Cognitive- Behavioral Assessment Panels Checklist Velandy Manohar, MD

These are a range of possible assessments for evaluating the nature and causes of Cognitive dysfunction and emotional disequilibrium in a Multi-dimensional format: I developed these assessment strategies while working in Mx. Health, Community Health center and Aware Recovery Care over the past 50 years. I used this document which I updated over the years as a check list to assist the members of my Teams to address the challenges presented by our patients comprehensively in Mx. health Aware Recovery care and the tightly integrated multi-disciplinary team of POD D at CHC where 9 of us interacted closely to all the patients associated with Pod D. Our Team was constituted by an experienced nurse, two nursing assistants, adult and child psychologists two PCPs, an LCSW and me an Adult Psychiatrist with interest in and extensive experience with diagnosing and managing confusional disorders and dementia type disorders. I shared these formulations with Specialists, Consultants and members of other teams we worked with on a regular basis. This greatly improved the scope and relevance of this checklist.

A.
Tests for status and Impact of Systemic disorders:
including Obesity, Obstructive Sleep Apnea, OSA, Hyper-Lipemia, HTN, T II DM, Significant COPD, Hypothyroidism, Anemia including chronic blood loss, Fe deficiency, Chronic Kidney Disease and Porto-systemic Encephalopathy even sub-clinical form especially after high protein meal by a person with Cirrhosis. Long COVID -19, Disorders affecting Nutrition and Electrolytes. Affordability of meds and Access to care including Transportation must be assessed.
Assessment of impact of current med regimen on Cognition and Behavior.
Assessment of impact of Pain Management Regimen on Cognition and Behavior
Assessment of Drugs of abuse – often an assortment of Illicit, Licit prescribed and unprescribed drugs and licit drugs including medicinal Cannabis. Alcoholism can have multiple effects including Wernicke’s and Korsakoff’s, Anemia, Liver disease .
Assessment of Chronic Head Trauma- CTE- Chronic Traumatic Encephalopathy from repeated blows with little or no immediate signs and symptoms
Assessment of Impact of Concussions in war from IED’s etc. [Signature -invisible wounds of OIF and OEF]
Assessment of Hearing and Vison. Especially the former.
Assessment on inhalation of toxic materials 1. 9-11 site in NYC, 2. Burn Pitts from OIF and OEF 3. Gulf war syndrome.4. Agent orange related effects. 5. Toxic exposure after massive leaks following Train accidents and coal mine accidents.6. CO poisoning due to hazards with home heating strategies
Assessment of shaken Baby syndrome- that has left residual effects.
Assessment of Seizure disorder and its contribution to Mood, Cognition and Behavior.
Assessment of Retinal changes over time that can reveal Alzheimer’s disorder: [Early in the course of the disorder] This new report was added to thid document after I shared the document with ProHealth Physicians.
Retinal pathological features and proteome signatures of Alzheimer’s disease | SpringerLink
Published: 11 February 2023, Excerpt:
This study identifies and maps retinopathy in MCI and AD patients, demonstrating the quantitative relationship with brain pathology and cognition, and may lead to reliable retinal biomarkers for noninvasive retinal screening and monitoring of AD. he accumulation of retinopathies in the early stages of functional impairment (MCI) was more pronounced in the inner layers and peripheral subregions and further progressed in AD dementia. The higher Aβ42 density in the far periphery versus central retina may suggest that Aβ42 aggregates more readily to plaques in peripheral subregions. In contrast, retinal GFAP+ macrogliosis was more significantly elevated in the central subregions closer to the optic disc in MCI and AD patients.

