Early Dementia Toolkit


DEFINITIONS

Mild Cognitive Impairment Dementia N.B. Major and Mild Neurocognitive Disorders are the new DSM-5 Terms for Dementia and Mild Cognitive Impairment

Checklist for Recognizing and Diagnosing Dementia

Diagnostic criteria

    Mild Cognitive Impairment (MCI) requires impairment:
    1. in ONE of the following cognitive domains: memory, language, visuospatial, executive function and behaviour
    2. that does not significantly affect their usual activities or work
    3. that is not explained by delirium or other major psychiatric disorder
    EARLY dementia requires impairment:
    1. in at least TWO of the following cognitive domains: memory, language, visuospatial, executive function and behaviour ✱
    2. that causes a functional decline usual activities or work
    3. that is not explained by delirium or other major psychiatric disorder
    ✱ Typical behaviours in early dementia include irritability, social withdrawal and impaired self-esteem.
    ✱ See reference: clinical features of dementia vs delirium vs depression
  ✱ Click cancel in eChart prompt to copy in preferred order.

Diagnostic Algorithm

Symptoms

    Symptoms of cognitive impairment, such as:
    1. missed office appointments
    2. frequent or inappropriate calls to the office
    3. medication issues: compliance or adherence problems and errors
    4. repetitive in conversation
    5. repeatedly misplacing items
    6. unable to recall treatment instructions from prior visits
    7. defers to family members in answering questions (consider possible hearing impairment or language barriers also) - e.g. head-turning sign
    8. presents with signs of declined self-care (example: poor hygiene, grooming, unexplained weight loss)
    9. frequent visits to the emergency department
    10. late life depression or anxiety
    11. motor vehicle accidents, fender benders or wayfinding problems
    Areas of difficulty in ADLs and iADLs
    Obtain collateral history from family and caregivers
  ✱ Click cancel in eChart prompt to copy in preferred order.

Medical history

    Consider:
    1. comorbidities:
      • REM sleep disorder, sleep apnea
      • contra-indications to AChEIs: CHF, brady-arrhythmia, COPD, asthma, ulcer, seizures, urinary retention, BPH, etc
    2. medication list (assess for polypharmacy)
      • AChEIs interact with: beta-blockers, Verapamil, Diltiazem, Digoxin, other anti-arrhythmics (risk of bradyarrhythmia)
    3. alcohol and illicit drug use/smoking history
    4. education and employment history
    5. family history (e.g. early dementia)
  ✱ Click cancel in eChart prompt to copy in preferred order.

Cognitive Assessment

    Cognitive assessment tools:
      1. - preferential in MCI/early dementia. Further info: www.mocatest.org
      2. - quicker alternative if one cannot complete MoCA; however conducting a MoCA test before giving a diagnosis is best practice
      3. Clock drawing test (CDT) - acts as a screening test; conduct when time is restricted but signs of memory loss are apparent
      4. Consider alternate tests in South Asian or others with language and/or educational barriers, as standard tests may have limited diagnostic value. Examples: translated MoCA, RUDAS and instructions.        
    Language and cultural differences, educational level, and health literacy are major challenges for many ethnic groups impacting the adminstration of cognitive assessments, and subsequently the diagnosis.  Whenever applicable, use translated resourcs such as the MoCA test and the accompnaying instructions availabe in 50+ languages online (www.mocatest.org) or administer tests in the presence of an interpreter. Translated MoCA tests: Pumjabi, Hindi, Urdu, Arabic, Tamil, Telugu, Bengali, and more on www.mocatest.org. Days of a week (Punjabi), Days of a week (Hindi), months of a year (Punjabi & Hindi).        
  ✱ Click cancel in eChart prompt to copy in preferred order.

Physical exam

    Focus physical examination to:
    1. rule out visual or hearing deficits - Blind MoCA
    2. assess for that raise red flag of alternate diagnosis and consider need to refer to specialist - e.g. Parkinsonian features, focal neurological deficits, gait issues
    3. assess for cardio/cerebrovascular disease - e.g. rhythm, pulses, etc
  ✱ Click cancel in eChart prompt to copy in preferred order.

