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Internal Medicine 18: 75-year-old man with memory

problems
User: Saad Jalal
Email: s.jalal@saba.edu
Date: March 09, 2018 01:51 GMT/UTC

Learning Objectives

The student should be able to:

Describe typical changes in each organ system that occur as part of the normal aging process.
TPerform a functional status assessment of the geriatric patient.
Identify risk factors for falls in the elderly patient.
Discuss the components of Medicare (including who and what services are covered).
Recognize the presentation of each type of urinary incontinence.
Differentiate among the subtypes of dementia and their associated findings.
Propose labwork to perform to evaluate reversible causes of dementia.
Participate in discussing basic issues regarding advance directives with patient and his or her family.

Knowledge

Initial Approach to Evaluation of Memory Problems

1. Focused History
2. Cognitive Assessment
3. Functional Evaluation

You go to the exam room and introduce yourself to Mr. Caldwell. He responds, "Happy to meet you. This is my
daughter Kathy."

After you've greeted them both briefly, you begin asking Mr. Caldwell questions about his memory.

1. Focused History

How Aging Affects Organ Systems

Learn more about major changes that occur in each organ system with aging.

Organ System Changes with Aging Functional Implications

Increased pulse pressure (increased systolic pressure Increased pulse pressure


with stable diastolic pressure). usually not harmful.
Cardiovascular Other changes can lead to
Decreased arterial compliance.
increased propensity for
Decreased baroreceptor sensitivity. orthostatic hypotension

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Multiple medications, decreased physical activity, and May lead to frequent
Gastrointestinal concomitant illness can contribute to constipation, physician visits and use of
which is common, although not "normal" in elderly OTC medications, including
patients. laxatives.

Women

Women Decreased lubrication and


possible dyspareunia.
Atrophy of labia, vagina, uterus, ovaries.
Urinary incontinence.
Weakening of pelvic floor muscles, especially in
women who have given birth. Men

Men Urinary incontinence or


urgency, dribbling due to
Genitourinary Enlarged prostate (benign prostatic hypertrophy BPH.
(BPH)).
Both
Both
Decreased ability to retain
Decreased renal salt. retention/regulation salt can predispose patient
to orthostatic hypotension.
Decreased ADH secretion at night.
Increased nocturia.
Decline in renal function
Changes in medication
metabolism and excretion.

Stable weight/BMI does not


imply stable body
Increase in body fat with decrease in lean mass.
composition.
Musculoskeletal Increase in joint deformities.
Risk of osteoarthritis.
Decreased bone mineral density.
Risk of osteoporosis and
fractures.

Memory loss has no major


effects if a result of normal
aging.
Mild loss of short-term memory.
Decreased vibratory sense
Neurologic Mild decrease in vibratory sensation.
can predispose to loss of
Mild muscle atrophy. balance.

Muscle atrophy not usually


clinically perceptible.

Depression, while not a


Decreased mobility, increased dependence on others,
consequence of "normal"
Psychiatric and other life changes, while not "normal," can
aging, is common among
contribute to psychiatric illness.
older patients.

No major change in gas


Decreased chest wall compliance. exchange at rest or with
exertion.
Respiratory Decreased static recoil in lung.
Possible decreased ability
Decreased respiratory muscle strength. to compensate in setting of
acute illness.

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Decreased skin thickness. Increased susceptibility to
Skin bruising.
Decreased elasticity of skin.
Wrinkles.

Decreased innate immunity Greater morbidity with


Immune
Dysregulation of immune responses infections

2. Cognitive Assessment

Mini-Mental State Exam (MMSE)

1. Orientation: To time (year, season, date, day, month) and place (state, county, city or town, location)

"What is the date?"

2. Registration: Ability to retain and repeat the names of three given, common objects

"Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are ... APPLE
(pause). PENNY (pause). TABLE (pause). Now repeat those words back to me."

3. Attention and calculation: Ability to spell a word backward

"Please spell 'world' backward for me."

4. Recall: Ability to remember the three words named earlier in the test

"Can you please tell me the three words I asked you to repeat earlier?"

5. Language (receptive and expressive): Ability to verbally identify two common items, repeat a phrase, follow a
three-step command, read and follow simple instructions, write a sentence, and copy a drawing.

"What is this?" (Point to a pencil or pen.)

"Please read this and do what it says." (Show a card with "CLOSE YOUR EYES" written on it.)

