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DEMENTIA AGS Geriatrics Evaluation and Management Tools (Geriatrics E&M Tools) support clinicians and systems that are caring for older adults with common geriatric conditions. From the AMERICAN GERIATRICS SOCIETY Geriatrics Evaluation & Management Tools SCREENING Although routine screening for dementia is not currently recommended for all geriatric patients by the US Preventive Services Task Force, patients should be asked about memory concerns and a cognitive evaluation should be done if appropriate. If a patient or family member expresses concerns about cognitive decline, or a provider notices dementia warning signs, a mental status assessment and dementia evaluation is indicated. ■ Possible warning signs include unkempt appearance, poor historian, difficulty following directions, repeating the same question, lost in familiar places, missing appointments, frequently misplacing items, and difficulty managing bills, finances, or medications. ■ Cognitive testing should be conducted in the patient's primary language (if possible). ■ Diagnosis of dementia is a clinical diagnosis taking into account multiple factors with cognitive screening being only one. Examples of Screening Instruments for the Evaluation of Cognition <table><tr><td>Instrument Name</td><td>Cognitive Domains Assessed</td><td>Available</td></tr><tr><td>Mini-Cog</td><td>Visuospatial, executive function, recall</td><td>http://geriaticus.uthscsa.edu/tools/MINICog.pdf</td></tr><tr><td>St. Louis University Mental Status (SLUMS) Examination</td><td>Orientation, recall, calculation, naming, attention, executive function</td><td>http://medschool.slu.edu/agingsuccessfully/pdfsur.veys/slussexam_05.pdf</td></tr><tr><td>Montreal Cognitive Assessment (MoCA)</td><td>Orientation, recall, attention, naming, repetition, verbal fluency, abstraction, executive function, visuospatial</td><td>Developers require training/certification to administer, score and interpret. www.mocatest.org</td></tr><tr><td>Folstein Mini-Mental Status Examination</td><td>Orientation, registration, attention, recall, naming, repetition, 3-step command, language, visuospatial</td><td>Copyrighted document for purchase: www.minimental.com</td></tr></table> DIFFERENTIAL DIAGNOSIS <table><tr><td>Normal Aging</td><td>Mild Cognitive Impairment</td><td>Alzheimer Dementia (DSM-5 Diagnostic Criteria)</td></tr><tr><td>Mild decline in memoryMore effort/time needed to recall new infoNew learning slowed but well compensated by lists, calendars, etc. Decreased efficiency in divided attention tasks (ie multi-tasking)No impairment in social and occupational functioning</td><td>Subjective complaint of cognitive decline in at least one domain of memory, executive function, language or visuospatial perceptionCognitive decline is noticeable and measurable (see screening instruments)No impairment in social and occupational functioning</td><td>Significant objective decline in memory and learning in one or more cognitive domain of disturbed executive functioning, language, visuospatial ability, perceptual motor abilityThe cognitive decline is steady and progressive.The cognitive deficits interfere with independence in everyday activities.Other medical and psychiatric conditions, including delirium, have been excluded</td></tr></table> <table><tr><td></td><td>Alzheimer Disease</td><td>Vascular Dementia</td><td>Lewy Body Dementia</td><td>Frontotemporal Dementia</td></tr><tr><td>Onset</td><td>Gradual</td><td>Sudden or stepwise</td><td>Gradual</td><td>Gradual (age of onset <65)</td></tr><tr><td>Cognitive domains and symptoms</td><td>Memory, difficulty learning, language, visuospatial, managing complex tasks</td><td>Depends on location of ischemia</td><td>Memory, visuospatial, visual hallucinations, fluctuating symptoms; REM sleep behaviors; extreme sensitivity to neuroleptic medication</td><td>Executive dysfunction, personality changes, disinhibition, language, ± memory</td></tr><tr><td>Motor symptoms</td><td>Rare early Apraxia later</td><td>Correlates with ischemia</td><td>Parkinsonism, present at time of onset of cognitive changes; frequent falls</td><td>None</td></tr><tr><td>Progression</td><td>Gradual (over 8-10 yr)</td><td>Gradual or stepwise</td><td>Gradual, but faster than Alzheimer's disease</td><td>Gradual, but faster than Alzheimer disease</td></tr><tr><td>Imaging</td><td>Possible global atrophy</td><td>Cortical or subcortical ischemic changes on brain MRI</td><td>Possible global atrophy</td><td>Atrophy in frontal and temporal lobes</td></tr></table> HISTORY OF PRESENT ILLNESS ■ Document cognitive domains affected; interview patient and family or other informant. ■ Document time course of onset and progression of cognitive and motor symptoms. ■ Document time course of onset and progression of impairment in social and occupational functioning. ■ Impairment in social and occupational functioning may be evidenced by impairment in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ■ Exclude depression (see Screening, AGS Geriatrics Evaluation and Management: Depression). ■ Exclude delirium (see Screening, AGS Geriatrics Evaluation and Management: Delirium). PAST MEDICAL HISTORY ■ Possible risk factors for Alzheimer disease include advancing age, history of head trauma, late-onset major depressive disorder, fewer years of formal education, risk factors for cardiovascular disease, and family history of Alzheimer disease in first-degree relative. FAMILY HISTORY ■ Most commonly Alzheimer disease begins late in life, after age 65. ■ Rare forms of familial Alzheimer disease begin before age 60. Dementia.indd 1 4/2/21 8:36 AM <table><tr><td>SOCIAL HISTORY</td><td>Document educational level primary language, work history, living arrangement, substance use and abuse, driving, firearms, and caregiver stress/ adequacy of caregiver support.