Cognitive Impairment Suspected

Cognitive changes, although important, do not define dementia, any of the following symptoms may indicate the need to evaluate for dementia.

Cognitive Changes	New forgetfulness, difficulty finding a word, difficulty following the flow of a conversation or understanding written text.
Impairments to Activities of Daily Living	Difficulty following recipes, difficulty managing bills & finances, neglecting self-care.
Changes to Personality	Quick to anger, easily frustrated, social withdrawal or inappropriate flirtation, excessive friendliness.
Psychological Changes	Depression, anxiety, apathy, insomnia, paranoia
Behavioural Changes	Agitation, wandering, restlessness

 

History

Patient History

History is key to the diagnosis and may require several consultations to fully gather.

Leave questions open ended initially     

• In what way… what were you like before…
• Give me examples…
• When did it start…
• How has it progressed…
• How is your mood…

 

Questions could focus on whether the patient is experiencing any of the following:

Memory loss	While its normal to occasionally forget appointments, names or telephone numbers, those with dementia will forget such things more often and not remember them later
Difficulty performing familiar tasks	For example, steps for preparing a meal, using a household appliance, participating in a lifelong hobby
Problems with language	Forgets simple words or substitutes unusual words, making his or her speech or writing hard to understand.
Disorientation to time and place	For example, getting lost on their own street, forgetting where they are and how they got there, and not knowing how to get back home.
Poor or decreased judgment.	Individuals with dementia often show poor judgment about money.
Problems with abstract thinking	For example, difficulty balancing a check-book
Misplacing things	Such as putting things in unusual places: an iron in the freezer or a watch in the sugar bowl.
Changes in mood or behaviour	Such as, rapid mood swings for no apparent reason.
Changes in personality	For example, being suspicious, fearful, or dependent on a family member
Loss of initiative	For example, being uncharacteristically passive, sitting in front of the television for hours, sleeping more than usual, or not wanting to do usual activities.

Collateral History

Collateral is essential: "Do you mind if I talk to your partner/daughter etc?"

Review original history especially with regards onset and progression. Ask about any problems with the following:

• Repetitive questions?
• Remembering appointments, family occasions?
• Writing cheques, paying bills, balancing the cheque book?
• Shopping independently?
• Taking medications according to instructions?
• Getting lost while walking or driving in familiar places?
• Mood / Socially withdrawn?

If responses are unclear ask focused questions:

• Would he/she manage to cook a meal for the family?
• Would you be happy to go away and leave him/her to manage alone for 2 weeks- why/ why not?

Cognitive Assessment Tools

The following validated tools are most appropriate for routine dementia screening in general practice. They take less than five minutes to perform. These tools are:

• General Practitioner Assessment of Cognition (GPCOG)
• Memory Impairment Screen (MIS)
• Mini Cog

See links below to online versions of these tools and to printable PDF versions.

Other available tools include

• MOCA (Montreal Cognitive Assessment)
  • MOCA is another good test but it is lengthy and so may be difficult to use within the confines of a general practice consultation.
•  MMSE (Mini Mental State Exam)
  • The MMSE has copyright limitations. The test itself is lengthy and has cultural and educational bias.

Further Reading

• GP Cognitive Test
• Memory Impairment Screen
• Minicog Test
• Montreal Cognitive Assessment Test (MoCA)

Physical Exam

The purpose of the exam is to exclude any other potential causes of cognitive decline or delirium.

Consider:

• UTI
• Respiratory infection
• Stroke
• Encephalitis
• Meningitis
• Brain Tumour

During the physical exam, features to support a possible subtype may be identified. For example:

• Parkinson features
• Evidence of vascular disease to support a possible vascular dementia

Identify potentially reversible causes

 Consider Depression

• Depression may masquerade as dementia and is probably the most common differential diagnosis that should be considered. 
• Be aware that depression and dementia may co-exist and depression may precede dementia. 
• If strongly suspected, a trial of antidepressants may be indicated, with a reassessment of the individual’s capabilities and cognitive function 6-8 weeks later.
• Consider using the Geriatric Depression Scale to help objectively screen for depression (see PDF below)
• Geriatric Depression Scale

Medication Review

Anticholinergic medications should be stopped where possible.

