Brief Initial Screening Tests For Cognitive Impairment
Brief screening tests are useful to quickly assess the need for further evaluation. In 2013, the Alzheimer’s Association recommended three screening tests that could be completed within the time frame of a Medicare wellness visit: Mini-Cog, Memory Impairment Screen, and General Practitioner Assessment of Cognition.33 These tools require less than five minutes to complete, can be administered by nonphysician personnel, and are validated in the primary care office setting. Subsequently, a systematic review called into question the sensitivity of the Memory Impairment Screen within well-designed studies.34 The Ascertain Dementia 8-Item Informant Questionnaire is also a quick, validated, and sensitive screening tool. Guidelines advocate combining the Mini-Cog with this questionnaire.29,35 Ascertain Dementia 8-Item Informant Questionnaire is also a quick, validated, and sensitive screening tool. Guidelines advocate combining the Mini-Cog with this questionnaire.29,35
This article briefly discusses the screening tests. A more detailed discussion was published previously in American Family Physician.36 Additional information can be found in the American Academy of Family Physicians National Research Network’s Cognitive Care Kit at .
Medications Often The First Suspect
Medications save lives and can be vital to the wellbeing of millions around the world. But all medications have possible side effects. For some people, especially older people, a prescribed medication may help the condition for which it is taken, but it may also have mental side effects. Combinations of several medications heighten this risk. People with dementia symptoms should have all medications checked by their primary physician, and possibly by a neurologist.
Dementia With Lewy Bodies
Dementia with Lewy bodies, also known as Lewy body dementia, is caused by protein deposits in nerve cells. This interrupts chemical messages in the brain and causes memory loss and disorientation.
People with this type of dementia also experience visual hallucinations and have trouble falling asleep at night or fall asleep unexpectedly during the day. They also might faint or become lost or disoriented.
Dementia with Lewy bodies shares many symptoms with Parkinson and Alzheimer diseases. For example, many people develop trembling in their hands, have trouble walking, and feel weak.
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Cognitive Tests For Patients Who Screen Positive On Initial Testing
Patients who screen positive for cognitive impairment on brief screening tests should be evaluated further to quantify the degree of impairment.29 A variety of tools are available for this purpose, but only some are practical for the office setting. The following brief cognitive tests have limited sensitivity and specificity, particularly in patients with high intelligence and education levels. Physicians should consider referral for neuropsychiatric evaluation if a patient has normal findings on brief cognitive tests but cognitive impairment is still strongly suspected.
Wernicke’s Encephalopathy And Korsakoff’s Syndrome
A deficiency in thiamine is often, but not always, caused by alcohol abuse and can lead to Wernicke’s encephalopathy and Korsakoff’s syndrome. Wernicke’s encephalopathy is an acute condition of confusion, abnormal vision and eye movements, and problems with balance and body control. This condition is sometimes reversible with emergency treatment at the hospital.
Korsakoff’s syndrome is typically a long-term condition that sometimes follows an incident of Wernicke’s encephalopathy. It more closely resembles dementia’s symptoms and includes confusion, memory loss, hallucinations, and confabulation .
According to the Alzheimer’s Association, about 25% of people with Wernicke-Korsakoff syndrome will fully recover.
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Medication Adverse Effects And Interactions
Cognitive impairment resulting from prescribed medications is more likely to occur in older than younger adults because theyre already vulnerable to dementia caused by neurodegeneration. Adding a moderately neurotoxic medication might trigger delirium or memory issues.
Identification
To definitively identify a medication thats causing dementia symptoms, the drug causing impairment would have to have been administered before confusion onset and return to normal cognitive baseline would have to occur when the medication is stopped. However, these conditions rarely are met because many older adults take multiple medications. Medicines that can potentiate delirium in adults older than 65 years are found in the American Geriatric Society 2019 Beers Criteria®. These medicationsincluding those with strong anticholinergic properties, conventional and atypical antipsychotics, benzodiazepines, and nonbenzodiazepine and benzodiazepine receptor agonist hypnoticsshould be avoided.
Management
Medications causing dementia-like symptoms should be discontinued, as ordered by the provider, while still treating the underlying medical condition. You can educate patients about the risks of taking multiple drugs, work with them to ensure theyre taking only essential medications, and recommend alternative medications when necessary. Always ask patients if theyre taking any over-the-counter medicines, supplements, or natural products, which may adversely interact with prescribed medications.
