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Royal College 2023 > Dementia Diagnosis > Flashcards

Dementia Diagnosis Flashcards

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1
Q

Estimated economic burden of dementia by 2038

A

> 872 billion

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2
Q

4 proposed interventions to reduce the economic burden of dementia

A
  1. Increased physical activity
  2. Hypothetical program to delay dementia onset
  3. Caregiver development and support program
  4. System navigator
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3
Q

What is construct validity?

A

The ability of a test to measure what it was designed to measure (and not other things)
ex. a test designed to measure depression should measure that and not anxiety

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4
Q

What is criterion-related validity?

A

The ability of a test to correlate with the gold standard

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5
Q

What is reliability?

A

The consistency of a measure
Being reliable is necessary but not sufficient for validity

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6
Q

What is internal consistency?

A

Consistency across items

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7
Q

What is inter rater reliability?

A

Consistency across researchers or raters

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8
Q

Test-retest reliability

A

Consistency across time
Ex. using same test on different occasions to same group of test takers, not practical because of carry-over effect

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9
Q

What is validity?

A

The extent to which scores from a measure represent the variable they are intended to

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10
Q

Rising Tide current number of people living with dementia?

A

500 000

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11
Q

Rising Tide projected number of people with dementia in 2030?

A

912 000

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12
Q

Rising Tide incidence of new dementia dx per year?

A

25 000

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13
Q

Rising Tide, those 65+ what % of dementia dx are among women?

A

65%

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14
Q

Rising Tide, proportion of Canadians who experience caring for someone with dementia?

A

1 in 5

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15
Q

Rising Tide, incidence and prevalence of dementia in 2038?

A

Incidence (# new cases/yr) = 250 000/year
Prevalence (total # cases) = 1.1 million (2.8%)

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16
Q

Rising Tide, projected demand for LTC by 2038?

A

10 times current (2008) demand

17
Q

6 factors that affect psychometric properties in screening cognitive tools

A

Reliability
1. Inter rater
2. Test-retest
Validity
1. Construct
2. Concurrent (ability to distinguish between groups)
3. Predictive (ability to predict something)
4. Convergent (degree to which it’s similar to tests it should be similar to)
5. Discriminant (degree to which it’s not similar to tests it should be similar to)
6. Face
7. Content

18
Q

List 5 cons of the MMSE

A
  1. Not sensitive for detecting MCI and mild dementia
  2. Limited usefulness with low level English literacy
  3. Limited usefulness in those either end of educational spectrum
  4. Not much capacity to test frontal/executive and visuospatial
  5. Now proprietary and not free
19
Q

What two impairments could cause this? What lobes are affected? (clock draw)

A
  1. Impaired executive function/abstraction
  2. Superior quadrantanopia

Lobes:frontal, temporal, occipital

20
Q

Give 3 reasons why cognitive screening for asymptomatic individuals above 65 is not recommended?

A
  1. Low dementia prevalence and only moderately high Sp, number of FP>number TP
  2. FP could lead to psychological harm, anxiety, unnecessary tests
  3. Screening could lead to loss of autonomy (employment, drivers license, finances)
21
Q

Name each cut on imaging and what structures are seen best in each view.

A
  1. Saggital - midline and lateral structures
  2. Axial - all lobes
  3. Coronal - temporal lobes (esp hippocampus) and perisylvian fissures
22
Q

What are the indications for neuroimaging based on CCCDTD-5 guidelines?

A
  1. Onset cognitive changes last 2 years
  2. Unexpected decline in cog/fxn in pt with known dementia
  3. Recent/sig head trauma
  4. Unexplained neurological sx at onset or during evolution (HA, seizure, gait, Babinski)
  5. Anticoagulant use or bleeding disorder
  6. Sig vascular risk factors
  7. Hx cancer
  8. Hx UI and gait disorder
23
Q

Type of imaging and biomarker recommendations for new dx of dementia

A
  1. MRI recommended over CT, use 3D T1, FLAIR, T2 or DWI
  2. If CT = non contrast, coronal views
  3. FDG-PET or SPECT if standard work up done and unclear pathology
  4. Imaging biomarkers (tau or neuroinflammation) not recommended
  5. Don’t recommend CSF unless diagnostic uncertainty and <65 yo to R/O AD, diagnostic uncertainty and predominance of language, visuospatial, dysexecutive or behavioural to rule out AD
24
Q

What lab investigations recommended in work up of dementia?

