Describe typical changes in each organ system that occur as part of the normal aging process

Internal Medicine 18: 75-year-old male with memory problems User: Ralph Marrero Email: ralph2888@stu.southuniversity.edu Date: March 9, 2022 8:50 PM

Learning Objectives

The student should be able to:

Describe typical changes in each organ system that occur as part of the normal aging process. Perform a functional status assessment of the geriatric patient. Identify risk factors for falls in an older adult patient. Recognize the presentation of each type of urinary incontinence. Differentiate among the subtypes of major neurocognitive disorder and their associated findings. Propose lab work to evaluate for reversible causes of major neurocognitive disorder. Participate in discussing basic issues regarding advance directives with the patients and their families.

Knowledge

Initial Approach to Evaluation of Memory Problems

1. Focused history 2. Cognitive assessment 3. Functional evaluation

You go to the exam room and introduce yourself to Mr. Caldwell and his daughter, Kathy. Focused History

Mr. Caldwell admits to occasional memory issues, such as misplacing keys or forgetting items at the grocery store, but he reports no concerns with long-term memory recall, such as his anniversary or grandchildren’s names. He also reports difficulty with higher-level tasks such as balancing his checkbook and managing his medications, both of which his daughter now manages.

How Aging Affects Organ Systems

Learn more about major changes that occur in each organ system with aging.

Organ System Changes with Aging Functional Implications

Cardiovascular

Increased pulse pressure (increased systolic pressure with stable diastolic pressure).

Decreased arterial compliance.

Decreased baroreceptor sensitivity.

Increased pulse pressure is usually not harmful.

Other changes can lead to increased propensity for orthostatic hypotension.

Gastrointestinal

Multiple medications, decreased physical activity, and concomitant illness can contribute to constipation, which is common, although not “normal” in elderly patients.

Weakening of internal and external anal sphincters.

May lead to frequent physician visits and use of OTC medications, including laxatives.

Incontinence of bowels.

Hepatic Reduced hepatic blood flow.

Impaired hepatic microcirculation.

Impaired detoxification.

Impaired metabolism of many medications.

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Genitourinary

Women

Atrophy of labia, vagina, uterus, and ovaries.

Weakening of pelvic floor muscles, especially in women who have given birth.

Men

Enlarged prostate (benign prostatic hypertrophy (BPH)).

Women

Decreased lubrication and possible dyspareunia.

Urinary incontinence.

Men

Urinary incontinence or urgency, dribbling due to BPH.

Renal

Decreased renal salt retention/regulation.

Decreased ADH secretion at night.

Decline in renal function.

Decreased ability to retain salt can predispose patients to orthostatic hypotension.

Increased nocturia.

Changes in medication metabolism and excretion.

Musculoskeletal

Increase in body fat with decrease in lean mass.

Increase in joint deformities and stiffness. Loss of flexibility.

Decreased bone mineral density.

Stable weight/BMI does not imply stable body composition.

Risk of osteoarthritis.

Risk of osteoporosis and fractures.

Imbalance, gait difficulty, and risk of falls.

Neurologic

Mild loss of short-term memory.

Mild decrease in vibratory sensation.

Mild muscle atrophy.

Memory loss has no major effects if a result of normal aging.

Decreased vibratory sense can predispose to loss of balance.

Muscle atrophy not usually clinically perceptible.

Psychiatric Decreased mobility, increased dependence on others, and other life changes, while not “normal,” can contribute to psychiatric illness.

Depression, while not a consequence of “normal” aging, is common among older patients.

Respiratory

Decreased chest wall compliance.

Decreased static recoil in lung.

Decreased respiratory muscle strength.

No major change in gas exchange at rest or with exertion.

Possible decreased ability to compensate in setting of acute illness.

Skin Decreased skin thickness.

Decreased elasticity of skin.

Increased susceptibility to bruising.

Wrinkles.

Immune Decreased innate immunity.

Dysregulation of immune responses. Greater morbidity with infections.

Ophthalmologic Decreased tear production.

Development of cataracts, glaucoma, and macular degeneration.

Chronic dry eye.

Loss of vision.

Otological Loss of hair cells.

Cerumen accumulation. Hearing loss.