Treating And Managing Dementia Symptoms
Dementia symptoms generally begin to appear later in life, after or around age 60, with the most common form being Alzheimer’s disease. Most forms of dementia are treatable, but not curable. For treatable, but degenerative forms of dementia, medication can help manage symptoms, although for most people, there are only modest benefits to treatment.
However, sometimes dementia symptoms may be caused by treatable conditions, and if the underlying conditions are treated, the patient’s mental functions can at least partially, if not completely, improve. It is estimated that about 20 percent of patients with dementia symptoms actually have a curable condition, thus it is important to rule these out in order to make a firm diagnosis of a degenerative type of dementia.
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Evaluation Of Suspected Dementia
NATHAN FALK, MD, and ARIEL COLE, MD, Florida Hospital Family Medicine Residency, Winter Park, Florida
T. JASON MEREDITH, MD, Offutt Air Force Base Family Medicine Residency, Offutt Air Force Base, Nebraska
Am Fam Physician. 2018 Mar 15 97:398-405.
Dementia is the fifth leading cause of death in Americans older than 65 years. The United States population is aging, with 46 million persons older than 65 yearsa number that is expected to double by 2060.1 Consequently, by 2050, the estimated number of Americans living with dementia will increase from 5 million to 14 million, and the estimated cost of dementia care will increase from $236 billion to $1 trillion.2 Early recognition of cognitive impairment is integral to patient counseling, advance care planning, assessment of secondary or reversible causes of impairment, and consideration of medical therapy. The U.S. Preventive Services Task Force and the American Academy of Family Physicians have concluded that current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults.3,4
This article focuses on the evaluation of patients with suspected dementia, including diagnostic criteria, brief screening tests suitable for use during primary care office visits, and diagnostic testing .
SORT: KEY RECOMMENDATIONS FOR PRACTICE
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Recommendations from the Choosing Wisely Campaign
BEST PRACTICES IN NEUROLOGY
FIGURE 1.
General Practitioner Assessment Of Cognition
The General Practitioner Assessment of Cognition comprises a patient screen and, if necessary, an informant component. Advantages of this test include validation in the primary care setting, little to no education bias, and availability in multiple languages.34 It has been studied only in Australian populations, however. The patient screen consists of recall, time orientation, clock drawing, and information components. The patient screen takes less than four minutes to complete, and the informant portion takes less than two minutes. The General Practitioner Assessment of Cognition has a sensitivity of 85% and specificity of 86%.34
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Other Causes Of Reversible Dementia
Other causes of reversible dementia include:
- infections such as HIV and urinary tract infections, which should be ruled out when performing a dementia assessment. Treating the infection may eliminate the dementia symptoms.
- benign brain tumors that place pressure on the hippocampus, prefrontal cortex, or other brain regions involved in short-term memory. In some cases, the benign tumor can be treated and the cognitive impairment reversed.
Access references at visit myamericannurse.com/?p=72396.
Angela Humbel is an undergraduate bachelor of science in nursing student at The Ohio State University in Columbus. Michael Carter is a distinguished professor emeritus at The University of Tennessee Health Science Center in Memphis. Todd B. Monroe is an associate professor at The Ohio State University.and Todd B. Monroe, PhD, RN-BC, FNAP, FGSA, FAAN
What Is Dementia Symptoms Types And Diagnosis
Dementia is the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a personâs daily life and activities. Some people with dementia cannot control their emotions, and their personalities may change. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a personâs functioning, to the most severe stage, when the person must depend completely on others for basic activities of living.
Dementia is more common as people grow older but it is not a normal part of aging. Many people live into their 90s and beyond without any signs of dementia.
There are several different forms of dementia, including Alzheimers disease. A persons symptoms can vary depending on the type.
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Isnt Dementia Part Of Normal Aging
No, many older adults live their entire lives without developing dementia. Normal aging may include weakening muscles and bones, stiffening of arteries and vessels, and some age-related memory changes that may show as:
- Occasionally misplacing car keys
- Struggling to find a word but remembering it later
- Forgetting the name of an acquaintance
- Forgetting the most recent events
Normally, knowledge and experiences built over years, old memories, and language would stay intact.
