Neuropsychological Perspective Emily Trittschuh, PhD

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Differentiating Dementia, Mild Cognitive
Impairment, and Depression Neuropsychological
Perspective
Emily Trittschuh, PhD Geriatric Research
Education and Clinical Center (GRECC) VA Puget
Sound Health Care System emily.trittschuh_at_va.gov
Dept of Psychiatry and Behavioral
Sciences University of Washington
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Learning Objectives

• Characterize Dementia, Mild Cognitive Impairment,
  and Depression in Older Adults
• Recognize warning signs and initiate diagnostic
  work-up
• Understand components of a Neuropsychological
  Evaluation
• Cognitive Profiles unique/overlapping features
• Utilizing this information to guide treatment and
  care planning

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The Aging Population

• Older Americans represent 12 of the
  population.
• 26 percent of physician office visits
• A third of all hospital stays and of all
  prescriptions
• Almost 40 of all emergency medical responses
• 90 of nursing home residents
• In 2011, the first baby boomers will reach their
  65th birthdays.
• By 2029, all baby boomers will be at least 65
  years old.
• This group will join the rest of older adults to
  total an estimated 70 million people aged 65 and
  older.

As reported by the Alzheimers Association in
2010
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Typical Cognitive Aging

• Autobiographical memory
• Recall of well-learned information
• Procedural and Episodic Memory
• Emotional processing

• ? Encoding of new memories
• Slower to learn new tasks
• ? Working memory
• May need more repetitions to learn new info
• ? Processing speed
• Slower to respond to novel situations

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What you might hear in clinic

• I cant focus
• Shes not interested in her usual activities
• I cant come up with the word I want
• My energy is low
• My short-term memory is shot
• I lost my car in the parking lot
• My husbands selective attention is worse he
  doesnt listen to me

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Dementia

• A decline of cognitive ability and/or comportment
  . . .
• primary and progressive
• due to a structural or chemical brain disease
• Not secondary to sensory deficits, physical
  limitations, or psychiatric symptomatology.
• to the point that customary social, professional
  and recreational activities of daily living
  become compromised.

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Probable Alzheimers Disease

• Dementia established by clinical and
  neuropsychological examination.
• Explicit memory impairment plus at least 1 other
  area of dysfunction.
• Activities of daily living have been affected.
• Insidious onset and progressive course.
• Risk increases with age rare onset before age 60
• Other diseases capable of producing a dementia
  syndrome have been ruled out.

NINCDS-ADRDA Criteria from 1984 consensus group
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Causes that Mimic Dementia (but are treatable)
Medications, B12 deficiency, hypothyroidism
Toxic/metabolic
Systemic illnesses
Infections, cardiovascular disease, pulmonary
Other
Depression, sleep apnea, psychosocial stressors,
drugs
Treatment may improve, but not fully reverse,
symptoms
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Prevalence of AD in the US
Millions of people
Hebert, et al, 2003, Archives of Neurology
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Is it always Alzheimers disease?
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Lim, et al. J Am Geriatr Soc. 1999
May47(5)564-9.
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Mild Cognitive Impairment

• Objectively measured deficits in memory and/or
  other thinking abilities
• Subjective memory complaint
• Normal ADLs
• Prevalence rates vary widely depending on age and
  community vs clinic sample

Conversion to dementia is significantly higher
in people with MCI MCI 12 - 15 per
year Normal controls 1 - 2 per year
(Petersen et al., 1999, 2001)
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Depression in Older Adults

• Mood disorder characterized by
• Sadness
• Guilt, negative self-regard
• Apathy loss of motivation, loss of interest
• Vegetative Symptoms sleep, appetite, energy
• Psychomotor changes agitation or slowing
• Trouble thinking, concentrating
• Loss of interest in life suicidal ideation
• Must occur for at least 2 weeks and interfere
  with daily living
• Higher prevalence rates of mood disorder in the
  elderly

DSM-IV and ICD-10 criteria
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When the Veteran has concerns or you notice a
change . . .

• Medical Evaluation
• History, physical
• Blood tests, brain scans

• Formal Cognitive Testing
• Evaluate relative to others in the same age group

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Diagnostic Challenges

• If dementia, changes can begin up to 20 years
  before noticeable by self others
• importance of prevention
• Is this normal aging? Is it a change?
• Clinical presentations can be similar
• may not be detectable using screening tests
• Comprehensive assessment is essential
• rule out other treatable causes

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Clinical Neuropsychology

• Integrative approach psychology, psychiatry,
  and neurology
• Record review
• History is often the most important diagnostic
  tool
• Collateral information is helpful
• Objective cognitive testing to aid in diagnosis
• Multiple domains of cognitive function must be
  evaluated
• Importance of using appropriate measures and
  appropriate normative data

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Geriatric Neuropsychology

• Tests
• Consider age of subject and overall health/energy
• Consider adjusting measures administered based on
  referral question (e.g., first diagnosis vs.
  current function)
• Normative populations
• Limited normative information for 90
• Non-native English speakers
• Ethnicity/Cultural differences
• Premorbid estimates
• Individualized benchmark

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What is impaired?
Gold standard premorbid baseline data
Standard benchmark Compare to the average
performance within an age group
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-2.5
-3
2.5
3
Standard deviations
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What is impaired?
Gold standard premorbid baseline data
Personal benchmark Compare test results to an
estimate of premorbid abilities
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3
-2.5
2.5
-3
Standard deviations
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Clinical Symptoms of Cognitive Decline

• Memory loss is often the most commonly reported
  symptom
• Forgetfulness
• Repeats self in conversation
• Asks the same questions over and over
• Gets lost in familiar areas
• Cant seem to learn new information (routes,
  tasks, how to use a new appliance or electronics)

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Clinical Symptoms cont . . .

