Download 7._Dementia

Understanding
Dementia
Dr Asso Fariadoon
Ali Amin
MRCP(UK)
Why is Dementia Important?
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Dementia is an acquired decline in memory and other cognitive function
(s) in an alert non delirious person that is sufficiently severe to affect daily
life ( home, work, or social function).
There are about 820,000 people in the UK with dementia
The number is set to double by 2030
Prevalence:- rare before the age of 65 , increase with age , 65-69 (1.4%),
70-74 ( 2.8%), 75-79 ( 5.6%), 80-84 (11.1%), more than 85 (23.6%)
There are about 18,500 people in the UK under 65 who have dementia
There is no cure
Prevalence of Alzheimer’s Disease
Prevalence of Alzheimer’s
disease in an aging
population.
Prevalence increases
dramatically with age and
approaches 50% of those
over 85 years old.
(Adapted from Evans et al.,
1989.)
Dementia - Diagnosis
Diagnosis ICD-10 & DSM-IV:
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Multiple cognitive defects which must include:
Amnesia
Functional impairment
Clear consciousness
Clear change from previous level
Long duration (>6 months)
Forms of Dementia
Alzheimer’s disease
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Vascular Dementia
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Dementia in Parkinson’s & Dementia with Lewy Bodies
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Frontotemporal Dementia
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Reversible (<5%):- Subdural haematoma, normal pressure
hydrocephalus, metabolic, drugs
Neurological dementias:
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Cerebral Vasculitis
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Corticobasal Degeneration
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Dementia in MS
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HIV/AIDS Dementia
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Huntington’s Dementia
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Lysosomal storage diseases
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Prion Diseases – CJD
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Prevalence of the forms of dementia
Cause
Percentage
Alzheimer’s disease
55%
Vascular dementia
20%
Dementia with Lewy Bodies
15%
Frontotemporal dementia
5%
Rarer causes (all)
5%
Clinical Diagnosis
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History:- Take a careful history from the patient and the relative,
concentrate mainly on the onset and progression of symptoms, , take careful
drug history, social history. Deterioration of cognitive function is slow in
Alzheimer disease within years , faster in vascular dementia, and very rapid in
reversible like metabolic causes.
Deterioration occurs in :retention of new information like appointments, events, or working a new
household appliance)
Managing complex tasks e.g. Paying bills , cooking a meal)
Language ( word finding difficulty)
Behaviour ;- become aggressive, irritability, poor motivation and wandering)
orientation getting lost in familiar places.
recognition:- failure to recognise people
Ability to self care :- bathing , dressing.
Reasoning:- poor judgement
Alzheimer’s – Diagnosis
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Fulfil criteria for dementia syndrome
Insidious onset
Gradual progression
No focal neurological signs
No evidence for a systemic or brain disease
sufficient to cause dementia
Alzheimer’s Diagnosis DSM IV
The development of multiple cognitive deficits manifested
by both:
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Memory impairment and:
2.
One or more of the following cognitive disturbances:
a)
Aphasia
b)
Apraxia
c)
Agnosia
d)
Disturbed executive function
Alzheimer’s Diagnosis DSM IV
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1)
2)
3)
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The cognitive impairments above lead to significant
impairment in social or occupational functioning & are a
decline from a previous level
The course is gradual in onset & shows continuous decline
The cognitive impairments are not due to:
Other CNS conditions that cause progressive deficits in
memory & cognition
Systemic conditions that cause dementia
Substance induced conditions
The deficits do not occur during the course of delirium
Alzheimer’s - features
Cognitive symptoms
Amnesia – early features are impaired new learning & recall,
disorientation in time & place, late features include impaired
semantic memory & visuospatial memory
Aphasia (dysphasia) – deficits in cortical language function –
early features are nominal aphasia, verbal perseveration, late
features include mutism & echolalia
Apraxia (dyspraxia) – common forms are: ideomotor
dyspraxia (cannot carry out motor function to command),
constructional dyspraxia (manifested by inability to copy
intersecting pentagons or draw a clockface)
Cognitive Features
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Agnosia especially visual agnosia (inability to recognise
objects) & prosopagnosia (inability to recognise faces)
Frontal-executive dysfunction – inflexible (concrete
thinking). Difficulties with problem solving or planning,
difficulty correctly sequencing behaviour.