Causes Of The Dementia Syndrome
Many different disease states can produce the clinical syndrome of dementia. These can be divided into two groups:
* Reversible * Irreversible
Reversible dementia syndrome
The term reversible or potentially/ partially reversible is used to define a cognitive disorder in which normal or nearly normal function may be restored. The potential to reverse or delay deterioration emphasizes the importance of an early diagnosis of a reversible dementia. The most common causes of reversible dementia are depression, delirium, and drug toxicity. Other causes include normal pressure hydrocephalus, neoplasms, metabolic disorders, trauma, medications and infections.
Irreversible dementia syndrome
The most common causes of irreversible dementia include:
* Alzheimers disease
These account for at least 7080% of all cases.
Less common, and more difficult to recognize clinically, are:
* Dementia of Lewy body type * Picks disease
Patients, especially geriatrics, with irreversible dementia are commonly placed in nursing homes for special care.
Alzheimers disease
Diagnosing Alzheimers disease
Although the prospect of developing a cure is unlikely in the foreseeable future, new symptomatic treatments are becoming available. This further supports the value of early recognition of AD.
AD prognosis
Figure 2. National history of Alzheimers disease
Figure 3. Causes of dementia
International Psychogeriatric Association
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Metabolic And Toxic Causes
Several endocrinal disorders and vitamin deficiencies can masquerade as dementia and need to be investigated, especially in young and rapidly progressive dementias. Several toxins can cause RPD. Exposure to heavy metals, such as arsenic, mercury, aluminum, lithium, or lead, can lead to cognitive decline, particularly after acute exposure. Most cases of acute exposures result in florid encephalopathies that progress over hours to days and thus would not be confused with rapidly progressive dementias, which progress over weeks to months. Manganese toxicity, found usually in miners, can present with significant Parkinsonism. Bismuth is a metal used to treat gastrointestinal disorders, principally peptic ulcer disease and diarrhea. Bismuth intoxication, typically caused by overdosing on bismuth-containing products, such as Pepto-Bismol, can cause a disorder mimicking Creutzfeldt-Jakob disease . Patients initially manifest with apathy, mild ataxia, and headaches, which progress to myoclonus, dysarthria, severe confusion, hallucinations , seizures, and, in severe cases, even death. Blood levels of bismuth, greater than 50 mg/L, are considered in the toxic range. The condition usually is reversible however, extremely prolonged use can result in permanent tremors.
Lyme And Other Hidden Infections
Lyme on the brain. Thats how Dawn DeSylvia, MD, an integrative physician and founder of Whole Life Health MD in Los Angeles, describes dementia that stems from undiagnosed Lyme disease. Although known to be carried by ticks in the northeastern U.S., Lyme disease can be contracted from other sources in other areas, particularly the upper Midwest. The infection can linger for decades, triggering chronic inflammation. A healthy immune system can ward off noticeable signs but eventually gets overwhelmed, and debilitating dementia is one possible symptom. Epstein Barr, parasites, and other infections can also cause dementia. Testing for Lyme disease in a person with dementia who lives in the upper Midwest or Northeastern United States is reasonable.
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How Reversible Are Reversible Dementias
European Neurological Review,
Abstract:
Overview
Reversible dementias comprise different groups of disorders of variable aetiologies, such as structural brain lesions or metabolic, infectious, toxic, autoimmune, paraneoplastic and psychiatric disorders. When patients present with cognitive symptoms, especially in the younger age groups, the first thought of the attending neurologist should be to try to identify an underlying treatable cause. The incidence of degenerative dementia rises with older age and its symptoms progressively become more evident and typical in such cases, a differential diagnosis is limited and the chance of uncovering a treatable disorder is minimal. However, although uncommon, treatable dementias or dementia-like symptoms do exist. Future studies with better design and methodology, as well as longer observation periods and larger patient populations, are needed to clarify the controversial issues concerning the epidemiology and accurate diagnosis of, and treatment possibilities for, reversible dementias.
Keywords
Reversible dementia, classification, differential diagnosis, treatment, review
Article:
Traditional and New Approach to Reversibility
Traditional Causes of Reversible Dementias
Structural Brain Lesions
Alcoholic Dementia
Nutritional Disorders
Endocrine Disorders
Metabolic Disorders
Toxic Conditions
Psychiatric Disorders
Miscellaneous Causes
New Causes of Reversible Dementias
Epileptic Disorders
Dementia Is An Umbrella Term For Memory Loss But There Are Actually Many Different Types Of Dementia
Which type of dementia is potentially reversible. Depression medication side effects drug interactions drug overdose alcohol abuse drug abuse dietary vitamin and mineral deficiencies a c b 12 and folate traumas due to falls concussions or contusions to the head hormonal dysfunction thyroid. Low levels of vitamin b12 can cause symptoms that are very similar to alzheimer s disease. Excess alcohol consumption smoking inflammation depression drug effects and interactions lung problems metabolic disease or abnormalities sleep problems stress vitamin deficiency.