Defining Cognition

The DSM-5 defines six domains of cognition. These domains and associated symptoms in patients with cognitive impairments are outlined below:

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Cognitive Domain Symptoms and Observations

Complex attention Normal tasks take longer, are harder to complete, and a person is distracted if multiple stimuli are present.

Work requires rechecking.

Executive function

Difficulty in completing multistep tasks like cooking.

Reduced interest in activities.

Social outings are less enjoyable and seem more taxing.

Language

Word-finding difficulty.

Mispronouncing words.

Problems understanding written and spoken communication.

Learning and memory

Forgetful of information or requiring frequent repetition.

Difficulty recalling events.

Forgetting to complete tasks like paying bills or requiring to-do lists to complete tasks.

Perceptual-motor Gets lost in familiar surroundings.

Difficulty using tools or technology they are familiar with.

Social cognition

Impaired judgment.

Loss of empathy.

Abnormal or inappropriate behaviors.

Lack of interest in social activities.

Classifying Disorders of Cognition

The DSM-5 also updated the diagnostic terminology for cognitive impairment and dementia. Dementia is now housed under the term, “major neurocognitive disorder.” Mild cognitive impairment is now termed, “mild neurocognitive disorder.” It is important to note that the term major neurocognitive disorder encompasses many subtypes some that are subtypes of dementia, such as Lewy body dementia, Alzheimer disease, vascular dementia/disease, etc., and also encompasses neurocognitive impairment related to other conditions such as HIV, prion disease, Huntington disease, etc. The diagnostic criteria for neurocognitive disorders are noted in the table below:

Major Neurocognitive Disorder Mild Neurocognitive Disorder

Significant decline in at least one cognitive domain as determined by concerns noted by patient or family/friend AND objective neurocognitive assessments.

Interference with instrumental activities of daily living.

Cannot occur only in episodes of delirium.

Cannot be attributed to another psychiatric or mental disorder.

Can be classified by one or more of the DSM-5 subtypes.

Mild cognitive decline in at least one cognitive domain as determined by concerns noted by patient or family/friend AND objective neurocognitive assessments.

Does not interfere with instrumental activities of daily living, but they may take longer or require more effort through the use of compensatory strategies and accommodations.

Screening Tools for Cognitive Impairment

Several brief tools exist for screening for cognitive impairment in the primary care setting. The Mini-Mental State Exam (MMSE), which has been the diagnostic standard, is about 90% sensitive and 90% specific. It provides a score of 0-24 that could help categorize the severity of a patient’s cognitive impairment. It is patent-protected, therefore some clinicians choose to use other, freely available tools.

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One commonly used brief dementia screening tools is called the Mini-Cog. It is a test of three-item recall and clock drawing. You can review the Mini-Cog form and scoring algorithm at the following link: http://mini-cog.com/wp- content/uploads/2015/12/Universal-Mini-Cog-Form-011916.pdf (PDF). Perhaps the best screening tool used is the Montreal Cognitive Assessment (MoCA). It is available free online and tests many domains of cognition: http://www.mocatest.org/pdf_files/test/MoCA-Test-English_7_1.pdf (PDF). This is a one page diagnostic test that takes about ten minutes to administer. It assesses executive function, naming, memory, attention, language, abstractions, delayed recall, and orientation. The assessment is pictured below:

