Transcript Overview of Dementia

A neurology primer
Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906)
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Dementia is an inevitable part of aging
Dementia is synonymous with Alzheimer’s
disease
Dementia cannot have an acute onset
Dementia is an untreatable disorder
Dementia cannot be accurately diagnosed
without autopsy
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Dementia is a “global” disorder of cognitive
function
Dementia is only a memory problem
Dementia always impairs insight into
cognitive deficits
Dementia is only a cognitive & not a
behavioral disorder
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Primary care physicians see large numbers of
patients with dementia
Dementia can be accurately diagnosed and
managed in a primary care setting
General medical health is closely related to
late life cognitive function
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Failure to recognize symptoms of dementia
Negative attitudes towards treatment and
therapeutic nihilism
Limited time
Lack of confidence in establishing a particular
diagnosis
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Planning for the future
Identify patients at high risk of complications
Early treatment may delay progression
Refer to community based resources
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Decreased speed and efficiency of learning
Difficulty inhibiting irrelevant information
Troubles with “working memory”
No true language dysfunction
No more rapid forgetting when controlling for
initial learning
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Troubles finding words, coming up with
names
Difficulty understanding conversations
Getting lost
Troubles recognizing people or objects
Repeating conversations
Difficulty managing medications,
appointments, finances
Personality changes, withdrawal, apathy
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Troubles managing medications
Difficulty providing detail in medical
interview
Repetitive questions
New onset personality or mood changes
Family members expressing concerns over
memory or behavior
Episodes of delirium after surgery or during
hospitalization
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Acquired disorder of memory and at least one
other cognitive domain (language,
visuospatial function, executive functions)
Occurs in the setting of a clear sensorium
Affects occupational and social functioning
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Over 100 illnesses cause dementia
Majority of cases are Alzheimer’s disease
Non-AD dementias account for ~50%
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Vascular dementia ~15%
Dementia with lewy bodies ~20%
Frontotemporal dementias ~5%
Other (NPH, syphillis, HIV, Parkinson’s disease
dementia, vasculitis, etc.)
5 % FTD
5 % Other
15 % Dementia
Lewy Bodies
20 % Vascular
Dementia
55 % Alzheimer’s disease
Delirium
Acute onset
Marked fluctuations
Poor attention
Changes in alertness
Marked circadian
disturbances
Dementia
Gradual
Less fluctuation
Generally attentive
Generally alert
Mild circadian
disturbance
Cortical
 Normal speed of
thought
 Aphasia
 Amnesia
 Visuospatial
dysfunction
 Normal gait
 Paratonic rigidity
Subcortical
 Bradyphrenia
 No aphasia
 “Forgetful”, poor recall
 Visuospatial
dysfunction
 Impaired gait, posture
 Movement pathology
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Development of cognitive deficits
manifested by both
 impaired memory
 aphasia, apraxia, agnosia, disturbed
executive function
Significantly impaired social, occupational
function
Gradual onset, continuing decline
Not due to CNS or other physical conditions
Not due to an Axis I disorder (e.g.,
schizophrenia)
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Age
Family history
CV risk factors (hypertension, diabetes,
elevated homocysteine, cholesterol?)
Late onset depression
Delirium
Fewer years of education
Head injury
 NSAIDs
 Statins
 Antihypertensives
 Antioxidants
 Exercise
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Complete blood count
Thyroid function test (TSH)
Vitamin B-12 level/folate
Complete metabolic panel (BUN/Cr,
glucose, calcium, LAEs, electrolytes)
Neuroimaging should be done at least once
◦ Non-contrast CT
◦ MRI brain without contrast
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Mini Mental Status Exam
Clock-drawing tests
Blessed-dementia rating scale
Mini-cog
7-minute screen
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Attention
Language
Memory
Visuospatial/perceptual functions
Executive functions
Praxis
Calculations
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Look for extrapyramidal dysfunction
Asymmetric findings
Pyramidal tract findings and pathologic
reflexes
Gait dysfunction
Coordination
Sensation
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Erythrocyte sedimentation rate
RPR
Lumbar puncture
HIV
Serial neuroimaging
Functional neuroimaging (PET, SPECT)
Full neuropsychological testing
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Poor short term memory
Difficulty learning and retaining new
information
Mild word-finding difficulties
Naming problems
Problems with organization, and complex
planning
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Worsening memory problems
Remote memory becomes involved
More obvious language problems
Visuospatial and topographical orientation
Getting lost, unable to find way back home
Behavioral changes (delusions, aggression,
irritability, anxiety)
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Aphasia (unable to comprehend language
other than simple commands)
Agnosia (difficulty recognizing objects,
people, etc.)
Apraxia (inability to perform skilled
movements despite intact motor/sensory
skills)
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Slow or delay progression
Correct exacerbating factors/conditions
Treat and prevent concomitant CVD
Treat behavioral and psychiatric problems
Treat functional problems
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Acetylcholinesterase inhibitors
◦ Donepezil (Aricept)
◦ Rivastigmine (Exelon)
◦ Galantamine (Reminyl)
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N-methyl-D-aspartate inhibitors
◦ Memantine (Namenda)
◦ May be used in conjunction with CHEIs
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Approved for mild-moderate AD
Aricept just approved for severe AD
Start as early as possible
Continue as long as possible
Use maximum dose tolerated
Failure to respond to one does not preclude
response to another
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Most AD patients decline by 3-4 points on
MMSE per year
Treatment generally may delay progression
by ~ 6 months
Behavior and function may improve in
addition to cognition
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ChEI treatment is the standard of care for mild to
moderate AD
Improvement, stabilization, or slowed decline
represent treatment success
◦ Evaluate treatment response in the context of progressive
decline
◦ Inform patient and caregiver that stabilization is desirable
◦ Use follow-up visits to reinforce realistic expectations
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Aricept has proven benefits on cognitive,
functional, and behavioral symptoms
ChEI = cholinesterase inhibitor.
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Detect and diagnose early
Provide early and persistent treatment
Evaluate treatment response in the face of
progressive decline
Manage physician, patient, and caregiver
expectations of disease course and treatment
response
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Dementia is a major public health problem
Dementia is under recognized in all settings
Dementia is a disorder of cognition, behavior
and function
Effective treatments exist that may improve
or help preserve all 3 domains