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CME / ABIM MOC

Case 3: Patient With Evidence of Cognitive Impairment: Dementia or Something Else?

  • Authors: Charles Vega, MD
  • CME / ABIM MOC Released: 10/14/2022
  • Valid for credit through: 10/14/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians (PCPs) (including internal medicine, family medicine, geriatricians), AD specialists, neurologists, nurse practitioners (NPs), and physician assistants (PAs) caring for patients with AD across the globe.

The goal of this activity is for learners to be better able to identify and communicate with patients experiencing early forms of cognitive impairment.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Important elements to communicate with patients following the identification of a specific cause of cognitive impairment
  • Have greater competence related to
    • Identification of specific causes of cognitive impairment in patients


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Faculty

  • Charles Vega, MD

    Clinical Professor of Family Medicine
    University of California, Irvine
    Irvine, California

    Disclosures

    Charles Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: GlaxoSmithKline; Johnson & Johnson

Editor

  • Frances McFarland, PhD, MA

    Associate Medical Education Director, Medscape, LLC

    Disclosures

    Frances McFarland, PhD, MA, has no relevant financial relationships.

  • Megan Breuer, PhD, CMPP

    Medical Writer, Medscape, LLC

    Disclosures

    Megan Breuer, PhD, CMPP, has no relevant financial relationships.

Compliance Reviewer

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


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    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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CME / ABIM MOC

Case 3: Patient With Evidence of Cognitive Impairment: Dementia or Something Else?

Authors: Charles Vega, MDFaculty and Disclosures

CME / ABIM MOC Released: 10/14/2022

Valid for credit through: 10/14/2023

processing....

Activity Transcript

Doctor: Hello, good morning, Angela and Mary, please come in and have a seat.

Angela and Mary: Good morning, Dr Vuong. Thank you, thank you very much.

Doctor: What can I do for you today?

Mary: Well, I thought it might be a good idea to come and see you because I’m a little concerned about my Mom. She seems to be forgetting things more often.

Angela: I don’t think I’m that forgetful.

Mary: Mom, you forget what you’ve told me the day before, and it seems like you’re having more trouble finding the right word. She also forgot my brother’s birthday a couple of months ago and my niece’s birthday a couple of weeks ago. She’s always been big on birthdays. And she sleeps a lot during the day. Sometimes I’ll come over in the afternoon and find her sleeping on the couch. She’s always been on the go. 

Angela: I’m just getting old and tired, Mary. I just need more shut eye, that’s all. You’re making a big fuss over nothing.

Mary: But I still want to talk with the doctor, Mom. I just want to make sure you’re ok. We talked about this.

Angela: I know, I know. Oh I guess it can’t hurt.

Doctor: Ok, I’m going to start by just asking you a few questions, Angela, if that’s ok?

Angela: Sure, that’s fine.

Doctor: Can you describe your daily activities? Have you been noticing any changes there?

Angela: Oh, that’s all right. I haven’t really noticed anything. I try to get out for a walk most days, and I go to the supermarket once a week. I see my good friend, Tilly, a few times a week. She lives a few doors down from me and she’s retired, too. I’m just really tired all the time.

Doctor: Are you sleeping well at night?

Angela: Not really. I haven’t been sleeping at night for the past few months.

Doctor: I see. And are you taking any medications at the moment?

Angela: Well, my doctor has me on trazodone. I take that every night before bed. My doctor also put me on zolpidem, maybe a couple times a week, also right before bed. Plus, I’m taking another medication called… what’s it called again? Mary, do you remember?

Mary: Escitalopram?

Angela: That’s right – escitalopram.

Doctor: Ok. So you are probably taking the escitalopram for depression, is that right?

Angela: Yes, and it’s also supposed to help me sleep, I think.

Doctor: Have you had any illnesses recently that you also received medication for?

Angela: No, nothing like that.

Doctor: And is there a history of Alzheimer’s disease in your family, Angela, that you know of?

Angela: No, not that I can recall. Do you think I might have Alzheimer’s disease?

Doctor: It’s much too early to say, Angela, and sometimes patients may have symptoms like yours that seem to mimic Alzheimer’s disease but can be explained by other causes. I would like to do some tests to help us get to the bottom of this, if you don’t mind?

