Memory Assessment - Early Dementia Assessment Flowchart

By Travis Peters,2014-10-17 13:28
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Memory Assessment - Early Dementia Assessment Flowchart


    Southwest Etobicoke accepted if the referring How to Use this Toolkit

    physician is affiliated with Trillium. This toolkit provides information to be used

    How to Refer: Fax a completed referral form to by family physicians to assess for dementia in

    the above number. the primary care setting. The toolkit contains:

    Definitions ; Introduction

    Mild cognitive impairment (MCI) is an age-; Flowchart for Assessments

    related change in memory without functional loss. ; Brief Screening Tool

    This is often noted by the patient, but not by an ; Key Informant Questionnaire

    observer such as family member. ; Mini-Mental Status Exam Tool

    ; Physical Examination Tool Dementia is a syndrome of cognitive impairment

    ; Treatment & Follow-up Plan resulting in functional loss and behaviour change

    and is to be distinguished from depression and ; Information about medications, referral

    delirium. It includes aphasia (problems in naming sources, & patient education sources. and comprehension), apraxia (problems in Introduction performing tasks such as combing hair or Distinguishing normal age-related memory dressing), agnosia (problems in recognizing complaints from true dementia and familiar objects such as a pen or watch) and distinguishing the type of dementia involves disturbance in executive functioning (planning determining the quality of the memory loss and organization). and any associated functional or behavioural Depression may present with the patient changes. complaining of memory loss and difficulty concentrating, but also includes apathy, loss of When to Refer? appetite, poor energy, sleep disturbance, Most cases of dementia can be managed in psychomotor agitation and anxiety. Depression primary care. Indications for referral include: can co-exist with dementia. ; Uncertainty about diagnosis or if there

    are atypical features Delirium is an acute confused state of rapid onset,

    characterized by poor attention, concentration, ; If the patient is young

    disorganized thoughts, and a fluctuating course. ; If there is a rapid course

    The physical exam and lab investigations often ; Failure of appropriate medications

    reveal evidence of infection, adverse drug effects ; If you require assistance with

    or metabolic derangement. managing behaviours

    References Geriatric Mental Health Services Alberta Medical Association. Guideline for cognitive Trillium Health Centre impairment: is this dementia? Symptoms to diagnosis. Phone: 905-848-7596 January 2002.

    Gauthier, Serge. Screening for dementia: how and why? The Fax: 905-848-7602

    Canadian Alzheimer Disease Review Oct 2002: 18-20 Services Offered: Assessments and case Dalziel W. Assessment of dementia: diagnostic challenges management for those at risk of and toolkit. September 2002 hospitalization; assessments in home or long-

    term care facility in Mississauga for those This toolkit has been developed by Dr. W. Bakker, Dr. S.

    Egier, Dr. C. Hewitt, Dr. B. Hickey, Dr. J. Kingston, and Dr. unable or unwilling to come to clinics.

    G. Morningstar in the Department of Family Practice at Referral Criteria: Over age 65 years (those Trillium Health Centre, September 2003 with assistance under age 65 years may be considered based from Dr. Richard Shulman. on symptoms/issues). Referral by physician

    These recommendations have been developed to assist only. Clients living outside of Mississauga and

    clinical decision-making by family physicians in conjunction

    with their patients.


    Assessment Flowchart

This is an outline of how to use the tools in primary care practices when a patient presents

    with memory problems.

Family physicians may want to divide diagnostic work into phases that can be carried out in

    separate visits.

     History, VisitPurpose: Could this Visit 1 Brief Screen, individual have dementia? Lab Testing

    If concerned, ask reliable observer to complete Key

    Informant Questionnaire

    Purpose: Is this problem Review Key Informant Visit 2

    dementia or could it be Questionnaire

    something else? Conduct MMSE with patient

    Purpose: Rule out other Physical Examination reversible causes and Visit 3 distinguish type of


    Purpose: Develop

    management and Action & Management Plan treatment options Visit 4

    - referral

    - family education

    Purpose: Assess response Follow -up to treatment and progress On-Going of disease.


    Brief Screening Tool

    Date: _________________________________________________________________ Patient Name: __________________________________________________________ Family History of Dementia: Yes No __________________________________ Birthdate / Current Age: ______________/___________________________________ Level of Education: ______________________________________________________

    Key Informant Name & Relation to Patient: __________________________________ Key Informant Contact Number: ___________________________________________

Description of Cognitive Problems:

    1) Describe: problems, onset, progression, associated issues, language deficiencies (e.g. vagueness of

    language, lack of detail, no descriptive quality to language)





    Ask patient:

    1) Do you have any concerns about forgetfulness or your

    memory? Yes No

    2) Orientation: Ask patient the current year, month, day, season.


