Download Is not a normal process of aging

APPROACH TO DEMENTIA
IN PRIMARY CARE
HÜLYA AKAN, MD
Assocc Prof of Family Medicine
DEFINITION
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A syndrome, not a diagnosis
An acquired degeneration of
intellectual and cognitive abilities,
which persists at least several months or
takes chronically worsening course leading
to major impairment in the patient’s
everyday life
Is not a normal process of aging
PREVALENCE
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Prevalence doubles every 5 years after age 60.
Over 85 years,it is about %25-45
The percentage of geriatric population is
increasing all over the world. It shows that with
increasing geriatric population, the number of
dementia patients will increase
It is the 6th leading cause of death in
elderly population in the USA
Approximately 2/3 of dementias are
Alzheimer type dementia.
Is it a community health problem?
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Geriatric population is increasing all over the world
Only 10% of dementia is reversible, of these most of
them to some extent
Median life expectancy for AD patients 3-15 years
Needs continous care at home and after than at an
instituty
As many as 90% of patients with dementia are
eventually institutionalized. Median time to nursing-home
placement is 3-6 yrs after diagnosis. (what about in
Turkey?)
What is Cognition?
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The operation of the mind by which we become
aware of objects of thought or perception; it
includes all aspects of perceiving,thinking and
remembering
Memory
Orientation
Language
Judgement
Perception
Attention
Ability to perform tasks in order
What is normal cognitive change in
elderly?
Cognitive changes seen in normal aging
- Age Associated Memory Impairement (AAMI)
- Aging-Associated Cognitive Decline (AACD)
 Mild cognitive impairement (MCI)
 Dementia : usually complaint of relatives not the patient
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Cognitive changes seen in elderly
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Perform more slowly on timed tasks
Slower reaction time
Subjective problems such as difficulty recalling
names or where an object placed
The persons often remembers information later
Intact learning
Any deficits in memory function are subtle,
stable and do not cause functional
impairement
Mild Cognitive Impairement
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Not within normal limits for the patient’s age and
education but not severe enough to qualify as dementia
Subjective memory complaint
Objective memory impairement in the context of normal
abilities on most other cognitive domains
(language,executive function); and intact functional
status
May represent very early form of AD. Among patients
with MCI; 10-15% per year convert to AD compared
with 1-2% of age-matched controls
They may progress to other types of dementias or
remain stable-FOLLOW UP
Dementia
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Most severe type of cognitive disorders
Diagnosis requires multiple deficit in
multiple domains of cognitive functioning
Memory + At least one another that
represent a significant change form
baseline and that are severe enough to
cause impairement in daily functioning
Causes of Dementia
Cerebral disorders
without extrapyrimidal
features
Cerebral disorders with
extrapyrimidal features
Cancer
Alzheimer disease
Prominent memory loss, language impairement,
visuospatial
disturbance,depression,anxiety,delusions
Pick disease
Apathy,disinhibition,anosognosia,logorrhea,echolal
ia,palilalia
Creutzfeld-Jakob disease
Myoclonus, ataxia,periodic EEG complexes
Normal-pressure hydrocephalus
Incontinence , gait disorder
Dementia with Lewy bodies
