Guide for PCPs: Suspecting, Testing, and Managing Cognitive Impairment / Dementia.
This document is an attempt at a Primary Care algorithm for people with suspected Cognitive Impairment that any PCP can use to initiate care. I invite constructive criticism. Sorry about the formatting, wrote it up in Pages and i’m new to elementor. drv@ensocure.com
1. Suspecting Cognitive Impairment in a Patient [1-4]
Signs and Symptoms to Look For:
• Memory Loss: Difficulty remembering recent events, names, appointments, or where things are kept.
• Problem-Solving and Planning Issues: Challenges with tasks that require organising or planning, such as cooking a meal or making decisions.
• Language Difficulties: Problems with communication, such as finding the right words during a conversation or following a storyline.
• Disorientation: Losing track of the date, time, or getting lost in familiar settings.
• Misplacing Items: Frequently losing items and being unable to retrace steps.
• Difficulty with Familiar Tasks: Struggling with tasks done many times before, like using a remote control or a phone.
• Changes in Judgment: Poor decision-making, especially with money or driving.
• Withdrawal from Social Activities: Losing interest in hobbies, work activities, or social engagements.
• Mood and Personality Changes: Experiencing rapid mood swings, increased confusion, suspicion, depression, fear, or anxiety.
2. Initial Cognitive Impairment Screening [5]:
• Orientation (Total Score: 10)
• Date (day, month, year)
• Day of the week
• Name of the place (home, hospital, etc.)
• Season
• Patient’s full name
Scoring: 2 points for each correct answer. Normal range: 8-10 points.
Memory (Total Score: 10)
1. Ask the patient to remember three items (e.g., banana, sofa, 5 rupee coin) and recall after 5 minutes.
Scoring: 3 points for each item recalled without cueing, 1 point with cueing. Cueing is help from the tester to remember the object. Normal range: 7-10 points.
Attention and Calculation (Total Score: 5)
1. Subtract 7 from 100, and continue five times (93, 86, 79, 72, 65).
Scoring: 1 point for each correct subtraction. Normal range: 3-5 points.
Language (Total Score: 10)
1. Naming two common objects.
2. Repetition of a simple sentence.
3. Following a three-step command.
4. Reading a sentence and performing the action.
Scoring: Points as indicated. Normal range: 7-10 points.
Visuospatial Abilities (Total Score: 5)
1. Copying a complex figure (e.g., intersecting pentagons)
Scoring: 5 points for accurate copy. Normal range: 3-5 points.
Interpretation:
• Normal Cognitive Function: 33-40 points
• Mild Cognitive Impairment: 25-32 points
• Moderate Cognitive Impairment: 17-24 points
• Severe Cognitive Impairment: 0-16 points
Secondary Assessment of an Individual with Mild to Severe Cognitive Impairment [6,7,19-21]
Some level of cognitive impairment can almost always be attributed to reversible conditions such as nutritional deficiencies, thyroid disorders, infections or depression.
Testing, including lab tests and imaging, can identify these conditions, allowing for appropriate treatment to potentially reverse or mitigate the cognitive decline. Not all cases of decline will require neuro-imaging, but most will require a through evaluation of the patients metabolic health.
If resources are available, and the symptoms are still mild, referral to a Neurologist for advance cognitive testing (WAIS,WMS,CVLT, Stroop Test) before medical intervention is initiated. If not, it is encouraged that the PCP and family attendants measure key cognitive insight in an organised manner before and after initiation of therapy.
When Brain Imaging / Neuro-Consult is Absolutely Necessary [16-18]
1. Atypical or Rapidly Progressive Symptoms: When a patient exhibits atypical symptoms or a rapid progression of cognitive decline, brain imaging is crucial to rule out other neurological conditions, such as tumors, hydrocephalus, or strokes.
2. Early Onset Dementia: For patients presenting with dementia symptoms before the age of 65, imaging helps identify unusual causes that are more common in younger populations.
3. Focal Neurological Signs: Presence of focal neurological signs such as one sided weakness, vision changes, or sensory loss. These warrant imaging to exclude vascular events or other structural brain lesions.
