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CLINICAL SYNTHESIS   |    
Evaluation of Cognitive Impairment in Older Adults
Douglas W. Scharre, M.D.; Paula T. Trzepacz, M.D.
FOCUS 2013;11:482-500. doi:10.1176/appi.focus.11.4.482
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Author Information and CME Disclosure

Douglas W. Scharre, M.D., Director, Division of Cognitive Neurology, Associate Professor of Neurology, Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH

Paula T. Trzepacz, M.D., Senior Medical Fellow, Neurosciences, Lilly Research Laboratories; Clinical Professor of Psychiatry, Indiana University School of Medicine, Indianapolis, IN; Adjunct Professor of Psychiatry, Tufts University Medical School, Boston, MA.

Dr. Trzepacz is a full-time salaried employee and minor shareholder at Eli Lilly and Company with responsibilities for florbetapir-PET and holds the copyright for the Delirium Rating Scale-Revised-98. Dr. Scharre is a consultant for Eli Lilly and Company and developer of the Self-Administered Gerocognitive Examination (SAGE).

Address correspondence to Dr. Trzepacz (PTT@lilly.com).

Abstract

Cognitive complaints are common in older persons. With the shifting demographic pattern toward more aged individuals, more physicians will be needed who have competency in the differential diagnosis for cognitive impairment because there are not enough geriatric subspecialists. Psychiatrists who can evaluate patients for mood and different cognitive disorders will be key societal contributors in caring for the growing elderly population. We describe major differential diagnostic categories for cognitive impairment and characterize their examination, cognitive, laboratory, and neuroimaging findings. We discuss the 3 D’s (depression, delirium, dementia) as common conditions for which older persons are at risk, as well as key differential diagnostic features for the common causes of dementing disorders. Because these disorders may be comorbid, the practitioner needs to carefully evaluate and interpret a range of signs and symptoms indicative of their underlying conditions and manage those accordingly, including referring to subspecialists when necessary. Psychiatrists and neurologists are well positioned to diagnose older patients who have cognitive impairment or dementia. The coauthors leverage their geriatric psychiatry and cognitive-behavioral neurology expertise in addressing this topic for practitioners and cite guidelines and tools that have application in clinical practice.

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Figure 1. Flow Diagram for Assessment of the 3 D’s

Assessment of the 3 D’s (depression, delirium, dementia) in older persons begins with ruling out depression and delirium, followed by consideration of examination findings in conjunction with neuroimaging or laboratory tests targeted to diagnose or rule out particular dementing disorders as noted in the schematic. Clinically available brain scans are listed related to relevant diagnostic considerations. Information in Tables 13 provides additional practical details for the clinician while working through the decision tree.

Figure 2. Characteristic Neuroimaging Findings

Findings shown by three types of neuroimaging (MRI, amyloid PET and FDG PET scans) in two case examples. Arrows denote key findings. Part A  is a patient with dementia due to Alzheimer’s disease. MRI FLAIR transverse image shows diffuse cortical atrophy consistent with gray matter volume loss due to neurodegeneration. FDG PET fused with a CT scan image, where red areas represent the highest metabolism, shows reduced red in the posterior temporal-parietal cortical region (greater on the right), a hypometabolism pattern consistent with Alzheimer’s disease. Florbetapir F18 PET image shows black in the cortical gray matter and a loss of the gray/white matter border in more than two cortical regions, consistent with moderate to frequent density of cortical amyloid plaques and a pathological diagnosis of Alzheimer’s disease. Part B  is a patient with frontotemporal dementia. MRI FLAIR transverse image shows significant bilateral atrophy of frontal and temporal cortices. FDG PET fused with CT scan image shows bilateral frontal and anterior temporal cortical areas with decreased red as compared with more posterior regions, a pattern of hypometabolism consistent with clinical diagnosis of frontotemporal dementia. Florbetapir F18 PET scan is negative for amyloid plaques (having none to sparse density), and shows white matter pathways (in black) and clear borders between white matter pathways and cortical gray matter (in gray), which is inconsistent with a pathological diagnosis of Alzheimer’s disease.

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Table 1.Key Neuropsychiatric/Neurological Examination and Test Findings for Differential Diagnosis of Common Dementing Disordersa
Table Footer Note

a CSF=cerebrospinal fluid; CT=computed tomography; FDG=fluorodeoxyglucose; MRI=magnetic resonance imaging; PET=positron emission tomography; TDP=TAR DNA binding protein 43; APP=amyloid precursor protein; PS=presenilin

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Table 2.Features of Recommended Commonly Used Office-Based Multidomain Cognitive Tests and a Cognitive/Functional Questionnairea
Table Footer Note

a AD=Alzheimer’s disease; ADL=activities of daily living; MCI=mild cognitive impairment; MMSE=Mini-Mental State Exam; MoCA=Montreal Cognitive Assessment NCD=Neurocognitive disorder; PAR=Psychological Assessment Resources; SAGE=Self-Administered Gerocognitive Examination; SLUMS=Saint Louis University Mental Status.

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Table 3.Types of Testing Adjunctive to History and Physical Examination in the Differential Diagnosis of Cognitive Impairment due to Major Depression, Delirium, and Neurodegenerative Dementing Disorders in Clinical Practicea
Table Footer Note

a Additional testing not reflected here may be performed in research settings and accessible via referral to dementia researchers. AD=Alzheimer’s disease; APOE=Apolipoprotein E; BUN=blood urea nitrogen; CSF=cerebrospinal fluid; FDG=fluorodeoxyglucose; FTD=frontotemporal dementia; DLB=dementia with Lewy bodies; MRI=magnetic resonance imaging; PET=positron emission tomography; SPECT=single-photon emission computed tomography; TSH=thyroid stimulating hormone; VDRL=venereal disease research laboratory; WBC=white blood cell.

Table Footer Note

b Assays may not be standardized yet for ranges and cut-off values as AD biomarkers

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