Cognitive Changes
Referral
-word-finding difficulty (tip-of-the-tongue phenomenon)
-memory complaints (often vague, sometimes language-related)
-dissect complaints into domains
Cognitive Domains
Use SAMPLE
-Social→ behavior
-Attention→ focus
-Memory→ retention
-Perceptual/ visuospatial→ navigation
-Language→ only language
-Executive function→ multisteps
Information gather
-pt & collateral equally
>Anosognosia vs high self-aware
high-performer→ subtle changes
low-performer→ under-recognize
-Normalize aging
"Have you noticed anything like that for yourself compared to your friends?"
-Comparative qs (now vs 1y ago)
>ADLs after baseline
ADLs
-Basic
>Eat, bath, dress, toilet, transfer, grooming
-Instrumental
>Managing meds, finances, cook, shop, housekeep, transportation
Multifactorial nature
-Avoid attributing changes solely to lab abnormalities
-Acute events (UTI) may unmask underlying impairment
-NDG vs non-NDG
Considerations
- LATE is an histopath dx
- PPA is divided into FTD (svPPA & nfvPPA) and AD (lvPPA) like
Physical exam
-Focal deficits→ sugg vasc
-EOM abnormality
-PD sx
-Gait
-Palmomental rfx & Myerson
Diagnostic tools
-MoCA (preferred)
> assess sAMPLE, 's' is talking w/ pt
If unclear pattern, do
>Trail A&B→ processing & executive
>BNT→ language
>Dig span→ attention + work memory
-MMSE
> if severe dementia (higher ceiling effect)
> assess mainly sa'M'p'L'e
> convert MoCA to MMSE
-Others
>ACE→ specialist
>Minicog→ PCP screening
>Fluency→ phonemic (AD) vs category
-NeuroPsych test→ domain-level profile
>High-performers for subtle complaints
>Discrepancy btw pt & family
>Legal quests
>Suspected FTD, PPA, atypical AD
>Mood vs cognitive
Investigation
-Reversible causes of dementia
>CBC, BMP (Ca), vitamins (B12 & MMA & HMC, folate, D, thiamine/ETKA), TSH, HIV, RPR
±ATN profile ±pTau217 (outpatient)
±APOE genotyping
±CSF amyloid
-if rapidly progressive→ LP
> CJD→ RT-QuIC, 14-3-3, t-tau
> AIE→ serum&CSF AIE panel
>SREAT→ anti-TPO, anti-TG, TSH cascade
-Neuroimaging s/f WMC, infarcts, atrophies
>bMRI ± NeuroQuant
±Amyloid PET (outpatient)
AD Treatment
Traditional meds
-AChEi (donepezil, rivastigmine, galantamine)
> N/V & diarrhea; check EKG 2/2 QT
*PDD→ RVS Patch
-Memantine
> early confusion & dizziness; CI szs
Anti-amyloid therapy
-Lecanemab & donanemab
-Specialist
Lifestyle
-Sensory optimization: hearing and vision tests
-Exercise
-Healthy diet
-Cognitive & social engagement
-Always assess caregiver burden