MENTAL FUNCTION AND COGNITION IN THE ELDERLY
From the 9th Annual Geriatric Medicine for the Primary Care Physician Summer Conference, presented August 3-5,
2006, by Orlando Regional Healthcare and the Geriatric Research, Education and Clinical Center
| OPTIMIZING MENTAL FUNCTION IN THE COGNITIVELY FRAGILE PATIENT —Stephen E. Nadeau, MD, Professor
of Neurology, University of Florida, College of Medicine, and Staff Neurologist, Geriatric Research, Education and Clinical
Center, Malcolm Randall DVA Medical Center, Gainesville, FL
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| Cognitively fragile patients: patients with dementia; patients with minimal cognitive impairment (MCI; ie, demonstrated
impairment in cognition in one domain [eg, memory]); frail elderly patients; identify treatable causes of dementia
(eg, degenerative processes)
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| Problems with arousal and attention: patients “off in space” or fall asleep during patient history and physical examination;
subacute cognitive decline often treatable; drugs beneficial in microvascular atheromatous disease (eg, stroke)
may be effective for slowing progression of vascular dementia, because vascular dementia partly caused by microatheromas
in small vessels and degenerative changes (no data available)
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| Drugs that contribute to cognitive impairment: antihypertensive agents—lipophilic β-blockers, eg, propranolol
(use atenolol or metoprolol); α1 -blockers; α2 -agonists (eg, clonidine); neuroleptic agents—quetiapine (Seroquel)
less potentially harmful; can be avoided; long-acting lipophilic benzodiazepines—older drugs, eg, diazepam (Valium),
chlordiazepoxide (Librium) with active metabolites that accumulate in fat; anticholinergic drugs—acetylcholine in brain
indispensable to formation of new memories (factual or procedural memory); donepezil, rivastigmine, and galantamine potentiate
effectiveness of daily experience in promoting constant relearning; anticholinergic drugs can cause unpredictable
alterations in attention and arousal and potentiate psychotic behavior; often implicated in development of hallucinations
and delusions; diphenhydramine (Benadryl), over-the-counter hypnotics, amitriptyline (Elavil), and antihistamines can
cause profound cognitive effects; sedative anticonvulsant drugs—phenobarbital; primidone (Mysoline); voltage-sensitive
sodium channel agents (eg, phenytoin, carbamazepine) and newer drugs (eg, lamotrigine, levetiracetam [Keppra])
have less impact on cognitive function; opiates—difficult to provide opiate regimen without associated cognitive effects;
consider risks and benefits
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| Neuroplasticity: neuroplastic potential in brains of older individuals; impairment caused by drugs (eg, neuroleptics, anticonvulsants,
benzodiazepines, anticholinergics, α1 -blockers, α2 -agonists) shown in animal studies; consider risks and benefits
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| Depression: common in elderly patients; when asked whether depressed, patients often say no (ask about anhedonia); can
be associated with cognitive impairment or increase in preexisting cognitive impairment
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| Sleep disorders: patients exhibit daytime hypersomnolence, constant exhaustion, and impaired concentration; ask about
concentration, eg, “are you mislaying things?” “are you losing track of what you were talking about in midsentence?”
“do you miss turns while you’re driving?”
