Week 9 discussion

Family Medicine 18: 24-year-old female with headaches
User: Ralph Marrero
Email: [email protected]
Date: March 9, 2022 8:53 PM

Learning Objectives

The student should be able to:

Identify the typical presenting signs and symptoms of common as well as serious causes of headache (tension, cluster, brain
tumor, intracranial hemorrhage, medication use).
Perform a reliable focused neurologic exam on a patient who presents with headache.
Discuss the importance of continuity of care when treating a patient who presents with chronic headache.
Conduct a focused history and physical exam appropriate for differentiating between common etiologies of a patient presenting
with headaches.
Summarize the key features of a patient presenting with headache, capturing the information essential for differentiating
between the common and “don’t miss” etiologies including tension, migraine, cluster, brain tumor, intracranial hemorrhage,
medication use headaches.
Propose a cost-effective diagnostic work-up for a patient presenting with headache.
Describe the acute and prophylactic management of common headaches including migraine.
Find and apply diagnostic criteria and surveillance strategies for substance use disorder.

Knowledge

Causes of Headache

Common types of headache seen in the outpatient setting:

1. Tension-type
2. Migraine
3. Medication overuse
4. Cluster headache

Serious causes of headache:

1. Meningitis
2. Brain tumor
3. Intracranial hemorrhage
4. Traumatic brain injury

Causes of Serious Secondary Headaches

Etiology of
secondary
headache

Findings

Meningitis Headache with fever, mental status changes, or stiff neck.

Intracranial
hemorrhage Sudden onset of headache, severe headache, recent trauma, elevated blood pressure.

Brain tumor Cognitive impairment, weight loss or other systemic symptoms, abnormal neurologic examination.

Traumatic
brain injury

Head injury with subsequent confusion and amnesia. Loss of consciousness sometimes occurs. Subsequent
headache, dizziness, and nausea, and vomiting. Over hours and days: mood and cognitive disturbances,
sensitivity to light and noise, and sleep disturbances.

Common Etiologies of Secondary Headaches

1. Headache due to depression or anxiety

Features

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Similar to tension-type headache:
Bilateral, pressing, and/or tight
Last from 30 minutes to seven days

Some experts feel that depression or anxiety can trigger tension-type headaches. In those cases, tension-type headaches are
considered secondary, not primary headaches.
2. Medication overuse headache

Chronic use of any analgesic can cause this type of headache in patients with pre-existing primary headache—it is an interaction
between a therapeutic agent used excessively and a susceptible patient.
Features

Mild to moderate in severity
Diffuse, bilateral headaches that can occur almost daily and are often present on first waking up in the morning.
Often aggravated by mild physical or mental exertion.
Can be associated with restlessness, nausea, forgetfulness, and depression.
Headaches may improve slightly with analgesics but worsen when the medication wears off. Tolerance develops to abortive
medications and there is decreased responsiveness to preventive medications.
Medication overuse headache can occur at varying doses for different types of medication; it may occur with as low as an
average of 10 doses of triptans per month.

Diagnostic criteria

More than 15 headaches per month in a patient with pre-existing primary headache.
Regular overuse of an analgesic taken for acute treatment of headache for more than three months.
Not better accounted for by another diagnosis.

Treatment

Stop the overused medication.

Important Physical Exam Findings with Headache

Signs of increased intracranial pressure:

Papilledema
Altered mental status

Other important findings to look for:

Signs of meningeal irritation such as Kernig’s sign or Brudzinski’s sign
Focal neurologic deficits such as unilateral loss of sensation, unilateral weakness, or unilateral hyperreflexia.

Triggers for Tension & Migraine Headaches

Physical or environmental triggers:

1. Intense or strenuous exercise
2. Sleep disturbance
3. Menses
4. Ovulation
5. Pregnancy (though for many women, headaches improve during pregnancy)
6. Acute illness
7. Fasting
8. Bright or flickering lights
9. Emotional stress

Medications or substances that act as triggers:

1. Estrogen (birth control/hormone replacement)
2. Tobacco, caffeine, or alcohol
3. Aspartame and phenylalanine (from diet soda)

When to Initiate Prevention of Migraines

The American Migraine Prevalence and Prevention Study outlines recommendations as to when daily pharmacological treatment
should be initiated:

At least six headache days per month
At least four headache days with at least some impairment
At least three headache days with severe impairment or requiring bed rest.

Prevention should be considered:
Four to five migraine days per month with normal functioning
Two to three migraine days per month with some impairment
Two migraine days with severe impairment.

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DSM-5 Substance Use Disorder

The DSM-5 substance use disorder criteria combine the DSM-4 criteria for dependence, addiction, and tolerance. There is now one
term, “substance use disorder,” that encompasses a continuum of problems with substances from mild to severe. Each specific
substance use disorder is diagnosed in similar fashion, using a list of 11 symptoms to determine the severity of illness.
For opioid use disorder, the 11 symptoms are:

Opioids taken in larger amounts than intended
Unsuccessful efforts to control use
Significant time spent in opioid-related activities
Craving
Use results in unmet obligations at work, school, or home
Continued use despite significant interpersonal problems related to use
Other activities neglected due to use
Use in physically hazardous situations
Continued use despite physical or psychological problems related to use
Tolerance
Withdrawal

Note: The last two symptoms do not apply to patients taking opioids solely under appropriate medical supervision.

Clinical Skills

How to Perform a Neurological Exam

Test cranial nerves II through XII:

Cranial
Nerves Test

II and
III Pupils are equal, round, and reactive to light.

II

Use Snellian Chart to test visual acuity

Test visual fields with confrontation.

Confrontation: Ask the patient to look with both eyes into your eyes. While returning their gaze, place your hands about
2 feet apart, lateral to their ears, and instruct them to point to your fingers as soon as they are seen. Then slowly move
your wiggling fingers on both hands along an imaginary bowl encircling their head toward the line of gaze until they
identify them. Do this in the upper and lower temporal quadrants.

III, IV,
and VI

Extraocular eye movements are intact.

Convergence intact.