Lab tests


    Consider tests to rule out reversible causes of cognitive change and establish baseline.
    • Rule out remedial contributary medical illnesses:
      1. Complete Blood Count (CBC) + Ferritin
      2. B12
      3. Urinalysis
      4. Glucose - fasting
      5. HgbA1c
      6. TSH
      7. Sodium
      8. Albumin/Calcium
      9. Creatinine/eGFR
      10. ECG (AV block, QT prolongation - may be contra-indication to AChEI use)
    • In patients with risk factors, check:
      1. Liver enzymes
      2. Syphilis (T pall EIA)
      3. HIV
      4. Drug levels (e.g. Digoxin, Phenytoin)
  ✱ Click cancel in eChart prompt to copy in preferred order.

Imaging

    Head imaging is not routinely necessary.  
    Request CT head if:
    • Age < 60 yrs old
    • Abrupt onset
    • Rapid progression
    • Recent head injury
    • History of cancer (especially breast and lung)
    • Suggestion of stroke
    • Any localizing neurological sign or symptom
    • Patient is on anticoagulation or has a bleeding disorder
  ✱ Click cancel in eChart prompt to copy in preferred order.

Differential Diagnosis

Contributory causes/Differential diagnosis

  1. depression - , clinical features: dementia vs delirium vs depression
  2. delirium - BC Guidelines: Delirium Screening and Assessment Tools
  3. alcohol dependence - , Problem Drinking
  4. adverse drug effects and polypharmacy, e.g. narcotics, benzodiazepines, HS sedation
  5. co-morbid diseases, including sleep apnea
  6. Anticholinergic burden
  ✱ Click cancel in eChart prompt to copy in preferred order.

Referral

Consider referral to aid in diagnosis

  • Abnormal imaging
  • Abnormal neurological exam, focal neurological signs or symptoms:
    • Urinary incontinence, gait dysfunction - consider normal pressure hydrocephalus (NPH)
    • Rigidity, bradykinesia, postural instability, tremor - consider Parkinson’s Disease Dementia (PDD)
    • Early falls, eye movement abnormalities - consider Progressive Supranuclear Palsy (PSP)
    • Early psychosis (visual hallucinations) and REM sleep disorders - consider Dementia with Lewy Bodies (DLB)
  • Rapid progression
  • Abrupt progression
  • Age < 60 yrs old
  ✱ Click cancel in eChart prompt to copy in preferred order.

Disclosure

Diagnosis disclosure

Diagnosis of MCI or early dementia should be disclosed to the patient as soon as possible, preferably with a family member or caregiver present.  To minimize stress, the timing and extent of disclosure should be individualized and carried out over several visits.
  ✱ Click cancel in eChart prompt to copy in preferred order.

Management (General Care and Support)

Overview

The following MANAGEMENT information is abstracted and adapted from the BC Guidelines Cognitive Impairment: Recognition, Diagnosis and Management in Primary Care (2016).
  • Establish a register of patients (ICD9 code 290)
  • Reassess cognition and function at planned visits.
  • Involve the patient and caregiver in setting goals. See Associated Document: Clinical Action Plan (flow sheet); and...
  • Consider vaccinations, vitamin D supplementation, falls risk assessment, and exercise prescriptions.  Refer to BCGuidelines.ca for other chronic disease guidelines which may be useful.
  ✱ Click cancel in eChart prompt to copy in preferred order.

Non-pharmacological Management of Dementia

    Memory
    • Aids like calendars, diaries and telephone reminders
    • Keeping keys, glasses, wallet in same designated place ("landing spot")
    • Accompaniment to appointments
    • Exercise
    • Healthy brain games. Example: Sudoku puzzles, crossword puzzles, games (cribbage), jigsaw puzzles and word searches
    Medication Management
    • User blister packages/dossette trays and suggest caregiver supervision to improve safety and compliance or daily medication dispensing through local pharmacy
    • Medication monitoring through
    Household Safety
    • Monitor kitchen for mishaps (fires, burned pots); unplug stove or install automatic stove turn-off device
    • Functioning smoke detectors
    • Assess home for other safety hazards (unsafe smoking, firearms in the home)
    • Check for spoiled food in fridge
    • 911 stickers for telephones
    • A personal alarm service in case of patient accident (Life Line)
    • Referral for home assessment through
    Shopping
    • Use of lists when shopping
    • Shopping assistance from caregiver
    • Use of shop by phone program, if available
    Behavioural Symptoms
    • Common early dementia behavioural manifestations include changes in mood or personality, such as becoming confused, suspicious, depressed, fearful or anxious.  They may be easily upset at work, at home, with friends or in places where they are out of their comfort zone and feel loss of control.  Education of the patient and family is extremely important in management of behavioural symptoms of early dementia.  Consider referral to First Link and Alzheimer Society
    • Carrying identification when out alone; use of ID bracelet or registering with the MedicAlert® Safely Home® Program
    Nutrition
    • Monitor for weight loss
    • Meal support services - healthy delivered prepared meals or pre-preapred frozen foods
    Socialization
    • Awareness that patients with dementia may become socially withdrawn
    • Referral to First Link® and Alzheimer Society for their education, services, support and contact with resources
      1. Ask the individual or familiy member for permission to forward their name to First Link®
      2. Complete a referral form and fax it to:
          Alzheimer Society of B.C. (604-669-6907)
      Contact will be made within five business days or after three weeks for those who are adjusting to the diagnosis.  You will receive a confirmation note when contact has been made.

