DEMENTIA/LONG-TERM CARE
From the West Coast Geriatric Psychiatry Conference, presented by the University of California, San Diego, School of
Medicine
| DIAGNOSING DEMENTIA FOR THE NON-NEUROLOGIST —Mark Kritchevsky, MD, Professor of Neurosciences,
University of California, San Diego, School of Medicine, and Staff Neurologist, VA San Diego Healthcare System
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| Criteria for dementia: normal level of consciousness; absence of delirium, lethargy, stupor, and coma; impairment of
memory and of at least 1 other cognitive ability; diminished intellectual functioning to degree that interferes with everyday
social or occupational functioning; most dementing illnesses come on gradually
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| Causes of dementia: >100 causes of dementia, but only 6 are common; most common causes fairly easy to recognize
based on history and physical examination; single most common cause is Alzheimer’s disease (AD); other causes include
neurodegenerative diseases other than AD, multiple brain infarctions (called multiinfarct or vascular dementia), alcohol-
related cognitive dysfunction, psychiatric disorders (especially depression), and certain toxic, metabolic, nutritional, and
endocrinologic conditions
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| Alzheimer’s disease: ≈70% of patients have typical presentation of insidious onset and gradual progression over years
and can be diagnosed from history and physical examination; AD usually starts with amnesia, then progresses to inability
to learn new facts and events, anomia, and more widespread cognitive dysfunction; neuropsychiatric features
such as paranoia and delusions may occur; sensory and motor functions and social graces preserved early on
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 | Atypical presentations: most common is insidious onset of gradually worsening memory problems, then progression to
other cognitive dysfunction; uncommonly, AD starts in part of brain other than temporal lobes and first presents as
frontal-lobe syndrome, visual agnosia, aphasia, or neuropsychiatric syndrome; rarely presents as autosomal dominant
condition with relatively early age of onset
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| Risk factors for sporadic AD: age (prevalence 1% at 65 yr of age, doubles with every 5 yr of age); ApoE genotype predicts
likelihood of elderly developing AD; Down syndrome; head trauma; female sex; low education
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| Diagnosing AD: brain tissue required for definitive diagnosis; neuropsychologic testing can support diagnosis by demonstrating
typical pattern of cognitive deficits; functional neuroimaging studies may support diagnosis but lack sensitivity
and specificity; reliable blood and cerebrospinal fluid (CSF) markers being sought but, so far, none found; ask all patients
>60 yr of age and reliable outside observer whether patient has memory problems; consider performing careful
mental-status examination or administering screening test for AD to all patients >60 yr of age
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| Lewy body variant of AD (Lewy body disease, Lewy body dementia): progressive Alzheimer-like dementia
often associated with parkinsonian motor features; patients more likely to have fluctuations in symptoms and psychotic
features than patients with typical AD; patients more sensitive to side effects of dopamine-blocking drugs
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| Frontotemporal dementias: degenerative disorders that typically present with progressive behavioral abnormalities
or progressive language disturbance; memory preserved early in course of disease; sometimes associated with parkinsonism
or features of motor neuron disease
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| Multiinfarct (vascular) dementia: patient usually has history of multiple small strokes, with stepwise deterioration
of cognitive function associated with concurrent development of focal sensory and motor signs and symptoms; head scan
typically shows strokes, but small lacunar strokes may not be detectable; beware of neuroimaging findings of “deep
white-matter changes of uncertain clinical significance”
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| Alcohol-related cognitive dysfunction: over time, consumption of too much alcohol produces frontal-lobe dysfunction;
at worst, consists of mild dementia; not related to Wernicke-Korsakoff syndrome; head scan may show atrophy,
which is at least partially reversible with cessation of alcohol intake, but cognitive dysfunction often persists
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| Dementia of depression: sometimes called depressive pseudodementia; theoretically, completely reversible; no underlying
structural brain abnormality; depressive symptoms antedate dementia; patient appears depressed, often answers
questions with “I don’t know,” but cognitive performance inconsistent; consider diagnostic trial of therapy for depression
to see whether dementia improves as depression improves; dementia of depression may be presenting symptom of AD in
elderly patient with no history of depression
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| Toxic, metabolic, nutritional, and endocrinologic disorders: typically present as “quiet delirium” that mimics
dementia; may be partially or entirely responsible for cognitive impairment; drug toxicity most common
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| Uncommon causes of dementia: normal pressure hydrocephalus—produces cognitive dysfunction unlike that of
AD, more like that of frontal-lobe syndrome; memory and recognition better than in patients with AD; no language problems;
draining CSF from ventricles produces improvement; neurodegenerative disorders—Parkinson’s disease; Huntington’s
disease; progressive supranuclear palsy; multisystem atrophies; corticobasal degeneration; infectious disorders—
