10/6/2017 Ob Objectiv ctives es • Ev Evaluate when when and and ho how to to do do an an of office ce based based Our Our Gr Grey ey Mat Matter Mat Matters: asse assessment in in me menopausal pausal wo women wi with th memor memory co concerns ns A Case Case in in Po Point • Under nderstand the the opti optional onal of office ce scr screenin ing te test sts Vivien Brown MDCM, CCFP,FCFP, NCMP • Asses Assess when when to to re refer fo for eva evalua uati tion of of subje subjective Assistant Professor, University of Toronto co cognitive de declin cline Vice President, Medical Affairs, Medisys Healthy Group Past President, Federation of Medical Women of Canada Board Member, Women’s Brain Health Initiative My My Pa Patient: The The st story • Mrs B. is a longstanding patient in my practice. Now age 77, at the time of presentation, age 73 • Worked as a bookkeeper for many years • Rushed, scheduled, often in on her lunch hour. • Businesslike • Over the last few visits, 1 ‐ 2 years, late for appointments, slightly disheveled with things falling out of her purse, slightly anxious and upset. • Made a few mistakes at work, bills unpaid and couldn’t remember some basic facts 1
10/6/2017 Framing the Discussion of Aging to Women Number of Persons > 65 years in US 80,000 Many women face Women-live longer Build up lower 65-74 a real threat of 70,000 than men however: entitlements to 75-84 Number (000s) poverty and social pension benefits 60,000 • in general spend less time in 85+ exclusion in their the formal labour market 50,000 post-retirement • are more likely to work in phase of life 40,000 atypical forms of employment (i.e. part-time, temporary work) 30,000 • more likely to engage in unpaid work (due to caring 20,000 Widowed/divorced resposibilities) older women do not 10,000 • earn on average less over their remarry (58%), life 0 versus 84% of 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 • face occupational segregation widowed/divorced • in general retire earlier men who remarry Next steps: Hx and Physical Exam Normal memory changes with Age versus AD Alzheimer’s Disease Age-Related • BP, cardiac evaluation Poor judgment and decision making Making a bad decision once in a while • Lipids and routine BW Inability to manage a budget Missing a monthly payment • TSH Losing track of the date or the season Forgetting which day it is and • B12 remembering later • Urine culture Difficulty having a conversation Sometimes forgetting which word to use • Consider neuroimaging Misplacing things and being unable to Losing things from time to time • Review medications, risk side effects retrace steps to find them Alzheimer’s Association 2
10/6/2017 Neuroimaging Guidelines Me Medications ons: • Neuroimaging if • Age <60 • Antianxiety drugs : dampen the activity in key areas of the brain • Rapid decline (1 or 2 months) in cognition or function • Statins : may lower cholesterol in the brain which is needed for • “short” duration of dementia <2 yr. connections • Recent significant head trauma • Anti ‐ seizure medication : dampens the flow of signals in the CNS • Unexplained neuro sx (severe headache, seizure) • History of cancer (esp those that metastasize to brain) • Antidepressants : blocks the action of brain transmitters • Use of anticoagulants or bleeding disorder • Parkinson’s Drugs : alters activation of dopamine • History of urinary incontinence or gait disturbance early in course of dementia (NPH) • Any new localizing signs • Narcotic Painkillers : stem the flow of pain perception, but also • Unusual or atypical cognitive sx (progressive aphasia) chemicals involved in cognition • Any new localizing signs (hemiparesis) • Beta blockers : interferes or blocks key chemicals • Gait disturbance • Sedatives : acts on brain pathways, affecting chemical transmission • NEW CT or MRI suggested in assessment of cognitive impairment if the presence of unsuspected cerebrovascular disease would change the clinical management • Incontinence drugs : Blocks acetylcholine, which though helpful if • NEW MRI recommended when radiologist/neuroradiologist or a cognitive specialist can incontinent, can inhibit memory and learning interpret patterns of atrophy/other features that may provide added diagnostic or predictive value (grade 2B) • Antihistamines : also inhibit acetylcholine • Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, 2012 TREATABLE CONDITIONS 1. Memory loss that THAT IF LEFT UNTREATED, disrupts daily life CAN MIMIC ALZHEIMER’S DISEASE: • medication interactions • low vitamin B12 • an underactive thyroid • a tumor • a urinary tract infection • untreated depression 3