      First Link® offers your patients:
      • Proactive contact and follow up
      • Ongoing access to learning opportunities and support
      • Connection to a supportive community of others living with dementia
      • Knowledge, confidence and skills to live well with the challenges of dementia
    Financial & Legal Issues
    • Discuss advance care planning as early as possible (refer to My Voice Advance Care Planning Guide for aid in discussing sensitive topics like tube feeding.  Available in English, Punjabi, and Simplified Chinese.  See also form)
    • Encourage patient to have an up-to-date will, a power of attorney agreement for financial management, a representation agreement for health management and/or an advance directive
    Driving
      Dementia is a medical condition that impacts fitness for driving (see BC Driver Fitness Handbook for Medical Professionals).
      Start early to engage the patient on the topic of driving as part of their future planning.  Discussion with patient about the importance of memory and cognitive skills for driving and signals/concerns about driving safety.
      If there are concerns about a patient’s functional ability to drive, consider to RoadSafetyBC to have their skills assessed.
      Under Section 230 of the Motor Vehicle Act, a primary care provider must report to RoadSafetyBC if a patient:
      • has a medical condition that makes it dangerous to the patient or to the public for the patient to drive a motor vehicle; and
      • continues to drive after being warned of the danger.
      Revoking a driver’s license is not te health care provider’s responsibility, but when significant deficits are seen, reporting it is part of our duty. (UBC Dementia Management in Family Practice Facilitator Syllabus, used with permission).
      To supplement or replace driving, encourage patient to register with HandyDart and TaxiSavers (see see Guide for Patients and Caregivers).    

      For patients who need assistance with the HandyDart and HandyCard application form, direct them to the HandyDART & HandyCard: Simplified Form Instructions.
    Mental Health & Specialty Services
    • Be aware that dementia may co-exist with other complex mental health conditions
    • Involve mental health teams and resources, such as Community Mental Health Services, to help in distinguishing depression from dementia, and assessing and treating significant behavioural problems and managing caregiver stress; and
    • Involve allied health professionals (e.g., Home & Community Care mental health teams, counsellors, pharmacists, occupational therapists, physiotherapists, dietitians).
    Caregiver Support
    • Discuss needs, coping strategies, support system and stress management with caregiver;
    • Aid in co-ordination, communication, planning, education and connecting with resources; and
    • Assess the caregiver for caregiver burden and burn out. Monitor and check in with caregiver with each visit.
    • Consider screening tool: Zarit Burden Interview
  ✱ Click cancel in eChart prompt to copy in preferred order.

Pharmacological Management of Dementia

    Overview
      The following information has been abstracted from the UBC Dementia Management in Family Practice Facilitator Syllabus, used with permission, and the Ministry of Health’s Cognitive Impairment: Recognition, Diagnosis and Management in Primary Care. BCGuidelines
      The use of acetylcholinesterase inhibitors/memantine is controversial.  While data from clinical trials report statistical evidence of benefit, clinical benefits are unclear.  It should be noted that drugs may benefit only a small minority of patients, and the evidence for long term use is insufficient.  Short term benefits (6-12 months) may include cognitive, functional, and global improvement. However, patients and their caregivers should be advised that benefits are limited, and that side effects and drug interactions are common.  End points for discontinuation of medication should be discussed.
    Pharmacotherapy in Early Dementia
      The most commonly prescribed drugs for Alzheimer’s disease and some of the other dementias are known as Acetylcholinesterase inhibitors (AChEIs).  They inhibit an enzyme in the brain thereby increasing neurotransmitter acetylcholine. There are three such drugs on the market:
      • Donepezil (or Aricept™)
      • Galantamine (or Reminyl™)
      • Rivastigmine (or Exelon™): comes in pills and in transdermal patches (patches are not normally covered by Pharmacare but might be in special case appeals).