Angela: That sounds serious. What kind of tests?

Doctor: Just some short exams to test your memory, and I would like you to fill out a questionnaire so we can assess your depression a little better. I would also like to have some blood drawn so we can perform a couple of laboratory tests to rule out other causes. Does that sound ok?

Angela: All right.

Charles Vega, MD: Hello, I'm Chuck Vega, clinical professor of Family Medicine at the University of California, Irvine. And really excited to be talking to you today about cognitive impairment. Particularly as adults get older, we see more and more cases of cognitive impairment. And I find that it's actually the patients who come in and say, "I can't remember things." Oftentimes when I do objective testing for them, they do fine. It's when their daughter, their son, a grandchild is telling me, "They're slowing down and they're forgetting a lot of things. And they're repeating themselves a lot. And they got lost last week." Those are the cases that are usually positive. But I always take cognitive complaints quite seriously. I think that's really important. There's so much stigma and shame around cognitive impairment that a lot of patients may hide their symptoms. So, I really want to draw them out and give them a place where they and the reporter, whoever is with them and telling me about the symptoms they may be having, feel that it's a safe place. 

Doctor: Ok, Angela, first, I would like to do a short cognitive assessment to get some objective evidence regarding your memory, and then we can discuss what will happen next.

Angela: Ok, that sounds good.

Doctor: This exam is called the Mini-Cognition test, and it takes about 3 minutes to do. Ok?

Angela: Ok, Dr Vuong, I’m ready.

Doctor: Please listen carefully. I’m going to say 3 words and I want you to repeat them back to me now and try to remember. The words are: “daughter, heaven, and mountain”. Can you repeat those words for me?

Angela: Daughter, heaven, mountain.

Doctor: Terrific. Now, I would like you to take this pen and paper, and could you please draw a clock for me? First, put all the numbers where they should go.

Doctor: And now, could you put the hands of the clock at 10 minutes past 11?

Doctor: That’s just fine, thank you Angela. Can you tell me the 3 words I asked you to remember again?

Angela: Daughter, heaven, mountain.

Doctor: Excellent, thank you Angela. That’s just fine.

Angela: Did I do ok?

Doctor: Indeed, that was great. So, the next thing I think we should do is take some blood for some lab tests, just to rule out some other possible causes for your symptoms, ok?

Angela: What would the lab tests be looking for?

Doctor: We will do a pretty broad workup to make sure that you don’t have anemia or dysfunction in a major organ like your liver, kidneys, or thyroid. 

Angela: I see. It would be good to rule those out. 

Mary: Do you think something else might explain my Mom’s symptoms?

Doctor: That’s what we need to figure out. It could be medications, maybe something is a little off with her electrolytes, or maybe it’s something else. Angela, you did just fine on the Mini Cognition test, so I need to do a little more detective work to get to the bottom of your symptoms. I think it might be a good idea to do some further tests. I’m concerned about your sleep patterns, and about your underlying depression. I would like to see how those fit into this picture, ok?

Angela: Yes, that’s fine.

Dr Vega: For Angela's case, mild cognitive impairment, Alzheimer's disease could be part of her cognitive impairment. But it's not the only reason she might have cognitive impairment. So, if she has medical conditions that are uncontrolled, such as diabetes, medications. Frequently it's sedating drugs that can cause problems. Anticholinergic drugs that can cause problems with cognition. And finally, she could have other neurological or mood disorders. Depression looks very much like cognitive impairment and Alzheimer's disease among older adults.

So some important questions: the duration of symptoms? I want to look at the course as we know that Alzheimer's dementia takes generally a slowly progressive course over time. But if it's really episodic, I might think about a different disorder on my differential diagnosis. How much disability does she have? The degree of if it's actually causing some disability. And then also asking about family history, because family history of dementia tends to promote higher rates of dementia. And then it's time to move on from there once you get a history to get to your diagnosis and plan.

So, I'm going to communicate that all cognitive impairment is not Alzheimer's disease, especially at its earlier stages. And it's certainly true that patients can have both hypothyroidism and some depression and have MCI. So that's not an unusual case, especially among older adults with a lot of comorbid conditions before they even come in.

