#201: Dementia Part 1: Gray Matters Segment

[SPEAKER_00]: The following has meant to be for medical education and not formal medical advice. [SPEAKER_00]: Remember to always consider the patient in front of you, especially with matters that's gray as these. [SPEAKER_00]: The views expressed in this episode don't reflect the views of any affiliated institutions.

[SPEAKER_05]: I think a lot of folks really shy away from addressing cognitive impairment because it often feels so hopeless because many of these diagnoses are really devastating and don't have the greatest treatments, but you're really doing everyone a disservice and propelling the patient towards a crisis point when there's a lot that can be done to prevent that crisis. [SPEAKER_00]: Welcome to Gray Matters, where we unpack how medical management is rarely black or white.

[SPEAKER_02]: And go on, lots of deep dives along the way. [SPEAKER_00]: I'm Dr. Nick Philano, and today I'm joined by a new friend. [SPEAKER_02]: Hey, Nick. [SPEAKER_02]: Hey, everyone. [SPEAKER_02]: I'm Dr. Indu Parth, a general internist and PCP at the University of Arizona College of Medicine Tucson and Banner University Medicine. [SPEAKER_00]: Alright, Indu, it's great to be here with you. [SPEAKER_02]: I am so excited to be joining you today, Nick.

[SPEAKER_02]: This is my first Korean podcast, and I honestly just can't believe it. [SPEAKER_02]: I have been a longtime listener and now a first time host. [SPEAKER_00]: Yeah, super exciting.

[SPEAKER_00]: And that opening sound by definitely hit pretty hard for me. [SPEAKER_00]: Sounds like you're bringing a pretty tough case to us today. [SPEAKER_02]: Yeah, tough, but common and important. [SPEAKER_02]: We took care of a patient and resident clinic a while ago, who's routine follow-up turned into a pivot and redirect. [SPEAKER_02]: But honestly, Nick, I think many of our listeners are going to relate to this story. [SPEAKER_00]: OK, I'm definitely hooked.

[SPEAKER_00]: Tell me more. [SPEAKER_02]: So let me introduce you to Ms. Wiseneck. [SPEAKER_02]: She was a 77-year-old woman we were following regularly in our internal medicine residency continuity clinic for hypertension, which had been well controlled until one day it just suddenly wasn't. [SPEAKER_02]: The resident and I were caught off guard.

[SPEAKER_02]: Ms. [SPEAKER_02]: Wise was consistent and we knew her well, but now she was very confused about what her home medications and blood pressures were. [SPEAKER_02]: And she hadn't done any of the nursing follow-up that we had suggested at her last visit. [SPEAKER_00]: As soon as you're really jarring, I mean, you said you knew this patient really well, knew sort of their adherence and how they had been, you know, pretty regular about following up.

[SPEAKER_00]: What do you think change for them? [SPEAKER_02]: Yeah, we were caught off guard and just equally confused. [SPEAKER_02]: It just wasn't our blood pressure. [SPEAKER_02]: It was sort of like the visit started going sideways. [SPEAKER_02]: I mean, we were repeating the same instructions. [SPEAKER_02]: We had given on our last visit. [SPEAKER_02]: And I was just wondering if perhaps we had been clear enough for our plan was too complicated.

[SPEAKER_02]: We tried to keep asking her different types of questions, but our answers kept going off topic and didn't really make sense. [SPEAKER_02]: And then it hit me. [SPEAKER_02]: I was wondering, maybe this was an issue with her mind. [SPEAKER_02]: Did she have a cognitive deficit we hadn't picked up on? [SPEAKER_00]: Oh, man. [SPEAKER_00]: So you're trying to work through her blood pressure. [SPEAKER_00]: And now you start worrying about her memory. [SPEAKER_00]: That is a can of worms.

[SPEAKER_00]: And to be honest, I really don't know where to start with it. [SPEAKER_00]: I mean, what do you do now? [SPEAKER_00]: Do you stick to your original plan, go through her chronic medical issues, or do you really have to get into the memory issues now? [SPEAKER_02]: Yeah, I mean, we were getting a bit anxious and overwhelmed too. [SPEAKER_02]: Do we need to make this into a memory visitor? [SPEAKER_02]: Could we just wait until her annual wellness exam?

[SPEAKER_02]: I mean, I know that this is a scenario that happens to a lot of us, and I knew I needed some help. [SPEAKER_02]: So it was great to sit down with some wonderful geriatricians to make this all just a bit more manageable. [SPEAKER_02]: So let's head to our first deep dive.

[SPEAKER_05]: I think when you start to have the suspicion is when it becomes the primary issue that you have to manage, and everything else has to take a back seat. [SPEAKER_05]: It doesn't matter to me if you're concerned that this person may have an active malignancy and needs a work up, if you have not addressed the elephant in a room that their brain may not be functioning the way it used to, they will not be able to fall up on whatever beautiful plan you create to work up that other issue.

[SPEAKER_05]: and you have to identify one what is going on to what the severity is and three what resources they have and please inform for what resources they need to be able to manage their health going forward. [SPEAKER_05]: So it takes primacy. [SPEAKER_02]: That is Dr. Laura Perry who we also heard at the top of the episode. [SPEAKER_05]: My name's Laura Perry. [SPEAKER_05]: I am the Springs Living Regional Chair of Geographic Medical Education for Providence in Oregon.

[SPEAKER_02]: So, I mean, I get what Dr. Perry is saying. [SPEAKER_02]: We usually have an agenda for a visit, and then when something new and not easy to tackle like cognitive impairment comes up, it can be really tempting just to push it off to the next visit. [SPEAKER_02]: But, you know, right now we needed to acknowledge that cognitive impairment was Ms. [SPEAKER_02]: Wise's most critical problem.