    3) Recall: Name three objects and ask patient to repeat them.


    4) Clock Test: Ask patient to draw a clock, put in the numbers and set the time at 10 minutes past 11



    5) Recall: Ask patient to repeat objects from Question 3.


Ask key informant (caregiver/friend/family member):

    6) Have you noticed observable decline in the patient’s ability to:

    1. remember things that happened recently? Yes No

    2. use the telephone? Yes No

    3. travel? Yes No

    4. use medications correctly? Yes No

    5. handle finances? Yes No

    6. take care of personal hygiene? Yes No

Is there any indication of?

    ; Delirium Yes No

    ; Depression Yes No

    ; Hypothyroidism Yes No

    ; Substance abuse Yes No

    ; Medication side effects Yes No

    ; Significant hearing vision problem Yes No

    ; Recent fall or head injury Yes No

    Preliminary Diagnosis (circle most appropriate answer):

    Cognition Normal Minimal Cognitive Impairment Dementia


    Mini-Mental Status Exam

    (Assessment of Cognitive Ability)

    Date: _____________________________________________________________ Name: _____________________________________________________________

Activity Score

Orientation 1 point for each answer

Ask: “What is the (year)(season)(date)(day)(month)?” _______/5

    Ask: “Where are we? (country)(province)(city)(street)(office) _______/5

Registration 1 point for each object properly repeated

Name three objects: Give the patient one second to say each.

    Ask the patient to: repeat all three after you have said them.

    Repeat them until the patient learns all three. _______/3

Attention & Calculation 1 point for each correct subtraction

Ask the patient to: spell WORLD forward, then backwards

    (D-L-R-O-W: 1 point for each correct letter backwards) _______/5

Recall - 1 point for each correct answer

    Ask the patient to: name the three objects from above. _______/3


Ask the patient to:

    ; identify and name a pencil and a watch (1 pt each) _______/2

    ; repeat the phrase, “No ifs, ands or buts.” _______/1

    ; “Take a paper in your right hand, fold it in half,

     and put it on the floor” (1 point for each task completed properly) _______/3

    ; read & obey the following:“Close your eyes” _______/1

    ; write a sentence. _______/1

    ; copy a complex diagram of two interlocking pentagons _______/1

     TOTAL: _______/30

     Optional (not part of MMSE): Name as many four-legged animals as possible in 1 minute. (Normal =12-15)

     Interpreting results of the MMSE: Severity of cognitive impairment can be categorized as follows:

     - Mild 21-26 - Moderate 10-20 - Severe <10 (MMSE scores are influenced by age and years of schooling.)

     Folstein MF, Folstein SE, McHugh PR. “Mini-mental state” A practical method for grading the cognitive state of patient for

    the clinician. J Psychiatr Res. 1975;12:189-98. Physical Examination Tool


    Physical Examination Tool

    (A general physical examination should be performed.) Age: Living Arrangements:

    ETOH Use: Smoking Status:

    Exercise Regime: Dietary Intake:

    Review of Systems:

Current Medications:

BP: P: Wt: Ht:


    1) Risk Factors for Vascular Disease:

    a. Hypertension, diabetes, hyperlipidemia, atrial fibrillation, ischemic heart disease,


    2) Other Causes of Memory Impairment:

    a. Depression, delirium, thyroid disease, B vitamin deficiencies, ETOH, drug adverse

    effects, vision& hearing loss, head injury. 3) Red Flags to make you consider a diagnosis other than Alzheimer’s Dementia:

    a. Mixed or Vascular Dementia recent CVA or TIA, stepwise decline, localizing

    neurological signs

     Parkinsonian features (particularly falls), fluctuating cognition, b. Lewy Body Dementia

    hallucinations, executive function (planning, organizing) worse than memory

    c. Fronto-Temporal Dementia personality changes impulsivity, disinhibition, self-

    neglect, socially inappropriate

     disturbed gait, incontinence d. Normal Pressure Hydrocephalus

    e. Jakob-Creutzfeld rapid progression, myoclonus

    1. Localizing Neurological Signs:

    a. Power / Symmetry_______________ d. Tone ________________

    b. Reflexes ________________________ e. Babinski ___________

    c. Cerebellar ______________________ f. Tremor /Myoclonus__

    2. Cardiovascular:

    a. Blood pressure: Lying _______ Standing _______ d. Heart Rate _______

    b. Congestive heart failure ______________ e. Atrial Fibrillation ______________________ c. Peripheral Vascular Disease _____________ f. Carotid bruits __________________________