Alcohol or drug abuse tumors subdural hematomas blood clots beneath the outer covering of the brain normal pressure hydrocephalus a buildup of fluid in the brain metabolic disorders such as a vitamin b12 deficiency low levels of thyroid hormones. The following are among the more common causes of reversible dementia. For example it can be vascular dementia or frontotemporal dementia.
Causes of dementia that may be reversible include. Commonly referred to as water on the brain normal pressure hydrocephalus nph is a. Alzheimer s is the most common type of dementia and is the 6th leading cause of death in the united.
But dementia can also be. 10 causes of potentially reversible dementia symptoms normal pressure hydrocephalus. This disease can co exist with.
What are the most common types of irreversible dementia.
Reversible Dementia And Delirium
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What Are The Reversible Causes
There are several clearly reversible causes of dementia that are remembered by the mnemonic DEMENTIA:
Drugs , emotional- depression, metabolic , eyes and ears declining, normal pressure hydrocephalus tumor or other space-occupying lesion, infection , anemia .
The major syndromes with progressive dementia include Alzheimer disease , vascular dementia , dementia with lewy bodies and frontotemporal dementia .
Its Not Necessarily Alzheimers
More than 50 conditions can cause or mimic the symptoms of dementia, and a small percentage of dementias are reversible. Two common examples are dementia caused by vitamin B12 deficiency or an underactive thyroid . Getting the right diagnosis is important so that you know what options you have, because symptoms subside when the underlying problem is treated.
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Is There Treatment Available
There is not yet a cure for FTD, or any disease modifying treatment. However, various therapies can help with some of the symptoms. Secondary symptoms, such as depression, may be helped by medication.
Knowing more about FTD and why the person is behaving as they are can help people to cope with the disease.
Family members and carers can, with support, develop coping strategies to work around problems rather than trying to change the behaviour of the person with FTD.
Psychological therapies are important to help manage abnormal behaviour.
Speech therapy is of benefit to people with PNFA, particularly in helping to develop alternative communication methods.
The input of an occupational therapist can help improve everyday functioning at home.
What Is An Example Of Reversible Dementia
In the literature, the most frequently observed potentially reversible conditions identified in patients with cognitive impairment or dementia are depression, adverse effects of drugs, drug or alcohol abuse, space-occupying lesions, normal pressure hydrocephalus, and metabolic conditions land endocrinal conditions like
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How Is Dementia Treated
Treatment of dementia depends on the underlying cause. Neurodegenerative dementias, like Alzheimers disease, have no cure, though there are medications that can help protect the brain or manage symptoms such as anxiety or behavior changes. Research to develop more treatment options is ongoing.
Leading a healthy lifestyle, including regular exercise, healthy eating, and maintaining social contacts, decreases chances of developing chronic diseases and may reduce number of people with dementia.
Is Dementia Reversible A Simple Test May Tell
Bottom Line: The accuracy of testing can be as high as 97%â¦
Source: A study, Gait Analysis in PSP and NPH: Dual-Task Conditions Make the Difference, published in the February 21, 2018, online edition of Neurology.
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How well can you do two things at once? For people with certain forms of dementia, the answer is quite telling.
Background: A neurological condition known as idiopathic normal pressure hydrocephalus causes symptoms that are often confused with other forms of dementia. When iNPH is misdiagnosed, its particularly troubling because the symptoms caused by this conditionunlike other forms of dementiaare reversible.
iNPH is caused by excess fluid in the brain, and its symptoms include walking, balance and thinking problems. Because it is so often misdiagnosed, researchers wanted to find a way to help doctors easily identify it. Heres what they came up with
Recent study: Among its symptoms, iNPH causes a distinctive gait disturbance , so researchers devised a test that involves walking while simultaneously performing a simple task that challenges a persons thinking skills. The speed with which the tasks could be performed was surprisingly accurate in identifying people who had iNPH.
A study, Gait Analysis in PSP and NPH: Dual-Task Conditions Make the Difference, published in the February 21, 2018, online edition of Neurology.
Date
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