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 | Quantitative: ask how quickly patient falls asleep; ask whether patient sleeps through night; ask about total hours of sleep
and time spent sleeping during day; determine why patient has difficulty with sleep; nocturia—more common in men
than women; commonly due to benign prostatic hyperplasia (BPH; treated with α1 -blocker or surgery); sleeping in
hospital bed with head raised ≈20º reduces nocturnal diuresis; treat pain with hypnotics or opiates; use benzodiazepines
to treat idiopathic insomnia and titrated dose of trazodone to help sustain sleep
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| Qualitative: obstructive sleep apnea—suspect in patients with history of snoring; patient history of daytime hypersomnolence
and impaired concentration even when patient seems to be getting adequate sleep; perform sleep study; restless limb
syndrome and periodic limb movements of sleep—limb movements typically monitored in sleep studies; treat with
dopaminergic agonists (eg, levodopa and carbidopa [Sinemet], pramipexole, ropinirole in titrated dose at bedtime); treatment
effective; complaints include aching or burning legs, tingling, shooting pain, persistent discomfort, and kicking;
may be unilateral; limb movements or apneic spells lead to arousal and shallow sleep; treatable
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| Use of drugs with potential central nervous system (CNS) effects: impact on cognitive function not related to
dose; when patients on multiple drugs, ensure every drug and dose essential and effective
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| Treatment of dementia: symptomatic therapy for Alzheimer’s disease (AD) and intentional (ie, vascular)
dementia—acetylcholinesterase (AChE) inhibitors (eg, donepezil, rivastigmine, galantamine, memantine); data show
dopaminergic agents and noradrenergic agents (eg, methylphenidate, amphetamine) can be beneficial in cognitive impairment
caused by traumatic brain injury; familial support
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| Behavioral management: wandering—lock and hide things; obstruct or conceal exits; fiddling—replace dangerous objects
with harmless objects; fixated behavior or belligerence—patients often become agitated during mealtime or bath
time; leave patient momentarily and return with softer approach; socially reprehensible behavior—common in nursing
homes; groping (common in patients with frontotemporal dementia; keep distance); delusions and hallucinations—
often caused by underlying sleep disorder; AChE inhibitors can be effective; often benign (can be tolerated without medication);
anxiety—assemble no-fail environment
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| Optimal approach to health care: anticipatory approach; maintain regular contact with patient; systematically inquire
about problems; take preemptive action before patients require hospitalization or placement in nursing home
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| Protecting against cognitive decline: 5 of 7 studies show slower cognitive decline in people with greater social engagement;
5 of 6 studies show slower cognitive decline in people who participated in more leisure activity; 7 of 8 studies
show slower cognitive decline in people who are more physically active; results with dementia comparable; studies may
be flawed; animal studies supportive
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| ASSESSING COGNITION AND AFFECT IN OLDER PATIENTS WITH SUSPECTED MEMORY PROBLEMS —Robert
J. Cohen, PsyD, Clinical Neuropsychologist, Department of Neuropsychology, Orlando Regional Healthcare, Memory Disorders
Clinic, Orlando, FL
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| Neuropsychology: study of brain-behavior relationship; identifies parts of brain and effects of disease on behavior; assessment
takes 2 to 6 hr; neuropsychologists may recommend medications and perform diagnostic testing
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| Patient assessment: interview family; check language function; problem-solving skills; attention; concentration; sensory
perception; motor performance; emotional and personality function; scoring variables include ethnicity, age, and education
level; differentiate normal aging process from degenerative process; early dementia often undiagnosed
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| Benefits of early detection: appropriate referral to neurologist or neuropsychologist; delay in progression of illness up
to 5 yr with early treatment; AChE inhibitors more effective when used early; allows patient to have greater role in planning
for future; misdiagnosis (of, eg, AD) can lead to anxiety, depression, limited insurance qualification, and unnecessary
medication; screening test by primary care physician may identify patients with undiagnosed dementia; patients may
present with anosognosia (ie, poor insight and unawareness of memory loss)
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| Criteria for dementia: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)—
memory impairment and ≥1 area of cognitive disturbance (eg, aphasia, agnosia, apraxia, executive dysfunction [eg, difficulty
planning or organizing]); symptoms must cause significant impairment in social or occupational functioning and represent
decline from past or premorbid functioning; International Classification of Diseases, Ninth Revision (ICD-9)—
2 areas of cognitive disturbances; does not include memory as necessary impairment
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| Delirium vs dementia: delirium—patient unable to maintain attention during testing; clouded consciousness; onset
fast; potentially reversible; dementia—attention unaffected during testing; conscious and aware; slow, progressive, and
irreversible; ≈70% of cases due to AD, ≈23% due to Lewy body dementia (66% also have AD), and 18% due to vascular
dementia (77% mixed etiology); less common causes include syphilis, Creutzfeldt-Jakob disease, HIV, neurologic issues,
and nutritional and/or metabolic issues
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| Mild cognitive impairment: high conversion rate from MCI to AD; defined as cognitive impairment in one area of