Dyslexia
Dysgraphia
Acalculia
R/L disorientation
Non-cognitive symptoms
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Psychotic:
Delusions often paranoid
Hallucinations: commonly visual
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Mood:
Depression
Anxiety
Euphoria
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Behavioural: Apathy
Over activity
Aggression
Non-cognitive symptoms
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Neurovegetative Symptoms:
Sleep disturbance, day-night reversal in about 30% patients
Eating: poor oral intake or binge eating
Sexual disinhibition
Personality change
Physical Symptoms:
Primitive reflexes (grasp & palmomental reflexes)
Incontinence (often a late feature in AD)
Weight loss
Deterioration in gait
Falls
Vascular Dementia
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Evidence of dementia and
Cerebrovascular disease: focal signs on neurological
testing & evidence of cerebrovascular disease on brain
imaging (CT or MRI): multiple large infarcts, single infarct
in the angular gyrus, thalamus, basal forebrain or PCA or
ACA territories, or multiple basal ganglia & white matter
lacunar infarcts or extensive periventricular white matter
lesions or a combination of the above
A relationship between the onset of dementia & the
presence of cerebrovascular disease:
 Onset of dementia within 3 months of a stroke
 Abrupt deterioration in cognitive function or a fluctuating
or stepwise deterioration
Vascular Dementia
Other features which may be associated:
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Early gait disturbance:
‘Marche a petit pas’, Parkinsonian (lower limbs), apraxicataxic
History of unsteadiness or frequent falls
Early urinary symptoms not explained by urological
disease
Pseudobulbar palsy, depression, psychomotor retardation
& abnormal executive function
Dementia with Lewy Bodies (DLB)
(Consensus Criteria)
(1) Evidence of dementia with:
(2) Two of the following core features are essential in
order to diagnose possible DLB:
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fluctuations with pronounced variations in alertness & attention
recurrent visual hallucinations that are typically well formed &
detailed
spontaneous features of parkinsonism e.g. rigidity, bradykinesia,
tremor
(3) Other supportive features:
Repeated falls, syncope,
systematised delusions, hallucinations in modalities other
than vision
Parkinson's disease Dementia
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Elderly with Parkinson's are more likely to develop
dementia.
Motor symptoms proceed by at least one year. Then followed
by cognitive function deterioration
No hallucination.
Frontal Lobe Dementia
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Neurodegenerative disease with insidious onset and low progression.
Onset is often early ( 35-75), and either behavioural or language
symptoms dominate the clinical picture. Forgetfulness is mild, insight is
lost early. Difficulties at work may be the first sign.
Using MMSE can miss the diagnosis ( require FLT)
Behavioural problems include disinhibition, mental rigidity, inflexibility,
impairment of executive function, decrease personal care and repetitive
behaviours.
Language dysfunction:- include word finding difficulties, problem with
naming or understanding words. Lack of spontaneous conversation.