Dementia

Epidemiology: Dementia is a disorder of the elderly; it is rare in people under 60 years of age.
Diagnosis: It can be diagnosed when two or more problems in brain function are seen. Language, memory,
perception, emotional behavior or personality and cognitive skills may all be affected by dementia.
Forgetfulness is the most common first sign.
Classification:

MMSE Score Severity of Dementia

20-24* Mild

12-20 Moderate

< 12 Severe

* MMSE scores can vary based on educational level and language skills. The cut-off value for the lower limit of
normal varies slightly between guidelines, the original recommendation was < 24. The test results should be
interpreted with caution in patients for whom English is a second language and in patients with less than a middle-
school level of education.

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Memory Loss Classification

Specific clinical symptoms can help categorize memory loss on a continuum as follows:

1. Mild memory loss associated with normal aging


2. Mild cognitive impairment which may be associated with early dementia
3. Dementia: the MMSE score may be useful to further define dementia as mild, moderate, or severe

Mild cognitive impairment

Symptoms: The difference between mild memory loss associated with normal aging and mild cognitive
impairment can be difficult to assess:

Mild Memory Loss due to


Mild Cognitive Impairment
Aging

Memory Mild deficit in short-term Slightly more significant memory impairments and difficulty
impairment memory with complex tasks

Impact on daily
None None
activities

Cognitive Normal scores on dementia Abnormal scores on MMSE and more comprehensive
assessment screening tests memory tests

Clinical course: Patients with mild cognitive impairment are at risk of progression to Alzheimer's or other
clinically significant dementia, but many patients will also return to normal memory and cognitive function
within a year.
Treatment: Currently, no therapies are known to prevent progression from mild cognitive impairment to
overt dementia.

3. Functional Assessment: Activities of Daily Living

Activities of daily living (ADLs) are divided into two subcategories: basic and instrumental (IADLs)

eating

bathing and toileting

Basic ambulating

dressing

maintaining personal hygiene

managing finances

managing transportation

preparing food
Instrumental
shopping

managing medications

housekeeping

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The patient's family members may be very helpful with this information.

ADLs and Early Dementia

Any of the ADLs can be affected by dementia.

However, more complex tasks such as balancing the checkbook and managing medications tend to be affected
earlier in the course of the disease. Deficits in these areas can be very difficult to identify at first, especially if the
patient lives alone and takes care of his or her own medications and finances.

As dementia progresses, simpler tasks and basic ADLs are often affected also.

Avoid Polypharmacy, Especially in Elderly

Review the medication list at every visit to ensure the most appropriate and least number of medications are being
prescribed.

Polypharmacy is a common problem among elderly patients and can result in avoidable adverse drug events.

Don't forget to include over-the-counter medications, supplements, and herbal remedies.

Common Issues to Assess in the Geriatric Patient: Fall Risk, Frailty, & Urinary Incontinence

Fall Risk

Learn more about recommendations for prevention of falls in older patients.

Screening for Hearing and Vision Deficits

While hearing and vision impairment may contribute to fall risk in the elderly, routine hearing and visual acuity
screening in the asymptomatic elderly person (age 50 years or older) is not currently recommended by the U.S.
Preventive Services Task Force.

Hearing: In 2012 it was concluded that current evidence is insufficient to assess the balance of benefits and harms
of screening for hearing loss in this population. (Grade I statement.)

Vision: In 2016 it was concluded that current evidence is insufficient to assess the balance of benefits and harms
of visual acuity screening in the improvement of outcomes in older adults. (Grade I statement.) This guideline is in
the process of being updated.

Fall Risk Factors

The more risk factors a patient accumulates, the more likely he or she is to fall.

The most well-described fall risk factors include:

History of falls
Gait impairment or use of an assistive device
Use of more than four prescription medications
Use of particular types of medications, including psychotropic medications (such as benzodiazepines,
antipsychotics and some antidepressants) and cardiac medications (especially diuretics, class I anti-
arrhythmics, and digoxin)
Cognitive impairment
Dementia

Other risk factors for falls include: dizziness and lightheadedness. In the elderly these are often multifactorial
and can be due to medications, orthostatic hypotension, and other causes. It is important to elicit this history,
because these problems can clearly predispose to a feeling of unsteadiness, falls, and even syncope.

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Frailty Criteria

Using the Physical Frailty Phenotype screening tool, if a patient meets 3 or more of the following criteria they are
considered frail. If they meet 1 or 2 of the criteria, they have pre-fraility.

Physical exhaustion by patient's report


Weakness measured by grip strength
Slowed walking speed (more than 7 seconds to walk 15 feet)
Low physical activity
Weight loss > 10 lbs in one year

It is important to ask elderly patients how much they eat because elderly patients are particularly at risk for
nutritional deficiencies for many reasons, including:

Medications may lead to decreased appetite.


