Initial Behavioral Neurology Appointment Guide

Practical approach to behavioral neurology initial appointment (60 minutes interview / examination, 30 minutes staffing). The visit will consist of four parts:

1. The history (from patient, other informants, and chart)
2. The elemental neurological examination
3. The cognitive examination
4. Review of laboratory and imaging data

This is a lot of data, so one must learn how much time to spend during each. Some pieces of information should be reviewed and prepared before the patient is seen, given the limitations of data collection in the given appointment timespan.

I generally try to divide the time into 30 minutes of history, 5-10 minutes of neurological examination, and 20-25 minutes of cognitive testing.

Core questions to obtain during the history:

HPI

1. When was the problem first noticed?
2. Is it progressive or stable?
3. Do they repeat themselves?
4. How does it interfere with daily functioning / what has it limited the patient from doing?
5. Are there safety concerns (driving accidents or near misses, leaving stove on, risk of getting lost)?
6. Are they depressed or anxious?
7. Do they have symptoms of sleep apnea?

Medical history

1. Vascular risk factors (HTN, HLD, DM, afib)?
2. History of moderate – severe traumatic brain injury?
3. History of seizure disorder / other neurological disorders?

Social history

1. How far did they go in school, did they have any learning disabilities?
2. Do they use any substances?

Family history

1. Is there family history of early onset dementia?

Core pieces of the neurological examination:

1. Cranial nerves: eye movement abnormalities, masked facies?
2. Motor: cogwheeling, resting tremor?
3. Gait: is bradykinesia present? Is there retropulsion?

Core components of cognitive testing:

1. Global measurement by MoCA
2. Add semantic fluency (list as many animals possible in 60 seconds)
3. Do they remember recent news events?
4. Can they name their grandchildren?

Core components of laboratory or imaging review

1. MRI
   1. T2 FLAIR axial images to review white matter disease
   2. Coronal T1 to review hippocampus
   3. SWI to review for hemosiderin deposits
2. Laboratory
   1. Vitamin B12, TSH, CBC, BMP

Basic summary of the patient:

The patient may fall into three categories:

1. Subjective cognitive impairment: no deficits on cognitive tests and no impairment in iADLs
2. minor neurocognitive disorder (AKA MCI): deficits on cognitive tests and no impairments in iADLs
3. major neurocognitive disorder (AKA Dementia): deficits on cognitive tests and impairment in iADLs

If an individual has gradual worsening of cognitive symptoms over time, they may have neurodegenerative disorder. The most common underlying pathology of dementia is Alzheimer’s +/- vascular disease. The second most common is Lewy body disease. Mixed neuropathology is a rule rather than an exception in neurodegenerative disorders.

In this basic assessment, supporting evidence of Alzheimer’s disease would include:

• patient has gradually progressive cognitive symptoms with short-term memory and word-finding difficulties
• medial temporal / parietal atrophy on MRI
• poor free recall not supported by cues on MoCA, and worse semantic fluency (list of animals) than letter fluency (F-words on MoCA)

Additional common contributing risk factors (and potential targets of treatment) to cognitive impairment include:

• Premorbid baseline and effects of normal aging.
• Iatrogenic effects (i.e. medication side-effects).
• Obstructive Sleep apnea. (Osorio et al, 2015)
• Short sleep duration. (Tworoger et al, 2006; Keage et al, 2012)
• Obesity. (Debette et al, 2011)
• Hypertension. (Hassing et al, 2004)
• Cardiovascular disease. (Debette et al, 2011)
• Diabetes. (Cooper et al, 2015)
• Chronic pain. (Berryman et al, 2013; Moriarty et al, 2011)
• Depression. (Cooper et al, 2015; Geerlings et al, 2000)
• Anxiety. (Sinoff and Werner, 2003; DeLuca et al, 2005)
• Smoking. (Debette et al, 2011)
• Physical impairment. (Robertson et al, 2013); Solfrizzi et al, 2017)
• Physical activity. (Heyn et al, 2004)
• Substance use (Alcohol, cannabis, opioids, inhalants)
• Traumatic brain injury
• Nutritional deficiency
• Endocrine disorders

References

Berryman C, et al. Evidence for working memory deficits in chronic pain: a systematic review and meta-analysis. Pain 154, 1181–1196. (2003) https://pubmed.ncbi.nlm.nih.gov/23707355/

Cooper C, et al. Modifiable predictors of dementia in mild cognitive impairment: a systematic review and meta-analysis. Am. J. Psychiatry 172, 323–334. (2015) https://pubmed.ncbi.nlm.nih.gov/25698435/

Debette S et al. Midlife vascular risk factor exposure accelerates structural brain aging and cognitive decline. Neurology 77, 461–468. (2011) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146307/

DeLuca AK, et al. Comorbid anxiety disorder in late life depression: association with memory decline over four years. International Journal Geriatric Psychiatry 20, 848–854. (2005) https://pubmed.ncbi.nlm.nih.gov/16116585/

Geerlings MI, et al. Depression and risk of cognitive decline and Alzheimer’s disease: results of two prospective community-based studies in the Netherlands. Br. J. Psychiatry 176, 568–575. (2000) https://pubmed.ncbi.nlm.nih.gov/10974964/

Hassing LB et al. Comorbid type 2 diabetes mellitus and hypertension exacerbates cognitive decline: evidence from a longitudinal study. Age Ageing 33, 355–361. (2004) https://pubmed.ncbi.nlm.nih.gov/15136287/

Heyn P, Abreu BC, and Ottenbacher KJ. The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch. Phys. Med. Rehabil. 85, 1694–1704. (2004) https://pubmed.ncbi.nlm.nih.gov/15468033/

Keage HA et al. What sleep characteristics predict cognitive decline in the elderly? Sleep Med. 13, 886–892. (2012) https://pubmed.ncbi.nlm.nih.gov/22560827/

Moriarty O, McGuire BE, and Finn DP. The effect of pain on cognitive function: a review of clinical and preclinical research. Prog. Neurobiol. 93, 385-404. (2011) https://pubmed.ncbi.nlm.nih.gov/21216272/

Osorio RS et al. Sleep disordered breathing advances cognitive decline in the elderly. Neurology 84, 1964–1971. (2015) https://pubmed.ncbi.nlm.nih.gov/25878183/

Robertson DA, Savva GM, and Kenny RA. Frailty and cognitive impairment—a review of the evidence and causal mechanisms. Ageing Res. Rev. 12, 840–851. (2013) https://pubmed.ncbi.nlm.nih.gov/23831959/

Sinoff G, and Werner P. Anxiety disorder and accompanying subjective memory loss in the elderly as a predictor of future cognitive decline. International Journal Geriatric Psychiatry 18, 951–959. (2003) https://pubmed.ncbi.nlm.nih.gov/14533128/

Solfrizzi V et al. Reversible cognitive frailty, dementia, and all cause mortality. The Italian longitudinal study on aging. J. Am. Med. Dir. Assoc. 18, 89.e81–89.e88. (2017) https://pubmed.ncbi.nlm.nih.gov/28012505/

Tworoger SS, et al. The association of self-reported sleep duration, difficulty sleeping, and snoring with cognitive function in older women. Alzheimer Dis. Assoc. Disord. 20, 41–48. (2006) https://pubmed.ncbi.nlm.nih.gov/16493235/