Montreal Cognitive Assessment Patients can score up to 30 points. A score of 26 or greater is considered normal, 18-25 suggests mild impairment, 10-17 suggests moderate impairment, and <10 suggests severe impairment. Major Neurocognitive Disorder The main subtypes of major neurocognitive impairment that classify as forms of dementia are as follows: Alzheimer disease Vascular disease/dementia Lewy body dementia Frontotemporal lobar degeneration The additional subtypes are as follows: Parkinson disease Traumatic brain injury © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 4/11 http://mini-cog.com/wp-content/uploads/2015/12/Universal-Mini-Cog-Form-011916.pdf http://www.mocatest.org/pdf_files/test/MoCA-Test-English_7_1.pdf HIV infection Prion disease Huntington disease Substance/medication induced Other medical condition Multiple etiologies Prevalence The DSM-5 estimates that the prevalence of Major Neurocognitive Disorder (which they use congruently with the term dementia) varies across ages. The prevalence of Major Neurocognitive Disorder is approximately 1-2% at age 65 and as high as 30% by age 85. The prevalence of Mild Neurocognitive Disorder ranges from 2-10% at age 65 and from 5-25% by age 85. Development and Course: When due to neurodegenerative conditions like the common forms of dementia, the onset of symptoms is usually insidious and gradual. Later in life it may be difficult to distinguish normal aging from prodromal phases of mild neurocognitive disorder. In addition, given the high prevalence of other medical conditions in older individuals, the symptoms of these conditions often go unnoticed or are overlooked due to the coexisting problems. Risk Factors: Age is the most common risk factor since increased age leads to greater neurodegenerative and cerebrovascular disease. Females are also more prone to developing these conditions, although this may be due to their overall increased lifespan. Functional Assessment: Activities of Daily Living Activities of daily living (ADLs) are divided into two subcategories: basic and instrumental (IADLs) Basic eating bathing and toileting ambulating dressing maintaining personal hygiene Instrumental managing finances managing transportation preparing food shopping managing medications managing communication housekeeping The patient's family members may be very helpful in providing this information. Avoid Polypharmacy, Especially in Older Adults Review the medication list at every visit to ensure the most appropriate and least number of medications are being prescribed. Polypharmacy is a common problem among older patients and can result in avoidable adverse drug events. Don't forget to include over-the-counter medications, supplements, and herbal remedies. Common Issues to Assess in the Geriatric Patient: Fall Risk, Hearing and Vision, Frailty, and Urinary Incontinence Fall Risk Learn more about recommendations for prevention of falls in older patients. Screening for Hearing and Vision Deficits While hearing and vision impairment may contribute to fall risk in older patients, routine hearing and visual acuity screening in people over 50 years old is not currently recommended by the U.S. Preventive Services Task Force. Hearing: In 2012 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in this population. (Grade I statement.) © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 5/11 https://www.cdc.gov/steadi/materials.html https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening Vision: In 2016 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of visual acuity screening in the improvement of outcomes in older adults. (Grade I statement.) Fall Risk Factors The more risk factors a patient accumulates, the more likely he or she is to fall. According to the CDC, risk factors for falls can be divided into​ Intrinsic and Extrinsic categories as outlined below: Intrinsic Factors Extrinsic Factors Advanced age Previous falls Muscle weakness Gait and balance problems Poor vision and hearing Postural hypotension Chronic conditions including arthritis, stroke, incontinence, diabetes, Parkinson Cognitive impairment Fear of falling Lack of stair handrails Poor stair design Lack of bathroom grab bars Dim lighting or glare Obstacles and tripping hazards Slippery or uneven surfaces Psychoactive medications Improper use of assistive device There are effective community and clinical interventions for some of these risk factors that may reduce falls. Urinary Incontinence Assessment Make sure to assess for this during your interviews, because patients often will not volunteer this information. Incontinence is a common problem in older patients and is often multifactorial. Additionally, this may increase a patient’s risk for falls as they must often get up at night. A symptom diary can be very helpful in assessing the severity of incontinence. This involves tracking when incontinence occurs and whether it seems to be triggered by specific times of day, beverages, medications, or other circumstances. Four types of incontinence: Symptoms Cause Treatment Stress Incontinence More common in women than in men. Small urine leakage occurs with coughing, laughing, exercise, or other maneuvers that increase intra-abdominal pressure. Pelvic muscle weakness (i.e., from multiple childbirths or chronic