A
  1. CBC
  2. Electrolytes
  3. Calcium
  4. Fasting glucose
  5. TSH
  6. B12 (supplement if low)
    Optional: folate if celiac, inadequate diet
    Insufficient evidence: homocysteine
25
Q

Cognitive tests to use for MCI

A

MOCA, cut off <26
Sn 90, Sp 87
TORCA
Sn 80, Sp 79

26
Q

Risk factors and rate of progression from MCI to MNCD

A

RFs
1. Older age
2. Less education
3. Stroke
4. Diabetes
5. Amnestic subtype
Testing
1. Positive amyloid PET
2. APOE4
3. Low CSF AB42, high CSF total tau and pTau
4. Dual task gait impairment
5. Lower MMSE

Rate of progression
About 10% per year
May remain stable, return to normal or progress

Follow up annually with serial assessments

27
Q

Sn and Sp of APOE4 screening?

A

1 allele 53% Sn, 67% Sp
2 alleles 21% Sn, 93% Sp
Homozygotes 50% lifetime risk
Heterozygotes 20-30% lifetime risk
Average risk 11% M, 14% F

28
Q

Prevalence of amyloid in CSF in individuals with no cognitive impairment?

A

65 yo - 20%
75 yo - 30%
85 yo - 40%

29
Q

Why would you not advise CSF testing for patient with dementia?

A
  1. Cost - not covered
  2. Not required for currently available therapies
  3. Risks of LP
  4. Limited diagnostic value for classic presentation AD
30
Q

Why would you not advise CSF testing for family member of patient with dementia?

A
  1. Unclear clinical trajectory for those biomarker positive without clinical syndrome
  2. Absence of preventative therapies
  3. Psychological implications
  4. False reassurance if false negative
31
Q

What does ATN stand for?

A

3 categories of AD biomarkers
1. Amyloid beta plaques (CSF AB42, amyloid PET)
2. Tauopathy (CSF pTau, Tau PET)
3. Neurodegeneration (structural MRI, FDG-PET, CSF total tau)

32
Q

3 reasons why screening for AD biomarkers not appropriate

A
  1. Lack of standardization of biomarkers b/w labs
  2. AD pathology may occur in people who are never symptomatic in their lifetime
  3. Access to biomarkers is limited
  4. Lack of disease modifying therapy for AD
  5. Health system burden
33
Q

Social, economical and ethical issues involved in informing patient of diagnosis of AD early in the course

A

Social
1. Stigma, discrimination
2. Caregiver burden
Economical
1. May impact ability to work/get money
2. May impact driver’s license and therefore costs of alternative arrangements
Ethical
1. Capacity/decision making ability
2. Patient privacy and confidentiality

34
Q

Limitations of DSM-V criteria in diagnosing dementia

A
  1. Heterogeneity - dementia is not a single disorder but a syndrome with multiple underlying causes, criteria doesn’t address this
  2. Ongoing updates - published in 2013
  3. Not better explained by another mental disorder - may be concurrent with depression etc.
  4. Says significant cognitive decline but doesn’t specify what this means
35
Q

What is the main difference between using brief cognitive tests for screening versus case finding with regards to tests such as the MOCA or MMSE?

A
  • Cognitive assessments are not recommended to be used as population screening for cognitive impairment (CCDDTD-5)
  • Screening involves testing individuals without prior identification of concerns for cognitive impairment (a.k.a. ‘Asymptomatic older adults’)
  • This would result in many false positives (low overall prevalence of dementia in ‘all-comers’ over the age of 65)
  • Neither the MMSE or MoCA have not been validated for this purpose, and lack the sensitivity (esp. the MMSE) to function as screening tests
  • Cognitive assessments are recommended to be used for case finding when there is a diagnostic suspicion of cognitive impairment
  • They have been validated for this purpose
  • Based on the test characteristics (PPV, NPV, Sn, Sp), the clinician is able to strengthen the diagnosis / their clinical suspicion of cognitive impairment
    Used in this way, the MMSE and MoCA (used in the correct education and language-matched population) have good specificity for a diagnosis of cognitive impairment
36
Q

List 5 advantages to telemedicine (telephone or video) for cognitive assessment. List 5 disadvantages to telemedicine (telephone or video) for cognitive assessment.

A

Advantages
* Patient doesn’t have to be present (mobility limitation)
* Patients in remote areas can be assessed
* Easier to schedule
* Testing can be done by RN or whomever while physician gets collateral
* Evidence supporting virtual cognitive assessment (e.g. TICS)
* “The TICS was adapted from and correlates highly with the MMSE (Pearson correlation 0.94, p < 0.0001).”
* “Videoconference-based cognitive assessments were 100% sensitive and specific for diagnosing dementia compared with in-person cognitive assessments in a third study.”

Disadvantages
* Gaps still remain in diagnostic certainty
* “No studies compared telephone with inperson cognitive assessment accuracy”
* Several tests (e.g. MMSE, RUDAS) don’t have a virtual option (i.e. test is modified)
* Telephone assessment less accurate at differentiating
* Sensory challenges (e.g. patient must have intact hearing if telephone)

Royal College 2023 (79 decks)

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