Patients may have decreased access to food due to physical or financial constraints.
Depression, dementia, and other illnesses may decrease the drive to eat.
Patients also may limit their diets because they are trying to adhere to recommendations from health care
providers to avoid salt or other specific ingredients.
Many patients may not recognize or volunteer that they are at risk for nutritional deficiency.

Urinary Incontinence

Assessment

Make sure to assess for this during your interviews, because patients often will not volunteer this information.
Incontinence is a common problem in elderly patients and is often multifactorial.

A symptom diary can be very helpful in assessing the severity of incontinence. This involves tracking when
incontinence occurs and whether it seems to be triggered by specific times of day, beverages, medications, or
other circumstances.

Four types of incontinence:

Symptoms Cause Treatment

More common in women than in men. Small Pelvic muscle weakness Strengthening the
Stress urine leakage occurs with coughing, laughing, (i.e., from multiple muscles of the pelvic
Incontinence exercise or other maneuvers that increase intra- childbirths) or vaginal floor with Kegel
abdominal pressure. atrophy due to menopause. exercises.

Dysfunction of the detrusor


Presents as a sudden need to void, and patients Scheduled voiding
Urge muscle, either due to
describe "almost making it" to the bathroom. and other behavioral
Incontinence medications, stroke, or
They typically leak larger amounts of urine. exercises.
idiopathic overactivity.

Surgery or
Most common type of incontinence in men. Mechanical obstruction,
Overflow medications to
Presents with dribbling, hesitancy, and leakage often benign prostatic
Incontinence relieve the
of small volumes of urine. hypertrophy (BPH).
obstruction.

Treated with
This can occur in physically
environmental
Functional Occurs as result of a person's inability to get to a or mentally handicapped
modifications, such
Incontinence bathroom for any reason. patients, including patients
as bedside
with dementia.
commodes.

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Assessing Geriatric Syndromes on Physical Exam

Mini mental state exam.


Dementia
Complete neurological exam.

Joint exam for abnormalities.

Falls Cardiovascular exam, including examination for bruits and orthostatic vital signs.

Complete neurologic exam, especially focused on proprioception and strength.

Grip strength testing.


Frailty
Walking speed (normal is 15 feet in < 7 seconds).

Men: Prostate exam to assess for hypertrophy or nodules.


Urinary
incontinence Women: Complete pelvic exam to assess for atrophy, pelvic floor muscle weakness or
pelvic masses.

"Get Up and Go" Test

Patient rises from a chair without using arms, walks 10 feet, and returns to chair.
Normal elderly adult can complete this test within 16 seconds.
In addition to timing, observe for gait disturbance, need to use hands for balance and other abnormalities.

Dementia Subtypes

Review the different subtypes of dementia.

Alzheimer's dementia (AD) accounts for 75% of cases of dementia. It usually presents as gradual memory loss,
with specific difficulties in short-term memory and in learning new facts. Patients may have a family history of AD.
It is caused by amyloid plaques and neurofibrillary tangles in the brain, which can only be confirmed at autopsy.
However, the clinical diagnosis is up to 90% accurate. AD should be considered a terminal illness; average life
expectancy after diagnosis is about six years.

Lewy body dementia (LBD) is probably the second most common cause of dementia after Alzheimer's disease. It is
caused by the deposition of Lewy bodies in the nuclei of cerebral cortical neurons. LBD is characterized by
fluctuations in memory and cognition, visual hallucinations and parkinsonism. "Parkinsonism" refers to resting
tremor, bradykinesia, rigidity and postural instability that are typically associated with Parkinson's disease but can
be caused by other disorders.

Vascular dementia classically manifests as step-wise deterioration in memory. It is thought to be due to damage
from discrete vascular events, such as strokes or transient ischemic attacks (TIAs). Patients have other vascular
risk factors and evidence of past stroke on exam or imaging. Rather than causing dementia independently, it is
likely that strokes and TIAs exacerbate other causes of dementia in most cases.

Frontotemporal dementia (FTD) is characterized by dementia associated with behavior/personality changes and
language impairment. FTD is typically used to describe a group of disorders that have different causes, but all
types involve atrophy of the frontal and temporal lobes, which is thought to be the cause of symptoms.

Alcohol abuse is also a relatively common cause of dementia.

Allied Health Professionals


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Occupational therapist- health care practitioner who evaluates and treats a patient's daily living skills and
develops a treatment plan individualized for the patient. Training requirements include graduate degrees of
a Masters in Occupational Therapy or Doctorate of Occupational Therapy.
Physical therapist - health care practitioner who evaluates a patient's mobility and functional status and
develops a treatment plan individualized to the patient. Training requirements include graduate degrees in a
Masters in Physical Therapy or Doctorate of Physical Therapy.