4. Rule Out Reversible Causes: Potentially Reversible Conditions: Imaging is essential to identify potentially reversible causes of cognitive impairment, such as normal pressure hydrocephalus, chronic subdural hematomas, or significant vascular contributions.
3. Basic Treatment and Pharmacotherapy
Non-Pharmacological Interventions[12-13]:
1. Personalised Care Plans: Regular assessments, customised social activities.
2. Safe Environment: Safety modifications Ramps, Rails), orientation aids.
3. Nutrition and Hydration: Tailored nutrition plans, regular fluid/salt intake.
4. Emotional Support: Training caregivers to understand emotional agitation in CI patients and give consistent & compassionate support.
5. Physical Activity: Regular physical therapy assessment & exercise, therapeutic activities.
Pharmacological Treatment [8-11]:
This treatment plan presupposes a detailed history and rationalisation of existing medication with current healthcare situation.
Treatments aimed at slowing progression or improving cognitive symptoms for a time.
Cholinesterase Inhibitors:
Note: Only ONE Cholinesterase Inhibitor can be given at a time. Combinations of these drugs can cause or worsen adverse reactions like Nausea, Vomiting, Loose Motion and Bradycardia.
Donepezil: For all stages, better started the earlier cognitive impairment is noted.
Starting Dose: 5 mg once daily, taken orally
Maintenance Dose in Mild to Moderate CI: After 4-6 weeks of the initial dose, if well tolerated, the dose can be increased to 10 mg once daily.
Maintenance in Moderate to Severe CI: After 4-6 weeks on 10 mg once daily, if necessary and well tolerated, the dose can be further increased to 23 mg once daily. Note that 23 mg tablets are designed for patients with moderate to severe CI who have been on 10 mg/day for at least 3 months.
Administration:
Donepezil should be taken in the evening just before bedtime.
It can be taken with or without food.
Ensure the patient swallows the tablet whole; do not crush or chew
Special Considerations
Titration: Titrate the dose gradually to minimise side effects.
Adverse Effects: Monitor for common side effects such as nausea, diarrhea, insomnia, muscle cramps, fatigue, and anorexia. Serious side effects may include bradycardia and gastrointestinal bleeding.
Patient Monitoring: Regularly assess cognitive function, daily living activities, and side effects to determine the effectiveness and tolerance of the medication.
Guidelines for Missed Dose
If a dose is missed, instruct the patient to take it as soon as they remember.
If it is almost time for the next dose, skip the missed dose and resume the regular schedule. Do not double the dose to make up for a missed one.
Patient and Caregiver Education
Educate patients and caregivers about the purpose of the medication, expected benefits, and potential side effects.
Emphasise the importance of adherence to the prescribed dosing schedule.
Advise them to report any severe or unusual side effects immediately.
Rivastigmine for Mild to Moderate Cognitive Impairment
Starting Dose: 1.5 mg twice daily (morning and evening) with meals.
Maintenance Dose Titration:
• After a minimum of 2 weeks, if the initial dose is well tolerated, increase to 3 mg twice daily.
• Further increases to 4.5 mg twice daily and then to 6 mg twice daily should be based on tolerability and occur at intervals of at least 2 weeks.
Effective Dose Range:
• 3 mg to 6 mg twice daily. The maximum recommended dose is 6 mg twice daily.
Oral Admin:
• Rivastigmine should be taken with meals to minimise gastrointestinal side effects.
• The oral solution can be mixed with water, cold fruit juice, or soda.
Special Considerations
• Titration: Gradual titration is crucial to minimise side effects, particularly gastrointestinal issues such as nausea, vomiting, and diarrhoea.
• Adverse Effects: Monitor for common side effects including nausea, vomiting, diarrhoea, anorexia, dizziness, and headache. The patch formulation may reduce the incidence of gastrointestinal side effects but can cause skin irritation.
• Patient Monitoring: Regularly assess cognitive function, daily living activities, and side effects to determine the effectiveness and tolerance of the medication.
