Medical Evaluation of the Patient with Brain

Failure

Medical Evaluation of the Patient with Brain

Failure

Jane F. Potter, MDJane F. Potter, MD

Chief Section of Geriatrics & GerontologyChief Section of Geriatrics & Gerontology

University of Nebraska Medical CenterUniversity of Nebraska Medical Center

DeliriumDelirium

• Clinical Presentation: A syndrome of acquired impairment of attention, level of consciousness, and perception.

Evaluation: Confusion Assessment Method (CAM)Evaluation: Confusion Assessment Method (CAM)

Change in cognition that has Change in cognition that has bothboth:: AcuteAcute onset and fluctuating courseonset and fluctuating course AND InattentionAND Inattention

And eitherAnd either Disorganized thinkingDisorganized thinking OR altered level of consciousnessOR altered level of consciousness

Acute Onset AND FluctuationAcute Onset AND Fluctuation

Symptoms develop over Symptoms develop over hours to dayshours to days

(need a reliable informant; if not observed (need a reliable informant; if not observed may present late) may present late) ANDAND

Symptoms Symptoms varyvary through out through out the day; characteristic the day; characteristic lucid interval lucid interval

AND Inattention AND Inattention

Difficulty focusing, sustaining, and shifting Difficulty focusing, sustaining, and shifting attentionattention

Difficulty maintaining conversation or Difficulty maintaining conversation or following commandsfollowing commands

AND Either: Disorganized ThinkingAND Either: Disorganized Thinking

E.G. disorganized E.G. disorganized or incoherent or incoherent thinkingthinking

E.G. Rambling or E.G. Rambling or irrelevant irrelevant conversation conversation ((unpredictable switching unpredictable switching subjects?)subjects?)

OR: Altered Level of ConsciousnessOR: Altered Level of Consciousness

Vigilant (hyperalert, very easily startled)Vigilant (hyperalert, very easily startled)

Lethargic (drowsy, easily aroused)Lethargic (drowsy, easily aroused) Stupor (difficult to arouse)Stupor (difficult to arouse) Coma (unarousable)Coma (unarousable)

Evaluation: CAMEvaluation: CAM

Change in cognition that has Change in cognition that has bothboth:: AcuteAcute onset AND fluctuating courseonset AND fluctuating course

AND Inattention AND Inattention

And eitherAnd either Disorganized thinkingDisorganized thinking OR altered level of consciousnessOR altered level of consciousness

Risk Factorsfor Delirium Risk Factorsfor Delirium

Advanced ageAdvanced age DementiaDementia DepressionDepression Impaired physical Impaired physical

functionfunction Sensory lossSensory loss Decreased oral intake Decreased oral intake

(food and fluids)(food and fluids)

Drugs (ETOH)Drugs (ETOH) Coexisting Medical Coexisting Medical

Illness (severe, multiple, Illness (severe, multiple, CKD, LD, fractures, CKD, LD, fractures, stroke, neurological ds, stroke, neurological ds, HIV)HIV)

Who Gets Delirious? Why?Who Gets Delirious? Why?

VULNERABLE PATIENT

# of RISK FACTORS

INSULTS

DementiaDementia

• Clinical Presentation: A syndrome of acquired impairment of memory and other cognitive domains sufficient to affect daily life

• Etiology: Any disorder causing damage to brain systems involved in memory. Alzheimer’s disease is the most common cause in later life

Brain FailureBrain Failure The most common The most common

cause of disability in cause of disability in later lifelater life

A focus for geriatric A focus for geriatric practitionerspractitioners

Objectives:Objectives:

Identify the common (non-dementia) causes Identify the common (non-dementia) causes of cognitive dysfunction. of cognitive dysfunction.

Describe a basic approach to evaluate Describe a basic approach to evaluate physical causes of cognitive dysfunctionphysical causes of cognitive dysfunction

Understand interdisciplinary contributions Understand interdisciplinary contributions to evaluation of cognitive dysfunctionto evaluation of cognitive dysfunction

The Brain Failure Evaluation: What to ExpectThe Brain Failure Evaluation: What to Expect

Identification of reversible causesIdentification of reversible causes

Treatment of disabling conditionsTreatment of disabling conditions

Family information, counseling, and referralFamily information, counseling, and referral

CAREFULCAREFUL

CLINICAL OBSERVATION CLINICAL OBSERVATION

IS EVERYTHING!IS EVERYTHING!