neurosyphilis; Lyme disease; HIV infection; multiple small brain abscesses; chronic meningitides; Creutzfeldt-Jakob disease;
others—head trauma; multiple sclerosis; brain tumor; partial complex status epilepticus; cerebral vasculitis
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| Evaluation of possible dementia: obtain history from patient and reliable observer; administer complete mental status
examination; consider Mini Mental State Examination as screening test; obtain selected tests if high degree of suspicion;
consider consultations by neurologist, psychiatrist, neuropsychologist, behavioral neurologist, or neuropsychiatrist;
reevaluate after appropriate interval
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| Evaluation of probable dementia: obtain history from patient and reliable observer; administer complete mental status
examination; obtain complete blood count (CBC), chemistry panel, thyroid function tests, and vitamin B12 level; consider
lumbar puncture or electroencephalography (EEG); if typical AD suspected, consider computed tomography (CT)
of head without contrast; if other cause of dementia suspected, consider magnetic resonance imaging (MRI) of brain; reevaluate
after appropriate interval
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| Other evaluations that might be indicated: examination of family members and medical records; consultations as
above; home visit to check for drugs, alcohol, and safety; chest x-ray; electrocardiography (ECG); urinalysis; erythrocyte
sedimentation rate (ESR); arterial blood gases (ABG); antinuclear antibody (ANA); ammonia level; toxicology screen
and drug levels; HIV test; syphilis serology; CSF examination for cells, protein, glucose, and Venereal Disease Research
Laboratory (VDRL) test; EEG to look for Creutzfeldt-Jakob disease or partial complex status epilepticus; positron emission
tomography (PET) or single photon emission computed tomography (SPECT) to distinguish unusual neurogenic
from psychogenic condition; “large volume” lumbar puncture to look for normal-pressure hydrocephalus
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| Who should diagnose cause of dementia? physician with appropriate expertise in diagnosing dementia
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| ISSUES IN LONG-TERM CARE —John W. Daly, MD, Associate Clinical professor of Geriatric Medicine, University of
California, San Diego, School of Medicine
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| Introduction: as people age, support systems likely to be lost; disability increases with age; psychiatric illness common
in nursing home patients (study in 1990s estimated 80% to 90% of patients in long-term nursing homes had psychiatric
illness, and 50% to 70% of those had some form of dementia)
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| Long-term care (LTC) environments: skilled nursing care—geared to rehabilitation and convalescence after acute
hospitalization; custodial nursing care—traditional long-term care of people unable to care for themselves in one or
more areas; residential care for elderly—geared mostly to independent people with few needs; short stay—1 to 6 mo;
includes hospice for terminal illness, and rehabilitation and treatment of subacute illness with goal of patient’s recovery
and return to community at previous or higher level of function; long stay—>6 mo; patients are impaired cognitively,
physically, or both; special features of LTC include patient population (“by definition, the frail elderly”), comorbid conditions,
availability or lack of medical information, polypharmacy, and limitation of resources
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| Patients in LTC: dependent in activities of daily living (ADLs) and instrumental activities of daily living (IADLs); have
impaired mobility, sensory perception, communication, and/or cognition
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| Factors that lead to LTC placement: lack of caregiver support; symptoms difficult to deal with in home-care environment;
incontinence; pain; impaired mobility; behavioral or cognitive disorder; ADL dependence
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| Sources of admission to LTC: acute-care hospital; home; another long-term care facility; emergency departments;
adult protective services; many of these patients have not had medical evaluations, leading to emergence of acute illness
in LTC facility
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| Dangerous combinations in LTC: impaired mobility and incontinence can lead to falls and fractures; cognitive and/
or motor impairment can lead to dehydration, malnutrition, and falls and fractures; sensory and cognitive impairment can
lead to depression, delusions, agitation, and falls and fractures
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| Comorbidity in LTC: previously diagnosed conditions (long-term care facility is aware of them); previously undiagnosed
conditions; previously misdiagnosed conditions; new conditions that develop after admission to LTC (may not
present in typical manner); chart review of admissions to Senior Behavioral Medicine unit (inpatient geriatric psychiatry
facility) at speaker’s institution showed that 40% of patients admitted had previously unrecognized and untreated medical
conditions; hence, Dr. Daly’s first rule in evaluation of LTC patient, “do not assume that the list of diagnoses on the admission
history and physical examination (H & P) is complete or even accurate”; unrecognized comorbid illness can lead
to iatrogenic complications, adverse drug reactions, and other problems
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| The medical record in LTC: often incomplete and/or uninformative; beware of “chart lore” (“something gets written
down on a sheet somewhere in a chart, and it gets written down by everybody who sees that sheet of paper; the problem
is that sometimes people address those issues that aren’t there” or fail to address issues that are there); usually present—
