Dementia 2010

Mild cognitive impairment is defined as impairment of

_______ beyond that expected for a person’s age.

(A) Information processing speed (B) Memory

(C) Executive functioning (D) Attention

Answer

• (B) Memory

Dementia is a syndromal term that refers to which of the

following?(A) Loss of cognitive function associated with impaired daily

functioning(B) Marked change in emotions

and temperament(C) Neurologic dysfunction

(D) All the above

Answer

• (D) All the above

An imaging report notes “white matter changes consistent with

microvascular disease”; this _______ the diagnosis of

vascular dementia.(A) Establishes (B) Does not

establish

Answer

• (B) Does not establish

Lewy body dementia is characterized by:

1. Insidious onset and relentless progression of cognitive dysfunction

2. History of stroke3. Fluctuating cognitive impairment4. Dysautonomia with unexplained

falls5. Formed and/or

microhallucinations(A) 1 (B 2,3 (C) 3,4,5 (D) 2,3,4,5

Answer

• 3. Fluctuating cognitive impairment

• 4. Dysautonomia with unexplained falls

• 5. Formed and/or microhallucinations

• (C) 3,4,5

The hallmark of frontotemporal dementia is:

(A) Marked change in personality or language

(B) Early severe cognitive impairment

(C) Loss of executive functioning

Answer

• (A) Marked change in personality or language

The diet believed to be most beneficial for brain health is the equivalent of

the _______ diet.(A) South Beach (B)

Pritikin (C) Mediterranean (D) Vegan

Answer

• (C) Mediterranean

If cognitive impairment resolves after treatment of depression, there is little risk that the patient will

later developdementia.

(A) True (B) False

Answer

• (B) False

A longer interval between the diagnosis of depression and that

of Alzheimer disease (AD) _______ the risk for

developing AD.(A) Increases(B) Decreases

(C) Has no association with

Answer

• (A) Increases

In evaluating a patient for dementia, which of the following are

significant findings?1. Significant weight loss2. Urinary incontinence

3. Unexplained falls4. History of stroke, seizure, or head

injury with loss of consciousness(A) 1,3 (B) 1,3,4 (C) 3,4 (D) 1,2,3,4

Answer

• 1. Significant weight loss

• 2. Urinary incontinence

• 3. Unexplained falls

• 4. History of stroke, seizure, or head injury with loss of consciousness

• (D) 1,2,3,4

Select the correct statement about obtaining neuroimaging of

patients with depression in mid to late life:

(A) All require neuroimaging(B) None require neuroimaging(C) No hard and fast rule exists

Answer

• (C) No hard and fast rule exists

Of the following, which is considered the key indicator that

a patient is suffering from delirium?

(A) Impaired recall (B) Visuospatial impairment

(C) Fluctuating attention(D) Visual hallucinations

Answer

• (C) Fluctuating attention

Thiamine deficiency typically presents as enlargement of the

_______ on magnetic resonance imaging.(A) Sulci

(B) Mammillary bodies (C) Caudate nuclei

(D) Subarachnoid space

Answer

• (B) Mammillary bodies

Comatose patients without involvement of the deep gray

matter of the thalamus are typically able to:

(A) Localize painful stimuli (B) Track faces or fingers

(C) Sit or stand (D) All the above

Answer

• (A) Localize painful stimuli

In patients displaying altered mental status, nystagmus across

the vertical plane typically indicates:

(A) Metabolic disorder (B) Delirium

(C) Parasympathetic overactivity (D) Structural pathology

Answer

• (D) Structural pathology

Symptoms of bleeding into the subarachnoid space include:(A) Chemical meningitis and

delirium (B) Aphasia and tremor

(C) Horizontal nystagmus and myoclonus

(D) All the above

Answer

• (A) Chemical meningitis and delirium

Patients with Alzheimer disease typically exhibit loss of recent

memory, but unlike with delirium, their

_______ is frequently preserved.(A) Attention span

(B) Visuospatial cognition (C) Abstract reasoning

(D) Motor skills

Answer

• (A) Attention span

Patients who score _______ on a Mini-Mental State Examination (MMSE) are considered to have

milddementia.