Neuroimaging usually demonstrate frontal/temporal atrophy
50% positive FH
FLD include many spectrum like FL Degenration, Picks disease, MND
with dementia
Normal Pressure Hydrocephalus
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Wide gate (gate disturbance)
Urinary incontinence
Cognitive impairment
CT large ventricle disproportional to cerebral atrophy
MMSE and gait assessment before LP
LP is diagnostic and therapeutic ( normal pressure, remove
20-30ml and re-assess gait and cognitive function)
Some improve with ventricular-peritoneal shunt. Gait is
more likely to improve. Complication infection and SDH
Differential Diagnosis
Causes of memory problems / confusion that are not
dementia
Delirium
Depression ‘pseudo-dementia’
Mild cognitive impairment or benign cognitive
impairment of aging
Learning difficulties
Previous brain injury
Memory Complaints in Aging, Depression
& Dementia
Aging
Depression
Dementia
Complaint
May report a mild or
subtle memory
problem
More likely to complain
about their memory
Expresses variable, nonspecific memory
problems or may be
unaware
Functional
Interference
No interference with
daily functioning
Minimal interferencefunctional problems
more likely due to mood
disorder
Clearly interferes with
daily functioning:
missing appointments,
unpaid bills, medication
compliance
Cognitive
Status
Onset of problem
unclear. Cognition is
normal on testing
Onset may be reported
Gradual onset &
as sudden, subtle deficits progression
on testing only
Cognition impaired on
testing
Mood
Not associated with
depression or anxiety
Associated with a
depressed or anxious
mood
May be associated with
fluctuating or blunted
affect
Assessment
Important points in the history:
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Duration, fluctuation, progression
Forgetfulness, repetitiveness
Misplacing or losing things
Judgement – ability to manage finances
Safety concerns
Changes in personality or behaviour
Loss of hygiene
Falls
Insight
PMH
Medications and compliance
Assessment II
Mental state examination
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Appearance & behaviour
Speech
Mood
Delusions
Hallucinations
Personality – past & present
Insight
Cognition
Assessment III
Cognitive Assessment
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MMSE & Frontal Lobe Score
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MMSE & Clock Drawing Test
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Addenbrooke’s Cognitive Examination – Revised (ACE-R)
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Alzheimer’s Disease Assessment Scale for Cognition
(ADAS-Cog)
Assessment of Mood
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Geriatric Depression Score
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Hospital Anxiety & Depression Score
Assessment IV
Physical Assessment
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Focal neurological weakness
Evidence of Parkinsonism
Evidence of intercurrent illness causing a delirium
Evidence of significant anaemia or hypothyroidism
Evidence of dyspraxia
Investigations
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All patients should have FBC, U&E’s, LFT’s, Ca, glucose to
look for systemic causes of confusion
B12, Folate, TFT’s
VDRL if clinically suspect syphilis
Cranial imaging to confirm / exclude :
Cerebral tumours, Normal Pressure Hydrocephalus, subdural
haematoma & to assess degree of vascular insufficiency
DaTSCAN (Ioflupane SPECT) for clinically difficult to
diagnose Dementia with Lewy Bodies
EEG – not generally indicated but is abnormal in sporadic
CJD
DaTSCAN in DLB
Normal DaTSCAN
DaTSCAN in PD & DLB –
Decreased dopaminergic
neurones in the striatal area
Management in Dementia - General
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Assess for physical illness & depression
Establish functional abilities & any risks
Capacity assessment
Carer assessment
Education of carers
Assess social care needs & support required
Planning for future care: advance directives, power of
attorney
Cholinesterase inhibitors
Management of behavioural problems
Terminal care
Mild Dementia
(Mild symptoms or MMSE 20-24)
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Appropriate counseling around the diagnosis
Advice on how to maintain health & well-being
Ensuring the individual has care to meet their needs prior to
discharge
Written information about dementia – leaflets produced by
the Alzheimer’s Society
Advice on Power of Attorney & how to plan for the future
Details of how to contact the Alzheimer’s Society for
ongoing support
Convey the diagnosis to the GP so they can arrange follow up
& refer to memory clinic if & when appropriate
Moderate Dementia
(Moderate symptoms or MMSE 10-20)
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As for mild dementia plus:
Assess eligibility for memory clinic & cholinesterase
inhibitors
Discussions should take place about how someone would
wish to be treated in the future: ceilings of treatment,
palliative care if appropriate on the ward
Severe Dementia
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If the patient has a clinical picture of dementia with severe
symptoms with or without an MMSE of <10:
As for mild to moderate dementia
Consider stopping cholinesterase inhibitor
Discussions should take place about how someone would
wish to be treated in the future: ceilings of treatment,
palliative care, where the individual would wish to die.