Brain Failure:Evaluation

Brain Failure:EvaluationBrain Failure:Evaluation

History/physicalHistory/physical NeurologicNeurologic MedicationsMedications MoodMood AbilitiesAbilities SocialSocial

The Brain Failure EvaluationHistoryThe Brain Failure EvaluationHistory

Collateral SourceCollateral Source

Onset, Course, Progression, Risk FactorsOnset, Course, Progression, Risk Factors

Characteristic Course of Alzheimer’s DiseaseCharacteristic Course of Alzheimer’s Disease

HISTORY OF SYMPTOMSHISTORY OF SYMPTOMS

From a From a

caregiver or caregiver or

someone close someone close

to the patientto the patient

HISTORY OF SYMPTOMSHISTORY OF SYMPTOMS

What were the What were the first symptoms?first symptoms?

How have things How have things changed?changed?

Is this typical Is this typical for AD?for AD?

TYPICAL SYMPTOMS OF ALZHEIMER’S DISEASE TYPICAL SYMPTOMS OF ALZHEIMER’S DISEASE

Functional loss in reverse order to Functional loss in reverse order to which skills were gainedwhich skills were gained

Brain Failure: Case 1Brain Failure: Case 1

An 83 year old widower is evaluated because An 83 year old widower is evaluated because his family is concerned that he is mildly his family is concerned that he is mildly

cognitively slowed. He is still successfully cognitively slowed. He is still successfully maintaining homes in Arizona and Iowa. maintaining homes in Arizona and Iowa.

He describes a 9 month history of decline in He describes a 9 month history of decline in his golf game, a 6 month history of his golf game, a 6 month history of

unexplained falls, and a 1 month history of unexplained falls, and a 1 month history of urinary incontinence.urinary incontinence.

Brain Failure:RecognitionBrain Failure:Recognition

In patients or families presenting with a In patients or families presenting with a complaint of cognitive dysfunction a complaint of cognitive dysfunction a

negative screening test does not exclude negative screening test does not exclude dementia. dementia.

The Brain Failure EvaluationPhysicalThe Brain Failure EvaluationPhysical

Special SensesSpecial Senses

Heart / Lung / Liver / KidneyHeart / Lung / Liver / Kidney

Bladder / Bone / MobilityBladder / Bone / Mobility

VisionVision

HearingHearing

Brain Failure: Special SensesBrain Failure: Special Senses

A 79 year old widower is a member of a A 79 year old widower is a member of a

multigenerational household. He has had multigenerational household. He has had

progressive cognitive problems over the last progressive cognitive problems over the last

7 years. He is independent in all self care 7 years. He is independent in all self care

activities, but at night he wanders about activities, but at night he wanders about

knocking things over and urinating in trash knocking things over and urinating in trash

canscans

•Brain Failure:Case 2•Brain Failure:Case 2

Brain Failure: Case 3Brain Failure: Case 3 A 68 year old married man suffers from A 68 year old married man suffers from

AD. Despite successful treatment of an AD. Despite successful treatment of an

associated depression, he is inattentive and associated depression, he is inattentive and

often does not respond to his wife or often does not respond to his wife or

daughter.daughter.

Brain Failure: organ system dysfunctionBrain Failure: organ system dysfunction Heart and Lung: hypoxic encephalopathyHeart and Lung: hypoxic encephalopathy Hepatic encephalopathyHepatic encephalopathy Renal encephalopathyRenal encephalopathy Thyroid disordersThyroid disorders HyperparathyroidismHyperparathyroidism

Brain Failure: Case 4Brain Failure: Case 4 A 75 year old widow is evaluated at the A 75 year old widow is evaluated at the

request of her family for progressive request of her family for progressive cognitive impairment over the last 9 cognitive impairment over the last 9 months. Her MMSE is 18. During the months. Her MMSE is 18. During the interview she admits to exertional fatigue, interview she admits to exertional fatigue, and lack of energy. On exam she has and lack of energy. On exam she has diffuse expiratory wheezing in all lung diffuse expiratory wheezing in all lung fields.fields.

Brain Failure = DisabilityBrain Failure = Disability

Families/Patients are complaining of the Families/Patients are complaining of the disabilitydisability caused by brain dysfunction.caused by brain dysfunction.

The population at risk is characterized by a The population at risk is characterized by a burden of burden of co-morbiditiesco-morbidities..

Look for Look for un or under-treatedun or under-treated comorbidities comorbidities causing dysfunction.causing dysfunction.

High yield for disorders of bladder, bone, High yield for disorders of bladder, bone, mobility.mobility.

Families/Patients are complaining of the Families/Patients are complaining of the disabilitydisability caused by brain dysfunction.caused by brain dysfunction.

The population at risk is characterized by a The population at risk is characterized by a burden of burden of co-morbiditiesco-morbidities..

Look for Look for un or under-treatedun or under-treated comorbidities comorbidities causing dysfunction.causing dysfunction.

High yield for disorders of bladder, bone, High yield for disorders of bladder, bone, mobility.mobility.