• Anticholinergic medications work by decreasing the number of cholinergic neurotransmitters available - these neurotransmitters are the very thing that medications such as Donepezil, which can slow the initial progression of dementia symptoms, are trying to enhance.  
• Anticholinergics as a class of drugs can potentially contribute to a medication-induced cognitive impairment. 

Drugs with a strong anti-cholinergic burden include:

• Drugs for bladder instability: oxybutin, solifenacin, tolterodine
• Amitriptyline
• Hydroxyzine

   

The following medications can cause confusion and contribute to, or mimic, cognitive impairment:

1. Anticonvulsants – all anticonvulsants can potentially impair cognitive function
2. Antidepressants – risks highest in tricyclics. Withdrawal delirium also occurs
3. Antipsychotics – those with considerable anticholinergic activity may worsen delirium
4. Anti-parkinsonian drugs – risk highest in those with anticholinergic activity
5. Cardiac drugs – including digoxin and calcium antagonists
6. Corticosteroids – risk is dose-related
7. Hypnotics/Sedatives – more common with long-acting benzodiazepines
8. Opioid analgesics – risk highest with pethidine

Blood Tests

FBC, ESR, U&E, TFTs, Glucose, Lipids, Calcium & B12:

• to detect co-morbid conditions such as anaemia due to B12 deficiency or renal disease
• to exclude reversible causes (e.g. hypothyroidism).

Syphilis serology and HIV testing are not routinely recommended unless patients are considered at risk.

Address any Identified potentially reversible causes

 

Were there any abnormalities detected on history or testing suggestive of cognitive impairment? 

If the answer is No - 

Subjective Memory Complaints

• This term refers to a situation where there are subjective memory complaints but normal testing based on age and educational norms.
• This patient is best managed by addressing modifiable risk factors; smoking, dyslipidemia, diabetes, hypertension, alcohol consumption, exercise.
• Advise patient to return if any progression of symptoms.
• It is important to be aware of individuals that have a very high pre-morbid IQ. As a result of their high intellectual capacity, these individuals may score within the normal range for their age and education making the diagnosis very difficult.
• Direct the individual to further resources on dementia prevention:
  • See PDF document below on dementia prevention
  • Link below to 'Brain Health' website run by Trinity College Dublin

Further Reading

• Hello Brain - A campaign to promote brain health and healthy ageing

Downloads

• Dementia Prevention

 

Were there any abnormalities detected on history or testing suggestive of cognitive impairment? 

If the answer is Yes

Consideration of possible diagnosis

Establishing a diagnosis of dementia is a complex assessment and usually requires several consultations.

Below is a framework for the initial assessment, however, several more consultations may be required. Similarly, fewer consultations may be required if the presentation is less complex.

Consultation 1: Usually an unanticipated visit where concerns are first identified by the patient, the GP, or sometimes a relative. This consultation involves:

• A brief history of the problem
• GPCOG (or equivalent cognitive assessment tool)
• Consideration of differentials:
  • Medication review
  • Rule-out delirium
  • Consider depression

 

Consultation 2: Collection of Information

• More detailed history taking
  • Consider using Geriatric Depression Scale
• Bloods
• Invite a relative to attend the next consult for collateral if the patient consents.

 

Consultation 3: Collateral & Review

• Further clarification of symptoms
• Collateral if possible
• Review of  blood results
• Consider direct referral for CT or MRI brain (if accessible)

 

Consultation 4: Review & Disclosure

• Review history and investigations to date.
• Disclose diagnosis or
• Disclose your impression of the most likely diagnosis and explain referral pathways
• Provide relevant Patient Information Leaflets (PIL)

A) Mild Cognitive Impairment

• People with MCI have more memory problems than would be expected from someone at a similar age.
• They are able to function independently and do not show other signs of dementia, such as impaired reasoning or judgment.
• MCI does not always lead to dementia but in two-thirds of cases, it does.