Anti-dementia drugs
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Cholinesterase inhibitors:
Donepezil:
A reversible inhibitor of acetyl cholinesterase
Galantamine: As for Donepezil + nicotinic receptor agonist
Rivastigmine: Non-competitive inhibitor of acetyl cholinesterase,
Licensed for dementia in PD & DLB
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N-methyl-D- aspartate (NMDA) receptor antagonist:
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Memantine: Some evidence it is effective in more advanced
dementia, & beneficial in behaviourally disturbed AD in
conjunction with a cholinesterase inhibitor
PDD,DLB,ALZ have greatest cholinergic deficit
What do NICE say? (November 2006)
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The cholinesterase inhibitors can be prescribed for clinically
moderate AD or those with an MMSE 10-20
NMDA receptor antagonists to be prescribed ‘de novo’ only
in recognised clinical trials
Only specialists in Old Age Psychiatry or those geriatricians
with specific expertise may start therapy
Patients need to be reviewed at 3/12 & then 6/12 intervals to
assess response with an MMSE score, a global functional &
behavioural assessment & carer views to be considered
If benefit noted they may continue on therapy until the
MMSE<10
Management of Behavioural Problems
Non-Pharmacological intervention
Assess for intercurrent illnesses, pain ,constipation, urinary retention etc
Ensure environment is appropriate for their needs:
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Lighting levels appropriate for the time of day
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Regular (at least 3xday) cues to orientate
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Use of clocks & calendars
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Hearing aids & glasses available & functioning
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Continuity of care from nursing staff
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Encouragement of mobility & engagement in activities
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Approach & handle gently, explain who you are, what you are going to do &
why
Non-pharmacological measures
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Elimination of unexpected & irritating noise
Good pain control
Encourage visits from family & friends especially at meal
times
Ensure adequate fluid & dietary intake
Adequate CNS oxygen delivery
Monitor bowels – avoid constipation
Encourage a good sleep pattern
Avoid inter & intra ward transfers
Avoid catheters where possible
Pharmacological interventions
Indications for sedation:
 In order to carry out essential investigations or
treatment
 To prevent a patient endangering themselves or
others
 To relieve distress in a highly agitated or
hallucinating patient, after assessing whether there is
a physical cause for that distress
Pharmacological intervention
Acutely: Haloperidol, Olanzapine, trazodone 50mg nocte to 300mg
max. and Lorazepam
are the drugs of choice
Do not use Haloperidol in patients with
Parkinson’s disease or Dementia with Lewy
Bodies
Medium term : Haloperidol or atypical antipsychotics:
(up to 6 weeks) Amisulpiride, Quetiapine, Olanzapine,
Risperidone (caution in cerebrovascular disease)
Longer term:
Cholinesterase inhibitors, NMDA Receptor
antagonists
Prevention of Dementia
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Life style
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Physical activity
Cognitive activity
Diet:- fish oil
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Medication
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HRT
NSAID
Antioxidant Vitamin E&C
Antihypertensive
Statin
Dementia Questionnaire
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Give 3 key features of dementia
How long should symptoms have been present for to
diagnose dementia?
Give 3 different types of dementia.
Which blood tests should be done routinely in a possible
dementia patient?
Why?
Give 3 differential diagnoses for cognitive dysfunction.
Name 3 assessments of cognitive function.
Name a treatment for dementia? What class of drug are these?
What are the standard criteria for eligibility for this drug?
Give one key clinical feature of Alzheimer’s dementia.
Give one key clinical feature of vascular dementia.
Dementia Questionnaire
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An 82 year old lady presents having had recurrent falls, she
doesn’t know why she is in hospital, her niece reports that she
was fully able to look after herself and was driving 4 weeks
ago. She is covered in bruises and her obs/WCC/urine
dipstix/chest X-ray are normal. What is the most likely
diagnosis?
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You are asked to review a 79year old surgical patient with
“confusion” He has been confused since admission and looks
thin and unkempt. He does not know where he is but is GCS
15. His son tells you he has stopped being able to cook meals,
and does not recognise his grandchildren anymore. This has
been going on for over a year. What is the likely diagnosis?
Dementia Questionnaire
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An 86 year old lady is brought in with dehydration, apart
from a raised urea her other investigations are normal. She
reports having a memory problem which she is very anxious
about, on testing her cognitive function is just below normal.
She has trouble concentrating on the test. On the ward she is
able to wash and dress herself, but keeps to herself. What is
the likely diagnosis?
You are called to the ward at night because a patient is
threatening the nurses with his Zimmer frame. The nurses
report that he is usually a “lovely old man” but today he has
been more agitated. He is currently being treated for a UTI.
What is the likely diagnosis?
www.Alzheimer’s.org.uk
Bournemouth Office:
Alzheimer’s Society
c/o King’s Park Community Hospital
Gloucester Road
Bournemouth
BH7 6JE
Telephone: 01202 309084
Thank you for listening