    3. Gait Abnormality

    Ataxia ________________________ Parkinsonian Features (falls)_________________

     Suggested tests (if not recently done): Consider CT Scan if :

    ; Glucose, BUN, Creatinine, Electrolytes ; Under age 60

    ; CBC ; Recent heard trauma / seizure

    ; ? Vascular or mixed dementia ; TSH

    ; Liver function test ; NPH (incontinence, abnormal gait)

    ; ECG if history of CVD/risk factors or ; History of cancer / bleeding disorder

    considering AchEI therapy ; Atypical presentation

    ; Calcium ; Sudden onset / rapid progression

    ; B12/VDRL ; Neurological symptoms / signs


    Action & Management Tool

    Use this tool to guide you in the next steps to discussing the diagnosis, and planning for treatment and management.


    1. Discuss diagnosis and general prognosis for with the patient and caregiver. Average survival for

    Alzheimer’s Disease is approximately 10 years with a range of 2-20 years from onset of

    memory loss.

     Longterm care institutional placement expected < 1 year.

    2. Discuss risk of superimposed delirium / depression and the effect of other illness, surgery,



    1. Review concurrent medical problems (Review /revise other medication use; treat risk

    factors to modify progression of disease)

    2. Refer patient to CCAC and other resources (See Management Resources)

    3. Consider pharmacologic intervention (see Fact Page on Medications)

    4. Consider nutrition issues: Consider multi-vitamin and mineral supplements. High calorie,

    nutrient rich foods will assist in weight maintenance (BMI 22-27). Altering the eating

    environment may reduce distractions and increase social interaction. Creative feeding strategies

    include altering food texture (thickeners, finger foods), serving one food at a time, and providing

    continuous access to food. Review effects of medications (e.g. dry mouth, constipation, nausea,

    decrease in appetite.

Safety Planning

    1. Driving: Mandatory reporting to Ministry of Transportation (416-235-1773) required for patients

    with clinical dementia. For patients with early Alzheimer’s but whose functional impairment is not

    sufficient for dementia, use DriveABLE to evaluate driving competency (located in North York

    416-498-6429). _______________________________________________________________________

    2. Medication compliance: ____________________________________________________

    3. Falls (Mobility assessments through Walking Mobility Clinics 905-804-1015): _____________________

    4. Wandering:______________________________________________________________

    5. Cooking, use of appliances: _________________________________________________

    6. Ability to live alone: ______________________________________________________


    1. Agitation: _______________________________________________________________

    2. Aggression:______________________________________________________________

    3. Apathy: ________________________________________________________________

Legal Issues

    1. Discuss Power of Attorney (for financial & personal care): ________________________

    2. Discuss Will:_____________________________________________________________

    3. Discuss Capacity if patient felt to be capable: ___________________________________

    (Capacity Assessment Office, Ministry of Attorney General 416-327-6683)

    4. Discuss Advance Directives:________________________________________________

Care Giver Burden

    1. Discuss & assess stress, depression.

    2. Consider respite care and long term care placement (contact CCAC).


    Key Informant Questionnaire

This can be sent home with the caregiver or other reliable witness to obtaining information which will be

    important to establishing a diagnosis and making future comparisons.

This should be reviewed at the next office visit and a copy returned to the caregiver to provide input at

    follow-up visits.

     Baseline Follow-up in 3 Follow-up in 6 Follow-up in 12

     months months months

    Date: Date: Date: Date:

     1. Cognition

     Does your relative have problems:

     Yes No Yes No Yes No Yes No ; Remember names and events?

     Yes No Yes No Yes No Yes No ; Finds appropriate words?

     ; Keeps track of time? Yes No Yes No Yes No Yes No ; Stay aware of their environment? Yes No ; Follow instructions? Yes No Yes No Yes No Yes No ; Stay tuned in and focused?

