MTC 6/24: Take your VITAMINS to ward off dementia!

Dr. Priya Sharma, one of our phenomenal senior residents, presented a “hot case” this morning: a middle-aged man with rapidly progressive dementia characterized by language deficits, behavioral changes, paranoia/obsessions, and tremors that evolved over the course of several months. After a initial workup ruled out reversible medical etiologies, the patient was ultimately transferred to the Neurology service for further workup.

We were incredibly fortunate to have been joined by Dr. David Coughlin, our movement disorder specialist extraordinaire, who reviewed key historical features and exam findings while evaluating a rapidly progressive dementia syndrome. It is important to obtain collateral information, assess the patient’s psychosocial milieu, and rule out any contribution from delirium. The differential diagnosis for rapidly progressive dementia is quite broad and includes vascular, infectious, toxic-metabolic, autoimmune, malignant, iatrogenic, neurodegenerative, and systemic/structural/seizure-related causes. If initial laboratory and imaging studies fail to disclose an etiology, additional serum/CSF, advanced imaging, and electrographic studies should be considered.

Several studies are still outstanding for our patient. The working differential includes Creutzfeldt-Jakob disease, autoimmune encephalitis (e.g., limbic encephalitis, anti-LGI1 encephalitis), and an atypical presentation of frontotemporal dementia. We anticipate some of these studies will return in the next few weeks. Stay tuned for an update!

Thank you to Dr. David Coughlin and the Neurology team for participating in this multidisciplinary morning report and for taking wonderful care of this patient.

Medical Spanish Word of the Day: el cerebro = brain

12/30 VA MTC: Approach to memory impairment

Today, PGY-2 and RACE track star Alex Cours presented a case of a 66 year old woman with concerns for memory impairment. We took a thorough history, finding out she had a history of depression on two antidepressants, extensive supplement use, and regular marijuana use. We reviewed a diagnostic schema for memory impairment, discussed various screening tools for dementia, and diagnostic work-up and definition of dementia.

Clinical pearls:

  1. Not all memory impairment means dementia, or even mild cognitive impairment! Keep a wide differential to consider organic causes of memory impairment. Remember the three “D”s: delirium, dementia, and depression.
  2. Screening tools such as the mini-cog and MOCA may be positive when abnormal but are NOT diagnostic of dementia
  3. Screening should only be considered in those with “red flags” or concerns expressed either by individual or family

Grand Rounds – Geriatrics Chiefs Jean Guan & Shannon Devlin!

Our Chief Resident Grand Rounds series continued with two of our Geriatrics-fellowship bound (luckily for us, both at UCSD) chiefs Dr. Jean Guan & Dr. Shannon Devlin! Jean Guan – Aging in Place Why does this matter? Preventing a sense of loss of home and community as people age. Where is “home and community” for our older adults? Some are physical locations like senior apartments or retirement communities, but others are important services that allow patients to age-in-place (home health, adult day care, etc). Home and community can also be people! The average adult moves 3 times in the last 3 years of their life. Has important impacts on sense of community, can be tied to depression, increased financial burden and loss of personal possessions which can have an emotional impact. Those that live at home through the end of their life, has less acute hospitalizations and better control over chronic diseases. 79% of adults say they’d prefer to stay at home,

read more Grand Rounds – Geriatrics Chiefs Jean Guan & Shannon Devlin!

Friday School: Dementia! And Advanced Communication!

Today, we learned about dementia, how to disclose the diagnosis, and the challenges around this disease. This is HIGH YIELD stuff. Dementia is like the last frontier, where clinical acumen is necessary. We do not have one test that gives a slam dunk diagnosis. To start if you are thinking about dementia, you need to consider depression and delirium. According to Dr. Sladek, these are the three a”D”go’s! You also should think about the reversible causes. Reversible causes make up <1% of dementia but you can save someone’s life. Alzheimer’s disease is the most common, but there are other types of dementia you need to know. Check out this list:

Friday School: Ultrasound and Journal Fight Club

Friday school this week was the last session of our ultrasound curriculum for the academic year! HUGE shout-out to our amazing chief residents, Dr. Kevin Eng and Dr. Jack Temple, for putting together a phenomenal curriculum! Also thank you to Dr. Dan Sweeney and all of the other faculty and fellows for helping to facilitate all the sessions! The residents also had another journal fight club today. This week’s topic was the use of antipsychotics for the treatment of ICU delirium. We had great article presentations by Drs. Justin Chen, Jeremy Kong, Carlos Lago-Hernandez, and Karen Yun, followed by a lively debate between Drs. Jeremy Hirst and Bob Owens (co-author of the Mind-USA trial)!! Here are the articles we discussed: Quetiapine ICU Delirium CritCareMed 2010 Quetiapine vs Haloperidol Drug Design 2013 HOPE-ICU JAMA 2013 MIND-USA NEJM 2018 Our winner this time was Dr. Bob Owens – his award is that he gets to be Brad Pitt on the Journal Fight

read more Friday School: Ultrasound and Journal Fight Club

Grand Rounds – Dr. Mark Lachs – Elder Abuse

Defining the Problem: Elder abuse is difficult to define some terms commonly used include: 1) abuse – infliction of pain or mental anguish, 2) neglect – withholding food, medicines or care, 3) exploitation – improper control of finances or property, 4) restricted freedom or autonomy. It happens very commonly: Epidemiologic studies from New York show that 141 of 1,000 of older New Yorkers have experienced an elder abuse event since turning age 60. Gender is not a risk factor, nor is advanced age. ADL and cognitive impairment are risk factors, as it prevents victims from being able to report. Verified self-neglect or elder mistreatment is shown to be an independent risk factor for death (adjusted for age, and other comorbidities). Who are the abusers? Abusers can include: adult children, spouses, grandchildren, other relatives, paid or informal care providers, often dependent on victim for housing/finances. Forensic Geriatrics/Elder Abuse: Studies of normal bruising vs traumatic bruising have shown that patients undergoing abuse tend to bruise more

read more Grand Rounds – Dr. Mark Lachs – Elder Abuse

Friday School: Patient Encounters, Tai Chi, and Billing/Coding Game!

Today our residents and interns had the opportunity to practice revealing a diagnosis of dementia and their goals of care conversations with standardized patients in our professional development center. Thank you to all of our geriatrics, palliative care, primary care, and pulmonary critical care faculty who helped to facilitate the session! You can find the original article outlining the SPIKES framework to help with patient conversations here. Our residents also got a chance to learn and practice tai chi (outside, so they got some vitamin D also!) with tai chi master, Dr. Jesse Tsao. Remember this has been shown to decrease fall risk and chronic pain! They finished off the afternoon with a session on billing & coding with Dr. Deanna Hill – with a game created by our very own Dr. Joe Meserve!