age, particularly long sightedness. Common impairments include macular degeneration (centre of visual field is blurry) and cataracts. The ability to track objects moving may also decrease due to muscle reduction. Hearing: Most common --- Presbycusis which is typically caused by exposure to noise as well as the normal loss of neural cells. Generally hearing is more difficult in areas with background noise and higher frequencies. Balance: As with hearing, cell death frequently occurs in the specialist nerves contained within the inner ear. Balance is also further affected by changes to the visual and proprioceptive systems.  Systemic changes Integumentary (Skin) Cardiovascular Respiratory Immune Neuromusculoskeletal Digestive Endocrine Genito-urinary  So what isn’t part of normal ageing? Cardiovascular diseases Dementia Cancer Specific eye diseases Arthritis (osteo & rheumatoid) Fractures Osteoporosis Stroke / CVA COPD Diabetes Copyright State Library Victoria: http://handle.slv.vic.gov.au/10381/308769 And the list goes on… Normal Aging vs. Progressive dementia Mild Cognitive Impairments =  AGING VS DISEASE CONTINUUM Mild Major Normal Aging Neurocognitive Neurocognitive Disorder Disorder Decline from Primarily Needs help lifelong intact cognition, with daily abilities in 1 or subtle processing activities + more areas of speed slowing & substantial thinking + less efficient decline in 1 or inefficiency in more attention & daily activities cognitive executive reasoning abilities  Functional/Clinical Decline Define client's functional capacity COGNITIVE DOMAINS DAILY FUNCTIONING General Intelligence Basic transfers, ambulation, bathing, hygiene, Sensory Motor & feeding Attention/Concentration Processing Speed INSTRUMENTAL ACTIVITIES Visual Spatial Functions Safe use of appliances Language Functions Phone answering & dialing Memory – Auditory & Visual Laundry Housekeeping Executive – higher thinking & reasoning Meal Preparation Shopping MOOD & BEHAVIORS Management of finances Management of meds Depression Driving Introverted Agitated Major Neuro Cognitive Disorders Small dots called Lewy body spread around the cortex Hallucinations (auditory & visual) Most agitated (yelling or reacting to hallucinations) = LBD Executive symtpom  Part I. Definition, Terms & Epidemiology  The Last Few Years of Life of Our Late Prof. Charles KAO, Father of Fiber Optics 1933 - 2018 Late Prof. KAO suffered from Alzheimer's disease from early 2004 and had speech difficulty, but had no problem recognising people or addresses. His father suffered from the same disease.... In 2016, Prof. Kao lost the ability to maintain his balance. At the end-stage of his dementia he was cared for by his wife and intended not to be kept alive with life support or have CPR performed on him. Late Prof. KAO died at Bradbury Hospice in Hong Kong on 23 September 2018 at the age of 84. Pictures from a presentation on “Caring for people with dementia: From a carer's perspective” by Mrs Kao May Wan Gwen - Chairman, Board of Governors, Charles K Kao Foundation for Alzheimer's Disease at “CADENZA Symposium 2011 - Caring for People with Dementia: Needs and Services” Q1: What differences do you observe? Cerebral cortex: to become dry, smaller, and covered with lines as if by crushing or folding Hippocampus: plays a critical role in the formation, organization, and storage of new memories as well as connecting certain - sensations and emotions to these memories. - Q2: What kind of problems will be anticipated?  History & Old Definition In 1907, Alois Alzheimer reported - Alzheimer’s disease – Auguste D., a 51 year old lady presented with progressive cognitive deterioration and neuropsychiatric symptoms – Said to be the commonest form of dementia Ageing is the main risk factor for dementia. – Age related prevalence While dementia can occur in ppl aged under 65, risk doubles every 5 or 6 ppl aged over 65 Dementia – The word "Dementia" is derived from the Latin demens, meaning "without mind", "mad," or "insane ". – … a degenerative brain syndromes affecting one’s memory, thinking, behaviour and emotion. It causes loss of memory, along with impairments in the sensory system, the person losses control over his or her impulse system, may not remember things and at last stage, may have complete memory loss (Old definition) – Although there are many types of dementia, they have a number of features in common.  Key pathological findings Shrinkage of the brain – Cerebral atrophy Abnormal protein deposition – Tau in Neurofibrillary tangles, Amyloid plagues Inflammatory reactions Neuronal death Tau is a protein that helps stabilize the internal skeleton of nerve cells Since the identification of tau as the main component (neurons) in the brain. of neurofibrillary tangles in Alzheimer's disease and The tau proteins are a group of six related tauopathies, and the discovery that mutations in highly soluble protein isoforms the tau gene cause frontotemporal dementia, much produced by alternative splicing from effort has been directed towards determining how the the gene MAPT (microtubule- aggregation of tau into fibrillar inclusions causes associated protein tau) neuronal death.  