Fluctuating cognitive didorder, visual
halucinations,parkinsonism
Corticobasal ganglionic
degeneration
Parkinsonism, apraxia,cortical sensory loss,alienhand syndorome
Huntington disase
Chorea,pschosis
Progressive supranuclear palsy
Supranuclear opthalmaplegia,pseudobulbar
palsy,axial distonia in extension
Brain tumor
Headache, focal neurologic signs,papiledema
Meningeal neoplasia
Focal weakness or sensory
deficit,areflexia,pyrimidal signs,headache
Infection
Metabolic
disorders
Organ
failure
AIDS
Oppurtunistic infections,memory loss,psychomotor
retadation,ataxia,pyrimidal signs,white matter lesions on MRI
Neurosyphilis
Reactive CSF VDRL,pschosis,Argyll-robertson pupils,facial
tremor,strokes, tabes dorsalis
Progressive multifocal
leukoencephaly
Visual disturbances,white matter lesions on MRI
Alcholism
Prominent memory loss, nystagmus,gait ataxia
Hypothyroidism
Myxedema, hair loss,skin changes, hypothermia, headache,
hearing loss, tinnitus, vertigo, ataxia, delayed relaxation of
tendon reflexes
Vitamin B12 deficiency
Macrocytic anemia,low serum vit. B 12 level, psychosis, sensory
disturbance, spastic paraparezis
Dialysis demetia
Dysarthria, myoclonus, seizures
Non-Wilsonian hepatocerebral
degeneration
Cirhosis, eosaphageal ulcers, fluctuating mental satatus,
dysarthria, pyrimidal and extrapyrimidal signs, ataxia
Wilson disease
Cirhosis, dysarthria, pyrimidal and extrapyrimidal signs, ataxia,
decreased serum ceruloplasmin, Keiser-Fleischer rings of
kornea
Trauma
Vascular
disorders
Peudode
Headache, variable pyramidal and exrtapyramidal signs
Chronic subdural hematoma
Headache, hemiparezis,extraaxial collection on CT or MRI
Vascular dementia
Hypertension, diabetes, stepwise progression of
deficits,hemiparezis,aphasia, infarcts on CT or MRI
Depression
Depressed mood, anhedonia,anorexia, weight loss, insomnia or
Most Common Types of Dementia
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Alzheimer Disease 40-50%
Mixed AD/Vascular dementia 15-20%
Lewy Body dementia 10-20%
Pick’s type (frontotemporal) 5-10%
Vascular dementia 5-10%
Other 5%
Reversible Causes of Dementia
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Toxic affects of medications or drug
interactions (especially elderly people use
lots of drugs prescribed or unprescribed)
Hydrocephalus-brain tumor
Infection
Electrolyte imbalance
Malnutrition
Endocrine and metabolic disorders
Variable
Dementia
Delirium
Depression
Onset
İnsidous/gradual
Abrupt
Fairly abrupt
Duration
Months-years
Days-weeks
Weeks-months
Source of complaint
Usually family,
caregiver,friend
Providers,family
Patients themselves
Level of
conciousness/alertness
Usually normal
Varies throughout the
day
Usually normal
Orientation
Disoriented later in
disease
Usually disoriented
early
Usually normal
Attention/concentration
Good
Poor
Poor
Effort
Good
Poor or fluctuating
Poor
“Don’t know” answers
Uncommon
Memory loss for recent
vs. Remote information
Greater for recent
Greater for recent
~equal for both
Lost of social skills
Late
Abrupt changes,labile
Early
Thought
process/context
Impoverished
Disorganized
May be slow
Psychomotor symptoms
Normal until late in the
disease
Hyper- or hypoactive
Hypoactive
----
Common
ALZHEIMER DISEASE
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Most common type of dementia
DSM IV Diagnostic Criteria
Developement of gradual cognitive deficits manifested
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
(e.g,parkinson, delirium)
Not due to axis I disorder (eg. Schizophrenia)
RISK FACTORS OF ALZHEIMER
KNOWN
 Age
 Specific mutations on chromosomes 1,14,21
 Family history
 Down syndrome
 Apolipoprotein E ε4 genotype
PROBABLE
 Low education level
 Women
 Depression
 Brain trauma
How Does Alzheimer Patient Apply
to the Physician?
