Differentiating Dementia, Mild Cognitive Impairment, and Depression: Neuropsychological Perspective Emily Trittschuh, PhD Geriatric Research Education.

Differentiating Differentiating Dementia, Mild Dementia, Mild Cognitive Impairment, Cognitive Impairment, and Depression: and Depression: Neuropsychological PerspectiveNeuropsychological Perspective

Emily Trittschuh, PhDGeriatric Research Education and Clinical Center (GRECC)VA Puget Sound Health Care [email protected]

Dept of Psychiatry and Behavioral SciencesUniversity of Washington

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

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 Alzheimer’s Association in 2010

“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

What you might hear in clinic

I can’t focus She’s not interested in her usual activities I can’t 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 husband’s “selective attention” is worse – he

doesn’t listen to me

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.

Probable Alzheimer’s Disease

NINCDS-ADRDA Criteria from 1984 consensus groupNINCDS-ADRDA Criteria from 1984 consensus group

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.

Causes that Mimic Dementia (*but are treatable)

Toxic/metabolicMedications, B12 deficiency, hypothyroidism

Systemic illnessesInfections, cardiovascular disease, pulmonary

OtherDepression, sleep apnea,psychosocial stressors, drugs

*Treatment may improve, but not fully reverse, symptoms

Mill

ions

of

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f pe

ople

0.01.02.03.04.05.06.07.08.09.0

2000 2010 2020 2030 2040 2050

65-74

75-84

85+

Prevalence of AD in the USPrevalence of AD in the US

Hebert, et al, 2003, Archives of NeurologyHebert, et al, 2003, Archives of Neurology

Is it always Alzheimer’s disease?

Lim, et al. J Am Geriatr Soc. 1999 May;47(5):564-9.

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

Mild Cognitive Impairment

(Petersen et al., 1999, 2001)(Petersen et al., 1999, 2001)

**** Conversion to dementia is significantly higher in Conversion to dementia is significantly higher in people with MCIpeople with MCI

MCI MCI 12 - 15% per year12 - 15% per yearNormal controlsNormal controls 1 - 2% per year 1 - 2% per year

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

Medical EvaluationMedical Evaluation History, physicalHistory, physical

Blood tests, brain scansBlood tests, brain scans

Formal Cognitive TestingFormal Cognitive Testing Evaluate relative to others in Evaluate relative to others in

the same age groupthe same age group

When the Veteran has concerns or When the Veteran has concerns or you notice a change . . .you notice a change . . .

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

Diagnostic Challenges Diagnostic Challenges

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

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

What is “impaired”?What is “impaired”?

““Gold” standard:Gold” standard: premorbid baseline datapremorbid baseline data

Standard benchmark: Standard benchmark: Compare to the average Compare to the average

performance within an age groupperformance within an age group

-2-2 -1.5-1.5 -1-1 -.5-.5 00 .5.5 11 1.51.5 22-2.5-2.5 2.52.5 33-3-3

Standard deviationsStandard deviations

What is “impaired”?What is “impaired”?

““Gold” standard:Gold” standard: premorbid baseline datapremorbid baseline data

Personal benchmark: Personal benchmark: Compare test results to an Compare test results to an

estimate of premorbid abilitiesestimate of premorbid abilities

-2-2 -1.5-1.5 -1-1 -.5-.5 00 .5.5 11 1.51.5 22-2.5-2.5 2.52.5 33-3-3

Standard deviationsStandard deviations

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 Can’t seem to learn new information (routes, tasks,

how to use a new appliance or electronics)

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

Impairments in Attention

• Starting jobs but not finishing them

• Absentmindedness

• Difficulty following a conversation

• Distractibility

• Losing train of thought

• Problems expressing one’s thoughts in conversation (can’t find the right words)

• Consistently misusing words

• Trouble spelling and/or writing

• Difficulty understanding conversation

Impairments in Language

Impairments in Visuospatial Function

• Getting turned around (even in one’s own home)

• Trouble completing household chores (using knobs or dials)

