Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Question 1

what are the 3 elements of the biological diagnosis of alzheimers disease

Answer 1

ATN

amyloid beta deposition

pathological Tau

Neurodegeneration

*premature to use in general medical practice

Question 2

should you use amyloid or tau imaging to assess people without memory decline

Answer 2

no, not outside research setting (as presence of these factors is of uncertain significance)

Question 3

what imaging technique is recommended to investigate VASCULAR cognitive impairment

Answer 3

MRI > CT

Question 4

what tools are recommended for the diagnosis of vascular mild cognitive impairment and vascular dementia

Answer 4

use of STANDARDIZED criteria

i.e one of:

Vascular Behavioural and Cognitive Disorders Society criteria (VAS-COG)

DSM 5

Vascular Impairment of Cognition Classification Consensus Study

or American Heart Assoc consensus statement

Question 5

why should you treat HTN

Answer 5

treatment of HTN may reduce the risk of dementia and thus clinicians should assess, diagnose and treat HTN according to HTN Canada guidelines

Question 6

which patients should be treated with antihypertensives

Answer 6

those with cognitive disorders in which vascular contribution is known or suspected–> if avg. diastolic is at or above 90mmHG and /or systolic at or above 140mmHG

Question 7

is the use of aspirin recommended for patients with MCI or dementia who have brain imaging evidence of covert white matter lesions of presumed vascular origin without history of stroke or infarcts

Answer 7

no

Question 8

are cholinesterase inhibitors or memantine recommended for treatment of vascular cognitive impairment

Answer 8

may be considered in selected patients

Question 9

is cognitive screening recommended in asymptomatic patients

Answer 9

no

Question 10

list risk factors for cognitive disorders

Answer 10

1. late onset depressive disorder or lifetime history of MDD
2. untreated sleep apnea
3. hx stroke or TIA
4. unstable metabolic or CV morbidity
5. a recent episode of delirium
6. first major psychiatric episode at an advanced age (i.e psychosis, anxiety, depression)
7. recent head injury
8. parkinsons disease

Question 11

what rapid, objective assessments of cognitive function are recommended by the guidelines

Answer 11

1. Memory Impairment Screen (MIS) + clock drawing test
2. the Mini-Cog
3. the AD8
4. the four item version of the MoCA
5. GP Assessment of Cognition (GPCOG)

Question 12

what are the four items included on the four item MoCA

Answer 12

clock drawing

tap at letter A

delayed recall

orientation

Question 13

what is the most widely used cognitive assessment instrument

Answer 13

MMSE

has high sensitivity and specificity for separating moderate dementia from normal cognition

Question 14

what is a weakness of the MMSE

Answer 14

lacks sensitivity for the diagnosis of mild dementia or MCI

Question 15

why might you use the MoCA over the MMSE

Answer 15

more sensitive to MCI

use when MCI is suspected or when there is suspicion for cognitive impairment or concern about patients cognitive status but the MMSE score is within normal range

Question 16

what is the normal range on the MMSE

Answer 16

24+/30

Question 17

what are the more comprehensive psychometric screening tools listed in the guidelines

Answer 17

Modified Mini Mental State (3MS) exam

MMSE

Rowland University dementia assessment scale (RUDAS)

Question 18

name an example of a longitudinal series cognitive assessment

Answer 18

QuoCo curves

Question 19

what is a questionnaire a caregiver or informant could fill out about dementia in a patient

Answer 19

AD-8

IQCODE (informant questionnaire on cognitive decline)

Question 20

what tools can be used to assess BPSD in a patient if a behavioural, personality or mood change has been observed

Answer 20

short version of the Neuropsychiatric Inventory (NPI-Q)

Mild Behavioural Impairment Checklist (MBI-C)

(or PHQ-9 if mood change)

Question 21

what are 2 tools that can be used for rapid screening of functional autonomy in suspected dementia

Answer 21

the Pfeffer Functional Activities Questionnaire (FAQ)

or the Disability Assessment for Dementia (DAD)

Question 22

can diagnosis of MCI or dementia be made solely on impaired result on cognitive screening tests

Answer 22

no it shouldnt be

Question 23

in which disorders might the DCQ be particularly helpful

Answer 23

behavioural variant FTD

primary progressive aphasia

alzheimers disease variants

as it is based on updated criteria for atypical syndromes like these –> MMSE, MoCA were not designed for screening for atypical syndromes and are often not sufficient to capture subtle cognitive and social cognition changes associated with atypical dementia

Question 24

why is getting corroborative history essential when someone has subjective concerns about their cognition

Answer 24

has prognostic significance

Question 25

what is recommended as one of the primary tools for tracking cognitive response and change over time

Answer 25

folstein’s MMSE

*has been used in several clinical trials of cholinesterase inhibitors

Question 26

what is one major determinant of hospitalization or nursing home placement for patients with dementia

Answer 26

caregiver burnout

should be regularly assessed in followup of patients with dementia

Question 27

what is a structured scale to measure caregiver burnout

Answer 27

Zarit Burden Interview

Question 28

is MRI or CT preferred? why?

Answer 28

MRI–> higher sensitivity to some vascular lesions as well as for some subtypes of dementia and rarer conditions

Question 29

what should you look for on CT when assessing dementia

Answer 29

hippocampal atrophy

Question 30

should you do CT or non contrast CT when assessing dementia

Answer 30

non con

Question 31

what type of imaging can be helpful in assessing/diagnosing cognitive imapirment linked to Lewy Body Disease

Answer 31

SPECT scan (where diagnosis is suspect but remains unclear)

consider PET scan first due to cost

Question 32

what motor marker is suggestive of future dementia

Answer 32

slower gait speed

when slow gait speed + cognitive impairment the risk is higher

Question 33

by how much does parkinsonism increase risk of developing dementia

Answer 33

up to 3x

Question 34

what are two other factors associated with development of dementia

Answer 34

sleep disturbance

hearing impairment

–> should assess both of these in primary clinics as dementia risk factor

(insufficient evidence to support assessment of vision as dementia risk)

Question 35

what diet is recommended to decrease risk of cognitive decline

Answer 35

mediterranean

Question 36

what type of exercise interventions have been shown to improve cognitive outcomes in older adults

Answer 36

dance

mind body (ie yoga, qi gong)

aerobic and/or resistance exercise

Question 37

how does OSA affect risk of dementia

Answer 37

treatment with CPAP in presence of OSA may improve cognition and decrease risk of dementia

Question 38

for those on a cholinesteras inhibitor for alzheimers, parkinsons dementia, lewy body or vascular dementia for MORE THAN 12 months, when should you consider discontinuation of the medication

Answer 38

when:
1. there has been a CLINICALLY MEANINGFUL WORSENING of dementia as reflected by changes in cognition, functioning, global ax over the past 6 MONTHS in absence of other medical condition or enviro factors

2. NO clinically meaningful benefit was observed at any time during treatment
3. person has severe or end stage dementia
4. development of intolerable side effects
5. medication adherence is poor and precludes safe ongoing use of meds

**this is the same for deprescription of memantine in those taking for same indications

Question 39

should you prescribe cholinesterase inhibitors for frontotemporal dementia or other neuro-degenerative conditions

Answer 39

these should be discontinued

*same for memantine