[SPEAKER_00]: Right, and I mean, even if it's not easy to tackle and takes time, I mean, you could argue that's even more reason to get the ball rolling, right? [SPEAKER_05]: to work up cognitive impairment, come up with a diagnosis and a plan, is going to take on average about three to four visits. [SPEAKER_05]: And I like to divide that process up into what am I getting accomplished this time? [SPEAKER_05]: What do I need to do in the intervisit care?

[SPEAKER_05]: How can my clinic team support me and getting those things done? [SPEAKER_05]: And how can I plan for a successful next visit? [SPEAKER_02]: So I felt a lot better hearing this. [SPEAKER_02]: Yeah, we need to address the elephant in the room, [SPEAKER_02]: Hey, we don't need to figure it all out now. [SPEAKER_02]: It may take up to three or four visits. [SPEAKER_00]: Okay, so we're just getting started and we can take this in pieces that's definitely reassuring.

[SPEAKER_00]: But we're definitely gonna need to start somewhere, right? [SPEAKER_00]: Asking the patients some questions. [SPEAKER_00]: I mean, that's why I think this feels hard to me. [SPEAKER_00]: I mean, like, how do you ask someone questions about their memory without them feeling defensive at best and maybe even insulted at worst? [SPEAKER_05]: asking about cognitive health as part of my general review of systems. [SPEAKER_05]: And I have two questions that I do as part of that.

[SPEAKER_05]: One, I ask, you know, how's your brain? [SPEAKER_05]: I think that that is a less charged way of asking rather than saying how's your memory because neurodegenerative dementia's don't just incorporate memory that also can include things like organization, executive function, mood. [SPEAKER_00]: How's your brain, really? [SPEAKER_00]: I was imagining something a little less, I don't know, very direct, I mean, does that work?

[SPEAKER_02]: Yeah, believe it or not, it gets some pretty straightforward responses. [SPEAKER_02]: Like, I just don't think I'm as sharp as I used to be. [SPEAKER_00]: Hmm. [SPEAKER_00]: Yeah, I mean, I get that. [SPEAKER_00]: I think if the patient has some insight, that can be super helpful. [SPEAKER_00]: But, you know, like we see for a lot of issues, I could also imagine the patient saying, I'm fine. [SPEAKER_02]: Right.

[SPEAKER_02]: But then we see the adult child or the spouse vigorously shaking their head and disagreement in the background, basically saying, no, they are not fine. [SPEAKER_00]: Yeah. [SPEAKER_00]: I've definitely seen that before. [SPEAKER_00]: I mean, these stories never just have one side.

[SPEAKER_02]: Yeah. [SPEAKER_02]: They never do, but Dr. Perry offered a really good piece of advice where she said, she just redirects the conversation saying something like, I see your daughter disagrees, do you mind if I get her perspective on what's going on? [SPEAKER_00]: I like that. [SPEAKER_00]: That's kind of a respectful way of getting a collaborative history. [SPEAKER_00]: You're not dismissing the patient. [SPEAKER_00]: You're including the family.

[SPEAKER_05]: The other question that I ask about is how is your sleep? [SPEAKER_05]: Because there's so many other factors that can lead to cognitive impairment, often the best sort of gateway into that conversation is talking about sleep, which is such a problem for so many people and what I will tell people is sleep is nature's best medicine for the brain. [SPEAKER_05]: If you're having trouble sleeping, of course you're not going to feel your smartest or your sharpest.

[SPEAKER_00]: I would love it if all of our podcasts just end up being an advertisement for sleep. [SPEAKER_00]: I mean, who doesn't love sleep? [SPEAKER_00]: But, you know, I mean, to be serious, asking about sleep is going to help us in a few ways, right? [SPEAKER_00]: I mean, sleep apnea is super common and it's been associated with the higher risk of dementia. [SPEAKER_00]: Even if the evidence of how treating an effects dementia risk is not super clear yet.

[SPEAKER_00]: Also, sleep arousal issues, like acting out dreams while sleep or restless likes syndrome, can be seen in a specific type of dementia, Louis body dementia. [SPEAKER_02]: So it seems pretty clear that we need to ask about brain and sleep health to get a quick snapshot into our patient's cognitive health. [SPEAKER_02]: But we've got to keep in mind that there are other things that can impact our patient's brains.

[SPEAKER_02]: And though there are lots of things we could be highlighting, I think three super common and low hanging fruit that we can address today are medications hearing and depression. [SPEAKER_04]: I think I really like to specifically ask patients, do you take it over the counter medicines? [SPEAKER_04]: And I might even specifically say, do you take anything for sleep? [SPEAKER_04]: Do you take Tylenol PM? [SPEAKER_04]: Because I think people just don't think about it.

[SPEAKER_04]: And sometimes, you know, if they bring all their bag of medicines in and you find enough anti-chlorine or drug medicines, there's a lot of potential to improve their cognition. [SPEAKER_04]: That's Nurse Practitioner, Mary Beth Kubrick, our next discussant. [SPEAKER_04]: I'm Mary Beth Kubrick. [SPEAKER_04]: I'm a Nurse Practitioner Providence Health in Portland, Oregon.

[SPEAKER_04]: I also help lead our Devension Aviation Service, which aims to better support caregivers of people with dementia. [SPEAKER_00]: So, talking about medications reminds me when we were initially workshopping this episode. [SPEAKER_00]: A friend of the pod, Dr. Emily Satron, told us about a patient who was taking nightly benedrial to sleep, Emily stopped it, and basically her signs of cognitive decline completely clear.

[SPEAKER_00]: I mean, that was like super notable to me, the effect of medication can have. [SPEAKER_00]: And it's also surprising how many of these P.M. medications have dive and hydramine, or another first-generation antihistamine in them. [SPEAKER_02]: Yeah, you're reminding us of what we should always be doing. [SPEAKER_02]: A thorough prescription and over-the-counter medication reconciliation.

[SPEAKER_02]: I mean, we had a patient who complained to us that she was just feeling so foggy headed every single day. [SPEAKER_02]: We ended up stopping her oxybuton and boy what a difference. [SPEAKER_02]: She was so grateful to us for making her feel so much better. [SPEAKER_02]: Another quick and easy thing to do, Nick. [SPEAKER_02]: Check your patients hearing.

