Transcript DEMENTIA - The Carter

EVALUATION OF THE
PATIENT WITH DEMENTIA
Jonathan T. Stewart, MD
Professor in Psychiatry
University of South Florida College of Medicine
Chief, Geropsychiatry Section
Bay Pines VA Medical Center
DEMENTIA
A syndrome characterized by acquired,
progressive cognitive impairment
 Affects 10% of individuals over 65
 Caused by at least 80 different diseases,
many reversible


Unfortunately, the most common diseases (85 –
90%) are irreversible
Diagnosis will have prognostic and treatment
implications
 All demented patients need a work-up


…and it’s mostly a good history
PRIMARY SYMPTOMS
ATTENTION
 MEMORY
 POSTROLANDIC (“COGNITION”)
 EXECUTIVE (FRONTAL/SUBCORTICAL)
 INSIGHT

PRIMARY SYMPTOMS
ATTENTION: clouded sensorium, delirium
 MEMORY: forgetfulness
 POSTROLANDIC: aphasia, apraxia, getting
lost
 EXECUTIVE: poor judgment, disinhibition,
abulia, urge incontinence
 INSIGHT: anosognosia, catastrophic
reactions
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TWO TYPES OF DEMENTIA
 Postrolandic
 Frontal/subcortical
POSTROLANDIC
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Memory deficits
Aphasia
Apraxia
Agnosia
Personality more or
less preserved
MMSE valid
FRONTAL/SUBCORTICAL
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Memory deficits
Loss of behavioral plasticity
and adaptability, judgment
Personality changes
 Disinhibition
 Abulia
Urge incontinence
MMSE useless
THE REST OF THE HISTORY
 Time
course
 Depressive symptoms
 Past medical history
 Medical
and psychiatric conditions
 Family Hx
 EtOH
 Medications (including OTC, OPM)
THE REST OF THE EXAM
 Physical
exam
 Neurologic exam
 Mental status exam
THE FOLSTEIN MMSE
 Most
studied and used of the
standardized exams
 Quick and easy to administer
 Excellent inter-rater reliability
 Accurately measures the severity and
progression of Alzheimer’s disease
 Does not detect executive deficits at
all
BEYOND THE MMSE
digit span or “DLROW”
 MEMORY: 3 word recall, orientation
 POSTROLANDIC: naming, praxis,
calculations, intersecting pentagons
 EXECUTIVE: contrasting programs,
Luria figures, go-no go, controlled word
fluency, frontal release signs
 ATTENTION:
LURIA’S RECURSIVE
FIGURES
LURIA’S RECURSIVE
FIGURES
LURIA’S RECURSIVE
FIGURES
THE GERIATRIC
DEPRESSION SCALE (GDS)
 Good
screen for most patients
 Easy to administer and score
 Face-valid, so patients can “fake good”
or “fake bad”
 Valid for demented patients with an
MMSE above about 12
 Use
DMAS or Cornell scale for severely
demented patients
THE REST OF THE WORKUP
 Basic
labs
 Thyroid function tests
 B12 (methylmalonic acid and
homocysteine if borderline)
 Serology
 HIV, drug screen, others, as indicated
 Neuroimaging study, usually
 LP or EEG, rarely
PLEASANT SURPRISES
Depression
 Iatrogenic (anticholinergics, sedatives,
narcotics, H2 blockers, multiple meds)
 Hypothyroidism
 B12 deficiency
 Neurosyphilis
 Alcoholic dementia
 Normal pressure hydrocephalus
 Subdural hematoma
 Others

POSTROLANDIC
DEMENTIAS
 Alzheimer’s
disease
 Diffuse Lewy body disease
ALZHEIMER’S DISEASE
 Slowly,
insidiously progressive
postrolandic dementia; executive sx’s
much later
 Neurologic exam, labs, neuroimaging
studies unremarkable
 Often familial, especially in younger
patients
ANTI-DEMENTIA DRUGS