pressure from obesity or high impact activities) or vaginal atrophy due to menopause. Strengthening the muscles of the pelvic floor with Kegel exercises. Urge Incontinence Presents as a sudden need to void, and patients describe "almost making it" to the bathroom. They typically leak larger amounts of urine. Dysfunction of the detrusor muscle, either due to medications, stroke, or idiopathic overactivity. Scheduled voiding and other behavioral exercises. Overflow Incontinence Most common type of incontinence in men. Presents with dribbling, hesitancy, and leakage of small volumes of urine. Mechanical bladder outlet obstruction, often benign prostatic hypertrophy (BPH) in men or fibroids or pelvic organ prolapse in women. Surgery or medications to relieve the obstruction. Functional Incontinence Occurs as a result of a person's inability to get to a bathroom for any reason. This can occur in physically or mentally handicapped patients, including patients with cognitive impairment. Treated with environmental modifications, such as bedside commodes. It is also important to note that men and women can have symptoms from several of these categories. Patients with symptoms of both stress and urge incontinence are described as having mixed incontinence. Assessing Geriatric Syndromes on Physical Exam © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 6/11 https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/impaired-visual-acuity-in-older-adults-screening Cognitive Impairment Mini mental state exam or other neurocognitive assessment Complete neurological exam Depression screening Falls Joint exam for abnormalities Cardiovascular exam, including examination for bruits and orthostatic vital signs Complete neurologic exam, especially focused on proprioception and strength Walking speed (normal is 15 feet in < 7 seconds) Urinary incontinence Men: Prostate exam to assess for hypertrophy or nodules Women: Complete pelvic exam to assess for atrophy, pelvic floor muscle weakness or pelvic masses "Get Up and Go" Test Instructions for patient: Get up (without armrests, if possible), stand still for a moment, walk forward 10 feet, turn around and walk back to the chair, turn and be seated. Assessment: A normal time ranges from 8-12 seconds. Patients who take greater than 14 seconds to complete this are at higher risk for falls. In addition, the assessor should make note of sitting balance, transfers from sitting to standing, pace and stability of walking, and ability to turn without staggering. Major Neurocognitive Disorder (Dementia) Subtypes Subtypes of Major Neurocognitive Disorder. Dementia Type Features Cause Alzheimer Dementia (AD) Accounts for 75% of cases of major neurocognitive disorder Gradual memory loss Specific difficulties with short-term memory and retaining new information May have family history of AD Clinical diagnosis is 90% accurate Considered terminal illness; life expectancy after diagnosis is about six years Amyloid plaques and neurofibrillary tangles in the brain Pathology confirmed at autopsy Lewy Body Dementia (LBD) Fluctuations in memory and cognition Visual hallucinations Parkinsonism (resting tremor, bradykinesia, rigidity and postural instability) Deposition of Lewy bodies in the nuclei of cerebral cortical neurons Vascular Dementia Step-wise deterioration in memory Patients often have other vascular risk factors (diabetes, HTN, smoking, etc.) Often see evidence of previous stroke on exam and/or imaging Heterogenous presentation due to variability in extent, severity, number and location of lesions Due to damage from discrete vascular events, such as strokes and TIAs Frontotemporal Dementia (FTD) Dementia associated with behavior and personality changes Language impairment Common cause of major neurocognitive disorder in patients younger than 65 Group of disorders with various causes, but all involve atrophy of frontal and temporal lobes * Recall from prior that other subtypes of major neurocognitive disorder include Parkinson’s disease, Huntington’s disease, traumatic brain injury, HIV infection, prion disease, substance/medication use, and cases of multiple etiologies. © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 7/11 Allied Health Professionals Occupational therapist - healthcare practitioner who evaluates and treats a patient's daily living skills and develops a treatment plan individualized for the patient. Training requirements include graduate degrees of a Masters in Occupational Therapy or Doctorate of Occupational Therapy. Physical therapist - healthcare practitioner who evaluates a patient's mobility and functional status and develops a treatment plan individualized to the patient. Training requirements include graduate degrees in a Masters in Physical Therapy or Doctorate of Physical Therapy. Medications for Alzheimer’s Dementia Although there are no medications to cure Alzheimer disease or other forms of dementia, there are several medications that may be used to help slow the progression of cognitive and functional decline. Amyloid beta-directed monoclonal antibody (Aducanumab) Indications: Approved for patients with mild cognitive impairment or mild dementia in those with evidence of amyloid beta plaques Effectiveness: Unknown, Phase 4 confirmatory trial of clinical benefit will be completed in 