[SPEAKER_05]: There's an increasing wealth of literature that's come out over the last five or ten years showing that we have this window of opportunity with hearing loss that there's a very strong two-way relationship between hearing loss and how our brain functions. [SPEAKER_05]: And if you catch someone in this window of opportunity and get them hearing aids that they use consistently, you can actually reverse cognitive decline.

[SPEAKER_05]: But if you wait too long and the brain goes without that input that it needs to function properly, eventually you will have irreversible neurodegenerative disease. [SPEAKER_02]: Another thing we just should not forget to do is to screen for depression. [SPEAKER_02]: A person's mental health has a tremendous effect on the brain and cognition, and this phenomenon is called pseudo dementia.

[SPEAKER_02]: So we need to make sure we screen all our patients with tools like the PHQ2 or the PHQ9, and this will really help us figure out if our patient needs referral to mental health services or referral for dementia care. [SPEAKER_00]: That's such a great point, but, okay, just to reorient us, we've looked at our patients sleep, we've looked at their med lists, we've assessed them for hearing loss and depression.

[SPEAKER_00]: Let's say we've done all that, and maybe we've found some things, but we're still worried something else is going on. [SPEAKER_00]: I feel like we need to back up that worry about some kind of cognitive impairment with something a little more objective, like measuring their memory in some way. [SPEAKER_02]: Yeah, I mean, I think we all do much better with numbers and certainties.

[SPEAKER_02]: So we definitely need to find something objective to document our patient's cognitive decline. [SPEAKER_01]: So the mini cog takes probably two, three minutes to do. [SPEAKER_01]: It's basically a three word recall and a clock drawing task. [SPEAKER_01]: It can tell you if there is, you know, something suspicious here for either dementia, or if it's overt, or at least some degree of cognitive impairment. [SPEAKER_02]: That's Dr. Gadbarshall, our third and final discussant.

[SPEAKER_01]: I'm a god-mushal. [SPEAKER_01]: I'm a behavioral neurologist in Boston, and I'm the director of clinical trials at the Center for Alzheimer Research and treatment at breakout. [SPEAKER_00]: Okay, I'm going to start with a mini-cug. [SPEAKER_00]: I mean, it sounds like it's short. [SPEAKER_00]: It's easy to add on, and it can be administered by clinic staff.

[SPEAKER_00]: But if this is a screening test, I'm guessing if the mini-cug is positive, we still need to do more detail testing to confirm it, right? [SPEAKER_02]: right. [SPEAKER_02]: Let's offer get that our clinical concern is a screening tool to neck. [SPEAKER_02]: If a patient shows signs of cognitive decline or has a diagnosis already, we really shouldn't be reassured that the mini-cog is normal. [SPEAKER_02]: We need to follow up on our clinical intuition.

[SPEAKER_02]: And once the issue is found, we really do need to bring our patient back for a formal focus on memory loss. [SPEAKER_00]: got it. [SPEAKER_00]: So maybe I could take a stab at summarizing this deep dive. [SPEAKER_00]: Basically, if something makes us worried about our patient's cognitive health, we should start by just asking them directly about their brain health.

[SPEAKER_00]: Then we should ask them about their sleep health, you know, dive into any sleep habits to make sure they're doing a good job there and look out for an octurnal symptoms. [SPEAKER_00]: Then we should screen their medication list, including over the counter medications for anything that can affect cognition, especially anti-colonurgics, not forgetting that a lot of sleep aids like Tylenol PM and Benadryl have these anti-colonurgic effects.

[SPEAKER_00]: The last two things, make sure that you test your patients hearing and you screen them for depression. [SPEAKER_02]: fantastic. [SPEAKER_02]: I think we've got our listeners up to speed and we're going to head back to his wise. [SPEAKER_02]: So she was not on any concerning medications and her hearing was fortunately fine. [SPEAKER_02]: But as far as her many colleagues was concerned, there were problems. [SPEAKER_02]: She only had one word recall, but the clock draw was fine.

[SPEAKER_02]: So my resident night, we're really glad that we had paid attention to that initial instinct that something was wrong with our memory. [SPEAKER_02]: But if I'm being honest, we now sort of felt like we had opened up Pandora's box. [SPEAKER_02]: Basically, we were at that now what do we do moment? [SPEAKER_00]: Yeah, I totally empathize with that and I agree like I'm convinced something's going on with your patient too, but I don't really know where we go from here.

[SPEAKER_00]: I mean, are we testing for dementia now? [SPEAKER_00]: Is this whatever the heck mild cognitive impairment is? [SPEAKER_02]: Yeah, I think a lot of us wonder how we're supposed to quantify or qualify something that has been traditionally such a clinical diagnosis. [SPEAKER_02]: We don't have a biopsy, we don't have an echo that can help us stage or grade our patient symptoms. [SPEAKER_02]: This led me to our second deep dive.

[SPEAKER_02]: What tools should we use to characterize and stage cognitive decline?

[SPEAKER_05]: One of the most common errors that we see in caring for someone with dementia is that people assume that dementia is like an on-off switch you either have it or you don't. [SPEAKER_05]: But it is a progressive disease and the most important part of caring for someone with dementia is figuring out where on that spectrum are they that's going to determine everything about how you care for them. [SPEAKER_02]: Nick let's talk about one end of the spectrum.

[SPEAKER_02]: Have you ever had a patient or a friend come and talk to you with worries about their memory? [SPEAKER_02]: But then when you ask more questions, you realize that their day-to-day life really isn't being affected? [SPEAKER_00]: Oh yeah, definitely. [SPEAKER_00]: Like, they forgot why they went into a room or maybe they can't remember the name of an actor and a TV show they used to know. [SPEAKER_00]: But you know, generally seem fine.