• Presenting symptoms can also consist of changes
  in one or more of these areas
• Attention
• Language
• Visuospatial abilities
• Executive function
• Personality/judgment/behavior

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Impairments in Attention

• Starting jobs but not finishing them
• Absentmindedness
• Difficulty following a conversation
• Distractibility
• Losing train of thought

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Impairments in Language

• Problems expressing ones thoughts in
  conversation (cant find the right words)
• Consistently misusing words
• Trouble spelling and/or writing
• Difficulty understanding conversation

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Impairments in Visuospatial Function

• Getting turned around (even in ones own home)
• Trouble completing household chores (using knobs
  or dials)
• Difficulty getting dressed
• Trouble finding items in full view
• Misperceiving visual input

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Impairments in Executive Function

• Disorganization
• Poor planning
• Decreased multi-tasking
• Perseveration
• Decreased ability to think abstractly

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Changes in Personality or Comportment

• Quantitative change in behavior
• Increase- disinhibition, impulsivity, poor
  self-regulation, socially inappropriate
• Decrease- flat affect, reduced initiative, lack
  of concern, lack of interest in social activities
  (often initially mistaken for depression)
• Behavior not typical of premorbid personality

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Case Example Key Features

• 68-year-old, r-handed, AA female
• Masters degree Associate dean
• No significant past medical history
• Referred from primary care MD for complaints of
  memory loss
• Insidious onset, seems progressive

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Symptom History at Initial Visit

• 2 year decline in memory
• Social skills maintained
• Living alone, independent in all ADLs
• Collateral endorsed a change

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Neurocognitive Profile - MCI
SEVERE
MODERATE
MILD
NORMAL
Attention
Mood
Lang
Spatial
Memory
ADLs
Executive
Initial (2 yr after onset)
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Changes at Second Visit

• Sense of progression
• Social skills maintained
• Still living alone independent for basic ADLs
• Changes in IADLs
• Having trouble driving (minor accidents got
  lost)
• Trouble managing medications

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Neurocognitive Profile - Dementia
SEVERE
MODERATE
MILD
NORMAL
Attention
Mood
Lang
Spatial
Memory
ADLs
Executive
Initial (2 yr after onset)
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Neurocognitive Profile - MCI
SEVERE
MODERATE
MILD
NORMAL
Attention
Mood
Lang
Spatial
Memory
ADLs
Executive
Initial (2 yr after onset)
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Symptom History at Initial Visit

• 2 year decline in memory collateral notes change
• Affective Changes
• Loss of interest in normal activities
• Sadness and decreased social network
• Living alone, independent in basic ADLs
• IADLs
• Sometimes forgets medication dosages
• a few examples of inattention while driving

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Neurocognitive Profile - Depression
SEVERE
MODERATE
MILD
NORMAL
Attention
Mood
Lang
Spatial
Memory
ADLs
Executive
Initial (2 yr after onset)
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Complicating issues

• Chronic depression is a risk factor for dementia
• Reported rates of depression in dementia range
  from 0-86 of cases
• Recent meta-analysis found 50 prevalence
• Discriminating depression from dementia is even
  more challenging in non-AD dementias
• With the trajectory of MCI unknown, the
  relationship to depression is less clear
• Depression may indicate prodromal dementia

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Treatment and Care Planning

• Dementia
• No cure and the causes are not entirely
  understood
• Effective intervention improve functional
  status to a degree discernable to caregivers or
  health care providers
• In the case of a progressive disorder,
  improvement slower decline

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Current FDA-Approved Medications
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AGE
Head Injury, Depression, Female, Presence of APOE
e4 allele Chronic Illness
Cognitive Decline Alzheimers Disease Diagnosis
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Mild Cognitive Impairment
MCI
Dementia
Normal
An ideal point of intervention?
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Risk Factors that can be Managed or Avoided
Medical Conditions
Behavioral Factors

• Nutrition/Diet
• Alcohol / Tobacco
• Exercise
• Stress
• Socialization

• High Blood Pressure
• High Cholesterol
• Type II Diabetes

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Type II Diabetes
Bennett, et al. Religious Orders Study. Archives
of Neurology, 2004
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Depression in the Elderly

• Depression is not a normal part of aging
• Estimated that only 10 of Older Adults with
  depression receive treatment
• Suicide rates higher in the elderly and higher
  in Veteran populations
• Risk of cognitive decline should be monitored

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Dang! . . . Now where was I going?

• Dementia?
• Mild Cognitive Impairment?
• Depression?

Superman in his later years
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Thank you

• Questions?
• Please also email me at emily.trittschuh_at_va.gov