2030 Common side effects: Brain swelling and tiny brain bleeds (typically asymptomatic), headaches, falls, diarrhea, and confusion Cost: $56,000 per year (2021 costs) Cholinesterase inhibitors (ex: donepezil, rivastigmine, and galantamine) Indications: Used for patients with dementia of any severity—mild, moderate, or severe Effectiveness: There may be small, beneficial effects in cognitive and functional performance, though the clinical significance of these effects is unclear Common side effects: Nausea, vomiting, and diarrhea, but these usually get better if people keep taking the medications Memantine Indications: Moderate or severe Alzheimer’s dementia Effectiveness: Studies have shown small improvements in cognition but the clinical significance is unclear Common side effects: Dizziness, possibility of confusion and hallucinations There is some research that demonstrates the potential for cognitive and functional performance may be better if memantine and a cholinesterase inhibitor are used together, but once again the clinical significance remains unclear. These medications may all cost more than $150 per month if paid for out of pocket. However, with insurance coverage the cost is much lower. For each of these medications, treatment decisions should be individualized and consider drug tolerability and cost. Other There are ongoing studies on various supplements including vitamins for treatment or prevention of dementia. So far, the available research has been disappointing and no supplement or vitamin can be recommended at this time based on the studies to date. Advance Directives Clinicians should have a discussion with their patients regarding advance directives. An advance directive is a legal document that details how a patient wishes to be cared for and treated if he or she is unable to make decisions for him or herself. It may include information about what treatments or interventions the patient would or would not want. Patients should be encouraged to be as specific as possible so as to avoid confusion. For example, patients often request no “heroic measures”, but this can have different meanings to different people. When discussing an advance directive with a patient, it may also be a good idea to discuss other legal documents like a living will and a Do Not Resuscitate order. Advance directive forms are usually available at doctors’ offices, but they can also be accessed online and through local and state health departments. After completion, the patient should be encouraged to share a copy with his or her physician, family members, and to retain a copy for his or her personal medical records. Finally, patients should be reassured that if they change their mind, they can alter the document at any time. Additional resources for patients can be found through the National Institute on Aging at the following link: https://www.nia.nih.gov/health/legal-and-financial-planning-people-alzheimers Clinical Skills Delivering Bad News © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 8/11 https://www.nia.nih.gov/health/legal-and-financial-planning-people-alzheimers The SPIKES protocol can be used as a method to deliver bad news. Although initially applied for oncologic patients, this protocol can be used in many situations. It is a six-step​ protocol outlined as follows: Step 1: Set-up the Interview Before meeting with the patient, you should review your plan for telling the patient the news and plan for how he or she may respond and what questions he or she may ask. You should arrange for a private setting, be sure to involve family members if the patient chooses, and be sure that all parties involved are in a relaxed sitting position. It is very important to establish a connection with the patient, either through good eye contact or even touching the arm or holding the patient’s hand if he or she is comfortable with this. Step 2: Assess the Patient’s Perception This is a reminder to ask the patient his or her understanding of the present medical situation to gauge his or her knowledge thus far. You may ask patients questions like “What have you been told thus far?” or “Do you understand what the laboratory and imaging tests were done for?”. Having this understanding prior to delivering the bad news will help you correct any incorrect information and tailor how you present the news. Step 3: Obtaining the Patient’s Invitation It is important to recognize that some patients may want to know everything and others may not want to know all the details they may be presented with. It is requisite to ask patients their preferences before delivering bad news. An example question is “Would you like me to give you all the information about the tests or simply talk about the diagnosis and what steps may be taken going forward?” In addition due to personal or cultural issues, this may allow the patient the opportunity to ask that the information be delivered to a family member instead of him or herself. Step 4: Giving Knowledge and Information to the Patient It is helpful to prepare the patient that he or she is about to receive bad news. You may say something like “Unfortunately, I have some bad news to tell you”. This allows them to prepare and may lessen the shock of the news to come. Be sure to deliver the news in simple language that is