Laurence Lacoste Ph. D, Paris, FranceLaurence Lacoste Ph. D, Paris, France

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Introduction : Why ?Introduction : Why ?

Population’s Ageing is a Public Health issue and dementia Population’s Ageing is a Public Health issue and dementia for the Elderly a realityfor the Elderly a reality

Examination of cognitive disorders for the Elderly are Examination of cognitive disorders for the Elderly are done to help them to have the better ageing possible in done to help them to have the better ageing possible in spite of Alzheimer disease and related disorders, spite of Alzheimer disease and related disorders, Parkinson disease, psychiatric and/or addictive disorders, Parkinson disease, psychiatric and/or addictive disorders, and also to reassure people with no cognitive troubles to and also to reassure people with no cognitive troubles to prevent pathological ageing.prevent pathological ageing.

But the way to do it is what is the most important, taking But the way to do it is what is the most important, taking care of each subject in his own history.care of each subject in his own history.

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Who is requesting it ? Who is requesting it ?

It can be :It can be : Either a subject who comes by himselfEither a subject who comes by himself Or a family which is in difficulties with an Or a family which is in difficulties with an old relativeold relative Or a general practitioner or a hospital MDOr a general practitioner or a hospital MD Or a care provider in institution for the Or a care provider in institution for the elderlyelderly

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How is it done ?How is it done ?

With first interview using MMSE or MOCA With first interview using MMSE or MOCA tests with a Doctor qualified in tests with a Doctor qualified in Gerontology and Neuropsychology who Gerontology and Neuropsychology who works with a Neuropsychologist to have an works with a Neuropsychologist to have an idea of the complaint.idea of the complaint.

And history of the patient (Medical and And history of the patient (Medical and Psychological with questions of the Psychological with questions of the person’s biography)person’s biography)

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Which data are required ?Which data are required ?

Patients and care givers ’ self-questionnaires Patients and care givers ’ self-questionnaires if someone of the family is present if someone of the family is present

Imaging (MRI scan, functional MRI)Imaging (MRI scan, functional MRI) Cerebrospinal fluid markersCerebrospinal fluid markers Neuropsychology assessment : memory, Neuropsychology assessment : memory,

language, executives functions, troubles of language, executives functions, troubles of behaviour…behaviour…

Depression state using DSM V or ICD 10’s Depression state using DSM V or ICD 10’s criteriacriteria

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Specificity of consultations in Specificity of consultations in institutionsinstitutions

Firstly, it’s necessary to provide a Firstly, it’s necessary to provide a preliminary training of nursespreliminary training of nurses

The question is : why is the assessment The question is : why is the assessment required ?required ? Then we process to clinical interviews of Then we process to clinical interviews of the elderly persons and to an assessment the elderly persons and to an assessment using simple standardized tests using simple standardized tests Liaison with the main care provider*Liaison with the main care provider*

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Evaluations for Research in Evaluations for Research in Epidemiology Epidemiology

First, we need the opinion of practitioners First, we need the opinion of practitioners to eliminate contraindicationsto eliminate contraindications Then, we write a letter to inform the elderly Then, we write a letter to inform the elderly person taking part in the research and his person taking part in the research and his informant explaining why the study is carried informant explaining why the study is carried out.out.Finally, a cognitive assessment is done Finally, a cognitive assessment is done that can be linked to factors of risk and that can be linked to factors of risk and protection.protection.

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Decisional tree with MMSEDecisional tree with MMSE

If MMSE > 17 : complete battery If MMSE > 17 : complete battery of testsof tests

If MMSE is between 10 and 17 : If MMSE is between 10 and 17 : simple standardized tests simple standardized tests

If MMSE < 10 : no more tests If MMSE < 10 : no more tests (case of severe Dementia) (case of severe Dementia)

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Management goals for patients Management goals for patients with cognitive complaint*with cognitive complaint*

For all patients with cognitive For all patients with cognitive complaint, we have 3 mains goalscomplaint, we have 3 mains goals : :

1/ Maintening function and 1/ Maintening function and independenceindependence

2/ Preventing further cognitive decline2/ Preventing further cognitive decline

3/ Ensuring quality of life3/ Ensuring quality of life

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Subjective cognitive impairmentSubjective cognitive impairment

For this patients, the goals are :For this patients, the goals are :- ReassuranceReassurance- Optimizing management of comorbiditiesOptimizing management of comorbidities- Promoting a healthy lifestylePromoting a healthy lifestyle

However, they should be monitored carefully However, they should be monitored carefully for any signs of progression predictive of for any signs of progression predictive of future MCI.future MCI.