      • AChEIs are approved for the symptomatic treatment of mild to moderate Alzheimer’s, with Donepezil being the only AChEI indicated for severe Alzheimer’s disease.

      • Shown in RCTs and meta-analyses to:
        • Decrease cognitive decline
        • Improve or maintain ADL function
        • Improve behavior
          • Improve overall subjective clinical ratings
        • Possibly delay institutionalization.

      • Benefits are seen in those with Alzheimer’s Dementia, Vascular Dementia, Mixed AD/VaD, Parkinson’s Dementia, Diffuse Lewy Body Dementia.

      • Not seen to benefit those with other forms of dementia (such as Fronto-temporal Dementia, Alcohol Dementia, NormoPressure Hydrocephalus, or more rare forms of dementia).

      • Under current BC Special Authority coverage, they must have:
        • SMMSE score of ≥ 10 and ≤ 26 AND
        • Global Deterioration Score (GDS) of ≥ 4 and ≤ 6 AND
        • Diagnosis to include a component of Alzheimer’s Disease.
        • Patient must be registered with Fair Pharmacare and meet the specified requirements for coverage (eg: certain income level, meet the deductible, applicable limits in place).

      • NOTE: New BC Special Authority Rules (April 2016) can be found here:

      • ✱ The medications section was current as of September 2017 and is subject to change.  For updated information including prescribing and Pharmacare, please view the Ministry of Health website
    Considerations for Pharmacotherapy
    • Goal of treatment - slowing down cognitive, social and functional decline
    • Not curative and improvement on cognitive testing is not expected
    • If patient stops and restarts, benefits are not regained

    Decision to initiate AChEI therapy requires an individualized patient assessment, involving the patient and caregivers in the following discussion points:
    • Clinician, patient, and caregiver expectations of benefit with AChEI therapy.
    • Presence of comorbidities and life expectancy.
    • Potential drug interactions with concurrent medications.
    • Ability of the patient or caregiver to adhere to pharmacotherapy.
    • Potential benefits as compared to potential harms of AChEI therapy.
    • Patient and caregiver preferences, including cost of therapy.
    Relative Contraindications
    • Severe Cardiac disease (CAD, CHF)
    • Cardiac conduction abnormalities (slows AV nodal conduction)
      • Pulse check for bradycardia and/or ECG prior to start and soon after start of these meds
    • Severe respiratory disease (increases bronchospasm)
    • Recent peptic ulcer disease or increased risk of same (increases gastric acid secretion)
    • Significant GI symptoms or weight loss (most common side effects are nausea, diarrhea, decreased appetite and weight loss). GI intolerance rate is quite high.
    • Severe renal or liver disease
    • Seizure disorder or history of seizures (lowers seizure threshold)
    • Obstructive Urinary disease (may worsen symptoms)
    • Certain medications (see BC Guidelines)
      • Many drug interactions exist through the cytochrome (CYP) liver enzyme system.
      • Important to consider drug interactions with additive potential to cause bradycardia (B-blockers, verapamil, diltiazem, digoxin and other anti-arrhythmics).
      • Make sure no drugs on board with opposing anticholinergic pharmacology.

    • There are some advantages and disadvantages that come with starting AChEIs later in the progression of dementia:
      • Advantages: cost savings, side effects avoided.
      • Disadvantages: have lost ground already (have missed the opportunity to maintain the patient at a potentially higher level of cognition and functioning for longer)

    • NOTE: When increasing the dose or tapering someone off the medications, it is important to do so slowly (dose change every 4-6 weeks)

      Further information: BC Pharmacare Cholinesterase Inhibitors Info Sheet 2016

      It is worthy to note:
      • Medications are not indicated for Mild Cognitive Impairment (MCI)
      • Behavioural and Psychological Symptoms occurring in early dementia (confusion, suspiciousness, depression, fear or anxiety) should be treated using a combination of behaviour or environment modification, together with directed pharmacotherapy (e.g. antidepressant for concurrent depression)