(A) 30 (B) 20 (C) 10 to 20 (D) <10

Answer

• (B) greater than or equal to 20

Studies show that driving abilities significantly

deteriorate once a patient with dementia scores

_______ onthe MMSE.

(A) <25 (B) <20 (C) <15 (D) <10

Answer

• (B) <20

Acting as a caregiver for an individual with dementia is

associated with a high likelihood of developing:

(A) Post-traumatic stress disorder (B) Acute stress disorder

(C) Anxiety and depression (D) Adjustment disorder

Answer

• (C) Anxiety and depression

In patients with advanced dementia, feeding tubes reduce

the rates of aspiration pneumonia and are associated

with measurable increases in survival.

(A) True (B) False

Answer

• (B) False

Delerium• the ability to provide lucid history with normal orientation,

attention, recent recall, and speech eliminates the possibility of delerium

• A history that suggests cognitive problem necessitates methodical mental status examination

• In the setting of altered mental status, signs on general examination indicate presence of delirium and differentiate sympathetic nervous system overactivity from underactivity

• in delirium, acute cognitive changes occur over hours to days• fluctuating attention key indicator; may affect all aspects of

cognition, including memory, language, and visuospatial testing

Diagnostic tests• memory tests unreliable after diagnosis of confused state• digit span testing—in young adults, average recall spans 7 forward and 4

backward• forward testing typically sufficient• digit span recall declines slightly with age (80-yr-old should still recall 6

digits forward)• test of recent memory—patients must retain information for short period

(eg, recall 3 different objects 5 min later)• sympathetic overactivity states—eg, alcohol withdrawal, hyperthyroidism,

drug effect• sympathetic underactivity—caused by eg, sedative hypnotics• history from witnesses frequently presents conflicting information due to

fluctuating nature of syndrome

Risk factors for delirium• age >65• baseline cognitive dysfunction (lowers threshold for delirium;

prolongs recovery) establish true baseline by contacting caretakers• diminished hearing or vision• poor general health• bladder catheters (associated urinary tract infections)• new medications• Restraints• sleep deprivation;• screen for metabolic causes and sepsis

Dementia

• poor intellectual or cognitive function with no disturbance of consciousness

• older patients at risk for both delirium and dementia• patients with dementia typically• display social behavior and engage in basic conversation• similarities and differences—useful bedside test assesses abstract thinking;

eg, ask patient to explain differences and commonalities between apples and oranges

• delirium impairs even basic abstract thought• cognitive functioning— established by questioning family and friends after

establishing cognitive baseline• ask about functional cognitive activi activities engaged in by patient (eg,

finances)

Dementia• Visual hallucinations—frequently attributed to metabolic disorders (eg,

alcohol withdrawal)

• typically related to neurodegeneration in patients with Parkinson’s disease

• Lewy body dementia—frequently causes visual hallucinations

• may account for 15% to 25% of patients diagnosed with Parkinson’s disease

• visual hallucinations increase over time; responds to carbidopa-levodopa (Sinemet), resulting in frequent misdiagnosis of Parkinson’s disease

• carbidopa-levodopa causes visual hallucinations in absence of pathology

• as neurodegeneration progresses, even low doses may trigger hallucinations

• stroke and visual deficit—typically produces inability to see, rather than hallucinations in visual field; neurodegenerative symptoms overlap with symptoms of delirium, but persist significantly longer

Thiamine deficiency

• presents with enlarged mammillary bodies on MRI• metabolic cause of delirium with highly specific treatment• frequently underrecognized• in autopsy studies, only 10% of patients accurately diagnosed

before death expecting presence of all 3 major indicators (confusion, limitation of eye movements, truncal ataxia) frequently leads to missing diagnosis of thiamine deficiency