Extraocular eye movements:

Ask the patient to refrain from moving their head while following your finger movements with their eyes, and make a
wide H in the air, leading their gaze:

(1) To the extreme right

(2) To the right and upward

(3) Down on the right

(4) Then, without pausing in the middle, to the extreme left

(5) To the left and upward

(6) Down on the left

Convergence:

Ask the patient to follow your fingertip with their eye as you move it towards the bridge of her nose.

V Ask the patient to close her eyes and then ask if the two stimuli feel the same when you lightly touch their right, then leftforehead; right, then left cheek; right, then left chin.

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VII

Observe for facial asymmetry while the patient is talking or performing the following maneuvers:

1. Raise eyebrows

2. Frown

3. Close both eyes tightly while you try to open them

4. Show both upper and lower teeth

5. Smile

6. Puff out both cheeks

VIII Rub your fingers near each ear

XI Ask the patient to elevate their shoulders against resistance

IX, X,
and XII Note if speech is clear and tongue and palate are midline

Management

Patient Management of Migraine and Tension-Type Headaches

1. Headache diary

Make note each day of whether or not you have a headache.
Keep track of the severity of the headaches and which treatments are effective.
Identify and avoid headache triggers. Use a list of things that trigger headaches, and monitor which of these triggers worsen
your headaches.
You can find an example of a headache diary here.

2. Caffeine

Caffeine can help headaches but an excess can make them worse, especially when stopping it abruptly. Slowly decrease the use
of diet sodas. The caffeine worsens both migraines and tension-type headaches, but coming off of caffeine too quickly may make
things worse in the short term.
3. Sleep

Try to get more sleep. Aim for seven to nine hours each night and establish a regular sleep routine, meaning try to go to sleep at
the same time each night. Make sure the bedroom is quiet, dark and relaxing, and at a comfortable temperature. Remove
electronic devices like TVs, computers, and smartphones from the bedroom. Avoid large meals, caffeine, and alcohol before
bedtime.

Examples of Effective Stress Relievers

Meditation or a scheduled moment of stillness
Listening to a relaxation audio program
Setting limits on other people’s expectations
Talking with trusted family and friends
Getting moderate, regular exercise
Getting at least seven to nine hours of restful sleep each night

Migraine Medications

Migraine-
specific
treatments:

Treatment Generic name(trade name) Contraindications Side effects

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triptans

sumatriptan
(Imitrex, Imigran),
naratriptan
(Amerge, Naramig),
rizatriptan (Maxalt),
zolmitriptan
(Zomig),
frovatriptan (Frova,
Migard),
almotriptan (Axert),
eletriptan (Relpax)

Concurrent use of
ergotamine, MAOIs;
history of
hemiplegic or
basilar migraine;
significant
cardiovascular,
cerebrovascular, or
peripheral vascular
disease; severe
hypertension; in
combination with
SSRI’s, may cause
serotonin
syndrome. There is
a theoretical risk of
vasoconstriction
impacting a
pregnancy, so they
should be used with
caution in
pregnancy.

Dizziness, sleepiness, nausea,
fatigue, paresthesia, throat
tightness/closure, chest pressure.

ergot alkaloids

ergotamine
(Ergostat),
ergotamine/caffeine
(Cafergot),
dihydroergotamine
(DHE)

Concurrent use of
triptans, many
possibly serious
drug interactions;
heart disease or
angina,
hypertension,
peripheral vascular
disease, pregnancy,
renal insufficiency,
breastfeeding.

Severe reactions possible. MI,
ventricular tachyarrhythmias, stroke,
hypertension, nausea, vomiting,
diarrhea, dry mouth, rash.

Non-specific
treatments
(effective for
any pain
disorder):

Treatment Generic name(trade name) Contraindications Side effects

acetaminophen/aspirin/caffeine (Excedrin)
Pregnancy;
sensitivity to
aspirin.

Nausea; GI bleed; hypertension.

Older
medications
no longer
recommended
because of
increased risk
of overuse:

Treatment Generic name(trade name) Contraindications Side effects

aspirin/butalbital/caffeine (Fiorinal)

Risk of chronic
daily use or
dependence higher;
history of porphyria
or peptic ulcers;
bleeding risk;
pregnancy.

Anaphylaxis, toxic epidermal
necrolysis, Stevens-Johnson
syndrome,
myelosuppression/thrombocytopenia,
GI bleed.

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acetaminophen/butalbital/caffeine
(Esgic, Fioricet,
Phrenilin (lacks
caffeine))

History of
porphyria;
pregnancy; caution
in drug abuse.

Dizziness, drowsiness, dyspnea,
nausea, vomiting, abdominal pain,
agranulocytosis, thrombocytopenia,
respiratory depression, Stevens-
Johnson syndrome.

acetaminophen/dichloralphenazone
(Midrin
(discontinued in the
U.S.))

Hepatorenal
insufficiency;
diabetes;
hypertension;
glaucoma; heart
disease; MAOI use.

Hypertension, dizziness, rash.

Opioid/Butalbital Last Resort Migraine Therapy

Note: Don’t use opioid or butalbital treatment for migraine except as a last resort.

According to the Choosing Wisely Campaign, “Opioid and butalbital treatment for migraine should be avoided because more
effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches.
Opioids should be reserved for those with medical conditions precluding the use of migraine-specific treatments or for those who
fail these treatments.

Migraine prophylaxis

Patients who have migraines more frequently than twice weekly are at risk for medication overuse headache. Migraine
prophylaxis should be considered in these patients if lifestyle changes aren’t effective .