     2. Social Interactiveness

     ; Does your relative show little interest

     Yes No Yes No Yes No Yes No in usual hobbies/leisure activities (e.g.

     playing cards/sewing, knitting)

     ; Does your relative have difficulties

     Yes No Yes No Yes No Yes No participating in conversation?

     3. Function

     Does your relative have problems:

    o Bathing and grooming themselves? Yes No Yes No Yes No Yes No o Dressing themselves appropriately? Yes No Yes No Yes No Yes No o Preparing snacks/meals? Yes No Yes No Yes No Yes No o Handling the mail? Yes No Yes No Yes No Yes No o Shopping? Yes No Yes No Yes No Yes No o Using the telephone? Yes No Yes No Yes No Yes No o Handling money/finances? Yes No Yes No Yes No Yes No o Using appliance? Yes No Yes No Yes No Yes No o Driving or using public transportation? Yes No Yes No Yes No Yes No

     4. Behaviour

     Does your relative display signs of:

    o Apathy, lack of interest and/or

    withdrawal ? Yes No Yes No Yes No Yes No o Anxiety and/or nervousness? Yes No Yes No Yes No Yes No o Irritability and/or anger Yes No Yes No Yes No Yes No o Depression, sadness, and/or emotional

    outbursts? Yes No Yes No Yes No Yes No o Hallucinations, delusions, and/or

    paranoia? Yes No Yes No Yes No Yes No o Lack of motivation to compete tasks? Yes No Yes No Yes No Yes No o Is your relative likely to wander? Yes No Yes No Yes No Yes No 5. Caregiver Burden Poor Good Poor Good Poor Good Poor Good

    1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 ; Level of caregiver (your)


    Low High Low High Low High Low High ; Level of caregiver (your) feelings of 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 isolation.

     ; Level of caregiver (your) energy 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 ; Level of caregiver (your) stress



Geriatric Mental Health Services - Trillium Health Centre

    Phone: 905-848-7596; Fax: 905-848-7602

    Services Offered: Assessments and case management for those at risk of

    hospitalization; assessments in home or long-term care facility in Mississauga for those unable or unwilling to come to clinics.

    Referral Criteria: Over age 65 years (those under age 65 years may be considered based on symptoms/issues). Referral by physician only. Clients living outside of Mississauga and Southwest Etobicoke accepted if the referring physician is affiliated with Trillium.

    How to Refer: Fax a completed referral form to the above number.

Alzheimer’s Society

    (Peel 905-278-3667) (Toronto 416-322-6560): supports people with Alzheimer Disease

    and related conditions, and their relatives and/or caregivers. Services include wandering patient registry. counselling, support groups, education & information, and a day hospital (Peel only; small fee applies). Toronto agency will provide referrals to the appropriate respite and day programs. Hours of operation Mon - Fri. 9am 5pm.

Accommodation & Case Management for Seniors

    Community Care Access Centre (CCAC)

    (Peel 905-796-0040) (Etobicoke 416-626-2222): provides in-home health services,

    information and referral services, placement in care facilities, and short-term respite care. CCAC staff coordinate services and develop individualized plans. CCAC services may include case management, placement for long term care facilities, short term respite care, nursing, physiotherapy, occupational therapy, speech language therapy, nutrition counselling, social work, personal support (bathing, dressing, feeding), access to drug benefit card & laboratory services.

    Case Managers will work with family physicians and the patient/family to assess needs, determine eligibility, develop an individualized plan of care, arrange for the delivery of services, identify alternate community resources as required (e.g. Meals on Wheels).

    To be eligible to receive services, patients must have a valid Ontario health care, have needs which cannot be met as an out-patient, have a medical condition which can be adequately treated at home, require at least one professional/personal support service, and have family participation if possible.

Other Resources

    Lifeline (1-800-LIFELINE, or through CCACs): offers monitoring services and products to

    people who want the assurance of 24 hour assistance at the touch of a button while remaining independent in their homes. Included with the monitoring service, Lifeline rents each Subscriber the equipment they require: a Communicator/Telephone and a Personal Help Button.

Health Information & Wellness Centre (Trillium Health Centre 905-848-7100 ext 7511 or

    ext 4187): can help anyone find information on a health-related topic, either in person at Trillium Health Centre (Mississauga or Queensway sites), or over the phone. Links to health information have been established on the Trillium Health Centre website at


    Facts on Medications

Role of Aceltylcholine

    Acetylcholine (ACh) is an important neurtransmitter in areas of the brain involved in memory

    formation (e.g. hippocampus, cerebral cortex, and amygdala)

Loss of ACh occurs early in Alzheimer’s disease (AD) and correlates with memory impairment.