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Usually the complaint of family or caregivers not
patient him/herself
In early dementia patient usually apply to the
physician for other reasons
Patient aim to deny the illness – no in-sight
Family members usually aim to relate the
symptoms to other reasons- loss of partner,
aging, recent operation etc
How to Diagnose Alzheimer Disease
Probable Diagnosis( usually clinical diagnosis)
 History
 Physical examination
 Cognitive tests
 DSM IV Criteria
Definite Diagnosis
- Brain biopsy
COMMON COGNITIVE DISORDERS IN AD
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Memory Loss
- Diffuculty in learning
- Short term memory loss
Disorientation
- Time disorientation
- Place confusion
Aphasia
-Anomia: naming of objects
-Difficulty in finding words
-Meaningless, undirected speech
-Difficulty in understanding
COMMON COGNITIVE DISORDERS IN AD
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Apraxia:
-Ideamotor apraxia: Difficulty in turning an
idea into movement (brushing teeth)
-Extremity-kinetic apraxia:Difficulty in
determining the place of own body parts in
space (putting dress, sitting on chair)
Complex Visual dysfunction
- Agnosia: difficulty in recognizing
- Visual spatial dysfunction
COMMON COGNITIVE DISORDERS IN AD
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Disorder in applying
-Disorder in planning
-Disorder in judgement
Disorder in abstract thinking
Disorder in solving problem
- Disinhibition
Anosognozi
- Unawareness of the disorder
- Denial of the disease
Common Noncognitive Signs in AD
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Personality Changes
- Passive
- Self-oriented
- Agitated/irritable
Apathy
- Difficulty in beginning
- Insufficiency to continue effort
Depression
Anxiety
Common Non-cognitive Signs in AD
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Delusions
- Paranoia
- Misidentification
Hallucinations
Agitation
- Nonspecific motor behaviours
- Verbal agressiveness
- Physical agressiveness
Sleep disturbances
- Circadian lapse
- Insufficient sleep
How to approach a patient
presenting with cognitive problem
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First step : Is it a disturbance of level of conciousness
(acute confusional state, coma) or content of
conciousness (wakefullness preserved)
Second step: Determine the cognitive function and the
degree of cognitive impairement, decide dementia
Third step: Differantiate reversible and irreversible
dementia and also pseudodementia (e.g. depression)
Check prescribed, unprescribed drugs and also herbal
drugs and substance abuse (e.g,alcohol)
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Consider neurologic and neurophysciatric
consultation
Consider the treatment of reversible causes of
dementia
Consider treatment of dementia
Consider daily activities scalas, determine the
care needs of the patient
Counselling of the patient, family and caregivers
Consider treatment of behavioural disorders
HISTORY TAKING
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Most important part of the diagnosis
Altough it may be unreliable, first try to take the
history from the patient.
Asking questions about past and present social
life and medical history gives lots of information
about recent and remote memory. Don’t forget
patient may feel uneasy with lots of questions
and aim to deny self memory problem (no
insight)
Since patient has memory problem, you must
confirm history by some one accompanying
her/him. This also gives some clues about the
degree of the problem.
HISTORY TAKING
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Most of cognitive problems can be recognized and tested
during history taking
You may begin with asking “What do you like to do in
your free times?” (Measure abstract thinking.For a
meaningful response the patient must remember a list of
activities and how they are organized). Alzheimer
patients typically aim to answer with generalized terms
(like reading). In this case clinician may specify by
asking “What are you reading recently?” If patient has
difficulty, the clinician must go into more detailed tests
by saying “It seems you have difficulty in remembering
some things. Maybe we better to do some more detailed
tests.”
HISTORY TAKING
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Special attention to drug use: Most of geriatric
patients use lots of unprescribed and prescribed
drugs having anticholinergic effects. Another
problem is that the patient may forget and aim
to take drugs several times a day.Ask for drug
use and if possible ask for a written list and
check with the patient and caregiver.
Special attention to hearing and visional
problems. These are also very common in
elderly people. Undiagnosed problems may
interfere with cognitive tests and may lead to
lower scores.
HISTORY
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Duration of symptoms and nature of progression of
symptoms
Presence of specific symptoms related to:
-Memory (recent and remote)
-Language (word finding problems, diffuculty
expressing self)
- Visuospatial skills (getting lost)
- Executive functioning (calculations,planning, carrying
out multistep tasks)
- Apraxia (not able to do previously learned motor tasks
eg:slicing of bread)
- Behaviour or personality changes
-Psychiatric symptoms
(apathy,hallucinations,delusions,paranoia)
HISTORY
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Functional assesment (ADLs, IADLs)
Social support assesment
Medical history, comorbidities
Through medication review, including over-thecounter medications, herbal products
Family history
Review of systems including screening for
depression and alcohol/substance abuse
PHYSICAL EXAMINATION
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Cognitive examination
General physical examination with special
attention to:
- Neurologic examination, looking for focal
findings, extrapyrimidal signs, gait and balance
assessment
- Cardiovascular examination
- Signs of abuse and neglect
Screen for impairments in hearing and vision
Cognitive Examination
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Rapid cognitive test
MMSE
Clock Draw Test
Rapid Cognitive Test
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Most of the items can be performed
during history taking and physical exam.
Normal healthy adults usually finish this
test in 5 minutes or less.
It can show if there is need more detailed
tests.
Rapid Cognitive Test
1- Abstract Thinking: “What do you like to do in
your free times?”
A: If the answer is appropiate and well
constructed or if there is no cognitive or
behavioral signs, it may not needed further
asssesment.