Drugs used
(daily dose
range)

FDA
Approved? Efficacy/cost

Contraindications /
Cautions

Pregnancy
Category Side effects

Beta-blockers

First line:

Metoprolol (47.5-
200 mg)

Propranolol (20-
160 mg)

Timolol (10-30
mg)

Second line:

Atenolol

Nadolol

Yes Good-excellent/cheap

Asthma, depression,
severe COPD, DM
requiring insulin,
Raynaud’s disease

Category C

Fatigue,
bronchospasm,
lightheadedness,
insomnia, bradycardia,
depression, sexual
dysfunction

Tricyclic
Antidepressants

First line:

Amitriptyline (10-
150 mg)

No (off-
label)

Excellent/cheap and
also work for
fibromyalgia and
tension-type
headache

Cardiac conduction
defects, MAOI Category C

Drowsiness, weight
gain, dry mouth

Neurostabilizers

Second line:

Divalproex sodium
(500-1500 mg);
Topiramate (25-
200 mg)

Yes Good/expensive

Pregnancy/risk of
pregnancy

Divalproex: hepatic
disease

Divalproex:
Category D

Topiramate:
Category D

Divalproex: birth
defects, weight gain,
alopecia, pancreatitis,
ovarian cysts

Topiramate:
abdominal pain,
change in tastes, renal
stones, weight loss

Goals of Headache Treatment

The American Migraine Prevalence and Prevention Study outlined recommendations as to when daily pharmacological treatment
should be initiated:
Prevention should be initiated:

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At least six headache days per month.
At least four headache days with at least some impairment.
At least three headache days with severe impairment or requiring bed rest.

Prevention should be considered:
Four to five migraine days per month with normal functioning.
Two to three migraine days per month with some impairment.
Two migraine days with severe impairment.

The 2000 US Headache Consortium defined the following goals for preventive treatment:
1. Decrease attack frequency by 50% and decrease intensity and duration.
2. Improve responsiveness to acute therapy.
3. Improve function and decrease disability.
4. Prevent the occurrence of a medication overuse headache (MOH) and chronic daily headache.

Studies

Indications for Brain Imaging in the Evaluation of Headache

Don’t do imaging for uncomplicated headache. The “Choosing Wisely” campaign of the American Board of Internal Medicine
Foundation states that “imaging headache patients absent specific risk factors for structural disease is not likely to change
management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention
are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur.
Also, incidental findings lead to additional medical procedures and expenses that do not improve patient wellbeing.”
The American Academy of Neurology and the U.S. Headache Consortium guidelines recommend neuroimaging only
if:

1. The patient has migraine with atypical headache patterns or unexplained abnormalities on neurological examination
2. The patient is at higher risk of a significant abnormality including:
…a. Patients with associated head trauma
…b. New or changing headache over the age of 50
…c. New or changing headaches in those less than 6 years old
3. The results of the study would alter the management of the headache
Symptoms that increase the odds of positive neuroimaging results include:

Rapidly increasing frequency of headache
Abrupt onset of severe headache
Marked change in headache pattern
A history of poor coordination, focal neurologic signs or symptoms, and a headache that awakens the patient from sleep.
A headache that is worsened with use of Valsalva’s maneuver
Persistent headache following head trauma
New onset of headache in a person age 35 or over
History of cancer or HIV

Clinical Reasoning

Defining Characteristics of Primary Headaches

Migraine Tension type Cluster

Severity of
pain Moderate to severe. Mild to moderate. Severe.

Associated
symptoms

Often occurs with nausea and vomiting,
photophobia, or hyperacusis. May occur
with aura.

May occur with
photophobia or
hyperacusis.

Associated with rhinorrhea, lacrimation, facial
sweating, miosis, eyelid edema, conjunctival
injection, and ptosis.

Quality of
pain Pulsating and can be unilateral.

Pressing, tightening,
and bilateral.

Severe unilateral orbital, periorbital, supraorbital, or
temporal pain.

Aggravating
factors Worsened with physical activity.

Typically not
worsened with
physical activity.

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Duration of
symptoms Last from 4-72 hours.

Last from 30
minutes to 7 days. Last 15-180 minutes.

Number of
episodes 5 episodes needed for diagnosis.

10 episodes needed
for diagnosis. 5 episodes needed for diagnosis.

Screening for Anxiety and Depression

The two questions you asked are a screening tool for anxiety in the primary care setting known as the GAD-2. There is a
similar screening tool for depression known as the PHQ-2.
GAD-2

Over the last two weeks, how often have you been bothered by the
following problems?

Not at
all

Several
days

Nearly half the
days

Nearly every
day

Feeling nervous, anxious, or on edge? 0 1 2 3

Not being able to stop or control worrying 0 1 2 3

(For office scoring, total score T = __ ___ + ___ + ___ )

A positive screening test is a score > 2 points.
PHQ-2

Over the last two weeks, how often have you been bothered by
the following problems?

Not at
all

Several
days

More than one-half
the days

Nearly every
day

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

A negative response to both questions is considered a negative result for depression.
A positive response to either question in the PHQ-2 or the GAD-2 is highly sensitive for either depression or anxiety, respectively.
However, neither test is very specific .
If a patient has a positive response to one of the questions, a more comprehensive screening tool, the PHQ-9 or the GAD-7, should
be administered.
These longer questionnaires are more specific in identifying depression or anxiety.

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric
Publishing; 2013.

Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache. 2010;50(8):1366-70.

Bickley LS. Bates Guide to Physical Examination and History Taking. 10th edition. Philadelphia: Wolters Kluwer/Lippincott Williams &
Williams; 2009.

CDC. Centers for Disease Control and Prevention. Violence Prevention. Coping With Stress.
https://www.cdc.gov/violenceprevention/about/copingwith-stresstips.html. Reviewed November 25, 2020. Accessed February 10,
2021.

Diener HC, Holle D, Dodick D. Treatment of chronic migraine. Curr Pain Headache Rep. 2011;15(1):64-9.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep.
2016;65(1):1-49. Published 2016 Mar 18.

Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatr Dis Treat. 2013;9:709-20.

Expert Panel on Neurologic Imaging, Whitehead MT, Cardenas AM, et al. ACR Appropriateness Criteria® Headache. J Am Coll Radiol.
2019;16(11S):S364-S77.

Hainer BL, Matheson EM. Approach to acute headache in adults. Am Fam Physician. 2013;87(10):682-7.

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders,
3rd edition. Cephalalgia. 2018;38(1):1-211.