• suspect when confusion of unknown cause present with malnourishment

• deficiency typically impairs absorption, necessitating intravenous or intramuscular thiamine

Encephalopathy• clonus—typically elicited by rapid movement of joint or

hyperreflexia• frequently occurs at ankle, occasionally entire leg• rhythmic and induced by movement• myoclonus—almost uniformly presents with asynchronous features

(eg, twitching, but not rhythmic)• ongoing seizure—especially with rhythmic twitching of digit or

ocular deviation to one side with nystagmoid movement• dystonia—presents as abnormal, fixed posture (typically of leg or

trunk) with no rhythmic movements• postural tremor—fine high-frequency tremor when limb held against

gravity; subsides at rest

Seizures and delirium• delirium may persist after seizure into postictal state• mimics sedative-hypnotic drug effect, but may indicate

sympathetic overactivity• evaluate patient for earlier seizure• frequent subtle seizures (particularly• partial-complex type) may induce prolonged postictal

state• actual seizure activity often too short-lived for observation • specific metabolic disorders predispose patients to both

seizures and delirium (eg, severe hypoglycemia)

Receptive aphasia

• patients frequently fabricate words (neologisms) or speak nonsensically

• occasionally clinically indistinguishable from delirium (neuroimaging requiered to confirm diagnosis)

• majority of patients displaying receptive aphasia present with hemiparesis or visual field cuts

• screen for aphasia assesses repetition, naming, and comprehension (varies with severity of delirium)

• Meaningful response to any questions establishes comprehension, ruling out receptive aphasia

Brain Injury• subdural hematoma—compresses brain• Neurologic structures may shift across midline• In most severe cases, medial portion of temporal lobe extends and compresses brainstem and third cranial nerve• common in patients with no history of falling• computed tomography (CT) of head recommended for patients at high risk• nonfocal neurologic examination—common• neurologists have difficulty predicting findings associated with compression of brain• findings may refer to hemisphere opposite subdural hematoma• Early herniation—may present with evidence of partial third cranial nerve palsy (parasympathetic nerve fibers affected,

producing dilated pupils)• suspicion warranted even without pupil indications• prompt imaging required once brainstem symptoms manifest (to rule out incipient brainstem compression)• coma—patients without involvement of deep gray matter of thalamus typically maintain ability to localize painful stimulus• in absence of verbal communication, physicians may assess volitional activity by applying sternal rub• patients who reach toward sternum receive diagnosis of encephalopathic state (ie, not comatose)• brainstem reflexes—differentiate “dense” encephalopathy from coma• pupils correspond to upper and midbrain;• corneal function and “doll’s eyes” reflex correlate to middle brainstem• pons; respiration and cardiovascular function correlate to lower brainstem• mid-position fixed pupils—typically indicates late herniation compromising both sympathetic and parasympathetic nerves in

brainstem

Altered mental status• general examination—should focus on distinguishing delirium from alternative diagnosis• Look for tachycardia, fever, stiff neck, tremor, asterixis, or myoclonus (common accompaniments of delirium or encephalopathy)• patients with limited functioning may retain ability to track face or finger• horizontal nystagmus frequently indicates metabolic disorder• nystagmus in vertical plane typically indicates structural pathology (most often in posterior fossa requires immediate imaging)• measure sensory function and withdrawal on both sides of body (eg, with painful stimulus to nail beds)• facial response to painful stimulus may reveal asymmetry• motor examination—patients typically uncooperative• check limb movement against gravity• attempt to get patient walking or standing;• destructive processes in cerebellum (eg, hemorrhage) may selectively interfere with ability to sit or stand (no changes in limb coordination)• making patient sit and stand allows assessment for midline cerebellar findings• Cerebrospinal fluid (CSF) examination—underutilized• screens for infectious meningitis (acute and chronic) recommended with even slightest suspicion• indicated in unexplained delirium after imaging fails• assessment for xanthochromia critical• bleeding into subarachnoid space produces chemical meningitis and delirium• blood frequently not visible (depends on when hemorrhage occurred)• rule of halves— xanthochromia appears 0.5 day after hemorrhage, peaks at 0.5 wk, begins to disappear after 0.5 mo• meningitis— neoplastic meningitis typically accompanied by other systemic signs of advanced neoplasm• other types include chemical meningitis• patient may display evidence of vasculitis, sarcoidosis, or other uncommon disorders• HIV encephalopathy—causes impaired attention, forgetfulness, and white matter lesions• other sources of CNS involvement require exclusion• herpes simplex encephalitis—may present with only confusional state and abnormal behavior (due to temporal lobe involvement)• indicated by fever, headache, and focal findings; patients with abnormal CSF (pleocytosis and elevated protein in polymerase chain reaction)• typically receive acyclovir