NEUROLOGICAL EXAMNEUROLOGICAL EXAM

Cortical- frontal, Cortical- frontal, parietal, temporal, parietal, temporal, occipital lobesoccipital lobes

Sub-cortical- internal Sub-cortical- internal capsule, basal ganglia, capsule, basal ganglia, thalamusthalamus

NEUROLOGICAL EXAMNEUROLOGICAL EXAM

Apraxia, agnosia, Apraxia, agnosia, aphasia, focal motor or aphasia, focal motor or sensory signs sensory signs

Gait disturbance, Gait disturbance, rigidity, tremorrigidity, tremor

Frontal Lobe Release signsFrontal Lobe Release signs

MovieClips\Glabellar.movMovieClips\Glabellar.movGlabellar tapGlabellar tap PalmomenttalPalmomenttal GraspGrasp

GaitGait

CorticalCortical

SubcorticalSubcortical

Sutton’s Law:Sutton’s Law:

““Gee, Willy, why do you rob banks?Gee, Willy, why do you rob banks?

“BECAUSE

THAT’S

WHERE THE

MONEY IS”

Geriatrician’s Law:Geriatrician’s Law:

Go for the MEDS

Because that’s where the money is

Inspect the Drug BagInspect the Drug Bag

Three or more Three or more drugs increase the drugs increase the likelihood of an likelihood of an adverse effect or adverse effect or drug interactiondrug interaction

Drugs and Brain FailureDrugs and Brain Failure Many drugs can do this, e.g.

Sedatives, anxiolytics, anticholinergics, H2-blockers, centrally acting antihypertensives (clonidine, alpha-methyl dopa) antiarhythmics, beta blockers, digoxin, sinemet, selegeline.

Check all for CNS S.E.s Try a “Drug Holiday”

Alcohol and Brain Failure Alcohol and Brain Failure

Volume of Volume of

distribution for distribution for ETOH ETOH

with agewith age

No more than one/day No more than one/day

after age 65; stop all if after age 65; stop all if

cognition impairedcognition impaired

Brain Failure: Case 4Brain Failure: Case 4 An 83 year old widow presents with a An 83 year old widow presents with a

history of progressive cognitive failure. history of progressive cognitive failure. During interview she admits to a long term During interview she admits to a long term pattern of one drink before dinner. On pattern of one drink before dinner. On questioning, her daughter feels that she questioning, her daughter feels that she likely exceeds one drink per day.likely exceeds one drink per day.

Depression as Brain FailureDepression as Brain Failure

Emotional illness Emotional illness

slows cognitive slows cognitive

function function

Depression as a Cause of Brain FailureDepression as a Cause of Brain Failure

Dementia Insidious onset Long duration No psychiatric history

Conceals disability (often unaware of memory loss)

“Near-miss” answers

Day-to-day fluctuation in mood

Depression Abrupt onset Short duration Previous psychiatric history

Highlights disabilities (may complain of the memory loss)

“Don’t know” answers

Diurnal variation in mood, but generally more consistent

The Brain Failure EvaluationThe Brain Failure Evaluation

UNDERSTAND THE NORMAL UNDERSTAND THE NORMAL

AGE-RELATED CHANGES IN AGE-RELATED CHANGES IN

BRAIN AND MEMORYBRAIN AND MEMORY

Brain Failure vs Normal AgingBrain Failure vs Normal Aging

Normal aging Normal aging does not cause does not cause dysfunction dysfunction

The Brain Failure EvaluationLaboratory

The Brain Failure EvaluationLaboratory B-12, Folate, TSHB-12, Folate, TSH Chem profile, UA, ?OChem profile, UA, ?O2 sat sat

CBCCBC Other as indicated Other as indicated

The Brain Failure EvaluationRadiology & OtherThe Brain Failure EvaluationRadiology & Other

Head CT, ? Head MRIHead CT, ? Head MRI Chest X-rayChest X-ray EKG, EEGEKG, EEG

Things that Cause the Brain to Fail (whether or not an underlying dementia is present)

Things that Cause the Brain to Fail (whether or not an underlying dementia is present)

DrugsDrugs Emotional Illness (including depression)Emotional Illness (including depression) Metabolic/endocrine disordersMetabolic/endocrine disorders Eye/ear/environmentEye/ear/environment Nutritional/neurologicalNutritional/neurological Tumors/traumaTumors/trauma InfectionInfection Alcoholism/anemia/ atherosclerosisAlcoholism/anemia/ atherosclerosis

DEMENTIA

Therapy for ADTherapy for AD Cholinesterase inhibitorsCholinesterase inhibitors Vitamin EVitamin E NMDA inhibitor- MemantineNMDA inhibitor- Memantine ? Vaccination? Vaccination Not EstrogenNot Estrogen Not Anti-inflammatoriesNot Anti-inflammatories