Terms in line with the DSM-5 >> NeuroCognitive Disorders or NCDs (DSM-5 by American Psychiatric Association, 2013) – a new category in DSM-5 to replace the old category “dementia, delirium, amnestic, and other cognitive disorders”. – NCD an umbrella term for a number of neurological conditions, of which the major symptom is the decline in brain function due to physical changes in the brain. – NCD is distinct from mental illness the major symptom is the decline in brain function (Primarily COGNITIVE disorders) due to physical changes in the brain. Acquired and represent decline (i.e. not developmental, and, also distinct from mental illness) – Three groups Major NCD – previously Dementia or other debilitating conditions” Minor NCD – Previously “Cognitive Disorder, Not Otherwise Specified”, like “Mild cognitive impairment (MCI)” Delirium (acute confusional states) attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes (alcoholism) , which usually develops over the course of hours to days.  Figure 1 Timeline of the DSM-5 consultation and revision process Sachdev, P. S. et al. (2014) Classifying neurocognitive disorders: the DSM-5 approach Nat. Rev. Neurol. doi:10.1038/nrneurol.2014.181  Definition of Major Neurocognitive Disorder (or Dementia) according to DSM-5 A. Evidence of a significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications). C. The cognitive deficits do not occur exclusively in the context of a delirium. D. The cognitive deficits are not better explained by another mental disorder  The Six Cognitive Domains in DSM-5 DSM-V : CELL PS DSM-IV: Memory Complex attention impairment Executive function Aphasia Learning & Apraxia memory Agnosia Executive Language dysfunction Perceptual-motor Social cognition (a new domain specified in DSM- Figure 2 Neurocognitive domains 5) Sachdev, P. S. et al. (2014) Classifying neurocognitive disorders: the DSM-5 approach Nat. Rev. Neurol. doi:10.1038/nrneurol.2014.181  Cognitive Domain - Complex attention A collective term consists of Possible Objective Assessment proposed by DMS-5 – Sustained attention (concentration) – Divided attention – Selective attention Maintenance of attention, e.g., press a – Processing speed button every time a tone is heard, over a period of time. Example of symptoms Divided attention, e.g., tap in response to Easily distracted by different emerging signs while learning a story. environmental stimuli Difficult to hold new information in Selective attention, e.g., hear numbers and mind letters, but count only the letters. Unable to perform mental Processing speed: carry out any timed task. calculations Take longer time in thinking  Cognitive Domain - Language Possible Objective Assessment proposed by A collective term consists of DMS-5 – Receptive language Receptive language: comprehend /define (Comprehension) words, carry out simple commands. – Expressive language (Naming, word finding, fluency, Expressive language: naming of e.g., objects grammar) or pictures; fluency for words in a given Example of symptoms category (e.g. animals) or beginning with a Word finding difficulties given letter, as many as possible in one ↓ Agnosia cant recognise objects, persons, sounds, shapes or smells minute. Often use general use phrases i.e. “that thing” Grammar and syntax: omitting or incorrectly Stereotype of speech - speech that is repetitive in thought process using articles, prepositions & verbs. Reverse Echolalia words order. persistent mechanical repetition of speech describe when a child repeats or imitates what someone else has said  Cognitive Domain - Learning and Memory Possible Objective Assessment proposed by DMSV Memory components consists of Immediate memory: Repeat a list of words or digits. Long term / short term Recent memory: Episodic / Semantic / Working / Free recall: recall as many items as possible from, e.g., a Procedural list of words, or a story, or a diagram. Memory processes Cued recall: with examiner providing cues, e.g., “recall as Encoding / Storage / Retrieval many food items as you can from the list.” Recognition: with examiner asking, e.g., “was there an Example of symptoms apple on the list?” Repeat self in conversation, often within same conversation Semantic memory: recall well-known facts. Has difficulty in recalling recent events Autobiographical memory: recall personal events. Requires frequent reminders to orient to Implicit (procedural) memory: recall skills to carry out task procedures. Forgetful in IADL task  Cognitive Domain – Perceptual-Motor A collective term includes Possible Objective Assessment proposed Visual-perception (Any visual defect, neglect) by DMS-5 Visuo-constructional (Assembly of items Visuo-constructional: e.g., Draw, copy, requiring eye-hand coordination) assemble blocks. Perceptual-motor (Integrating perception with purposeful movement) Perceptuomotor: e.g., Insert blocks or Praxis (Ability to carry out unfamiliar actions or pegs into appropriate slots. sequences) Praxis: Mime gestures such as “salute” Gnosis (Perceptual integrity of awareness and recognition) or actions such as “use hammer.” Example of symptoms Rely more on others for directions Gnosis: e.g., recognize faces and Needs to expend