Memory Loss And Dementia: Issues in Early Detection & Intervention Adam Rochmes , Ph.D.

1. Alzheimer’s Association of Northern CA & NV 251 Lafayette Circle, Suite 250 Lafayette, CA 94549 adam.rochmes@alznorcal.org Memory Loss And Dementia: Issues inEarly Detection & InterventionAdam Rochmes, Ph.D.

2. To become familiar with: • Detection pitfalls • Advantages of early detection and intervention • Warning signs of dementia • A quick screening tool • Referral and follow-up • Dementia’s family impact • Family and patient resources Objectives

3. Is a chronic brain illness that affects cognition, behavior, and function. • Is frequently misdiagnosed when mild. • Is frequently misdiagnosed in the absence of medical, educational, occupational history. • Cannot be treated effectively without including family and/or caregivers. Dementia:

4. Dementia is cognitive decline that: • Occurred from a higher level of function. • Is severe enough to interfere with usual activities and daily life. • Affects more than one of the following four core cognitive domains: • Recent memory - ability to learn and recall new information. • Language - either comprehension or expression. • Visuospatial ability — comprehension and effective manipulation of nonverbal, graphic or geographic information. • Executive function — ability to plan, perform abstract reasoning, solve problems, focus despite distractions and shift focus when appropriate. Diagnostic Guidelines

5. Memory problems go undiagnosed as a result of: • Family and social support for ignoring problems. • Pt avoidance of the subject (or not remembering to mention memory problems to physician). • Physician reluctance to ask. (There’s little time, it’s a can of worms, the patient is difficult to communicate with.) • Pts in early stage looking normal. • Misdiagnosis as depression or “normal aging.” Diagnostic Pitfalls

6. A struggle to maintain normalcy—denying, minimizing and psychologizing. • Anxiety and confusion. • Family disruption, alienation, conflict. • Financial mismanagement. • Poor management of concurrent conditions. • More difficulty gaining acknowledgment. Consequences of Delayed Diagnosis

7. Differential diagnosis enables proper care. • Diagnosis mitigates social burden. • The PWD can participate in treatment and care planning, benefit from existing treatments and clinical trials. • Family members can receive support and education in caregiving. Advantages Of Early Diagnosis

8. Memory changes which disrupt daily life. Challenges in planning and solving problems. Difficulty completing familiar tasks at home, at work, or at leisure. Confusion with time or place. Trouble understanding visual images and spatial relationships New problems with words in speaking or writing. Misplacing things and losing the ability to retrace steps. Decreased or poor judgment. Withdrawal from work or social activities. Changes in mood or personality. Early Warning Signs

9. MMSE • Mini-Cog • Talking with family members Brief Screening Tools

10. Source: Adapted from Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11):1021–1027, and Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr. The Mini-Cog assessment instrument combines an uncued 3-item recall test with a clock-drawing test (CDT) that serves as a recall distractor. The Mini-Cog can be administered in about 3 min, requires no special equipment, and is relatively uninfluenced by level of education or language differences. (The Mini-Cog may be influenced by cultural factors.) Mini-Cog

11. Make sure you have the patient's attention. Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat the words back to you (to be sure the patient heard them). Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time (11:10 and 8:20 are most commonly used and more sensitive than some others). These instructions can be repeated, but no additional instructions should be given. If the patient cannot complete the CDT in 3 min, or less, move on to the next step. Ask the patient to repeat the 3 previously presented words. Administering the Mini-Cog

12. Give 1 point for each recalled word after the CDT distractor. Score 0–3 for recall. • Give 2 points for a normal CDT, and 0 points for an abnormal CDT. • The CDT is considered normal if all numbers are depicted, once each, in the correct sequence and position, and the hands readably display the requested time. Add the recall and CDT scores together to get the Mini-Cog Score: • 0–2 indicates positive screen for dementia. • 3–5 indicates negative screen for dementia. Scoring the Mini-Cog

13. THe Mini-Cog Scoring Algorhythm

14. Screening isn’t sufficient. • Some dementias are reversible if proper treatment is initiated early enough. • Different treatment may be indicated for irreversible dementias with different etiologies, e.g. AD/LBD. • Full diagnostic workup is essential. For recommended guidelines, including the diagnostic workup, go to: www.alz.org/professionals_and_researchers_14902.asp Diagnostic Workup

15. This is when the Alzheimer’s Association and other community resources come in. Families need: • Time to absorb the diagnosis. • Opportunity to vent feelings. • Thorough explanation of the expected course and the treatment options. • Knowledge that they’re not alone. • Connection to community resources for ongoing follow-up and support. Follow-up

16. Persons with dementia need to: • Maintain their dignity and sense of self. • Engage in relationships. • Participate in decisions to the extent of their ability. • Function at their highest possible level. • Be active and mentally stimulated. Helping PWDs Live with Dementia

17. Family caregivers need: • Education about the disease. • Lessons in how to speak “Alzheimer’s.” • Legal and financial advice. • Care planning and coordination. • Counseling/psychotherapy and social support. • Home safety adaptation. • Respite. Helping Families Live with Dementia

18. Support groups. • Activity programs. • Adult day care programs. • In-home care services. • Case management services. • Placement services. • Residential care facilities. Care Receiver Resources

19. Alzheimer’s Association • Family Caregiver Alliance • CCC Adult Agency on Aging • Association for Frontal-Temporal Dementias • Lewy Body Dementia Association Community/National Organizations

20. Information & Referral — 24/7 Helpline (800) 272-3900 • Counseling—post-diagnosis, family crisis, and care consultation • Care planning • Early stage and caregiver support groups • Education • MedicAlert®+Safe Return Alzheimer’s Association Programs