[SPEAKER_00]: Like, I can't remember [SPEAKER_02]: Yeah, I think this is really common and happens to the best of us. [SPEAKER_02]: And when we do the testing, the minicog is normal, this is what we call subjective cognitive decline. [SPEAKER_00]: Okay, so subjective cognitive decline is that family member who's worried about their memory, but there isn't any like clear pathology, at least not yet, and this can definitely be a part of just normal aging, I imagine.

[SPEAKER_00]: So if that's subjective cognitive decline, there must be an [SPEAKER_02]: there is. [SPEAKER_02]: And I really hope our listeners by the end of this podcast understand how to properly classify objective cognitive decline. [SPEAKER_02]: So someone with mild cognitive impairment or MCI is going to have some objective changes like a lower score on a cognitive test.

[SPEAKER_02]: And their daily function is generally preserved, but others in their lives may have noticed some changes like forgetting recent conversations. [SPEAKER_00]: Okay, so, mild cognitive impairment sounds like there's more cognitive impairment than subjective cognitive decline that makes sense, and it sounds like there's maybe some functional issues, but nothing too severe.

[SPEAKER_00]: That sounds a little bit clearer to me now, and then is the stage after that of someone progresses dementia. [SPEAKER_02]: Yes. [SPEAKER_02]: So I learned that the DSM5 has replaced the term dementia with major neural cognitive disorder in an effort to kind of reduce the stigma that's associated with the word and to better reflect the spectrum of severity.

[SPEAKER_02]: So a person who is diagnosed with major neural cognitive disorder will have [SPEAKER_02]: and their objective cognitive testing, and these are folks whose daily lives are actually impacted in a way that others have noticed. [SPEAKER_02]: They might not be able to manage their medications or they may get lost while they're driving. [SPEAKER_02]: These are the folks that are going to maybe need assistance with dressing or toileting.

[SPEAKER_00]: Okay, so if I was to lay out the spectrum of objective cognitive decline, it was start with mild cognitive impairment and the new progressed to major neuro cognitive disorder and then within major neuro cognitive disorder or dementia, you would have mild moderate and severe disease. [SPEAKER_02]: Yes, that's exactly right.

[SPEAKER_02]: And if nothing else, I hope our listeners come away with a really clear understanding of these various buckets and describing their patient's cognition. [SPEAKER_00]: Yeah, it can definitely be confusing. [SPEAKER_00]: I mean, we have disorders, declines, impairments, but maybe you just put this little more simply. [SPEAKER_00]: It sounds like subjective cognitive decline is, I feel slower, but testing is normal.

[SPEAKER_00]: In mild cognitive impairment, it's a case of IAM slower and the tests reflect that, but I'm still functioning independently. [SPEAKER_00]: And then with major neurocognitive disorder dementia, it's IAM slower, but also I can't manage my life without help. [SPEAKER_02]: That's exactly it. [SPEAKER_00]: Okay, that makes more sense. [SPEAKER_00]: But I just the question I have is like, are people progressing through these stages in a really reliable way?

[SPEAKER_00]: Like if someone has mild dementia, can we expect in like three or six months, or whatever it might be that it's gonna be moderate? [SPEAKER_02]: You know, this is really the hard part when counseling patients. [SPEAKER_02]: I wish there was some kind of standard example or template that we could provide to our patients to let them know how their dementia trajectory is going to play out. [SPEAKER_02]: But there are just so many factors that can influence this.

[SPEAKER_02]: Like age, a person's baseline cognitive function, nutritional status, exercise, blood pressure obesity. [SPEAKER_02]: So while we can tell our patients that yes, unfortunately your cognition is going to decline over time, we just unfortunately cannot really predict how fast this is going to happen or which domains of the brain function are going to be impacted first. [SPEAKER_00]: Oh man, that's unfortunate, but it does make some sense.

[SPEAKER_00]: So I guess now we should really get into some tests to figure out where on that spectrum our patient is, right? [SPEAKER_00]: I mean, I think this is gonna be really useful. [SPEAKER_00]: But I'm also a little bit worried because I know that there's approximately like, I don't know, 300 give or take tools for testing cognitive impairment and that kind of frightens me. [SPEAKER_00]: Where do we go from here and do?

[SPEAKER_02]: Yeah, maybe not quite 300 tests, Nick, but there are a lot and a lot of acronyms to learn. [SPEAKER_02]: And sometimes it just feels like further testing takes so much time and it's hard to administer. [SPEAKER_02]: But honestly, it's really worth the effort for our patients. [SPEAKER_02]: This data can be used over time to let us know where our patients were. [SPEAKER_02]: The last visit compared to where they are now.

[SPEAKER_02]: and from a resource standpoint, it might allow them to get approved for work up or medications as well. [SPEAKER_00]: Okay, well, sounds like it's definitely needed then. [SPEAKER_00]: So I've heard of the mocha and the mini mental status exam should we be using those and like how are they even different? [SPEAKER_02]: Yeah, so both the mocha and the MMSC can be used to pick up and track cognitive decline, but the mocha is actually more sensitive to early disease.

[SPEAKER_02]: And there was actually a study in JAMAIM that showed really great sensitivity for the mocha in picking up. [SPEAKER_02]: MCI actually 89% so I think of varies from clinic to clinic. [SPEAKER_02]: You sort of pick one screening and just stick with it. [SPEAKER_02]: Our clinics use the mocha and just follow our patients over time using that same screening. [SPEAKER_00]: Okay, wow. [SPEAKER_00]: I didn't know that.

[SPEAKER_00]: So it sounds like there's some, you know, maybe just choice based on where you practice, but for a patient like Ms. [SPEAKER_00]: Wise, where this is the first time that you're really wondering if they have cognitive decline, that maybe a time that a mocha could be helpful because it's more sensitive for early or mild cognitive impairment, right? [SPEAKER_02]: Exactly, and that's what we chose to do with Ms. [SPEAKER_02]: Wise.