May improve cognitive function, ADL’s to a
modest extent; often ineffective

Dechallenge if no meaningful benefit
Possibly delay nursing home placement
 Cholinesterase inhibitors may cause nausea,
diarrhea, weight loss
 Memantine occasionally causes agitation
 THESE AGENTS DO NOT SLOW THE
RATE OF DECLINE

A TYPICAL STUDY
BEWARE!
DIFFUSE LEWY BODY
DISEASE
 Second
most common dementia in
autopsy studies
 Characterized by Lewy bodies
throughout the cortex
 Non-familial
 2:1 male:female ratio
CLINICAL FEATURES

Postrolandic dementia
More rapidly progressive than AD
 Fluctuation, episodes of “pseudodelirium” common

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Mild parkinsonism
Tremor often absent
 Poor response to antiparkinsonian meds
 Shy-Drager sx’s common

Prominent psychotic sx’s, esp visual
hallucinations
 SEVERE NEUROLEPTIC INTOLERANCE
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FRONTAL/SUBCORTICAL
DEMENTIAS
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Vascular dementia
Frontotemporal dementia and Pick’s disease
Alcoholic dementia
Huntington’s disease, Wilson’s disease, progressive
supranuclear palsy, late Parkinson’s disease
AIDS dementia complex, neurosyphilis, Lyme disease
Normal pressure hydrocephalus
Most head injuries
Anoxia, carbon monoxide
Multiple sclerosis
Tumors
ANY ADVANCED DEMENTIA
TYPES OF VASCULAR
DEMENTIA
 Multi-infarct
dementia
 Small vessel disease
 Lacunar
state (gray > white)
 Binswanger’s disease (white)
 Hemorrhagic
vascular dementia
 Strategic infarct dementia
 Dementia due to hypoperfusion
SMALL VESSEL DISEASE
 At
least 50% of all vascular dementia
 Often coexists with MID
 Usual vascular risk factors, especially
HPT
 Steady, not step-wise deterioration
 Relatively more abulia than disinhibition
FRONTOTEMPORAL DEMENTIA
 Relatively
uncommon, non-familial
illness
 Prominent (macroscopic) atrophy of
frontal and anterior temporal cortex
 Symptoms include executive deficits,
Klüver-Bucy syndrome
 About 25% of pts have Pick bodies
MANAGEMENT
BEHAVIORAL PROBLEMS IN
DEMENTIA
 Present
in 80% of cases
 Major source of caregiver stress,
institutionalization
 Common at all stages of the disease
 Much more treatable than the
underlying dementia
 Poorly described in the literature
OTHER
MEDS
WOOF.
THREE BASIC PRINCIPLES
 Simplicity
 Limited
goals
 The “no-fail” environment
“THE CUSTOMER
IS ALWAYS
RIGHT!”
DEPRESSION
incidence in Alzheimer’s
disease, often early in the course of the
illness
 Most important treatable cause of
excess disability
 Responds very well to treatment
 20-30%
ACUTE BEHAVIOR CHANGE
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I atrogenic
I nfection
I llness
I njury
I mpaction
I nconsistency
I s the patient depressed?
AGITATION
 Present
in up to 80% of patients
 Up to 34% of patients are combative
 Few predictors
 Probably a very heterogeneous problem
 Cornerstone of treatment is
nonpharmacologic
EMPIRICALLY EFFECTIVE
MEDS FOR AGITATION
Atypical neuroleptics (best when agitation is
clearly related to delusions or hallucinations)
 Anticonvulsants
 Trazodone
 Beta-blockers
 Buspirone
 Benzodiazepines
 Others
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THE BEST NUMBER OF
MEDICATIONS TO USE IS
ZERO (or sometimes one)
WHEN IN DOUBT, GET RID OF
MEDICATIONS!
DON’T FORGET SAFETY
ISSUES!
 DRIVING
 FIREARMS
 POWER
TOOLS
 SMOKING IN BED
 POISONS, MEDICATIONS
 FALL RISK
GOOD LUCK!
MEDS
OTHER
WOOF!