Dementia: Diagnosis and management in the primary care setting

Clinical Pearls for the Front-line PCP

A 73-year-old woman presents with her daughter, who lives down the street from her, and her husband of 51 years for her annual Medicare wellness visit. She has been a patient in the practice for the past 7 to 8 years. She is a retired teacher.

As part of the annual wellness visit (AWV), the medical assistant (MA) performs the Mini-Cog, which was abnormal. The score on a follow-up Montreal Cognitive Assessment (MoCA) was 18, which is significantly abnormal. The Patient Health Questionnaire-9 (PHQ-9) was 11, consistent with mild to moderate depression. The patient had somewhat of a difficult time with some of the questions and kept repeating herself throughout the visit. Her mood is upbeat, and she laughs off her misses on the screening tests. She is moderately hard of hearing. After using a pocket talker amplification device, she can hear much better.

Philip A. Bain

The patient’s medical history is notable for hypertension, hypercholesterolemia, chronic low back pain and urinary incontinence. Medications include atorvastatin, lisinopril, hydrocodone and oxybutynin.

The astute MA makes note of the MoCA test results and administers surveys of activities of daily living (ADLs) and instrumental ADLs (iADLs).

The patient drives only short distances since going the wrong way on a street downtown 2 years ago. She can dress and toilet herself independently. She needs to be reminded about certain hygiene measures and, at times, needs help choosing clothes for the day. She wears adult diapers because of her urinary incontinence. She has preferred to go out less in the past few months as she becomes rather confused in unfamiliar places. She has been more forgetful recently and is often unable to remember the names of her grandchildren, even the ones who live in town and visit her often. She left the stove on for 4 hours 2 weeks ago. Fortunately, this has not happened before or since.

The MA enters the SmartPhrase “.MAmemoryissues” into the note.

 Source: Philip A. Bain, MD, FACP

SmartPhrases are time-saving tools in the electronic health record that can pull together long phrases or paragraphs into a note. They can standardize the approach and help users to recall key concepts of evaluation, history and physical as well as patient information. The phrases can be built by your informatics specialist.

 Source: Philip A. Bain, MD, FACP

The MA presents the case to the physician:

“Doc, the patient is here for her AWV accompanied by her daughter and husband. She denies any symptoms or issues. Her daughter is concerned that she is ‘really slipping.’ She has become much more forgetful over the past year. Her husband has his own medical problems. Two months ago, he fell off a ladder and broke his hip. While hospitalized, his wife became much more confused. Her daughter had to act as caregiver for both of her parents. She says that she is holding up okay, but I worry that she is becoming really burned out. She has a full-time job, is a single mother of three kids and now this.

The patient’s MoCA was 18, which is a lot worse compared to a year ago. Her PHQ-9 was borderline for moderate depression. She repeated herself many times during my time with her.”

The primary care physician reviews the MA’s note and data collected, then enters the room. The patient is pleasant, obviously forgetful and often makes jokes about her memory. Her gait is steady without shuffling. No tremor or rigidity was noted. The PCP notes that her daughter looks overwhelmed, and her husband is quite passive. The patient denies having any hallucinations, psychotic symptoms or depression. Her daughter nods her head in agreement. The patient and her husband deny loud snoring, witnessed apnea or significant daytime fatigue. The physical exam was otherwise unremarkable. The PCP makes the diagnosis of Alzheimer’s dementia and orders labs for reversible causes of dementia. Her daughter asks if the patient needs a CT or MRI of her brain. The PCP replied that in this situation, neither would offer much benefit.

The PCP reviews the medications and stops the atorvastatin, which was started for primary prevention of atherosclerotic CVD. She has her wean off oxybutynin, as this is associated with more confusion. She orders home health care for scheduled toileting education, assessment of ADL assistive devices and safety issues. The home health social worker meets with the patient and family to assess needs of the family and review the health care power of attorney. After they met with the social worker, they decided to complete the Practitioner Orders for Life Sustaining Treatment (POLST) form and have decided that she would like to be DNR status. Together, they decide that mom can no longer drive at all. Fortunately, her husband still drives, and their daughter is confident that he is a safe driver. The social worker gives the family information about adult day services (ADS) and respite care options in the community.

The PCP notes that the patient takes two hydrocodone tabs daily and has done so since her knee replacement surgery 5 years ago. She recommends that they try a heating pad or patch and/or topical NSAIDs and acetaminophen and only use hydrocodone for severe pain.

For her moderately decreased hearing, they are not able to afford hearing aids, but were impressed enough how well the pocket talker device worked that they were interested in purchasing one.