greater effort for spatial tasks Difficulties in previously familiar activities colors Difficult to navigate in familiar environment  Cognitive Domain – Executive functions A collective term consists of Possible Objective Assessment proposed by DMS-5 Planning Planning: e.g., maze puzzles, interpret sequential Decision making pictures or arrange objects in sequence. Decision making with competing alternatives, e.g., Working memory simulated gambling game. Error correction Working memory: hold information for a brief period Overriding habits / inhibition and manipulate it, e.g. repeat a list of numbers Mental flexibility (i.e. shifting between backward. concepts) Feedback utilization: Use feedback on errors to infer rules to carry out tasks. Override habits; choose the correct but more complex Example of symptoms and less obvious solution, e.g., read printed names of Increased effort required to complete colors rather than naming the color in which they are complex task printed. Cognitive flexibility: Shift between sets, concepts, tasks, Increased fatigue from extra effort required rules, e.g., alternate between numbers and letters. to organize, plan and make decisions Rely on others in IADL Abandon complex projects  Cognitive Domain – Social Cognition Ability to Possible Objective Assessment Recognize others emotion proposed by DMSV Consider another persons’ mental state, rights, desires, intentions (Theory of Mind) Recognize emotions: Identify egocentric, X aware others' emotions pictures showing e.g., happy, sad, Example of symptoms scared, angry faces. Change in personality Theory of mind: Consider another Less ability to recognize social cues person’s thoughts, intentions when Difficult to read facial expressions Decreased empathy looking at story cards, e.g., “why is Behavior out of acceptable social the boy sad?” range Poor insight  Recognized Neurological Conditions under this umbrella of Major NCD Alzheimer disease Vascular dementia Dementia with Lewy Bodies Frontotemporal For personal use only lobar dementia A slide from CADENZA’s Web-based Course for Professional Health and Social Care All rights reserved Workers “CTP004 - Dementia: Preventive and Supportive Care” https://www.cadenza.hk/index.php?option=com_content&view=article&id=11&lan g=en (accessed in Feb. 2022)  For personal use only Epidemiology All rights reserved  World Health Organisation Worldwide, around 50 million people have dementia, with nearly 60% living in low- and middle-income countries. Every year, there are nearly 10 million new cases. The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5 to 8 per 100 people. The total number of people with dementia is projected to reach 82 million in 2030 and 152 million in 2050. Much of this increase is attributable to the rising numbers of people with dementia living in low- and middle-income countries. Alzheimer's Disease International (ADI) http://www.alz.co.uk/research/statistics Data published by the World Health Organisation (WHO) the prevalence of dementia doubles following every increase in age of 5.1 years from about 60 to 90 (an exponential growth) there is no overall sex difference in prevalence for the dementia syndrome Regional variations in rates of different types of dementia: Alzheimer's disease is more common in Europe and North America than in Asian countries. But a higher prevalence of vascular dementia in Asian countries such as China and Japan (Hong et al., 1996; Ng, Cheng, & Poon, 1997). 34 Prevalence of dementia Compared with Western counterparts, prevalence studies of dementia, amongst Chinese population, are relatively fewer. The rates of dementia range from 1.5% to 10.6% (Chiu et al., 1998; Woo, Ho, Lau, & Yuen, 1994; Zhang et al, 1990). The differences in rates might be due to difference of methodology, such as sampling methods, case definitions, and use of measures. 35 Number of Persons with Dementia If you would be working at a Residential Care Home for the Elderly or a Day Care Centre, around half of your workload would be devoted to the care of Persons with Dementia (PwD) For personal use only A slide from a presentation at “ Care of Older People with Dementia in Hospitals – Lecture 2 – Dementia ” by Dr. Felix CHAN – ex-Clinical Division Chief (Geriatrics), University Department of Medicine, The Hong Kong All rights reserved University  Common forms of dementia There are many different forms of dementia Major NCD. Alzheimer's disease is the most common form of dementia and may contribute to 60–70% of cases. Other major forms include Vascular Dementia Lewy Bodies Dementia (abnormal aggregates of protein that develop inside nerve cells) a group of diseases that contribute to Frontotemporal Dementia (degeneration of the frontal lobe of the brain) The boundaries between different forms of dementia are indistinct and mixed forms often co-exist. http://www.who.int/en/news-room/fact-sheets/detail/dementia Risk & Possible Protectors of Alzheimer’s disease Risk factors Possible Protector factors Advance age Women live Female gender ? longer than men + age is the risk Complex occupational environment factor of AD Low educational dementia Physical exercise For personal use only attainment Cognitive activities Genetic predisposition Dietary preferences – Early onset Sleep – Late onset – Apolipoprotein E gene Cardiovascular risk factors Depression & Anxiety ? All rights reserved  Essential features of dementia Multiple cognitive deficits that include memory impairment and at least one of the following: aphasia, apraxia, agnosia, or a disturbance in executive functioning (the ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior). The order of onset and relative prominence of the cognitive disturbances and associated symptoms vary with the specific type of dementia. 