Types of Dementia• Alzheimer disease—recent memory loss prevalent, but

attention span typically preserved in mild cases, patients recall forward digit spans of 6 to 7

• Vascular dementia—fairly common; occurs with extensive vascular disease and shows extensive vascular changes on neuroimaging

• frontotemporal dementias—produce changes in behavior and anxiety; patients typically perform well on mental status examinations but exhibit deeper cognitive changes

Driving safety• older individuals estimated to comprise 25% of drivers by 2030• responsible for 7% of accidents, but• 15% of traffic fatalities• mixed evidence associates mild cognitive impairment and mild dementia with increasedmcrash rates• dementia inevitably affects driving safety• Physicians must assess for increased safety risks• loss of driver’s license significant and affects quality of life (associated with poorer health and

depression)• several states make reporting mandatory; assessing driver safety—• document driver history• ask about recent accidents and tickets, getting lost, frequency of driving, and self-limiting behavior (eg,

driving only for specific purposes)• Objective second individual should be asked about driving safety (in private)• American Medical Association guide—assesses vision, motor function, and cognition; includes visual

acuity testing, rapid walking, and range of motion test (ie, ability to look over shoulder)• cognitive tests include trails B and clock draw• clock draw—patient asked to draw clock face on blank paper and illustrate time using both hemispheres

Driving Safely• trails tests—assess executive functioning

• Trails A involves connecting series of numbers in order

• trails B connects interspersed letters and numbers (high difficulty)

• American Academy of Neurology review (2000)— evidence-based review of Alzheimer disease and driving risk

• recommended patients with MMSE <20 not drive

• studies correlate scores <20 with worse driving ability

• Absolute cutoff score not defined

• MMSE scoring combined with results from clock draw and trails tests before making decision

• behind-the-wheel testing—gold standard; typically administered by driving rehabilitation specialist

• Usually not covered by insurance (costs $200)

• State mandatory reporting laws—physicians immune from litigation in these states

Increased supervision• independent activities of daily living• (IADL)—primary focus when assessing increased need for supervision• includes complex tasks (eg, shopping, paying bills, personal grooming, housekeeping)• financial activities typically impaired first• ask about ability to handle checkbook; • activities of daily living (ADLs)—include eating, dressing, toileting, and transferring;

safety of independent living—determined on case-by-case basis• need for assistance with 1 core ADLs typically necessitates 24-hr• supervision (not absolute)• physicians should ask family members about home accidents (eg, items left unattended

on stove) and wandering behavior• caregiving—informal care provided by family members and friends• Caregivers require multidisciplinary support, including health care• providers, social workers, home care workers, and clergy

