DEMENTIA AND DECISION-MAKING:

FUNCTIONAL ASSESSMENT OF THE OLDER ADULT I

Myriam Edwards MD Geriatrician, Assistant Professor, and

Geriatric Medicine Fellowship Program Director

Hurley Medical Center / Michigan State University

Geriatric Education Center of Michigan

Geriatric Education Center of Michigan activities are supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Public Health Service Act, Title VII, Section 753(a).

This module was developed byMark Ensberg, MDGeriatric Education CenterMichigan State University

Define• Delirium• Dementia• Decision-

making capacity

• Competence

Identify• Tools to assess

cognitive status

Recognize:• Decision-

making ability includes• nature of the

decision• cognitive

capabilities of person

LEARNING OBJECTIVES

CognitionDecision-making capacity

Goal Setting

WHAT IS NORMAL?Recall may be

delayed

Memory storage is normal

Divided Attention Tasks (more difficulty with

multi-tasking)

Slide 6

NORMAL AGING● No consistent, progressive deviations on

testing of memory

● Some decline in processing and recall of new information: slower, harder

● Reminders work – visual tips, notes

● Absence of significant effects on ADLs or IADLs due to cognition

WHAT IS MCI?(MILD COGNITIVE IMPAIRMENT)

Memory Impairment

No Other Cognitive Deficits

Normal Daily Activities

WHAT IS DEMENTIA?Memory Impairment

• Language (word finding, naming)• Executive function (planning & organizing)• Apraxia or Agnosia

Other Cognitive Problems

Problems with Daily Activities

DEMENTIA IS SNEAKY

Stop, Look, and Listen

Look for Red Flags

( ‘Triggers’ )

Listen to Caregivers

Brief Screen of Cognitive

Function

Arrange Follow-up Evaluation

DAILY ACTIVITIES: IADLS INSTRUMENTAL ACTIVITIES OF DAILY LIVING

* relevant to the medical office visit

Shopping Transportation Housework Meal Prep

Finances* Medication* Telephone*

*

‘TEN WARNING SIGNS’

Alzheimer’s Association

1. Memory loss2. Difficulty performing familiar tasks 3. Problems with language4. Disorientation to time and place5. Poor or decreased judgment6. Problems with abstract thinking7. Misplacing things8. Changes in mood or behavior9. Changes in personality10. Loss of initiative

BRIEF SCREENS: COGNITIVE FUNCTION

■ Conversation■ Clock Drawing Test■ Mini-Cog

■ Three-Item Recall■ Clock Drawing

JAGS 1993; 41: 576.

CLOCK-DRAWING: 4-POINT SCORING

1 pt - Draws a closed circle1 pt - Numbers in correct positions1 pt - All 12 correct numbers included1 pt - Hands placed in correct position

MINI-COG

■ Negative Screen for Dementia■ Score of 3 on 3-item recall■ Normal Clock and a Score of 1 or 2

■ Positive Screen for Dementia■ Score of 0 on 3-item recall■ Abnormal Clock and a Score of 1 or 2

FOLLOW-UP EVALUATION■ Mini-Mental State Examination (MMSE)■ Montreal Cognitive Assessment (MoCA)

■ Functional Activities Questionnaire- Bills & Checks - Prepare Meals- Organizing Papers - Current Events- Shopping - TV Magazines- Games & Hobbies - Appointments- Making Coffee - Transportation

DSM IV CRITERIA FOR DEMENTIA1. Memory impairment

2. Additional Cognitive Problems

3. Deficits cause significant impairment in social or occupational function and represent a significant decline from a previous level of function

4. Exclude Acute Confusion (delirium)

5. Exclude Depression

SCREENING FOR DEPRESSION

• Do you feel sad or blue?• Have you lost interest in doing

things that you have enjoyed?PHQ - 2

• What are you looking forward to?• What do you do for enjoyment?

Other Good

Questions

TYPES OF DEMENTIA

Alzheimer’s disease

Vascular dementia

Lewy Body disease Other

Slide 23

THE EPIDEMIOLOGY OF ALZHEIMER’S DISEASE

• 6%‒8% of people age 65+ have AD

• Nearly 30% of those aged 85+ have AD

Slide 24

THE IMPACT OF DEMENTIA Economic• $100 billion annually for care and lost productivity• Medicare, Medicaid, private insurance provide only

partial coverage• Families bear greatest burden of expense

Emotional• Direct toll on patients• Nearly half of caregivers suffer depression

Slide 25

RISK FACTORS FOR DEMENTIADefinite

• Age

• Down’s syndrome

• Family history

• APOE4 allele

Possible

• Head injury

• Fewer years of education

• Late onset of major depression

• Cardiovascular risk factors

Slide 26

ASSESSMENT: HISTORY

Ask both the patient & a reliable informant about the patient’s:

• Current condition

• Medical history

• Current medications & medication history

• Patterns of alcohol use or abuse

• Living arrangements

Slide 27

ASSESSMENT: PHYSICAL Examine:• Neurologic status• Mental status• Functional status

Include:• Quantified screens for cognition

eg, Folstein’s MMSE, Mini-Cog• Neuropsychologic testing

ASSESSMENT: LABORATORY• Blood chemistries• CBC• Liver function tests• Urinalysis

• Serologic tests for:RPR

TSH

Vitamin B12 level

Folate level

Slide 29

ASSESSMENT: BRAIN IMAGING Consider imaging when:• Onset occurs at age <65 years• Symptoms have occurred for <2 years• Neurologic signs are asymmetric or focal• Clinical picture suggests normal-pressure hydrocephalus• Patient has had recent fall or other head trauma

Consider:• Noncontrast computed topography head scan• Magnetic resonance imaging• Positron emission tomography

Slide 30

DIFFERENTIAL DIAGNOSIS

• Normal aging• Mild cognitive impairment• Delirium• Depression• Alzheimer’s disease• Vascular (multi-infarct) dementia• Dementia associated with Lewy bodies• Other (alcohol, Parkinson's disease, Pick’s disease,

frontal lobe dementia, neurosyphilis)

Slide 31

DELIRIUM vs DEMENTIA

Delirium and dementia often occur together in older hospitalized patients; the distinguishing signs of delirium are:

Acute onset Cognitive fluctuations over hours or days Impaired consciousness and attention Altered sleep cycles

Slide 32

DEPRESSION vs DEMENTIA (1 of 2)

The symptoms of depression and dementiaoften overlap:

• Impaired concentration

• Lack of motivation, loss of interest, apathy

• Psychomotor retardation

• Sleep disturbance

Slide 33

DEPRESSION vs DEMENTIA (2 of 2)• Patients with primary depression are generally

unlike those with dementia in that they: Demonstrate motivation during cognitive testing Express cognitive complaints that exceed measured

deficits Maintain language and motor skills

• Effective treatment of depressive symptoms may improve cognition

Slide 34

ALZHEIMER’S DISEASE• Onset: gradual

• Cognitive symptoms: primarily memory with difficulty learning new

information

• Motor symptoms: rare early, apraxia later

• Progression: gradual, over 8–10 yr ave.

• Lab tests: normal

• Imaging: possible global atrophy, small hippocampal volumes

Slide 35

DSM-IV DIAGNOSTIC CRITERIA FOR AD• Development of cognitive deficits manifested by:

Impaired memory and Aphasia, apraxia, agnosia, disturbed executive function

• Significantly impaired social, occupational function

• Gradual onset, continuing decline

• Not due to CNS or other physical conditions (eg, PD, delirium)

• Not due to an Axis I disorder (eg, schizophrenia)

Slide 36

VASCULAR DEMENTIA

• Onset: may be sudden/stepwise

• Cognitive symptoms: depend on anatomy of ischemia

• Motor symptoms: correlates with ischemia

• Progression: stepwise with further ischemia

• Lab tests: normal• Imaging: cortical or subcortical

changes on MRI

Slide 37

DSM-IV DIAGNOSTIC CRITERIA FOR VASCULAR DEMENTIA

• Development of cognitive deficits manifested by: Impaired memory and Aphasia, apraxia, agnosia, disturbed executive function

• Significantly impaired social, occupational function

• Focal neurologic symptoms & signs or evidence of cerebrovascular disease

• Deficits occur in absence of delirium

Slide 38

LEWY BODY DEMENTIA• Onset: gradual

• Cognitive symptoms: memory, visuospatial, hallucinations,

fluctuations

• Motor symptoms: parkinsonism

• Progression: gradual, but usually fasterthan AD

• Lab tests: normal

• Imaging: possible global atrophy

Slide 39

FRONTOTEMPORAL DEMENTIA• Onset: gradual, usually age

<60• Cognitive symptoms: executive: disinhibition,

apathy, behavior changes

• Motor symptoms: none; may be associated

with ALS in rare cases• Progression: gradual but faster than

AD• Lab tests: normal• Imaging: atrophy in frontal and

temporal lobes

Slide 40

PRIMARY GOAL OF TREATMENT

To enhance quality of life

and maximize functional performance

by improving cognition, mood, and behavior

Slide 41

NONPHARMACOLOGIC MANAGEMENT

• Cognitive rehabilitation

• Individual and group therapy

• Physical and mental activity

• Regular appointments

• Family and caregiver education and support

• Environmental modification

• Attention to safety

Slide 42

PHARMACOLOGIC MANAGEMENT

• Treatment should be individualized• Cholinesterase inhibitors:

donepezil, rivastigmine, galantamine• Memantine• Other cognitive enhancers• Antidepressants• Psychoactive medications