free of medical jargon and easy to understand. Avoid excessive bluntness as in the example of “You will die in a year unless you receive treatment”. Provide the information in small pieces to aid in understanding. When the prognosis is poor it is better to still focus on ways to help the patient, even if it is through good pain control and symptom relief if not treatment or cure. Step 5: Addressing the Patient’s Emotions with Empathic Responses Patients may respond with shock, isolation, grief, or anger. An empathic response to these emotions is critical. You should observe for signs of these emotions and identify the emotion and the reason for it which is usually related to the bad news. Allow the patient time to experience the emotion even if it feels uncomfortable to you. The patient may be silent or may express his or her feelings. Demonstrate your understanding through an empathic response such as “I am so sorry to have had to share the news regarding this new diagnosis; I know this is not what you wanted to hear.” Step 6: Strategy and Summary It is important to have a clear plan for further treatment and care. This provides reassurance and often relief of some anxiety associated with the diagnosis. Presenting treatment options to patients also helps promote shared-decision making and is a way to respect their wishes. In addition, it is important to explore a patient’s hopes and expectations in order to both be supportive and realistic when discussing both treatment and prognosis. Management Reducing Fall Risk Adjust the number and type of medications . The risks and benefits of any medication should be reviewed and nonpharmacologic alternatives considered. Educate patients about cognitive impairment as a risk factor for falls. Address home hazards , especially for patients who have fallen in the past. This includes removing slippery rugs, improving lighting and adding bars for stabilization in the bathroom. Physical therapy is beneficial for pain related to osteoarthritis and may help improve strength and balance. Medicare Coverage of Home Hazard Assessment And Physical Therapy Patients who are homebound (do not have a car or access to public transportation), and are on Medicare will receive coverage for home physical therapy and home hazard-assessment and modification. Other patients may need to come to the office to receive physical therapy. If patients do not have insurance that covers home-hazard modification, physicians or other clinic staff can teach patients and give them printed educational materials. Medication Side Effects in Older Adults All medications can have unwanted side effects, but older patients are at higher risk for many reasons. 1. Older adult patients are often on multiple medications that interact. 2. With aging, there are physiologic changes affecting pharmacokinetics and pharmacodynamics. 3. Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications. 4. Drug clearance may be decreased by an age-associated decline in renal function. © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 9/11 5. As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and patients may require lower doses of drugs. It's important to consider all of these factors before prescribing a medication to an older patient. In particular, reviewing the appropriateness and indications for opioids, anxiolytics (including lorazepam), and any medications with anticholinergic properties should be done at each visit. Major Neurocognitive Disorder—Safety & End-Of-Life Planning Early in the course of mild or major neurocognitive disorder, it is important for clinicians to help patients and families keep the patient safe in the present while they plan for the future. Many patients early in the course of this disorder have difficulty with IADLs, such as managing finances and driving, so discussion of how to manage these problems is warranted. 1. Estate and end-of-life care planning Patients should be encouraged to appoint a durable power of attorney (DPOA) for healthcare. A DPOA for healthcare is usually a trusted family member or friend who will make healthcare-related decisions for the patient when he or she is no longer able to do so. The patient should also be encouraged to complete a living will, which specifies what types of medical interventions he would want at the end of life or if he or she is unable to speak for himself or herself. Dysphagia is a common disorder in major neurocognitive disorder and addressing whether tube feedings should be implemented is a part of end-of-life planning. 2. Driving safety Clinicians should discuss driving safety with any patient who has an impairment in memory or vision as well as for someone who has seizures or other episodes of loss of consciousness that may impair his or her ability to drive. States vary in their laws about physicians' obligation to report potentially impaired drivers to the Department of Motor Vehicles, but it is always reasonable to advise patients not to drive if you think that is the safest course. 