UW ECHO in Geriatrics09/09/2021 | Mentation: Assessing and Addressing Dementia & Depression.

Emma Bjore, MD; Mary Kerber, MD; Maya Pignatore, PhD

wycoa@uwyo.edu www.uwyo.edu/wycoa

Outline

• Objectives

• IHI 4Ms-Mentation

• Assessing Dementia

• Assessing Depression

• Pseudodementia

• Case Study

• Addressing Dementia

• Addressing Depression

• Closing Remarks

Objectives

• Review the Institute of Healthcare Improvement’s 4Ms initiative with a focus on Mentation

• Discuss clinical tools to assess both dementia and depression with special consideration of a pseudodementia process

• Learn how to approach addressing dementia and depression

IHI 4Ms-Mentation

Assessing Dementia

• When first assessing for dementia, start with a conversation

• Do you or your loved ones have concerns about your memory?

• Any new changes in your memory?

• Do you have any safety concerns in relationship to your memory?

• Are you interested in memory testing?

Assessing Dementia

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Assessing Dementia

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Assessing Dementia

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BIMS score Interpretation

0 - 7 Severe cognitive impact

8 - 12 Moderate impairment

13 – 15 Intact cognitive response

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The Blessed Orientation-Memory-Concentration (BOMC) Test

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The BOMC is a screening tool allowing family members, caregivers, or health care professionals to check for suspected dementia in an elderly. Dementia is described as the progressive loss of memory and at least of one other cognitive area, such as language or behavior.

❖ It’s a bit different from other assessments, in that errors are scored rather than points earned. High score = more problems.

https://www.dysmd.com/staticContent/quizzes/en/TheBlessedOrientation.htm

Assessing Depression

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Assessing Depression

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Geriatric Depression Scale 15

Pseudodementia

• Pseudodementia is a fancy way of saying that other causes are contributing to the clinical presentation of cognitive impairment or memory problems. Depression, anxiety, stroke, pain, medical issues such as thyroid abnormalities or sleeplessness can often masquerade and be attributed to either "normal aging", or dementia. To most nontrained medical people, dementia is a horrific and end-stage result of memory impairment. To a clinician, the word dementia refers to full spectrum of cognitive concerns ranging from early to mild all the way to severe.

• Forgetfulness is probably the most common chief complaint of the patient or patient's family. Learning and retaining new information, handling complex tasks, reasoning, spatial abilities especially getting lost, word finding difficulties and other language problems and behavior changes are other aspects of dementia so we need to look for other causes.

• Depression and apathy probably the most common causes of pseudodementia. Behavioral and nonpharmacologic strategies are preferred before most medication. However, medical causes need to be addressed promptly. The American Academy of neurology recommends screening for B12 deficiency, CBC, TSH, or other pertinent laboratories. Full pharmacologic screening of what the patient is taking, prescribed and over-the-counter, nutritional and hydration assessment as well as evaluation of pain and sleep are recommended.

Case Study Background

• New client to primary care team as of 2021.

• 82 y.o. Caucasian, male client. 12 years education. Married with 3 kids. One adult child lives with client and his wife. No history of MH problems.

• Worked as a civil servant, hobby in carpentry/handyman work. Built/remodeled much of his own house. Retired 15 yrs. ago, around the same time that he developed total blindness.

• Doesn’t like getting blood drawn.

• Health Problems: type 2 diabetes mellitus, peripheral neuropathy, glaucoma, hypertension, eye enucleation, cataract, central retinal vein occlusion, rubeosis iridis

Case Study Background

• Family report he has always had a pleasant disposition, but in the last year has appeared more depressed.

• Client denies depression, though also states that he “doesn’t want to go on” and would be “better off dead.”

• Client spends all day in his room, mostly laying in bed. • Eats in room, uses bedside commode. Listens to TV and radio throughout the day. • Sleeps at night; unclear how much he sleeps during the day. • Uninterested in activities, aside from visiting with family members.