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International Headache Society. 2021. IHS Classification ICHD-3. Migraine. https://ichd-3.org/1-migraine/. Accessed February 4, 2021.

International Headache Society. 2021. IHS Classification ICHD-3. Tension-type headache (TTH). https://ichd-3.org/2-tension-type-
headache/. Accessed February 4, 2021.

Jackman RP, Purvis JM, Mallett BS. Chronic nonmalignant pain in primary care. Am Fam Physician. 2008;78(10):1155-62.

Kristoffersen ES, Lundqvist C. Medication-overuse headache: a review. J Pain Res. 2014;7:367-78. Published 2014 Jun 26.

Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care.
2003;41(11):1284-92.

Locke AB, Kirst N, Shultz CG. Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam
Physician. 2015;91(9):617-24.

Maurer DM, Raymond TJ, Davis BN. Depression: Screening and Diagnosis. Am Fam Physician. 2018;98(8):508-15.

Mayans L, Walling A. Acute Migraine Headache: Treatment Strategies. Am Fam Physician. 2018;97(4):243-51.

Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006;73(1):72-8.

Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine
prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American
Headache Society. Neurology. 2012;78(17):1337-45.

Work Group on Substance Use Disorders, Kleber HD, Weiss RD, et al. Treatment of patients with substance use disorders, second
edition. American Psychiatric Association. Am J Psychiatry. 2006;163(8 Suppl):5-82.

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Internal Medicine 18: 75-year-old male with memory
problems
User: Ralph Marrero
Email: [email protected]
Date: March 9, 2022 8:50 PM

Learning Objectives

The student should be able to:

Describe typical changes in each organ system that occur as part of the normal aging process.
Perform a functional status assessment of the geriatric patient.
Identify risk factors for falls in an older adult patient.
Recognize the presentation of each type of urinary incontinence.
Differentiate among the subtypes of major neurocognitive disorder and their associated findings.
Propose lab work to evaluate for reversible causes of major neurocognitive disorder.
Participate in discussing basic issues regarding advance directives with the patients and their families.

Knowledge

Initial Approach to Evaluation of Memory Problems

1. Focused history
2. Cognitive assessment
3. Functional evaluation

You go to the exam room and introduce yourself to Mr. Caldwell and his daughter, Kathy.
Focused History

Mr. Caldwell admits to occasional memory issues, such as misplacing keys or forgetting items at the grocery store, but he reports
no concerns with long-term memory recall, such as his anniversary or grandchildren’s names. He also reports difficulty with
higher-level tasks such as balancing his checkbook and managing his medications, both of which his daughter now manages.

How Aging Affects Organ Systems

Learn more about major changes that occur in each organ system with aging.

Organ System Changes with Aging Functional Implications

Cardiovascular

Increased pulse pressure (increased systolic pressure with stable
diastolic pressure).

Decreased arterial compliance.

Decreased baroreceptor sensitivity.

Increased pulse pressure is
usually not harmful.

Other changes can lead to
increased propensity for
orthostatic hypotension.

Gastrointestinal

Multiple medications, decreased physical activity, and
concomitant illness can contribute to constipation, which is
common, although not “normal” in elderly patients.

Weakening of internal and external anal sphincters.

May lead to frequent physician
visits and use of OTC
medications, including laxatives.

Incontinence of bowels.

Hepatic
Reduced hepatic blood flow.

Impaired hepatic microcirculation.

Impaired detoxification.

Impaired metabolism of many
medications.

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Genitourinary

Women

Atrophy of labia, vagina, uterus, and ovaries.

Weakening of pelvic floor muscles, especially in women who
have given birth.

Men

Enlarged prostate (benign prostatic hypertrophy (BPH)).

Women

Decreased lubrication and
possible dyspareunia.

Urinary incontinence.

Men

Urinary incontinence or urgency,
dribbling due to BPH.

Renal

Decreased renal salt retention/regulation.

Decreased ADH secretion at night.

Decline in renal function.

Decreased ability to retain salt
can predispose patients to
orthostatic hypotension.

Increased nocturia.

Changes in medication
metabolism and excretion.

Musculoskeletal

Increase in body fat with decrease in lean mass.

Increase in joint deformities and stiffness. Loss of flexibility.

Decreased bone mineral density.

Stable weight/BMI does not imply
stable body composition.

Risk of osteoarthritis.

Risk of osteoporosis and
fractures.

Imbalance, gait difficulty, and
risk of falls.

Neurologic

Mild loss of short-term memory.

Mild decrease in vibratory sensation.

Mild muscle atrophy.

Memory loss has no major effects
if a result of normal aging.

Decreased vibratory sense can
predispose to loss of balance.

Muscle atrophy not usually
clinically perceptible.

Psychiatric
Decreased mobility, increased dependence on others, and other
life changes, while not “normal,” can contribute to psychiatric
illness.

Depression, while not a
consequence of “normal” aging,
is common among older patients.

Respiratory

Decreased chest wall compliance.

Decreased static recoil in lung.

Decreased respiratory muscle strength.

No major change in gas
exchange at rest or with exertion.

Possible decreased ability to
compensate in setting of acute
illness.

Skin
Decreased skin thickness.

Decreased elasticity of skin.

Increased susceptibility to
bruising.

Wrinkles.

Immune
Decreased innate immunity.

Dysregulation of immune responses.
Greater morbidity with infections.

Ophthalmologic
Decreased tear production.

Development of cataracts, glaucoma, and macular degeneration.

Chronic dry eye.

Loss of vision.

Otological
Loss of hair cells.

Cerumen accumulation.
Hearing loss.

Defining Cognition

The DSM-5 defines six domains of cognition. These domains and associated symptoms in patients with cognitive impairments are
outlined below:

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Cognitive Domain Symptoms and Observations

Complex attention
Normal tasks take longer, are harder to complete, and a person is distracted if multiple stimuli are
present.

Work requires rechecking.

Executive function

Difficulty in completing multistep tasks like cooking.

Reduced interest in activities.

Social outings are less enjoyable and seem more taxing.

