So, let's discuss another
important subject among older adults.
It doesn't affect every older adult,
but as patients age, it certainly
becomes more and more prevalent.
And that's cognitive decline.
So, begin with a case.
We have a 75-year-old woman.
She has a new diagnosis of Alzheimer's disease.
Testing indicates that she has mild
dementia and mild loss of function overall.
So, what is the first-line treatment
for her Alzheimer's disease?
Is it Ginkgo?
Behavioral treatment only?
Or is it an acetylcholinesterase inhibitor?
The answer is acetylcholinesterase inhibitor
and we'll talk about drugs approved
for the treatment of Alzheimer's disease.
Epidemiology of cognitive decline,
as I mentioned, it is common.
The lifetime risk among individuals
who live over 65 years is up to 20%.
The majority of those cases
are due to Alzheimer's disease.
However, the United States Preventive
Service Task Force recommends
screening for cognitive decline only
when there's clinical suspicion of decline.
And remember that, many times, it won't be the
patient who tells you about cognitive decline.
It's going to be someone
who knows them well.
That's going to be a family
member – a son, daughter, spouse.
It's going to be somebody – a good friend
or somebody they know from church
because there's still a lot of stigma.
And you can imagine being diagnosed with
cognitive decline is a very scary proposition.
So, there’s a lot of denial among patients
and they'll stick to their routines
and ignore the fact that they're getting more confused,
have more trouble with memory rather
than facing this very severe diagnosis.
And really, I feel a lot of empathy.
Who can blame them for feeling that way,
faced with such a terrible disease?
So, when there is a
suspicion for cognitive decline,
when I get that story,
you know, I’m losing my –
I feel like I'm forgetting a lot of things lately.
And this is something I hear from
35-year-olds on a regular basis,
much less 75-year-olds.
You can think about doing different
tests for cognition within the office.
The Mini-Mental Status Examination
is probably the most widely used,
although it is proprietary.
It is something that’s still under copyright.
It’s an exam. It’s fairly lengthy.
And it’s also dependent upon
patient’s language and educational level.
So, I'm not saying it doesn't have a role.
It actually absolutely has a role
because it’s the coin of the realm.
Their score on the MMSE means something
and it’s easily understood by different providers.
But I do also like a quick
screening tool like the Mini-Cog,
especially for those 35-year-olds.
It's a simple test involving
first a three-item recall.
And if that’s passed, the chances of
any serious dementia is very, very low.
If the patient can only recall one or
two items, they’re given a clock draw test.
And if that's normal, their risk
of dementia is very, very low.
It has a 89% specificity for
at least mild dementia overall wrong
and it's not dependent on patients’
language and educational level.
So, therefore, it can be a really useful
test in the clinical setting as a screener.
If it's positive, that should be
followed up with more testing.
Some particular causes of dementia
and their symptomatology are worth noting.
It’s not something I see a lot in clinical practice,
but very well could come up on your exam.
Patients with that wide-based
gait and urinary incontinence,
think about normal –
as well as evidence for dementia,
normal pressure hydrocephalus.
Patients with ascending paresthesias,
feeling weakness, akathisia and weight loss,
vitamin B12 deficiency.
And then more clinically speaking,
always be thinking about medications and side effects,
particularly as individuals get older
and particularly with anticholinergic drugs
or other sedating drugs are going to have
a significant effect on cognition as well.
So, when you find a case of dementia,
the workup should include a CBC,
a comprehensive metabolic panel,
a TSH, B12 and folate levels,
and an RPR for tertiary syphilis.
And in my opinion, every patient with dementia
deserves at least one good neuroimaging study,
preferably an MRI because
it’s going to give more details.
Unfortunately, I see patients
are getting multiple studies
because there is no coordination of care
and that's a waste of resources.
But I think it is important to get one study
just to make sure that there is no gross lesion within the brain
and something that will
probably confirm the fact
that there’s generalized atrophy
consistent with dementia,
such as Alzheimer's.
So, first-line treatment for Alzheimer's,
as I mentioned, are acetylcholinesterase inhibitors.
They can be used in mild disease,
which is when they should be caught.
There's three agents available.
They’re generally similar in efficacy.
One comes in the form of a patch and
that may be associated with better tolerability.
Overall, you can expect mild improvements
in both cognition and function.
They’re statistically relevant.
Does it really matter in terms of something
clinically that patients can appreciate?
Generally, my opinion and
overall consensus is no.
These drugs tend to
hold the line and prevent –
they promote a slower decline
in cognitive ability and function,
but they don't cause a significant
improvement either for the majority of patients.
Nothing that they’ll notice.
If there's no improvement, if the patient
is continuing to decline six to eight weeks later,
the medicine can be discontinued
and there is a significant association
with nausea and vomiting and weight loss
and tolerability of these drugs is problematic.
But it’s what we have for mild Alzheimer's disease.
Because there is another class of drugs,
the NMDA receptor antagonists,
but it's indicated for more
moderate to severe Alzheimer's disease,
not mild disease.
And again, modest improvements overall in
cognition and function and in levels of agitation,
not something that you could really say,
certainly not a cure,
maybe something not even that the
patient nor the family can particularly notice,
but may just be slowing the decline of the disease.
But one thing is it's better tolerated at least
than the acetylcholinesterase inhibitors.
So, we know that as well.
Monoclonal antibodies directed against beta amyloid have recently been approved for individuals
with Alzheimer disease with mild cognitive impairment and documented amyloid pathology.
These include aducanumab and lecanemab. While these medications do appear to reduce beta amyloid plaques on the brain,
whether this correlates to clinical improvement remains to be seen.
Additionally, MRI monitoring is required to evaluate for amyloid-related imaging abnormalities,
such as edema, hemosiderin deposition, and microhemorrhages.