WE DETERMINE DECISION-MAKING CAPACITY

Courts determine competence

DECISION-MAKINGIADLs ( medications and finances)

Live safely at home

Drive a car

Informed Consent

Appoint DPOA –HC

Transact business

Make a will

DECISION-MAKING CAPACITY

Communication

Culture

Circumstances

Choices

Consequences

Consistency

Slide 46

ASSESSMENT OFDECISIONAL CAPACITY

Overarching factor is the patient’s ability to understand the consequences of a decision

Evaluate each patient individually, considering his or her beliefs, values, and goals of care

Avoid assuming on the basis of ethnic background that a patient holds certain beliefs

Slide 47

ELEMENTS OF CAPACITY TO MAKEMEDICAL DECISIONS

Ability to understand: The disease process The proposed therapy and alternative therapies The advantages, adverse effects, and potential

complications of each therapy The possible course of the disease without intervention

Ability to communicate a decision

Slide 48

ELEMENTS OF CAPACITY TO MAKEDECISIONS ABOUT SELF-CARE

Ability to care for oneself

or

Ability to accept the needed help to keep oneself safe

Slide 49

ELEMENTS OF CAPACITY TO MAKEFINANCIAL DECISIONS

Ability to manage bill payment

Ability to appropriately calculate and monitor funds

Slide 50

ELEMENTS OF CAPACITY TO MAKEA LAST WILL AND TESTAMENT

Ability to identify the individuals involved Ability to remember estate plans Ability to express the logic behind choices

Slide 51

STANDARDIZED TESTSOF DECISIONAL CAPACITY

Mini-Mental State Examination (limited utility) Executive Interview 25-item examination

(EXIT 25) of executive function Capacity to Consent to Treatment Instrument MacArthur Competency Assessment Tool –

Treatment

Slide 52

HIERARCHY OF DECISION-MAKING STRATEGIES

Use substituted judgment

Respect the patient’s last competent indication of their wishes

Use the principle of beneficence

Slide 53

LAST COMPETENTINDICATION OF WISHES

Most relevant when patients can foresee that they will become incapacitated, as when entering the terminal phase of an illness

Patients should be encouraged to give detailed advance directives (called advanced care plans in some contexts)

As long as the circumstances remain substantially as predicted, other persons should not be allowed to reverse these decisions

Slide 54

SUBSTITUTED JUDGMENT Defined as the process of constructing what the person

would have wanted if he or she had been able to foresee the circumstances and give direction for care

A patient can appoint someone to hold durable power of attorney for health affairs (called a health care agent or health care proxy)

A person granted durable power of attorney takes precedence over the next of kin

Slide 55

PRINCIPLE OF BENEFICENCE Making medical decisions for an incapacitated

person on the basis of the benefits and burdens of treatment and interventions

The analysis is best done by someone who is very aware of: What gives that patient pleasure What causes agitation, fear, pain, or discomfort How the patient reacts to a change in setting, use of

restraints, and similar matters

Slide 56

CONSERVATORS Appointed by a court in the absence of next of kin or

durable power of attorney Called guardians in some states Two types:

Conservator of finance Conservator of person (the patient can no longer make

personal decisions, such as medical decisions, or endangers himself and cannot understand or accept the need for help)

Slide 57

ADVANCE DIRECTIVES (LIVING WILLS)

Attempt to demonstrate what decisions a person would make in hypothetical clinical situations (eg, vegetative state, terminal illness)

Limited utility because of vagueness and lack of generalizability to decisions that commonly need to be made

Can be used by surrogate decision maker as evidence of preferences

SETTING GOALS OF CARE

Identify Decision-maker (include person)

Understand Patient as a Person (QoL)

The Condition/Diagnoses (prognoses)

Establish Plan of Care• Discuss ‘Best Guess’ transitions

and/or decision points

Review Plan

SETTING GOALS

Make sure goals are shared goals

Make goals as explicit as possible and be sure all involved understand

them

Make sure you make time to review (and revise if necessary)

goals, especially when condition changes.