Medicare Overview

More than 40 million Americans receive some form of Medicare coverage.

It is available to U.S. citizens and non-citizens of lawful alien status who are either:

Over the age 65


On Social Security Income (SSI) or Railroad Retirement disability for > 24 months
On chronic dialysis or who have had a kidney transplant

Medicare Part A includes hospital insurance, which includes inpatient hospital care, skilled nursing facility care,
hospice care, and some home health care. Most patients get this automatically at 65 years of age and do not pay a
premium. It is funded by an employer-based tax.

Medicare Part B is supplementary medical insurance that pays for physician fees and services, outpatient care,
some preventive services and some costs not covered by Part A. Patients must pay a monthly charge for Part B.
Since January 1, 2011, Medicare Part B covers a one-time "Welcome to Medicare" preventive exam and yearly
wellness visits.

Medicare Part C (Medicare Advantage plans) refers to private programs approved by Medicare that allow patients
to enroll in a health maintenance organization (HMO), preferred provider organization (PPO) or private fee-for-
service plan. These plans receive payments to provide Medicare-covered benefits, including hospital and physician
services as well as prescription drug benefits. There is an out-of-pocket expense for the insured and, depending
on the type of plan, they may provide more coverage than what is provided by "straight" Medicare.

Medicare Part D provides an outpatient prescription drug benefit, delivered through private plans that contract
with Medicare. The plans are required to provide a "standard" benefit package and may provide enhanced
benefits. Patients with modest income may be eligible for additional assistance with premiums and cost-sharing.
Medicare Part D does not cover vitamins or supplements. Many intravenous medications, especially those
administered in the clinic, are covered under Medicare Part B.

The Medicare website provides a tool to help patients select a plan available for them.

It's important to note what Medicare parts A, B, C and D do NOT cover:

Routine vision care and eyeglasses


Hearing evaluation and hearing aids
Dental care and dentures
Long-term care

Medigap plans (Medicare supplements) are sold by private insurance plans and help cover Medicare's cost-
sharing requirements and fill gaps in the benefit package.

Medications for Dementia

Cholinesterase inhibitors (ex: donepezil and galantamine)

Indications: Used for patients with dementia of any severity - mild, moderate, or severe
Effectiveness: As many as half of patients don't have a noticeable improvement with these medications,
although a small subset may have a significant improvement
Common side effects: Nausea, vomiting, and diarrhea, but these usually get better if people keep taking the
medications

Memantine

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Indications: Moderate or severe dementia.

These medications all cost more than $100 per month if paid for out of pocket.

Management

Reducing Fall Risk

Adjust the number and type of medications . The risks and benefits of any medication should be
reviewed and nonpharmacologic alternatives considered.
Educate patients about cognitive impairment as a risk factor for falls.
Vitamin D supplementation has been shown to reduce risk from falling and may even prevent falls in
community dwelling elderly patients.
Address home hazards, especially for patients who have fallen in the past. This includes removing
slippery rugs, improving lighting and adding bars for stabilization in the bathroom.
Physical therapy is beneficial for pain related to osteoarthritis and may help improve strength and balance.

Medicare Coverage of Home Hazard Assessment And Physical Therapy

Patients who are homebound, (do not have a car or access to public transportation), and are on Medicare will
recieve coverage for home physical therapy and home hazard-assessment and modification. Other patients may
need to come to the office to receive physical therapy. If patients do not have insurance that covers home-hazard
modification, physicians or other clinic staff can teach patients and give them printed educational materials.

Medication Side Effects in the Elderly

All medications can have unwanted side effects, but elderly patients are at higher risk for many reasons.

1. Elderly patients are often on multiple medications that interact.


2. With aging, there are physiologic changes affecting pharmacokinetics and pharmacodynamics.

Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications.
Drug clearance may be decreased by an age-associated decline in renal function.
As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and
patients may require lower doses of drugs.

It's important to consider all of these factors before prescribing a medication to an elderly patient. In particular,
reviewing the appropriateness and indications for opioids, anxiolytics, and any medications with anticholinergic
properties should be done at each visit. There is a list of high-risk medications in elderly patients (Beers Criteria)
that is available for clinicians.

Dementia - Safety & End-Of-Life Planning

Early in the course of dementia, it is important for physicians to help patients and families keep the patient safe in
the present while they plan for the future. Many patients with early dementia have difficulty with IADLs, such as
managing finances and driving, so discussion of how to manage these problems is warranted.