39  Dementia is a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including – memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not clouded. 40  Impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. The primary requirement for diagnosis is an evidence of a decline in both memory and thinking which is sufficient to impair personal activities of daily living, such as washing, dressing, eating, personal hygiene, excretory and toilet activities. 41  The impairment of memory typically affects the registration, storage, and retrieval of new information, but previously learned and familiar material may also be lost, particularly in the later stages. The above symptoms and impairments should have been evident for at least 6 months for a confident clinical diagnosis of dementia to be made. 42  Signs and symptoms Dementia affects each person in a different way, depending upon the impact of the disease and the person’s personality before becoming ill. The signs and symptoms linked to dementia can be understood in three stages. Early stage: the early stage of dementia is often overlooked, because the onset is gradual. Common symptoms include: – forgetfulness – losing track of the time – becoming lost in familiar places. Middle stage: as dementia progresses to the middle stage, the signs and symptoms become clearer and more restricting. These include: – becoming forgetful of recent events and people's names – becoming lost at home – having increasing difficulty with communication – needing help with personal care – experiencing behaviour changes, including wandering and repeated questioning. Late stage: the late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious. Symptoms include: – becoming unaware of the time and place – having difficulty recognizing relatives and friends – having an increasing need for assisted self-care – having difficulty walking – experiencing behaviour changes that may escalate and include aggression. The last aspect dementia pt lost is motor  Progression of Alzheimer’s Disease Mild Moderate Severe * * Short-term Behavioral, personality changes Increase in behavioral memory loss *Long-term memory affected, unable disturbances * Word-Finding Trouble to recall new information Unable to perform ADLs * Incontinence, unsteady gait, Mood Swings Wandering, agitation, aggression, Personality changes confusion falls * * * Diminished judgment Require partial assistance with ADLs Bedridden Placement in long-term care facilities ACT, Hospitals Age Care Team Family support, communit y dwelling  Behavioral and Psychological Symptoms of Dementia (BPSD) and Functional problems [The International Psychogeriatric Association Consensus Conference, 1999] ( BPSD refers to neuropsychiatric symptoms (the non-cognitive symptoms) of NCD patients that include: disturbed perception, thought content, mood or behavior that frequently occur in patients with dementia Neuropsychiatric symptoms including behavioral and psychological aspects Behavioral symptoms by observation include wandering, agitation, disinhibition, catastrophic reaction, complaining and negativism Psychological symptoms assessed through interviews with persons with dementia and their relatives – delusion, hallucination, depression, apathy and anxiety Psychological symptoms of BPSD can be further classified as “depressive type” and “psychotic type”. The “depressive type” includes anxiety, apathy, emotive incontinence, wandering, alterations of the sleep and the appetite, whilst “psychotic type” include hallucinations, delusion, psychomotor agitation, aggression, misidentifications, euphoria and disinhibition. Psychological symptoms of BPSD contributes significantly to caregiver burden, decreased quality of life for persons with dementia, and increased institutionalization of people with dementia (Benoit et.al, 2006; Yaffe et.al, 2002).  