Treatment Approach

    Enhancement of ACh function may significantly reduce the severity of cognitive loss. The only

    proven method to enhance ACh function is the prevention of its breakdown by drug inhibition of

    cholinesterase enzymes needed to biodegrade ACh in the synaptic cleft between nerve cells.

    Three cholinesterase inhibitors (ChEI) are available in Canada.

    ?; Aricept (donepezil hydrochloride) available since August 1997

    ?; Exelon (rivastigmine) - available since April 2000

    ?; Reminyl (galantamine) - available since September 2001

All three are indicated for the treatment of Alzheimer’s disease in mild to moderate severity.

All three are available under the Ontario Drug Benefit plan (ODB) for those over age 65 scoring

    between 10 and 26 on the mini-mental state exam (MMSE).

    Donepezil Rivastigmine Galantamine

    (Aricept?) (Exelon?) (Reminyl?)

    Sole mechanism of action: Dual mechanism of action; Dual mode of action: AchEI Mechanism

    acetyl cholinesterase non-selective inhibitor of both and stimulation of pre-synaptic of Action inhibitor (AchEI) AchEI and butyryl nicotinic receptors, which may

    cholinesterase (BuChE) increase release of Ach.

    70 hours with hepatic Short half-life of 1.5 hours 6-8 hours, with hepatic Half-Life

    metabolism via CYP 2D6 necessitates twice-a-day metabolism via CYP 2D6 and

    and 3A4. dosing. Non-CYP metabolism. 3A4.

    Minimal concern for Minimal concern for Interactions

    interactions due to dual interactions due to dual

    pathways and lack of pathways and lack of inhibition

    inhibition of CYP of CYP enzymes.


     Caution with use with other

    Caution with use with other CYP 2D6 drugs such as some

    CYP 2D6 drugs such as beta blockers.

    some beta blockers

    Therapeutic dose range of 6 to Therapeutic Once-a-day dosing of 5 mg Start with 4 mg BID, for 4 12 mg/d. Dosing starts at 1.5 Dose for 4 weeks then increases weeks, then increase to initial mg BID for 4 weeks, then to 1 0 mg/day. target maintenance dose of 8 increases to 3 mg BID for 4 mg BID. Maximum weeks, and then may increase

    recommended dose: 12 mg to 4.5 mg BID for 4 weeks,

    and then may increase to 6 mg BID, if clinically appropriate.


    347 for first 3-month trial, 354 for first 3-month trial, ODB Codes 347 for first 3-month trial, (MMSE required 348 for subsequent therapy 355 for subsequent therapy 348 for subsequent therapy for each prescription)


    Facts on Medications 2

Efficacy Profiles

    Using the Alzheimer’s disease assessment scale cognitive sub portion (ADAS-Cog):

     ADAS-cog ADAS-cog

     Effect Time for score to deteriorate back to

    Drug vs. placebo Baseline

    ?Reminyl 3.1 3.9 52 weeks

    ?Aricept 2.2 - 2.9 39 weeks

    ?Exelon 1.2 - 4.9 42 weeks

Adverse Effects

    Common effects include gastrointestinal (GI) adverse events including nausea, vomiting, diarrhea, anorexia and weight loss. These are often mild and transient. GI side effects seen more frequently (20% vs.10%) with Exelon? as compared to the other two but perhaps this was due to too fast a titration period used in the Exelon? pivotal studies (weekly as opposed to monthly).

    Suggested to be used cautiously in patients with asthma or COPD, supraventricular cardiac conduction disorders (bradycardia) and ulcers.

    Lack of efficacy and/or tolerability problems with one ChEI inhibitor does not predict similar problems with another agent.

Appropriate Expectations

    Typical rate of cognitive decline in untreated Alzheimer’s disease is 2-4 points per year on the


    Typical MMSE response to all three drugs in the first 6 months is 0-2 point improvement with eventual return to baseline after 9-12 months of therapy.

    Open label studies suggest ongoing slope of decline same as that over first year.

    Functional response is modest improvement or stability over first 6-12 months.

    Behavioural response is modest improvement or stability over first 6-12 months.

Predictors of Response

    None available.

    Patients in both mild and moderate stages may benefit, but commencing treatment earlier in the disease predicts better efficacy.

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