Increased supervision• physicians frequently unaware of patients in caregiving role• study found 24% of patients who see family physicians were caregivers• associated with high incidence of depression (30%-60%) and anxiety (17%); caregivers rate personal

health status significantly lower than controls• overall mortality risk among elderly spousal caregivers expressing burden or stress rises by 63% (vs

controls)• 20% of caregivers forced to leave jobs• 31% of families reported losing all or most of savings due to patient’s illness• Assisting caregivers—recognition of patients in caregiving role critical• provide disease-based education• watch for common associated health effects (eg, depression)• offer links to community resources; provide referrals for bereavement counseling when necessary• community resources— include home care, senior centers, and adult day programs• day programs geared toward dementia and provide respite for caregivers• Alzheimer’s Association and Area Agency on Aging provide online locators of respite care• National registries for dementia link with local police departments to provide alerts for lost patients

Advanced stages

• all patients with dementia eventually have difficulty eating; pocketing food—behavior caused by apraxia

• recommend preparing caregivers for inevitable feeding issues and providing information about behavioral indicators

• helpful feeding techniques—

• increased feeding assistance

• stable and upright feeding position

• smaller portions (on plate and fork); softening food (eg, with gravy)

• feeding tubes—multiple studies show no benefit for advanced dementia

• associated with chronic diarrhea, dislodgment problems, discomfort, increased risk for aspiration pneumonia, and increased use of restraints

• no measurable increases in survival found

Cognitive impairment associated with normal

aging• Loss of memory for words and names

• slowed processing speed

• difficulty sustaining attention when faced with competing environmental stimuli

• no functional impairment

Mild cognitive impairment• memory impairment beyond that expected for person’s age• memory impairment increasing over last 6 to 12 mo• other cognitive functions generally unimpaired• daily function not significantly impaired• not dementia• subjective complaint not usually useful (real changes more apparent to others

than to self)• 80% of people with mild cognitive impairment already have emerging dementia

that will convert to frank dementia within 5 yr (usually Alzheimer disease [AD])• prediction of who will convert currently difficult, but in near future, biomarkers

may be available to accompany clinical assessment• study indicates high level of psychopathology (eg, anxiety, irritability,

depression, paranoia)

Clinical management• no treatments approved by Food and Drug

Administration (FDA)

• monitor alcohol use, medications (eg, analgesics, psychotropics, over-the counter drugs)

• provide prophylaxis for cardiovascular risk factors

• treat anxiety and affective disorders, but eschew benzodiazepines

Unapproved treatments• acetylcholinesterase inhibitors studied exhaustively• most results negative• some definitive studies of donepezil (Aricept) showed

positive effect• “but not enough to define practice”; • Discuss both known and unknown effects of

acetylcholinesterase inhibitors with patient and family• no other agents (eg, vitamins, memantine) adequately

tested or show evidence of benefit

Dementia• syndromal term that refers to loss of

cognitive function associated with impaired daily functioning,

• eventual marked change in emotions and temperament

• in late stages, with neurologic dysfunction

• of 50 to 100 causes of dementia, AD by far most common

Warning signs of early dementia

• difficulty with learning and retaining information, vocabulary, and orientation

• trouble with daily tasks

• changes that interfere with function

• behavior changes (eg, passivity, irritation, suspiciousness)

• concerns should trigger evaluation of cognition, function, and behavior

Barriers to early diagnosis of AD

• average time between appearance of initial symptoms and diagnosis of possible dementia 4 yr

• average time between diagnosis and initiation of therapy 2 yr

• shortness of visits and constraints

• on reimbursement most significant barriers

Differential diagnosis• includes AD

• vascular dementia

• Dementia with parkinsonian features

• Lewy body dementia

• and frontotemporal dementia

Alzheimer disease• insidious onset• relentless progression of cognitive dysfunction

(usually, but not always, memory)• with subsequent generalization to other domains• (eg, language, visuospatial function, executive

function, problem-solving, insight, sequencing of events, prioritizing)

• minimal psychopathology in early stage• no prominent neurologic abnormalities

Vascular dementia• risk factors same as those for stroke (eg,heart disease, arrhythmia,

congestive heart failure, hypertension, dyslipidemia, diabetes, smoking, family history of stroke)