discharge summary of recent hospitalization; note from most recent treating physician; list of current medications; purified
protein derivative (PPD) or chest x-ray; often absent—information about more remote diagnoses and treatments; information
about prior functional or cognitive level; immunization history; information about health maintenance and
screening
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| Barriers to accurate medical information: patient unable to provide history; family members with limited or erroneous
understanding of patient’s history; involvement of many providers, and subspecialty fragmentation of history; doctor
shopping “shopping list” medical records
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| Geriatric pharmacology: patients often take numerous medications, and risk for adverse drug reaction high; speaker
observes that “drug subtraction is often more therapeutic than drug addition”; that is, taking away some drugs may be
more helpful than adding more; inquire about all medications, including prescription, over-the-counter, and under-the-
counter agents; ask about shared medications (“I get by with a little help from my friends”); best assessment tool for
polypharmacy is “brown-bag technique” (ie, have patient or family deliver all medications to physician in brown paper
bag); adverse drug reactions account for 10% to 17% of acute admissions of elderly; among elderly outpatients, 18% suffer
adverse drug reaction, and 35% of those who take ≥5 medications
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| The cognitively impaired patient in LTC: dementia—acquired syndrome of decline in memory and at least one
other cognitive function sufficient to affect daily life in alert person; delirium—acute or subacute mental syndrome that
features cognitive impairment, alterations in attention, level of consciousness, or psychomotor activity; severity of symptoms
tends to fluctuate unpredictably; 6-mo mortality for elderly patients admitted to LTC facility with delirium 25%;
with subsyndromal delirium, 18.3%; without delirium, 5.7%; patient may have dementia without delirium, delirium without
dementia, or delirium superimposed on underlying dementia (latter at highest risk for adverse outcome); differentiation
between delirium and dementia based on history; ask how patient was doing 1 wk ago, 1 mo ago, and 6 mo ago
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| Delirium: (for underlying causes of dementia, see above) metabolic disorder; infection; cardiovascular disease; cerebrovascular
disease; pulmonary disease; drug and/or alcohol intoxication; anemia; trauma; fecal impaction; urinary retention;
acute psychosis; altered or impaired sensory input; hypothermia; hyperthermia; pain
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| Pearls: in elderly patients with cognitive impairment, usual presenting symptoms of acute illness lose specificity and sensitivity;
most common presentation of acute illness is change in level of consciousness, behavior, or functional level;
agitation—consider as underlying cause fecal impaction, urinary retention, infection, hypoxia, pain, drug reaction, or
psychosis; decline in function—consider as underlying cause infection, anemia, hypoxia, cardiovascular disease, cerebrovascular
disease, occult fracture, or depression; change in level of consciousness—consider as underlying cause infection,
drug effect, hypoxia, cardiovascular disease, stroke, subdural hematoma, anemia, or dehydration
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| Special considerations in LTC: safety vs autonomy; quality of life, comfort care, hospice care; hospitalization; use of
emergency department; competence, capacity, and dignity
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| Residential care facilities for the elderly (RCFEs): defined as “a housing arrangement chosen voluntarily by the
resident, resident’s guardian, conservator, or other responsible person”; 75% of residents are ≥60 yr of age; varying levels
of care and supervision available; residents <60 yr of age must have needs compatible with other residents; RCFEs provide
assistance with ADLs and with taking medications, central storage and distribution of medications, arrangement of
and assistance with medical and dental care; protection and supervision of activities, monies, and property, and monitoring
of food intake; preadmission medical assessment should include—physical examination; examination for and diagnosis
of tuberculosis, other contagious diseases, or other precluded medical condition; history of previous medical
services, including height, weight, and blood pressure; record of current medications; documentation of physical limitations
and capabilities; ambulatory status; acceptable residents—capable of administering own medications; receive medical
care and treatment outside RCFE or from visiting nurse; need help with self-administration of medications due to
mild forgetfulness or physical limitation; require assistance with management of property or monies due to mild forgetfulness
or confusion; unacceptable residents—active communicable tuberculosis; need 24-hr skilled or intermediate-
care nursing; not elderly and has needs that conflict with those of other residents; primary need for care and supervision
results from dementia; bedridden
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| Conclusions: number of people in variety of long-term care settings increasing; these people represent medically complicated
and often frail population; disparity often exists between care needs and care availability, with poor coordination of
care in current system
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Suggested reading
Birke MG: Elder law, Medicare, and legal issues in older patients. Semin Oncol 2004, 31:282; Foy CM et al: Diagnosing
Alzheimer’s disease: non-clinicians and computerised algorithms together are as accurate as the best clinical practice.
