What’s in the web for family physicians – mild cognitive impairment and dementia

Adrian Wong 黃沛霖, Lisa WC Au 區頴芝, Vincent CT Mok 莫仲棠, Alfred KY Tang 鄧權恩

Dementia and Mild Cognitive Impairment (MCI)

Dementia is an increasingly prevalent healthcare problem in the rapidly ageing society in Hong Kong. During the past couples of decades, there is a shift of focus from dementia to earlier stage of cognitive decline, a condition commonly referred to as Mild Cognitive Impairment (MCI).¹ MCI is conceptualized as an intermediate stage between normal ageing and dementia. Clinical studies show that patients with MCI, in particular, the amnestic subtype which is characterized by a predominant memory impairment, are at 3-fold risk of progressing into Alzheimer ’s disease (AD) over the next 2 years. Therefore, amnestic MCI may represent a prodromal stage of Alzheimer’s disease. Like dementia, MCI is a clinical syndrome with heterogeneous causes, including reversible causes such as Vitamin B12 deficiency, obstructive sleep apnea, depression and hypothyroidism, etc. As patients with suspected dementia are often first brought to the attention of family physicians, they play a pivotal role in the assessment and management of patients with MCI and dementia.The original MCI criteria only considered memory impairment.² It was later revised to include non-memory impairment and concurrent impairments in multiple cognitive domains.³

1. Subjective cognitive complaint,preferably corroborated by an informant
2. Objective impairment in one or more cognitive domains documented on psychometric testing
3. Preservation of independence in functional abilities
4. Not demented

Dementia training materials for primary care practitioners

https://bhw.hrsa.gov/grants/geriatrics/alzheimerscurriculum

This website contains a comprehensive set of education materials on MCI and dementia for healthcare professionals. Topics range from diagnosis, assessment, management to palliative and end-of-life care. Materials are presented in PowerPoint presentation formats.

Bedside cognitive screening for MCI and dementia

http://www.mocatest.org

https://cog.mect.cuhk.edu.hk (request for HK-MoCA 5-minute Protocol)

The traditional cognitive screening, the Minimental State Examination (MMSE), has been shown to be insensitive to MCI.⁴ It is also copyrighted and it requires a fee for its use (https://www.parinc.com/ products/pkey/237). The Montreal Cognitive Assessment (MoCA) is designed for the detection of MCI. It measures a comprehensive set of cognitive domains impaired in a wide spectrum of conditions. The MoCA has been adapted into a Hong Kong version (HKMoCA), which takes 10-15 minutes to administer and score.⁵ In addition, a briefer version, namely the HKMoCA 5-minute Protocol, was developed and validated in the local population.⁶ It is suitable for ultra-quick screening in busy clinics. Furthermore, as the HKMoCA 5-minute Protocol does not involve drawing, it can be completed by older patients who are reluctant to draw or stroke patients with hemiparesis in their dominant limb. Age and education-adjusted norms for the HK-MoCA and HK-MoCA 5-minute Protocol are available for accurate classification of patients’ performance.⁷ The HK-MoCA and HK-MoCA 5-minute Protocol are now used as standard cognitive screens for dementia in public healthcare settings, enabling better integration and continuity of patient care between community and hospital-based healthcare.

Clinical rating of dementia severity

http://knightadrc.wustl.edu/cdr/cdr.htm Clinical Dementia Rating (CDR)

https://www.fhca.org/members/qi/clinadmin/global.pdf Global Deterioration Scale (GDS)

http://geriatrics.uthscsa.edu/tools/FAST.pdf Functional Assessment Staging (FAST)

The CDR, GDS and FAST Staging scale are widely used scales for clinical rating of cognition. Ratings are performed by integration of information on cognitive and functional performance obtained in clinical interview and cognitive testing. Family physicians can make use of these scales for diagnosis and monitoring of disease progression and treatment outcome.

Risks of drug management for behavioural and psychological symptoms of dementia (BPSD)

https://psychiatryonline.org/doi/book/10.1176/appi. books.9780890426807

Dementia is a constellation of cognitive, psychological and behavioural symptoms. Cognitive enhancing medications for Alzheimer ’s disease include: (1) acetylcholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine) and (2) NMDA receptor antagonist (Memantine). Apart from cognition, psychotic and behavioural symptoms in dementia are both common and troublesome. To date, there is no FDAapproved drug for the treatment of neuropsychiatric symptoms in dementia. Off-label prescriptions of antipsychotics are common because of the significant distress and no effective alternative treatments are available. However, anti-psychotics are associated with a number of major adverse outcomes e.g. sedation, parkinsonism, falls, cognitive decline, stroke and death. Patients and caregivers should be informed of these risks.⁸ Anti-psychotics should only be judiciously initiated after failure of non-pharmacological options and patient is threat to self or others. Low doses should be used, with slow titration as needed. Close monitoring of response and side effects should be reviewed. In patients who show adequate response, a discontinuation trial should be considered unless the patient experienced a recurrence of symptoms with prior attempts at tapering of anti-psychotic medication.⁹

Education resources on behavioural management of BPSD

http://www.elderly.gov.hk/tc_chi/carers_corner/ dementia_care/behavioralmanagement.html (Chinese)

http://kch.ha.org.hk/form/D1.pdf (English)

Apart from drug treatment, non-pharmacological treatment including behavioural and environmental management are useful to reduce BPSD. Family practitioners may share such information with dementia caregivers or even train these caregivers to use these skills in the daily context. English version for domestic helpers are available.

Dementia education for elderly patients and their families

https://cog.mect.cuhk.edu.hk (Therese Pei Fong Chow Research Centre for Prevention of Dementia, The Chinese University of Hong Kong (CUHK) )

https://www.alz.org/what-is-dementia.asp (English)

Awareness of signs and symptoms of dementia by family and friends are the key steps for diagnosis and management. There is an abundance of education information on dementia in different languages available on the internet. The CUHK Therese Pei Fong Chow Research Centre for Prevention of Dementia website shows a microfilm depicting how a family comes across the signs and symptoms of dementia in an elderly family member. This microfilm is free for use and family practitioners may show it in the clinic waiting area. Moreover, the same website offers dementia education in audio presentation by a famous local Disc Jockey. Patients and families can learn about dementia in this website like they are listening to a radio program at their leisure.