[SPEAKER_02]: We administered the mocha, and just to remind you and our listeners, the mocha score is going to tell you the severity of the cognitive impairment and the different questions that are asked are going to tell you which and how many of the key domains are affected in your patient. [SPEAKER_00]: Okay, that's really good to know. [SPEAKER_00]: So we're not just getting a number, we're sort of getting this like vertical slice of our patients' health.

[SPEAKER_00]: I mean, it really feels like you're getting sort of a snapshot of like a point in time. [SPEAKER_00]: So naturally, I would think then that we're not just doing this once. [SPEAKER_00]: We're sort of doing this over and over for our patient to sort of see what direction they're going and how fast they're going down it. [SPEAKER_00]: Does that sound right? [SPEAKER_02]: Yeah, the Moca and MMSC are great cognitive tests, but there are limitations to both of them.

[SPEAKER_02]: We need to keep in mind that the tests may be biased towards those who are more educated and those who come from a Western cultural background. [SPEAKER_02]: We have to keep in mind that you can adjust the Moca score up to a point if they have less than a high school education. [SPEAKER_02]: And I do want to introduce two other cognitive tests, Nick, the slums test and the RUDOS test.

[SPEAKER_02]: We're going to link these in the show notes, but these slums test can be more inclusive of those cross different educational backgrounds, and the RUDOS can be more inclusive across different cultural backgrounds. [SPEAKER_00]: Oh wow, I never knew we had those options. [SPEAKER_02]: there are a lot of options, but which test we choose is actually not the only source of bias. [SPEAKER_02]: It's also about the context in which the test was administered.

[SPEAKER_02]: We have to think about the patient where they wearing their glasses, their hearing aids when they took the test, where they mildly delirious in the hospital setting versus at their baseline in the office. [SPEAKER_00]: Yeah, that's a great point. [SPEAKER_00]: One of our discussions Mary Beth actually talked about a time that a patient scored a 16 at a 30 on the slums test. [SPEAKER_00]: That's when they were in the hospital.

[SPEAKER_00]: But then when she read it in the office, they scored a 20 at a 30. [SPEAKER_02]: Yeah, that's a good reminder, Nick, for us to maybe write a qualifier next to a cognitive score. [SPEAKER_02]: Maybe we're indicating that this is their score in the hospital or wearing their hearing aids or missing their glasses.

[SPEAKER_00]: right and even if we choose the right test and we have a qualifier saying exactly how the test was done, the other source of bias to remember is that this test doesn't tell us exactly what our patients can do.

[SPEAKER_00]: I remember one patient that I cared for who's mocha score was a bit on the lower side, so when I went in, I was worried about is this person going to be able to take care of themselves at home, but I was kind of surprised because the family was just telling me, yeah, they're living independently and they're caring for themselves

[SPEAKER_00]: So the chart made it seem like he was doing worse than he really was and really reminds me that we sometimes miss functional status with this cognitive testing. [SPEAKER_05]: So the number one thing I want to see on the problem is under the diagnosis of dementia is what is their fast stage. [SPEAKER_05]: There are various scales used for the severity of dementia. [SPEAKER_05]: I'd say the fast scale is the most commonly used one again because it focuses on function.

[SPEAKER_05]: What can this person still do? [SPEAKER_05]: And that's something that I [SPEAKER_00]: Sorry, what is the fast skill? [SPEAKER_00]: I hear fast, and I'm reaching for the ultrasound. [SPEAKER_02]: Oh man, thankfully, no ultrasound needed here, Nick. [SPEAKER_02]: I would be in huge trouble.

[SPEAKER_02]: So fast actually stands for functional assessment, scale tool, and there are stages, one through seven, that basically describe what a patient can do with respect to their activities of daily living. [SPEAKER_05]: I tell them, think about what a child learns how to do as it's going from infant to toddler to child to teenager to eventually adult and think about how sophisticated their brain is at each of those times.

[SPEAKER_05]: In a lot of ways, in dementia, you lose those cognitive abilities and the functions that come with them in approximately the order that you learn them in reverse over approximately a similar time period. [SPEAKER_00]: Yet capturing all this information for a patient with cognitive issues, it can feel intimidating, but our awesome, core-IM friend and geriatrician Dr. Brooklyn Ski had a great recommendation.

[SPEAKER_00]: She recommends including a one-line or in a patient's chart that tells providers where is the patient living, what stage of cognitive impairment are they in, and what is their functional status? [SPEAKER_00]: What can they do? [SPEAKER_02]: Can I tell you how much I loved this tip? [SPEAKER_02]: I find it just so useful to develop this sort of functional status one liner using a current fast score or even just a description of what our patient is able or unable to do.

[SPEAKER_02]: And some theory traditions I talked to actually say that when dementia gets more advanced, they kind of stop using the mocha or MMSE and the functional description really becomes the main thing that they're following.

[SPEAKER_02]: So, for example, Ms. [SPEAKER_02]: Wise is a 77-year-old woman living alone in a trailer with a mocha of 24 out of 30 and a fast score of 4. [SPEAKER_02]: or maybe you say a 77-year-old woman living alone who was independent of her ADLs but needs assistance with medication management, appointment making and paying bills. [SPEAKER_00]: This would be so helpful for me when I'm admitting a patient and knowing exactly what it's changed from their baseline.

[SPEAKER_00]: I, as a hospitalist, I feel very seen right now. [SPEAKER_00]: But okay, so if we want to describe exactly what a patient can do, something we can use this fast tool or you said we can just sort of describe what ADLs or ideals they can do, right? [SPEAKER_00]: But can you remind me one more time? [SPEAKER_00]: What exactly are ADLs and I ADLs? [SPEAKER_02]: Thanks for asking Nick because I think it's really important to remember the difference between ADLs and IADLs.