B: If the answer is very concrete, suspicious or
not including details, go on item 2.
Rapid Cognitive Test
2-Focal Cortical function
a: Learning:” I want you to repeat and keep in
mind these three words, umbrella, rose, afraid”
b: Memory/counting assessment: “If I give you
one lira, five kuruş, ten kuruş and twenty five
kuruş, how much money I would have given to
you?”
c: Naming:”Please tell me the name of the
things I show you (shirt, jacket,pen etc)”
Rapid Cognitive Test
Temporaparietal tests
1- “Show how you nail on with your right hand”
2- Show how you use key when you are opening the lock with your
left hand”
3- “Show how you slice a loaf of bread by using your both hands”
4-Touch your left ear with your right hand”
5- “Use your left hand to show my left hand”
6- “Before showing the ceil please show the door.”
e: Drawings:
1- “Draw a clock and put the numbers in it and show the time
08:20.”
2- “Please draw the same of this figure”
d:
Rapid Cognitive Test
f: Memory: “Please tell me the words that I have
told you to memorize few minutes ago.”
How to interprate?
A: If the patient performs the tests in section 2,
assess again in 6-12 months
B: If patient can’t success in 2 or more parts of
section 2 , consider more detailed assesment.
Clock Draw Test
Instructions
 “Draw the face of the clock, putting the numbers
in the correct position. I’ll then ask you to
indicate a time after you are done.”
 Ask the patient to draw in the hands at ten
minutes after eight.”
Scoring
 Draw a closed circle: 1 point
 Place numbers in correct position: 1 point
 Includes all 12 correct numbers: 1 point
 Correct indication of time: 1 point
Clock Draw Test
Interpration
 CTD 4: approximates MMSE nearly 30 or MCI
 CDT 2: puts the patient in moderate cognitive
impairement, MMSE about high teens
 CTD 1 reflects moderate to low scores on
mmse- low teens
 Clinical judgement MUST be applied
 Abnormal results needs further assesment
MMSE
Mini – Mental State Exam
Not “ gold standart”, but most commonly
accepted
 30-point scale to evaluate orientation,
concentration, verbal and visual spatial skills
 Subject to level of educational attainment,
language barrier and vision/hearing
requirements
 Scoring:
Early stages: 21 - 30
Moderate stages: 11 - 20
Late stages: 0 - 10
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LABORATORY
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CBC
Electrolytes, Glucose, BUN/Cr.,Ca, LFTs
Thyroid funtion tests
Vit B12
VDRL (Syphilis),HIV (AIDS)
ESR, Urine analysis
Toxicology screen, 24 hour urine for heavy metals
EEG (optional)
Neuroimaging (optional)
-CT: to rule out other dx
-MRI: to rule out other dx
PET, SPECT (optional)
CSF fluids: High tau and low beta amyloid
Is It Needed Neuroimaging?
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Routine brain imaging in the diagnostic
evaluation of a patient with cognitive
impairement dementia is controversial.
If there is oppurtunity, uncontrasted CT or
MRI is advised.
New developments in diagnosis
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Functional imaging: FDG(fluorodeoxyglucose)
PET- reduced use of glucose (sugar) in brain
areas important in memory, learning and
problem solving
Molecular imaging technologies : highligts
amiloid plaques in PET
Pittsburgh compound B (PIB)
18F flutemetamol (flute)
Florbetapir F 18 (18F-AV-45)
Florbetaben (BAY 94-9172)
How To Differentiate AD and
Depression (Pseudodementia)
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Depression is common in dementia
patients, also in elderlies.
Clinically when they are found together it
may be very diffucult to differentiate.
In every patient you think dementia, try to
differentiate pseudodementia- depression.
Treatment of depression may improve
cognitive problems.
How To Differentiate AD and Depression
(Pseudodementia)
DEMENTIA
DEPRESSION
Insidious onset
Abrupt onset
Progressive deterioration
Plateau of dysfunction
No history of depression
History of depression may exist
Patient typically unaware of extent of
deficits and does not complain
memory loss
Patient aware of and may exaggerate
deficits and frequently complains
memory loss
Somatic complaints uncommon
Somatic complaints and
hypochondriasis common
Variable affect
Depressive affect
Few vegetative symptoms
Prominent vegetative symptoms
Impairement often worse at night
Impairement usually not worse at
night
Neurologic examination and laboratory Neurologic examination and laboratory
studies may be abnormal
studies normal
When To Refer To Neurology
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Abrupt onset
Extrapyrimidal symptoms or focal neurologic
symptoms other than cognitive symptoms
Abnormal neurologic examination except
cognitive impairement
Rapid deteriotion
During follow-up new neurologic signs or
symptoms unrelated to AD
If you are not sure of the diagnosis
When to Counsel for
Neuropsychologic Tests?