Language

Word-finding difficulty.

Mispronouncing words.

Problems understanding written and spoken communication.

Learning and
memory

Forgetful of information or requiring frequent repetition.

Difficulty recalling events.

Forgetting to complete tasks like paying bills or requiring to-do lists to complete tasks.

Perceptual-motor
Gets lost in familiar surroundings.

Difficulty using tools or technology they are familiar with.

Social cognition

Impaired judgment.

Loss of empathy.

Abnormal or inappropriate behaviors.

Lack of interest in social activities.

Classifying Disorders of Cognition

The DSM-5 also updated the diagnostic terminology for cognitive impairment and dementia. Dementia is now housed under the
term, “major neurocognitive disorder.” Mild cognitive impairment is now termed, “mild neurocognitive disorder.” It is important to
note that the term major neurocognitive disorder encompasses many subtypes some that are subtypes of dementia, such as Lewy
body dementia, Alzheimer disease, vascular dementia/disease, etc., and also encompasses neurocognitive impairment related to
other conditions such as HIV, prion disease, Huntington disease, etc.
The diagnostic criteria for neurocognitive disorders are noted in the table below:

Major Neurocognitive Disorder Mild Neurocognitive Disorder

Significant decline in at least one cognitive domain as
determined by concerns noted by patient or
family/friend AND objective neurocognitive
assessments.

Interference with instrumental activities of daily living.

Cannot occur only in episodes of delirium.

Cannot be attributed to another psychiatric or mental
disorder.

Can be classified by one or more of the DSM-5
subtypes.

Mild cognitive decline in at least one cognitive domain as
determined by concerns noted by patient or family/friend AND
objective neurocognitive assessments.

Does not interfere with instrumental activities of daily living,
but they may take longer or require more effort through the
use of compensatory strategies and accommodations.

Screening Tools for Cognitive Impairment

Several brief tools exist for screening for cognitive impairment in the primary care setting. The Mini-Mental State Exam (MMSE),
which has been the diagnostic standard, is about 90% sensitive and 90% specific. It provides a score of 0-24 that could help
categorize the severity of a patient’s cognitive impairment. It is patent-protected, therefore some clinicians choose to use other,
freely available tools.

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One commonly used brief dementia screening tools is called the Mini-Cog. It is a test of three-item recall and clock drawing. You
can review the Mini-Cog form and scoring algorithm at the following link: http://mini-cog.com/wp-
content/uploads/2015/12/Universal-Mini-Cog-Form-011916.pdf (PDF).
Perhaps the best screening tool used is the Montreal Cognitive Assessment (MoCA). It is available free online and tests many
domains of cognition: http://www.mocatest.org/pdf_files/test/MoCA-Test-English_7_1.pdf (PDF).
This is a one page diagnostic test that takes about ten minutes to administer. It assesses executive function, naming, memory,
attention, language, abstractions, delayed recall, and orientation. The assessment is pictured below:

Montreal Cognitive Assessment
Patients can score up to 30 points. A score of 26 or greater is considered normal, 18-25 suggests mild impairment, 10-17 suggests
moderate impairment, and <10 suggests severe impairment.

Major Neurocognitive Disorder

The main subtypes of major neurocognitive impairment that classify as forms of dementia are as follows:
Alzheimer disease
Vascular disease/dementia
Lewy body dementia
Frontotemporal lobar degeneration

The additional subtypes are as follows:
Parkinson disease
Traumatic brain injury

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HIV infection
Prion disease
Huntington disease
Substance/medication induced
Other medical condition
Multiple etiologies

Prevalence

The DSM-5 estimates that the prevalence of Major Neurocognitive Disorder (which they use congruently with the term dementia)
varies across ages.
The prevalence of Major Neurocognitive Disorder is approximately 1-2% at age 65 and as high as 30% by age 85.
The prevalence of Mild Neurocognitive Disorder ranges from 2-10% at age 65 and from 5-25% by age 85.
Development and Course:

When due to neurodegenerative conditions like the common forms of dementia, the onset of symptoms is usually insidious and
gradual. Later in life it may be difficult to distinguish normal aging from prodromal phases of mild neurocognitive disorder. In
addition, given the high prevalence of other medical conditions in older individuals, the symptoms of these conditions often go
unnoticed or are overlooked due to the coexisting problems.
Risk Factors:

Age is the most common risk factor since increased age leads to greater neurodegenerative and cerebrovascular disease. Females
are also more prone to developing these conditions, although this may be due to their overall increased lifespan.

Functional Assessment: Activities of Daily Living

Activities of daily living (ADLs) are divided into two subcategories: basic and instrumental (IADLs)

Basic

eating

bathing and toileting

ambulating

dressing

maintaining personal hygiene

Instrumental

managing finances

managing transportation

preparing food

shopping

managing medications

managing communication
housekeeping

The patient’s family members may be very helpful in providing this information.

Avoid Polypharmacy, Especially in Older Adults

Review the medication list at every visit to ensure the most appropriate and least number of medications are being prescribed.
Polypharmacy is a common problem among older patients and can result in avoidable adverse drug events.
Don’t forget to include over-the-counter medications, supplements, and herbal remedies.

Common Issues to Assess in the Geriatric Patient: Fall Risk, Hearing and Vision, Frailty, and Urinary
Incontinence

Fall Risk

Learn more about recommendations for prevention of falls in older patients.
Screening for Hearing and Vision Deficits

While hearing and vision impairment may contribute to fall risk in older patients, routine hearing and visual acuity screening in
people over 50 years old is not currently recommended by the U.S. Preventive Services Task Force.
Hearing: In 2012 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of screening
for hearing loss in this population. (Grade I statement.)

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Vision: In 2016 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of visual acuity
screening in the improvement of outcomes in older adults. (Grade I statement.)