[SPEAKER_02]: So ADLs are those activities that one needs to take care of themselves, bathing, dressing, eating, toileting and transferring. [SPEAKER_02]: And my patient Ms. [SPEAKER_02]: Wise was okay in this regard. [SPEAKER_02]: I ADL from the instrumental activities of daily living are the activities that one needs to take care of their life, managing medications and finances, preparing meals, housekeeping and driving, and this is where Ms. [SPEAKER_02]: Wise needed help.

[SPEAKER_00]: You know, this is a callback for me to the five pearls episode in geriatric care and, you know, they talked about how a patient not trimming their toenails can actually be an indication of functional independence. [SPEAKER_00]: I mean, it sounds arbitrary, but these are things that we need to do to maintain our daily health and some of these things can really be early science.

[SPEAKER_00]: So it sounds like speaking practically, I can imagine asking someone about, you know, can you prepare meals? [SPEAKER_00]: It can be useful because if they can't, maybe you look into like meal services. [SPEAKER_00]: But like, as you collect all this information, are you like using it holistically in any other way? [SPEAKER_02]: I think we need to keep in mind, Nick, that history is really key in our patients with dementia.

[SPEAKER_02]: It's going to allow us to see what's happened and what's changed with our patients the last time we saw them. [SPEAKER_02]: Do they need more help now? [SPEAKER_02]: Are there safety concerns that didn't exist before? [SPEAKER_02]: Understanding the changes in ADLs and IADLs is really going to help me know what I need to plan for next. [SPEAKER_00]: that's really helpful.

[SPEAKER_00]: So it sounds like what we're saying here is that we really have two buckets to think about for these patients. [SPEAKER_00]: The first bucket is all about tracking someone's cognitive status using tools like the mocha or the MMSC over time. [SPEAKER_00]: And the second bucket are the tools we have to track someone's functional status, whether that's something formal like the fast, or even just a direct review and description of their ADLs and IDLs.

[SPEAKER_00]: So the next clinic note, the next discharge summary that you're writing, try to actually include both these buckets and describe what you're actually seeing in the patient from a cognitive and functional standpoint. [SPEAKER_02]: perfectly said, Nick, I think one of the things that I really find with taking care of a patient with dementia is that our questions can lead to more questions.

[SPEAKER_02]: We had identified the places where Ms. [SPEAKER_02]: Wise needed help, but there was just no way for us to make it happen. [SPEAKER_02]: We couldn't move in with her to ensure she was taking care of herself.

[SPEAKER_02]: Her friend who was a caregiver couldn't increase her hours and Ms. [SPEAKER_02]: Wise didn't have the money to get more [SPEAKER_02]: So we felt really bad calling her daughter just to inform her that something was off with her mom, but we didn't know what the diagnosis was and we weren't really sure how to fix things. [SPEAKER_02]: And on top of it all, we were concerned about her safety at home. [SPEAKER_00]: Man, that is a lot to process.

[SPEAKER_00]: It definitely is a series of steps and I'm glad that you started when you did. [SPEAKER_00]: It seems like, you know, from here, having an actual diagnosis would make things maybe a little bit more clear. [SPEAKER_00]: But, you know, I'm also wondering, like, how aggressive we need to be in finding the cause of this patient's cognitive decline.

[SPEAKER_00]: I mean, I feel like a lot of times I've seen people just check, you know, a thyroid test of vitamin B12, and then just presumous Alzheimer's disease, unless there's something else going on. [SPEAKER_00]: What are we supposed to do here? [SPEAKER_02]: I think that question is one that we are all wondering. [SPEAKER_02]: So let's go to deep by three. [SPEAKER_02]: How do we determine the ideology of cognitive decline?

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[SPEAKER_00]: And we're trying to figure out next steps. [SPEAKER_00]: And we're seeing the first step is to try to figure out what is causing the cognitive decline [SPEAKER_00]: That sounds great, but I just feel like these disease processes are like universally challenging to diagnose, let alone treat. [SPEAKER_00]: I mean, how important is it really to pinpoint the exact type of neurocognitive disorder that a patient has?

[SPEAKER_02]: What I really picked up on for my conversations with our discussants is that there aren't an extensive number of diagnostic tests looking at the ideology of dementia. [SPEAKER_02]: The testing is really targeted towards making a diagnosis that has disease modifying medications available like Alzheimer's disease, and in addition to that to allow the patient and their loved ones to plan for the future. [SPEAKER_00]: Okay, that makes sense.

[SPEAKER_00]: So the first thing that we already did was identify that something's going on, try to get a sense of how bad it is, what they're able to do, what their functional status is. [SPEAKER_00]: But it sounds like in looking for an ideology, we're hoping that this can guide treatment and also give us a sense of overall progression in prognosis.

[SPEAKER_02]: Exactly, Nick. [SPEAKER_02]: I think we really need to keep in mind that the point of doing a work up for a diagnosis is to see if we can intervene with some treatment and have some impact on prognosis. [SPEAKER_02]: So for instance, if we have a patient who has already been declining for 10 years and has reached a point where they are unfortunately dependent on others for ADLs and I ADLs.

[SPEAKER_02]: We probably realize that there's not going to be any treatment intervention that is approved for this advanced stage of neural cognitive decline, and the prognosis seems pretty clear. [SPEAKER_02]: We are not going to be able to make them independent again.

[SPEAKER_02]: In contrast though, if a formerly high functioning individual is noted to be in the early stages of dementia, [SPEAKER_02]: We may actually be able to intervene with some disease modifying medication and we may be able to help this individual better understand the prognosis and the trajectory that they can expect. [SPEAKER_01]: So I would say that in terms of prognosis and not just prognosis, what do you expect next? [SPEAKER_01]: The ideology certainly makes a difference.

[SPEAKER_01]: And I think a lot of what we do with patients and families is education and maximizing the quality of life. [SPEAKER_01]: And so I think that it is important for that reason. [SPEAKER_01]: I would say that it's important for treatment purposes as well. [SPEAKER_01]: In terms of our medication options. [SPEAKER_00]: Okay, so now that we've gone over why we're doing this testing, let's go through the actual steps we need to do to do a full diagnosis.