• history of focal or nonfocal events

• Focal findings on examination

• supported by imaging

• Imaging reports of “white matter changes consistent with microvascular disease” not diagnostic

• such changes seen in 80% of normal older individuals; diagnosis difficult accounts for only 5% of patients with dementia

• look for pattern of stabilization, decline, stabilization, decline

Dementia with parkinsonian features• requires specialist to distinguish between AD with

parkinsonian features, Lewy body dementia, and Parkinson disease with dementia

• Lewy body dementia: indicated by slowly progressive, but peculiarly fluctuating course “like … chronic delirium”

• characterized by fluctuating cognitive impairment, atypical and nonprogressive parkinsonian features (with onset of dementia after that), and dysautonomia with unexplained falls

• hallmark—vivid psychopathology with formed hallucinations and/or microhallucinations

Frontotemporal dementia

• early but mild cognitive impairment

• hallmark—marked change in personality or language

Evaluation of possible dementia

• patient history

• Differential diagnosis (looking at cognition, function, and behavior)

• Mini-Mental State Examination (MMSE)

• category retrieval

• clock draw (patient asked to draw clock set to, eg, 11:10)

• complete blood count; imaging studies; many optional tests (eg, genetic testing

• Structural magnetic resonance imaging (sMRI)

• biomarkers in blood and urine

• functional positron emission tomography (fPET) expected to become routine in 5 yr

Impact of AD• cost of care—currently $120 billion/yr in

• United States

• by 2050, $1.2 trillion/yr

• physical and psychologic toll on caregivers

• high risk for major depression and medical morbidity associated solely with demands of providing care

Brain fitness strategies• epidemiologic studies suggest medications for other physical conditions may confer brain health or

protection against dementia (controversial; speaker does not recommend)• no evidence for benefit of nutriceuticals; stress reduction• depression highly correlated with cognitive dysfunction• pearl—if first onset of depression occurs late in life, patient has high likelihood of developing AD• physically active adults have lower risk for AD (requires equivalent of 40-min brisk walk 3

times/wk)• other lifestyle choices—avoid sports with potential for brain trauma• smoking cessation• moderate consumption of red wine (4-14 4-oz servings/wk) possibly beneficial• equivalent of Mediterranean diet healthiest diet (brightly colored fruits and vegetables; fish• olive oil• Dairy in moderation• minimize red meat and simple carbohydrates);• mental activity (must involve mental effort [“something stimulating that you don’t ordinarily do”])• Memory or other cognitive training techniques (benefit can be significant, but limited to specific

function addressed)

Things to Remember

• brain aging inevitable

• many age-related changes mitigated by healthy lifestyles

• memory-training techniques (eg, look, snap, connect technique)

Depression and Dementia• depression and dementia are syndromes, not etiologies• Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition (DSM-IV) • definition of dementia—impairment in memory and 1 other

domain of cognition• these must cause functional impairment• deficits not solely due to delirium• definition of major depressive syndrome• presence of 5 of 9 symptoms that cause functional impairment

unrelated to bipolar disorder• symptoms cannot be better accounted for by another condition

5 of the 9 following symptoms• 1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or

observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.

(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) fatigue or loss of energy nearly every day

(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Etiologies• dementia—include AD, cerebrovascular disease, Lewy

body disease, and other brain diseases (eg, HIV infection)• unknown whether depression causes dementia,• but depression often earliest symptom of AD• depression—include AD, cerebrovascular disease,

substance and prescribed medication use (eg, alcohol, interferon),

• genetic predisposition• reaction to psychosocial stressors

Relationship between depression and dementia

• Cognitive impairment can be feature of depressive episode, but does not always resolve with treatment of depression

• conversely, depression also common (50%) in dementia• recent meta-analysis showed depression approximately

doubles chance of having Alzheimer’s dementia• unknown whether depression is prodrome of or

independent risk factor for dementia (evidence exists for both)