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Mild Cognitive Impairment (MCI) Mild Cognitive Impairment (MCI) (1)(1)

An important goal to achieve is An important goal to achieve is accepting the uncertainty surrounding accepting the uncertainty surrounding this diagnosis given the possibility of this diagnosis given the possibility of either progression, or stability, or either progression, or stability, or even improvement.even improvement.

Other goals to consider as well are :Other goals to consider as well are :

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Mild Cognitive Impairment (MCI) Mild Cognitive Impairment (MCI) (2)(2)

Optimizing management of comorbidities Optimizing management of comorbidities and especially treat vascular risk factorsand especially treat vascular risk factors

Minimizing medications affecting cognitive Minimizing medications affecting cognitive functionsfunctions

Promoting physical and mental healthPromoting physical and mental health Building a partenership with patient and Building a partenership with patient and

caregiver to establish a safety net and caregiver to establish a safety net and advance care planning.advance care planning.

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DementiaDementia

Caregiver support becomes increasingly Caregiver support becomes increasingly important as disease progresses and important as disease progresses and dependance increasesdependance increases

Vigilance and early intervention for Vigilance and early intervention for neuropsychiatric symptoms, sleep neuropsychiatric symptoms, sleep disturbance and incontinence…disturbance and incontinence…

Meeting patient’s goals for end-of-life Meeting patient’s goals for end-of-life care.care.

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*Nonpharmacologic Strategies*Nonpharmacologic Strategies

To date, no nonpharmacologic To date, no nonpharmacologic interventions have been shown to prevent interventions have been shown to prevent further decline in patients with either further decline in patients with either subjective cognitive impairment or MCI.subjective cognitive impairment or MCI.

On the other hand, numerous On the other hand, numerous nonpharmacologic interventions targeting nonpharmacologic interventions targeting patients with dementia, their caregiver or patients with dementia, their caregiver or the patient-caregiver dyad have been the patient-caregiver dyad have been investigated.investigated.

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Physical exercisesPhysical exercises

Possible mechanisms by which exercise Possible mechanisms by which exercise may improve or maintain cognitive function may improve or maintain cognitive function include :include :

Improving central adiposity and insulin Improving central adiposity and insulin resistanceresistance

Decreasing oxydative stressDecreasing oxydative stress Improving vascular functionImproving vascular function Increasing cerebral blood flowIncreasing cerebral blood flow

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Cognitive stimulationCognitive stimulation

Cognitive stimulation uses enjoyable Cognitive stimulation uses enjoyable activities to engage memory and activities to engage memory and concentration in a social setting.concentration in a social setting.

Two of the larger studies using this Two of the larger studies using this approach reported improvements in approach reported improvements in cognitive functions and quality of life, but cognitive functions and quality of life, but not in functional status, mood, or not in functional status, mood, or behavioral symptoms.behavioral symptoms.

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Cognitive trainingCognitive training

To date « brain training » programs have To date « brain training » programs have not provided strong evidence of benefit on not provided strong evidence of benefit on cognition, function or mood in patients with cognition, function or mood in patients with mild to moderate dementia.mild to moderate dementia.

Patients and caregivers should be Patients and caregivers should be cautioned against expensive programs cautioned against expensive programs that promise to prevent or reverse that promise to prevent or reverse dementia.dementia.

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Cognitive reframing for carersCognitive reframing for carers

It’s a component of Cognitive Behavioral It’s a component of Cognitive Behavioral Therapy (CBT)Therapy (CBT)

It focuses on caregiver’s maladaptative, It focuses on caregiver’s maladaptative, self defeating or distressing cognition self defeating or distressing cognition about their relative behaviorabout their relative behavior

It focuses also on their own performance It focuses also on their own performance in the caring rolein the caring role

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ConclusionConclusion

Neuropsychological evaluation is very useful Neuropsychological evaluation is very useful to help doing diagnosis as precisely as to help doing diagnosis as precisely as possible in Alzheimer disease and related possible in Alzheimer disease and related disordersdisordersBut to date, there are too few studies to But to date, there are too few studies to show how to treat patients with MCI diagnosis show how to treat patients with MCI diagnosis and subjective cognitive impairment. So, and subjective cognitive impairment. So, preventing Alzheimer disease and related preventing Alzheimer disease and related disorders is almost impossible.disorders is almost impossible.

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AcknowledgementsAcknowledgements

F. Petitjean, F. Petitjean, Psychiatrist, Psychiatrist, Psychiatric Hospital Psychiatric Hospital Center of Ainay-Le-Center of Ainay-Le-Château, France.Château, France.

C. TrivalleC. Trivalle

GeriatricianGeriatrician

Paul Brousse Paul Brousse Hospital, South ParisHospital, South Paris

2020

THANK YOU VERY THANK YOU VERY MUCH FOR YOUR MUCH FOR YOUR

ATTENTION…ATTENTION…

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