cognitive function greater than expected for age but does not cause significant decline in everyday living; patients express
complaints; types include amnestic (memory main complaint) and nonamnestic (memory not main complaint; patient
may have problems with decision-making or changes in intellect or language function); screen patients with MCI
again after 1 yr
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| Changes in AD: depression, agitation, and psychotic features can occur at any stage, but more common in moderate
and severe stages; motor deficits rare because motor strip spared; clinical course slow and progressive; MCI to mild
changes—poor recent memory; long-term memory intact; navigational disturbances; decreased verbal fluency; insight
good to fair; moderate changes—effect on remote memory (eg, forgetting children’s names); impulsivity; disinhibition;
disorders in visuospatial orientation; problems with calculation, comprehension, judgment, and sequencing; loss of
hygiene and grooming ability; end stage—loss of motor skills and sphincter control
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| Changes in vascular dementia: disinhibition; greater change in behavior than intellectual functioning; increased depression,
apathy, and perseveration (especially in patients with lacunar infarcts); neuropsychologic studies failed to distinguish
consistent cognitive differences between AD and vascular dementia cases; motor and visuospatial changes;
sequencing and writing more affected than in AD; some studies show relative sparing of orientation, verbal recall, and
language ability, compared to AD patients; AD patients have better attention, executive functioning skills, self-regulation,
and fine motor control; verbal recognition higher in vascular dementia patients, compared to AD patients; depression
and anxiety twice as common in vascular dementia than in AD
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| Use of screening tools: testing should take ≤5 min; can be administered by any trained individual; identifies red flags;
affective screening tests should be given at every visit; cognitive screening test should be given 1 to 2 times yearly; positive
screening test should result in diagnostic interview and clinical examination by neuropsychologist, geriatrician, or
neurologist; talk with family; screening tests indicate potential impairment, but not diagnostic tools
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| Mini-Mental Status Examination (MMSE): sensitivity and specificity good; score of 27 to 30 normal, 21 to 26 indicates
mild impairment, 11 to 20 indicates moderate impairment, 1 to 10 indicates severe impairment; accurate for
whites with at least high school education (education contributes most variance in scores); arbitrary cut-off scores lead to
false-positive results in patients with low education, and false-negative results in highly educated patients; score <23 red
flag; assessment—ask about year, season, day, and month; ask patient to name 3 objects; serial 7s test; ask patient to
spell “world” backwards; disadvantages—paper and pencil required; may require >5 min
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| Clock-drawing test: ask patient to draw face of clock at 10 min after 11 o’clock; common errors by patients with AD
include perseveration (ie, drawing same number multiple times), counterclockwise numbering, absence of numbers, and
numbers outside of clock; scoring from 1 to 6 or by 16-item method
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| Categorical verbal fluency test: assesses phonemic fluency (eg, ask patient to name letter and words that begin with
that letter); animal-naming test measures prefrontal function, auditory function, attention, short-term memory, speeded
mental process, and long-term vocabulary; note repetitions and paraphasic errors; phonemic fluency in AD patients low
average and semantic fluency borderline to moderately impaired
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| Recommendations: give Blessed memory test (ask patient to repeat “John Brown, 42 Market Street, Chicago”) followed
by 1-min animal-naming test, and repeat Blessed memory test after 2 to 3 min; score of ≥3 errors on memory test
and ≤11 animals in animal-naming test indicates impairment; sensitivity and specificity equal to MMSE
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| Depression: difficult to distinguish psychiatric issues from disease process; retrieval deficits may be due to poor initial
processing or intention; depressed patients lack internal motivation to complete testing; poor effort results in invalid results
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| Pseudodementia: dementia-like symptoms, but no dementia; symptoms persist without treatment; frequently caused by
major depression; can be related to psychotic disorders; if depression treated with therapy and/or psychopharmacology,
short-term memory deficits may remit; difficulties with diagnosis—depression accompanies progressive dementia in
25% of cases; older patients do not report common symptoms of depression as younger patients do; patients demonstrate
decreased motivation or energy during neuropsychologic examination; patients often express cognitive and affective
complaints; language and motor skills intact; verbal and phonetic fluency, vocabulary, and intellect unaffected; performance
on challenging cognitive tests better than on easier tests due to greater internal motivation; encouragement improves
performance; clock-drawing test normal
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| Geriatric depression scale: 15-item scale; easy to give; takes <5 min; more somatic and sleep complaints in older patients;
more subclinical symptoms
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| Management of patients: discuss referral to neuropsychologist or neurologist with patient and family; determine history
of depression or anxiety that could affect cognition; neuropsychologic assessment covered by Medicare;
summary—early detection important; use of brief screening tools effective
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Educational Objectives
| The goal of this program is to educate the listener about mental function and memory loss in cognitively fragile patients.