Guidelines for Missed Dose
1. If a dose is missed, take it as soon as remembered unless it is almost time for the next dose.
2. Do not double the dose to make up for a missed one.
3. If Rx is interrupted for several days, restart at the lowest dose and titrate again.
Patient and Caregiver Education
• Education: Explain the purpose of the medication, expected benefits, and potential side effects.
• Adherence: Emphasise the importance of taking the medication as prescribed and attending follow-up appointments.
• Reporting Side Effects: Advise reporting any severe or unusual side effects immediately.
Immediate-Release (IR) Galantamine Tablets or Oral Solution for Moderate to Severe Cognitive impairment.
Starting Dose: 4 mg twice daily (morning and evening) with meals.
Dose Titration:
1. After a minimum of 4 weeks, if the initial dose is well tolerated, increase to 8 mg twice daily.
2. After another minimum of 4 weeks, if 8 mg twice daily is well tolerated, increase to 12 mg twice daily.
3. The effective dose ranges from 16 mg to 24 mg per day, divided into two doses (8 mg to 12 mg twice daily).
Extended-Release (ER) Galantamine Capsules
Starting Dose: 8 mg once daily in the morning with meals.
Dose Titration:
1. After a minimum of 4 weeks, if the initial dose is well tolerated, increase to 16 mg once daily.
2. After another minimum of 4 weeks, if 16 mg once daily is well tolerated, increase to 24 mg once daily.
3. The effective dose ranges from 16 mg to 24 mg once daily.
Administration
Immediate-Release Tablets or Oral Solution:
• Take twice daily with meals (morning and evening) to minimise gastrointestinal side effects.
• Ensure the oral solution is measured accurately and can be mixed with non-alcoholic beverages.
Extended-Release Capsules:
• Take once daily in the morning with meals.
• Swallow capsules whole; do not crush, chew, or open them.
Special Considerations
• Titration: Gradual titration is important to minimise side effects such as nausea, vomiting, diarrhoea, and dizziness.
• Adverse Effects: Monitor for common side effects, including gastrointestinal symptoms (nausea, vomiting, diarrhoea), weight loss, and decreased appetite. Less commonly, bradycardia and syncope may occur.
• Patient Monitoring: Regularly assess cognitive function, daily living activities, and side effects to determine the effectiveness and tolerance of the medication.
Guidelines for Missed Dose
1. If a dose is missed: Take it as soon as remembered unless it is almost time for the next dose. Do not double the dose to make up for a missed one.
2. If treatment is interrupted: If Galantamine is discontinued for more than several days, restart at the lowest dose and titrate up to the previous maintenance dose to minimise the risk of side effects.
Patient and Caregiver Education
• Education: Explain the purpose of the medication, expected benefits, and potential side effects.
• Adherence: Emphasise the importance of taking the medication as prescribed and attending follow-up appointments.
• Reporting Side Effects: Advise reporting any severe or unusual side effects immediately.
Clinical Considerations Between Cholinesterase Inhibitors
1. Efficacy: All three drugs have similar efficacy in improving cognitive function and daily living activities in Cognitive disease. The choice often depends on patient tolerance and response to the medication.
2. Side Effect Management: Rivastigmine in the patch form may be preferred for patients who experience significant gastrointestinal side effects with oral medications.
3. Dosing Convenience: Donepezil and the extended-release form of galantamine offer once-daily dosing, which may improve adherence compared to the twice-daily dosing required for rivastigmine oral forms and immediate-release galantamine.
4. Specific Indications: Rivastigmine is also approved for Parkinson’s disease dementia, which may influence the choice of drug in patients with this comorbidity.
B. NMDA Receptor Antagonists (Memantine):
Trials have shown that combo therapy with a cholinesterase inhibitor and memantine can provide greater benefits to cognitive function and activities of daily living when compared to cholinesterase inhibitor mono therapy.
Guideline Recommendations: The American Academy of Neurology (AAN) and the Alzheimer’s Association, support the use of memantine in combination with cholinesterase inhibitors for patients with moderate to severe Alzheimer’s disease. Interpersonal issues like the total number of medications being taken and possible interactions should be taken into consideration.
Dosage and Administration of Memantine:
• Memantine Dosing: Typically starts at 5 mg once daily and is titrated up to 10 mg twice daily (20 mg per day), with increments of 5 mg per week.
