5-Step Brain Health Work-up

Listen for concerns about changes in memory or other cognitive functions expressed by the patient or someone who knows the patient well, or perhaps you have your own concerns based on the behavior you have observed. Many patients or families may not offer these concerns unless directly asked. For patients over the age of 50, on a regular basis such as every 1–2 years, we recommend that you ask the patient and an informant (someone who knows the patient well), “Have there been any changes in your memory or thinking skills?” Informants are not always available, but when they are, their perspective is often valuable for early detection of cognitive change.

If there is a concern, further assessment is needed, which could be scheduled as part of a dedicated Brain Health Visit that would encompass Steps 2–4. You may wish to order brain health labs (Step 3) in advance of this visit so you have the results when you see the patient to guide their care.

This involves cognitive testing (e.g., the Brain Health Assessment) and asking the patient and an informant whether they have noticed cognitive changes. Changes in movement, mood and behavior can also be signs of neurological disease. The informant’s perspective can be obtained from a survey such as the Brain Health Survey, which is part of the Brain Health Assessment. Consider together the test results with the patient and informant perspectives to determine whether there is likely cognitive change.

• If the testing, the patient perspective, and the informant perspective indicate that the patient is likely cognitively normal, reassure the patient. You may wish to give the patient a handout on healthy brain aging.
• If any evidence suggests likely cognitive impairment, proceed to Step 3.

Next, determine if the change is rapid and a delirium work-up is indicated. To do this, you could ask, “In the past few days or weeks, has the patient had a sudden change in how they think or act (e.g., been unusually distractible or confused)?” If the Brain Health Survey was completed, the automated report will include the informant’s response to this question.

We recommend that for every patient with a cognitive concern you order TSH, CBC, CMP, vitamin B12, and calcium; consider ordering HIV and RPR. A Patient’s Guide to Lab Testing for a Dementia Evaluation (PDF) may be helpful. Also evaluate for centrally-acting medications, psychiatric conditions, substance use disorders, sleep disorders including sleep apnea, and comorbid health conditions that may be causing or contributing to impairment. Of course, your patient may have a neurodegenerative disease and a treatable cause of cognitive impairment. It is helpful to assess for reversible causes because addressing them may improve the person’s cognitive status even if there is still underlying impairment. Here is some more information on conditions to rule out before diagnosing a neurodegenerative disease.

Other Issues for Primary Care to Rule Out Before Diagnosing a Neurodegenerative Disease

• Reactions to medications. Some medications have side effects that mimic the symptoms of dementia. Even a single dose of a medicine may trigger such a reaction in an older person or in someone whose liver fails to eliminate the drug normally. Interactions among two or more drugs may lead to reversible symptoms of dementia as well.
• Metabolic abnormalities. Decreased thyroid function (hypothyroidism) can result in apathy or depression that mimics dementia. Hypoglycemia, a condition in which there isn’t enough sugar in the bloodstream, can cause confusion or personality changes. Pernicious anemia caused by an inability to absorb vitamin B-12 also can cause cognitive changes. Similarly, changes in blood sodium, calcium, heavy metals or other compounds can cause a reversible dementia.
• Nutritional deficiencies. Chronic alcoholism can be associated with deficiencies of thiamin (vitamin B-1), which can seriously impair mental abilities. Severe deficiency of niacin (vitamin B-3) may cause pellagra, a neurological illness with features of dementia. Dehydration also can cause confusion that may resemble dementia.
• Emotional or psychiatric problems. The confusion, apathy, and forgetfulness associated with depression are sometimes mistaken for dementia, particularly in older individuals. Depression is not common in people with frontotemporal dementia (FTD), but apathy and emotional withdrawal are, and this can lead to the misdiagnosis of depression. Even though people with FTD may appear to be depressed, when you ask them about their mood, they often offer that they feel happy. Similarly, bipolar disorder and schizophrenia can be misdiagnosed as dementia.