Behavioral & Psychological Symptoms of Dementia (BPSD) BPSD is defined as "symptoms of disturbed perception, thought content, mood or behaviour that frequently occurs in patients with dementia" (Finkel & Burns, 1999) Simple methods of grouping BPSD – Behavioural symptoms: Observations of the patient – Psychological symptoms: Assessed by interviews with patients and relatives Behavioural symptoms Psychological symptoms Agitation Psychosis Aggressive behaviour Hallucination (e.g. visual – In form of animals/insects, Physical Aggression – assault the others, kicking, biting, grabbing people strangers, relatives in the house, children) Delusion (e.g. Delusion of theft: One's possessions are Verbal Aggression – screaming, cursing, temper outbursts, making strange being hidden or stolen. Delusion of persecution: Belief noises that somebody else do harm to somebody, etc.) Wandering, e.g. Aimless walking, Attempts to Leave home, Night-time walking, etc. Depression Abnormal vocalization, e.g. Anxiety 'shouting', 'screaming' or constant demands for 'attention' Apathy Disinhibition (loss of inhibition), e.g. Sexual disinhibition, Speech disinhibition (e.g. repeat over and over on a word, a phrase or a story), Restlessness Eating disorder, e.g. Eating non-food substance Changes in the circadian rhythm Increased sleepiness and number of naps in daytime while wandering at night time Functional problem in areas Activities of daily living (ADLs): Bathing, dressing, transferring, toileting, grooming, feeding Instrumental activities of daily living (IADLs): Using telephone, preparing meals, managing finances, taking medications, doing laundry, doing housework, shopping, managing transportation  For personal use only Part II. Diagnosis & Staging All rights reserved 1. Poor Short 6. Difficulty in Term Memory Managing affecting Daily Familiar Work Activities 2. Difficulty in 7. Deterioration For personal use only Expression & in Judgement Communication 3. Behavioral & 8. Loss of Psychological Motivation Disturbance 9. Difficulty in 4. Change in Calculation & Personality Reasoning 5. Confusion in 10. Misplacing Time & Place Daily Gadgets in Wrong Positions All rights reserved Diagnostic Flow Chart for Neurocognitive Disorders (Dementia) Cognitive decline Complex Attention Language Executive Function Dementia Behavioral and Assessment For personal use only syndromes psychiatric and disturbance Investigation Diagnosis Learning with Staging Social and Cognition Memory Perceptual Motor Physical health & Functional Consider and exclude Deterioration other Dx Dementia cannot be diagnosed on the basis of radiological, biochemical, genetic, or psychological tests alone. Such tests serve to confirm the presence of altered brain function and to help determine the cause of the dementia syndrome A slide from a presentation at “December 2020 Seminar Series on Management of Dementia in the Community – Session 2 – Assessment & Investigation in a Primary Care Setting” by Prof. Linda CW LAM – Dept. of Psychiatry, CUHK All rights reserved  Common Steps of Diagnosis (HIS LAB-PC) “Ask” “Order” “Conduct” (sometimes relied on OT’s report for validation) Patient History Structural imaging (when indicated) Physical Examination Progress of illness Computed Tomography (CT) Gait & Balance Risk factors Magnetic Resonance Imaging (MRI) Vision and eye movement Vascular like DM, HT Functional neuroimaging Hearing Family history For personal use only Functional MRI Neurological examination Head trauma Single photon emission CT Stroke Smoking/alcohol Nuclear Magnetic Resonance Parkinsonism Education level spectroscopy Event of stroke? Parkinsonism? Positron Emission Tomography (PET) LABoratory test (Exclude systematic Cognitive Test Family Interview diagnoses which associated with Brief cognitive test cognitive impairment) Presence and severity of memory Separate history taken from and cognitive deficits caregiver/family member; especially Blood test those fail to be noticed or reported Complete blood count Communication across health by patient disciplines Thyroid stimulating hormone o e.g. Abbreviated Mental Test (AMT) Functional impairment (e.g. Serum calcium, electrolytes and o Montreal Cognitive Assessment Disability Assessment for fasting blood glucose (MoCA) Dementia) o Clock drawing test Folate level "Embarrassing behavior" electrocardiogram (ECG) Neuropsychological and psychiatric Assess the need of family and social assessment (e.g. Neuropsychiatric Inventory) support Chest X-ray This slide is adapted from a slide from CADENZA’s Web-based Course for Professional Health andAll rights Social Carereserved Workers “CTP004 - Dementia: Preventive and Supportive Care” https://www.cadenza.hk/index.php?option=com_content&view=article&id=11&lang=en (accessed in Feb. 2022)  Secondary Dementia & Other Psychiatry Conditions mimicking Dementia Implication of “Secondary Other Psychiatry Conditions mimicking Major NCD Dementia” >> potentially reversible if the cause(s) can be identified and treated as early as possible – before becoming irreversible For personal use only Infective Information to be obtained from records & interviews – HIV – Syphilis Prion diseases [disease of structurally abnormal proteins, e.g. Creutzfeldt–Jakob disease (CJD)] Metabolic – Electrolyte imbalance – Endocrine disturbance Nutritional – Folate, Vitamin B12 deficiency – Thiamine Traumatic – Head injury Space occupying lesions All rights reserved  For personal use only Cognitive Assessment All rights reserved  Cognitive Assessment - Screening Test Purpose of Use Common Tools in local practice Is there cognitive impairment The Informant Questionnaire on Cognitive How severe Decline in the Elderly (IQCODE) The Pattern of impairment Abbreviated Mental Test (AMT) Association with underlying disease Montreal Cognitive Assessment – Hong For personal use only characteristics Kong Version HK-MoCA (Full version) Consideration