• Difficulty getting dressed

• Trouble finding items in full view

• Misperceiving visual input

Impairments in Executive Function

• Disorganization

• Poor planning

• Decreased multi-tasking

• Perseveration

• Decreased ability to think abstractly

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

Case Example: Key Features

68-year-old, r-handed, AA female

Master’s degree; Associate dean

No significant past medical history

Referred from primary care MD for complaints of memory loss

Insidious onset, seems progressive

Symptom History at Initial Visit

2 year decline in memory

Social skills maintained

Living alone, independent in all ADLs

Collateral endorsed a change

MILDMILD

NORMALNORMAL

SEVERESEVERE

AttentionMood Lang Spatial Memory ADLsExecutive

Neurocognitive Profile - MCINeurocognitive Profile - MCI

MODERATEMODERATE

Initial:Initial:(2 yr after onset)(2 yr after onset)

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

MILDMILD

NORMALNORMAL

SEVERESEVERE

AttentionMood Lang Spatial Memory ADLsExecutive

Neurocognitive Profile - DementiaNeurocognitive Profile - Dementia

MODERATEMODERATE

Initial:Initial:(2 yr after onset)(2 yr after onset)

1st F/U:1st F/U:(3 yr after onset)(3 yr after onset)

2nd F/U:2nd F/U:(5 yr after onset)(5 yr after onset)

MILDMILD

NORMALNORMAL

SEVERESEVERE

AttentionMood Lang Spatial Memory ADLsExecutive

Neurocognitive Profile - MCINeurocognitive Profile - MCI

MODERATEMODERATE

Initial:Initial:(2 yr after onset)(2 yr after onset)

1st F/U:1st F/U:(3 yr after onset)(3 yr after onset)

2nd F/U:2nd F/U:(5 yr after onset)(5 yr after onset)

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

MILDMILD

NORMALNORMAL

SEVERESEVERE

AttentionMood Lang Spatial Memory ADLsExecutive

Neurocognitive Profile - DepressionNeurocognitive Profile - Depression

MODERATEMODERATE

Initial:Initial:(2 yr after onset)(2 yr after onset)

Tx x 1 yr:Tx x 1 yr:(Incomplete remission)(Incomplete remission)

Tx x 1 yr:Tx x 1 yr:(Effective)(Effective)

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

Treatment and Care Planning

DementiaNo cure and the causes are not entirely

understoodEffective intervention = improve functional

status to a degree discernable to caregivers or health care providers

In the case of a progressive disorder, “improvement” = slower decline

Current FDA-Approved Medications Acetylcholinesterase Inhibitors

tacrine Cognex® hepatotoxic

donepezil Aricept® 1 month

galantamine Razadyne® 4 months

rivastigmine Exelon® 4 months; patch

NMDA receptor antagonist

memantine Namenda® 1 month; approved for mod-severe AD

Adjunct Therapies (off label) Antidepressants

Antipsychotics

SSRIs, mirtazapine

risperidone, quetiapine

Environment Genetic

AGEAGE

Neuronal and Synaptic dysfunction

Cognitive DeclineAlzheimer’s Disease Diagnosis

Alzheimer’s pathology NFTs

Amyloid Plaques

Head Injury, Depression, Female,

Presence of APOE e4 allele Chronic Illness

Risk

Factors

NormalNormal MCIMCI DementiaDementia

An ideal point of An ideal point of intervention?intervention?

Mild Cognitive ImpairmentMild Cognitive Impairment

Risk Factors that can be Managed or Risk Factors that can be Managed or AvoidedAvoided

Medical ConditionsMedical Conditions

High Blood PressureHigh Blood Pressure

High CholesterolHigh Cholesterol

Type II DiabetesType II Diabetes

Nutrition/DietNutrition/Diet

Alcohol / TobaccoAlcohol / Tobacco

ExerciseExercise

StressStress

SocializationSocialization

Behavioral FactorsBehavioral Factors

Older adults (>55 yrs) with diabetes have a 65% increased risk of developing Alzheimer’s disease (compared to those without diabetes)

Adults with diabetes havelower scores on cognitive tests

Type II Diabetes

Bennett, et al. Religious Orders Study. Archives of Neurology, 2004

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

Dementia?

Mild Cognitive Impairment?

Depression?

Superman in his later years

Dang! . . . Now where

was I going?

Thank you

Questions?Please also email me at [email protected]