1. Estate and end-of-life care planning

Patients should be encouraged to appoint a durable power of attorney (DPOA) for health care. A DPOA for health
care is usually a trusted family member or friend who will make healthcare-related decisions for the patient when
he/she is no longer able to do so. The patient should also be encouraged to complete a living will, which specifies
what types of medical interventions he would want at the end of life or if he is unable to speak for himself. It is
important to help patients with early dementia make these decisions while they are still able to participate in the
decision-making process, because as memory deteriorates, patients lose capacity for independent decision-
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making.

2. Driving safety

Physicians should discuss driving safety with any patient who has an impairment in memory or vision as well as for
someone who has seizures or other episodes of loss of consciousness that may impair his/her ability to drive.
States vary in their laws about physicians' obligation to report potentially impaired drivers to the Department of
Motor Vehicles, but it is always reasonable to advise patients not to drive if you think that is the safest course. The
American Medical Association provides more information on state reporting laws for physicians.

3. "Safe return" bracelet

A "safe return" bracelet is available through the Alzheimer's Association and may be beneficial for patients who are
at risk for getting lost.

Studies

Evaluating For Reversible Causes Of Dementia

Experts disagree about the lab tests necessary to evaluate for reversible causes of dementia.

The American Academy of Neurology (AAN) and the Canadian Consensus Conference on Dementia (CCCD)
agree that all patients with a new diagnosis of dementia should be:

Evaluated for depression


Checked for hyper- or hypothyroidism and vitamin B12 deficiency

The CCCD also recommends evaluation of electrolytes in patients with dementia.

TSH

Hypothyroidism is more common than hyperthyroidism as a cause for dementia because it causes a general
cognitive slowing. However, hyperthyroidism can present atypically in elderly patients who can seem slowed and
may not demonstrate "typical" signs, such as increased energy.

Vitamin B12

While both folate and B12 deficiencies can cause macrocytic anemia, only B12 deficiency can cause posterior
column disease and dementia. Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation and
would not necessarily be elevated in dementia.

Both the AAN and CCCD recommend checking a rapid plasma reagin (RPR) to evaluate for neurosyphilis, but
only if the patient has risk factors.

Electrolytes

Hypercalcemia can cause confusion, psychiatric disturbances, and memory loss, particularly in older patients.
Hypocalcemia is not known to cause these problems chronically, although acute hypocalcemia could cause mental
status changes. Mild hyponatremia can cause mental status changes in elderly adults. Other electrolyte
abnormalities are typically unrelated to memory problems or dementia.

Imaging

The question of whether to obtain imaging, such as a head CT or MRI in the workup of dementia is also
controversial. The AAN recommends a non-contrast head CT or MRI as part of the routine workup. The CCCD
recommends imaging only in the setting of "red flags" such as dementia in a person younger than 60, rapidly
progressive dementia, focal neurologic deficits, gait disturbance, new urinary incontinence, recent head trauma,
use of anticoagulants or history of malignancy.

If a red flag is present, brain imaging can help to diagnose other etiologies such as chronic subdural hematoma,
intracranial mass, including malignancy, normal pressure hydrocephalus, and other less common etiologies.

Thiamine deficiency

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In patients with a history of alcohol abuse, or who are not receiving adequate nutrition, it is also reasonable to
consider thiamine deficiency. Laboratory assessment of thiamine deficiency is somewhat complicated, so
treatment is usually empiric. In the U.S., thiamine deficiency is most commonly seen in alcoholic patients and
typically causes Wernicke-Korsakoff syndrome. Wernicke's syndrome is characterized by nystagmus or other
ocular abnormalities, gait abnormalities, and memory loss with other mental status changes. It develops over days.
Korsakoff syndrome includes retrograde and antegrade amnesia. These syndromes are part of a spectrum of
disorders. Alcoholic patients with thiamine deficiency also often develop peripheral neuropathy.

References

Screening for Hearing Loss in Older Adults, Topic Page. U.S. Preventive Services Task Force.
http://www.uspreventiveservicestaskforce.org/uspstf/uspshear.htm. Accessed May 4, 2017.

Screening for Impaired Visual Acuity in Older Adults , Topic Page. U.S. Preventive Services Task Force.
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/impaired-visual-acuity-in-older-
adults-screening?ds=1&s=visi. Accessed May 4, 2017.

​Raina P, et al. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a
clinical practice guideline. Ann Intern Med. 2008 Mar 4;148(5):379-97.

McShane R, et al. Memantine for dementia. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003154.

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