Fall Risk Factors

The more risk factors a patient accumulates, the more likely he or she is to fall.
According to the CDC, risk factors for falls can be divided into​ Intrinsic and Extrinsic categories as outlined below:

Intrinsic Factors Extrinsic Factors

Advanced age
Previous falls
Muscle weakness
Gait and balance problems
Poor vision and hearing
Postural hypotension
Chronic conditions including arthritis, stroke, incontinence, diabetes,
Parkinson
Cognitive impairment
Fear of falling

Lack of stair handrails
Poor stair design
Lack of bathroom grab bars
Dim lighting or glare
Obstacles and tripping hazards
Slippery or uneven surfaces
Psychoactive medications
Improper use of assistive device

There are effective community and clinical interventions for some of these risk factors that may reduce falls.

Urinary Incontinence

Assessment

Make sure to assess for this during your interviews, because patients often will not volunteer this information. Incontinence is a
common problem in older patients and is often multifactorial. Additionally, this may increase a patient’s risk for falls as they must
often get up at night.
A symptom diary can be very helpful in assessing the severity of incontinence. This involves tracking when incontinence occurs
and whether it seems to be triggered by specific times of day, beverages, medications, or other circumstances.
Four types of incontinence:

Symptoms Cause Treatment

Stress
Incontinence

More common in women than in men. Small
urine leakage occurs with coughing, laughing,
exercise, or other maneuvers that increase
intra-abdominal pressure.

Pelvic muscle weakness (i.e., from multiple
childbirths or chronic pressure from obesity
or high impact activities) or vaginal atrophy
due to menopause.

Strengthening the
muscles of the pelvic
floor with Kegel
exercises.

Urge
Incontinence

Presents as a sudden need to void, and
patients describe “almost making it” to the
bathroom. They typically leak larger amounts
of urine.

Dysfunction of the detrusor muscle, either
due to medications, stroke, or idiopathic
overactivity.

Scheduled voiding
and other behavioral
exercises.

Overflow
Incontinence

Most common type of incontinence in men.
Presents with dribbling, hesitancy, and leakage
of small volumes of urine.

Mechanical bladder outlet obstruction, often
benign prostatic hypertrophy (BPH) in men
or fibroids or pelvic organ prolapse in
women.

Surgery or
medications to
relieve the
obstruction.

Functional
Incontinence

Occurs as a result of a person’s inability to get
to a bathroom for any reason.

This can occur in physically or mentally
handicapped patients, including patients
with cognitive impairment.

Treated with
environmental
modifications, such
as bedside
commodes.

It is also important to note that men and women can have symptoms from several of these categories. Patients with symptoms of
both stress and urge incontinence are described as having mixed incontinence.

Assessing Geriatric Syndromes on Physical Exam

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Cognitive
Impairment

Mini mental state exam or other neurocognitive assessment

Complete neurological exam

Depression screening

Falls

Joint exam for abnormalities

Cardiovascular exam, including examination for bruits and orthostatic vital signs

Complete neurologic exam, especially focused on proprioception and strength

Walking speed (normal is 15 feet in < 7 seconds)

Urinary incontinence
Men: Prostate exam to assess for hypertrophy or nodules

Women: Complete pelvic exam to assess for atrophy, pelvic floor muscle weakness or pelvic
masses

“Get Up and Go” Test

Instructions for patient:

Get up (without armrests, if possible), stand still for a moment, walk forward 10 feet, turn around and walk back to the chair, turn
and be seated.
Assessment:

A normal time ranges from 8-12 seconds. Patients who take greater than 14 seconds to complete this are at higher risk for falls.
In addition, the assessor should make note of sitting balance, transfers from sitting to standing, pace and stability of walking, and
ability to turn without staggering.

Major Neurocognitive Disorder (Dementia) Subtypes

Subtypes of Major Neurocognitive Disorder.

Dementia Type Features Cause

Alzheimer
Dementia (AD)

Accounts for 75% of cases of major
neurocognitive disorder
Gradual memory loss
Specific difficulties with short-term memory and
retaining new information
May have family history of AD
Clinical diagnosis is 90% accurate
Considered terminal illness; life expectancy after
diagnosis is about six years

Amyloid plaques and neurofibrillary tangles in
the brain
Pathology confirmed at autopsy

Lewy Body
Dementia (LBD)

Fluctuations in memory and cognition
Visual hallucinations
Parkinsonism (resting tremor, bradykinesia,
rigidity and postural instability)

Deposition of Lewy bodies in the nuclei of
cerebral cortical neurons

Vascular
Dementia

Step-wise deterioration in memory
Patients often have other vascular risk factors
(diabetes, HTN, smoking, etc.)
Often see evidence of previous stroke on exam
and/or imaging
Heterogenous presentation due to variability in
extent, severity, number and location of lesions

Due to damage from discrete vascular events,
such as strokes and TIAs

Frontotemporal
Dementia (FTD)

Dementia associated with behavior and
personality changes
Language impairment
Common cause of major neurocognitive disorder
in patients younger than 65

Group of disorders with various causes, but all
involve atrophy of frontal and temporal lobes

* Recall from prior that other subtypes of major neurocognitive disorder include Parkinson’s disease, Huntington’s disease,
traumatic brain injury, HIV infection, prion disease, substance/medication use, and cases of multiple etiologies.

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Allied Health Professionals

Occupational therapist – healthcare practitioner who evaluates and treats a patient’s daily living skills and develops a
treatment plan individualized for the patient. Training requirements include graduate degrees of a Masters in Occupational
Therapy or Doctorate of Occupational Therapy.
Physical therapist – healthcare practitioner who evaluates a patient’s mobility and functional status and develops a
treatment plan individualized to the patient. Training requirements include graduate degrees in a Masters in Physical
Therapy or Doctorate of Physical Therapy.