Pseudodementia

• occurs when individual appears to be demented due to severity of depression

• in study of older patients, 70% converted to true dementia within 5 yr, even if cognitive impairment resolved with treatment of depression

Depression as risk factor• longer interval between diagnoses of

depression and AD associated with increased risk for development of AD

• on autopsy, more plaques and tangles seen in brains of patients with lifetime history of depression

Possible trajectories linking depression and dementia

• 1) depression results in no cognitive deficit, and cognition remains stable over time

• 2) some shrinking of hippocampus occurs in both depression and dementia

• perhaps resulting in mild cognitive impairment that remains stable over time

• 3) patient already has neuropathology of AD that may progress to mild cognitive impairment and later to AD

• 4) combination of AD neuropathology and cerebrovascular disease may cause frontal striatal damage, which leads to depression;

• 5) cerebrovascular disease in and of itself results in depression and vascular dementia

Frontotemporal dementia• initial symptoms can mimic those of depression

• overlapping symptoms include emotional blunting

• decline in personal hygiene

• Distractibility and impersistence, hyperorality

• dietary changes,

• weight changes,

• altered speech output

Evaluation• watch for red flags of dementia• obtain detailed history, including personality changes,

risk factors for dementia (eg, substance use, HIV infection)

• do thorough review of systems, including significant weight loss, urinary incontinence, unexplained falls, and history of stroke, seizure, or head injury with loss of consciousness

• perform complete physical and neurologic examinations

Mental status examination• include MMSE for evaluation of cognition in all patients• if red flags occur, consider more extensive evaluation• Modified MMSE: adds 4 new test items and more scoring

gradations to standard MMSE• Clock-drawing task: several available; provides

information that can indicate presence of cognitive impairment

• Montreal Cognitive Assessment (MoCA): takes about same time as MMSE, with some additions

• Available free at www.mocatest.org

Laboratory evaluation• complete blood count

• Electrolyte levels

• liver function tests

• thyroid-stimulating hormone level

• vitamin B12 and folate levels

• syphilis screen (either rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL])

• depending on circumstances, consider measures of inflammation (erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP])

• Autoimmune disease (rheumatoid factor [RF] or antinuclear antibody [ANA])

• HIV test

• Lyme disease test

• lumbar puncture,

• and/or electroencephalography

Neuroimaging• no hard-and-fast rule on whether to obtain

neuroimaging on patients with depression in mid to late life

• if red flags seen, consider computed tomography (CT) of head or MRI (preferred)

• if concern high for frontotemporal dementia, consider PET or single proton emission computed tomography (SPECT

• Medicare approved to distinguish Alzheimer dementia from frontotemporal dementia)

Misdiagnosis of delirium• delirium common in acute-care settings and may

present with depressive symptoms;• study found that of 67 consecutive patients

referred to psychiatry for evaluation of depression, • 28 delirious• common symptoms included low mood, feelings

of worthlessness, and frequent thoughts of death• Delirium initially considered in differential

diagnosis of referring physician in only 3 patients

Preventing dementia• potentially modifiable risk factors include• Smoking• high blood pressure in midlife• High body mass index in midlife• high cholesterol in midlife• Diabetes• unknown whethter controlling these risk factors prevents

dementia, but may help• Mediterranean diet (rich in polyunsaturated fats and

antioxidants) appears protective for heart disease and possibly for cognition

Preventing dementia• Key components of Mediterranean diet: ample fruits and

vegetables• healthy fats (eg, olive oil, canola oil)• Small portions of nuts• red wine in moderation (study suggests same effect with any

alcohol• lower quantity recommended for women than for men)• fish on regular basis• minimal red meat • Other cognitive protective factors: physical and mental exercise

Treatment• if unsure whether patient has depression,

dementia, or both

• treat for depression first and monitor for response

• in general, antidepressants have favorable risk/benefit profiles and are effective