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Neuropyschologic tests consist in-depth battery
of standardized examinations that test multiple
cognitive domains including
intelligence,memory,language, visuospatial
abilities,attention, reasoning and problem
solving as well as other executive functions and
applied by neurophysciatrists.
Patients who have early or mild syptoms
(diffuculty in diagnosing or differentiating)
High premorbid intelligence
Patients with low intelligence/educational level
Is it needed Genetic Counselling?
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Late- onset AD (>60-65 yrs):Is associated with genes
that increase the risk of AD but not in autosomal
dominant fashion.
ε4 increase AD 2-3 times, ε2 protective, but absence of
ε4 does not rule out diagnosis. So it is not needed in
practical means.
Early-onset AD (<65 yrs, usually between 40-50 yrs):
Familial.Inherited autosomal dominant. It is not needed
in practical means, but if children of the patient wish to
know whether they have inherited the gene, the family
shoud be referred for genetic counselling.
TREATMENT
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MAIN GOALS
Preserve function and anatomy for as long
as possible
Maintain quality of life for both the patient
and caregivers
DRUG TREATMENT
Cholinesterase Inhibitors: Effect sizes are modest
in clinical trails 40-50%
A stable or improved MMSE over 6-12 mo suggests
the drug is effective.
- Rivastigmine
- Donezepil
- Tacrine
NMDA (N-methyl-D-Aspartate) Antagonists
- Memantine
Other pharmacologic agents tried have given
controversial results
Treatement of Behavioural
Problems
Commonly seen behavioural and psychiatric problems in
AD:
- Agitation and aggression
- Disruptive vocalization
- Psychotic features (delusions,hallucinations,paranoia)
- Depressive symptom
- Apathy
- Sleep disturbances
- Wandering or pacing
- Resistance to personal care (bathing and grooming)
- Incontinence
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Treatement of Behavioural
Problems
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Antipsychotics
(haloperidol,risperidone,olanzapine,
trazadon)
Antidepressants (SSRIs eg:sitoprolam)
Mood stabilizers (eg: carbamazepine)
Non-Pharmacological Treatement
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Music
Reminiscence Therapy
Exposure to pets
Outdoor walks
Bright light exposure
Non-Pharmacological Treatement
Advice to family and care givers:
 Maintain familarity and routines as much as
possible
 Decrease number of choices
 Tell, don’t ask
 Understand they can’t, rather than they Won’t
 Don’t try logic or reason
 Always keep the goals in mind
Follow-up
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Repeat MMSE every 6-12 months: In AD 3 point
decrease/every year is expected
Determine new behavioral changes and their
causes
Repeat complete physical examination including
weight and determine if any new developed comorbidity
Assess the efficacy of the drugs given for
dementia (MMSE+ clinical judgement)
Check medication list
Check the stress level of caregiver
SAFETY ISSUES
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Driving
Home Safety: Every potential harms must
be discussed detailly eg: stoves, carpets,
lightining
Wandering: sewn in clothing, identification
bracelet
Care giver assistance
PROGNOSIS
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Median life expectancy 3-15 yrs
Needs continous care
Eventually becomes bed ridden
In advanced dementia patient has difficulty with even
most basic things such as feeding themselves
Often urinary and bowel incontinence
Patients who do not die of other comorbidities tend to
develope concomitant complications (malnutrition,
pressure ulcers,recurrent infections)
The most common cause of death is pneumonia.
EVIDENCE BASED POINTS
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AD is the most common form of dementia, accounting
approximately 66% of patients with dementia
Routine brain imaging in the diagnostic evaluation of a
patient with cognitive impairement dementia is
controversial.
Genetic testing, including APOE genotyping,is not
indicated for clinical use.
Actylcholinesterase inhibitors for tratement of AD have
modest benefits on cognition, physical functioning and
behaviour.
Behavioral and psychologic symptoms of dementia are
associated poor outcomes.