in Choosing a Tool HK-MoCA (5-min Protocol) [originally intended for telephone interview] Quick & Easy to use Hong Kong Brief Cognitive Test [originally Give accurate information about likelihood intended for client with low education level] of cognitive impairment +/- diagnosis of Clock-Face Drawing dementia Sensitive and specific Mini-mental Status Examination (MMSE) [fading out due to charges] Clinician versus trained personnel Limitations Screening is a preliminary screen Cutoff is not absolute diagnosis All rights reserved  https://pdsp.hk/tc/caregiving-skills/what-is-dementia/10-signs-of-dementia/iq-code/index.html (accessed in Feb. 2022) IQCODE (The Informant Questionnaire on Cognitive Decline in the Elderly) Originally intend for clients with less educational For personal use only background asks informant for ratings of an individual’s changes in everyday cognitive functions in 26 items during the previous 10 years. For the IQCODE, the optimal cutoff score of >3.4 for dementia yielded an 89% sensitivity and an 88% specificity. Fuh, Teng, E. L., Lin, K. N., Larson, E. B., Wang, S. J., Liu, C. Y., Chou, P., Kuo, B. I. T., & Liu, H. C. (1995). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening tool for dementia for a predominantly illiterate Chinese population. Neurology, 45(1), 92–96. https://doi.org/10.1212/WNL.45.1.92 All rights reserved Abbreviated Mental Test (Hong Kong Version) A screening test with 10-item scale, with a cut-off score 6/10 For personal use only Administration: approximate 3 minutes Cognitive domain involved Memory ( Semantic, short term, remote memory) Orientation Attention/calculation Can tell whether the individual is "at risk" of cognitive impairment, but not its severity or progress Lam, S., Wong, Y., & Woo, J. (2010). RELIABILITY This topic would be further elaborated in corresponding AND VALIDITY OF THE ABBREVIATED MENTAL TEST (HONG KONG VERSION) IN RESIDENTIAL “EnOcc / OT Apply” lecture. CARE HOMES. Journal of the American Geriatrics All rights reserved Society (JAGS), 58(11), 2255-2257.  Montreal Cognitive Assessment (Hong Kong Ver.) A 30-point assessment tools for screening cognitive impairment, especially mild cognitive impairment It has a higher sensitivity and specificity than For personal use only MMSE, esp. for Mild Cognitive Impairment (MCI) cases Cut-off scores (for MCI & Dementia) is adjusted with education level Cognitive domain involved Memory (Short term) Visualspatial/ Constructional praxis Executive functions This topic would be further Language elaborated in corresponding Attention/Calculation “EnOcc / OT Apply” lecture. Orientation Yeung, P., Wong, L., Chan, C., Leung, J., & Yung, C. (2014). A validation study of the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in Chinese older adults in Hong Kong. Hong Kong Medical Journal, 20(6), 504-510. All rights reserved HK-MoCA 5-Minute Protocol (for Telephone Administration) This topic would be further elaborated in corresponding “EnOcc / OT Apply” For personal use only lecture. Wong, A., Nyenhuis, D., Black, S., Law, L., Lo, E., Kwan, P.,... Mok, V. (2015). The MoCA 5-min protocol is a brief, valid, reliable and feasible cognitive screen for telephone administration. Stroke (1970), 46(4), 1059-1064. All rights reserved  HKBC For personal use only Performance on existing brief cognitive tests is frequently affected by educational level. HKBC intends for populations of older people with low Chiu, H., Zhong, B., Leung, T., Li, S., Chow, P., Tsoh, J.,... Wong, M. (2018). educational level. Development and validation of a new cognitive screening test: The Hong Kong Brief Cognitive Test (HKBC). International Journal of Geriatric Psychiatry, All rights reserved 33(7), 994-999.  Clock Drawing Test Purpose Measure Executive control functions. Executive control functions (ECFs) are cognitive processes that coordinate simple ideas and actions into complex goal-directed behaviors. Examples include goal selection, planning, motor For personal use only sequencing, selective attention, and the self monitoring of a subject’s current action plan. Executive impairment is strongly associated with functional disability Lam, Chiu, H. F. K., Ng, K. O., Chan, C., Chan, W. F., Li, S. W., & Wong, M. (1998). Clock-Face Drawing, Reading and Setting Tests in the Screening of Dementia in Chinese Elderly Adults. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 53B(6), P353–P357. https://doi.org/10.1093/geronb/53B.6.P353 All rights reserved  For personal use only Assessing on Disability (Functional Deterioration) All rights reserved  Chinese Version – DAD A slide from a presentation at “2019 May HA IAAHS & OTCOC - Cognitive Assessment and Rehabilitation for Elderly People with Neurocognitive Disorder – Disability Assessment for Dementia” by Ms. Natalie LAI, OTI – Occ. Th. Dept., CPH For personal use only This topic would be further 47 items under 11 scales elaborated in the BADL: hygiene1, dressing2, continence3, eating4 corresponding “EnOcc / OT Mok, C., Siu, A., Chan, W., Yeung, K., Pan, P., & Li, S. (2005). Functional Disabilities Profile of Chinese IADL: meal preparation5, telephoning6, going on an outing7, Apply” lecture. Elderly People with Alzheimer’s Disease – A Validation Study on the Chinese Version of the finance8, medications9, housework10 Disability Assessment for Dementia. Dementia and Leisure11 All rights reserved Geriatric Cognitive Disorders, 20(2-3), 112-119.  