[SPEAKER_00]: The first step, it sounds like we already did. [SPEAKER_00]: I mean, we're ruling out mimics of dementia. [SPEAKER_00]: You know, we assess for depression. [SPEAKER_00]: We made sure they weren't on any medications that can affect cognition. [SPEAKER_00]: We evaluated their sleep and their hearing.

[SPEAKER_00]: And then, of course, there's biochemical testing that I think a lot of us are familiar with, you know, trap an email testing, vitamin B12, TSAH, and of course, we can't forget HIV testing. [SPEAKER_00]: But then, I mean, once we've done this, and we're really just left with the actual dementia diagnoses, I mean, that's where I feel like I'm often at a loss, because I think a lot of them are like pathologic diagnoses, but we're not doing brain biopsies for these patients.

[SPEAKER_00]: So, I mean, are we often just looking at their clinical presentation and their pattern of symptoms? [SPEAKER_02]: Yeah, I mean, we don't want to discount utilizing clinical presentations to help us make a diagnosis. [SPEAKER_02]: I mean, as we all learned, dementia subtypes can present in pretty characteristic ways, like Louis body and dementia, for instance, patients can often have hallucinations or sleep disturbances.

[SPEAKER_02]: And I think most of us are familiar with the signs and symptoms of Parkinsonism, [SPEAKER_02]: And of course, frontal temporal dementia is often manifesting with behavioral changes such as dissinhibition or anodonia. [SPEAKER_02]: And with fascular dementia, it may not be so much clinical symptoms, but we usually have a prior medical history of cerebral vascular disease or old imaging that shows prior infarcts. [SPEAKER_00]: Right.

[SPEAKER_00]: I definitely understand that if you have typical symptoms that you might be thinking of one of these specific dementia subtypes, but what if you don't have symptoms that are very suggestive of one of these dementia subtypes? [SPEAKER_00]: I mean, I guess I would be wondering, is this Alzheimer's or is it just one of the other diseases and it's just early on? [SPEAKER_00]: Because Alzheimer's doesn't really have clear path economic findings, right?

[SPEAKER_00]: Isn't that just sort of like a diagnosis of exclusion? [SPEAKER_02]: Yeah, I mean, I think in the past definitely Nick, if our patient didn't kind of fit into one of these other categories, we just kind of dump them into an Alzheimer's bucket. [SPEAKER_02]: But now we actually can do some specific testing for Alzheimer's disease and to kind of get us PCP started, Dr. Marshall recommends and MRI as the first line study.

[SPEAKER_02]: And if that's not an option for our patient, then a head CT would be a second choice. [SPEAKER_00]: Oh, really, what would an MRI show you? [SPEAKER_02]: So, stay with me here with MRIs in Louis body dementia. [SPEAKER_02]: You're going to typically see some atrophy, but with hippocampal sparing.

[SPEAKER_02]: And with frontal temporal dementia, as the name would suggest you see atrophy in the frontal and temporal lobes, whereas vascular dementia, like we mentioned, may show some prior ischemic infarcts. [SPEAKER_02]: And in the past, if we didn't see those findings, we just basically said Alzheimer's disease, but now we know that specific findings like medial temporal lobe and hippocample atrophy can be pretty suggestive of Alzheimer's disease.

[SPEAKER_02]: And while they're not definitive findings, if we're already considering Alzheimer's disease as a diagnosis for our patient, these findings on MRI can definitely help strengthen our confidence in making this diagnosis. [SPEAKER_00]: got it. [SPEAKER_00]: That's really helpful because I didn't know that, but if I do know anything about imaging, instead if there's a new way to use a test, it means a very specific protocol that we're going to have to order to make it happen, right?

[SPEAKER_00]: Like there must be some kind of fancy new name for these MRIs. [SPEAKER_02]: Honestly, Nick, I think this is probably a good time to pick up your phone and call radiology and then save that exam on your quick order, because I can't lie. [SPEAKER_02]: I can't [SPEAKER_00]: Yeah, same, flare just still makes me think of office space, but it sounds like, I mean, how practical is getting this test? [SPEAKER_00]: I mean, specialized MRI protocol, is that pretty expensive?

[SPEAKER_02]: Believe it or not, it's actually got good Medicare coverage for routine use in the work above dementia. [SPEAKER_02]: I mean, obviously, you're going to need to clearly document the clinical symptoms that prompted you to start this work up. [SPEAKER_00]: got it.

[SPEAKER_00]: Okay, so MRIs can diagnose different forms of dementia and in Alzheimer's disease, we're not just looking for lack of other findings, we're actually looking for typical findings of hippocampal and medial temporal lobeatrophy and that can increase our concern for Alzheimer's disease. [SPEAKER_00]: But you said that it wasn't 100% diagnostic. [SPEAKER_00]: I mean, like what other testing could we do and in what patients are we doing further testing to confirm that diagnosis?

[SPEAKER_02]: It is actually quite an exciting time now, Nick. [SPEAKER_02]: It's pretty amazing that there are now new tests that can help us make the diagnosis of Alzheimer's disease. [SPEAKER_02]: I mean, these are things like pet scanning that are going to show decreased activity in those areas that we spoke about before.

[SPEAKER_02]: The hip-a-campus and the media temporal lobe, we might see amoloid on amoloid pet imaging, which, you know, as we all learned is pretty classic of Alzheimer's disease pathology. [SPEAKER_02]: And you can also get CSF findings like high towel levels and even newer plasma biomarkers can help make the diagnosis.

[SPEAKER_00]: That's really interesting, but it also seems like a lot to put someone through, especially someone who's dealing with cognitive impairment, pet scans, lumbar punctures. [SPEAKER_00]: Is that why we're not doing this more often? [SPEAKER_02]: Yes. [SPEAKER_02]: I think this testing is going to be reserved for patients who have an unclear diagnosis.