Doctor: Ok, Angela, your PHQ-9 score is 11, which is in the moderate depression range. Your lab tests show that you have no other underlying conditions that would explain your symptoms. I think the cause of your symptoms could be the trazodone and zolpidem, so I think the first step is to wean off both of those medications.

Angela: But won’t that affect how I sleep at night? I might not sleep at all if I don’t take them.

Doctor: I know, but we won’t stop the medications right away. We’ll cut down the doses a little bit at a time, until you can stop taking them altogether. I know it seems a little overwhelming, but I really do think that these medications are the cause of your symptoms.

Angela: Ok, but I’m still a bit concerned.

Doctor: I understand, but I think it will be best for you in the long run. It would also help if you tried very hard not to take any more naps during the day and focus all of your sleep at night. This can be another gradual change over the next few months, but it’s the healthiest option.  These changes can be challenging.  Would you consider speaking with a therapist to help you with your sleep and mood?

Angela:  I don’t think that I want psychoanalysis. That scares me.

Doctor:  I understand, but this isn’t psychoanalysis.  It’s more like working on practical techniques to help your energy and mood. I think it could really help.

Angela: OK, I guess if you say so. And what about the escitalopram? Should I stop taking that, as well?

Doctor: When you first started receiving treatment, did you notice an initial improvement?

Angela: Yes, I did.

Doctor: Ok then. Since your PHQ-9 test indicates that you are still experiencing symptoms, and you did respond to your initial treatment dose, what I would like to do is actually increase the dose of your escitalopram while you are decreasing the dose of your sleep medications.

Angela: I don’t know, Dr Vuong, it seems like an awful lot of fuss over a few hours of missed sleep.

Mary: Don’t worry, Mom, I’ll help you keep track of everything. I’m sure it will turn out ok. Would she start feeling better right away? 

Doctor: It may take a few weeks before you start noticing any significant improvements, Angela, but I really do think this is the best course of action for you. 

Angela: Well all right then. This all sounds like a good plan to me. I’m just so glad that I don’t have Alzheimer’s disease. One less thing to worry about!

Doctor: Agreed! I think that you will do better, but let’s schedule a brief telehealth visit in the next few weeks to check in.  And remember, you can always come back and see me if things still aren’t going as well as you’d like, Angela. But give yourself some time to adjust, at least a month or two, ok?

Angela: Ok, I can do that, thank you.

Mary: Thank you so much!

Dr Vega: So, I think during the conversation with patients, and when we do suspect early Alzheimer's disease or mild cognitive impairment, I'm realistic. Particularly about Alzheimer's disease. So, I will state that it is a progressive illness. It does have a variable course from person to person, but there also is no cure. And then I shift from that reality quickly towards messages of hope. Because that's a difficult thing to discuss with patients. But in turning right away towards, "Well, there are still things we can do about it." And the first thing I would consider is lifestyle changes. So, this is the time if there is excessive alcohol use, if there's poor sleep, if there's no physical activity, no and poor cognitive stimulation, we want to start addressing those particularly in the earliest stages of illness. Because they still make a difference, and they can promote overall better wellbeing and health too. 

So, thinking about Angela's case specifically, and this is one of those situations where I'm highly suspicious that we are causing a problem for her in terms of her cognition. We're doing that through the prescription of trazodone and zolpidem. Those agents can really pack a wallop for particularly older and more frail individuals. So really want to be careful and judicious with their use overall. Now, she's on escitalopram. That's a good agent which I probably want to continue that one because I don't want her to have more severe depression, which would, of course, promote worse cognitive function. Instead, what I would try to do is talk about sleep hygiene and normal sleep. Then I would try to wean down first on the zolpidem, which I would probably consider the more offending of the 2 agents, and then eventually think about the trazodone too with closer follow-up. If it was available, I would do some talk therapy for her to help her with both her depression and her sleep problems. I think beyond sleep hygiene, it's just a nice way to reinforce some of that same messaging. Then we could do that via telehealth, so she doesn't necessarily need to come in. It makes it more convenient for her and for her family. Then I want to take a look at once those medications are off, how is her cognition? I have a strong feeling it's going to be substantially improved. Put her through an objective test, like a MoCA again, and then move forward from there.

Thank you very much for joining us in this activity today. Please continue on to answer the questions and complete the evaluation. Take care.

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