"I am Feeling Forgetful, Doc": Do You Know the Next Step?
What is the difference between DEMENTIA and MILD COGNITIVE IMPAIRMENT?
List FOUR diagnostic criteria for delirium
How many diagnostic criteria are required to make a diagnois of delirium?
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
Acute onset and fluctuating course AND
Disorganized thinking OR
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.
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.