Medications for Alzheimer’s Dementia

Although there are no medications to cure Alzheimer disease or other forms of dementia, there are several medications that may
be used to help slow the progression of cognitive and functional decline.
Amyloid beta-directed monoclonal antibody (Aducanumab)

Indications: Approved for patients with mild cognitive impairment or mild dementia in those with evidence of amyloid beta
plaques
Effectiveness: Unknown, Phase 4 confirmatory trial of clinical benefit will be completed in 2030
Common side effects: Brain swelling and tiny brain bleeds (typically asymptomatic), headaches, falls, diarrhea, and
confusion
Cost: $56,000 per year (2021 costs)

Cholinesterase inhibitors (ex: donepezil, rivastigmine, and galantamine)
Indications: Used for patients with dementia of any severity—mild, moderate, or severe
Effectiveness: There may be small, beneficial effects in cognitive and functional performance, though the clinical
significance of these effects is unclear
Common side effects: Nausea, vomiting, and diarrhea, but these usually get better if people keep taking the medications

Memantine

Indications: Moderate or severe Alzheimer’s dementia
Effectiveness: Studies have shown small improvements in cognition but the clinical significance is unclear
Common side effects: Dizziness, possibility of confusion and hallucinations

There is some research that demonstrates the potential for cognitive and functional performance may be better if memantine and
a cholinesterase inhibitor are used together, but once again the clinical significance remains unclear.
These medications may all cost more than $150 per month if paid for out of pocket. However, with insurance coverage the cost is
much lower.
For each of these medications, treatment decisions should be individualized and consider drug tolerability and cost.
Other

There are ongoing studies on various supplements including vitamins for treatment or prevention of dementia. So far, the
available research has been disappointing and no supplement or vitamin can be recommended at this time based on the
studies to date.

Advance Directives

Clinicians should have a discussion with their patients regarding advance directives.
An advance directive is a legal document that details how a patient wishes to be cared for and treated if he or she is unable to
make decisions for him or herself. It may include information about what treatments or interventions the patient would or would
not want. Patients should be encouraged to be as specific as possible so as to avoid confusion. For example, patients often request
no “heroic measures”, but this can have different meanings to different people.
When discussing an advance directive with a patient, it may also be a good idea to discuss other legal documents like a living will
and a Do Not Resuscitate order.
Advance directive forms are usually available at doctors’ offices, but they can also be accessed online and through local and state
health departments.
After completion, the patient should be encouraged to share a copy with his or her physician, family members, and to retain a
copy for his or her personal medical records. Finally, patients should be reassured that if they change their mind, they can alter the
document at any time.
Additional resources for patients can be found through the National Institute on Aging at the following link:
https://www.nia.nih.gov/health/legal-and-financial-planning-people-alzheimers

Clinical Skills

Delivering Bad News

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The SPIKES protocol can be used as a method to deliver bad news. Although initially applied for oncologic patients, this protocol
can be used in many situations. It is a six-step​ protocol outlined as follows:
Step 1: Set-up the Interview

Before meeting with the patient, you should review your plan for telling the patient the news and plan for how he or she may
respond and what questions he or she may ask. You should arrange for a private setting, be sure to involve family members if the
patient chooses, and be sure that all parties involved are in a relaxed sitting position. It is very important to establish a connection
with the patient, either through good eye contact or even touching the arm or holding the patient’s hand if he or she is
comfortable with this.
Step 2: Assess the Patient’s Perception

This is a reminder to ask the patient his or her understanding of the present medical situation to gauge his or her knowledge thus
far. You may ask patients questions like “What have you been told thus far?” or “Do you understand what the laboratory and
imaging tests were done for?”. Having this understanding prior to delivering the bad news will help you correct any incorrect
information and tailor how you present the news.
Step 3: Obtaining the Patient’s Invitation

It is important to recognize that some patients may want to know everything and others may not want to know all the details they
may be presented with. It is requisite to ask patients their preferences before delivering bad news. An example question is “Would
you like me to give you all the information about the tests or simply talk about the diagnosis and what steps may be taken going
forward?” In addition due to personal or cultural issues, this may allow the patient the opportunity to ask that the information be
delivered to a family member instead of him or herself.
Step 4: Giving Knowledge and Information to the Patient

It is helpful to prepare the patient that he or she is about to receive bad news. You may say something like “Unfortunately, I have
some bad news to tell you”. This allows them to prepare and may lessen the shock of the news to come. Be sure to deliver the
news in simple language that is free of medical jargon and easy to understand. Avoid excessive bluntness as in the example of
“You will die in a year unless you receive treatment”. Provide the information in small pieces to aid in understanding. When the
prognosis is poor it is better to still focus on ways to help the patient, even if it is through good pain control and symptom relief if
not treatment or cure.
Step 5: Addressing the Patient’s Emotions with Empathic Responses

Patients may respond with shock, isolation, grief, or anger. An empathic response to these emotions is critical. You should observe
for signs of these emotions and identify the emotion and the reason for it which is usually related to the bad news. Allow the
patient time to experience the emotion even if it feels uncomfortable to you. The patient may be silent or may express his or her
feelings. Demonstrate your understanding through an empathic response such as “I am so sorry to have had to share the news
regarding this new diagnosis; I know this is not what you wanted to hear.”
Step 6: Strategy and Summary

It is important to have a clear plan for further treatment and care. This provides reassurance and often relief of some anxiety
associated with the diagnosis. Presenting treatment options to patients also helps promote shared-decision making and is a way to
respect their wishes. In addition, it is important to explore a patient’s hopes and expectations in order to both be supportive and
realistic when discussing both treatment and prognosis.

Management

Reducing Fall Risk

Adjust the number and type of medications . The risks and benefits of any medication should be reviewed and
nonpharmacologic alternatives considered.
Educate patients about cognitive impairment as a risk factor for falls.
Address home hazards , especially for patients who have fallen in the past. This includes removing slippery rugs,
improving lighting and adding bars for stabilization in the bathroom.
Physical therapy is beneficial for pain related to osteoarthritis and may help improve strength and balance.

Medicare Coverage of Home Hazard Assessment And Physical Therapy

Patients who are homebound (do not have a car or access to public transportation), and are on Medicare will receive coverage for
home physical therapy and home hazard-assessment and modification. Other patients may need to come to the office to receive
physical therapy. If patients do not have insurance that covers home-hazard modification, physicians or other clinic staff can teach
patients and give them printed educational materials.