</td></tr><tr><td>REVIEW OF SYSTEMS</td><td>Screen for behavioral disturbances such as wandering, self-neglect, physical aggression, hallucinations, delusions, etc. (see Screening, AGS Geriatrics Evaluation and Management: Behavioral Disturbances in Dementia).</td></tr><tr><td>MEDICATIONS</td><td>Thoroughly review medications and decrease or discontinue medications that increase cognitive, physical, or functional disability. Discontinue non-essential medications in late-stage disease. (see AGS Geriatrics Evaluation and Management: Appropriate Prescribing).</td></tr><tr><td>PHYSICAL EXAMINATION</td><td>Comprehensive physical exam with focus on neurologic exam to characterize dementia subtype or exclude treatable conditions that cause or exacerbate cognitive impairment:Gait (Lewy body dementia, normal-pressure hydrocephalus)Motor function (vascular dementia)Reflexes (vascular dementia)Extrapyramidal signs: rigidity, tremor, bradykinesia (Lewy body dementia)</td></tr><tr><td>DIAGNOSTIC TESTING</td><td>Evaluate for potentially reversible causes of cognitive loss:Complete blood countComprehensive metabolic panelVitamin B12/folateThyroid-stimulating hormoneIf indicated, consider serologic tests for syphilis and HIV.Neuroimaging, such as brain CT or MRI without contrast or FDG PET, may be useful if:Onset <65 years oldSymptoms begin suddenly or progress rapidlyEvidence of focal or asymmetrical neurologic deficitsClinical picture suggests normal-pressure hydrocephalus (eg, onset has occurred within 1 year, gait disorder or unexplained incontinence is present)History of recent fall or other head trauma</td></tr><tr><td>MANAGEMENT STRATEGIES</td><td>Evaluate for persistence of cognitive dysfunction after discontinuing or decreasing dosages of medications that affect cognition, treating depression and delirium, and treating potentially reversible causes of cognitive loss (see “Diagnostic Testing” above).Primary treatment goals for patients with dementia are to enhance quality of life and maximize functional performance by improving or stabilizing cognition, mood, and behavior. Both to the extent possible, nonpharmacologic and pharmacologic treatments are available.Provide patient and/or caregiver with information regarding:Dementia diagnosis, prognosis, and associated behavioral symptomsEnvironmental modifications and communication strategiesHome safety (fall prevention, firearm safety, wandering prevention, etc)Medication managementAdult day care and respite staysSupport groups and classes for caregiversAdvance care planning and advance directives, including establishing a surrogate decision-makerExamples of resources for education and supportAlzheimer's Association (www.alz.org)Family Caregiver Alliance (www.caregiver.org)Alzheimer's Disease Education & Referral Center (www.nia.nih.gov/Alzheimers)</td></tr><tr><td>Considerations before initiation of treatment with cholinesterase inhibitors (ChIs):</td></tr><tr><td>Alzheimer disease</td><td>Studies have shown modest clinical benefits for short- and long-term treatment with ChIs.Treatment for 6 months with ChIs improved cognitive function on average only 2.7 points on the 70-point Alzheimer's Disease Assessment Cognitive Subscale, and showed small improvement on measures of ADLs and behavior.Memantine is FDA approved for moderate-severe Alzheimer disease as a single agent or in conjunction with Chl.</td></tr><tr><td>Vascular dementia</td><td>Widespread treatment with ChIs is not recommended because of limited cognitive benefits.Discussion of initiation of stroke prophylaxis medications is recommended for patients with mild to moderate vascular dementia, because vascular risk factors can worsen cognitive impairment and increase mortality.</td></tr><tr><td>Lewy body dementia</td><td>Some studies suggest ChIs may help manage attention and behavioral disturbances (avoid neuroleptics because of extreme sensitivity).</td></tr><tr><td>Frontotemporal dementia</td><td>There appears to be no role for ChIs, because evidence suggests they may worsen agitation.</td></tr><tr><td>Patients and families should be counseled to have realistic expectations regarding treatment with ChIs.Clinical evaluation after 6 months of ChI therapy is suggested to evaluate progression of disease and efficacy of treatment.Tapering off ChIs should be considered after a reasonable time if decline continues at the rate expected without treatment or when patients have an initial positive response to treatment followed by continued cognitive decline despite maximal treatment. Abrupt discontinuation of ChIs is not recommended.No consistent, proven cognitive benefit from vitamin E, Ginkgo, antioxidants, omega-3 fatty acids or medium-chain triglycerides.</td><td></td></tr><tr><td>REFERRAL</td><td>Refer patients with newly diagnosed dementia for a driving assessment or advise them not to drive, depending on severity of impairment.Full neuropsychologic testing may be needed to accurately define the character and severity of the cognitive deficits, especially in atypical cases or when presentation may be confounded by a high level of education or subtle changes.</td></tr></table> Copyright © 2021 American Geriatrics Society. Dementia.indd 2 4/2/21 8:36 AM