After hearing and assimilating this program, the participant will be better able to:
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| 1. Select appropriate drugs to optimize mental function in elderly patients.
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| 2. Identify causes of cognitive impairment such as depression and sleep disorders.
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| 3. Approach patients with behavioral changes associated with dementia.
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| 4. Differentiate dementia from delirium and Alzheimer’s disease.
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| 5. Use effective screening tools to identify cognitive impairment.
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Discussed on This Program
Amitriptyline HCl [Elavil]
Amphetamine sulfate (racemic amphetamine sulfate)
Atenolol [Tenormin] Carbamazepine [Carbatrol, Epitol, Tegretol, Tegretol-XR]
Chlordiazepoxide HCl [Librium]
Clonidine HCl [Catapres, Duraclon]
Diazepam [Diastat, Diazepam Intensol, Valium]
Diphenhydramine HCl (several trade names)
Donepezil HCl [Aricept, Aricept ODT]
Galantamine HBr [Reminyl, Razadyne]
Lamotrigine [Lamictal, Lamictal Chewable Dispersible]
Levetiracetam [Keppra]
Levodopa and carbidopa [Parcopa, Sinemet-10/100, Sinemet-25/100, Sinemet-25/250, Sinemet CR]
Memantine HCl [Namenda]
Methylphenidate HCl [Concerta, Metadate CD, Metadate ER, Methylin, Methylin ER, Ritalin, Ritalin LA, Ritalin–SR]
Metoprolol succinate [Lopressor, Metoprolol Tartrate, Toprol XL]
Phenobarbital [Bellatal, Luminal Sodium, Solfoton]
Phenytoin [Dilantin Infatab, Dilantin-125]
Pramipexole [Mirapex]
Primidone [Mysoline]
Propranolol HCl [Inderal, Inderal LA, InnoPran XL]
Quetiapine fumarate [Seroquel]
Rivastigmine tartrate [Exelon]
Ropinirole HCl [Requip]
Trazodone HCl [Desyrel, Desyrel Dividose]
Suggested Reading
Boyle PA et al: Mild cognitive impairment: risk of Alzheimer disease and rate of cognitive decline. Neurology 67:441,
2006; Briones TL: Environment, physical activity, and neurogenesis: implications for prevention and treatment of
Alzhemier's disease. Curr Alzheimer Res 3:49, 2006; Burton CL et al: Cognitive functioning and everyday problem
solving in older adults. Clin Neuropsychol 20:432, 2006; Doraiswamy PM et al: Anticholinergic drugs and elderly
people: a no brainer?. Lancet Neurol 5:379, 2006; Gutchess AH et al: Categorical organization in free recall across
culture and age. Gerontology52:314, 2006; Hanon O et al: Relationship between antihypertensive drug therapy and
cognitive function in elderly hypertensive patients with memory complaints. J Hypertens 24:2101, 2006; Jelic V et al:
Clinical trials in mild cognitive impairment: lessons for the future. J Neurol Neurosurg Psychiatry 77:429, 2006;
Karantzoulis S et al: Subject-performed tasks improve associative learning in amnestic mild cognitive impairment. J
Int Neuropsychol Soc 12:493, 2006; Lautenschlager NT et al: Physical activity and cognition in old age. Curr Opin
Psychiatry 19:190, 2006; Le Rhun E et al: Different patterns of Mini Mental Status Examination responses in primary
progressive aphasia and Alzheimer's disease. Eur J Neurol 13:1124, 2006; Murphy KJ et al: Verbal fluency patterns in
amnestic mild cognitive impairment are characteristic of Alzheimer's type dementia. J Int Neuropsychol Soc 12:570, 2006;
Oosterman JM et al: Distinguishing between vascular dementia and Alzheimer's disease by means of the WAIS: a
meta-analysis. J Clin Exp Neuropsychol 28:1158, 2006; Scalco MZ et al: Prevention of Alzheimer disease. Encouraging
evidence. Can Fam Physician 52:200, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Nadeau and Cohen spoke at the 9th Annual Geriatric Medicine for the Primary Care Physician Summer Conference,
in Lake Buena Vista, FL, presented August 3-5, 2006, by Orlando Regional Healthcare and the Geriatric Research,
Education and Clinical Center. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in
the production of this program.
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