Medication Side Effects in Older Adults

All medications can have unwanted side effects, but older patients are at higher risk for many reasons.
1. Older adult patients are often on multiple medications that interact.
2. With aging, there are physiologic changes affecting pharmacokinetics and pharmacodynamics.
3. Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications.
4. Drug clearance may be decreased by an age-associated decline in renal function.

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5. As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and patients may
require lower doses of drugs.

It’s important to consider all of these factors before prescribing a medication to an older patient. In particular, reviewing the
appropriateness and indications for opioids, anxiolytics (including lorazepam), and any medications with anticholinergic properties
should be done at each visit.

Major Neurocognitive Disorder—Safety & End-Of-Life Planning

Early in the course of mild or major neurocognitive disorder, it is important for clinicians to help patients and families keep the
patient safe in the present while they plan for the future. Many patients early in the course of this disorder have difficulty with
IADLs, such as managing finances and driving, so discussion of how to manage these problems is warranted.
1. Estate and end-of-life care planning

Patients should be encouraged to appoint a durable power of attorney (DPOA) for healthcare. A DPOA for healthcare is usually a
trusted family member or friend who will make healthcare-related decisions for the patient when he or she is no longer able to do
so. The patient should also be encouraged to complete a living will, which specifies what types of medical interventions he would
want at the end of life or if he or she is unable to speak for himself or herself. Dysphagia is a common disorder in major
neurocognitive disorder and addressing whether tube feedings should be implemented is a part of end-of-life planning.
2. Driving safety

Clinicians should discuss driving safety with any patient who has an impairment in memory or vision as well as for someone who
has seizures or other episodes of loss of consciousness that may impair his or her ability to drive. States vary in their laws about
physicians’ obligation to report potentially impaired drivers to the Department of Motor Vehicles, but it is always reasonable to
advise patients not to drive if you think that is the safest course.
3. A Medical Alert ID system

Many companies offer varying levels of products that can help identify and return patients at risk for wandering. These can be as
simple as an inexpensive bracelet or there are systems with sophisticated electronic surveillance.

Studies

Evaluating For Reversible Causes Of Major Neurocognitive Disorder

Depression Screening:

All patients with concern for cognitive impairment should be screened for depression. This condition is common in older adults and
may be mistaken for cognitive impairment. There are several validated screening tools like the Patient Health Questionnaire (PHQ)
2 or 9 and the Geriatric Depression Scale (GDS).
Laboratory Testing:

The American Academy of Neurology (AAN) recommends screening for B12 deficiency with a B12 level and a complete blood
count as well as screening for hypothyroidism with a TSH level. Other potential tests are detailed below.
TSH

Hypothyroid or hyperthyroid conditions can contribute to cognitive impairment.
Vitamin B12 and Complete Blood Count

While both folate and B12 deficiencies can cause macrocytic anemia, only B12 deficiency can cause posterior column disease and
cognitive impairment. As part of the evaluation for vitamin B12 deficiency,​ the AAN also recommends a complete blood count.
Complete Metabolic Panel

While some metabolic abnormalities can lead to memory impairment there is no clear evidence that this test is useful or cost-
effective so it should not be routinely sent. Examples of electrolyte issues that could cause cognitive symptoms include:
Hypercalcemia leading to confusion, psychiatric disturbances, and memory loss, particularly in older patients, and hyponatremia
leading to mental status changes in older adults.
Rapid Plasma Reagin (RPR) and HIV

Screening for these conditions is not routinely recommended unless the patient is at high risk due to sexual history or travel.
Thiamine (Vitamin B1)

In patients with a history of alcohol use disorder or those who are not receiving adequate nutrition, it is also reasonable to
consider thiamine deficiency. In the U.S., thiamine deficiency is most commonly seen in patients with alcohol use disorder and
typically causes Wernicke-Korsakoff syndrome. Wernicke syndrome is characterized by nystagmus or other ocular abnormalities,
gait abnormalities, and memory loss with other mental status changes. It develops over days. Korsakoff syndrome includes
retrograde and anterograde amnesia. These syndromes are part of a spectrum of disorders.
Neuroimaging

The question of whether to obtain imaging, such as a head CT or MRI in the workup of dementia is also controversial. The AAN
recommends a non-contrast head CT or MRI as part of the routine workup. In theory, this imaging would help exclude other
contributing pathologies such as stroke, subdural hematoma, normal pressure hydrocephalus, and an intracranial mass.

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Other governing bodies recommend this imaging only in the presence of unusual or atypical findings.

References

American Academy of Family Physicians. Information from our family doctor. What you should know about advanced directives. Am
Fam Physician. 2012 Mar 1;85(5):467. https://www.aafp.org/afp/2012/0301/p467.html.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES – A Six-step protocol for delivering bad news: application to the
patient with cancer. Oncologist. 2000;5(4):302-311.

Clinical Summary: Hearing Loss in Older Adults: Screening. US Preventive Services Task Force.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hearing-loss-in-older-adults-screening . Accessed November
15, 2021.

Epperly T, Dunay MA, Boice JL. Alzheimer Disease: Pharmacologic and Nonpharmacologic Therapies for Cognitive and Functional
Symptoms. Am Fam Physician. 2017;95(12):771-778.

Fact Sheet: Risk Factors for Falls. Center for Disease Control and Prevention. https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-
RiskFactors-508.pdf. (.pdf 172 KB) Accessed November 15, 2021.

Final Update Summary: Impaired Visual Acuity in Older Adults: Screening. US Preventive Services Task Force.
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/impaired-visual-acuity-in-older-adults-
screening?ds=1&s=visi. Accessed November 15, 2021.

Maurer DM. Screening for depression. Am Fam Physician. 2012;85(2):139-144.

McCleery J, Abraham RP, Denton DA, et al. Vitamin and mineral supplementation for preventing dementia or delaying cognitive
decline in people with mild cognitive impairment. Cochrane Database Syst Rev. 2018 Nov 1;11:CD011905.

Simmons BB, Hartmann B, Dejoseph D. Evaluation of suspected dementia. Am Fam Physician. 2011;84(8):895-902.

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