While the patient was very reluctant to go to ADS, she agreed to go three times as a trial. She found that she actually enjoyed it and reconnected with a friend there who she went to high school with. Her husband has started to go once or twice weekly and he also has enjoyed it. They have started chair exercises at the ADS. A home safety evaluation was done, and her daughter decided to permanently turn off the stove. They have a microwave available, and her daughter has been making extra portions, which they freeze. The social worker helps them sign up for Meals on Wheels. Home health arranges to have grab bars installed in the shower and orders a shower seat. Two loose throw rugs are removed and a ramp with railings was installed to eliminate the need to go down the two steps to the garage.

The exercise at the ADS has helped her mood and one of the staff members at the ADS put on songs that the patient and her husband played during their courtship. That also brought her joy.

The PCP offered a 6-month trial of donepezil. Unfortunately, she did not tolerate it very well — loose stools and lightheadedness. They agreed to stop it.

The patient ultimately moved in with her daughter. She has become much more dependent on her daughter for ADLs. She has become much more withdrawn and no longer attends ADS.

She is now incontinent of stool and urine. Her daughter is becoming much more exhausted.

Geriatric nurse practitioners now do house calls on the patient as it is much more difficult for her daughter to transport her to the office. The patient’s functional assessment staging tool (FAST) score is now 7. Referral to hospice is made and the hospice staff have been able to see her more often. Her daughter had to have an elective cholecystectomy and the hospice staff was able to have the patient admitted to respite care for 5 days while her daughter recuperated.

The patient’s medications were stopped due to her deterioration in status. She now sleeps 12 to 16 hours per day. She became gradually weaker and when it was clear that she was actively dying, her daughter and grandchildren came to her bedside and were with her when she passed away peacefully.

Lessons learned:

1. Dementia is very common, especially as patients become older. Alzheimer’s dementia is still the most common etiology. Other etiologies include Lewy body dementia, frontotemporal dementia and other less common causes.
2. It is important to regularly address medications, especially looking for those medications that can add to confusion and/or other adverse effects. Also, it is important to assess whether the medications are still necessary. Many medications can be discontinued such as atorvastatin if the risks outweigh the benefits.
3. Medications for dementia can be considered. No medication can prevent or reverse the expected memory decline of dementia. In some patients, it can slow down the cognitive impairment decline. Once started, if stopped, memory decline can accelerate. Generally, donepezil or another centrally acting cholinesterase inhibitor is started first and if not helpful, memantine may help.
4. Assessment of medication benefit can be tricky as even on medication, cognitive impairment can (and likely will) progress. Following MoCA is not helpful as a reason to stop cognitive medications. It is important to be vigilant for adverse events.
5. Reversible causes of dementia are possible but quite rare. It is reasonable to check TSH, B12, CBC and BMP. Brain scans are usually not needed unless the presentation is atypical, there are abnormal neurological findings on exam or the course is rapidly progressive. If there is any suspicion for sleep apnea, this should be screened for as untreated sleep apnea can significantly add to cognitive impairment.
6. Many very helpful services are available to help keep the person with dementia at home safely.
7. It is very important to address advanced directives early on. Having to go to court to assess competency or designate a surrogate decision maker can be very arduous.
8. Remember the caregivers; burnout is very common. Give resources and support.
9. When dementia is advanced, consider hospice if FAST score is 7.
10. Early on, behavioral modification — music therapy, pet therapy and exercise — can be helpful.
11. Hearing loss is an important reversible risk factor for dementia.

If you have any suggestions to make this column more relevant to you, the front-line PCP, email primarycare@healio.com with the subject line “clinical pearls.”

References:

• Alzheimer’s Association. https://www.alz.org/. Accessed May 24, 2023.
• Arvanitakis Z, et al. JAMA. 2019;doi:10.1001/jama.2019.4782.
• Clinical stages of Alzheimer’s. https://www.alzinfo.org/understand-alzheimers/clinical-stages-of-alzheimers/. Accessed May 24, 2023.
• Dementia and driving. https://www.alz.org/help-support/caregiving/safety/dementia-driving. Accessed May 24, 2023.
• End-of-life decisions. https://www.alz.org/national/documents/brochure_endoflifedecisions.pdf. Accessed May 24, 2023.
• Evaluation of suspected dementia. https://www.aafp.org/pubs/afp/issues/2018/0315/p398.html. Published March 15, 2015. Accessed May 24, 2023.
• Hospice care. https://www.alz.org/help-support/caregiving/care-options/hospice-care. Accessed May 24, 2023.
• The POLST form: What it is and how to use it. https://www.alzoc.org/the-polst-form-what-it-is-and-how-to-use-it/. Accessed May 24, 2023.