• Combination with Cholinesterase Inhibitors: Memantine can be safely added to ongoing treatment with donepezil, rivastigmine, or galantamine. There is no need to discontinue the cholinesterase inhibitor when starting memantine.
II. Treatments aimed and managing adverse Behavioural and Psychological Symptoms:
These are situations best managed in consultation with a Psychiatrist, a Neurologist or both.
• Antidepressants: Sertraline, Citalopram, Escitalopram.
• Antipsychotics: Risperidone, Quetiapine, Olanzapine.
• Mood Stabilizers: Valproic acid, Carbamazepine.
• Anxiolytics: Lorazepam, Oxazepam.
Referral to a Neurologist
During the course of repeated interactions between the PCP it may become necessary to refer the Patient for a visit to a Neurologist. These are some guidelines that may help in decision making.
When Referral May Not be Necessary:
• Mild cognitive impairment improving with treatment.
• Stable patients with clear diagnosis and manageable symptoms.
• Regular follow-up in situations where there is a stable response to initial treatment.
When Referral is Necessary:
• Rapid progression of symptoms or atypical presentation.
• Complex cases with significant behavioural or psychological symptoms.
• Uncertain diagnosis after primary testing.
• Need for advanced diagnostic testing (e.g., neuro-imaging, detailed neuropsychological assessment).
• Requirement for specialised treatments or interventions not available in primary care.
General References on Cognitive Decline and Dementia
1. Alzheimer’s Association. (2020). 2020 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 16(3), 391-460.
2. Burns, A., & Iliffe, S. (2009). Dementia. BMJ (Clinical Research Ed.), 338, b75.
Diagnostic Criteria and Screening Tools
5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders.
7. Nasreddine, Z. S., et al. (2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695-699.
Pharmacological Treatments
8. Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimer’s disease.Cochrane Database of Systematic Reviews, (6), CD001190.
9. NICE Guidelines (TA217) detail the usage of Rivastigmine for treating Alzheimer’s disease. https://www.nice.org.uk/Guidance/TA217
10. Winblad, B., et al. (2007). Memantine in moderate-to-severe Alzheimer’s disease: a meta-analysis of randomised clinical trials. Dementia and Geriatric Cognitive Disorders, 24(1), 20-27.
11. Raina, P., et al. (2008). Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline. Annals of Internal Medicine, 148(5), 379-397.
Non-Pharmacological Interventions
12. Clare, L., & Woods, R. T. (2004). Cognitive training and cognitive rehabilitation for people with early-stage Alzheimer’s disease: a review. Neuropsychological Rehabilitation, 14(4), 385-401.
13. Livingston, G., et al. (2014). Non-pharmacological interventions for agitation in dementia: systematic review of randomised controlled trials. The British Journal of Psychiatry, 205(6), 436-442.
Behavioural and Psychological Symptoms Management
14. Ballard, C., et al. (2009). Management of agitation and aggression associated with Alzheimer disease. Nature Reviews Neurology, 5(5), 245-255.
15. DICE Approach, https://diceapproach.com/system/files/2019-04/BMJ%202015.pdf
Neurological Assessments and Imaging
16. Jack, C. R., et al. (2018). NIA-AA research framework: Toward a biological definition of Alzheimer’s disease. Alzheimer’s & Dementia, 14(4), 535-562.
17. Dubois, B., et al. (2007). Research criteria for the diagnosis of Alzheimer’s disease: revising the NINCDS–ADRDA criteria. The Lancet Neurology, 6(8), 734-746.
18. McKhann, G. M., et al. (2011). The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7(3), 263-269.
Advanced Cognitive Testing
19. Wechsler, D. (2008). Wechsler Adult Intelligence Scale–Fourth Edition (WAIS–IV). San Antonio, TX: Pearson.
20. Delis, D. C., et al. (2000). California Verbal Learning Test–Second Edition (CVLT–II). San Antonio, TX: Pearson.
21. Stroop, J. R. (1935). Studies of interference in serial verbal reactions. Journal of Experimental Psychology, 18(6), 643-662.