B. Office Assessment and except for the grip test can be done by using Zoom modality
1.
Brain, Mood, Anxiety, psychoses and Cognition Assessment
a. Montreal Cognition Assessment MoCA
b. Mini-Cog
c. Mini- Mental Status
d. Number connecting Tests.
e. Trail making Test
f. Epworth Daytime Sleepiness Scale for Sleep Apnea related deficits in wakefulness and alertness. OSA can also result in significant impairment, affect, concentration, cognition, memory, self-care.
g. GAD-7,
h. PHQ-9, plus as indicated by response to Q9 question- on Life being worth living. Perform the PHQ -9 possibly every quarter if not sooner if the answer to question 9 is significant. Depression irrespective of obvious mood change can impede physical activity diminish interest in social interactions and significantly impair, affect, concentration, cognition, memory, self-care, judgement.
i. Columbia Suicide Severity Rating Scale [C-SSRS] If Suicidal- Gun Ownership and Gun Safety practices must be ASSESSED especially for older males.
2.
Simple Tests Predict Dementia Risk in Older Women Years in Advance : ScienceAlert
The classic, early cognitive symptoms of dementia – like misplacing valuable objects, forgetting names, and finding planning difficult – can creep up slowly over time.
But there are other, more noticeable changes to the body that correlate with dementia risk and can be picked up over a decade before diagnosis. Recent research has found that hearing difficulties may be a warning sign of dementia that arises years before other symptoms of the disease.
Now, a study suggests that measuring grip strength and mobility are two potentially useful and inexpensive ways to gauge dementia risk in older women.
In the study, around 1,200 women in their 70s were tested for grip strength using a hand-held dynamometer and for mobility using a timed-up-and-go test where the person rises from a chair, walks 3 meters (9.8 feet), turns around, and returns to sit in the chair. The participants' health was tracked using linked health records for the next 14.5 years. In that time, nearly 17 percent of women had been hospitalized with dementia or had died due to a dementia-related cause.
While the observational study could not show cause and effect, the researchers did find a neat, linear relationship between physical strength and mobility and the dementia events that occurred over a decade later. Women who fell into the lowest quartile for grip strength or mobility were more than twice as likely than women in the upper quartile to be hospitalized with or die from dementia later in life.[Please review the graphs in the link.}
2. a. Random and timed Blood sugar- including Finger Stick, Random Pulse oximetry
2. b. Appropriate Blood and Urine tests.
3. MRI No contrast
1. Hippocampus Volume
2. Entorhinal cortex,
3. Total Cerebral White Matter Volume
4. Total Gray matter Volume
5. Total Combined Hippocampal Volume.
6. Inferior Lateral Ventricle Volume
7. Microangiopathy

C. Driving Tests. To determine if independence of the person can be safely maintained

D. Ability to consistently manage safe Use and reliable process of refilling, storing of Prescription and OTC drugs. Inconsistent, stopping and starting, over or underusing medications especially if the individual is unavoidably on 5-6 or more medications at different times of the day

E. Nutritionist and Pharmacist Consultations. Including assessment of what is the refrigerator, shopping, storing safely and cooking, preparing food.

F. Food and Housing Security, Health care access and affordability of meds and Transportation issues must be assessed.

G. Clinical Effect of Early vs Late Amyloid Positron Emission Tomography in Memory Clinic Patients: The AMYPAD-DPMS Randomized Clinical Trial | Dementia and Cognitive Impairment | JAMA Neurology | JAMA Network

Original Investigation
May 8, 2023
Clinical Effect of Early vs Late Amyloid Positron Emission Tomography in Memory Clinic Patients. The AMYPAD-DPMS Randomized Clinical Trial
Question Is early amyloid positron emission tomography (PET) clinically useful in memory clinic patients?
Findings In this randomized clinical trial, we demonstrated that performing amyloid PET early in the diagnostic workup (within 1 month) allowed 40% of memory clinic patients to receive an etiological diagnosis with very high diagnostic confidence after only 3 months, 3.5 times more frequently than patients who had not undergone amyloid PET (11%).
Meaning This study adds evidence to previous studies showing that amyloid PET has a relevant clinical effect in memory clinic patients.
H. Linking Cognitive Decline to Brain Changes: A Diffusion MRI Study (physiciansweekly.com)
Linking Cognitive Decline to Brain Changes: A Diffusion MRI Study
Apr 19, 2023
The following is a summary of the “Association of longitudinal cognitive decline with diffusion MRI in Gray Matter, Amyloid, and Tau deposition,” published in the January 2023 issue of Neurobiology of Aging by Wang, et al.
In 171 individuals with no cognitive impairment, 103 with mild cognitive impairment, and 44 with Alzheimer’s disease, we measured cortical volume, free water, fractional anisotropy (FA), and amyloid and tau SUVRs. When the 3 groups were combined, the entorhinal cortex and hippocampus of amyloid-negative individuals showed decreased extracellular free water with increasing amyloid burden, while the entorhinal cortex and hippocampus of tau-positive individuals showed increased extracellular free water.

I welcome responses. It is advisable to set aside time with Nursing Assistant and Nurse to assess many Items of the diagnostic process, order tests and refills.
Velandy Manohar, MD
Distinguished Life Fellow, Am. Psychiatric Association.