 

Advice

• Many people with MCI are very aware of their memory problems and are often concerned that they have dementia. Knowing that they have MCI confirms to them that their memory concerns are valid and they can feel reassured to know that having MCI does not necessarily mean they will develop dementia.
• Being aware of their increased risk of dementia also allows people with MCI to plan for the future – evaluate their support systems, address legal and financial issues.
• There are no specific treatments available (ChEI’s are not recommended for MCI).
• It is important to address risk factors; hypertension, diabetes, cholesterol, smoking, and to encourage the person with MCI to engage in cognitive training and physical exercise.
• Provide the patient with PIL on Mild Cognitive Impairment (available below)

 

When to refer

• Mild Cognitive Impairment is a difficult diagnosis to make
• As part of a comprehensive workup patients with MCI should have brain imaging and comprehensive standardised cognitive assessments.
• We would, therefore, recommend getting specialist input from your local memory clinic, gerontologist, old age psychiatrist or neurologist.

B) Dementia

Dementia differs from Mild Cognitive Impairment in that in addition to a decline in cognitive function there is also an impairment in daily function/activities of daily living. 

Dementia Subtypes

Dementia is an umbrella term and includes the following conditions:

• Alzheimer's disease
• Vascular Dementia
• Dementia with Lewy Bodies
• Fronto- temporal dementia
• Mixed Dementia

It is important to identify the correct sub-type where possible for two reasons:

1. The different types of dementia will have different symptoms and disease progression
2. Different diseases will require different treatments. In particular, it is important to avoid the use of antipsychotics in Lewy Body Dementia.

Although GPs can proficiently diagnose and disclose the diagnosis of dementia, determining the exact subtype usually requires specialist assessment and access to brain imaging.

For the interested reader, a PDF below provides some information on the different dementia subtypes.

Importance of making a diagnosis

• Person has a right to know- if they wish to
• To facilitate planning for the future – medical, legal, financial
• Psychological benefit to a person with dementia and/or family
• To maximise treatment possibilities (cholinesterase inhibitors/memantine)
• Facilitate access to patient services and supports
• Allows for the coding for dementia in patient records 
• Allows potential risks to the patient to be addressed – driving, financial, self-care

Disclosure & Advice

• Disclosing the diagnosis of dementia is complex.
• A person-centered approach should be adopted. First, you need to establish what the patient wants to know and how much detail they would like on the diagnosis.
• If the patient would like further information you can provide them with information leaflets available below. Please visit the Patient Information Leaflet of this site for more information.
• See the Post Diagnostic Support section of this site for more information on how to support a patient with a new diagnosis of dementia
• See below for some helpful training videos produced by the Hospice Foundation on Breaking Bad News.

When to refer a person with suspected dementia

Refer if :

• Diagnostic uncertainty
• Parkinsons Disease with new onset dementia.
• Dementia in a person aged <65
• Non-typical presentation or course
• High risk situations at presentation e.g. challenging behaviour, wandering, psychosis.
• Potentially contentious legal issues
• Associated psychiatric morbidity
• Patients with a learning disability or significant previous head injury, who may be difficult to assess.
• Suspected alcohol related dementia
• Patient request referral

 

Situations where you may not refer:

• Definite non-complex alzheimers-type dementia
• Patient declines referral

Further Reading

• How to break bad news - link to videos produced by the Irish Hospice Foundation

Downloads

• Dementia Subtypes
• Coping with the Early Stages of Dementia

C)Diagnosis Uncertain

Dementia is a complex and difficult diagnosis to make. If the diagnosis is uncertain we would recommend getting specialist input from your local memory clinic, gerontologist, old age psychiatrist or neurologist.

 

Link to Post Diagnostic Support

• Post Diagnostic Support