      ✱ The medications section was current as of September 2017 and is subject to change. For updated information including prescribing and Pharmacare, please view the Ministry of Health website
    Cognitive Impairment in Culturally and Linguistically Diverse Groups
      The assessment and management of cognitive impairment in diverse individuals can be challenging for several reasons:
      • Communication difficulties, cultural factors, low education, and literacy impact formal cognitive screening, with poor inter-rater reliability – use interpreter services (where available) and translated/adapted cognitive assessment tools to assist in more accurate patient screening and assessment.  Whenever applicable, use translated resources such as the MoCA test and the accompanying instructions available in 50+ languages online (www.mocatest.org).  Translated MoCA tests: Punjabi, Hindi, Urdu, Arabic, Tamil, Telugu, Bengali, and more on mocatest.org; Days of a week (Punjabi), Days of a week (Hindi), months of a year (Punjabi & Hindi).
      • Dementia symptoms may be unfamiliar or viewed as a normal part of the aging process, and there may be stigma to mental health issues, resulting in diagnosis delay – provide culturally sensitive patient information on dementia to patients and families.
      • Language barriers may result in a lack of awareness of community supports – provide Guide for Patients and Caregivers.
      • Community supports may not provide culturally appropriate care, resulting in lack of adoption of these services and increase in caregiver stress; and
      • Families may share caregiver responsibilities by rotating the residence of the patient amongst family members – this is generally discouraged as it confuses the patient with dementia and complicates the provision of services between the staff of many agencies and the extended family.  One familiar, safe and secure environment is encouraged.
  ✱ Click cancel in eChart prompt to copy in preferred order.

Resources

Make an early referral to support resources:
  • Alzheimer Society of BC
  • First Link Dementia Helpline
  • HandyDart         Instructions (English)     (Punjabi)     (Hindi)
  • BC211
  • Better at Home
  • HealthLink BC
  • Fraser Health Crisis Line
  • Seven Numbers for Early Dementia (English)     (Punjabi)     (Hindi)
  • Keep your Brain Healthy brochure (English)     (Punjabi)     (Hindi)
  • MedicAlert
  • Lifeline
  • Get up & Go
  • Home Health
  ✱ Click cancel in eChart prompt to copy in preferred order.

Workflow and Appendices

Possible Workflow and Fee items (3 visit suggested, but can extend to more):
  • Consider use of GPSC code(s) (Current as of September 2018):
    • GP Annual Complex Care Management Fee (2 Diagnoses) → 14033
    • ...or GP Frailty Complex Care Planning and Management → 14075 (cannot bill BOTH 14033 and 14075)
    • GP Mental Health Planning fees → 14043
    • GP Mental Health Management fee → 14046-8
    • GP-Patient Telephone Management Fee → 14076
    • GP-Allied Care Provider Conference Fee → 14077 (per 15 min)
    • GP Email/Text/Telephone Advice Relay Fee → 14078
  • Visit 1 suggestion:
    • Obtain presenting History
    • General physical exam
    • Labs to rule out reversible causes
    • Remind patient to bring historian/family/friend to next appointment
    • Remind patient to bring all medications to next appointment (including over the counter)
  • Visit 2 suggestion:
    • History and corroborative history
    • Medications review
    • Lab result review
    • Dementia specific physical exam
    • Cognitive testing (MD or other)
    • Establish likely diagnosis
  • Visit 3 suggestion:
    • Disclosure
    • Referral to specialist if necessary
    • Connection to resources
    • Power of Attorney POA/Representation agreement
    • Driving considerations
    Appendix 1: Clinical relevance of neurological exam in patients with cognitive impairment:
    Appendix 2: Neurological exam findings in different causes of cognitive impairment:
  ✱ Click cancel in eChart prompt to copy in preferred order.

About Dementia Toolkit v0.1.3

Use This Tool At Your Own Risk!

Ideally, users of this tool will have attended the SGLS on Dementia.
Please notify the authors of any errors you find.
Use of this eForm constitutes your acceptance of these conditions.

Authors

  • Development: Dr. Leena Jain, Dr. Peter O’Connor and the Dementia Working Group for health care providers in British Columbia. Funding for this initiative was provided for by the Specialist Services Committee (SSC), a joint collaborative committee of the Doctors of BC and the BC Ministry of Health.
  • eForm Adaption: Dr. J.C.P Yap
  • Layout Design: Jeremy Ho

License

The Dementia Toolkit v0.1.3 is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
The LeadLab eForm Bootstrap Template v1.0.1 is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
V3_Dec11_2022 to update weblinks and eFORM names, by John Yap, is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.
Permissions beyond the scope of this license may be available at http://www.oscarcanada.org.