AGS

Mind

Mind

History

  • What is the older adult’s baseline cognitive status?
  • Any recent changes in cognition, confusion, or memory loss?
  • Anxiety or depression?
  • Changes in hearing or vision?

Promote Brain Health

  • Be a lifelong learner.
  • Stay socially and physically active.
  • Control hypertension, diabetes, hyperlipidemia, sleep apnea.
  • Avoid smoking, limit alcohol use.
  • Exercise regularly and sleep well.
  • Eat a Mediterranean diet rich in fish and nuts.

Delirium: Acute brain failure leading to confusion, inattention, and altered mental status, often in a hospitalized or ill older adult.

A mneumonic to Remember contributors to “DELIRIUM”9

Drugs
Electrolyte disturbances
Lack of drugs
Infection
Reduced sensory input
Intracranial disorders
Urinary and fecal disorders
Myocardial and pulmonary disorders

Delirium Screening

Ultra-Brief 2-Item Screener (UB-2)10

  1. Please tell me the day of the week.
  2. Please tell me the months of the year backward; say “December” as your first month.

If both items are correct, screen is negative for delirium. If one or both items are incorrect, screen is positive.

Delirium Diagnosis

Confusion Assessment Method (CAM) 11

  1. Acute onset and fluctuating course
  2. Inattention
  3. Disorganized thinking
  4. Altered level of consciousness

If yes to 1 and 2 AND either 3 or 4, then positive for delirium.

Cognitive Evaluation Screening

Mini-Cog evaluation (mini-cog.com):

  • 3 words: banana sunrise chair
  • Clock draw: “draw the face of a clock, put in all numbers, set time at 10 past 11”)12

If Mini-Cog is abnormalà select appropriate longer cognitive screening tool, as appropriate, such as MOCA (see mocacognition.com for instructions and certification)13

Dementia: progressive neurocognitive disorder (e.g., Alzheimer disease, Vascular dementia, Dementia with Lewy bodies, Frontotemporal dementia, Parkinson disease, Mixed dementia).

Dementia evaluation includes: assess for depression, alcohol use, hearing impairment, obtain serum vitamin B12 level, thyroid-stimulating hormone, other lab tests as indicated such as Chem 7; obtain non-contrast head CT or MRI.14

Staging Dementia

FAST scale (selected stages)15

  • Stage 3: Decreased job functioning evident to coworkers, difficulty in traveling to new locations
  • Stage 4: Decreased ability to perform complex tasks (eg, planning dinner, handling finances)
  • Stage 5: Requires assistance to choose proper clothing
  • Stage 6: Decreased ability to dress, bathe, and toilet independently
    • Substage 6a: Difficulty putting clothing on properly
    • Substage 6b: Unable to bathe properly, may develop fear of bathing
    • Substage 6c: Inability to handle mechanics of toileting (flushing, wiping)
    • Substage 6d, e: Urinary incontinence, fecal incontinence
  • Stage 7: Loss of speech, locomotion, and consciousness
    • Substage 7a, b: Ability to speak limited (1 to 5 words), all intelligible vocabulary lost
    • Substage 7c: Nonambulatory (hospice eligible)
    • Substage 7d, e, f: Unable to sit up independently, smile, or hold up head

Depression screening

PHQ-216

Over the past two weeks, how often have you been bothered by any of the following problems?

  1. Little interest or pleasure in doing things
  2. Feeling down, depressed, or hopeless

Scoring: not at all=0, several days=1, more than half the days=2, nearly every day=3

If PHQ-2 score ≥3, do longer depression assessment such as PHQ-9 (used to track severity) or Geriatric Depression Scale.

Hearing impairment is a modifiable risk factor for delirium, dementia and depression, as well as falls.

Tips for Speaking to Patients with Hearing Impairment17

  • Speak low and slow (high-pitched hearing loss), face the patient.
  • Rephrase, use pictures or write things down.
  • Check ears for wax (carbamide drops + ear cleaning).
  • Request a pocket amplification device.
  • Evaluate hearing aids with audiology.

Interprofessional Team Involvement: Consider nursing, psychiatry, psychology, social work, audiology, ophthalmology.

Tools for Mind

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