• 10 lb. weight loss in last year.

• Family reports client uses lifestyle changes to manage his diabetes. • A1C at time of admission: 14.3. • Prior A1C from 2018 was 7.3

Case Study Key Points

June 2021-

• PHQ-9: 26- severe depression

• BOMC: 26 suggests significant dementia• (Score of 10 or higher suggests dementia)

• Started mirtazapine for depression

July 2021

• MoCA: 6 (≤ 26 suggests cognitive impairment)

• PHQ-9: 6- mild depression

• GDS: 3- does not suggest depression

• Still making statements of “hoping to die soon,” “would be better off to wake up dead.”

Addressing Dementia - Nonpharmacologic

Set-up routines

01Set-up reminders to help a person stay oriented (reminders of date, location, people)

02Keep individual engaged and active; provide activities appropriate for their cognitive level(sensory disabilities as consideration)

03

Addressing Dementia - Pharmacologic

• Cholinesterase inhibitors are Aricept, Razadyne or Exelon. These can increase the amount of normal chemicals in the brain. They do not actually "cure" memory problems, but some people feel that these medications can slow down the course of memory loss.

• NMDA receptor antagonists such as Namenda can also improve the brain chemistry and slow down the progression of memory loss.

• Antidepression or antianxiety medications may help the person feel less depressed and anxious. This can result in more self-confidence, and possibly even improve sleep or energy.

• Incontinence medications are surprisingly useful if the patient is self-conscious about incontinence

• Anticonvulsant or antipsychotic medications should be used cautiously to control delusions which are false believes, hallucinations such as hearing or seeing things that are not there, or violent behaviors. They can be cautiously tried if the person is easily angered, restless, or violent.

Addressing Depression - Nonpharmacologic

• Behavioral Activation - planning pleasant activities, helps individual identify activities that contribute to positive mood

• Cognitive-Behavioral Therapy - helps individual identify and change negative thought patterns. Helps individual find activities that contribute to positive mood states.

• Problem-Solving Therapy - empowers individual to consider new ways to approach problems in their life

• Interpersonal Psychotherapy for Depression - addresses role loss, relationship changes that contribute to development of depression, interpersonal skills deficits

Addressing Depression-Nonpharmacologic

Address causes and triggers which can include treatable conditions such as pain or infection. Identify possible need such as hunger, thirst, fatigue, and poor sleeping habits, environmental stressors including excessive noise, overstimulation, heat or cold. Investigate sensory deficit such as poor vision or hearing loss. Provide opportunities for "purposeful activities”, such as music, art, conversation, pet therapy, aromatherapy. Physical exercise may include walking, chair) yoga, tai chi, or stretching. Focus on socialization and spiritual or religious activities if this is a patient preference. Structure and routine are also important.

Closing Remarks

• Addressing the Mentation M is important to providing the best care for older adults

• Using clinical tools can help identify and monitor dementia and depression

• Remembering to think about pseudodementia in evaluation is helpful

• Having an understanding of clinical and community resources to address dementia and depression is essential

References

• Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual elderly Int J Geriatric Psychiatry 2000; 15(11):1021.

• Kroenke, K., Spitzer, R.L., Williams, J.B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care, 41:1284–92

• MoCA - Cognitive Assessment (mocatest.org)

• Saliba D, Buchanan J, Edelen MO, Streim J, Ouslander J, Berlowitz D, Chodosh J. MDS 3.0: brief interview for mental status. J Am Med Dir Assoc. 2012; 13(7):611-7.

• Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986 June;5(1/2):165-173.

• SH Tariq, N Tumosa, JT Chibnall, HM Perry III, and JE Morley. The Saint Louis University Mental Status (SLUMS) Examination for detecting mild cognitive impairment and dementia is more sensitive than the MiniMental Status Examination (MMSE) - A pilot study. Am J Geriatr Psych 14:900-10, 2006

Questions

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wycoa@uwyo.edu | (307) 766–2829

www.uwyo.edu/wycoa