[SPEAKER_02]: Perhaps their MRI and their clinical symptoms are equivocal and we're not really sure if we can rule out other types of dementia or if we have a patient who has confirmed Alzheimer's disease, testing for amoloid on a hemorrhoid PET scan can help qualify them for specific treatments. [SPEAKER_02]: or perhaps they're early in their course of cognitive decline and we don't know what their trajectory is going to look like.

[SPEAKER_02]: But I have to say, Nick, this sometimes feels a little bit aspirational for me. [SPEAKER_02]: It's just hard for me to see a lot of the patients that we see in our clinics being able to show up for all of this testing, either due to finances, insurance concerns, or just [SPEAKER_00]: Yeah, that makes a lot of sense. [SPEAKER_00]: I mean, it sounds like we have to basically be selective about who we're doing testing for and have a good reason to do it.

[SPEAKER_00]: And I mean, really what it sounds like is that these patients where we're unsure thinking about other testing, these are the patients we're also referring to neurology to get more input there. [SPEAKER_00]: But, you know, it sounds like MRIs are a good starting place. [SPEAKER_00]: Is that something that you can order as a PCP? [SPEAKER_02]: Yeah, I'd love the fact that we can get a lot done for our patients with dementia.

[SPEAKER_02]: So, primary care folks, remember, we can handle a lot before we refer to a specialist. [SPEAKER_02]: We need to make sure there aren't any metabolic factors that play. [SPEAKER_02]: Look over our patients' medications. [SPEAKER_02]: screen for depression, we can obtain the lab work such as the TSH, the vitamin B12, trepony multithing and HIV, and then order first line imaging an MRI or a CT scan if that's not available.

[SPEAKER_00]: That's a great summary, and of course I want to also include to keep an eye out during your work up for any typical presentation of symptoms that could suggest a specific type of dementia. [SPEAKER_00]: And if you can do all that yourself, I'm sure your patients would be excited about avoiding a six month wait for a specialty clinic. [SPEAKER_00]: But as we said, some patients do need to see neurology.

[SPEAKER_00]: We said specifically those within unclear or atypical presentation, or those where we have a diagnosis, we're just considering advanced therapies. [SPEAKER_00]: What does that process look like?

[SPEAKER_01]: And if there's an atypical presentation, you know, I think that you can have somebody who has more of a language predominant presentation or visual perception presentation or exactly dysfunction and you're not sure what you're dealing with refer to specialists, maybe they need neuropsychological testing, you know, to really break down what's going on. [SPEAKER_00]: Okay, so break this down for me.

[SPEAKER_00]: We kind of talked about typical presentations, but what could an atypical presentation look like exactly. [SPEAKER_02]: So patients can present with a significant deficit in an area like language or visual perception or maybe executive function and sure we could blame any and all of these on changes seen in dementia. [SPEAKER_02]: But there aren't going to be other illnesses that we need to ensure we are not missing that can cause the same symptoms.

[SPEAKER_02]: I mean, things like brain tumors or seizures and cephalitis stroke [SPEAKER_00]: got it. [SPEAKER_00]: So it sounds like we said that we're empowered to start the work up, but if anything a typical shows up, a specialist can help us work through that differential, and then we should probably even low threshold to reach out if we're worried anything else might be going on.

[SPEAKER_02]: Yeah, and the subspecialists will often do more testing to confirm diagnosis using new or biomarkers to help track disease or help patients qualify for specific treatments. [SPEAKER_02]: Dr. Marshall, for instance, orders the Amoid pet to confirm an Alzheimer's diagnosis if he's considering treatment with the new monoclonal antibodies in town, Lakana Mab or Danana Mab. [SPEAKER_02]: He also uses the Amoid pet for a typical presentations or to help with prognostication.

[SPEAKER_00]: got it. [SPEAKER_00]: You know, so to summarize, we said as a PCP or, you know, general medicine doctor, we're really focusing on ruling out non-dementia diagnoses doing the blood work up, doing imaging.

[SPEAKER_00]: But for anything atypical, we're really relying on our subspecialists to try and make sure we're not missing something here, and also make sure that they're using these newer biomarkers to track disease, or newer imaging to see if people qualify specific treatments that we're going to talk about in the next episode. [SPEAKER_02]: exactly. [SPEAKER_02]: So bringing back our case with Ms. [SPEAKER_02]: Wise.

[SPEAKER_02]: We did our lab testing in our B12 and TSH for normal as we expected. [SPEAKER_02]: She unfortunately had a lot of issues with scheduling and transportation, but finally got the MRI done. [SPEAKER_02]: and it was suggestive of Alzheimer's disease. [SPEAKER_02]: She really didn't have any other atypical findings in her history or exam that suggested other forms of dementia. [SPEAKER_02]: So we felt pretty confident in giving her a diagnosis of Alzheimer's. [SPEAKER_00]: God, wow.

[SPEAKER_00]: Okay, so we have a diagnosis. [SPEAKER_00]: What did you do with that? [SPEAKER_00]: I mean, how did you break the news of this diagnosis to miswise and [SPEAKER_02]: Well, Nick, we have covered a ton today and I'm sorry to say you're just going to have to wait. [SPEAKER_02]: You and the rest of our listeners are going to get the rest of the story in episode two, so make sure to tune in next time. [SPEAKER_00]: Ah, Indu, leaving me hanging.

[SPEAKER_00]: Alright, I will be back for part two and I hope all of you will be too. [SPEAKER_00]: Let's find out what happened with Ms. [SPEAKER_00]: Wise and talk about next steps in her care. [SPEAKER_02]: I am a huge fan of sleep, but it's kind of funny Nick, it affects me every day because you know, my husband actually does this for a living. [SPEAKER_00]: He sleeps for a living? [SPEAKER_02]: No, he actually practice a sleep. [SPEAKER_02]: That's good.

[SPEAKER_00]: He'd be like, no, he actually does sleep medicine. [SPEAKER_00]: He watches other people sleep.