Int J Geriatr Psychiatry 2007, May 25; [Epub ahead of print]; Gualtieri CT: Dementia screening using
computerized tests. J Insur Med 2004, 36:213; Kaufer DI: Long-term care in dementia: patients and caregivers. Clin
Cornerstone 2001, 3:52; Kim KW et al: Diagnostic accuracy of mini-mental status examination and revised Hasegawa
dementia scale for Alzheimer’s disease. Dement Geriatr Cogn Disord 2005, 19:324; Konetzka RT, Spector W, Limcangco
MR: Reducing hospitalizations from long-term care settings. Med Care Res Rev 2007, Sep 25; [Epub ahead of
print]; Leentjens AF, van der Mast RC: Delirium in elderly people: an update. Curr Opin Psychiatry 2005 18:325;
Marcantonio ER et al: Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc
2005, 53:963; Messinger-Rapport BJ et al: Intensive session: New approaches to medical issues in long-term care. J
Am Med Dir Assoc 2007, 8:421; Nagga K et al: Evaluation of factors of importance for clinical dementia diagnosis. Dement
Geriatr Cogn Disord 2005, 19:289; Placentino A et al: Clinical characteristics in long-term care psychiatric patients:
A descriptive study. World J Biol Psychiatry 2007, May 8, [Epub ahead of print]; Reinhard SC et al: Nurse
delegation of medication administration for older adults in assisted living. Nurs Outlook 2006, 54:74; Small GW et al:
Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for
Geriatric Psychiatry, the Alzheimer’s Association, and the American Geriatrics Society. JAMA 1997, 278:1363; van der
Steen JT et al: Prediction of 6-month mortality in nursing home residents with advanced dementia: validity of a risk
score. J Am Med Dir Assoc 2007, 8:464; van Hout HP, Vernooij-Dassen MJ, Stalman WA: Diagnosing dementia
with confidence by GPs. Fam Pract 2007 Sep 7; [Epub ahead of print]; Weaver JD, Espinoza R, Weintraub
NT: The utility of PET brain imaging in the initial evaluation of dementia. J Am Med Dir Assoc 2007, 8:150; Wolfs CA
et al: The added value of a multidisciplinary approach in diagnosing dementia: a review. Int J Geriatr Psychiatry 2006,
21:223.
Educational Objectives
| The goal of this program is to help the practitioner to diagnose the underlying cause of dementia and to provide updated information
about the services available in long-term care facilities. After hearing and assimilating this program, the clinician
will be better able to:
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| 1. Identify the six most common causes of dementia in the elderly.
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| 2. Enumerate some of the less common causes of dementia.
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| 3. Evaluate the patient with suspected dementia.
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| 4. Describe the varieties of long-term care facilities and the levels of services they offer.
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| 5. Discuss the patients who are suitable or not suitable for admission to residential care facilities for the elderly.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Kritchevsky and Daly were recorded at West Coast Geriatric Psychiatry Conference, held March 7-10, 2007, in San
Diego, CA, and sponsored by the University of California, San Diego, School of Medicine. The Audio-Digest Foundation
thanks the speakers and UCSD for their cooperation in the production of this program.
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