10/6/2017 2. Challenges in planning 3. Difficulty completing a task or solving problems 5. Trouble 4. Confusion with time or place understanding visual images and spatial relationships 4
10/6/2017 9 10 6. New problems with words 7. Misplacing things and in speaking or writing losing the ability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work or social activities 5
10/6/2017 Qui Quick Scr Screen en 10. Changes in mood and personality • 1. 3 word recall (OR 3.1) • 2. Animal names in 1 minute (OR 20.2) • 3. Clock Draw (OR 24) • OR= Odds Ratio Qui Quick Scr Screen en Quick Scr Qui Screen en 3 ‐ Item Registration: Instruction: Tell the person you are going to do a short memory test. “I will • Clock Drawing Test : Instruction: give you 3 words to remember – after I finish please repeat the words back to me.” Then repeat them again a second time, asking the person to repeat back the 3 words to you. Then finish with, “in a few minutes I will ask you to remember the 3 words.” • A. Ask patient to put the numbers that you would • see on the face of a watch or clock. • 1 2 1 2 1 2 Ball Chair Home • B. Draw the hands of the clock to show the time as 2. Animal Naming: Instruction : Please name as many 4 ‐ legged ANIMALS from anywhere in the world you can think of in one minute … as many 4 ‐ legged animals anywhere in the world in 1 ten after eleven or ten past eleven. minute starting now. • • 1 st 15 seconds ________________________________________________ • 2 nd 15 seconds ________________________________________________ • 3 rd 15 seconds ________________________________________________ • 4 th 15 seconds ________________________________________________ • • Number of ANIMALS _________ (only count 4 ‐ legged animals, no repeats) 6
10/6/2017 MMS MMSE vs vs MOC MOCA • MMSE (Mini Mental State Exam) • 26 or greater is normal • 20 ‐ 25 mild cognitive impairment • 10 ‐ 19 moderate cognitive impairment • 0 ‐ 9 severe cognitive impairment • Specificity 100% (no false positives) • Used since 1975 (Folstein), well validated • Copies available from many sources on the internet including BCGuidelines.ca MMSE MMSE vs vs MoCA MoCA • MoCA (Montreal Cognitive Assessment) • 26 or greater is normal • <26 detects • 90% of MCI • 100% of mild AD • Specificity 87% (13% false positives) • More sensitive for MCI, mild AD • Created 1996, well validated • Available in several languages • Free access at mocatest.org 7
10/6/2017 MMS MMSE vs vs Mo MoCA • MoCA tests 5 domains; delayed recall involves 5 words, registration and recall separated by several other activities; greater sensitivity for milder impairment of cognitive function than MMSE • MoCA identifies visual ‐ spatial difficulties (unlike MMSE) with 3 tests; abbreviated Trails B, cube draw and clock draw. MMSE pentagon test is single visual ‐ spatial assessment. Visual ‐ spatial assessment important for any patient driving. • REMEMBER…both MoCA and MMSE are SCREENING tests. A score of less than 26 suggests cognitive impairment. Diagnosis is made by history and interpretation of clinical and cognitive tests. Fa Factors: Cogni Cognitiv ive decline decline/Risk sk of of Al Alzh zheimer’s Di Diseas ase Risk Factors Protective Factors • Age • Apolipoprotein E ε 2 allele • Women • Years of education • Genetic mutations • Cognitive activities • Apolipoprotein E ε 4 allele * • Diabetes* • Cerebrovascular disease* • Physical activities * • Depressive symptoms • Psychological distress • Social activities • Parkinsonian signs • * effect stronger in women 8
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