• Dr. Felicia Presenza MD CCFP

"I am Feeling Forgetful, Doc": Do You Know the Next Step?


SNAP SAMP:

  1. What is the difference between DEMENTIA and MILD COGNITIVE IMPAIRMENT?

  2. List FOUR diagnostic criteria for delirium

  3. How many diagnostic criteria are required to make a diagnois of delirium?

  4. List SIX laboratory investigations you would order for a patient with new-onset dementia.

Answers are in the blog post below

Approach to patient with new cognitive concerns:

STEP 1: RULE OUT DELIRIUM

  • Use the confusion assessment method (CAM)

Diagnosis of delirium requires criteria 1 and 2, plus either 3 or 4

  1. Acute onset and fluctuating course AND

  2. Inattention

  3. Disorganized thinking OR

  4. Altered level of consciousness (alertness)

STEP 2: RULE OUT DEPRESSION

  • Use PHQ2 1. Are you down, depressed, hopeless? 2.Do you have little interest or pleasure in doing things?

  • Consider atypical presentations (more common in elderly): concentration difficulty, irritability, physical symptoms

STEP 3: RULE OUT REVERSIBLE CAUSE

  • Labs to consider: Serum TSH, B12 level, creatinine, sodium, calcium, A1C or fasting glucose. (Be sure to BE SPECIFIC and have a complete answer on the exam - write SERUM and also FASTING blood glucose, so the examiner knows you aren’t asking for urine or random glucose! Also – the CCFP says that you can’t just write “electrolytes” so make sure you specify “sodium, calcium” separately)

  • CT head if: age <60, duration <2years, rapid course (over 1-2 months), recent head trauma, bleeding disorder, use of anticoagulants, unexplained neurological symptoms, history of cancer, focal neurological signs, symptoms of NPH, gait disturbance

STEP 4: RULE OUT MCI

  • dementia: MMSE change + impairment of ADLs

  • MCI: MMSE change, NO impairment of ADLs

  • normal cognitive aging: NORMAL MMSE (>26) MOCA (>26)

STEP 5: MAKE DIAGNOSIS OF NEUROCOGNITIVE DISORDER (and specifically, which type)

Neurocognitive disorder is the new name for Dementia as per the DSM-5.

Ref:

DSM-5

Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948.

http://www.cfpc.ca/uploadedFiles/Education/Certification_in_Family_Medicine_Examination/SAMPS%20instructions%20-%20Eng.pdf

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