   

  Medications that may have an impact on cognition and should be discontinued or avoided:

  • Anti-cholinergics: there are many medications that have anticholinergic properties and this list of anticholinergic effects should be consulted. There are some surprising ones, like diphenhydramine, which can have very strong cognitive side effects and should be avoided.
  • Anti-depressants: most do not have cognitive side effects, but those that do are paroxetine, amitriptyline, nortriptyline, desipramine, imipramine
  • Anti-psychotics: unless specifically indicated for a psychotic disorder or chosen to treat behavioral symptoms of dementia after an informed consent process with the patient and/or their decision maker
  • Anti-spasmodics: medications for bladder incontinence and muscle spasms can have serious cognitive side effects and should be avoided or down-titrated. Such medications include oxybutynin, tolterodine, dicyclomine, and baclofen, among others.
  • Benzodiazepines: this is a highly dangerous medication in older people and linked to cognitive impairment, delirium and falls. This class should be used with extreme caution and the only clear indications are alcohol withdrawal, active seizure, and panic attacks or disorder.
  • Opioids: if newly initiated and at higher doses, opioids may cause cognitive impairment, though they may also be safely prescribed.
  • Sleep agents: most of the sleep agents, such zolpidem, or medications used for their drowsy side effects, such as diphenhydramine or benzodiazepines, can cause serious cognitive side effects.
  • Tricyclic antidepressants: these are also used for neuropathic pain and should be avoided, particularly desipramine and amitriptyline.

If you have detected progressive cognitive decline, the next step is to diagnose mild cognitive impairment (the patient is still able to independently perform all day-to-day activities) or dementia (the patient is unable to independently perform activities that they were able to independently accomplish in the past). For example, you could ask the patient and the informant “Does the patient have difficulty doing something that they used to do easily (e.g., cooking, hobbies, operating electronics/TV)?” If the Brain Health Survey was completed by an informant as part of the Brain Health Assessment, the automated report will include informant responses to this question and other questions about functional change.

Document the mild cognitive impairment or dementia diagnosis as an ICD-10 code so that other providers will be aware of the diagnosis when planning the patient’s care.

A dementia diagnosis can be as unsettling, but when done well, families feel supported and prepared. 

• PREPARE and set up the conversation: communicate the goal (to go over the results of your brain health assessment) and determine who else the patient/care partner would like present.
• ASSESS what the patient and care partner already know about the condition and how much more they want to know about their diagnosis; assess their hopes and worries.
• SHARE the diagnosis in clear language (e.g., mild cognitive impairment, dementia, or type of dementia if known). 
• SUPPORT empathically respond to reactions; explore their response and check for understanding; communicate support for future conversations, guidance and referral to services; plan follow-up in the short- term. While there may not be curative treatments yet, reassure that care will still be provided.

Share A Patient’s Guide to Mild Cognitive Impairment (PDF) or A Patient’s Guide to Dementia (PDF). These handouts include some community resources that may be valuable to the patient and family.

At this step, you may also consider a referral to identify the cause of the mild cognitive impairment or dementia syndrome. Some providers refer all patients with cognitive disorders to a specialist to determine the cause, whereas others refer some to specialists and diagnose and manage others, such as those with uncomplicated presentations of Alzheimer’s disease, within their practice. This decision may be based on your own comfort level, the practical limitations of your practice, and the availability of specialists in your area.

The handout A Patient’s Guide to Alzheimer’s Disease (PDF) may help, and disease-specific education including handouts on common and less common neurodegenerative diseases can be found on the disease description pages on this website. See the California Alzheimer’s Disease Centers’ guide on how to diagnose Alzheimer’s disease versus non-Alzheimer’s dementias (Assessment of Cognitive Complaints Toolkit for Alzheimer's Disease [PDF]). The Gerontological Society of America’s KAER Toolkit offers additional education and resources for providers on the detection, diagnosis, and management of dementia.