SAFER-HOME (esp. for those who want to stay at home but lack support) Independence Examples of Recommendations: / Autonomy For personal use only Versus This topic would be Safety further elaborated in corresponding “EnOcc / OT Apply” lecture. Chiu, T., & Oliver, R. (2006). Factor Analysis and Construct Validity of the SAFER-HOME. OTJR (Thorofare, N.J.), 26(4), 132-142. Chiu, T., Oliver, R., Ascott, P., Choo, L., Davis, T., Gaya, A., & Letts, L. (2006). Safety Assessment of Function and the Environment for Rehabilitation-Health Outcome Measurement and Evaluation (SAFER-HOME, 3rd ed.). Toronto: COTA Health. All rights reserved  For personal use only Assessing on Behavioral and Psychiatric Disturbance All rights reserved 1. 2. Assessment 3. / of BPSD 4. / Examples of related assessment tools 5. Neuropsychiatric For personal use only Inventory-Questionnaire 6. / (NPI-Q) Cohen-Mansfield Agitation Inventory (CMAI) 7. / This topic would be 8. further elaborated in corresponding “EnOcc / OT Apply” lecture. The 9. / related assessment guide has been Wong, A., Cheng, S., Lo, E., Kwan, P., Law, L., Chan, A.,... uploaded to Black Mok, V. (2014). Validity and 10. Board. Reliability of the Neuropsychiatric Inventory Questionnaire Version in 11. ( A specific FU Patients With Stroke or Transient Ischemic Attack ) assessment on selected Having Cognitive Impairment. behaviour would be Journal of Geriatric 12. Psychiatry and Neurology, All rightstoo. discussed reserved 27(4), 247-252. 67 ?  For personal use only Other Investigations All rights reserved Laboratory Tests & Physical Examination Common Laboratory Tests Physical Examination (Performed base on physician’s Balance & Mobility clinical judgment and available For personal use only Look for physical signs that may be resources) suggestive of underlying causes Complete blood picture e.g. focal neurological signs, vitamin Vitamin B12 level & folate B12 deficiency, Parkinson’s disease, Thyroid stimulating hormone thyroid disease Liver function tests Kidney function tests Serum calcium Fasting glucose, lipid profile Other tests when clinical suspicion warrants, e.g. syphilis serology, HIV All rights reserved  Structural Imaging Types of Diseases Structural MRI characteristics Structural MRI Alzheimer’s disease Hippocampal & medial temporal Exclude space occupying lesion cortical atrophy (SOL), major bleeding or For personal use only hydrocephalus Small vessel disease White matter changes Give additional information on Lacunar infarcts Regional brain atrophy Frontal atrophy in later stages Lacunar infarcts Bleeds Lewy body disease Less specific Small vessels disease White matter degeneration Frontotemporal lobar Temporal cortical & frontal degeneration atrophy MR angiography checks for stenosis, occlusions or abnormalities An angioplasty may be done with an angiogram if you have narrowed blood vessels All rights reserved  For personal use only Assessing the Staging of Dementia All rights reserved  Staging ‘Stages of Dementia’ refer to how far a person's dementia has progressed. For personal use only Defining the stage of dementia can determine the most appropriated treatment approach and aid the communication between health providers and caregivers. The history is the cornerstone of any assessment (Lui, 2008) Some patients may not have awareness of cognitive deficits or the high quality of information is limited by the cognitive impairment. The history should be verified by a reliable informant and supplementary information form other sources All rights reserved  Clinical Dementia Rating A semi-structured clinical interview with A trained clinician based rating informant and subject on different areas of Free online training cognition and functioning. http://alzheimer.wustl.edu/cdr/de Developed https://knightadrc.wustl.edu/fault.htm For personal use only by Charles Hughes, Leonard Berg, John C. Morris and other colleagues at Washington Certified rater can apply in everyday work University School of Medicine Requires knowledge and familiarity of subject for over 30 years with clinicopathological under assessment correlations for Alzhiemer’s diseases Assessment of clinical information on cognition and everyday functioning Does not depend on single cognitive domain Inter-rater reliability ensured thru’ online Overall severity of cognitive impairment training for certify raters A global score CDR 0 – Not demented CDR 0.5 – Very mild dementia CDR 1-3 – Mild, Moderate and Severe dementia Usually conducted by Psychiatrist All rights reserved  Questions for Informant: Orientation Questions for Informant: Memory Questions for Informant For personal use only All rights reserved  Questions for Informant: Questions for Informant: Community Affairs Judgement and Problem Solving Questions for Informant For personal use only All rights reserved Questions for Informant Questions for Informant: Questions for Informant: Personal Care Home & Hobbies For