3. A Medical Alert ID system Many companies offer varying levels of products that can help identify and return patients at risk for wandering. These can be as simple as an inexpensive bracelet or there are systems with sophisticated electronic surveillance. Studies Evaluating For Reversible Causes Of Major Neurocognitive Disorder Depression Screening: All patients with concern for cognitive impairment should be screened for depression. This condition is common in older adults and may be mistaken for cognitive impairment. There are several validated screening tools like the Patient Health Questionnaire (PHQ) 2 or 9 and the Geriatric Depression Scale (GDS). Laboratory Testing: The American Academy of Neurology (AAN) recommends screening for B12 deficiency with a B12 level and a complete blood count as well as screening for hypothyroidism with a TSH level. Other potential tests are detailed below. TSH Hypothyroid or hyperthyroid conditions can contribute to cognitive impairment. Vitamin B12 and Complete Blood Count While both folate and B12 deficiencies can cause macrocytic anemia, only B12 deficiency can cause posterior column disease and cognitive impairment. As part of the evaluation for vitamin B12 deficiency,​ the AAN also recommends a complete blood count. Complete Metabolic Panel While some metabolic abnormalities can lead to memory impairment there is no clear evidence that this test is useful or cost- effective so it should not be routinely sent. Examples of electrolyte issues that could cause cognitive symptoms include: Hypercalcemia leading to confusion, psychiatric disturbances, and memory loss, particularly in older patients, and hyponatremia leading to mental status changes in older adults. Rapid Plasma Reagin (RPR) and HIV Screening for these conditions is not routinely recommended unless the patient is at high risk due to sexual history or travel. Thiamine (Vitamin B1) In patients with a history of alcohol use disorder or those who are not receiving adequate nutrition, it is also reasonable to consider thiamine deficiency. In the U.S., thiamine deficiency is most commonly seen in patients with alcohol use disorder and typically causes Wernicke-Korsakoff syndrome. Wernicke syndrome is characterized by nystagmus or other ocular abnormalities, gait abnormalities, and memory loss with other mental status changes. It develops over days. Korsakoff syndrome includes retrograde and anterograde amnesia. These syndromes are part of a spectrum of disorders. Neuroimaging The question of whether to obtain imaging, such as a head CT or MRI in the workup of dementia is also controversial. The AAN recommends a non-contrast head CT or MRI as part of the routine workup. In theory, this imaging would help exclude other contributing pathologies such as stroke, subdural hematoma, normal pressure hydrocephalus, and an intracranial mass. © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 10/11 Other governing bodies recommend this imaging only in the presence of unusual or atypical findings. References American Academy of Family Physicians. Information from our family doctor. What you should know about advanced directives. Am Fam Physician. 2012 Mar 1;85(5):467. https://www.aafp.org/afp/2012/0301/p467.html. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES - A Six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302-311. Clinical Summary: Hearing Loss in Older Adults: Screening. US Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening . Accessed November 15, 2021. Epperly T, Dunay MA, Boice JL. Alzheimer Disease: Pharmacologic and Nonpharmacologic Therapies for Cognitive and Functional Symptoms. Am Fam Physician. 2017;95(12):771-778. Fact Sheet: Risk Factors for Falls. Center for Disease Control and Prevention. https://www.cdc.gov/steadi/pdf/STEADI-FactSheet- RiskFactors-508.pdf. (.pdf 172 KB) Accessed November 15, 2021. Final Update Summary: Impaired Visual Acuity in Older Adults: Screening. US Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/impaired-visual-acuity-in-older-adults- screening?ds=1&s=visi. Accessed November 15, 2021. Maurer DM. Screening for depression. Am Fam Physician. 2012;85(2):139-144. McCleery J, Abraham RP, Denton DA, et al. Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment. Cochrane Database Syst Rev. 2018 Nov 1;11:CD011905. Simmons BB, Hartmann B, Dejoseph D. Evaluation of suspected dementia. Am Fam Physician. 2011;84(8):895-902. © 2022 Aquifer, Inc. - Ralph Marrero (ralph2888@stu.southuniversity.edu) - 2022-03-09 20:50 EST 11/11 Internal Medicine 18: 75-year-old male with memory problems Learning Objectives Knowledge Initial Approach to Evaluation of Memory Problems How Aging Affects Organ Systems Defining Cognition Classifying Disorders of Cognition Screening Tools for Cognitive Impairment Major Neurocognitive Disorder Functional Assessment: Activities of Daily Living Avoid Polypharmacy, Especially in Older Adults Common Issues to Assess in the Geriatric Patient: Fall Risk, Hearing and Vision, Frailty, and Urinary Incontinence Fall Risk Factors Urinary Incontinence Assessing Geriatric Syndromes on Physical Exam "Get Up and Go" Test Major Neurocognitive Disorder (Dementia) Subtypes Allied Health Professionals Medications for Alzheimer’s Dementia Advance Directives Clinical Skills Delivering Bad News Management Reducing Fall Risk Medicare Coverage of Home Hazard Assessment And Physical Therapy Medication Side Effects in Older Adults Major Neurocognitive Disorder—Safety & End-Of-Life Planning Studies Evaluating For Reversible Causes Of Major Neurocognitive Disorder References