Episode 49 - Dementia in Primary Care - a podcast by Rio Bravo Family Medicine Residency Program

Episode 49: Dementia in Primary Care. 

Dr Ryan Townley explains what to do when a patient reports “memory problems”, including labs, imaging, and more. Question of the month: Fever and Cough.

Introduction: Dementia
By Hector Arreaza, MD

Today is April 26, 2021.

Dementia is an umbrella term that includes many conditions that have in common a cognitive decline affecting ADLs. It is an acquired condition that presents after the brain is fully developed. As our population ages, the topic of dementia has become more pertinent. 

Recently we had an introduction about the link between poor sleep and dementia, episode 42. The next two episodes will be about dementia.

Today we would like to discuss further this relevant topic. We talked with Dr Ryan Townley, who is an assistant professor in the Department of Neurology at the University of Kansas Medical Center, and the director of the Cognitive and Behavioral Neurology Fellowship. 

We will discuss dementia screening, how to evaluate our patients who report “memory problems”, including additional testing and imaging, when to send to a neurologist or neuropsychologist, and some things we can do for prevention of dementia. This episode is not intended to be a comprehensive lecture about dementia, but it may motivate you to keep learning about this topic. I hope you enjoy it.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

 

Question of the Month
Written by Hector Arreaza, MD, read by Terrance McGill, MD

This is a 69-yo male patient, with controlled hypertension. He comes to an urgent care clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. He does NOT smoke tobacco, but smokes recreational marijuana once a month, and drinks 1-2 beers a week. He goes to the doctor once a year for check-ups. He takes benazepril 10 mg daily for his hypertension. He does not believe in vaccines and his last shot was a tetanus shot 5 years ago. No surgical history. He retired as an accountant 5 years ago. Vital signs are normal except for tachycardia of 110 (his baseline is 85) and temperature of 101.5 F (38.6 C). He has bibasilar crackles on auscultation. You perform labs in clinic and he has a white count of 13.5, and a chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

Let’s repeat the question: What are your top 3 differential diagnoses and what is the acute management of a 69-year-old male, non-smoker, who has fever, cough, shortness of breath, tachycardia, bibasilar crackles, elevated WBCs, a right lower lobe consolidation, and a negative rapid COVID-19 test?

Send us your answer before May 7, 2021, to rbresidency@clinicasierravista.org and the best answer will win a prize!

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Dementia in Primary Care. 
With Ryan Townley, MD, and Hector Arreaza, MD.

Ryan Townley, M.D., is an assistant professor in the Department of Neurology at the University of Kansas Medical Center and is the director of the Cognitive and Behavioral Neurology Fellowship. He is also the Alzheimer's Clinical Trials Consortium Associate Director and Primary Investigator at the University of Kansas Alzheimer's Disease Center. Dr. Townley is certified by the American Board of Psychiatry and Neurology. He joined the KU Medical Center faculty in August 2019. 

Prior to medical school, he earned a bachelor of science in neurobiology from the University of Kansas. He graduated from the University of Kansas School of Medicine, where he earned the 2013 Dewey K. Ziegler Award for Excellence in Neurology presented by the KU Department of Neurology and was honored with the American Academy of Neurology's Outstanding Neurology Medical Student Award. He then completed his neurology residency, an internal medicine internship, and a two-year cognitive behavioral fellowship at the Mayo Clinic School of Graduate Medical Education. 

He is the author of many publications and has presented more than two dozen lectures and posters nationally and around the world. His clinical and research interests include atypical Alzheimer's diseases, normal pressure hydrocephalus, frontotemporal lobar degeneration and dementia with Lewy bodies. He also has interests in patient, resident and medical student education, and preventative health against neurodegenerative disease.

Questions discussed during this episode:

What to do when someone complains of "memory problems" in primary care?

When should a primary care doctor refer a patient to Neurology for evaluation of dementia?

Dementia vs Normal aging. 

What are the types of dementia?

When should a primary care doctor start medications for Alzheimer's disease? 

First-line pharmacologic treatment of Alzheimer's disease. 

Prevention of Alzheimer's disease: 

 

 

 

Resources mentioned in this episode:

AD8 Dementia Screening Interview: It is a tool given to an informant (ideally) or to the patient. It can be self-administered or administered by someone in clinic or by phone.

AD8 in English: https://www.alz.org/media/Documents/ad8-dementia-screening.pdf

AD8 in Spanish: https://championsforhealth.org/wp-content/uploads/2017/01/AD8-Screening-Spanish.pdf

 

Mini-Cog: It is a 3-minute instrument that can increase detection of cognitive impairment in older adults. It can be used effectively after brief training in both healthcare and community settings. It consists of two components, a 3-item recall test for memory and a simply scored clock drawing test. It does not substitute for a complete diagnostic workup.

Mini-Cog in English: http://mini-cog.com/wp-content/uploads/2018/03/Standardized-English-Mini-Cog-1-19-16-EN_v1-low-1.pdf

Mini-Cog in Spanish: http://mini-cog.com/wp-content/uploads/2018/03/SPANISH-Mini-Cog.pdf

 

Montreal Cognitive Assessment (MoCA): Dementia screening tool, no longer free, it requires training and certification. Available in several languages: https://www.mocatest.org/

 

Saint Louis University Mental Status Examination (SLUMS): Screening tool for dementia, training advised and available for free, available in Epic.

Training video: https://www.youtube.com/watch?v=z4ctoWU-qzw

SLUMS in English: https://health.mo.gov/seniors/hcbs/hcbsmanual/pdf/4.00appendix8slumsform.pdf

SLUMS in Spanish: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/spanish-pr.pdf

 

Short Test of Mental Status, The University of Oklahoma Health Science Center, https://www.ouhsc.edu/age/Brief_Cog_Screen/documents/STMS.pdf

Dementia prevention, intervention, and care: 2020 report of the Lancet Commission, The Lancet, Vol 396, Issue 10248, P413-446, AUGUST 08, 2020. https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext

 

Dementia Update Course: July 23, 2021, and September 3, 2021. Register at: https://www.eeds.com/portal_live_events.aspx?ConferenceID=634196

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Conclusion.

Now we conclude our episode number 49 “Dementia in Primary Care”, Dr Ryan Townley explained different tools we have to assess patients with “memory problems” and explained some interesting concepts in the assessment of cognitive impairment. Talking about dementia, don’t forget to answer our question of the month. Send us your top 3 differential diagnosis and acute management of a 69-year-old male with fever, cough, tachycardia, and right lower lobe consolidation. Send your answer before May 7, 2021, and win a prize! Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Ryan Townley, Ariana Lundquist, and Terrance McGill. Audio edition: Suraj Amrutia. See you next week! 

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