personal use only All rights reserved  Questions for the Patient Memory Orientation Judgement and Problem Solving For personal use only All rights reserved  https://naccdata.org/data-collection/tools-calculators/cdr Algorithm in Arriving at the Global Score (accessed in Feb. 2022) Score for each individual aspect For personal use only Or use any “Online Calculator”, e.g. All rights reserved  Two OTHER commonly used staging systems For personal use only 1. Global Deterioration Scale or GDS (https://www.fhca.org/membe rs/qi/clinadmin/global.pdf accessed in Sept. 2022) 2. Functional Assessment Staging Test or FAST (https://www.compassus.com/ healthcare- professionals/determining- eligibility/functional- assessment-staging-tool-fast- scale-for-dementia accessed in Feb. 2022) All rights reserved  Stages of Dementia (more commonly used) Early stage: the early stage of dementia is often overlooked because the onset is gradual. Common symptoms may include: forgetfulness losing track of the time becoming lost in familiar places. For personal use only Middle stage: as dementia progresses to the middle stage, the signs and symptoms become clearer and may include: becoming forgetful of recent events and people's names becoming confused while at home having increasing difficulty with communication needing help with personal care experiencing behavior changes, including wandering and repeated questioning Late stage: the late stage of dementia is one of near total dependence and inactivity. Memory disturbances are serious and the physical signs and symptoms become more obvious and may include: becoming unaware of the time and place having difficulty recognizing relatives and friends having an increasing need for assisted self-care having difficulty walking experiencing behavior changes that may escalate and include aggression. All rights reserved Currents Views about the Development of AD Preclinical AD Prodromal AD Moderate AD Mild AD Dementia Amyloid accumulation & Amyloid accumulation & Dementia normal cognitive function mild cognitive For personal use only CDR global >=2 impairment Cognitive & functional impairments occur years after brain degeneration sets in. Brain reserve may influence symptoms. Death ** It appears that if something can be done at the earlier times (i.e. during the preclinical & prodromal periods), there may be MORE rewarding outcomes. ** Remark: Arrows indicate fitted progression and reversion rates between stages in the multi-state model. Moderate to severe AD dementia is shortened to moderate AD dementia for readability. Vermunt, Sikkes, S. A.. S. A.., van den Hout, A. A., Handels, R. R., Bos, I. I., van der Flier, W. M. W. M., Kern, S. S., Ousset, P.-J. P.-J., Maruff, P. P., Skoog, I. I., Verhey, F. R. F. R., Freund-Levi, Y. Y., Tsolaki, M. M., Wallin, Åsa K. Åsa K., Rikkert, M. O. M. O., Soininen, H. H., Spiru, L. L., Zetterberg, H. H., Blennow, K. K., … Visser, P. J. P. J. (2019). Duration of Preclinical, Prodromal and Dementia Alzheimer Disease Stages in Relation to Age, Sex, and APOE genotype. Alzheimer's & Dementia, 15(7), 888–898. https://doi.org/10.1016/j.jalz.2019.04.001 All rights reserved  For personal use only Part III. Medical Interventions All rights reserved  Stage Specific Management Goals & Areas for Intervention Preclinical 1. Modify risk factor(s) Mild Dementia For personal use only 2. Promote Cognitive Reserve 1. Optimize cognition and Moderate Dementia function independence 1. Stabilize 2. Prevent the onset remaining function Severe Dementia of neuropsychiatric 2. Guide and symptoms supervise on daily activity schedules 1. Stabilize physical & psychological 3. Prevent & function minimize neuropsychiatric 2. Maintain mental symptoms state & social interactions A slide from a presentation at “December 2014 HA CCTP 14/15 - Quality Care of Older People with Dementia in Hospitals – Lecture 2 – Dementia Care Policy in the UK” by Prof. June Andrews – Dementia Services Development Center, University of Stirling, UK A slide from a presentation at “December 2020 Seminar Series on Management of Dementia in the Community – Session 4 – Stage-Specific Advice to Clients & Family” by Prof. Linda CW LAM – Dept. of Psychiatry, CUHK All rights reserved  Medical Interventions Medications for Improving Cognitive For personal use only Symptoms and maintenance of function Managing non- cognitive symptoms & challenging behaviour (+/- comorbid emotional disorders) A slide from a presentation at “December 2014 HA CCTP 14/15 - Quality Care of Older People with Dementia in Hospitals – Lecture 2 – Dementia Care Policy in the UK” by Prof. June Andrews – Dementia Services Development Center, University of Stirling, UK All rights reserved Chemotherapy " Antipsychotics eg haloperidol Anticonvulsants eg carbamazepine and gabapentin Antidepressants eg citalopram, trazodone Anxiolytics eg. alprazolam (Xanax), diazepam (Valium) prevent or treat anxiety symptoms or disorders Pharmacologic management often needed for treating neuropsychiatric symptoms, but the evidence behind treatment is patients/surrogate decision makers should be discussed. Patients should receive individualized pharmacotherapeutic dosing tolerability.